Volume 173 Issue 11

Editorial "Should we treat leuchæmia in children?" Fifty years ago the first controlled clinical trial of cancer chemotherapy was published MJA 2000; 173: 568-569

Peter J Smith

Editorial General practice research in Australia: a timely reality check Do we need an independent body empowered to oversee general practice research? MJA 2000; 173: 569-570 General practice is the nub of Australia's healthcare. More than 90% of Australians visit a general practitioner each year: in 1997-98 alone, general practice consultations averaged 5.7 per citizen.1 The cost of providing these services, when added to the associated costs of pathology tests, radiology investigations, pharmaceuticals and allied health services, consumed 14% of the total healthcare bill of $42 267 million in 1997-98 and represents 1.2% of our gross domestic product (GDP).1It is entirely reasonable to expect that an industry with this level of impact on GDP would be underpinned by a thriving research and development program. Unfortunately, this is but a pipe dream! In most First World countries, including Australia, general practice research has a low priority. Indeed, a recent report in The Lancet lamented that this research vacuum made general practice ". . . one of the most intellectually underdeveloped disciplines in medicine".2 This underdevelopment stems from a lack of research culture, a heavy service commitment and the late arrival of academic GPs. Despite their Cinderella status, most Australian general practice academic units have actively pursued research for over 25 years. But what are the outcomes? Unless research leads to publication, its quality is essentially unknown. Through exposure to public scrutiny, individual research can be independently assessed. If deemed rigorous and relevant, it joins the living literature and may change clinical practice; if deemed inadequate or irrelevant, it lies buried in the grave of the silent literature. In this context, the report of Ward and colleagues3 in this issue of the Journal is a timely reality check. These investigators identified Australian general practice research published in the 20-year period 1980-1999 and compared selected characteristics of the research in the decades 1980-89 and 1990-99. The most noticeable difference was a nearly fivefold increase in publications in the second decade. The bulk of the research was published in two Australian journals (Australian Family Physician and The Medical Journal of Australia), but there were signs of an emerging international profile. Not surprisingly, the research was conducted mostly by affiliates of academic general practice units and nearly two-thirds of the authors were GPs. The second decade saw an encouraging twofold increase in randomised controlled trials, but they still accounted for less than 5% of publications. Finally, about half the research focused on topics of direct clinical relevance to general practice. What are we to make of all this? It is evident that general practice research in Australia is growing in stature, but, compared with other medical disciplines, is still in its adolescence. The pleasing increase in publications reflects a combination of factors, including the progressive maturity of our academic departments with their growing infrastructure and research staff, and the dedicated funding of general practice through the General Practice Evaluation Program (GPEP). Since 1990, this program has injected $10.5 million into projects evaluating general practice and promoting research.4 However, despite the encouraging report card from Ward et al, Australian general practice research still has some way to go. This was clearly recognised by the General Practice Review Group in their recent report Changing the future through partnerships, which recommended encouraging a general practice research culture; strengthening the infrastructure of academic general practice; and promoting a multidisciplinary approach to research, involving both consumers and the Divisions of General Practice.5 These are laudable recommendations. But any successful partnership requires sensible collaboration and sensitive cooperation. With at least 13 organisations representing general practice in Australia procuring productive partnerships may be a tall order!6 Clearly, a prime priority for nurturing general practice research is to build upon the current strengths of academic units through infrastructure support and realistic research fellowships for both established GPs and those in training. With the many competing concerns of general practice, a sensible approach might be a national independent body empowered to oversee general practice research. Its first task would be to define general practice research and formulate descriptors for monitoring research activity. In an address to the newly constituted National Health and Medical Research Council in 1937, W M Hughes, as then Federal Minister of Health, declared: We ought to be content with nothing less than original research. Australia, priding herself on being a nation, ought not be satisfied to follow, to imitate, to duplicate. She must blaze a track for herself, seek to lead rather than follow: and this calls for the services of specialists of high repute to train, inspire, and guide research along the right lines.7 More than 60 years later this is the very challenge for Australian general practice. Martin B Van Der Weyden Editor, MJA Hynes T. The financing of general practice. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 235-269. Horton R. Evidence and primary care [editorial]. Lancet 1999; 353: 609-610. Ward A, Lopez D, Kamien M. General practice research in Australia, 1980-1999. Med J Aust 2000; 173: 608-611. Hays R, Piterman L. Education and training for general practitioners. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 347-382. Department of Health and Family Services. General practice. Changing the future through partnerships. Report of the General Practice Strategy Review Group. Canberra: The Department, 1998. Kamien M. Academic general practice: past, present and future -- a personal view. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 519-526. Compston JHL. The health of the people. Canberra: Roebuck, 1978: 76. (Roebuck Series No. 19.) Make a comment

Editorial Media and young minds Despite the best efforts of J K Rowling, young Australians this Christmas will be more interested in video games and cyberspace MJA 2000; 173: 570-571 Whether linked with fictional suicides in 18th-century romantic literature or reports of real-world suicides in today's mass media, copycat suicides have generated suspicions that media images may undermine mental health and moral development.1 Suspicions have given way to uneasiness as a growing number of problems -- drug and alcohol abuse, sexual promiscuity, depression and eating disorders -- have been laid at the media's door. Young people's enthusiasm for new electronic media, where the pace of change outstrips current understandings of effects on health and development, has done little to diminish this sense of uneasiness. In this context, Bokey and colleagues2 have studied images of youth in the "old" media, focusing on "Notable Texts" recently recommended by the Children's Book Council of Australia. Suicide, mental disorder and failure were commonplace in portrayals of an insecure and pessimistic young generation. Psychiatrists were predatory or incompetent and offered no reprieve for the distressed. This genre has been termed "social realism" and its rise attributed to the social and economic changes that have aggravated the usual turmoil of adolescence. It is true that with these social changes familiar adult milestones such as stable employment, financial independence, parenthood and home ownership are delayed3 and rates of adolescent emotional and behavioural problems appear high.4 Even so, images of pervasive adversity, mental disorder and suicide are overly pessimistic and do little to destigmatise mental disorder in a group whose access to health services is already poor. Moreover, if these images are to be found in the familiar old media, how much more concerned should we be about the new? Hard answers are elusive. Academic research on the media and youth lags far behind that of marketing. Most work is North American, where the main focus has been on television violence. It is clear that childhood viewing of violence predicts later aggression and criminal behaviour.5 It is also clear that there are many powerful moderating influences. Parents, for example, have traditionally influenced not only what children watch but also the effect of those images on actual behaviour.6 The closer an image is to real-world scenarios, the greater the effect on behaviour.7 For this reason the virtual-reality experiences of the new media may prove particularly powerful. Trends in young people's media use are relevant. Only a third of today's Australian youth read for recreation.8 In contrast, electronic media have become pervasive and the convergence of telecommunication and computer technologies into the Internet has led to a dizzying growth in communication options. The new media offer individualised, two-way, synchronous interactions, and increasingly draw on sound and vision to offer sophisticated virtual environments. The effects are not all negative and the benefits from opportunities for social contact, education, publication and establishment of businesses, regardless of location, can not be dismissed lightly. The media's growing role in shaping youth lifestyles and cultures also deserves consideration. A longer period of full-time education, growing affluence and greater recreational time have made youth a distinct consumer group, with lifestyles shaped increasingly by the media. The new media offer myriad ways to market messages that affect self-concept, body image, sexuality, and drug and alcohol consumption. The tobacco industry has rightly been the main focus, but the health effects of marketing food, alcohol, fashion, pharmaceuticals and entertainment deserve greater attention. What options exist for action? One is to do little and allow the market forces behind the media to drive solutions. The success of the Harry Potter series is one example of market forces in action, as young readers turn away from a "social realism" they find boring.9 However, the dizzying pace of media change, and a mistrust of increasingly global marketing targeting the young, suggest that few will have confidence in this approach. One alternative is to rely on advisory bodies such as the Children's Book Council of Australia. However, with recommendations to librarians, teachers and parents based on artistic merit alone, a body such as the Book Council seems poorly placed to take on the role. It's a fair bet that, despite the best efforts of J K Rowling, young Australians this Christmas will be more interested in video games and cyberspace. Without better information from research, parents, media professionals and young people face difficult choices. For parents, media education may prove useful in overcoming their unfamiliarity with the new media, one reason for their diminishing monitoring role. For professionals working in competitive media and advertising industries, emerging ethical questions deserve expert advice. An encouraging step is the release by the Commonwealth Department of Health of a media resource kit as part of a mental health promotion strategy.10 It marks the beginning of a dialogue between the health professions and the media and one that should go further. Even with the best of parental and technical monitoring, today's young people will be exposed to a greater number and diversity of media images than any previous generation. For this and future generations, the role of media education in both interpreting images and dealing with virtually limitless information is likely to grow. Academic research may or may not tell us whether Harry Potter is a better companion than the cyberheroine Lara Croft, but should help us all make better-informed decisions about the presents we buy for our children in the years to come. George C Patton Professor Susan M Sawyer Associate Professor Centre for Adolescent Health William Buckland House, Melbourne, VIC Phillips DP. The influence of suggestion on suicide: Substantive and theoretical implications of the Werther effect. Am Sociol Rev 1974; 39: 340-354. Bokey KM, Walter G, Rey JM. From Karrawingi the emu to Care factor zero. Mental health issues in contemporary Australian adolescent literature. Med J Aust 2000; 173: 625-628. Furlong A, Cartmel F. Young people and social change: invidualisation and risk in late modernity. Buckingham, UK: Open University Press, 1997: 40-52. Rutter M, Smith D. Psychosocial disorders in young people: time trends and their causes. Chichester: Wiley & Sons, 1995. Cook DE, Kestenbaum C, Honaker LM, Anderson ER. Joint statement on the impact of entertainment violence on chikdren. Congressional Public Health Summit, American Academy of Pediatrics 2000. <http://www.aap.org/advocacy/releases/jstmtevc.htm> (accessed November 2000). Huesmann LR, Eron LD. Television and the aggressive child: a cross-national comparison. Hillsdale, NJ: Lawrence Erlbaum, 1986. Comstock G. Deceptive appearances: television violence and aggressive behaviour. J Adolesc Health Care 1990; 11: 31-44. Australian Bureau of Statistics. How Australians use their time. Canberra: ABS, 1998. (Catalogue No. 4153.0.) Waldren M. Return to Narnia. The Weekend Australian 2000 September 30: C6. Commonwealth Department of Health and Aged Care. Mental Health Promoting Media Strategy. Canberra: The Department, 1999. Make a comment

George C Patton · Susan M Sawyer

Conference Report XIII International AIDS Conference, Durban, 9-14 July, 2000 Nelson Mandela argues for urgent action against HIV in Africa John B Ziegler and Rosemary A Ffrench Let us not equivocate: a tragedy of unprecedented proportions is unfolding in Africa. AIDS today in Africa is claiming more lives than the sum total of all wars, famines and floods, and the ravages of such deadly diseases as malaria . . . Economic growth is being undermined and scarce development resources have to be diverted to deal with the consequences of the pandemic . . . Decades have been chopped from life expectancy and young child mortality is expected to more than double in the most severely affected countries of Africa. AIDS is clearly a disaster, effectively wiping out the development gains of the past decades and sabotaging the future. Earlier this week we were shocked to learn that within South Africa one in two, that is half, of our young people will die of AIDS. The most frightening thing is that all of these infections, which statistics tell us about, and the attendant human suffering, could have been, can be, prevented. Something must be done as a matter of the greatest urgency. And with nearly two decades of dealing with the epidemic, we now do have some experience of what works.-- Nelson Mandela1 MJA 2000; 173: 572-574 Prevention - Mother-to-child transmission - Vaccines - Treatment strategies - Hope - References - Authors' details Box 1: HIV in African countries, 1999 Box 2: Trends in mortality among children under five Nelson Mandela's closing address to the conference1 was a welcome contrast to the opening address by Thabo Mbeki, President of South Africa, who disappointed delegates by failing to resolve their concerns about his view that HIV does not cause AIDS. In his plenary address, David Ho (Director, Aaron Diamond AIDS Research Center, New York) noted that Mbeki would be judged harshly by history. Judge Ed Cameron, a gay white South African living with HIV, in a moving address, pointed out that his government had consistently mismanaged the epidemic, and that he was only alive because his income allowed him to purchase antiviral drugs not available to most South Africans with AIDS. Prevention Box 3: Probability of a Zimbabwean boy aged 15 dying before age 50 Box 4: Projected population structure, Botswana 2020 While news of the explosive spread of HIV in the Republic of South Africa highlighted the urgency of effective preventive strategies, there was relatively good news from some countries where decisive action by pragmatic governments was paying off: the HIV infection rate has stabilised at a relatively low level in Senegal; Uganda has brought its estimated prevalence rate down to about 8% from a peak of close to 14% in the early 1990s; Thailand's "100% condom use" campaign among female sex workers has contributed to falling prevalence in military recruits and antenatal clinic patients.2 In the opening plenary session, Professor Roy Anderson (Director, Centre for the Epidemiology of Infectious Disease, Oxford) explained that interventions to interrupt the spread of HIV in populations would have relatively little impact once prevalence was high. Targeting individuals engaging in high risk behaviours was only effective early in an epidemic; unfortunately, few governments have been prepared to invest resources in the early stages, when such efforts are most cost-effective. There was hope that relatively inexpensive strategies to prevent heterosexual transmission of HIV might emerge from the conference. Unfortunately, the results of a study of a vaginal microbicide containing nonoxynol-9 among sex workers in Côte d'Ivoire showed a higher infection rate in the experimental arm. This suggests that the microbicide's detergent action caused ulceration that enhanced HIV transmissibility. Mother-to-child transmission Amid the gloom of the inexorable spread of HIV in Africa and emerging epidemics in Eastern Europe, delegates were virtually unanimous that there should be no delay in implementing cost-effective measures to prevent mother-to-child transmission of HIV, especially with some drug companies offering to provide free drugs in less developed countries. Data from a prospective observational study in the USA showed that, with optimal maternal combination antiretroviral treatment, the risk of mother-to-child transmission falls to as low as 1%. In breast feeding populations treated with only one drug the gains were less dramatic, but nevertheless very impressive, with the potential to prevent the infection of 25 000 infants a year in South Africa alone. Data presented at the conference reinforced concern that the benefit of perinatal antiviral therapy would be lost when mother-to-child transmission occurred during subsequent breast feeding. However, analysis of the HIVNET 012 trial (mother and infant each received a single dose of nevirapine in labour and by Day 3, respectively) at 18 months showed that an absolute 8% reduction persisted despite prolonged breast-feeding.3 These interventions prevent only about a third of mother-to-child transmission, but they point to cost-effective strategies relevant in resource-poor settings. Implementation will be challenging; it was clear that many women attending African antenatal clinics do not accept HIV screening, do not return for results or do not accept antiretrovirals if HIV positive; attrition rates of 80% were reported. The role of breast feeding in perinatal transmission of HIV was firmly established by a randomised, controlled trial in Nairobi, Kenya.4 While observational data suggested that exclusive breast feeding may be safer than mixed feeding, bottle feeding provides the best protection against HIV infection. The Nairobi investigators reported that the mode of feeding did not affect survival to 24 months, either in the infected or uninfected infants. Surprisingly, breast feeding was associated with three times as much maternal mortality at two years as formula feeding. Vaccines New candidate HIV vaccines presented at the conference provided some hope for the future control of the pandemic. After the disappointing immunogenicity of the recombinant protein vaccines, which were designed to elicit antibody responses, it was thought that strategies for eliciting cellular immunity, particularly cytotoxic T lymphocyte (CTL) activity, may be more successful. The trials of vCP205 (a canarypox virus expressing HIV genes), both alone or with a recombinant protein boost, showed very few vaccine recipients with detectable CTL activity, and these few responses were not sustained. However, it was shown that responses were detected more frequently when vaccine recipients received higher doses of vCP205, so more antigen expresssion may be necessary to achieve the desired levels of immunity. Results of a Phase II trial of the whole, killed HIV vaccine, Remune, in HIV-positive individuals in Thailand were presented. The subjects who received the therapeutic vaccine had a small but significant increase in the CD4+ cell count (P = 0.05) of about 46 cells/µL, with increased antibody levels but no change in viral load. Probably the most controversial decision relating to HIV vaccines in the past few years was to take the AIDSVAX recombinant envelope protein into Phase III clinical trials (in Phase I/II trials the vaccine did not induce antibodies that would neutralise circulating strains of HIV). It was reported in Durban that enrolment in the Phase III trials had been completed in Thailand (n = 2100) and the USA (n = 5400). Efficacy data will not be available until early 2003. There are many new vaccine concepts currently undergoing preclinical testing and some impressive data were presented on experiments in mice and macaques. Stephen Kent (Principal Research Fellow, HIV Vaccines Laboratory, University of Melbourne) presented further evidence that a prime-boost vaccine strategy using DNA vectors, followed by fowlpox virus recombinant for gag and pol simian immunodeficiency virus genes, produced very high levels of cellular immunity in macaques, and that these responses could be increased by the co-expression of the cytokine gene IFN-g. This candidate vaccination strategy, for which the University of New South Wales was recently awarded $27 million by the US National Institutes of Health (NIH), will be tested in Phase I/II human clinical trials in Australia within two years. Another vaccine that has generated considerable interest was presented by Dr Robert Johnson (Director, Alphavax, Professor of Virology, University of North Carolina). The vector for the vaccine, a Venezuelan equine encephalitis replicon, was shown to target dendritic cells, one of the most powerful inducers of cellular immune responses. Testing of this vaccine will begin in South Africa early next year. Dr B. Ensoli (Virologist, Instituto Superiore di Sanità, Rome) also presented some convincing data on preclinical macaque studies of a vaccine targeting immune responses to the tat gene of HIV. She found that five of seven macaques were protected from infection with pathogenic simian/human immunodeficiency virus challenge, and that these monkeys had developed good cellular immune responses to tat protein. Clinical trials are due to begin with this vaccine in Italy and Africa. Thus, although HIV vaccines tested to date have produced somewhat disappointing results, there was optimism at Durban that the next generation of vaccines are promising. Treatment strategies Clinicians and patients have recently become excited by the concept of structured treatment interruptions, which have been suggested to enhance immune responses to HIV while providing relief from the cost, inconvenience and toxicity of complex antiretroviral regimens. Dr Tony Fauci (Director, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland) presented a pilot study of five patients selected because they had achieved undetectable viral levels with potent therapy. They then interrupted therapy for one week in two. During seven such interruption cycles the patients' viral levels remained undetectable and their immune function was preserved. However, because the cohort was small, the subjects highly selected (with extremely well controlled viral replication) and the period of observation was too short, the results did not provide reassurance that such a strategy would not be associated with the risk of induction of drug-resistant variants. It is thus much too early to recommend this strategy in clinical practice. Hope Overall, the conference was hugely successful. Despite talk of boycotts because of Mbeki's views, the conference was well attended. The colourful national costumes of delegates, signage, art and craft displays and street theatre all provided a celebratory atmosphere. There was a mood of optimism that the problems of access to treatments in resource-poor countries were at last beginning to be addressed. Simple, cost-effective, population-based prevention strategies are working in those countries which have implemented them. The hope is that an affordable preventive vaccine that is active against strains of HIV in areas of high prevalence is not too far off. References Closing address by former President Nelson Mandela at the 13th International AIDS Conference, 14 July 2000, Durban. <http://www.aids2000.com/> Accessed 1 November 2000. UNAIDS. Report on the global HIV/AIDS epidemic, June 2000.<http://www.unaids.org/epidemic_update/report/index.html> Accessed 1 November 2000. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354: 795-802. Nduati R, John G, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 2000; 283: 1167-1174. Authors' details Department of Immunology, Sydney Children's Hospital, Sydney, NSW. John B Ziegler, MD, FRACP, Associate Professor. Rosemary A Ffrench, PhD, Senior Scientist, Research Laboratory. Reprints will not be available from the authors. Correspondence: Associate Professor J B Ziegler, Department of Immunology, Sydney Children's Hospital, High Street, Randwick, NSW 2031. j.zieglerATunsw.edu.au 1: Seroprevalence of HIV in African countries in 1999 Over the last decade HIV has spread dramatically in sub-Saharan Africa, the fastest increases in prevalence occurring in Eastern and Southern Africa. (Reproduced by kind permission of the Joint United Nations Progamme on HIV [UNAIDS].) Back to text 2: Trends in mortality among children under five years old, with reference to adult HIV prevalence rate at the end of 1999 During the 1980s there were impressive improvements in child mortality attributable at least in part to improved immunisation rates, better management of diarrhoeal and respiratory disease and economic development. However, those gains are being lost and the increased child mortality rates are attributable to increasing incidence of perinatally acquired HIV. (Source: Demographic and Health Surveys, Macro Intenational, USA.) Back to text 3: Probability of a Zimbabwean boy aged 15 years dying before age 50 Trends are shown according to data from various national surveys. In high prevalance countries, a teenager has a greater than 50% chance of dying of AIDS before age 50. (Source: Feeney G, unpublished data, 1999.) Back to text 4: Projected population structure with and without the AIDS epidemic, Botswana 2020 The population chimney graph shows the dramatic impact that AIDS is predicted to have on the structure of the population of Botswana, where over a third of the 775 000 adults are now infected with HIV. The red pyramid shows the population structure as it would be in the absence of an AIDS epidemic. More children would be born (because more mothers would survive and remain fertile throughout their reproductive years) and fewer would have died because they acquired the virus from their mothers. Far fewer young adults would die before old age. The yellow areas show that the burden of AIDS will be greatest in children and in the most economically productive years of adult life. The implications of this change in population structure are shocking. The United States Census Bureau projects that in 20 years' time there will be more adults in their 60s and 70s in Botswana than in their 40s and 50s. This is based on the assumption that patterns of new infection will not change greatly over the next decade; however, as changes in future infection rates will principally affect men and women under 40 in 2020, the demographic chimney pattern for older adults is hardly affected by this assumption. The "missing adults" -- men and women who should have reached their 40s and 50s in 2020 -- are now in their 20s and 30s, although some have already died. Many more are already infected with HIV and will die before they reach their 50s.2 (Source: US Census Bureau, World Population Profile 2000.) Back to text

John B Ziegler · Rosemary A Ffrench

Raina K Plowright As a veterinarian working on an Adélie penguin research program, I was to spend six months on an island off the coast of Mawson Station in the Australian Antarctic Territory. During a field training exercise on my third day at Mawson, I fell into a crevasse with my four-wheel-drive quad bike and was crushed between the bike and the crevasse wall six metres below the rim. I had hypothermia and abdominal injuries, and underwent two emergency surgical procedures at Mawson Station. Sixteen days after the accident, I was evacuated by helicopter and ship. Here, I describe my experiences. The Antarctic plateau is a crevasse-riven mass of ice rising steeply behind Mawson Station. While riding across sastrugi (ridges in the ice formed by frozen accumulations of blown snow) on the plateau, I slowed to avoid skidding on a snowdrift that was barely visible in the glare. The front wheels of my quad bike reached the other side of the drift, but spun on blue ice. There was a deafening sound, like shattering glass, then ice and metal rushed past me as I plummeted down the walls of the crevasse and was crushed into the ice by the oppressive weight of metal. When everything stopped, I opened my eyes and found I couldn't breathe. I was wedged vertically in a narrow part of the crevasse, pinned between the bike and the ice wall 30 metres from the bottom. The 250 kg bike was crushing my abdomen and thorax against the ice, my chest flattened by the seat, the petrol tank against my lower body. Four-wheel-drive quad bikes being driven across sea ice. (Photograph courtesy of Kym Newbery) At that moment death seemed violently and terrifyingly close. The enormous weight of the bike was squeezing the life from me and I thought that I had only minutes to live. I knew something was very wrong where the bike was crushing my abdomen. Warm urine dribbled down my freezer suit and I could no longer feel my legs. The possibilities that crossed my mind included spinal injury and paraplegia, but I was unafraid, as a chance of life as a paraplegic was preferable to dying. Westbay and the area where I fell into the crevasse: a view from Mawson Station. (Photograph courtesy of Kym Newbery) Rescue By the time rescuers descended into the crevasse 90 minutes after my fall, I thought that I couldn't manage the extraordinary effort of moving air into my lungs any longer. As the bike was lifted off me I was crushed back into the ice and a white curtain of unconsciousness descended. It took six people over 15 minutes to haul me out of the crevasse using a "Z"-pulley rigged with ropes secured to an oversnow vehicle. I recall lying in a stretcher. Madeleine Wilcock, the station doctor, was peering down at me and asking what day it was, an oxygen mask was placed over my face and I was breathing rapidly, gulping for air, and I remember thinking, "I'm breathing! I'm breathing!". The stretcher was lifted onto the back of a utility, which started bumping over the ice, while I stared at the blue sky thinking, "I'm still breathing, I'm alive". Triage I have vague memories of painful needles being pushed into my arms and abdomen, uncontrollable shaking from the ice at my core and nausea that suddenly swept over me causing me to vomit a liquid like coffee grounds. I knew this was altered blood, but my mind refused to make the next logical step and question why I would be vomiting digested blood. There was a frantic effort to find Jason the electrician, as he was the only one of the 44 expeditioners on station who shared my Rh negative blood type. When Bryan Walpole walked in, with his cheerful hello, the relief of his familiarity was so overwhelming that Madeleine noticed a drop in my highly elevated pulse rate. Bryan had been the ship's doctor on my voyage to Antarctica on the Aurora Australis. The ship was still within helicopter range, and Bryan had been rushed 140 nautical miles over the sea ice to Mawson. It was extremely important to me, and for my morale, to see someone familiar taking control over a situation in which I had none. "We have to operate" The next morning Bryan announced that they had to operate. The thought of postoperative pain on top of discomfort and nausea I could already barely tolerate was devastating. I didn't even know if the station had surgical facilities, or if Madeleine or Bryan had surgical experience. It did not occur to me to ask them why I needed surgery. However, my haemoglobin level had fallen from 140 g/L to 100 g/L overnight, my pulse rate was rising, and I had developed abdominal pain. The only diagnostic tools available were haematological and biochemical tests, and x-rays. Thus, it was necessary to open me up to see if there was continued bleeding. There was also concern that I may have had a perforated gut, as I had been vomiting altered blood. It was a lonely and daunting experience being wheeled into an empty, sterile room under bright surgical lights. At least the lights indicated that they had an operating theatre. My anaesthetist, his beard covered in a mask, sat at the head of my bed. I had met him just two days previously; he was an electronics engineer with only two weeks training in anaesthetics at The Royal Hobart hospital 12 months earlier. My nurses were a carpenter and a diesel mechanic. I recall being terrified -- too sick and narcotised to interact or understand; the situation was completely out of my control. I remember someone explaining that the anaesthetic was being injected and a mist washed over me and I couldn't see or breathe. I could hear instruments being dropped onto metal trays and people talking around me, but I felt unable to breathe. My neck had been cranked to one side and the discomfort was excruciating. Then something was placed down my throat, and the air that I was desperately craving flowed into my lungs. I needed another breath and I strained to inhale, but my body wouldn't respond. I realised that I was paralysed and experiencing anaesthetic awareness and the doctors were about to operate while I was still conscious. I started screaming and screaming but I couldn't open my mouth to make a sound. With the most enormous effort I tried to move my arms and open my eyes to show them that I was fully conscious, but nothing I did made me move. However, I must have lost consciousness, as I felt no pain during the surgery, and my next memory was of regaining consciousness on a wave of nausea. Someone was holding a bowl to my mouth, and as I vomited I felt a sensation like sutures ripping through the tissues in my abdomen. The surgery was over and I was wheeled back into my hospital room. During exploratory laparotomy, they found a mesenteric tear with some bleeding vessels, which were ligated, and a large retroperitoneal haematoma, about which they could do nothing. There were also crushing injuries to my small intestine. Dr Madeleine Wilcock putting an oxygen mask on me immediately after the first operation. (Photograph courtesy of Jason Reinke) My care team The next seven days were a blur of unbearable suffering, surrounded by the extraordinary compassion and dedication of Madeleine Wilcock, my doctor (Bryan was required to return to the ship), who understood my suffering as if she were going through it too. This was complemented by the diligence and kindness of my three dedicated (bearded) nurses, who were there 24 hours a day and would do anything for me. Their combined love and concern enveloped and helped me during those awful days. During long sleepless nights in the care of the nurses my veterinary skills were often useful, in ways such as guiding them in fixing blocked intravenous lines or giving injections. At first I was nervous about a diesel mechanic or a carpenter trying to give me intramuscular injections, but then I noticed that they were even more terrified than I. I learned how stressful it is having to endure and anticipate multiple painful procedures each day, and would have preferred all dressing changes, catheter changes, injections and other painful events to be finished in one go. I appreciated Madeleine's efforts to relieve my pain, such as administering local anaesthetic before inserting a cannula. I decided that I would take great care to avoid inflicting pain on my patients in the future. No visitors Madeleine understood that I was unable to cope with visitors and allowed only Lyn (my biologist colleague, and one of only two other women on the station) to visit every day to read emails, which were important for maintaining my morale. I appreciated Madeleine's sensitivity, as I found interaction with people almost unbearable. Moving, and especially speaking, caused the nasogastric tube to irritate my pharynx and induced gagging and vomiting. I was anxious for people to leave. If they remained for any length of time, I needed their reassurance that they didn't expect me to answer or to look at them. I needed them to acknowledge and empathise with my suffering, the awful nausea, and the pain that vomiting caused me, as well as the exhaustion from lack of sleep, and the demoralising affliction of the nasogastric tube. No medical details, please Uncharacteristically, despite my usual curiosity and medical background, I had no interest in my medical details. I was unable to process any information. My entire focus was on existing. Until I was well again I didn't ask what the outcomes of the surgery were. I could not think about the accident, full stop. Flashbacks were immediately pushed out of my mind, and it wasn't until the nausea had subsided and the nasogastric tube had been removed that I was ready to face the full psychological trauma of the accident. My past veterinary patients As I lay in the white hospital room, watching the opaque grey world of a passing blizzard through my tiny porthole, I remember thinking, "My God, this is what sick people feel like". This new insight into suffering was particularly harrowing when I related it to all of those animals which had sat in the back of their cages, unmoving and unresponsive: I now understood what they may have been experiencing. I was certain that I would never work as a veterinarian again; I never wanted to face anything -- human or animal -- that felt as sick and uncomfortable as I did then. A slow recovery Traumatic pancreatitis -- diagnosed during further surgery after my return to Melbourne -- and recurrent forceful vomiting contributed to delayed wound healing. Eleven days after my operation my wound completely dehisced, and the next day I underwent further surgery for abdominal wall repair at Mawson Station. The Aurora Australis was turned around from its position in the Southern Ocean to bring me home. This was a major disappointment, as I was so much looking forward to recovering among the people who had cared for me and to continuing working on the island with the penguins. However, as well as the risk of further complications, supplies of drugs, cannulas, and fluid administration kits were running very low. Moreover, there was no total parenteral nutrition and my body had wasted away. Six days after the second operation I was 12-13 kg lighter than before my accident. The Aurora Australis, which turned back to bring me home (Adélie penguins in the foreground). (Photograph courtesy of Kym Newbery) On returning to Australia, I spent two weeks at a rehabilitation hospital in Melbourne undergoing intensive physiotherapy for right lumbar plexopathy. Two months after the accident I underwent an incisional hernia repair and bowel resection because of adhesions. I have been fortunate and grateful to make a complete recovery. Madeleine Wilcock and my nurses, Garry Watson, Jason Reinke and Nick Mortimer, were awarded the Australian Antarctic Medal for their extraordinary efforts while I was under their care. I would like, once again, to express my deep gratitude for their dedicated, skilful and untiring efforts to nurse and restore me. I will always remember my journey to Antarctica by the aura of love and compassion and care that contained me during those critical days of recovery from the crevasse fall. Authors' details Wentworth Falls, NSW. Raina K Plowright, BVSc(Hons), Veterinary Surgeon. Reprints will not be available from the author. Correspondence: Ms R K Plowright, PO Box 241, Wentworth Falls, NSW 2782. rainapATozemail.com.au

Raina K Plowright

Responding to Crisis Sydney hailstorms: the health role in the recovery process Lynette A Lee and Anne Collings We highlight the involvement of community health, public health and mental health staff in the recovery period after a natural disaster (hailstorm and ensuing wind and rain over three weeks) which, despite causing relatively few deaths or severe injuries, affected 20 000 families and caused damage estimated at $1.5 billion. Many families were given information and advice, and 383 individuals were referred for health assessment and management by doctors and other healthcare workers over an eight-month recovery period. MJA 2000; 173: 579-582 The response - The hailstorm natural disaster - General response - Initial impact on emergency departments - Impact on health service buildings, property and staff - Recovery organisation - Health role in recovery - Lessons for the future - References - Authors' details - - More articles on Public and environmental health Few residents of the east coast of New South Wales for 50 km north and south of Sydney will ever forget the massive hailstorm on April 14, 1999, and its aftermath. The storm and the rain that ensued over the next two weeks brought damage to roofs, windows, walls and electricity lines, and flooded the homes and devastated the living conditions of nearly 20 000 families. There were 61 000 insurance claims for damage to cars, the total damage to public buildings (including buildings owned by the Department of Health) was estimated at $45 million, and 60 marine craft were damaged. Although this disaster was not significant internationally in terms of lives lost or total destruction of homes, it was the costliest disaster (in financial terms) in Australian history, with the total bill likely to exceed $1.5 billion.1 The response In this emergency, the "all hazards" approach was used. This is a legislated set of humanitarian tasks and management arrangements for the civilian population for responding to and recovering from natural and hostile disasters.2 Health services played their part in the "all agencies integrated" response to the event,2 being involved in the four elements of disaster management: prevention/mitigation, preparedness, response, and recovery. South Eastern Sydney Area Health Service (SESAHS) undertook a key role in administering the health response from the earliest stage, and its community health services continued to be involved until November 1999. The Department of Community Services, the lead agency in the recovery effort, closed its special Disaster Recovery Centre at the end of January 2000. In April 2000 the media reported that approximately 100 houses were still awaiting roof repairs.3 The hailstorm natural disaster In the afternoon of Wednesday, 14 April 1999, a storm cell formed about 150 km south of Sydney, and travelled northward along the coastline, mostly over the sea (Box 1). Two severe hailstorms, accompanied by strong winds and rain, hit the southern and eastern suburbs of Sydney, the first at about 8 pm and the second about two hours later. Hailstones up to 9 cm in diameter and weighing over 100 g caused significant damage to property. This storm's occurrence in autumn, rather than late spring or summer, was exceptional. In the 200 years since meteorological records have been compiled (Bureau of Meteorology), only five hailstorms have occurred in Sydney in April; hailstones over 8 cm diameter were last reported in 1947. The hail, which lasted only four hours, left homes devastated and exposed. The State Emergency Service estimated that nearly 20 000 roofs were affected. Many tarpaulins applied to roofs as a temporary measure blew off in high winds in the following weeks, re-establishing the exposure, which was compounded by continuing rain and very cold weather. The hailstorm was considered an emergency (defined in the State Emergency and Rescue Management Act 1989 [NSW] as "an occurrence which endangers or threatens to endanger, the safety or health of persons in the State . . . which requires a significant and co-ordinated response"), and the NSW State Disaster Response Plan (DISPLAN) was activated. General response Emergency Services The emergency response was conducted within the Emergency Management arrangements, as a combat agency managed operation, with the State Emergency Service (SES), the NSW Police Service, the NSW Ambulance Service, NSW Fire Brigades and Rural Fire Brigades being mobilised immediately and over ensuing weeks as more rain fell. As the extent of the damage became more evident, units from all over Sydney and outside moved in to assist in the response and clean-up. Support was also provided by the Army. Department of Community Services In accordance with DISPLAN, the Department of Community Services established and staffed a Disaster Recovery Centre at Randwick racecourse, where Health staff joined with Department of Community Services officers and volunteers from Anglicare, the Red Cross, the Salvation Army and other agencies for briefings, debriefings and planning of activities. Initial impact on emergency departments In the first 24 hours after the storm, the emergency departments at St Vincent's and Prince of Wales hospitals (serving the inner-city and eastern suburbs of Sydney) registered a 50% increase in presentations compared with the same period in 1998 and a 10% increase over the following weekend, requiring extra staff. There were two waves of injuries. The first included lacerations, fractures and soft tissue injuries related to the hailstones and the rain; the second involved injuries to people trying to repair their properties. Three people died (one in a boat at sea, one who had a cerebrovascular accident while in a barricaded house and one who fell from a roof), and one person had a C6 spinal cord injury. In the first week the hospital emergency departments gave priority to SES workers, and treated an average of two per day. The Sydney Children's Hospital reported one child with a soft tissue neck injury attributable to the storm. Impact on health service buildings, property and staff Damage to health service buildings across the city amounted to approximately $5 million. In particular, damage to St Vincent's Hospital's roof led to the day-surgery area being closed and patients in one ward being moved. The War Memorial Hospital at Waverley experienced roof damage in the day centre area, resulting in attendees being relocated to another part of the hospital for a number of weeks. Royal South Sydney Community Health Complex closed three-quarters of its buildings; most have still not reopened. Many community development and public health staff worked from home for many months; some have now returned to their previous office space, while many have been relocated to offices in other parts of the Area Health Service. Darlinghurst Community Health Centre incurred roof destruction and water damage. One-third of the Northern Sector Community Health car fleet was damaged. However, the fleet was reduced in size for only a few days, as priority was given to emergency replacement of the fleet's windscreens and windows. Damage to the homes and cars of a number of South Eastern Sydney Area Health Service staff compounded the stressful conditions under which they worked in the next few weeks as workplaces were relocated and damaged equipment was repaired. Many found themselves balancing their work commitments to affected residents of south-eastern Sydney against the needs of their own families for a prolonged period. The debriefings and peer-support meetings organised at many of our facilities were noted by staff to have been helpful. In addition, workloads were redefined and prioritised. Some staff members were relieved of some responsibilities and were assisted by temporary transfers of staff from other parts of the Area Health Service. It was noted that more "backfilling" of workers may have eased some of the tension. Recovery organisation In keeping with the recovery systems delineated in DISPLAN, in the first week community health staff in both Sutherland and the eastern suburbs were asked, by recovery staff (from Department of Community Services), to see three people needing urgent nursing home placement. By the end of that week, more referrals for healthcare assessments, particularly of older people living alone, were trickling in. In addition to visiting their regular clients, community health staff saw over 300 new referrals over the next few months. The Health Service Functional Area Co-ordinator was asked to become involved in the briefings at the Recovery Centre; many of the health activities were initiated from these meetings. South East Health staff (nurses and medical officers) attended the Recovery Centre for prolonged periods over the next three weeks, specifically for daily briefings and debriefings on progress in notifying residents of available relief assistance, and for receiving referrals for health assessments for individuals found by the Department of Community Services' Disaster Recovery Officers during door knocking. Health role in recovery Coordination The Health response was co-ordinated by the South Eastern Sydney Area Health Service (SESAHS), with four-hourly discussions with the State Health Functional Area Co-ordinator in the first few days, reducing to daily and then weekly reports. Staff from aged care teams in other parts of South East Health were recruited to assist in routine activities, thus freeing up staff familiar with local resources available in the eastern suburbs to work on special referrals resulting from the disaster recovery. Some of those affected by the storm lived in the area of the Central Sydney Area Health Service (CSAHS). Liaison officers from Mental Health and Aged Care services in CSAHS attended the four meetings held by the SESAHS Functional Area Co-ordinator at the SESAHS Disaster Control Centre, and they co-ordinated care for victims from their own areas affected by the storms. Public Health SESAHS Public Health Unit medical and environmental health officers with expertise in environmental health, food safety and infectious diseases attended the Recovery Centre daily during the acute period. They visited many affected homes and other premises to investigate and advise on potential public health risks. Public Health Unit staff prepared a fact sheet and other information for the general public, distributed by letterbox drops, advising on simple health precautions such as managing perishable food, wearing rubber gloves during clean-up, ensuring tetanus vaccination status and disinfecting areas affected by sewage overflows. Advice was also given on environmental health issues such as checking electrical safety, and on precautions to be taken when dealing with broken asbestos sheet roofing and damp areas. The importance of lead in ceiling dust and furnishings and the potential for lead exposure among young children and pregnant women was highlighted, particularly as carpets could not be rapidly or easily decontaminated. Mental Health Mental Health staff (State and Area) also prepared information sheets for the general public, volunteer staff and general practitioners on coping personally with the hailstorms: on normal reactions to a disaster, on positive ways of coping and when to ask for extra help. Principles of the State health disaster response plan (HEALTHPLAN) were followed, in that compassionate support was provided by welfare agencies such as Anglicare and the Red Cross, while disaster counselling was a professional responsibility which rested with specifically trained Mental Health staff. Mental Health staff attended the recovery centre debriefings for approximately two weeks. Twenty patients were formally referred to mental health services during the first three weeks; none became long term patients. A specific request for assistance came from the Department of Education, which had sustained $9 million damage to 48 government schools. School-wide training and information about coping with loss was provided for students, families and staff in the Bondi district in both primary and secondary schools, coordinated by the South Eastern Sydney Area Child and Adolescent Mental Health Team. Community Health Community Health staff visited 240 existing clients affected by the storms in the first few weeks, particularly on weekends and after hours, times for which they are normally not rostered. In addition, they established a small taskforce to prioritise "hailstorm referrals". Staff were allocated to the team, and other aged care staff from other parts of the Area Health Service were seconded to the roles normally performed by recovery team members. An undamaged area of Royal South Sydney Community Health Complex was set aside as a co-ordination centre with a dedicated phone line and computer database. Over the ensuing months, community health staff saw another 383 people for assessments and management of their health needs. The last "hailstorm referral" -- a woman returning to her home after living with relatives since the beginning of the disaster -- was received as late as November 1999. The Community Health staff response to each referral was no more than the usual response to a person with health and social needs. Those referred were assessed to determine the most appropriate way for those needs to be met (eg, medication management, nutrition, accommodation, personal support, consultation with general practitioners). The significance for the Department of Community Services, the Department of Housing and others in the recovery process was that health staff were available, visible and quickly accessible. Answers to the problems the other services uncovered did not lie in taking "patients" to the local emergency department, or even in asking a general practitioner to visit. They lay in referral to staff who had the primary resources to assist these people in distress and the networks to know how to gain assistance over and above the financial response being coordinated by the Department of Community Services. Usually, in April and May, community health staff call all their clients to advise them to seek influenza vaccinations to sustain them through the winter. Notably, more "hailstorm referrals" than regular clients were not able to be contacted at their April 1999 address -- some are now living with relatives, some are in nursing homes and some have since died. This group will be the subject of further research into the impact of the hailstorm disaster on their coping skills. Lessons for the future The story told here outlines the responsibilities assumed in this disaster and reports the scope of activity required for a prolonged period after such an event. In particular, it highlights the value of community health and mental health services and defines a role which has to date been undervalued. Specific lessons learned by this Area Health Service included: Daily information sharing in the early stages was valued by staff; The roles of public health and mental health staff were reinforced in this response to a disaster; Community Health staff are important members of disaster management planning teams; Other agencies find that involving health staff in recovery activities is useful for victims, and reassuring for staff members as individuals; Recovery may be a prolonged process, dedicated space may be required on a semipermanent basis for central coordination and regular relief from "special" duties needs to be provided; and Maintenance disaster training should incorporate the importance of briefing and debriefing skills. These lessons are also documented in reports of other notable Australian disasters4,5 and are used in training for disaster management. Lessons learned from the hailstorm disaster were used to actively involve Community Health staff in planning the care of housebound patients during road closures for special events, to learn from Public Health staff about planning for infectious disease surveillance, and to reinforce the communication partnerships required in the event of mass casualties or a disastrous community incident. References Henri C. The Sydney hailstorm: the insurance perspective. Aust J Emerg Manage 2000; 14: 16-18. Emergency Management Australia. Commonwealth counter disaster concepts and principles. Australian counter disaster handbook. Volume 1. 2nd ed. Canberra: National Capital Printing, 1993. Hailstorm rooves still leaking. Sun-Herald April 9 2000: 31. Wilkinson S. Port Arthur Disaster. Aust N Z J Surg 1999; 69: 569-570. Hodge J. Responding to mass casualty incidents in the rural setting: a case study. Aust J Emerg Manage 2000: 14 (4): 29-32. Authors' details South Eastern Sydney Area Health Service, Sydney, NSW. Lynette A Lee, FRACMA, FAFRM, MSc, Director, Clinical Services, and Conjoint Senior Lecturer, University of New South Wales; Anne Collings, BA(Hons), CertNeuroscienceNursing (Canada), Program Manager, Aged Care and Rehabilitation, Northern Community Health Reprints will not be available from the authors. Correspondence: Dr L A Lee, South Eastern Sydney Area Health Service, PO Box 430, Kogarah, NSW 1485. leelATsesahs.nsw.gov.au Make a comment Progress of the hailstorm Sydney radar images showing the progress of the storm on Wednesday, 14 April 1999. Areas of heaviest rain or hail are shown in red. Images courtesy of the Bureau of Meteorology Back to text

Lynette A Lee · Anne Collings

Responding to Crisis Malaria in the Australian Defence Force during and after participation in the International Force in East Timor (INTERFET) Scott J Kitchener, Alyson M Auliff and Karl H Rieckmann Malaria in Australian Defence Force members has been far more common in East Timor than in other recent overseas deployments. By six months after all 5500 members of the International Force in East Timor had returned to Australia, 267 malaria infections had been reported to the Army Malaria Institute. Only 64 of those affected had their first clinical episode during their 4-5 months in East Timor, and about two-thirds of these infections were caused by Plasmodium falciparum. The remaining 212 soldiers developed their first symptoms after returning to Australia, and all but two infections were caused by P. vivax. After treatment, 44 soldiers had relapses of their vivax infections; 11 had a second relapse and two had a third relapse. These findings raise several issues about prevention and management of malaria in the ADF. MJA 2000; 173: 583-585 Antimalarial measures - High malaria rates in two battalions - Notification of malaria infections - Malaria infections with onset in East Timor - Malaria infections with onset in Australia - Parasite resistance to drugs? - References - Authors' details - - More articles on Infectious diseases and parasitology On 12 September 1999, President Habibie of Indonesia invited an international peace-keeping force to help restore peace in East Timor after significant civil unrest. The United Nations Security Council Recommendation 1264 (15 September 1999) directed the formation of an International Force in East Timor (INTERFET). On 20 September, lead elements of INTERFET from the Australian Defence Force (ADF) landed in Dili and were soon followed by approximately 5500 ADF personnel assigned to serve in different parts of East Timor. INTERFET concluded on 23 February 2000, when most ADF personnel came under the command of the Peace Keeping Force of the United Nations Transition Administration for East Timor (UNTAET). Antimalarial measures ADF personnel used various personal protection measures against mosquitoes, including insect repellents and permethrin-treated mosquito-nets. Preventive medicine units also carried out mosquito control measures. Personnel were given doxycycline (100 mg daily) for prophylaxis, starting one or two days before departure for East Timor and continuing for two weeks after return to Australia. Weekly doses of mefloquine (250 mg) were used as an alternative if doxycycline prophylaxis was not tolerated or contraindicated. In addition, terminal prophylaxis with primaquine (7.5 mg three times daily) was given for two weeks after return to Australia. In general, chemoprophylaxis was not taken under supervision. High malaria rates in two battalions On 23 October 1999 -- approximately one month after deployment -- the first malaria infection was diagnosed in a soldier serving with the Second Battalion, Royal Australian Regiment (2RAR). During the four months of the battalion's deployment on the northern border region, mainly during the wet season, 17 members of the battalion developed malaria (monthly rate, 0.71%). Most of these cases were traced to exposures in Batugade (see Box 1). The Third Battalion (3RAR), deployed to the Oecussi (Ambino) enclave for five months, reported 24 cases of malaria (monthly rate, 0.73%). These malaria attack rates were the highest observed during the ADF involvement in INTERFET. Based on data from ADF units deployed to other areas of East Timor, other high risk areas were the mouth of the Komoro River in Dili (near the international airport) and the southern border regions near Suai. Within 7-8 months after returning to Australia, a further 127 soldiers from 2RAR and 3RAR had developed malaria. Combined with the 41 cases with onset overseas, this equates to nearly three (2.96) of every 100 soldiers from these two battalions acquiring malaria for every month's deployment to East Timor. This rate is higher than that experienced by Australian military forces deployed recently to Southeast Asia and Africa1 and Bougainville (unpublished), but lower than that observed during some military deployments to Papua New Guinea.2 Notification of malaria infections That malaria was a health problem was obvious during the five-month duration of INTERFET, and this became even more noticeable after the return of troops to Australia. Clinical episodes of malaria were reported to the Central Malaria Register of the ADF, which is managed by the Army Malaria Institute (AMI). The AMI records clinical and epidemiological data, and, whenever possible, confirms the diagnosis by microscopic examination of blood films or polymerase chain reaction (PCR). Malaria infections with onset in East Timor During deployment of the entire Australian contribution to INTERFET, 64 ADF members developed malaria while in East Timor (Box 2a). About two-thirds of these infections were caused by Plasmodium falciparum and the remainder by P. vivax. This 2:1 ratio reflects the relative prevalence of these two species in the local communities,3 and suggests that there was inadequate compliance with doxycycline prophylaxis or that there were other factors resulting in lower drug concentrations, such as drug deterioration under adverse environmental conditions or reduced bioavailability. The falciparum infections were treated with either a one-day course of mefloquine, or quinine (3 days) combined with doxycycline (10 days). One patient tolerated mefloquine poorly and received atovaquone and proguanil (3 days). None of the patients had a recurrence of clinical symptoms and were presumably cured of their infections. The vivax infections were treated with a combination of chloroquine (3 days) and primaquine (14 days). All affected patients responded well to treatment, but a few had a recurrence of clinical symptoms and parasitaemia (relapse) a few weeks to months later (Box 2b). Malaria infections with onset in Australia Many more malaria infections had their onset after soldiers had left East Timor, with the first clinical episode of malaria occurring in 212 ADF members after their return to Australia (Box 2a). They all had vivax malaria, except for two soldiers who developed falciparum malaria within two weeks of their return. This indicates that doxycycline prophylaxis effectively prevented the development of the blood stages of P. vivax, but that dormant parasites (hypnozoites) in the liver reactivated, entered the bloodstream, and initiated acute attacks of malaria after doxycycline prophylaxis was discontinued. Such initial episodes of vivax malaria could occur many months after return to Australia, with most ADF personnel involved in INTERFET leaving East Timor between December and March 2000 (Box 2b). A few more initial infections will undoubtedly emerge up to 12 months or longer after return from East Timor. It was obvious that terminal prophylaxis with primaquine had not been successful in eradicating all the residual hepatic parasites. As primaquine is the only drug capable of eliminating such parasites, the 210 patients hospitalised with vivax malaria received primaquine again (22.5 mg or 30 mg daily) in addition to a standard course of chloroquine (3 days). Compliance with treatment courses was undoubtedly better than with terminal prophylaxis. Forty-four soldiers had relapses 22-180 days (median, 77 days) after treatment. Although most soldiers were cured after a second course of chloroquine and primaquine, 11 had a second relapse 28 to 157 days (median, 82 days) after treatment and two had a third relapse 145 to 159 days after the third course of treatment. Apart from the distress caused by these recurrent acute episodes of malaria, the overall effect on operational capability was quite substantial. Clearly, there is an urgent need for more effective malaria prophylaxis. Parasite resistance to drugs? Doxycycline has proven to be very effective in the past for prophylaxis of both falciparum and vivax malaria. In combination with any rapid-acting drug, it also cures falciparum infections provided it is taken for 7-10 days. All the falciparum infections in East Timor were cured after treatment with doxycycline, indicating that the parasites had not developed resistance to doxycycline. Primaquine tolerance is a well-recognised phenomenon in Papua New Guinea2 and other Melanesian countries, but it has not been well documented in East Timor. The surprisingly large number of soldiers who developed vivax malaria after returning to Australia obviously had their infections suppressed effectively by doxycycline while they were in East Timor. Their delayed malaria attacks after their return were the result of either deteriorating drug compliance or primaquine-tolerant hepatic parasites. The fact that 44 (21%) of the 210 patients with vivax malaria had a relapse of their infections (a quarter on more than one occasion), under more closely supervised drug administration, indicates that primaquine-tolerant parasites are present in East Timor. Efforts currently being made to reduce the many malaria casualties in East Timor are summarised in Box 3. References Shanks GD, Roessler P, Edstein MD, Rieckmann KH. Doxycycline for malaria prophylaxis in Australian soldiers deployed to United Nations Missions in Somalia and Cambodia. Milit Med 1995; 160: 443-445. Rieckmann KH, Yeo AET, Davis DR, et al. Recent military experience with malaria chemoprophylaxis. Med J Aust 1993; 158: 446-449. World Health Organization. East Timor epidemiological profile, September 1999 <http://www.who.ch/eha/> (accessed November 2000). Authors' details Army Malaria Institute, Gallipoli Barracks, QLD. Scott J Kitchener, FAFPHM FACTM, Officer Commanding Clinical Field Section; Alyson M Auliff, BSc(Hons), Scientific Officer, Clinical Field Section; Karl H Rieckmann, MD, Director. Reprints: Major S Kitchener, AMI, Gallipoli Barracks, Milpo, QLD 4152. scott.kitchenerATdefence.gov.au Make a comment 1: East TimorMap showing Batugade and the Oecussi (Ambino) enclave, identified as sources of infection for the Secound and Third Battalions, Royal Australian Regiment. Back to text 2: Pattern of malaria infections during the deployment of the International Force in East Timor (INTERFET) (a) Distribution of malaria type and place of onset for the 267 infections among INTERFET peronnel deployed from September 1999 to March 2000. (Data collected up to September 2000). (b) Time of onset of 210 initial vivax malaria infections and 57 relapses after return to Australia (between December 1999 and March 2000). Back to text 3: Improvement of malaria control measures Increased vigilance for malaria in the border areas of East Timor, and continued surveillance of malaria infections after redeployment to Australia; Assessment of the effectiveness of personal protection measures and remedial measures to improve compliance; Evaluation of higher doses of primaquine for eradicating parasites from the liver; and Appraisal of the effectiveness of alternative control measures, including new prophylactic drug regimens. Back to text Plasmodium falciparum Plasmodium vivax

Scott J Kitchener · Alyson M Auliff · Karl H Rieckmann

Responding to Crisis Medical assistance to civilians during peacekeeping operations: wielding the double-edged sword Michael C Reade Peacekeeping operations have become the main operational activity of the armed forces of the developed world over the past 10 years -- a trend which appears likely to continue. Peacekeepers often remain deployed long after the armed conflict has ceased to help reconstruct civilian infrastructure. It is often possible to use the excess capacity of medical support units deployed with military forces to provide help to the local population. While this is appropriate immediately after a conflict when civilian clinics are overwhelmed, in the more prolonged reconstruction phase the seemingly simple clinical imperative to treat as many patients as possible becomes more complex. MJA 2000; 173: 586-589 The civilian situation - Treating civilians at the military hospital - Potential benefits of a foreign military medical presence - Potential benefits to the military hospital in aiding the civilian population - Potential disadvantages of a foreign military medical presence - Obstacles in aiding the civilian population - Conclusions - Acknowledgements - References - Authors' details - - More articles on Military medicine The difficulties of knowing how best to help a civilian population during rebuilding after armed conflict are illustrated by the experiences of a North Atlantic Treaty Organization (NATO) Stabilisation Force (SFOR) Multinational Integrated Medical Unit. Our hospital, which was accommodated in a disused factory complex in Sipovo in the Republica Srpska of Bosnia-Herzegovina, had one operating theatre, a four-bed intensive care unit, and a 12-bed general ward. There were two anaesthetists, one general surgeon, one orthopaedic surgeon, one physician and three general duties medical officers. Our primary role to was provide immediate care to 8000 NATO personnel. Front entrance of the destroyed factory which housed our hospital The civilian situation The Sipovo area has a civilian population of around 15 000. The 3000 Muslims living in the area were "ethnically cleansed" by Serb forces at the start of the 1992-1995 war, and, despite the best efforts of the international community, few have since returned. At the end of the war, Croat forces destroyed 65% of the buildings before their departure.1 The medical clinic had been completely destroyed. Rebuilt largely with overseas aid, the clinic is now run by nine Bosnian Serb general practitioners. There are no inpatient facilities. Management decisions are often guided by availability of consumables rather than best medical practice. Were it not for our military hospital, patients requiring a higher level of care would be driven for two hours in a private vehicle or one of the two "ambulances" (minibuses with red crosses) to the civilian hospital in the nearest large city, Banja Luka. There is no civilian aeromedical retrieval facility. Banja Luka hospital was a modern tertiary referral centre before the war, but is now chronically starved of funds. Treating civilians at the military hospital In light of the generally poor civilian health services in Bosnia, it may seem incongruous that we attempted to restrict the use of our hospital by local civilians. When the hospital opened in 1996,2 the first NATO unit to deploy undertook substantial humanitarian programs, including helping to establish local primary care clinics and to reconstruct the general urban infrastructure. The emphasis was on assisting a return to self-sufficiency; there was a fear of creating dependency on NATO. "Life and limb" surgery on civilians was undertaken, but elective surgery was not permitted. The policy at that time was that no facility could be provided which did not exist before the conflict. There had never been a surgical hospital in Sipovo. Destroyed apartment complex, Sarajevo By 2000, the guidelines had been relaxed. All patients were to be first assessed at the civilian clinic, but could be referred to our hospital if management -- emergency or elective -- was beyond their resources. Any minor emergency cases were to be sent back to the clinic, though what constituted "minor" was left to the discretion of the SFOR doctor. In practice, even our more relaxed guidelines proved difficult to enforce. Patients would arrive at our gate with an illegible referral note (usually written in Latin), or with no note at all. Our young, non-medical sentries saw only a patient in distress, and would understandably want to help. By the time the diagnosis had been established, it was difficult to turn away patients who had been inappropriately referred. We saw 10-15 civilian emergency presentations a week, mainly after hours. Many did not fall within our strict criteria, but few were turned away. In addition to this emergency service, civilians formed the bulk of the work of our specialty clinics. We accommodated up to three new referrals each day, plus patients returning for follow-up. We performed elective surgery, but could accept no more than three civilian patients at one time, and accepted no elective case where the postoperative hospitalisation was expected to exceed four days. During the first six months of 2000, 66 of the 137 operations performed in our theatre were on civilians; 37 (56%) of these were elective cases (mainly hernia repairs, cholecystectomies, and minor plastic surgery). The extent of the elective services we provided was officially left to the judgement of the individual clinicians. Should we have used our "spare" capacity in this way? Should we have actively encouraged even greater use? Potential benefits of a foreign military medical presence Patients can be treated locally at a standard comparable with First World medical practice -- The standard of care we offered was probably better than that provided in the overstretched Banja Luka hospital two hours away. Once a civilian patient had been admitted to our hospital, there was no restriction on resources. Unlike in the civilian hospital, there was no cost to the patient or the Bosnian government, and it could be argued that this should free resources for use in other reconstruction projects. Local doctors can receive training and military surgeons can perform operations which have been beyond the capacity of local surgeons -- This applies more in less developed countries. As medical services in Yugoslavia had been relatively advanced, there was little need for this type of work. The problem was more lack of resources than lack of expertise. The opportunity to offer a program of shared continuing medical education -- The availability of medical journals and funds to attend conferences have been very limited in Bosnia since the war. We were thus surprised to find that this initiative was greeted with little enthusiasm. The reasons for this were unclear, but may have included local resentment at being perceived as requiring "education" by SFOR, or simply inappropriate subject material or difficulties in communication. There was also, at times, substantial tension in meetings of doctors from each of the three ethnic groups. Equal treatment for all patients -- The civilian clinic in Sipovo was ostensibly open to patients of all ethnic backgrounds. However, many Muslims preferred to seek treatment in the Muslim-Croat Federation rather than in Serbian Sipovo, if this was within their means. Also, we were told that a complex system of social security meant the local clinic received less money for treating Muslims, who were funded by the Federation rather than the Republika Srpska. The Western medical ethic of treating all patients equally, even in a military context, is often not applied by local doctors in countries where peacekeepers are deployed. This bias can persist long after the conflict has ceased. A foreign medical presence has an obvious benefit to groups not adequately served by local doctors, and may encourage displaced people to return to the community. In fact, there was little to suggest any ethnic bias in the doctors in our region. Deliberate ethnically motivated malpractice after a conflict can be difficult for peacekeepers to detect. The presence of a military hospital may allow identification and even prevention of such malpractice. During our prolonged deployment, we destroyed our drugs and consumables when they were out of date, even though the civilian clinic could have made excellent use of them. The ethics of supplying expired medical supplies in such situations have been discussed in recent literature.3,4 There have been accusations that Western doctors are merely shifting the cost of destroying (often inappropriate) expired drugs to the recipient. Conversely, it is argued that drugs can be put to good use if properly selected. We felt we could not donate substandard supplies. Potential benefits to the military hospital in aiding the civilian population Justification of expenditure -- Humanitarian aid does not only benefit the recipient. Military forces are always under pressure to justify their expenditure, and few things do this more effectively than having peacekeepers appear on television dispensing aid. Opportunity to exercise skills and derive a sense of achievement -- Less cynically, military personnel usually genuinely want to help. Providing humanitarian assistance allows them to put skills into practice and fosters a justifiable sense of achievement. Fostering goodwill and support among the local population -- There is also a benefit to the peacekeeping mission as a whole. The population is more likely to be supportive if they can see the peacekeepers as an indispensable force for good. This was the Australian experience at the Medical Support Force in Rwanda in 1994,5 in a situation where security was much more obviously threatened than during our time in Bosnia. Potential disadvantages of a foreign military medical presence Creation of a culture of dependency -- A prime objective of most peacekeeping operations is to restore the community to a state of peaceful self-sufficiency. To replace local medical resources with those from overseas, whether civilian or military, fosters a culture of dependency. Many temporary aid programs have fallen into this trap, with ever-increasing requirements for financial support and little improvement in the overall standard of living for the people being "helped". This is perhaps the most important reason why we attempted to restrict our humanitarian medical activities. Many non-government agencies have already left Bosnia for fear of creating dependency.6There is a conflict between the clinical imperative to treat the presenting patient, and the public health imperative to think of the welfare of the society. The rejection by aid agencies of the offer by 300 ophthalmologists to travel to developing countries to undertake cataract surgery is a well documented example7 which parallels many of the issues we faced. This decision was based largely on the notion that international assistance should build countries' capacities to deal with their own problems, with the knowledge that aid money will eventually be diverted to more visible needy causes. It was accepted that this long term view would come at the expense of many individuals who would remain blind. In addition to this central issue, there were a number of less obvious reasons why we did not encourage more direct humanitarian work. Bosnian society has not only undergone the trauma of war, but a dramatic change from a communist to a democratic system. A major theme of our programs was to encourage ordinary people to pressure their own government for improvement -- a foreign concept only 10 years ago. To provide free First World hospital treatment would have worked against this objective -- why should local people work for improved locally provided healthcare if they are given excellent foreign health facilities with minimal effort? Creation of a vacuum of resources and skills -- One principal SFOR objective is to ensure there is no "vacuum" left when NATO departs. The Bosnian government is unlikely to have the resources to provide a surgical hospital in Sipovo, so, short of seeing no civilians, we can not achieve this objective. Further, the Bosnian government may not allocate appropriate healthcare resources to the region while our hospital is present. We may also be creating a vacuum in skills when we leave, as there has been an understandable tendency for local doctors to refer patients with more complex problems to our hospital. Over time this must reduce the expertise of local healthcare personnel in managing these cases. Questions of standard of care -- The ophthalmologists referred to earlier felt bound to offer the highest standard of treatment, while many of the aid agencies favoured cheaper alternatives which could be more universally applied. The implication that an inferior procedure was "good enough" for the target population invited criticism. However, in our case, running a large primary care and tertiary referral system to Western standards could have created long term problems, as "best practice" drugs may not be available after we leave. Should we have used different standards of care for Bosnian civilians and military patients? The practice of rotating military part-time consultant doctors for short periods may be necessary, but can result in less than optimal care, as doctors are often not around to see delayed complications. Indeed, many humanitarian organisations avoid the use of volunteer doctors on brief tours in the belief that this can foster poor medical practice. Fortunately, we did not see military doctors delivering a different standard of practice to that at home -- perhaps we are becoming more skilled at working in such a setting. Adverse effects on the status of local doctors -- Patients regarded our hospital as superior to any of their civilian facilities, even in specialty areas where this was plainly not the case. As highly educated members of their community, many local doctors hold positions of significant power, both formally and informally. There is the risk that if their medical services are superseded by our First World facilities, their influence in the community could diminish, destabilising the somewhat fragile order which has been re-established since the end of the war. In more tangible terms, the incomes of local practitioners may be eroded if our presence renders their services redundant. Antagonising community leaders in this way is not sound strategy for a foreign peacekeeping force. This is why, in all but emergency cases, we only saw patients if they had a referral note from their local doctor. Potential for abuse of the system by local doctors -- There is a risk such a referral system may be abused. It would be easy to simply scribble an unintelligible note and charge the patient the full fee while taking only a brief history and no responsibility. Local doctors could also abuse this role by charging an exorbitant fee for giving access to the elective surgical resources of the military hospital. Fortunately, we had no evidence that this was occurring in Sipovo. Unrealistic expectations -- The presence of a foreign military hospital may raise the expectations of a poor community to an impossibly high level. Disappointment may result for many reasons -- lack of resources, lack of appropriately trained doctors, or simply an impossible clinical problem. Local populations often do not appreciate that a military hospital is equipped only for conditions likely to affect young, fit soldiers, and that many chronic health problems of civilians will be outside the expertise of military staff. When combined with a lack of knowledge of local medical practices and resources, and the difficulty of follow-up for civilians living far from the hospital, the standard of care delivered may be inferior to that available locally. Impossibly high expectations can also have medicolegal consequences. Refugees treated for war wounds immediately after a conflict are unlikely to want to sue the treating doctor. However, five years after the conflict, a civilian who perceives he is the victim of a doctor's poor judgement may rightly contemplate seeking compensation. Should a patient be eligible for the same award of financial damages as a patient treated in the surgeon's home country? Or is the expected standard of care different? Inadvertent attraction of skilled locals into unskilled employment -- This was a definite negative effect of our presence in Sipovo. We employed tradesmen and cleaners from the local population. Our cleaners were paid around 600 deutschmarks (A$500) per month. Some would criticise this as exploitation of cheap labour, but a doctor in the local clinic earned only 500 deutschmarks, and a teacher much less. Inevitably, we removed many educated Bosnians from jobs essential to their society's reconstruction. Obstacles in aiding the civilian population Language -- The most obvious obstacle we faced was language. We were in a largely Serbian area, and our interpreters were young Serbs. Nonetheless, our interpreters were accused of favouritism and corruption, for example in negotiating offers of employment. If the local population had been more ethnically mixed, these problems could have been magnified. Persistent antagonism between patients from different sides of the former conflict -- Fortunately, this was not a problem in our hospital, as we were in a predominantly Serbian area and much of the animosity caused by the war had diminished. One could imagine former combatants accommodated in adjacent beds might add to the list of problems usually encountered by ward staff. Limits to the number of civilians able to be treated -- It is tempting to forget the real reason for the spare capacity in a hospital such as ours -- to be able to cope with a sudden large influx of military casualties. It is most important not to fill a ward with elective civilian surgical patients who can not be discharged rapidly if necessary. Conclusions There are striking parallels between the medical and public health situation in Bosnia at the end of the 1992-1995 war and the current situation in East Timor.8 Although many of the issues faced in Bosnia are specific to a relatively developed country, the decisions about how best to assist the East Timorese are equally critical. It is instructive to note that, despite an initial fear of creating dependence in Sipovo, we were allowing increasing use of our hospital by the local civilian population. This may be inevitable when clinicians, trained to treat all who present, are cast in the role of gatekeepers. If governments are truly committed to the principles of long term development rather than fostering dependency, there seems little alternative other than to take these decisions from the hands of those who traditionally act as advocates for individual patients. Acknowledgements I thank Lieutenant Colonel N Strowbridge, RAMC, Captain B Bowman-King, QARANC, and Dr Rajko Todorcevic for their assistance in gathering information for this article. References Hovey G. The rehabilitation of homes and return of minorities to Republika Srpska, Bosnia and Herzegovina. Forced Migrat Rev 2000; 7: 8-11. Thornton R, Cordell RF, Edmonds KE. Humanitarian aid operations in Republica Srpska during Operation Resolute 2. J R Army Med Corps 1997; 143: 141-145. Berckmans P, Dawans V, Schmets G, et al. Inappropriate drug-donation practices in Bosnia and Herzegovina, 1992 to 1996. N Engl J Med 1997; 337: 1842-1845. Hoehn JB. Inappropriate drug-donation practices in Bosnia and Herzegovina [letter]. N Engl J Med 1998; 338:1472-1473; discussion 1473-1474. Ramsey W, Bridgford LR, Lusby RJ, Pearn JH. The Australian medical support force in Rwanda. Med J Aust 1995; 163: 646-651. Bower H. Divided health is a minefield for Bosnia-Herzegovina [news]. Lancet 1997; 350: 1011. Gray BH. World blindness and the medical profession: conflicting medical cultures and the ethical dilemmas of helping. Milbank Q 1992; 70: 535-556. Plan of action for humanitarian health assistance and public health action in response to the crisis in Timor. Geneva: World Health Organisation, 2000. Authors' details Nuffield Department of Anaesthetics, University of Oxford, England. Michael C Reade, MB BS(Hons), BSc(Med)(Hons), Captain, Royal Australian Army Medical Corps (attached as Medical Officer, 16 Close Support Medical Regiment, Royal Army Medical Corps, Bosnia-Herzegovina, July-August, 2000). Reprints: Dr M C Reade, Clinical Research Fellow, Nuffield Department of Anaesthetics, University of Oxford, Radcliffe Infirmary, OX2 6HE, England. michael.readeATbrasenose.oxford.ac.uk Make a comment

Michael C Reade

Cracking the code Cracking the code: how will the Human Genome Project affect life as we know it? " I have seen the Devil in my microscope and I have chained him . . . The Devil . . . is nothing more than a tiresome collection of genes" (Marlon Brando as Dr Moreau in The Island of Dr Moreau; New Line Productions, 1996) MJA 2000; 173: 590 Thus says the scientist who plays God in a film adaptation of H G Wells's novel The island of Dr Moreau.1 As envisioned by Wells in the late 19th century, Moreau used vivisection in attempting to create the perfect human. A hundred years later, movies have turned to gene therapy. Fiction has given voice to some of our worst fears of science and technology out of control. It is therefore not surprising that, as the massive international effort of the Human Genome Project completes the sequencing of the human genome, the hype and hope have been blunted by legitimate concern about the potential for abuse of this technology. Cracking the DNA code is only the beginning. The challenges which lie beyond include detecting the clinical significance of variations in genetic sequences, identifying different functions of DNA, RNA and other molecular systems in the cell, and unravelling the complexities of gene-gene and gene-environment interactions.2,3 The tasks ahead are fraught with difficulties not just technical in nature -- ethical, legal and social implications are yet to be worked through.3 For the clinician, cracking the code will affect everyday practice in the not-too-distant future. Disease taxonomy will evolve from phenotype or clinical descriptors to genotype and molecular labelling.3 Recognising genetic variants which increase a person's susceptibility to certain diseases will lead to practical interventions which may be pharmacological (the burgeoning field of "pharmacogenetics"), environmental or behavioural.4 Picture these patients in a day's consultation: Guanosino, a 28-year-old with newly diagnosed type 2 diabetes mellitus and hypercholesterolaemia, consents to genetic analysis to determine his risk of further cardiovascular morbidity after routine genetic counselling. From a blood-spot sent to the laboratory, he is found to have a genetic mutation of the peroxisome proliferator-activated receptor gamma molecule, predictive for a severe form of diabetes.5 This leads you, his doctor, to advocate more aggressive treatment, including lifestyle measures and a new drug targeted specifically at this molecule. Guanosino also carries a variant cholesteryl ester transfer protein gene which lowers high-density lipoprotein cholesterol levels -- fortunately, treatment with pravastatin has been shown to retard the progression of coronary atheroma in such patients.6 Cytosina has been diagnosed with epilepsy and has come for the results of a metabolic screen for her genetic variants. The readout showing Cytosina's predictive profile for anticonvulsants enables you to prescribe the anticonvulsant to which she is most likely to respond and least likely to develop an adverse reaction, at the exact dose required for efficacy and her metabolism. True individual tailoring of therapy is now possible! Thymidinos has tinea of the toenails -- his blood-spot test shows genetic polymorphism of one of his cytochrome P450 enzymes, indicating that, should he take the preferred antifungal agent, his usual dose of antidepressant will need to be reduced to prevent toxicity.7 Adenina wonders whether she should take the Pill -- her mother once had a clot in the leg after surgery and was told never to take the Pill. Genetic susceptibility testing reveals Adenina has a prothrombin-gene mutation which greatly increases her risk of cerebral and deep-vein thrombosis, and, as the Pill would raise the risk even further, it is contraindicated.8 You spend the rest of the consultation discussing other forms of contraception and prevention of thromboembolic events. We asked people from diverse fields to explore the issues related to this genetic New World. What do two geneticists, a sociologist, a High Court judge and a politician have to say on the matter? No crystal ball gaze is complete without a reminder of how far we have come, and this journey is recounted by geneticist Ron Trent.9 And, back to the future, is eternal youth within our grasp? Geneticist Grant Sutherland speculates on the possible defeat of pathology, pathogens and the process of ageing,10 while sociologist Riaz Hassan ponders the socioeconomic impact of living longer.11 Michael Kirby and Natasha Stott Despoja take on the thorny ethical12 and legislative issues.13 Fiction may be overtaken by fact in the future, but it is more than likely the Human Genome Project will reaffirm that what constitutes humanity is much more than "a tiresome collection of genes". Mabel Chew Deputy Editor, MJA Wells HG. The Island of Dr Moreau. London: Heinemann, 1960. Cardon LR, Watkins H. Waiting for the working draft from the human genome project. BMJ 2000; 320: 1223-1224. Zimmern RL. The human genome project: A false dawn? BMJ 1999; 319: 1282. van Ommen GJB, E Bakker, den Dunnen JT. The Human Genome Project and the future of diagnostics, treatment, and prevention. Lancet 1999; 354 (suppl 1): 5-10. Barroso I, Gurnell M, Crowley VEF, et al. Dominant negative mutations in human PPARgamma associated with severe insulin resistance, diabetes mellitus and hypertension. Nature 1999; 402: 880-883. Kuivenhoven JA, Jukema JW, Zwinderman AH, et al. The role of a common variant of the cholesteryl ester transfer protein gene in the progression of coronary atherosclerosis. N Engl J Med 1998; 338: 86-93. Nebert DW. Polymorphisms in drug-metabolising enzymes: What is their clinical relevance and why do they exist? Am J Hum Genet 1997; 60: 265-271. Martinelli I, Sacchi E, Landi G, et al. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med 1998; 338: 1793-1797. Trent RJA. Milestones of the Human Genome Project: genesis to post genome. Med J Aust 2000; 173: 591-594. Sutherland GR. Just how long can we live? Med J Aust 2000; 173: 594-596. Hassan R. Social consequences of manufactured longevity. Med J Aust 2000; 173: 601-603. Kirby MD. The Human Genome Project in the dock. Med J Aust 2000; 173: 599-600. Stott Despoja N. The Human Genome Project: how do we protect Australians? Med J Aust 2000; 173: 596-598.

Mabel Chew

Cracking the Code Milestones in the Human Genome Project: genesis to postgenome Ronald J A Trent The Human Genome Project (HGP) will change medicine and medical research irrevocably. The obvious gains in genetic knowledge from the HGP, together with the advances which will flow into bioinformatics, biotechnology and the potential for novel therapeutic agents, will ensure that the financial investment in the HGP is repaid many times over. The HGP's costs in terms of ethical and social issues remain to be determined, but it is to be hoped that these will not detract from the scientific and medical achievements. How did such an endeavour start, and what path did it follow? A key player in the formative years of the Human Genome Project (HGP) was the United States Department of Energy (DOE). The DOE had a long term research focus on DNA because its early involvement in the World War II program that produced the atomic bomb had led to an interest in induced mutations. To understand the link between DNA and induced mutations, the DOE ultimately needed to characterise individual differences in DNA sequences. However, at the time, the sequences of only a few selected genes within the genome were known. Most of the estimated 40 000 human genes had yet to be discovered,1 and a considerable proportion of the 3 x 109 base-pairs making up the human haploid genome did not contain genes (about 30% is repetitive DNA2). Therefore, vast tracts of DNA with unknown function remained to be explored. A concerted effort to sequence the entire human genome within a reasonable time frame required the development of better technology. In addition, no research group was big enough to take on such a mammoth task. Despite the enormous obstacles, the majority of scientific opinion by the end of the 1980s was that sequencing the entire human genome was feasible. However, not all scientists were convinced -- there was considerable apprehension that it was a monumental exercise in data gathering rather than "true" research. There were also fears that the potential huge costs of the HGP would divert funds from more traditional research. Ultimately, the HGP, started in late 1990, was planned to be completed by 2005, and had a budget of US$3 billion. Politically, the HGP promised more than medical benefits -- it promised technological developments that would lead to economic wealth and job creation. David Smith, then Director of the DOE's Human Genome Program, described the HGP as "developing an infrastructure for future research". In reply to concerns about the potential for shrinking research funds in other areas, Smith said that, after the HGP was completed, "individual investigators would do things that they would never be able to do otherwise".3 A final point to note about the HGP is that the term "human" is a misnomer, as parallel work was also planned to sequence the genomes of model organisms, including a mouse, a fruit fly, various microorganisms, a worm, a plant and a fish. This work, called "comparative genomics", was undertaken to facilitate understanding of the human genome, as there are many similarities between human genes and those of other organisms (Box 1). Years 1-5 The goals identified for the first five years of the Human Genome Project are described in Box 2.6 During this time, many laboratories throughout the world carefully constructed maps of the genome, and then identified, by DNA sequencing, each base in the segment they were allotted. The HGP became a truly international endeavour, with the British and French participating early. Interestingly, in both countries, substantial funding for HGP-related activities came from outside the public purses (the Wellcome Trust, in the UK, and the Muscular Dystrophy Association, in France). Although the DOE was a key leading player, it was soon partnered by the National Institutes of Health (NIH). Today, the NIH is the leading public-sector player in the HGP. The Human Genome Organisation (HUGO) was formed to coordinate international efforts, as well as to facilitate education and rapid exchange of information. Australia has played a key role in HUGO, with Professor Grant Sutherland, from Adelaide, being one of the presidents of that body; the 1999 Human Genome Meeting (HGM'99) was held in Brisbane. Years 6-10 In contrast to the relatively low-key and steady progress made in the early stages of the HGP, more recent years have been considerably more turbulent. By 1998, the impressive developments in DNA-sequencing technology, particularly automation, had brought forward the timing for specific goals -- it was now believed that the complete sequence of the human genome would be determined by 2003. The first success stories of the HGP centred around the completed sequencing of genomes from model organisms (Box 3). These successes increased the momentum of the human genome work, as they confirmed that genomes could be completely sequenced, and that the information obtained had both scientific value, and potential medical importance. As the pace quickened towards the 10th year, so did the growing influence of the commercial sector (Box 3). As shown in Box 2, key goals of the HGP were the development of technology (particularly in relation to DNA sequencing), and the transfer of HGP outcomes into the private sector. The HGP represented an ideal venture in which the public and private sectors could cooperate (and compete). Governments and public funding bodies set aside substantial resources to participate in the HGP as part of the intellectual pursuit, but also as a base for economic development or alternative research funding. Developments coming from HGP were meant to be rapidly disseminated to users, an aim which would later come under some pressure. The HGP's goals requiring that DNA sequencing results were to be communicated freely and without delay were, to some extent, at odds with the protection of intellectual property through patenting. In 1991, the NIH was embroiled in an international controversy when it attempted to patent anonymous DNA sequences (those for which no function was known). Following public and international indignation, the NIH withdrew these patents.7 However, apart from the patent issue, free-flowing, publicly available information remained the rule rather than the exception, until the private sector became a major player. A high profile example of commercialisation came in the late 1990s with Celera Genomics, a privately funded organisation sponsored by Applied Biosystems (now PE Biosystems). Celera (company motto, "Speed matters") took on the might of the NIH and the world when it publicly boasted that with its resources (300 of the most modern automated DNA sequencers, and supercomputers second only to those in the US military), and a different strategy for sequencing DNA, it would finish the first draft of the human sequence before the NIH or other countries, and at a much reduced cost of US$200 million.8,9 This challenge had some positive effects, as it focused the cumbersome and slow-moving multicampus, multinational Human Genome Project, but, on the negative side, it once again highlighted that big corporations and big money can get there first, but at a cost -- the availability and access to future databases would no longer be free, at least in the short term. A new era In June this year, President Clinton, flanked by Dr Francis Collins of the NIH and Dr Craig Venter of Celera, announced simultaneously with the UK's Prime Minister Blair that the first draft of the human DNA sequence was now complete, having reached this stage with input from both the public and private sectors. Whether Celera or the NIH-sponsored initiative won the "race" is less relevant than who will control access to the databases containing the DNA sequences. At this stage, Celera appears to hold the upper hand, and is well on its way to the stated goal of being the definitive source of genomic and related medical and agricultural information.9 Although the HGP has officially reached its goals, it is important to note that this is only the first draft of the DNA sequence, and considerable work remains to ensure that DNA sequencing errors are removed. This will take a few more years. At the end of the HGP, the DNA sequence from the human genome will be deposited in various databases. What will be left is the mammoth task of working out the function of the genes. Hence, the post-genome era has been called functional genomics, which includes proteomics -- the technology and strategies required to determine the function of proteins. How this will be accomplished remains to be determined, but new technologies will be needed. The use of microarrays (a method by which the expression of many thousands of genes can be identified very rapidly with microchips) is an early, promising strategy in functional genomics. Bioinformatics will need to come up with more sophisticated programs by which the function of genes can be predicted. The traditional "wet-lab" approach to research might even give way to a complete "in-silico" (ie, computer) strategy! The first challenge -- sequencing the genome -- has been accomplished. Many more even larger challenges await us as we set out to determine the function of all human genes.10,11 References Aparicio AJR. How to count . . . human genes. Nat Genet 2000; 25: 129-130. Mueller RF, Young ID. Emery's elements of medical genetics. 10th ed. Churchill Livingstone, Edinburgh, 1998: 15. Smith D. Evolution of a vision: genome project origins, present and future challenges and far reaching benefits. Human Genome News 1995; 7: 3-4. (See <http://www.ornl.gov/hgmis/> accessed November 2000) Clark MS. Comparative genomics: the key to understanding the Human Genome Project. Bioessays 1999; 21: 121-130. Collins FS. Shattuck lecture -- medical and societal consequences of the Human Genome Project. N Engl J Med 1999; 341: 28-37. Human Genome Project Information <http://www.ornl.gov/hgmis/> (accessed November 2000). Anderson C. NIH drops bid for gene patents. Science 1994; 263: 909-910. Wadman M. Company aims to beat NIH human genome efforts. Nature 1998; 393: 101. Celera. A PE Corporation business. <http:www.celera.com/> (accessed November 2000). Burley SK, Almo SC, Bonanno JB, et al. Structural genomics: beyond the human genome project. Nat Genet 1999; 23: 151-157. Van Ommen GJ, Bakker E, den Dunnen JT. The human genome project and the future of diagnostics, treatment and prevention. Lancet 1999; 354 (Suppl 1): 5-10. Authors' details University of Sydney at the Royal Prince Alfred Hospital, Sydney, NSW. Ronald J A Trent, DPhil(Oxon), FRACP, FRCPA, Professor of Molecular Genetics. Reprints will not be available from the authors. Correspondence: Professor R J A Trent, Department of Molecular and Clinical Genetics, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. rtrentATmed.usyd.edu.au Top right-hand corner is a photo of James Watson (left) and Francis Crick (courtesy of A Barrington Brown, Sciences Source/Photo Researchers). ©MJA 2000 Make a comment GA_googleFillSlot("eMJA_Footer728x90"); Home | Issues | MJA shop | My account | Terms of use | Terms and Conditions | MJA Careers | More... | Contact | Topics | Search | RSS mja.com.au | The Medical Journal of Australia var gaJsHost = (("https:" == document.location.protocol) ? "https://ssl." : "http://www."); document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E")); try { var pageTracker = _gat._getTracker("UA-1577774-1"); pageTracker._setCustomVar(1, "access_level", "subscriber", 3); pageTracker._trackPageview(); } catch(err) {} 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/> © 2000 Medical Journal of Australia. We appreciate your comments. 1: Comparative genomics Genes that are important to survival have been conserved during evolution, and remain common to organisms ranging from yeast to humans. For example, it is estimated that about 74% of known human genes have a corresponding homologue in the nematode Caenorhabditis elegans.4,5 This is why it is often possible to identify the function of a human gene by working on the corresponding gene in a model organism. In mice, a gene can be "knocked out" (rendered non-functional) by genetic manipulation and the effect of this observed; in fruit flies, observing the phenotypes for natural or induced mutant genes enables the function of the corresponding gene in humans to be predicted. Back to text 2: Goals of the Human Genome Project6 Identify the 40 000 or so genes which make up the human genome. Determine the sequence of the approximately 3 billion bases which make up the human genome, as well as sequencing the genomes of model organisms. Store information in databases.* Develop tools for data analysis.* Transfer technologies to the private sector. (Private industry needed to be involved to make both technology development and research training effective.) Address the ethical, legal, and social issues arising from the HGP (approximately 3%-5% of the Department of Energy/National Institutes of Health budget was directed to this goal). * These goals would require very sophisticated bioinformatics capability, so the rapid development of bioinformatics (a discipline involving computational skills) has been a by-product of the HGP. Back to text 3: Landmarks on the road to realising the Human Genome Project Date Scientific achievement/Implications 1954 Watson and Crick describe the double-stranded nature of DNA. The beginning of "molecular medicine", as diseases could now be considered in molecular (DNA) terms. 1975 Sanger, Maxam and Gilbert describe how DNA can be sequenced. This would enable the human genome to be read base by base. 1985 Mullis and colleagues describe how DNA can be amplified with the polymerase chain reaction (PCR). PCR opened up the potential for diagnosing genetic disorders. 1987 Automated means by which DNA can be sequenced becomes available through the Applied Biosystems company (later PE Biosystems). Automation allowed sequencing of large segments of DNA. This was a critical development without which the Human Genome Project could not have been conceived. 1990 Human Genome Project starts. 1991 Controversy as the NIH attempts to patent anonymous DNA sequences. New genome research centres develop as start-up, for-profit companies. The private sector is involved because of the potential for DNA diagnostics and novel therapies based on DNA sequencing data. The human genome work becomes increasingly commercialised, with the potential for future ethical dilemmas in terms of access. 1995 The DNA sequence for the genome of the first model organism (Haemophilus influenzae) is published. This is achieved by TIGR, a company with commercial ties. Craig Venter from TIGR would later form Celera. In the next three years, the genomes for model organisms Escherichia coli, the yeast Saccharomyces cerevisiae and the nematode Caenorhabditis elegans are sequenced. The potential to understand pathogenicity at the DNA level would identify targets for novel therapeutic agents. 1996 Altruistic public policy reaffirmed that information coming from the Human Genome Project will be deposited in public databases within 24 hours. This response to the increasing influence of the commercial sector is an attempt to assuage fears among the more conservative researchers. However, with industry becoming involved, the user (government or individual) must eventually pay. 2000 The complete sequence of the fruit fly (Drosophila melanogaster) genome is announced by Celera and, as a sign of good faith, the company deposits the sequence in a public database. The first draft of the human sequence is announced by President Clinton. To date, knowledge of the DNA sequence has had a modest impact on medical practice, apart from increasing the potential for diagnosis of genetic disorders. However, with the functional genomics era will come novel therapeutics based on knowledge of DNA and its role in disease. Access to the Celera human database (as well as the mouse genome sequence due for completion soon) becomes available but only by subscription. The NHMRC is one of the first to subscribe to the Celera databases, allowing Australian scientists access to DNA sequence information not available in the public databases. Back to text Further historical information on the Human Genome Project can be found at the following web sites: http://www.ornl.gov/hgmis/ (the DOE version); http://www.gene.ucl.ac.uk/hugo/ (HUGO's role); http://www.nhgri.nih.gov/ (NIH information); http://www.fplc.edu/risk/vol5/spring/cookdeeg.htm (historical summary by Robert Cook-Deegan).

In June this year, United States President Clinton and British Prime Minister Blair jointly announced that the human genome had been sequenced. In another year or so, this information should be assembled into a much more useful form than that in which it now exists. The advances which will be made possible by the Human Genome Project and new genetic technologies may well extend the human life span still further. MJA 2000; 173: 594-596 Genetic susceptibility to common diseases - Cancer - Infectious disease - Aging genes - A longer life? - Acknowledgements - References - Authors' details - - More articles on Genetics The Human Genome Project will not be completed, in my view, until the functions of all human genes have been determined, knowledge of genetic variation between individuals is documented, and interaction between genes and between each gene and the environment and the contributions of these factors to human development and disease are established. This may take much of the coming century; however, substantial amounts of information of major importance to health and wellbeing have begun to emerge. In Australia, life expectancy rose by a little more than 20 years for males and 22 years for females in the 20th century (Box 1). Similar rises were recorded in most countries in which Western medicine was fairly readily accessible. This increase was achieved without input from the Human Genome Project, and involved factors that improved the environment (eg, sanitation, seat belts), as well as medical factors such as vaccines and antibiotics. How can the outcomes of the Human Genome Project be expected to eventually affect life expectancy? Genetic susceptibility to common diseases There are more than 100 relatively common diseases for which there are susceptibility genes present in the population (Box 2). Each of these genes may have only a small effect, but the additive actions of unknown numbers of such genes and their interactions with often unrecognised environmental factors lead to disease. Almost all these common diseases can shorten life, and many will be direct causes of death. Major academic and industrial research efforts are currently aimed at identifying susceptibility genes for these diseases.1Genes that confer a marked increase in risk of a common disease are fairly easy to find using standard genomic and molecular genetic approaches. Good examples of such genes are BRCA1 and BRCA2 for breast/ovarian cancer, and the DNA mismatch repair genes which lead to non-polyposis colorectal cancer. Although these genes are extremely important for those families in which they are present, heritable variations in them appear to be minor causes of the common diseases, accounting for less than 5%-10% of cases. Many susceptibility genes, which may only individually increase or decrease a baseline risk of disease by a few percent, are very difficult to identify using current approaches. This might change as a result of the Human Genome Project. There are two emerging technologies for the identification of susceptibility genes: SNP typing and DNA microarrays (Box 3).2 During the next few decades, these two approaches (and possibly new ones) should identify most of the susceptibility genes for most common human diseases. Once an understanding of the genetic basis of susceptibility is obtained, intervention should be possible. Many of the protein products of susceptibility genes will be novel targets for the development of new drugs that may either delay the onset of disease, or treat it once it is present, or both. There will be opportunities to identify, before starting treatment, the most appropriate treatment to use. This will be based both on an understanding of the genetic variations contributing to disease and on genetic variations that will determine drug side effects, dose and efficacy. Environment is certainly a key factor in much common disease, even if the environmental factors that are important for any particular disease are not known at all or are poorly understood. Once susceptibility genes are found, further research may identify the environmental factors that interact with them to increase the risk of disease onset. Public health education aimed at lifestyle changes may be targeted to genetically susceptible people, and be more likely to be heeded than education aimed at the whole population. Once genes are identified, diagnostic and therapeutic regimens will be developed. Then combinations of drug treatment, environmental modification (ie, lifestyle changes) and possibly even gene therapy will be able to delay onset of disease and provide effective treatment once onset occurs. Cancer Cancer at the cellular level is a genetic disease. The US National Cancer Institute has established a Cancer Genome Anatomy Project (http://www.ncbi.nlm.nih.gov/ncicgap), which will delineate the genetic changes in cancer cells at a whole-genome level. Understanding the cellular mechanisms of cancer will surely improve disease classification and prognostication and provide many therapeutic opportunities, including choice of the most appropriate treatment. Eventually cancer may be no more of a threat to life than is the common cold. Infectious disease Infectious diseases are still major causes of death, mainly in Third World countries, but also (although perhaps to a lesser extent) in First World countries. Genetic techniques have the potential to prevent these diseases through DNA-based vaccines, as well as to provide new treatments. Genomic approaches to infection will lead to tests for rapid identification of infecting organisms, allowing early commencement of specific therapy. In addition, DNA microarray analysis of gene expression in human macrophages is likely to identify infecting organisms that are resistant to culture or can not be identified by other means. The genomes of most common human pathogens (including viruses, bacteria and parasites) have already been sequenced. These genome sequences are providing a range of new targets for the development of novel antibiotics, antiviral and antiparasitic agents. The spectre of multiple drug-resistant bacteria should soon fade. However, we are likely to have to cope with the common cold and, more seriously, HIV, for a long time, until there are new approaches to dealing with highly mutable viruses. Aging genes Genes involved in the aging processes in simple organisms have been identified;7 however, in mammals, the only intervention shown to delay aging is caloric restriction,8 and the molecular mechanisms by which this acts are just beginning to be unravelled.9I think it unlikely that knowledge of the genetic basis of aging will lead to widespread anti-aging therapy in humans. However, this view could be proven wrong and aging genes, when identified, may be targets for the development of anti-aging drugs. If (when) gene therapy becomes relatively simple and safe, there may be ways to modify the actions of aging genes. A longer life? From anecdotal press reports we learn of rare individuals who live for about 120 years. Is this a genetically programmed maximum human lifespan? If it is, why can not most of us achieve it? Barring accidents (and there may be genes that promote risk-taking behaviours) or suicide (and there are certainly susceptibility genes here, possibly for suicide itself and certainly for a number of the psychiatric disorders that too frequently lead to suicide), we mostly die of common or infectious diseases before reaching 120 years. With mastery to be gained over many of our pathogens and with strategies to treat or to delay the onset of common diseases (including cancer), it is likely that the 21st century will see a similar increase in life expectancy to that witnessed in the 20th century. To be even more speculative, tinkering with our aging genes could add yet another 20 years in the 22nd century and get most of us up to or beyond 120 years of age. Unfortunately, none of the readers of this article will ever know the outcome of this speculation. And, if it is correct, the 120-year-olds had better be sprightly, as there may be standing room only on a grossly overpopulated planet. Acknowledgements I thank Dr Eric Haan and Dr John Mulley for constructive criticism of an earlier draft of this article. References Collins FS. Shattuck lecture -- medical and societal consequences of the Human Genome Project. N Engl J Med 1999; 341: 28-37. Young RA. Biomedical discovery with DNA arrays. Cell 2000; 102: 9-15. Martin ER, Lai EH, Gilbert JR, et al. SNPing away at complex diseases: analysis of single-nucleotide polymorphisms around APOE in Alzheimer disease. Am J Hum Genet 2000; 67: 383-394. Kruglyak L. Prospects for whole-genome linkage disequilibrium mapping of common disease genes. Nat Genet 1999; 22: 139-144. Celera Genomics launches SNP reference database product with more than 2.8 million unique SNPs [press release]. <http://www.pecorporation.com/press/ prccorp091300.html>. Accessed 14 November 2000. DeRisi JL, Iyer VR, Brown PO. Exploring the metabolic and genetic control gene expression on a genomic scale. Science 1997; 278: 680-686. Vanfleteren JR, Braeckman BP. Mechanisms of life span determination in Caenorhabditis elegans. Neurobiol Aging 1999; 20: 487-502. Weindruch R, Walford RL. The retardation of aging and disease by dietary restriction. Springfield, Illinois: CC Thomas, 1988. Campisi J. Chromatin and food restriction -- connecting the dots. Science 2000; 289: 2062-2063. Authors' details Department of Cytogenetics and Molecular Genetics, Women's and Children's Hospital, Adelaide, SA. Grant R Sutherland, AC, FAA, FRS, Professor and Director. Reprints will not be available from the author. Correspondence: Professor G R Sutherland, Department of Cytogenetics and Molecular Genetics, Women's and Children's Hospital, 72 King William Road, North Adelaide, SA 5006. gsutherlandATmedicine.adelaide.edu.au Make a comment 1: Life expectancy at birth for males and females born in Australia during the 20th century. Source: Australian Bureau of Statistics (www.abs.gov.au). Copyright in ABS data resides with the Commonwealth of Australia. Used with permission. Back to text 2: Some common diseases for which there is evidence for genetic susceptibility Arthritis Asthma Bipolar disorder Breast cancer Cardiovascular disease Colon cancer Depression Diabetes Endometriosis Epilepsy Hypertension Melanoma Schizophrenia Toxaemia of pregnancy And if you can't remember all these, Alzheimer disease is also in the group. Back to text 3: Emerging technologies for identifying disease-susceptibility genes SNP (single nucleotide polymorphism, pronounced "snip") typing is yet to be widely applied. In principle, typing large numbers of SNPs, perhaps up to 500 000 per individual, on large groups of patients with the same common disease will reveal clusters of SNPs that overlay susceptibility genes.3 This process is known genetically as looking for linkage disequilibrium.4 Celera Genomics recently announced that it had a database of 2.4 million proprietary SNPs, and had gleaned another 0.4 million from public databases, and, for a fee, this collection could be viewed, and presumably used to help find genes for common diseases.5 DNA microarrays come in several guises. One form contains very large numbers of DNA samples spotted at high density on glass slides. Most work to date has used arrays of the yeast genome -- all the genes of this organism can be displayed on a 2 cm x 2 cm area of glass.6 Arrays can then be used to determine which genes are active in any tissue, or the relative levels of gene expression in, say, normal compared with diseased tissue. For yeast, the response of the entire genome to changes in physiological conditions of culture (eg, temperature, nutrient stress) can be assessed with microarrays. For humans, the response of the entire genome is now beginning to be explored. The research question of which protein is involved in a particular process is being replaced by the simultaneous detection of the regulatory response of all proteins within a tissue in response to disease or experimentally induced conditions. Back to text

Grant R Sutherland

Cracking the Code The Human Genome Project: how do we protect Australians? Natasha Stott Despoja It is the moon landing of the nineties: the ambitious Human Genome Project -- identifying the up to 100 000 genes that make up human DNA and the sequences of the three billion base-pairs that comprise the human genome. However, unlike the moon landing, the effects of the genome project will have a fundamental impact on the way we see ourselves and each other. MJA 2000; 173: 596-598 Are consumers currently protected? - Is genetic information being misused? - References - Authors' details - - More articles on Genetics Within the next decade, the genetic information revolution will provide an abundance of genetic population screening tests, diagnostic tests and therapies. There is no doubt that these have the potential to bring great benefits, but technology's "double-edged sword"1 means that there will also be human costs and consequences. Thus, the community must determine how this new technology will be used. Genetic information has a number of characteristics that set it apart from other sensitive health and personal information. Unlike other personal information, genetic information is predictive. It may indicate a condition that might be expressed as a full-blown disease, a milder variant of that disease, or never be expressed at all. Techniques of genetic testing (and the assessment of its results) are still being perfected, raising the issue of the "quality" of genetic information.2 Moreover, genetic information can allow inferences to be drawn about blood relatives. It is an intimate part of an individual's identity which can not be superseded by events or changes in circumstances, and is potent for the entirety of that individual's life. Among the wide-ranging issues that face consumers and regulators are the ethical, legal and social issues designated "ELSI" under the Human Genome Project.3 They include questions about personal privacy, discrimination, and distribution and funding of healthcare services, such as: Will the promise of genetic therapies compensate for their costs or for a possible reduction in other health therapies or services? Will consumers be willing to subsidise the opportunity for would-be parents to preselect embryos produced by in-vitro fertilisation for desirable characteristics? What characteristics will be deemed undesirable? What will be the effect on the community if only those who can personally fund such services use this knowledge? What is the likelihood of a dystopian genetic underclass developing? Equity of access to genetic testing and therapies is gaining attention as a consumer issue. However, it is the ability of parties like employers, credit providers and insurers to obtain and draw conclusions from personal genetic information (and the dissuasive effect this may have on individuals considering a genetic test) which is of most concern to Australians. Genetic testing for many medical disorders is now routine in Australia. Neonatal screening for phenylketonuria, hypothryoidism and cystic fibrosis is standard practice, and tissue samples obtained during prenatal screening for cystic fibrosis, along with the corresponding test results, can be stored indefinitely.4 In fact, to qualify for accreditation in Australia, laboratories are required to store clinical genetic test results, the corresponding diagnosis and other written information indefinitely after reporting the results to the requesting doctor.5 If the test is for the purpose of research, the result is stored for a period "in accordance with good research practice".4 The accumulation of such information raises questions about its appropriate use and how individuals' interests should be protected, particularly in situations where diagnostic testing and research have moved from the public to the private sector. Are consumers currently protected? Existing legislation in Australia dealing with the protection of genetic information and its use for negative discriminatory purposes relies on a number of Commonwealth, State and Territory legislative instruments, self-regulatory guidelines and the common law.6The Commonwealth's human rights package and privacy laws, self-regulation through the National Health and Medical Research Council (NHMRC), the Therapeutic Goods Administration (TGA), the Genetic Manipulation Advisory Committee (GMAC), incidental legislation (eg, Section 29 of the Australian Institute of Health and Welfare Act 1987 [Cwlth]) and some self-regulatory measures in confined sectors provide some protection. Similarly, there is State and Territory legislation and additional legislation dealing with the donation of human tissues for specific purposes. The Australian Capital Territory's Health Records (Privacy and Access) Act 1997 covers personal health information (including genetic information) held in both public and private sectors. However, there is presently no legislation in any Australian jurisdiction dealing specifically with genetic privacy and non-discrimination, and there are a range of sectors in Australia which are not regulated and have no requirements to conform to any privacy or non-discrimination practices (specifically, interactions and transactions in the private sector, which is not covered by the Privacy Act 1988 [Cwlth]). The Interim Office of the Gene Technology Regulator, or the regulatory system proposed in the Gene Technology Bill 2000 (Cwlth), does not seek to amend the current regulatory arrangement for genetic information and samples. The Privacy Amendment (Private Sector) Bill 2000, introduced into the House of Representatives on April 12 this year, seeks to extend to the private sector the National Privacy Principles and privacy protection currently required under the Privacy Act. This Bill aims to establish "a comprehensive national scheme providing for the appropriate collection, holding, use, correction, disclosure and transfer of personal information by organisations in the private sector".6 Under this Bill, genetic information is classified as sensitive health information, in the same category as infectious health information. Consumers' genetic information is best protected under a comprehensive privacy scheme, such as that proposed by the federal Attorney General. However, whether such protection is provided for genetic information under the Privacy Amendment (Private Sector) Bill 2000 is currently under dispute as the Bill is debated in Federal Parliament. Privacy protection and the development of privacy "rights" in Australia should evolve with technological innovation and development. The unique nature of genetic information makes protecting such information integral to the evolution of privacy "rights" in Australia and worthy of specific legislative protection. It was from this conviction, rather than because of specific Australian examples of genetic discrimination or breach of privacy of which I was aware, that my Private Member's Bill (the Genetic Privacy and Non-discrimination Bill 1998) originated. The Privacy Amendment (Private Sector) Bill 2000 does not reflect the uniqueness of genetic information. Under the Bill, genetic information is defined as sensitive health information, being treated as prescriptive health information. This classification, when coupled with the specific exemptions for employee records and all transactions for businesses with an annual turnover of $3 million or less (estimated to exempt 94% of Australian businesses from the National Privacy Principles or similar approved privacy codes under the self-regulatory regime7), significantly undermines any protections to genetic privacy, specifically for online ehealth applications. Genetic privacy may be said to be the confidentiality that should apply to any "[g]enetic data associated with an identifiable person and stored or processed for the purposes of research or any other purpose".8 The Bill I introduced seeks to establish a "right" to genetic privacy. It also seeks to protect Australians from genetic discrimination. Genetic discrimination may be positive or negative. Positive discrimination can be either beneficial or adverse. For example, providing reduced premiums to individuals with a favourable record of genetic health may benefit the individual, but be argued from a consumer or public policy perspective to be unconstructive. On the other hand, positive discrimination on the basis of chromosome screening for potential susceptibility to workplace carcinogens and other toxins could arguably be a positive use of the technology. However, my concern is to protect individuals from treatment by a third party which would be disadvantageous to their interests. Is genetic information being misused? While there were examples of genetic discrimination in international jurisdictions,9-11 there were no documented Australian examples at the time my Bill was introduced. Barlow-Stuart and Keays12 have since reported 48 cases of genetic discrimination in Australia, 46 of which involved adverse treatment by insurance companies following genetic test results. In the absence of legislative protection, the Insurance and Financial Services Association (IFSA) has drafted a policy for genetic testing. This policy stipulates that: Insurers will not initiate any genetic tests for applicants for insurance or use genetic tests as the basis of preferred-risk underwriting; Results of existing genetic tests are only obtained by written consent of the tested individual for the sole purpose of assessing an insurance application for the individual on whom the test was conducted; Strict standards of confidentiality apply to the handling and storage of the results of genetic tests; and Access to the results of genetic tests will be restricted to the insurer's underwriters and reinsurers, and only other third parties with written authorisation of the insured individual. However, the policy endorses disclosure of the results of any genetic test undertaken voluntarily by a potential policy holder in assessing risk and therefore premium price. While IFSA's policy provides some protection to consumers in the absence of legislative protection, it still allows for certain negative genetic discrimination. Under Commonwealth law, the holder of the insurance policy has a duty to disclose information which is relevant to the insurer in assessing risk (Insurance Contracts Act 1984 [Cwlth]). State and federal antidiscrimination legislation provides consumers some protection, preventing discrimination by insurance companies on the basis of a disability or impairment. However, insurers are allowed to use reasonable actuarial or statistical data (which could include genetic information) in determining risk, and are able to discriminate if assessment was based on so-called other relevant "reasonable" factors if such information is not available (Disability Discrimination Act 1992 [Cwlth], s 46). International developments include United States President Clinton's endorsement of legislation banning genetic discrimination for employment purposes in United States federal agencies, and US presidential candidate George W Bush's announcement that he will ban genetic discrimination if elected to office. By contrast, in the United Kingdom, the government has ignored the recommendations of the Human Genetics Advisory Commission and consumers' calls for protection, and the UK has become the first country in the world to allow life insurers to require results of voluntarily taken genetic tests from any potential policy holder.13,14 The Australian Federal Government has announced an inquiry with the Australian Health Ethics Committee and the Australian Law Reform Commission which will extend over two years. In the meantime, consumers deserve privacy protection and legislative safeguards against genetic discrimination. The Human Genetics Society of Australasia and the Australian Consumers' Association have suggested a moratorium on the use of predictive test results by insurers while the Government performs its inquiry.15 While I welcome the Government's belated recognition of the issue and its commitment to explore the most appropriate way to ensure genetic privacy and non-discrimination, Australian consumers remain unprotected and affected industries remain uncertain in the interim. A moratorium would provide such protection and certainty for our community. References Suzuki D. Inventing the future: reflections on science, technology and nature. Sydney: Allen & Unwin, 1990: 55-78. Boyle P. Genetic services, social context, and public priorities. In: Aronowitz S, Martinsons B, Menser M. Techno science and cyber culture. London: Routledge, 1996: 206. Human genome project information. <http://www.ornl.gov/hgmis> (accessed October 2000). National Health and Medical Research Council. Ethical aspects of human genetic testing: an information paper. Canberra: NHMRC, February 2000: 24. National Pathology Accreditation Advisory Council, Retention of laboratory records and diagnostic material. Canberra. AGPS, 1998. Attorney General, Privacy Amendment (Private Sector) Bill 2000 Explanatory Memorandum: 6. Senate Legal and Constitutional Legislative Committee. Hansard. Department of Workplace Relations and Small Business. 8 September, 2000; 46. Universal Declaration on the Human Genome and Human Rights. Article 7. United Nations Educational, Scientific and Cultural Organisation, 29th Session of the General Conference, 11 November 1997. <http://unesdoc. unesco.org/images/0010/001096/109687eb.pdf> (accessed October 2000). Billings P, Kohn MA, de Cuevas M, et al. Discrimination as a consequence of genetic testing. Am J Hum Genet 1992; 50: 476-482. Lapham E, Kozma C, Weiss JO. Genetic discrimination: perspectives for consumers. Science 1996; 274: 621-624. Geller LN, Alper JS, Billings CI, et al. Individual family and societal dimensions of genetic discrimination: a case study analysis. Sci Engineer Ethics 1996; 2: 71-88. Barlow-Stuart K, Keays D. Genetic discrimination in Australia. J Law Med. In press. Highfield R. UK: News -- Insurance firms to use results of gene tests. Daily Telegraph. October 13, 2000; 13. Lee A, UK: British life insurers can use genetic tests. Straits Times. October 15, 2000. Petschler L. Access denied: genetic testing and your insurance. Australian Consumers' Association. Choice October 2000. <http://www.choice.com.au/ articles/a101713p1.htm> (accessed November 2000). Authors' details Adelaide, SA. Natasha Stott Despoja, BA, Deputy Parliamentary Leader, Australian Democrats: Senator for South Australia; Science and Consumer Affairs Spokesperson. Reprints will not be available from the author. Correspondence: Senator Natasha Stott Despoja, 212 Grenfell Street, Adelaide, SA 5000. Senator. Stott. DespojaATaph.gov.au Make a comment

Cracking the Code The Human Genome Project in the Dock Michael Kirby From a scientific viewpoint, the Human Genome Project is actually not in the dock, nor even under reasonable suspicion of wrongdoing. Overwhelmingly, it will prove of benefit to humanity. However, from legal, ethical and other societal points of view, there are many problems already being considered by bioethicists, philosophers, religious experts, lawyers and others in dialogue with scientists. MJA 2000; 173: 599-600 Manageable problems - More difficult problems - The big ones - Public debate - References - Authors' details - - More articles on Genetics I have just returned from meetings of the Ethics Committee of the Human Genome Organisation (HUGO) -- established by leading genome scientists in 1989 to promote international collaboration in the Human Genome Project (HGP)1 -- in London, and of the International Bioethics Committee (IBC) of the United Nations Educational, Scientific and Cultural Organisation (UNESCO) in Quito, Ecuador. At international meetings such as these, in national bodies, in lawmaking institutions and universities, a lot of minds are identifying the chief problems of the HGP. Some of these problems are comparatively straightforward. Others are complex and fundamental. Manageable problems Privacy and confidentiality: Patient confidentiality has long been fundamental to the healthcare professions, having its roots in rules even older than the Hippocratic Oath. However, when a disorder is the result of a genetic characteristic, is the "patient" solely the individual, or does the entire family have rights? Are there circumstances in which family members should be entitled, by law, to override an individual's desire for privacy to obtain information relevant to genetic conditions that may also affect them? Should a patient have a right not to know the genetic determinants of likely future medical problems? How do we reconcile the rights of the individual with the fact that genetic data may be very important for others, and how do we prevent discrimination based on such data? Third-party interests: The previous questions lead naturally to the legal rights of third parties. Should an employer have a right to require employees to submit to genetic testing to establish their likely future health status? If a blanket right is unacceptable, are there some kinds of employment for which such a right should exist by law? Are there other, less intrusive means for such employers to monitor relevant health conditions? And what of insurance companies, which traditionally have had to share largely unknown risks in sickness and life insurance with their clients? Now, would the use of newly available, near-perfect genetic tests not shift the scales unfairly to the insurers' advantage? Would it be feasible to deny the use of such tests, given that insurers can already require prospective clients to undergo other tests that may suggest genetic predispositions? Intellectual property: One of the key issues in genetic research is the desirability of permitting patenting of genetic sequences on the basis of their future therapeutic utility.2,3 In every country, legal rights in such research will depend on laws such as local intellectual property law, governing patents and copyrights. Such laws are usually influenced by international treaties. Opinions differ about patent protection for plant varieties and in respect of the genomes of humans and animals. One view is that the human genome is part of the common heritage of humanity -- like the open sea, outer space and the environment. Others argue that it belongs to God, and should not be subject to the profit motives of multinationals or the pretensions of passing generations. On the other hand, pharmaceutical corporations point to the costs of developing successful drugs and therapies. Such companies may not invest the large funds necessary to maximise the practical use of scientific discoveries if they are not given the advantage of temporary monopolies. All of the above questions can ultimately be answered in the traditional way. Parliaments can set up committees or refer questions to law-reform or similar bodies. Nations can consult with each other and answers will eventually be found. But beyond these problems are others which are more vexing. More difficult problems Criminal responsibility: The discovery of a genetic basis for many disorders raises the possibility of identifying genes associated with various forms of antisocial behaviour. Criminal law is normally based on the premise that it is necessary for the State to prove both that accused people acted as they did and that they had the necessary intention (mens rea) to do so. But what are the implications of discovering that an individual's actions may be caused, or profoundly influenced, by a pre-existing genetic characteristic?4 The law accommodates some genetic impairments in determining criminal responsibility. Proved and relevant impairment may be taken into account in sentencing, but will genetic discoveries present an even more profound challenge for our whole notion of criminal liability? Is it back to the drawing boards for assumptions about crime being the product of deliberate wrong-doing? Benefit-sharing: Much genetic research will be devoted to identifying the genetic characteristics that confer resistance or susceptibility to life-threatening or disabling conditions. Should a donor of genetic material that yields data useful for the development of drugs or therapies receive some share of the huge profits that may result? Or should the donation be put down to philanthropy for the benefit of humanity? Should something be paid to the donor's village, tribe or country if a sample proves valuable? How does the international community ensure that immediate research on the human genome focuses on problems like combating malaria and river blindness and not just wrinkles in the ageing rich? How can we promote distributive justice for humanity rather than selfish use of the HGP overwhelmingly for the illnesses of patients in the wealthy countries? The big ones As if the foregoing list did not present us with enough questions to cause headaches, there are two really big dilemmas presented by the advance of the HGP. Decision-making: It is important to realise that not to do anything, legally, about the HGP is to make a decision. It is to accept that science and technology may take our societies where they will. That may be a good thing. For example, there has been a great rush to legislate and regulate reproductive cloning of the human species based on intuitive objections to the very idea. Later thoughts have suggested that we may need to give the subject more consideration before we rush into total prohibition.5 In the past, there were similar responses, at first, to AIH (artificial insemination husband), AID (artificial insemination donor), IVF (in-vitro fertilisation) and reproductive cloning. Yet, apart from a few legislators, most politicians avoid the complex issues of the genome. The international community has the IBC and HUGO has its ethics committee. However, effective, well-resourced national and international advisory bodies are thin on the ground. Getting agreement at a national level is hard enough given the competing perspectives. Securing international agreement is almost impossible. Yet, without international rules, in genomic regulation, as with nuclear fission and Internet regulation, national laws can never be fully effective. Faced with local legal prohibition, scientists may simply move their laboratories to a less troublesome country. Genetic alteration: Fundamental questions are also raised by the long term effects of genetic alteration of the human species. For example, we have identified the genes that express themselves in Huntington's disease. Should the law permit, encourage or forbid the elimination of a fetus which manifests these genes? Elimination of a fetus with likely intellectual impairment is now not uncommon, but how far do we go down that track in the quest for the "perfect" child? Should we eliminate obesity, baldness, heart disease, homosexuality (if that turns out to be, at least in part, genetic)? Not to regulate these characteristics is, effectively, to permit them all. Already, in less well developed countries, crude steps are taken to eliminate one of the most common genetic conditions of all: the female sex. Should the law step in, or should we go with the flow? When it becomes possible to eliminate particular genes and transplant others, what will prevent the attempted creation of a superspecies? Or an under-species? Or an altered human species? We must be ready with our answers to these questions. It should not be assumed that sermons, political press releases and the solemn resolutions of corporate ethics committees will have the power to prevent developments deemed undesirable by most of humanity. Public debate Unless all of the foregoing questions are debated publicly, it is probable that legal responses, when they come, will be (as they were with reproductive human cloning) peremptory, emotional, intuitive. They may not be informed by knowledge of the best specific data. It is therefore the responsibility of the scientific community to inform their fellow citizens of exactly what is happening. It is the responsibility of politicians, lawyers and ethicists to engage in the public debate and to found their decisions or recommendations on the best available scientific information. These are not questions to be answered by the headlines of tabloids or the deadlines of politics or corporations. They require careful interdisciplinary dialogue. They should involve the community. It has begun, but it is not well funded. Its dilemmas are often very complex. It is far easier for most decision-makers to switch off. The neglect of the ethical issues raised by the race to produce the atomic bomb in the Manhattan Project ultimately caught up with humanity, and the puzzles of regulating the Internet are now with us. However, there is no more profound puzzle than the future of the human species. This is why the questions I have asked are of such importance to Australia and the world. I offer no clear answers, but the realisation that the questions must be answered, and soon, is the beginning of wisdom. References The Human Genome Organisation <http://www.hugo-international.org/hugo/ mission.html> (accessed November 2000). Chalmers DRC, Otlowski MFA, Nicol D, Skene L. Current research: project on the legal and ethical aspects of genetic research in Australia. J Law Med 1995; 3: 30-35. Oman R. Legal and ethical issues in intellectual property protection of human genome research. In: Hansen HC, editor. International intellectual property law and policy. Yonkers, NY: Juris Publications, 2000. Hodgson D. Guilty mind or guilty brain? Criminal responsibility in the age of neuroscience. Aust Law J 2000; 74; 661. Stem cell research: medical progress with responsibility. A report from the Chief Medical Officer's Expert Group reviewing the potential of developments in stem cell research and cell nuclear replacement to benefit human health. Department of Health, June 2000. <http://www.doh.gov.uk/cegc/stemcellreport.pdf> (accessed November 2000). Authors' details High Court of Australia, Canberra, ACT. The Hon. Michael Kirby, AC, CMG, Justice of the High Court of Australia, and member of the International Ethics Committee of UNESCO and the Ethics Committee of the Human Genome Organisation. Reprints will not be available from the author. Correspondence: Justice M Kirby, High Court of Australia, Parkes Place, Canberra, ACT, 2600. kirbyjAThcourt.gov.au Make a comment

Michael Kirby

Cracking the Code Social consequences of manufactured longevity Riaz Hassan The signs are that advances in biomedical sciences will add more years of "manufactured time" to life expectancy in industrialised countries, resulting in unprecedented rates of survival into older ages. Increasing longevity will force economic and social changes and the 20th-century revolution in social roles looks set to continue into the 21st century. MJA 2000; 173: 601-603 Life expectancy in rich and poor countries - Economic effects of longevity - Longevity and social structure - References - Authors' details - - More articles on Genetics In 1825, a British actuary, Benjamin Gompertz, discovered a distinctive pattern in human mortality statistics. He found that the probability of dying was high at birth, and then continued declining until sexual maturity, after which it increased at an exponential rate. He and other demographers speculated that the exponential rise in the risk of death following sexual maturity was the result of a natural law of mortality.1,2Ever since, scientists have been looking for evidence of a "universal" law of mortality that applies to all living things. Now there is evidence which suggests not only that a law of mortality may exist, but that the life span of human populations may have already exceeded the limits implied by such a law -- "a product of the survival time manufactured by medical technology and lifestyles modifications".3 For much of human history, life expectancy was around 25 to 30 years. The mean human life expectancy in industrialised countries has changed from 25 years in the 18th century to 50 years in 1900, and to about 75 years now.4 Over two-thirds of the improvements in longevity in the entire world, from prehistoric times until the present, has taken place since 1900.5 These changes in human populations raise a paradox: if evolutionary theories of senescence are correct and survival into the post-reproductive period serves no useful purpose, why is the human life span so much greater than the age when reproduction ceases?3 If, however, senescence is in fact the product of evolutionary neglect rather than evolutionary intent, then there is good reason to be optimistic that the process is modifiable, either through direct manipulation of crucial genes or, more indirectly, by controlling or manipulating the products of gene expression. Both of these interventions are a major focus of current biomedical research, boosted by the Human Genome Project. There may be a price to pay when only the progression or expression of senescent disease is modified. Such interventions may simply shift the burden of senescence to other forms of lethal or debilitating senescent diseases.3 Life expectancy in rich and poor countries The distribution of the "manufactured time" being added to human life expectancy as a result of advances in biomedical sciences is highly skewed in favour of industrialised countries. In poor countries, most deaths occur in the young, and result from infectious and parasitic diseases, wars and starvation.4 In rich countries, most deaths occur as a result of the diseases of old age, such as cancer, strokes and heart disease.4,6 The populations of the rich countries will be the major beneficiaries of the new biomedical advances. Overpopulation will once again become the concern of the wealthy countries, rather than just the poor countries with high fertility rates.4,7,8 Economic effects of longevity In the first half of the 20th century, when mortality began to fall, survival rates improved not only at the oldest ages but also in childhood and during the working years. Under these circumstances mortality decline is less costly for the State as it does not require major public welfare transfers. Greater mortality decline in the early years of life substantially increases the labour force, which helps to pay the aged pension costs and healthcare of the elderly. In the second half of the century, mortality decline slowed in the working ages, and accelerated in older ages. This is the pattern which now characterises the industrial countries.9 This change (which may be further boosted by the Human Genome Project) is likely to have major economic implications for the industrialised countries and will change their economies drastically over the next three to five decades. For example, in Australia, if present trends continue, the proportion of people aged from 20 to 39 years will increase by only 2% between 2001 and 2051. In the same period, proportions of populations aged 60 to 79 years and 80 and over will increase by 122% and 307%, respectively. By 2051, one in three Australians will be aged 60 and over. Never before have such proportions been reached in large human populations.10 The developed countries will have difficulty meeting the costs of supporting an increasingly larger proportion of elderly. Under these conditions, according to a World Bank study of the macroeconomic effects of aging populations, the industrial economies should see higher aggregate consumption relative to income and higher real interest rates.11 To avoid a fall in people's standards of living, economic productivity would need to be increased, and new tax policies would be needed to aid the process of capital formation. If the tax rates remain unchanged, government debt will increase substantially, resulting in higher real interest rates. Under these conditions, the real gross national product per capita in most industrialised countries will decline significantly.11,12 Healthcare costs will be increased by the addition of more years of life in the older age groups. Some healthcare workers argue that healthcare for the elderly places an unsustainable economic burden on national budgets, and one method of control would be rationing healthcare for older people, and even denying it to those who are 80 years of age or older. These arguments are supported by data from the United States -- 28% of Medicare bills are paid to only 6% of those Medicare-eligible, who die within a year.13 An intriguing aspect of healthcare spending in industrialised countries is that, in general, healthcare costs as a percentage of gross domestic product (GDP) appear not to be associated with population aging. Spending on healthcare is highest in the US, constituting about 14% of its GDP. However, the US has the lowest percentage of elderly (12.6%) people among the 12 most industrialised countries. In comparison, Sweden, with 17.8% of the population older than 65 years, spends 7.5% of its GDP on healthcare. Furthermore, healthcare spending does not necessarily rise with an increase in the percentage of elderly persons in the population. In Japan, the elderly population increased by more than 30% between 1980 and 1990, yet only a 1.6% increase in the proportion of its GDP during this period went to healthcare. In the US, where the proportion of those aged 65 and older increased by about 10% in the same period, healthcare spending went up by 31.5%.4,13 This means that more egalitarian industrialised countries like Sweden and Japan have not only longer life expectancies compared with the less egalitarian countries like the United States, but they are also more likely to be successful in coping with further increases in life expectancy in the future. The problems of high costs of healthcare arising from longer life expectancies are likely to be serious public issues in countries with greater social and economic inequalities. In this respect Australia is well situated to cope with the economic and social costs of increasing longevity of its population.4 Longevity and social structure As human life expectancy began to increase in the 20th century, it also began a revolution in shaping social roles at different stages of life-cycle. Life course began to become age-graded and differentiated. One consequence was the reduction in labour force participation among both the old and the young. The trend has been towards concentration of education in youth, work in early to middle adult years, and recreation in the post-retirement years. Human society became increasingly age-segregated. Although this had had many beneficial effects, such as expansion of education, greater economic productivity and innovation, it has also transformed industrial societies into rigidly age-segregated societies. The social patterns of modern life are now testing the usefulness of this structure of life course.14-16In countries like Australia, growing numbers of elderly people are rejecting the age constraints on paid work and biases against active participation of older people in society. Similarly, many young people are seeking "adult" roles in work, family and entertainment. These changes are increasing pressures for the development of age-integrated social structures. Unlike age-segregated structures, age-integrated structures do not use chronological age as a criterion for entrance, exit or participation. Sociologists have proposed an alternative model of life course that would allow learning, work and leisure to be integrated in the lives of individuals throughout the entire life course (Box).17 This life-course model is much more suited to the conditions of our society, which is adding more "manufactured time" to human life, producing unprecedented longevity. The evidence from Australian universities' enrolment statistics shows that education is becoming increasingly age-integrated and is now widely defined as "life-long". Barriers to work are also being relaxed, as evidenced by the increasing proportion of high school and university students who are in paid work. There is growing evidence that repudiates widely held beliefs about the inevitable and universal intellectual decline with aging, and ways to prevent the decline that does occur are being suggested.18,19 The most visible challenge to the age-segregated life course has come from women. Women have introduced a number of innovations which have made their life course flexible and age-integrated. Increasing proportions of women are combining work, education and family. If this transformation in sex-role attitudes and behaviours continues, it will affect every facet of modern life. Many middle-aged women today are performing more roles than men and will reach old age with greater role flexibility.19 An age-integrated society, with its accompanying cross-age interaction and flexible life course, will be conducive to promoting deeper understanding among people and reduce intergenerational conflict. It may lead to the development of more civil society. New social values will evolve when people from different age groups get accustomed to sharing work and family responsibilities, leisure time and cultural pursuits. These values may produce a greater sense of connectedness in the community and thus reduce loneliness, excessive individualism and materialism. Utopia may or may not result, but, of all the available futures, this appears the most promising for all ages. Whether we fear it or welcome it, this manufactured longevity will change our lives and human culture pervasively. References Gompertz B. On the nature of the function expressive of the law of human mortality and on a new mode of determining life contingencies. Philos Trans R Soc Lond 1825; 115: 513-585. Carnes BA, Olshansky SJ, Grahn D. Continuing the search for a law of mortality. Popul Dev Rev 1996; 22: 221-264. Olshansky SJ, Carnes BA, Grahn D. Confronting the boundaries of human longevity. Am Scientist 1998; 86: 52-61. Fossil M. Reversing human aging: it's time to consider the consequences. Futurist 1997; 31: 25-28. Preston SH. Mortality patterns in national populations. New York: Academic Press, 1976. Najman JM. The demography of death: Patterns of Australian Mortality. In: Kellehear A, editor. Death and dying in Australia. Melbourne: Oxford University Press, 2000. Roush W. Live long and prosper. Science 1996; 273: 42-46. Wilmoth JR. The future of human longevity: a demographer's perspective. Science 1998; 280: 395-397. Lee R. Long-term population projections and the US social security system. Popul Dev Rev 2000; 26: 137-143. Australian Bureau of Statistics. Australian demographic statistics. Canberra: ABS, 1999. (Catalogue no. 3101.0.) Mason PR. Long-term macroeconomic effects of aging. Finance Dev 1990; 27: 6-9. Mason PR, Tryon RW. Macroeconomic effects of projected populations aging in industrial countries. IMF Working Paper WP/90/5. Washington DC, 1990. Marwick C. Longevity requires policy revolution. JAMA 1995; 273: 1319-1320. Uhlenberg P. Introduction: why study age integration? Gerontologist 2000; 40: 261-265. Kohli MR. Social organization and subjective construction of the life-course. In: Sorensen AB, Weiner FE, Sherrod LR, editors. Human Development and the life cycle. Hiilsdale NJ: Erlbaum, 1988. Riley MW, Foner A, Riley JW. The aging and society paradigm. In: Bergtson VL, Schaie KW, editors. Handbook of theories of aging. New York: Springer, 1999. Riley MW, Riley JW Jr. Age integration: conceptual and historical background. Gerontologist 2000; 40: 266-270. Schaie WK, editor. Longitudinal studies of adult psychological development. New York: Guilford Press, 1983. Riley MW, Riley JW Jr. Longevity and social structure: the added years. Daedalus 1988; 115: 51-74. Authors' details Flinders University, Adelaide, SA. Riaz Hassan, PhD, FASSA, Professor, Department of Sociology. Reprints: Professor R Hassan, Department of Sociology, Flinders University, GPO Box 2100, Adelaide, SA 5001. Riaz. HassanATflinders.edu.au Make a comment Social structures Our current society is age-segregated -- we receive our education when we are young, we work until we are 60 or so, and then retire and spend our time in leisure. With increasing longevity, a better social structure would be age-integrated, in which education, work and leisure are all life-long activities. Back to text

Riaz Hassan

Forensic Medicine Shotgun suicide with a difference Initially, it appeared to be a straightforward shotgun suicide, then two more wounds were seen Peter B Herdson MJA 2000; 173: 604-605 The scene - Autopsy findings - Interpretation - Discussion - Acknowledgements - References - Authors' details - - More articles on Pathology In February 1995, a death in parkland close to residential property in Canberra was reported to the Australian Federal Police. The body of a man had been found at the edge of a steep slope, about 150 metres from his home. He was lying on his left side with his head towards the top of a ridge. There was a lot of blood on his right shoulder and an obvious injury to the lower jaw and neck. A pump-action shotgun was lying about a metre from the body with the barrel facing up the slope, and a pair of shoes lay next to the gun. The action of the gun was open and contained a fired No. 2 shot shell case which had not been ejected. The muzzle end of the barrel was bloodstained and smudged, consistent with the barrel being held by both hands. Initially, it appeared to be a straightforward shotgun suicide. When the body was turned over, however, two additional gunshot entry wounds were seen on the chest. To suicide was added the possibility of murder. The scene The police forensic team conducted a detailed search of the property (Box 1), finding a 12 gauge No. 2 shot shell cartridge on a sand pile near the rear stone wall of the property, with bloodstains on the ground nearby. Further examination of this area revealed shotgun pellet marks on the wall and some fragments of flesh. A second fired 12 gauge No. 2 shot shell cartridge case and an unfired cartridge were found on the ground close to a vehicle parked about 10 metres from the boundary of the property. A fragment of jaw with teeth and metal dental work and several bloodstains were found at this site, and a 12 gauge plastic shot shell wad was found 15 metres away. Autopsy findings The body was that of well-built, well-nourished, muscular white man of 39 years, 168 cm tall and weighing 80 kg. There was a gaping wound in the front of the neck slightly to the left of the midline, extending from the level of the lower mandible 9 cm downwards, measuring 9 cm from medial to lateral edge (Box 2A). This wound, which was consistent with a shotgun blast, showed some soot marks around part of the irregular edge; on dissection it was established that the anterior part of the larynx had been largely removed by the blast and there was blood and cartilaginous and muscular debris in the tracheobronchial tree. The carotid arteries and jugular veins were intact on both sides. The lower mandible had been fractured and some teeth were missing. On the anterior chest wall, there was an injury consistent with a shotgun blast, consisting of an entry hole about 2.5 cm towards the midline from the left nipple at about the level of the 5th rib (Box 2B). On dissection, this entry wound, which measured 2.5 x 2.3 cm and showed powder marks in a semilunar fashion on the upper rim, was found to be continuous immediately beneath the skin, outside the rib cage, with a large soft-tissue wound to the left and below the left nipple measuring about 12 x 8 cm (Box 2C). Further dissection showed that this wound had not penetrated the rib cage. Also on the anterior chest wall was another injury consistent with a shotgun blast. This wound was slightly to the left of the midline of the lower sternum, and measured about 3 x 2 cm, with powder marks in a semilunar fashion on the lower edge of the wound (Box 2D). This entry wound had a trajectory which was slightly up and to the left, and had completely blown apart the heart, leaving only shreds of cardiac muscle. There was about 800 mL of blood in the left hemithorax and 300 mL of blood in the right hemithorax, and the left lung was lacerated. A 12 gauge plastic shot shell wad and a number of No. 2 shot pellets were found in the mediastinum. There was mud over both knees and postmortem lividity and rigor mortis were present. There were no other significant external findings, and the remainder of the autopsy was unremarkable. Blood taken at the time of autopsy did not contain ethanol. Interpretation of the scene and autopsy findings The most likely chain of events in this intriguing case was as follows. The man had taken the shotgun, which measured 885 mm from muzzle to trigger, and loaded four 12 gauge No. 2 shot shell cartridges into the tubular magazine, cocked the weapon and loaded a cartridge from the magazine into the breech. He then got into a stooped position near the sand pile adjacent to the rock wall of the backyard. The butt of the shotgun was most likely resting on the ground, with the gun held to the right of the deceased and the muzzle in contact with the centre of the chest. He used the fingers or thumb of the right hand to pull the trigger. The shot charge and wad entered the subcutaneous tissues at a low angle, travelled outside the rib cage, and exited on the left side of the chest. The remainder of the shot charge, wad and particulate matter then hit the rock retaining wall. The action of the shotgun was then cycled, ejecting the shell case onto the sand pile. The man then walked to the vehicle. He loaded another cartridge from the magazine into the breech of the shotgun. Holding the shotgun to his right, with the left hand holding the barrel muzzle against his throat, he used the fingers or thumb of the right hand to pull the trigger. The shot charge and wad entered the right front side of his throat and exited on the left, taking a fragment of lower jaw with it. After this second shot was fired, the shotgun most likely fell to the ground, where the action opened and ejected the shell case onto the ground. The impact also caused an unspent cartridge to fall out onto the ground. The deceased then walked about 136 metres to the hill slope. He loaded the last cartridge from the magazine into the breech of the shotgun, then removed his shoes and lay on the ground on his left side. With the gun in front of him, he held the barrel with both hands, with the muzzle in contact with his chest. He used his toes to discharge the shotgun. The shot and wad entered the lower chest area and penetrated up into the chest cavity, demolishing the heart. The shotgun then fell to the ground, causing the action to open. The body then slid a short distance down the slope. At the coronial inquest, the Coroner and the lawyer representing the family of the deceased both attempted to replicate the man's supposed actions with the shotgun. The Coroner, some 20 cm taller than the deceased, with a longer reach, demonstrated that the barrel of the weapon was so long that, with a finger or thumb of the right hand on the trigger, the barrel could only contact the chest at an angle of about 45 degrees at best. Similarly, when the shotgun was held with its muzzle against the side of the neck, the barrel pointed forward and upward, as the right hand had to be a little to the rear of the body to press the trigger. These demonstrations explained why the first two attempts were not fatal, while the increased reach obtained by using a toe on the trigger resulted in the immediately fatal third attempt. Discussion Self-inflicted gunshot wounds are a common method of suicide, accounting for more than five per cent of all suicides in some series.1 Most of these deaths are caused by a single shot, usually directed to the chest or head. Occasionally, two shots have been fired in the suicide, either because the first shot was not immediately fatal2 or because a rapid-action weapon was used. Suicides involving three shots are very rare, although a fascinating report was presented recently concerning the death of a prisoner in the Tower of London in 1585. In that case, three balls were fired by the deceased into his chest from a pistol.3 This report describes a suicide in which death by gunshot was achieved on the third attempt, with the deceased showing remarkable stamina following the first two attempts. He walked about 15 metres from the site of inflicting the first, relatively superficial but obviously painful wound to his chest. At a second attempt, he shot out his larynx. Then, breathing through a gunshot-induced tracheostomy, he moved about 136 metres over parkland to make a final attempt. Shotguns of this type are now banned in Australia. As suicide weapons they are far from ideal, partly because of the length of the barrel, and partly because of their significant recoil. Acknowledgements I would like to thank the Coroner, G G Dellar, and P McFawn, E M Fuderer, and R Tait, of the Australian Federal Police. References Nowers M. Gunshot suicide in the county of Avon, England. Med Sci Law 1994; 34: 95-98. Solway R. Gunshot suicides in Victoria. Australia. Med Sci Law 1991; 31: 76-80. Gee DJ. Suicide of a prisoner with multiple missiles: a case report. Med Sci Law 1996; 36: 85-90. Authors' details Canberra Clinical School, Canberra, ACT. Peter B Herdson, FRCPA, FRANZCR(Hons), Professor of Pathology, and Consultant Forensic Pathologist. Reprints: Professor P B Herdson, Consultant Forensic Pathologist, PO Box 9585, Deakin, ACT 2600. peterpathATbigpond.com Make a comment 1: A map of the property Back to text 2: The four significant wounds visible externally The gunshot-induced tracheostomy (A) is obvious. The upper round entry wound (B) was continuous with the gaping exit wound over the left chest (C). The lower round entry wound (D) was caused by the third, fatal shot. Back to text

Peter B Herdson

Forensic Medicine Homicide or suicide? A jigsaw puzzle of incinerated human remains Alanah M Buck, Clive Cooke, Peter de la Motte and Stephen Knott Between 800 and 900 skeletal fragments were recovered and reassembled MJA 2000; 173: 606-607 The scene - Recovery - Analysis of the remains - Interpretation of the scene - Acknowledgement - References - Authors' details - - More articles on Pathology While hunting feral goats, the caretaker of a disused gold mine discovered a burnt-out car about 100 m from a service road. The vehicle was in previously burnt bushland. Licence plates were still attached to the car and identified it as belonging to a missing person. An investigation of the scene by local police officers revealed a set of charred and fragmented human remains a small distance from the vehicle. The suspected victim was in his mid-thirties; he had gone missing from a nearby town about four years before. He was alleged to have been an associate of known criminals and had accrued considerable gambling debts. In view of this history and the remoteness of the location, the circumstances of the death were considered suspicious. The scene The area in which the remains were found consisted of low scrub bush with a scattering of medium-sized trees. A small creek bounded the furthest edge of the demarcated area of interest. The creek was dry during the period of investigation (January); however, the area was known to flood during winter months. The immediate area where the remains were found was clear of vegetation, but several trees were growing in the surrounding area (Box 1). A large area of interest was identified using natural boundaries (eg, the creek bed) and police conducted a systematic grid search. An examination of the scene showed a series of burnt trees in the immediate vicinity; local shire information confirmed that a bushfire had passed through the area two years before. Branches from badly incinerated tree trunks were observed to have fallen in "ring-like" patterns around the charred stumps. A number of trees had silt build-up at the base of the trunks as a result of flooding. The direction of the water flow was towards the skeletal remains along an east-west axis. The skeletal remains were found in a clear area, removed from any trees. However, a series of charred tree branches were noted in the immediate vicinity of the skeletal scatter. Considering the ring-like branch patterns found around burnt trees, it was determined that a tree had in fact been located near the remains and had burnt down below the surface of the ground. Its stump was later uncovered. Recovery The skeletal elements were severely fragmented and scattered around an area about 3 x 2 m. The severe thermal damage and scattered appearance of the remains initially suggested that the body may have been deliberately cremated and the fragments dispersed. After photographic and video recording of the area of interest, a datum point was established and the skeletal elements were mapped using an x,y coordinate system. Each fragment was assigned an x,y coordinate and assessed in situ. This information was recorded both on the collection bag and independently on a police inventory list. Fragile material was packed in padded bags and taken to the State Mortuary. A metal detector was used to locate metal objects in the area of interest. A ring, several coins and the remnants of a gas lighter were recovered at the scene. An amalgam dental filling was later detected at the mortuary after careful sifting of associated soil. Analysis of the remains Between 800 and 900 skeletal fragments were recovered and reassembled in the State Mortuary (Box 2). The fragments of bone had been subject to varying degrees of fire damage, which was reflected in the range of colours observed (Box 2). Fewer than half the fragments could be placed back into their anatomical position. Portions of the right pelvic bone (including sciatic notch), left and right distal ends of the femora, the left clavicle and much of the left humerus were identifiable. The cranium was so fragmented that only 3-4 main regions could be identified -- these appeared to be male. Several teeth were also recovered; however, they were fractured as a result of extreme heat damage (Box 3). To determine the original position of the body on the ground, the location of the major fragments was plotted on an x,y graph in anatomical groupings. The distribution of the skeletal elements appeared to be random. Interpretation of the scene It appeared that the body had been initially cremated while it retained some or all of the soft tissue elements. This was confirmed by the type of intense fire damage sustained, similar to that seen in motor vehicle incinerations. This type of damage usually occurs in the presence of fat. The body appeared to have been originally in association with a large tree, which had burnt to the ground. The presence of the tree would also have added to the intensity and duration of the fire. An accelerant may have been used, although no evidence of this was found. This scenario would have accounted for the extreme calcination and fragmentation of the skeleton. After incineration, the remains became scattered over the ground and probably experienced a second scorching (at much reduced temperatures) by a scrub fire, hence the wide range of colour changes on the bones. Local flooding appears to have washed the remains along a narrow channel (along an east-west axis), causing the skeletal elements to be scattered indiscriminately out of anatomical context. Dental identification was difficult, as almost all records of the suspected victim had been disposed of owing to the long period (eight years) since his last dental visit. Fortuitously, the only remaining dental radiograph contained an image of the amalgam filling recovered from the scene (Box 4). Thus, a positive identification was made. Owing to the lack of sufficient and conclusive evidence regarding the cause of death, the Coroner returned an open verdict. Acknowledgement We would like to thank the Western Australian Coroner's Office. References Shipman P, Foster G, Schoeninger M. Burnt bones and teeth; an experimental study of color morphology, crystal structure and shrinkage. J Arch Sci 1984; 11: 307-325. White T. Prehistoric cannibalism. Princeton, New Jersey: Princeton University Press; 1992. Authors' details Department of Forensic Pathology, WA Centre for Pathology and Medical Research (PathCentre), Perth, WA. Alanah M Buck, PhD, Forensic Anthropologist; Clive Cooke, BMedSci, FRCPA, Chief Forensic Pathologist; Stephen Knott, BDSc, DipForensicOdont, Forensic Dentist. Major Crime Division, Western Australian Police Service, Perth, WA. Peter de la Motte, Detective Sergeant. Reprints will not be available from the authors. Correspondence: Dr A M Buck, Department of Forensic Pathology, WA Centre for Pathology and Medical Research, Locked Bag 2009, Nedlands, WA 6009. Alanah. BuckAThealth.wa.gov.au Make a comment 1: The location of the remains, in the centre of the photograph, and the surrounding area Back to text 2: Reconstruction of the remains in the mortuary The inset shows an example of the colour variation in bone brought about by differing temperatures. Bone passes through a series of colours in accord with temperature.1 Examples of calcination, which occurs at high temperatures (600ºC-700ºC)2 and exfoliation of bone surfaces indicate that portions of the body were subjected to very high temperatures. Other sections of the bone were black-brown in colour, indicating that it burnt at a much lower temperature. Back to text 3: Fragmented remains of the teeth, with the amalgam filling at the bottom right of the picture Back to text 4: Dental identification of the body The dental x-ray of the missing man's jaw complete with filling. The amalgam filling recovered from the scene. Small changes on the occlusal surface of the filling are due to wear over the eight-year period. Back to text

Alanah M Buck · Clive Cooke · Stephen Knott

The Research Enterprise General practice research in Australia, 1980-1999 Alison M Ward, Derrick G Lopez and Max Kamien MJA 2000; 173: 608-611 For editorial comment, see Van Der Weyden Abstract - Methods - Results - Summary and conclusions - Acknowledgements - References - Authors' details - - More articles on General practice and primary care Abstract There has been a nearly fivefold increase in the amount of Australian general practice research published in 1990-1999 compared with the previous decade. The university departments of general practice and other university departments have been responsible for most of the research. GPs were involved in at least 60% of all of the research reviewed. Half of the research was found to be clinically pertinent to the front-line GP. The National Health Priority areas, introduced in 1994, were poorly represented, but it is probably too soon for this research to be published. There has also been little research on rural general practice. This review provides a starting point for classifying general practice and primary healthcare research in the future. In Australia, the general practice research effort, begun by a few enthusiastic general practitioners (GPs) in the early 1970s, now extends to academic programs involving GPs and social scientists with an interest in general practice. The inception of academic departments of general practice resulted in a gradual professionalisation and an increase in research.1In 1991-92 the research effort received an extra boost through the General Practice Evaluation Program (GPEP) of the Commonwealth Department of Health, which aimed to develop data on the dynamics of general practice in Australia and to improve standards and quality assurance. In April this year, the Department announced a new funding initiative -- a national strategy for Primary Health Care Research, Evaluation and Development.2 In the light of these developments, we reviewed and analysed Australian general practice research published in the past 20 years to provide a baseline for future research initiatives. Methods Data sources We conducted literature searches in March and April 2000 to identify all Australian articles relating to general practice research published since 1980. Letters and editorials were excluded. The search strategies, search terms and outcomes are shown in Box 1. Study selection We restricted the review to the two decades 1980-1989 and 1990-1999; and We used a similar definition of general practice research to that used by Starfield for primary care research; that is, even if the problem being examined is a problem seen in general practice, it is not necessarily general practice research unless the context of the research is general practice.3We identified general practice research published in the past two decades by scanning the abstracts of the 2242 articles retrieved by our search (those articles without abstracts [about 28%] were viewed in full). Scanning identified 663 general practice research articles. The remainder were discussion papers, or not general practice research. Classification categories We classified each article and the research reported according to nine variables: Country of publication; Journal; Affiliation of authors: Determining affiliation was complicated by the name changes of departments of general practice. We compiled lists of department names and of academic GPs to help identify who was doing the research. Type of research: Searches of the Australian and overseas literature failed to find a comprehensive classification system for type of general practice research.3,4-6 We extended the classification categories used by the National Information Service (NIS) for the GPEP grants, giving 13 categories of general practice research. Research methodology: The research methods used were difficult to classify.7,8 The usual method categories for public health research do not include some methods used in general practice. We used the public health categories (see Box 6) as a starting point and expanded on these. International Classification of Primary Care (ICPC);9 National Health Priority areas; 10,11 Rural health; Other areas of concern (eg, Aboriginal or Torres Strait Islanders; aged or adolescent populations). Data analysis One of us (A M W) coded all articles and trained a research officer to check the coding. A test-retest reliability check on 41 articles showed an average reliability across the classification variables of 92% (98% for affiliation, 83% for type of research, 83% for methodology, 95% for ICPC category, 98% for National Health Priority areas, 98% for areas of concern, 90% for rural research). The classified data were analysed using SPSS.12 Results Number and location of publications (Boxes 2 and 3) Publications of Australian general practice research increased markedly in the second decade, with 82% published since 1990. As expected, most were published in Australia, but the proportion published overseas has increased from 17.1% in 1980-1989 to 31.7% in 1990-1999, with a marked increase in publications in England in the second decade. Over half of the research has been published in two journals -- Australian Family Physician (31%) and The Medical Journal of Australia (21%). The proportion published in Australian Family Physician almost halved in the second decade, with publications increasing across a range of other journals. Authors and affiliation (Box 4) The States with two or more universities with departments of general practice produced most research, with the amount from New South Wales (37%) being more than double that from any other State. Victoria was second with 18%, followed by Queensland (12%) and South Australia (12%). Universities were responsible for 58% of the research, with hospitals accounting for 12% and the Royal Australian College of General Practitioners (RACGP) 7%. The "other" category included health departments, and the Divisions of General Practice (the latter published less than 1%). The number of articles without a recorded affiliation decreased over the decades (the "institution" field was added to MEDLINE in 1988), but, as many of the early articles had no abstracts and were viewed in full, we were often able to identify the first author's affiliation. The contribution made by GPs to research not conducted in general practice academic departments was assessed by searching for GPs among the co-authors; 39% of the research in other academic departments had GPs as co-authors. We also found that 36% of the research conducted in hospitals and other organisations (eg, health departments) had GPs as co-authors. Overall, GPs were involved as authors in at least 64% of all research in general practice. This has implications for discussions about research conducted by GPs as opposed to research conducted on GPs. Type of research (Box 5) Twenty-seven per cent of research was in the category "GP behaviour, views and opinions". This includes screening, health prevention and promotion, prescribing, counselling and many other general practice activities. The number of GP behaviour studies increased in the second decade. Next most common was studies into education and training -- both undergraduate and postgraduate training. The "encounter" category included studies such as the Australian Morbidity and Treatment Survey (AMTS), clinical epidemiology studies, clinical presentation studies and Health Insurance Commission (HIC) data analyses. Very little research was found in workforce, finance or evidence-based medicine. The "other" category included studies evaluating national health promotion campaigns, and studies that could not be classified elsewhere. Methodologies used (Box 6) Two-thirds of the research was observational, nearly a quarter involved some form of intervention, and little qualitative research was published. There was an increase in both interventional and observational studies over the decades. Forty-one per cent of the studies were purely descriptive, many of these being surveys of GPs' views. Only 5% were randomised controlled trials. Many of the evaluation studies were evaluations of educational or training programs for GPs. Research topics (Box 7) ICPC categories: The psychological category was the most frequently studied (13%); over a quarter of these studies were on smoking behaviour. Most of the "female genital" studies were cervical or breast screening studies and 62% of the "respiratory" studies were on asthma. In over half of the studies, no specific ICPC category applied; 22% of these were education and training studies. However, at least half the research topics focused on a clinical area, indicating their pertinence for practising GPs. The main differences between the two decades were increases in cervical, breast and skin cancer studies, and in respiratory studies. National Health Priority (NHP) areas: Nearly two-thirds of the research did not focus on NHP areas. Research into cancer control accounted for 15%, and the proportion doubled over the two decades, followed by mental health (10%). Studies on asthma, cardiovascular disease and diabetes combined accounted for less than 10% of all the research. Other areas of concern: Only 5% of studies dealt with Aboriginal and Torres Strait Islanders, and aged or adolescent populations. Rural research: We found very little research on rural populations. The amount of rural research has remained constant (16%) over these two decades. The bulk is conducted by academic departments (56%), followed by hospitals (14%) and the RACGP (6%). Summary and conclusions This is the first rigorous review of general practice research in Australia. It has demonstrated a marked increase in the amount of research conducted in the past decade. The university departments of general practice have been responsible for most of the research, and GPs were involved in at least 60% of all of the publications reviewed. Half of all the research was found to be clinically pertinent to the front-line GP. The National Health Priority areas were poorly covered in the reviewed articles, but, as these were only formulated in 1994, there has been insufficient time to conduct the research and get it published. There has also been little research in rural general practice; most was conducted by university departments, although not always the general practice departments. The paucity of research on rural populations may be due partly to the fact that many rural studies were not focused specifically on general practice and not listed under "Family practice" in MEDLINE. In addition, the Australian Journal of Rural Health was not indexed in MEDLINE until 1995, which may account for the small number of general practice publications identified in this journal. The limitations of our review are that only one database was searched (MEDLINE) and several journals relevant to general practice research (eg, Education for General Practice) are not indexed in MEDLINE. By checking the curricula vitae of three prominent researchers in Australian general practice, we know that we missed some publications. This is because of inconsistencies in department names in the institution field and omission of the terms "family practice" or "physicians, family" in the medical subject headings (MeSH) field. We encountered difficulties in developing a comprehensive classification system for type of general practice research. We wanted the codes to be useful to both policy makers and providers, but the final categories were still broad. We will continue to refine this coding system in the future. This review did not examine quality of the research, an area which has presented problems for previous researchers.8 However, the proportion of randomised controlled trials was small, mirroring the findings of a review of general practice research in the United Kingdom in the mid-1990s.5 The 11 university departments of general practice in Australia are relatively small, with an average of three full-time equivalent core academic positions each. Most staff have large teaching loads and little time to pursue research activities. The marked increase in research being conducted by these departments over the last decade shows a commitment to research, despite the problems of finding time and adequately trained staff. To further encourage a research culture in general practice in Australia, the General Practice Strategy Review made several recommendations in 1998, including strengthening the research environment in academic departments of general practice, developing and supporting multidisciplinary career pathways in general practice research, and involving consumers and Divisions of General Practice.13 The success of the recently announced national strategy for Primary Health Care Research, Evaluation and Development1 in implementing the recommendations of the General Practice Strategy Review will, in part, be demonstrated by an increase in the quality, quantity and relevance of general practice research in Australia over the next decade. This overview of general practice research takes stock of where we are now and provides a starting point for classifying general practice and primary healthcare research in the future. Acknowledgements We would like to thank Sandra Pullman, of the University of Western Australia medical library, for performing the literature searches. References Lawson KA, Chew M, Van Der Weyden MB. The rise and rise of academic general practice in Australia. Med J Aust 1999; 171: 643-648. General Practice Branch, Department of Health and Aged Care. General practice in Australia: 2000. Canberra: The Department, May 2000: p 377. Starfield B. A framework for primary care research. J Fam Pract 1996; 42: 181-185. Silagy CA, Schattner P, Baxter RG. Current status of general practice research in Australia. Med J Aust 1992; 157: 108-113. Thomas T, Fahey T, Somerset M. The content and methodology of research papers published in three United Kingdom primary care journals. Br J Gen Pract 1998; 48: 1229-1232. Jones R. Primary care research: ends and means. Fam Pract 2000; 17: 1-4. Dawson-Saunders B, Trapp RG. Basic and clinical biostatistics. Connecticut: Appleton & Lange, 1990. Meijman FJ, de Melker RA. The extent of inter- and intrareviewer agreement on the classification and assessment of designs of single-practice research. Fam Pract 1995; 12: 93-97. Lamberts H, Wood M, editors. International classification of primary care. New York: Oxford University Press; 1989. National Health Priorities. In: Wood T, editor. Australia's health 1998. The sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare, 1998: 75. Better Health Outcomes for Australians. Canberra: AGPS; 1994. SPSS [computer program], version 8.0. Chicago, Ill: SPSS Inc, 1997. General Practice Strategy Review Group. General practice, changing the future through partnerships. Department of Health and Family Services. Canberra: The Department, 1998. (Received 27 Sep, accepted 9 Nov, 2000) Authors' details Department of General Practice, University of Western Australia, Perth, WA. Alison M Ward, BPsych, PhD, Senior Research Fellow. Derrick G Lopez, BSc, MMedSci, Research Officer. Max Kamien, MD, FRACGP, FRACP, Professor and Head of Department. Reprints: Dr A M Ward, Department of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010. alison.wardATuwa.edu.au Make a comment 1: Australian general practice research -- main search strategies, search terms and outcomes MEDLINE (via Ovid Technologies) 1. General practice research by Australian researchers The terms (physicians, family or family practice) in the medical subject headings (MeSH) field combined with the terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field; and 2. Research conducted by GPs regardless of the topic The terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with the names of all the academic departments of general practice ((family or general) and (physician$ or practi$)) in the institution field. Outcome 881 articles 3. General practice research published in Australia whether or not by GPs The terms (physicians, family or family practice) in the text field combined with (australia$) in the country-of-publication field. Outcome 834 articles 4. Research from departments possibly missed because of name changes The terms (australia$ or tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with ((community or primary) and (health or medicine or practice)) in the institution field. Outcome 480 articles 5. Additional searches, including using additional department names in the institution field; and the names of all heads of departments of general practice, and all professors of general practice in the author field. Outcome 47 articles Australasian Medical Index (AMI) (publications not catalogued in MEDLINE) Using the terms (family practice or physicians, family) in the MeSH field, we identified a further 991 possible articles. Many of these were in non-refereed journals, were duplicates of the MEDLINE articles or were only marginally relevant to general practice research. Because their short truncated titles and abstracts made it impossible to classify the type of research being reported they were not included. We estimate this meant possibly another 100-200 references were missed. Total 2242 articles $ = wild card (ie, search finds all words beginning with the letters before the $ sign). Back to text 2: Country of publication -- number (%) of publications Country 1980-1989 (n = 117) 1990-1999 ( n = 546) Australia England United States Europe (excluding England) Canada Unknown 97 (82.9%) 16 (13.7%) 3 (2.6%) 1 (0.9%) 0 0 373 (68.3%) 126 (23.1%) 35 (6.4%) 9 (1.6%) 1(1.6%) 2 (0.4%) Back to text 3: Top five journals publishing Australian general practice research -- number (%) of publications Journal 1980-1989 Journal 1990-1999 Aust Fam Physician Med J Aust Fam Pract Aust N Z J Psychiatry Community Health Stud* 59 (50.4%) 30 (25.6%) 9 (7.7%) 4 (3.4%) 2 (1.7%) Aust Fam Physician Med J Aust Aust N Z J Public Health* Fam Pract Aust J Rural Health † 145 (26.6%) 112 (20.5%) 44 (8.1%) 36 (6.6%) 21 (3.8%) * Community Health Stud became Aust N Z J Public Health in 1996. †Not indexed in MEDLINE until 1995. Back to text 4: Affiliation of first author -- number (%) of publications Afiliation 1980-1989 (n = 117) 1990-1999 (n = 546) University department of general practice Other university departments Other (eg, health department) Hospital RACGP Unknown 35 (29.9%) 17 (14.5%) 19 (16.2%) 12 (10.3%) 6 (5.1%) 28 (23.9%) 205 (37.5%) 131 (24.0%) 89 (16.3%) 65 (11.9%) 38 (7.0%) 18 (3.3%) Back to text 5: Type of research -- number (%) of publications Type of research 1980-1989 (n = 117) 1990-1999 (n = 546) Encounter and clinical epidemiology studies GP behaviour, views, opinions Education and training Patient behaviour, views, opinions, compliance GP and patient behaviour Workforce Organisation of general practice Health services interface Research methodology Finance Ethical/legal/professional Evidence-based medicine Other 28 (23.9%) 27 (23.1%) 15 (12.8%) 15 (12.8%) 10 (8.5%) 7 (6.0%) 5 (4.3%) 4 (3.4%) 2 (1.7%) 1 (0.9%) 0 0 2 (2.6%) 66 (12.1%) 153 (2.80%) 81 (14.8%) 34 (6.2%) 62 (11.4%) 14 (2.6%) 31 (5.7%) 51 (9.3%) 20 (3.7%) 7 (1.3%) 5 (0.9%) 3 (0.5%) 19 (3.5%) Back to text 6: Methodology used -- number (%) of publications Methodology 1980-1989 (n = 117) 1990-1999 (n = 546) Intervention Evaluation of a service Randomised controlled trial Other controlled trial 15 (12.8%) 3 (2.6%) 1 (0.9%) 102 (18.7%) 28 (5.1%) 6 (1.1%) Observation Descriptive without analytical component Cross-sectional quantitative or qualitative Observational over time Cohort 46 (39.3%) 19 (16.2%) 1 (0.9%) 1 (0.9%) 224 (41.0%) 112 (20.5%) 26 (4.8%) 9 (1.6%) Reviews Systematic review Meta-analysis alone 2 (1.7%) 0 11 (0.2%) 1 (0.2%) Other None of the above 29 (24.8%) 27 (4.9%) Back to text 7: International Classification of Primary Care categories -- number (%) of publications* ICPC category 1980-1989 (n = 117) 1990-1999 (n = 546) Psychological Female genital (pap smears, mammogram) Respiratory Pregnancy, child bearing, family planning Skin Circulatory Endocrine, metabolic, nutritional Digestive General and unspecified Male gential (eg, prostate screening) No ICPC category applied 20 (17.1%) 3 (2.6%) 1 (0.9%) 5 (4.3%) 1 (0.9%) 5 (4.3%) 4 (3.4%) 2 (1.7%) 3 (2.6%) 1 (0.9%) 69 (59.0%) 65 (11.9%) 37 (6.8%) 36 (6.6%) 20 (3.7%) 22 (4.0%) 17 (3.1%) 16 (2.9%) 12 (2.2%) 8 (1.5%) 8 (1.5%) 282 (51.6%) * Categories with fewer than 1% of articles (musculoskeletal; neurological; social problems; blood-forming organs; immune mechanisms; eye; urological; ear; hearing) are not listed. 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Alison M Ward · Derrick G Lopez · Max Kamien

The Research Enterprise Exploring the unknown: the challenges of a career in biomedical research Gordon L Ada Gordon Ada reminisces on his career as a researcher and a facilitator MJA 2000; 173: 612-615 Getting started - Walter and Eliza Hall Institute, Melbourne - John Curtain School of Medical Research, Canberra - World Health Organization, Geneva - Retirement projects - The take-home message? - References - Authors' details - - More articles on Immunology and allergy The attractions of a career in research are many, but first among these is the opportunity to be involved in important discoveries, either personally or though close association with other researchers. Experimenting first with viruses and then in immunology at the Walter and Eliza Hall Institute (1948-1968) was a great start. Later, by becoming head of a world-class microbiology department at the John Curtin School of Medical Research at the Australian National University, I was able to establish an environment that spawned important discoveries in medical science. Getting started I had a happy childhood. I was the fourth in a family of six children -- three boys and three girls. My father studied electrical engineering at Sydney University and later became a senior executive with the New South Wales Railways, but my mother had to leave school early when her mother died. When I entered Sydney University in 1940, my aim was to study biochemistry, having received a fascinating book the previous Christmas -- The science of life, by H G Wells, Julian S Huxley and G P Wells. My years at university might not have been so enjoyable if Jack Still had not returned to Sydney University in 1941 from Gowland Hopkins' Biochemistry Department at Cambridge. He enthused us with stories about the exciting research being done there. My first research position at the Commonwealth Serum Laboratories (CSL) (1944-1946), studying ways of stabilising human serum and avoiding denaturation, convinced me of the need for new techniques to isolate and study individual proteins. I applied for leave from CSL to work at the National Institute of Medical Research in London, where moving-boundary electrophoresis and ultracentrifugation were being used for this purpose. This request, although supported by the Director of CSL, Frederick G Morgan, was refused at a higher level, so I resigned, travelled to England, and worked unpaid at the Institute with Arthur S McFarlane, Head of the Biophysics Department. After a few months, McFarlane recommended my paid appointment to the research staff. Walter and Eliza Hall Institute, Melbourne In the early 1940s, Macfarlane Burnet, Director of the Walter and Eliza Hall Institute (WEHI), on a visit to Harvard University to give the Dunham Lectures, saw the need for his institute to gain these new techniques for studying proteins. He obtained a government grant of £20 000 to establish the technologies (including, later, electron microscopy) at the WEHI. As there was no expertise in Australia, Burnet invited me to join the staff at the WEHI and, with the senior biochemist, Henry Holden, to set up moving-boundary electrophoresis and ultracentrifugation. I arrived back in Australia in August 1948. Fortunately, Holden did much of the establishing and I was able to spend most of my time on research. I became a virologist, working mainly with influenza and later Murray Valley encephalitis viruses, studying their composition and biological properties. I crystallised the Vibrio cholerae neuraminidase. In 1957, after publication of his clonal selection theory,1 Burnet decided to phase out virology in favour of immunology at the Institute. In 1962, I decided to make the switch and, after much reading, began studying immune responses, in particular the fate of tiny amounts of antigen (using the highly immunogenic Salmonella flagella and flagellin labelled with radioactive iodine) to establish the nature and location of cells which bind antigen. Because of my general ignorance of this field, I asked Gus Nossal, then the Deputy Director (Immunology) at the Institute, to help me get started. He kindly agreed, but, when the first autoradiographs showing localisation of antigen over rat primary lymphoid follicles (Box 1) were so striking, Gus decided to collaborate full-time. When presented at a meeting in the United States, our findings ranked a column in the New York Times. The next six years studying the fate and role of antigen during primary and secondary immune responses were like a taste of researcher's heaven, and Gus was a great colleague. We studied the role of antibody in antigen localisation and demonstrated the absence of antigen in antibody-forming cells. Burnet later wrote: What I can be certain about however, is the immense importance of the work on the cellular localisation of antigen led by Ada and Nossal in the 1962-5 period.2 All these findings, together with studies on the influence of antigen structure on immunogenicity with a new PhD student, Chris Parish, were published individually and then finally woven into a monograph.3 John Curtain School of Medical Research, Canberra Despite the attractions of working at WEHI, an invitation to head a department with an international reputation in virology was too exciting to refuse, and in 1968 I succeeded Frank Fenner as Head of the Department of Microbiology at the John Curtin School of Medical Research. Although much was known about the humoral response to viral infections, knowledge about cell-mediated immune responses was almost non-existent. I reasoned that research projects combining both virological and immunological approaches, supported by basic research in both these fields, would surely lead to some exciting findings. This turned out to be the case. For example: In 1972 Chris Parish was the first to show the inverse relationship between antibody and cell-mediated immune responses, which led others to describe two classes of helper T cells. Bruce Stillman's studies on adenovirus in 1978 started him on the road to becoming Director of the renowned Cold Spring Harbor Laboratories in New York State. Robert Blanden was to lay the foundations for a major finding. Our department was acknowledged as a world leader in poxvirus research,4 and Blanden was studying the immune response to ectromelia, a poxvirus pathogenic for mice. In the next few years, using technology for assaying the newly discovered cytotoxic T cells gleaned from overseas meetings, Blanden, in late 1972, became the first to show that cytotoxic T cells would kill cells infected with ectromelia virus. But how did these cells recognise virus-infected cells? Early indications were that major histocompatibility (MHC) antigens were involved in some way, so some inbred mouse strains (members of the same strain having identical MHC antigen specificities) were imported to facilitate further studies. Peter Doherty came to the department as a postdoctoral fellow in 1972, and started work on lymphocytic choriomeningitis (LCM) virus infections of mice. In early 1973, Rolf Zinkernagel, a Swiss medical graduate, worked for a while with Blanden to learn about assaying cytotoxic T cell activity. I then asked Doherty and Zinkernagel to share the same laboratory, as they clearly had similar research interests. In some very elegant experiments, they found that cytotoxic T cells formed during an LCM viral infection would only lyse infected target cells if effector and target cells shared at least some MHC antigen specificities (ie, the T cell lytic activity was "MHC restricted"). They suggested that the cytotoxic T cell receptor recognised at the infected cell surface some virus-induced alteration of the MHC molecule, possibly caused by complexing with a viral antigen.5 They proposed the fundamental concept -- that a central function of MHC antigens on cells was to signal changes in "self", to what they now called "altered self", to the immune system.6 Once identified, such a cell would be lysed. This finding stimulated much research both in the department and elsewhere, and studies investigating the details of MHC restriction of T cell responses became a leading immunological topic internationally. Needless to say, Zinkernagel was awarded a PhD scholarship and graduated in record time. Both he and Doherty left to work overseas in the mid-1970s. Subsequently, analysis of crystals of MHC molecules, isolated from the surface of infected cells by US researchers, showed a viral peptide occupying a cleft in the MHC molecule so that parts of each were recognised by the cytotoxic lymphocyte receptor (Box 2). The award of the 1996 Nobel Prize in Physiology or Medicine to Rolf Zinkernagel and Peter Doherty (Box 3) recognised the importance of their original discovery, as it was the first description of the molecular mechanism used by vertebrates for the control and clearance of most intracellular infectious agents, especially viruses. World Health Organization, Geneva For 20 years, from 1971, I became associated with different World Health Organization programs, concerned mostly with the development and use of vaccines (Box 4). I was the first Chairman of the Programme for Vaccine Development (1984-1989), which is now a much larger WHO program with Gus Nossal as Chairman. These experiences focused my own research towards defining the roles of different components of the immune response to viral infections. Retirement projects As I approached retirement (December 1987), I was invited to do a six-month consultancy at WHO (to plan for a major review of studies on developing a vaccine to control pregnancy in women), to spend my retirement at Johns Hopkins School of Hygiene and Public Health in Baltimore, and to give the plenary lecture on The prospects for HIV vaccines at the Fourth International AIDS Congress in Stockholm in May 1988. I had never worked with HIV, but the Swedes apparently wanted an "independent" opinion. Stockholm By 1986, HIV RNA had been largely sequenced, and there was great optimism that a vaccine could be developed quickly. However, in the next two years, several disturbing findings were made, especially the very great sequence variation of the envelope antigen in different HIV isolates. There are three desirable properties of an infectious agent which can facilitate vaccine development (Box 5). At the Stockholm lecture,7 I listed seven reasons why it would be very difficult to develop an HIV vaccine based primarily on strong infectivity-neutralising antibody formation (Box 5). I then drew on recent research by two of my colleagues, David Boyle and Ian Ramshaw, at the John Curtin School of Medical Research. They had shown that DNA, coding for antigens of other infectious agents and of cytokines, could be inserted into the DNA of a poxvirus, such as vaccinia virus. Vaccination with this "chimeric" virus could protect against infection by the agent which was the source of the inserted DNA. I therefore suggested that, because the internal antigens of HIV (which are the source of many T cell epitopes) showed considerably less variation, a vaccine might be developed based on vaccinia virus containing the genes coding for the internal HIV antigens, gag and pol, as well as for the cytokine, interferon gamma.7 In mice, such a construct generated a strong cytotoxic T cell response; in man, this might be sufficient to better control, if not clear, an HIV infection. The 8000-strong audience was largely stunned by my assessment of the situation, although none subsequently disputed it. However, major vaccine manufacturers ignored it, determined to make an antibody-inducing subunit vaccine based on the HIV envelope antigen, a strategy driven by the success of the hepatitis B viral vaccine which contains the surface antigen of that virus. Baltimore and Washington On arrival in Baltimore in July 1988, I was warmly welcomed, made Associate Director of a new Center for AIDS Research and later became Director. In Washington, I was asked to participate in meetings and activities of the Division of AIDS (DAIDS) of the National Institute of Allergy and Infectious Disease. In 1991, after three years in the United States, my wife and I decided to return to Australia, but I was invited to continue the relationship with DAIDS and to join a new HIV Vaccine Working Group. The crunch came in 1995, when the Director of the US National Institute of Allergy and Infectious Disease refused to support a Phase III clinical trial of the then leading HIV candidate vaccine, based on the envelope antigen. Many reasons were given, but two critical ones were: Antibody from volunteers immunised with this candidate vaccine did not prevent infection by newly isolated HIV field strains; and The vaccine did not induce cytotoxic T cell formation in the volunteers. This was a major turning point in international HIV vaccine research. The National Institute of Allergy and Infectious Disease completely revamped its HIV vaccine development program, and my hectic travel schedule to and from the United States came to an end. My last task for the Working Group was to review the evidence supporting a role for cytotoxic T cells in controlling HIV infections.8 Return to Canberra In 1991, I was appointed Visiting Fellow in the (now) Division of Immunology and Cell Biology at the John Curtin School and Chairman of the HIV Vaccine Working Group, one of the committees of the National Centre in HIV Epidemiology and Clinical Research in Sydney. Ian Ramshaw had recently shown that a vaccination schedule involving priming with plasmids containing DNA coding for selected antigens, followed by boosting with chimeric fowlpox virus coding for the same antigens, gave a greatly enhanced immune response in mice. Stephen Kent (now at the University of Melbourne) and Ramshaw and their colleagues showed that Macaca nemestrina monkeys immunised in this way developed a strong cytotoxic T cell response and rapidly cleared a subsequent HIV infection.9 Any antibody induced was irrelevant. Supporting findings for this approach were later reported from the United States. Now Australia was set to develop an HIV vaccine initiative based on this vaccination technology. At a meeting of the HIV Vaccine Working Group, David Cooper, Head of the National Centre in HIV Epidemiology and Clinical Research, was elected to head an Australian HIV Vaccine Consortium. In June this year, out of 20 international applications received, the National Institute of Allergy and Infectious Disease awarded four contracts, three to US groups and the fourth to the Australian consortium ($27 million over five years) to carry out clinical trials of their vaccine formulation. It is anticipated that a strong immune capability based on cytotoxic T lymphocyte activity will greatly reduce viral titres. Thus, those infected by HIV will live longer and be much less likely to infect others. If this vaccination technology can be shown to generate strong cytotoxic lymphocyte responses in humans, it heralds a new approach to controlling other difficult infectious diseases, such as malaria, trachoma and pelvic inflammatory disease, and even pandemic influenza. The take-home message? From a career path in biochemistry, I switched to virology, then to immunology and became an enthusiastic supporter for the application of immunisation technology, not only for the more difficult infectious diseases but also for non-communicable diseases. Young researchers should jump at the chance to switch fields when exciting opportunities arise. Acknowledgement: I wish to acknowledge with gratitude the great support of my wife, Jean Ada, during my career. References Burnet FH. A modification of Jerne's theory of antibody production using the concept of clonal selection. Aust J Sci 1957: 20; 67-69. Macfarlane Burnet I. Walter and Eliza Hall Institute, 1915-65. Melbourne: Melbourne University Press, 1971. Nossal GJV, Ada GL. Antigens, lymphoid cells and the immune response. New York: Academic Press, 1971. Fenner F. Nature, nuture and my experience with smallpox eradication. Med J Aust 1999; 171: 638-641. Zinkernagel RM, Doherty PC. Restriction of in vitro cell-mediated cytotoxicity in lymphocytic choriomeningitis within a syngeneic or semi-allogeneic system. Nature 1974; 248: 701-702. Doherty PC, Zinkernagel RM. A biological role for the major histocompatibility antigens. Lancet 1975; 1: 1406-1409. Ada GL. Prospects for HIV vaccines. J Acquir Immune Defic Syndr 1988; 1: 295-303. Ada GL, McElrath MJ. Perspectives. HIV type-1 vaccine-induced cytotoxic T cell responses: potential role in vaccine efficacy. AIDS Res Hum Retoviruses 1997; 13: 243-248. Kent SJ, Zhao A, Best SJ, et al. Enhanced T-cell immunogenicity and protective efficacy of a human immunodeficiency virus type 1 vaccine regimen consisting of consecutive priming with DNA and boosting with recombinant fowlpox virus. J Virol 1998; 72: 10180-10188. Authors' details John Curtin School of Medical Research, Australian National University, Canberra, ACT. Gordon L Ada, AO, DSc, FAA, Emeritus Professor, and Visiting Fellow in the Division of Immunology and Cell Biology. Correspondence: Professor G L Ada, John Curtin School of Medical Research, P O Box 334, Canberra, ACT 2601. Make a comment 1: Antigen in the immune response Autoradiograph showing localisation of antigen over primary lymphoid follicles of rat popliteal lymph nodes, after footpad injection of Salmonella flagellin labelled with radioactive iodine. Back to text 2: The function of major histocompatibility antigens Schematic diagram of the cytotoxic T lymphocyte receptor recognition of the complex between the major histocompatibility antigen molecule and a nonapeptide derived from an infectious agent protein expressed on the surface of the infected cell. Back to text 3: At the 1996 Nobel Prize awards Evening banquet after the awarding of Nobel Prizes, Stockholm, December 1996. From left to right: Gordon Ada, Peter Doherty and Frank Fenner at the display of Nobel Prize medals and citations (photograph courtesy of Peter Pockley). Back to text 4: Involvement with World Health Organization programs 1971-1973 Member, Fellowship Selection Committee 1973-1976 Member, then Chairman (1975-1976), Scientific Council, International Agency for Research on Cancer, Lyons, France 1978-1984 Member, Scientific and Technical Advisory Committee, Tropical Diseases Research 1981-1984 Member, Global Advisory Committee on Medical (Health) Research 1984-1989 Chairman, Scientific Advisory Group of Experts, Programme for Vaccine Development. Member and later Consultant (1988), Vaccination Committee, Human Reproduction Programme 1985-1988 Member, Regional (Western Pacific) Advisory Committee on Health Research 1987-1989 Member, Research and Development Group, Expanded Programme on Immunization Back to text 5: Factors for and against the development of an effective vaccine Factors favouring the development of an effective vaccine Only one or a few strains of the infective agent exist; little or preferably no antigenic variation within a strain. Infective agent causes an acute infection; host completely recovers from a sublethal dose of the agent; agent does not persist. Agent is moderately (rather than highly) infectious. Factors militating against development of an effective vaccine (all these factors apply to HIV) Great antigenic variation; antigenic drift. Integration of viral DNA/cDNA into the host cell genome. Infection may be transmitted by cells which are latently infected. Immune enhancement: antibody can enhance infection of macrophages/monocytes if these cells are susceptible to infection. Agent infects cells in immunoprivileged sites in the host. Crucial cells of the immune system are infected, and either destroyed or their function is impaired. Failure to produce protective antibody and/or persisting cell-mediated immunity responses. Back to text

Gordon L Ada

The Research Enterprise John Kerr and apoptosis Michael G E O'Rourke and Kay A O Ellem MJA 2000; 173: 616-617 On 14 March 2000, John Foxton Ross Kerr, Emeritus Professor of Pathology at the University of Queensland, received the Paul Ehrlich and Ludwig Darmstaedter Prize for his description of apoptosis, a form of cell death. The prize, which he shared with Boston biologist Robert Horvitz, is considered to be one of the most prestigious European awards in science, second only to the Nobel Prize. John Kerr's discovery, initially called "shrinkage necrosis" but which he later renamed "apoptosis", came about in the late 1960s, when his attention was caught by a curious form of liver cell death during his studies of acute liver injury in rats. The findings of this seminal study were first published in 1965.1 Subsequently, Kerr and his co-authors (including Jeffrey Searle) described the unique morphological changes of this type of cell death, compared with those of necrosis, in a series of articles published during the 1970s and 1980s.2-4 These studies extended the range of pathological and physiological states in which apoptosis is known to occur. Further studies with other collaborators (who later included Alastair Currie and Andrew Wyllie)5 led to an increase in the understanding of the role of apoptosis in embryogenesis, spermatogenesis, cancer growth, and tissue remodelling during healing or functional regression. At first thought to be somewhat arcane as a topic, the literature on apoptosis initially grew slowly. However, recognition of the significance of this "protected" form of cell death on immune function and regulation was followed by an explosion of related publications in immunology. Biochemists now recite a mantra of enzymes involved in apoptosis, and chant a list of factors capable of modulating or regulating its expression. It has become de rigueur to adorn seminars and lectures with charts of the increasingly complex interactions which occur between signalling pathways as they are traversed by the informing reactions (which either trigger or defuse the suicidal steps leading to apoptotic cell death). The astonishing total number of publications on apoptosis is now over 35 539, including some of the world's leading scientific journals, such as Nature6-8 and Science.9-11 Apoptosis is now a growth industry, the clinical implications of which can be applied to chemotherapy, the endocrine treatment of cancer, autoimmune disease and neurodegenerative disease. This body of evidence is a tribute to the catalytic influence that John Kerr's insights have had in so many disparate disciplines and areas of biological study. These insights revealed the importance of this process as a universal microphenomenon in the macroevents of tissue and organismal function, and in disease. References Kerr JF. A histochemical study of hypertrophy and ischaemic injury of rat liver with special reference to changes in lysosomes. J Path Bact 1965; 90: 419-435. Kerr JF, Cooksley WG, Searle J, et al. The nature of piecemeal necrosis in chronic active hepatitis. Lancet 1979; 20: 827-828. Searle J, Lawson TA, Abbott PJ, et al. An electron-microscope study of the mode of cell death induced by cancer-chemotherapeutic agents in populations of proliferating normal and neoplastic cells. J Pathol 1975; 116: 129-138. Weedon D, Searle J, Kerr JF. Apoptosis. Its nature and implications for dermatopathology. Am J Dermatopathol 1979; 2: 133-144. Kerr JF, Wyllie AH, Currie AR. Apoptosis: a basic biological phenomenon with wide-ranging implications in tissue kinetics. Br J Cancer 1972; 26: 239-257. Wallach D. Apoptosis: Placing death under control. Nature 1977; 388: 123-126. Hengartner MO. Apoptosis: death cycle and Swiss army knives. Nature 1998; 391: 441-442. Martinou JC. Apoptosis: key to the mitochondrial gate. Nature 1999: 399; 411-412. Barinaga M. Apoptosis: forging a path to cell death. Science 1996; 273: 735-737. Barinaga M. Apoptosis: death by dozens of cuts. Science 1998; 280: 32-34. Brenner C, Kroener G. Apoptosis: Mitochondria -- the death cell integrators. Science 2000; 289: 1150-1151. Cotran R, Kumar V, Collins T, editors. Pathological basis of disease. 6th ed. Philadelphia: W. B Saunders, 1997: 18-24. Kerr JF, Winterford CM, Harmon BV. Apoptosis. Its significance in cancer and cancer therapy. Cancer 1994; 73: 2013-2026. Walker NI, Harmon BV, Gobe GC, et al. Patterns of cell death. Methods Achiev Exp Pathol 1988; 13: 18-32. Sandford N, Searle JW, Kerr JF. Sucessive waves of apoptosis in the rat prostate after repeated withdrawal of testosterone stimulation. Pathology 1984; 16: 406-410. Soubrane C, Mouawad R, Antoine EC, et al. A comparative study of Fas and Fas-ligand expression during melanoma progression. Br J Dermatol 2000; 143: 307-312. Andrane F, Casciola-Rosen L, Rosen A. Apoptosis in systemic lupus erthymatosus. Clinical implications. Rheum Dis Clin North Am 2000; 26: 215-227. Make a comment John Kerr (right) with Roland Koch, Prime Minister of Hesse, Germany, and Honorary Chairman of the Board of Trustees of the Paul Ehrlich Foundation, at a dinner for award recipients. 1: Other awards and lectures recognising John Kerr's achievements Keynote opening addresses at the Cold Spring Harbor, New York, Symposia, 1990. Opening lecture, The cell and molecular biology of apoptosis, at the Queensland Institute of Medical Research Cell and Molecular Biology Symposium, 1992. Opening lecture at the conference Apoptosis in AIDS, Paris, 1993. 12th Mildford D. Schultz Lecture, Harvard Medical School, Boston, 1993. Bancroft Medal (Queensland AMA), 1993. John Earnshaw Memorial Lecture, International Melanoma Conference, Brisbane, 1994. Fred W Stewart Award, Memorial Sloane-Kettering Cancer Center, New York, for contribution to cancer research, 1995. Doctor of Science honoris causa, University of Queensland, 1998. Fellowship of the Australian Academy of Science, 1998. Back to text 2: Apoptosis: programmed cell death The term "apoptosis" is derived from the Greek for "falling off" and describes a distinct form of cell death whereby cells die in a tightly regulated and morphologically uniform fashion.12 Morphologically, there is condensation of the nucleus and cytoplasm, membrane blebbing, and the formation of discrete, packaged apoptotic bodies which are phagocytosed by nearby cells, without provoking an inflammatory reaction.13 In contrast to necrosis, a degenerative process in which cells swell and lyse after irreversible tissue injury, apoptosis appears to be an active process14 which is subject to genetic regulation. Apoptosis can be triggered either from within the cell, or from outside the cell (mediated by binding of surface membrane receptors to "death activators" such as Fas-ligand and tumour necrosis factor). Electron micrograph showing apoptosis occurring spontaneously in cell culture. Note the discrete, membrane-enclosed nuclear fragments, with characteristic segregation of uniformly compacted chromatin, the crowding of well preserved cytoplasmic organelles and the marked convolution of the cellular surface, which is a prelude to conversion of the cell into a number of membrane-bound fragments or apoptotic bodies. N = nucleus, O = organelles. Apoptosis may occur in several different physiological, adaptive and pathological settings. For example, apoptosis acts as a homoeostatic mechanism for controlling cell populations, and in hormone-dependent tissue involution such as endometrial breakdown during menstruation, prostatic atrophy after castration,15 and cessation of lactation after weaning.12 Localised apoptosis plays a role in embryonic development, such as formation of interdigital clefts and involution of phylogenetic vestiges.5 In malignant tumours, apoptosis may occur spontaneously, or may increase in response to cytotoxic chemotherapy or irradiation.13 Impaired regulation of apoptosis is known to be associated with the development of various types of cancer,16 and with the pathogenesis of some autoimmune diseases such as systemic lupus erythematosus.17 Back to text

Rural Health A revolution in rural and remote Australia: bringing health education to the bush Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden A network of academic health units in rural areas may help solve the problems of rural health MJA 2000; 173: 618-624 The University Departments of Rural Health - Rural medical schools - What more is needed? - How to fix rural health? - The future - Authors' details - - More articles on Education A grand experiment is under way to improve health in the Australian bush. Poor health and access to health services are perennial problems in rural and remote Australia (Box). As one of its responses, the Federal Government, in 1996, announced a major new strategy -- the creation of academic units located in rural centres and focusing on rural and remote health. Four years later, there are seven of these University Departments of Rural Health (UDRHs), each headed by Professors or Associate Professors of Rural Health. In addition, in 1998, federal funding was announced for a prototype rural clinical school in Wagga Wagga, while, in 1999, a new medical school with a particular focus on rural, remote, Indigenous and tropical health commenced at James Cook University in Townsville. The experiment is now expanding -- the 2000 Federal Budget allocated funding for a further three UDRHs and nine rural clinical schools. We talked to the Professors of Rural Health at the UDRHs and James Cook University and to the Director of the Wagga rural clinical school to find how they are contributing to solving rural health problems and how they see the future. The University Departments of Rural Health The UDRHs were established essentially "to put bums on seats", according to several of the professors -- that is, to promote recruitment and retention of health professionals in rural and remote Australia through education, training and professional support. However, their overall mission is broader -- to reduce the health differentials between rural and non-rural communities and between Indigenous and non-Indigenous peoples -- and their activities also include research, development, facilitation and advocacy. They focus particularly on population and Indigenous health and on developing partnerships with existing healthcare providers. "The concept was to enhance the university presence and intellectual capital in rural and remote areas, while recognising and tapping into the rich experience of service providers in those areas", explained John Wakerman (Alice Springs). What are the UDRHs? Diverse origins: The UDRHs have evolved to be quite diverse in their activities and organisational arrangements, reflecting their individual histories and the needs and resources of their target regions. The first UDRHs were established in 1997 at Broken Hill and Mount Isa and have an emphasis on vocational courses and rural placements for healthcare students. At Broken Hill, the UDRH grew out of the public health oriented rural health training unit as "part of the evolution of the concept", said Head, David Lyle, becoming a department in the Faculty of Medicine at the University of Sydney. The Mount Isa Centre was established under Queensland Health and a management committee that includes representatives from rural health organisations, local health service providers and the community. It is unique in lacking a university affiliation, but will join James Cook University in 2001. The other UDRHs are the products of bids from single universities or consortia of universities and have varying mixes of activities. Common features: Despite this diversity, the UDRHs share some interesting features. Firstly, they are not shoestring operations. Most receive core Commonwealth funding of $1.5 million annually for an initial five years. Many have also been successful in obtaining external funds and grants for infrastructure. Still, there are poor cousins. The Tasmanian UDRH received less initial core funding ($500 000 annually), but this year renegotiated a new fully funded contract. The Shepparton UDRH remains the least endowed, sharing $1.5 million with the Victorian Universities Rural Health Consortium (a consortium of Ballarat, Deakin, La Trobe, Melbourne and Monash universities that aims to develop statewide responses to key rural issues). Secondly, the UDRHs are strongly multidisciplinary, both in their activities and staff. Most have between six and 12 academic staff (full-time equivalents), with many still actively recruiting. As well as medical practitioners, staff may include practitioners from a range of health professions (including nursing, allied health and pharmacy), and also experts in public health, Indigenous health, economics and the social sciences. Indeed, two of the UDRHs are headed by non-medicos. Many UDRHs also have Indigenous academics. In fact, Dennis Pashen (Mount Isa) expects that in five years 30%-50% of his UDRH's staff will be Indigenous, including the Head. Thirdly, the UDRHs are "multi-level", undertaking activities at all stages of education and practice, from promoting careers in healthcare in rural high schools (applying research showing that people from a rural background are more likely to practise in a rural area) through involvement in undergraduate and vocational training, university higher education, continuing education and professional development. The UDRHs are also collaborative. Their emphasis is on forming partnerships; they may have links with multiple universities, rural health organisations and services (eg, the Royal Flying Doctor Service and the Aboriginal Medical Service), local healthcare providers and the community. Finally, they are all based in rural centres but serve large regions with several or many subsidiary sites. Linking through information technology (IT) is therefore a high priority. For example, the Mount Isa Centre has a satellite link, four videoconferencing units and computer laboratory, with videoconferencing and Internet links in all its affiliated communities, and has negotiated with Telstra for high level connectivity to allow video transmission via the Web. A forerunner to the UDRHs that "established the model on which the UDRHs are based" was Monash Centre for Rural Health, said Head, Roger Strasser. Founded in 1992 as an initiative of Monash University and Latrobe Regional Hospital, Gippsland, it was "the first multidisciplinary, multi-level, rural health academic unit located in a rural setting". He is disappointed by the Commonwealth Government's failure to recognise the Centre through the UDRH program or core funding. What do the UDRHs do? Education: The Commonwealth's principal stated aim for the UDRHs was to promote education, training and professional support for rural and remote health workers and for city-based health workers interested in furthering their training and practising in a rural or remote setting. Some UDRHs offer courses to prepare health workers specifically for rural and remote practice. For example, both Broken Hill and Mount Isa offer courses for Indigenous health workers and nursing courses (eg, the Master of Nursing [Rural and Remote] at Broken Hill prepares nurses for the expanded role of nurse practitioner). Alice Springs offers a Master in Remote Health Practice, which is "the first multidisciplinary postgraduate course that prepares for work in remote areas", said John Wakerman, "and has streams for doctors, nurses and other health professionals". All the UDRHs are extensively involved in increasing the exposure of undergraduate healthcare students to rural and remote health, most commonly through provision of rural placements. For example, Broken Hill provides a centre for rural experience for healthcare students, at present mainly medical students. "Although we support the Sydney University medical program, we take students from anywhere -- primarily the Universities of New South Wales, Sydney, Adelaide and Newcastle", said Lyle. Placements (usually four to six weeks) "are structured to suit each university and provide experience of hospital and community-based practice and a remote health service. The competition is for people to come to us". Although medical students form the main market for placements at present, many UDRHs also provide placements for increasing numbers of other healthcare workers, including nurses, pharmacists, allied health workers and even dentists. Some UDRHs are aiming for longer programs -- Alice Springs is developing six-month placements for final-year medical students, and Tasmania a one-year integrated program in north-west Tasmania, similar to the Flinders Riverland scheme. In contrast, the WA focus is not so much on bringing students to the Centre -- the Department of General Practice at the University of Western Australia, under Professor Max Kamien, has run a very successful program of placements with rural general practitioners (GPs) for many years. Rather, the UDRH is "working with existing departments to look systematically at the rural health and Indigenous content of their curricula, assist in building and integrating it, so that placements become part of a broader educational thrust", said Ann Larson. The Tasmanian UDRH has a similar philosophy of "working with academics in medicine, nursing and pharmacy to raise the profile of rural health and contextualise it across the curriculum, rather than designing specific blocks of rural health", said Judi Walker. Nevertheless, both these UDRHs work to enhance the quality of placements, with Tasmania having set up a network of seven (soon to be 10) teaching sites around the State. These provide residential accommodation for students, as well as training and resources to allow local health professionals to be effective teachers and researchers, such as reliable information technology (IT), videoconferencing and journals. The UDRHs also contribute to vocational training for medical practitioners. The Monash Centre is particularly involved in GP and surgical registrar training and has run a regional training program for GP registrars in Gippsland since 1998. With the Commonwealth move to regionalise GP training, other UDRHs are working to develop regional GP training programs, while the Shepparton UDRH is developing a registrar training program for physicians. David Simmons explained: "A major barrier [to doctors entering rural practice] is the city focus of most training programs. That is the time when you get married, have your kids, buy your house. We want to bring doctors into rural areas at that stage", he said. Other UDRHs also support registrar and intern training programs. Interestingly, Mount Isa supervises a population health registrar working not with a public health unit but with the local Division of General Practice. In addition, the UDRHs offer university higher degrees. For example, staff at the WA UDRH supervise 16 postgraduate students, including one from the National Centre for Epidemiology and Population Health -- "the elite training ground for field epidemiology in Australia", explained Larson. She believes this is the first such rural placement. Continuing medical education (CME) and professional development are other important activities of the UDRHs. Not only do many offer seminars, lectures and other forms of CME, but they "provide the opportunity for local people to develop professionally in ways they would not have been able to in the past", said Lyle. "Now you can take on academic pursuits in Broken Hill which would have been difficult before we were here." Research: The UDRH research programs are at varying stages of development and, not surprisingly, tend to focus on rural and remote health issues, primary healthcare and public health. David Wilkinson is proud of the "strong focus on academic research" at Whyalla UDRH, "which has established posts for postgraduate fellows and a stream of publications". Major projects include an investigation of the distribution of health workers in rural Australia and a comparison of health status between rural and urban populations, in collaboration with the SA Department of Human Services. The WA UDRH is also particularly excited about its research and is recruiting for two new research positions -- an anthropologist and an epidemiologist. Research is often integrated with the other activities of the UDRHs. For example, WA "tracks rural school children and young adults thinking about tertiary education and health careers, to inform our interventions in education", explained Larson. The Tasmanian UDRH has used its research on the application of IT in healthcare to develop a strong health informatics teaching program. Research is also often related to the role of the UDRHs in health service and practitioner development. For example, the Monash Centre has a project seeking the best way to provide urgent care in towns that lack hospitals. At Alice Springs, research "focuses mainly on evaluation of remote health services and specific interventions. With a health economist on staff, this can incorporate economic analyses", explained Wakerman. Health service development: Many of the educational and research activities of the UDRHs contribute to health service development. In addition, some UDRHs have more direct involvement. For example, Whyalla takes an "aggressive approach to medical workforce issues", said Wilkinson, owning and running rural general practices around South Australia and recruiting doctors, some from overseas, into rural parts of the State. Other UDRHs also run teaching practices and after-hours services. The UDRHs are also involved in supporting public health and health-promotion programs. Several of the professors talked of "capacity building" -- providing rural and remote people with the infrastructure and resources they need to be effective, such as IT and libraries, and building links between rural practitioners. International activities: The Monash Centre has taken a lead internationally in developing rural health, said Strasser, who chairs the working party on rural practice of WONCA (World Organization of Family Doctors). "We are also currently working on the World Health Organization to develop programs that focus on rural health", he said. Rural medical schools More recent than the UDRHs are the prototype rural clinical school based in Wagga Wagga and the James Cook University medical school in Townsville. Both have been founded for similar reasons to the UDRHs -- primarily to increase the rural and remote medical workforce. The Wagga initiative is a full clinical school of the University of New South Wales and will take medical students for the final three years of their six-year medical course, as well as continuing its rural placement program. "Research shows that if you train doctors in rural environments, 60%-80% will practise in those environments, while only 20% of doctors who train in urban environments do so", explained Director, Mohamed Khadra. He also encourages students to integrate into the local community, with honorary memberships of local clubs and organisations. "I have absolutely no shame as a matchmaker", he explained, putting into practice evidence that spouse background is a major determinant of the choice of rural practice. The James Cook medical school represents another stage of evolution, having grown from a clinical school of the University of Queensland. Its aim is "to produce medical and other health practitioners who are capable of immediately working in rural and remote communities across northern Australia", said Associate Professor in Rural Health, Craig Veitch. With the creation of these new schools has come the opportunity to experiment and develop new models for medical teaching. The Wagga school has developed a new curriculum and way of delivering it -- the patient-centred longitudinal model. Students are attached not to teams or doctors, but to individual patients, whom they accompany throughout their illnesses and who provide the "trigger" for problem-based learning. As students accompany patients through their illnesses rather than doctors, this model is very sparing of doctors' time. To deliver the curriculum, the school is putting enormous effort into building an IT infrastructure connecting the region, aiming for IT facilities in the 12 most-used towns. It is also developing IT resources with text, questions, guidelines and practice cases. The James Cook school "is unique in Australia", according to Veitch, and has incorporated features from many models, including the medical schools at Newcastle, NSW, and Washington State, North Dakota and New Mexico in the United States. For example, it is discipline-based, not departmentally based. In the curriculum, the more basic medical subjects are integrated via the context of rural and remote health, Indigenous health and tropical medicine. The school has also appointed an academic to provide pastoral care and other support for Indigenous students. Both schools also undertake vocational and continuing medical education and research. Wagga is developing collaborations between local clinicians and basic scientists at Charles Sturt University. At James Cook, research is Veitch's primary responsibility. The disciplinary structure of the school fosters collaborative research, he said. For example, the school was successful in its bid for a National Breast Cancer Centre demonstration site, which he attributed at least partly to the involvement of all disciplines in formulating the proposal. What more is needed? We asked the professors what they would do with a windfall of $2 million. The most common priority was developing physical infrastructure. While most units have adequate facilities at their base and some subsidiary sites, the professors would like to provide more facilities at other sites. For example, Khadra would like an "academic structure" in Griffith to complement the buildings his school has in Wagga Wagga and has planned for Albury. This structure should include office space and student accommodation. Similarly, Strasser would like buildings in Bendigo and Mildura to house academic staff and teaching facilities. The problem of infrastructure is perhaps even more difficult in the outback. Wakerman (Alice Springs) would like to provide more physical and human infrastructure in the smaller towns, such as Tennant Creek, Katherine and Nhulunbuy, where people and organisations may be very keen to undertake academic activities but tend to miss out. Larson (Geraldton) needs some sort of satellite link to her more farflung constituents in the Pilbara and the Goldfields. In addition, facilities at the central site are not always adequate for the future: Pashen would like to extend his Centre in Mt Isa, as it has almost reached capacity and aims to double its staff over the next three years. The second most common priority was staff. Attracting and retaining experienced and skilled research staff was a priority for Lyle. Veitch would try to improve retention by offering research staff two- to three-year contracts rather than the shorter terms necessary when they are employed on research funds. A more flexible approach to staff recruitment using incentives is needed at Mt Isa, according to Pashen, who wishes "to be like the mining companies, able to pay big money to attract good staff". The need to improve the lot of rural GPs who take on teaching or research was highlighted by several professors. Walker would like to provide sabbaticals or release from clinical duties. "We expect so many rural clinicians to do things for nothing", she said. Indeed, Strasser would use extra funds to develop a new model for teaching in rural general practice, as the current system of clinical attachments has just about reached its capacity. He postulated providing rooms in general practices for students to see patients and study, IT resources and paid time for GPs to teach. More support for Indigenous and remote students was a priority for Wakerman, particularly better support networks for Indigenous students in tertiary education and research, and scholarships to allow remote practitioners to study. Wilkinson expressed the grandest dream -- to establish a rural stream in the University of Adelaide medical school that would turn current clinical training on its head. Students would undertake the bulk of their clinical training in the country and go to the city for placements. This might even be realised with the new funding for rural clinical schools. How to fix rural health? We asked the professors what advice they would give the Federal Minister for Health to tackle the rural health problems. Many felt the Minister is already on the right track with the UDRHs and rural clinical schools. However, Khadra was concerned about the fragmentation of resources in rural health education and training, particularly with the nine new rural clinical schools. "If you break up $150 million into 40 pots they are not going to achieve anything. If you put it into one pot to solve big problems in a coordinated way, then you are going to form answers." He proposed creating a "regional medical faculty" that coordinates all medical education in the bush in one centre, with IT links and with individual schools developing different parts of the curriculum. Pashen was also frustrated with the fragmentation of funding from different sources and with bureaucracy -- "just give us a block grant and performance indicators, and we'll do it for you". To tackle the shortage of health professionals in the bush at the educational level, the professors had a range of suggestions. Firstly, as students from the bush are more likely to return there after qualifying, both Veitch and Wilkinson suggested setting firmer intake quotas for students from rural and remote areas. Indeed, James Cook medical school has a funding-based requirement to take at least 25% rural and remote students. This could be applied more widely. In addition, Lyle suggested improving Indigenous communities' access to careers in healthcare. Secondly, "to have doctors in the bush, we need to train them in the bush", said Khadra. But attracting academics to deliver this education is a common problem. "The pot must be sweetened", he said, "at least in the short term until centres of excellence develop, and more research dollars must be directed to the bush". Veitch also suggested rotations of academics from the "sandstone" universities to allow cross-fertilisation. Thirdly, both Larson and Strasser suggested moving away from the fee-for-service model, which, said Strasser, "is neither sustainable in small communities nor attractive to new graduates". He proposed a contract arrangement with explicit negotiated contract periods to avoid the mismatch of expectations between communities (which tend to want doctors to stay for their entire careers) and recent medical graduates (who may want to stay only a few years). Strasser also suggested developing an alternative to the system whereby medical and other specialists drop into a town once every two to four weeks, with no real connection with local GPs and nurses. He would like specialist services to have a true consulting role to local practitioners. Other bureaucratic measures to encourage doctors to practise in the bush were a system of geographic provider numbers, allocated according to the number of doctors needed in a particular community, and removal of the cap on registrar GP training numbers, which favours the city over the country (Wilkinson). Several professors also saw a need for structural changes in the approach to rural health. Lyle called for greater coordination between rural health programs and organisations to avoid fragmentation of resources. Simmons suggested devolution of healthcare: "With the ageing of the population and epidemics of chronic diseases, communities need to decide their own priorities for healthcare." But the problem is larger than can be tackled by a Minister for Health alone. According to many professors, to attract doctors the bush needs to be made a more attractive place to live. "The process of regionalisation needs to be continued", said Lyle, with moving of resources, intellectual capital and infrastructure to the bush. "The Department of Education needs to follow the example of Health and put the same sort of resources into building up the intellectual capital in schools", suggested Simmons. And improving health in the bush requires more than just more doctors and better access to health services, emphasised Pashen and Wakerman. Governments need to address the underlying social and economic determinants of health within rural and remote communities. We also need "evidence-based funding decisions", continued Wakerman. The Health Minister should "move away from individuals with bright ideas and use the available evidence for what works to improve access to health services and the socioeconomic determinants of health". The future The UDRHs and rural schools are still at a developmental stage, most still recruiting and developing programs. In addition, they are now in a state of flux. The government move to create new UDRHs and rural clinical schools, or a more flexible intermediate model, the "rural health school", will dramatically change the scene. It has created the potential for UDRHs to upgrade to schools or to form new collaborations, and will certainly introduce more players to the field. There are many "chess games", commented several professors. One of the new UDRHs has been announced -- the Greater Green Triangle UDRH, a collaboration of Flinders and Deakin universities in the area straddling the South Australian-Victorian border. Successful bids for other UDRHs and schools are due to be announced soon. Most of the professors applauded the government's initiative in creating this network of UDRHs and schools, although Khadra warned about the potential for underfunding of the new rural clinical schools. Wilkinson believes the network is a "unique initiative in the Western world and shows tremendous vision". The units are making use of "the untapped talent among rural health professionals and the great wealth of patients in rural areas", said Walker. They are bringing intellectual and social capital and infrastructure to the bush. The seeds have been sown; will the harvest be the desired improvements in rural health? Authors' details The Medical Journal of Australia, Sydney, NSW Kerrie A Lawson, PhD, Assistant Editor; Mabel Chew, FRACGP, FAChPM, Deputy Editor; Martin B Van Der Weyden, MD, FRACP, Editor. Reprints will not be available from the authors. Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059. Make a comment Access to a general practitioner* (GP) by road in 1998 Over 750 000 Australians live more than a 20 km drive from the nearest GP, while almost 150 000 live more than 80 km. In addition, over 50 000 Australians live more than an 80 km drive from the nearest primary health location (defined as GP, pharmacy, nurse, multipurpose or Aboriginal health centre, hospital, aged care, or home and community care).1 *GPs were counted if they undertook more than 2000 consultations attracting a Medicare rebate per annum at that location. 1. The National Key Centre for Social Applications of Geographical Information Systems (GISCA). A study of provision of health services in non-metropolitan Australia. Report Number 1. Project overview and preliminary analysis. For the Department of Health and Aged Care. May 2000. <www.health.gov.au/ruralhealth/publications/gisca/hsreport1.pdf> Accessed 27 Oct 2000. (Map courtesy of GISCA, Adelaide, SA.) Back to text University of Sydney Department of Rural Health Based: Broken Hill, NSW Established: 1997 Affiliation: Department in Faculty of Medicine, University of Sydney David Lyle Position: Professor of Rural Health and Head Graduated: NSW medical school (1980) Discipline: Public health physician Rural links: Undertook rural electives as a medical student (Alice Springs and New Zealand) and research on rural issues What to do on a 3-day break: Sit on a beach, watching the surf Last book read: The regeneration trilogy by Pat Barker Recording for a desert island: video of the Yes, Minister TV series Back to text Greater Murray Clinical School Based: Wagga Wagga, NSW Established: 2000 Affiliation: One of five clinical schools of the Faculty of Medicine, University of New South Wales Mohamed Khadra Position: Professor of Surgery and Director Graduated: Newcastle medical school (1985) Discipline: Urologist Rural links: Grew up in small town in Ghana; undertook rural placements as student and trainee, and practised in Coffs Harbour, NSW What to do on a 3-day break: Catch an opera in Sydney, before returning to "the heaven of regional Australia" Last book read: Timeline by Michael Crichton CD for a desert island: Beethoven's violin concerto Back to text The Centre for Remote Health Based: Alice Springs, NT Established: 1999 Affiliation: Flinders University of South Australia and Northern Territory University John Wakerman Position: Associate Professor of Rural Health and Director Graduated: Sydney medical school (1981) Discipline: Specialist in public health medicine Rural links: Has worked or researched in Africa, Asia and the Pacific, as well as rural and remote Australia What to do on a 3-day break: Do something with his children -- he would let them choose Last book read: An Elmore Leonard crime novel CD for a desert island: Iron Butterfly's In-A-Gadda-Da-Vida Back to text Mount Isa Centre for Rural and Remote Health Based: Mount Isa, QLD Established: 1997 Affiliation: No current university affiliation; will join Faculty of Health, Life and Molecular Sciences, James Cook University, in 2001 Dennis Pashen Position: Associate Professor of Rural Health and Director Graduated: Queensland medical school (1973) Discipline: General practitioner and rural and remote specialist Rural links: Grew up in rural Queensland and practised as a GP in Ingham (QLD) for 20 years What to do on a 3-day break: Find a lecture room to sleep in! Last book read: Eucalyptus, by Murray Bail CD for a desert island: Ray Charles anthology Back to text School of Medicine, James Cook University Based: Townsville, QLD Established: 1999 Affiliation: School in Faculty of Health, Life and Molecular Sciences, James Cook University Craig Veitch Position: Associate Professor in Rural Health, and Head, Rural Health and Workforce Research Unit Graduated: DipAppSci (Therapy Radiography) (1976); PhD, University of Queensland (1995) Discipline: Epidemiologist and health services researcher Rural links: Grew up in rural QLD; has researched rural issues What to do on a 3-day break: "Go bush" and explore Last book read: Five patients: the hospital explained by Michael Crichton CD for a desert island: Led Zeppelin's BBC sessions Back to text South Australian Centre for Rural and Remote Health Based: Whyalla, SA Established: 1998 Affiliation: University of Adelaide and University of South Australia David Wilkinson Position: Professor of Rural Health and Head Graduated: Manchester medical school (1986) Discipline: General practitioner and specialist in public health medicine Rural links: Spent postgraduate career as clinician and researcher in rural South Africa What to do on a 3-day break: Get to know the local area better Last book read: AIDS doctors: voices from the epidemic by Ronald Bayer and Gerald Oppenheimer CD for a desert island: Yothu Yindi Back to text University Department of Rural Health, Tasmania Based: Launceston, TAS Established: 1997 Affiliation: Unit in the Faculty of Health Science, University of Tasmania Judi Walker Position: Associate Professor of Rural Health and Director Graduated: BA, University of the West Indies (1969); PhD, University of Tasmania (1993) Discipline: Health informatician and medical educator Rural links: Grew up in the rural West Indies; farms in northwest Tasmania. What to do on a 3-day break: Catch up on sleep at home on her farm Last book read: The sound of one hand clapping by Richard Flanagan CD for a desert island: Margaret Throsby's "Best of" classical selection Back to text Monash University Centre for Rural Health Based: Traralgon, VIC Established: 1992 Affiliation: Centre in Faculty of Medicine, Monash University Roger Strasser Position: Professor of Rural Health and Director Graduated: Monash medical school (1977) Discipline: General practitioner Rural links: Spent childhood holidays in the country; trained specifically in rural family practice (Australia, UK and Canada); has practised in Moe (VIC) for 15 years What to do on a 3-day break: Spend time with his children Last book read: Harry Potter and the goblet of fire by J K Rowling CD for a desert island: The later symphonies of Mozart Back to text University of Melbourne Department of Rural Health Based: Shepparton, VIC Established: 1999 Affiliation: Department in Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne David Simmons Position: Foundation Chair in Rural Health and Head Graduated: Cambridge University and Charing Cross medical school (1984) Discipline: Medical and diabetes specialist Rural links: Has experienced as clinician and researcher the barriers to care and prevention of diabetes, particularly in disadvantaged groups What to do on a 3-day break: Travel with his family and avoid work calls Last book read: The rainmaker by John Grisham CD for a desert island: CD-ROM of a strategic game, such as chess Back to text Combined Universities Centre for Rural Health Based: Geraldton, WA Established: 1999 Affiliation: University of Western Australia, Curtin University of Technology and Edith Cowan University Ann Larson Position: Associate Professor of Rural Health and Director Graduated: BA, Reed College, Oregon (1979); PhD, Australian National University (1987) Specialty: Demographer Rural links: Grew up in a small town in New York State; has spent career working with populations on the periphery (eg, in developing countries; Indigenous people) What to do on a 3-day break: Visit the special parts of the region as a tourist (eg, Coral Bay) Last book read: A Kinsey Millhone mystery by Sue Grafton Back to text

Kerrie A Lawson · Mabel Chew

Mental health issues in contemporary Australian adolescent literature So it was the emus were left in peace for three long years, during which Karrawingi, from a mere stripling, grew into a fine adult bird. His head was held over five feet high on his long smooth blue skinned neck. His eyes were splendidly large and of clear liquid brown, with black pupils . . . And now that Karrawingi was fully grown and winter was striding in once more, he began to feel strange urges in the blood. He was drawn to show his prowess in the company of female emus . . . He would whoosh and drum and dance and balance on one leg and puff out his throat feathers. (Karrawingi the emu, 1946, pp. 19-21) 1 She heaved herself up onto the railing. "Stay away from me. I'll jump!" "I hear that every day," he smirked. "People owing me rent. Girls wanting to get out of the game. My game. I take care of them, don't I? Come here, Larceny Farino. I'm going to take care of you. You won't jump. But then you are your mother's daughter." He smiled. She looked at him and saw the cruelty in his eyes. There was no escape. All the countless numbers of shrinks, pills, injections weren't as bad as this. Her head spun, but her thoughts were chillingly clear. And sane. "You're my daughter. You won't jump, will you?" She did. (Care factor zero, 1997, p. 206)2 MJA 2000; 173: 625-628 For editorial comment, see Patton & Sawyer Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Psychiatry Abstract Objective: To examine the depiction of mental health issues in contemporary Australian adolescent literature. This material might influence teenagers' understanding of mental illness and their willingness to seek help, and may provide insights into societal attitudes towards adolescents and the psychiatric problems encountered in this age group. Design: Systematic examination of a sample of 94 books, the "Notable Texts" in the "Older Child" category of the Children's Book Council of Australia Awards for the years 1996, 1997 and 1998. Main outcome measures: Number of works referring to psychiatry; characters who experienced trauma, loss, psychiatric symptoms, qualified for a psychiatric diagnosis, exhibited suicidal behaviour or sought help; and the nature of treatments given. Results: There was reference to psychiatry in over two-thirds of the works. In these books the image of psychiatry was generally negative or mixed. Most adolescent characters suffered major losses. Two-fifths of characters met criteria for a psychiatric diagnosis. The outcome for characters who satisfied criteria for a psychiatric diagnosis was more negative than those without. Of the 10 characters in the sample who committed suicide, eight had a psychiatric disorder. Conclusions: Psychiatric themes are a major component of the Australian teenage novel. Young people in contemporary Australian teenage literature are beset with trauma, loss and psychiatric disorders. Even when help is obtained, the outcome is seldom positive. This nihilistic view may increase hopelessness and pose a barrier for teenagers seeking help. In the inaugural decade of the Children's Book Council of Australia Awards (1946-1955), honoured books carried titles such as Karrawingi the emu,1Bush cobbers3 and Good luck to the rider.4 The titles reveal a fascination with Australiana - the flora, fauna, Indigenous population and traditional images of the white Australian family in an idealised rural landscape. By the late 1980s these themes had vanished and "realism" had settled into the Australian teenage novel. Among honoured books were Pausacker's What are ya!,5 which describes a lesbian relationship, and Marsden's So much to tell you,6 which portrays emotional abuse, post-traumatic stress disorder, elective mutism and psychiatric institutions. The apparent maturing of the teenage novel has been controversial. At issue is the potential impact of the novel's content on the well-being of the reader. A grassroots revolt against what is perceived as an increasingly nihilistic form of realism is emerging. In Sydney's Child, an article describes a parent's horror at the content of a Marsden novel: "Can we trust John Marsden with our children's minds?".7 In The Australian Magazine, Kate Legge asks "is the nihilistic trend in children's literature out of control?".8 The foci of these critics' discontent are no longer books about sex and rule-breaking, but books which showcase severe psychiatric illness and suicide (eg, Shoovy Jed,9Care factor zero2 and Dear Miffy10). The complaint is that the vividness of the contemporary teenage novel has gone beyond the honest to the offensive: "Young adult fiction is carving up the literary nature strip and hanging wheelies on the hard-baked bitumen of realism and it is not just nostalgic fogies and Christian Fundamentalists wrinkling their noses at the smell of burnt rubber."8 At a time of growing alarm at the high youth suicide rate,11 increasing awareness of the psychiatric problems confronting our adolescents,12 and concern about the effects of television, movies and video games on young people,13 it is worth ascertaining what we can learn from teenage literature. What attitudes to mental health issues are expressed in this literature and what impact might this literature have on the well-being of its readers? We aimed to explore these issues by systematic examination of a sample of Australian teenage novels. Methods Sample The sample comprised 94 adolescent literary works which represented all "Notable Texts" in the "Older Child" category of the Children's Book Council of Australia Awards for the years 1996, 1997 and 1998. The purpose of the Council is to select and honour books of high literary and artistic quality written for children.14 The category "Book of the Year - Older Reader" aims to identify works of fiction, drama or poetry which are appropriate for high school or upper primary school children. From all entries to the category, the judges choose "Notable Texts". These texts provide librarians, teachers and book sellers with a guide to book selection. Tools We designed two instruments: a 13-item instrument applicable to the literary work as a whole and a 70-item instrument applicable to the characters (available from the authors on request). Data sought with the first instrument included information about the novel's setting, humour, references to psychiatry and ending. Information obtained with the second instrument (which examined the main characters) included character demographics, experience of loss, abuse and life stressors, attitudes to life's challenges, presence of psychiatric symptoms and DSM-IV diagnosis,15 suicidality, sexual activity, help-seeking behaviours, and treatments. Only characters about whom there was information to answer at least 25 of the 70 items in the second instrument were included in the description of characters. The 94 works were read and rated by K M B over 10 months. Statistical analysis Because this is mainly a descriptive study, little statistical analysis was applied to the data to minimise overinterpretation. The χ2 test was used when comparing subgroups. Statistical significance was defined as P < 0.05. Results The works as a whole The context of the books was very much in the "here and now": 78% were set principally in Australia, 71% were reality-based, 76% had a contemporary setting and 63% had an urban backdrop. Humour was rare; only 4% of works were judged to be "funny". Thirty-four per cent of books had a happy ending. There was reference to psychiatric illness, institutions, treatments or mental health professionals in 69% of the books. In 9% of those, the reference was "slight" (eg, a one-line reference to Freudian psychoanalysis). In 75%, the reference was "significant" (eg, a refugee child suffers a post-traumatic stress disorder which strongly influences the story line). In the remaining 15%, the reference was "major" (ie, the work was about a character with a severe psychiatric illness or a child's experience of a parent with major psychiatric illness). Among works which refer to psychiatry, there were very few positive portrayals (6%); the depiction of psychiatry was usually negative (51%) or mixed (43%). A typical "negative" portrayal is one in which the sufferer of psychiatric illness is stigmatised, or there is futility expressed about seeking help from mental health professionals and institutions, or the mental health professional is depicted as emotionally abusive and the endpoint of mental illness is suicide. The characters There were 269 characters for whom there were sufficient data to answer at least 25 of the items in the second study instrument. The typical character was a teenager (76%), single (93%), a student (70%) with two or fewer siblings (67%). In 17% of cases the character or character's immediate family were migrants or refugees; 4% of characters had an Indigenous background. Twenty-three per cent had a medical or surgical illness. Fifty-three per cent had a conventional two-parent family background. Thirty-two per cent were sexually active in their teenage years. Most were uncertain (59%) or despairing (22%) about life's challenges. A fifth had experienced some form of child abuse (physical, sexual or emotional abuse, or neglect). Sixty-four per cent of characters experienced a "severe" stressor (eg, rape, sustained physical abuse, a life-threatening motor vehicle accident, or becoming a refugee from war). Having suffered a major loss (eg, death of family member or close friend, loss of home or homeland) affected 78% of characters. Fifty-seven per cent were distressed in some way. Specific psychiatric symptoms were identified in most characters and 41% met DSM-IV diagnostic criteria for a psychiatric diagnosis (Box 1). Most of these (63%) had one diagnosis; 31% had two (31%) and 6% had more than two. Of the 180 characters who were distressed, experienced psychiatric symptoms and/or had a psychiatric diagnosis, 73% received help (Box 2). The attitude of the 180 characters to seeking help was ambivalent (48%), negative (22%) and positive (24%), with no clear attitude described for the remaining characters. The 38 characters who sought help from mental health professionals accessed cognitive behavioural therapy (45%), hospitalisation in a psychiatric unit (37%), psychotropic medication (31%), family therapy (16%), dynamic psychotherapy (1%) and treatment in a therapeutic community (0.5%). Treatment outcomes varied: in 55% there was no change in symptoms; in 32% there was clear benefit, while in the remaining 13% mental health intervention had a negative effect. Twenty-six characters (10%) had suicidal thoughts; 22 of these characters had a psychiatric disorder. Twenty-one manifested suicidal behaviour and 10 actually killed themselves, a very high rate of completion. The psychiatric profile and means of suicide are shown in Box 3. Comparison of characters with and without a psychiatric diagnosis Only 1% of the 111 characters with a psychiatric diagnosis experienced no stressor, compared with 14% of the 158 without a diagnosis. For 84% of the characters with a psychiatric disorder the stressor was "severe", compared with 51% for the well characters (P < 0.001). Major loss was experienced by 92% of characters with a psychiatric disorder versus 68% of the well characters (P < 0.001). Characters with a psychiatric disorder were more likely to have been abused in childhood. This association was significant for neglect (P < 0.01) and approached significance for emotional and physical abuse. Characters with a psychiatric condition were less competent than their well counterparts, except in artistic ability. They were poorer scholars (P < 0.05), less able to socialise (P < 0.001), less attractive physically (P < 0.05), less capable of intimacy (P < 0.001), more pessimistic (P < 0.001), and more likely to have suicidal thoughts (P < 0.001), manifest suicidal behaviour (P < 0.001) and complete suicide (P < 0.05). Characters who had a psychotic illness were conspicuous for their pessimistic outlook and poor outcome; 78% of these characters had a pessimistic outlook, and 55% completed suicide. Discussion The books examined in this study are works of fiction and do not necessarily reflect what happens in the "real world". For example, the rate of family separation in our sample was about twice that found in the community (47% versus 21%),16 and the proportion of teenage characters who met criteria for a psychiatric diagnosis (41%) was much greater that the rate of mental health problems found among adolescents in a recent national survey (13.4%).12A limitation of our study is that we have no data on the instruments' reliability and validity. For instance, we do not know whether the assessments of the rater (a senior trainee in child psychiatry) about issues such as "humour" would concur with those of a teenage reader. Despite these shortcomings, this report describes how contemporary writers (and those who selected the books) view growing up in Australia at the end of the 20th century. What image of the times do these books project? The past decade appears to have been a time of trauma and loss for youth, unrelieved by humour or hope. Young people in these books experienced high levels of mental distress, but professional help was seldom obtained for mental health problems (only 38 out of 111 characters with a psychiatric condition accessed mental health services) and few patients actually benefited from the contact (only 12 of the 38 youths). Characters who met criteria for a psychiatric diagnosis were more likely to have been abused, traumatised and to have suffered a loss. They were less attractive, worse academically, and social failures. And for characters with a psychotic illness the outlook was even more grim (over half killing themselves). Considering this image of our times we may well ponder whether the genre has crossed the threshold from realism into nihilism. Yet, in some respects, the depiction of mental illness in teenage fiction can be applauded. Acknowledging mental illness is a first step towards understanding and the removal of prejudice. Many of the portrayals are so authentic that the teenage novel can be used to educate both general readers and students of psychiatry. However, we have concerns about some aspects of psychiatry's representation in these novels. Detailed speculation about the effect of literature on young people's behaviour is outside the scope of this article. Nevertheless, many questions arise. How will books that are scathing of mental health professionals influence the preparedness of young people to seek or accept treatment? As soon as she'd revealed a weakness, the shrink had gone for the jugular. To reveal that you were weak, scared or confused gave them power. And once they had the power, they could manipulate you, control you -- Who the hell did they think they were anyway, trying to pry into your soul: God? (Care factor zero, p. 106).2 What is the impact of books which feature psychiatric illness on vulnerable teenagers or those who either suffer a psychiatric illness or have a family member affected? For example, how can one safely expose a teenager with a psychiatric illness to a book in which the principal character (who also has a psychiatric illness) is bad/mad, consummately devilish and incurable,17 or to a book in which a teenage boy with schizophrenia is hounded to his death by the ignorance and cruelty of his peers, the abject failure of psychiatric help and the urgings of his hallucinations?18 Both these books are wonderfully crafted and educative, but at whose expense are we "doing wheelies on the hard baked bitumen of realism"? Similarly, will a character's decision that suicide is the best or only option tip the scales for teenagers going through a rough patch? Although data are lacking on the effects of reading literature on psychopathology and suicide, there are suggestions that other media -- newspapers, television, music -- may have an adverse impact.13,19,20 Do medical professionals have a valid role in encouraging accurate and therapeutic content in teenage literature, without becoming "thought police" or encroaching upon "artistic freedom"? Do authors feel that responsibility for the well-being of their readers is compatible with the right to such freedom? If so, these two professions should enter into a dialogue and exchange perspectives. A recently published resource kit to assist various media professionals portray mental illness and suicide makes no mention about the possible responsibilities of authors in this matter.21 In any case, there seems to be a very wide gap between Karrawingi the emu and Care factor zero. Exploring the reasons for this and its consequences may prove just as helpful for the future of Australian society as many epidemiological and clinical studies. Acknowledgements We thank Associate Professor John Stevens, Ms Pam Hatfield, and the New South Wales Branch of the Children's Book Council of Australia. Book covers reproduced with permission. Clark, M. Care factor zero. Sydney, Random House, 1997. Harnett, S. The devil's latch. Melbourne, Penguin, 1998. Hilton, N. Hothouse flowers. Sydney, HarperCollins, 1997. Marsden J. Checkers. Sydney, Pan Macmillan, 1997. Orr, W. Peeling the onion. Sydney, Allen and Unwin, 1996. Saliba, S. Watching seagulls. Melbourne, Longman, 1997. Walters, C. The killing of mud-eye. Brisbane, UQP, 1997. Winton, T. Lockie Leonard legend. Sydney, Pan Macmillan, 1997. References Rees L. Karrawingi the emu. Sydney: John Sands, 1946. Clark M. Care factor zero, Sydney: Random House, 1997. Morell M. Bush cobbers. Sydney: Australasian Publishing, 1948. Phipps J. Good luck to the rider. Sydney: Angus and Robertson, 1953. Pausacker J. What are ya? Sydney: Angus and Robertson, 1987. Marsden J. So much to tell you. Melbourne: McVitty Books, 1987. Bolt A. Do you want your children influenced by the world of John Marsden? Sydney's Child, Dec 1999/Jan 2000: 52. Legge K. Life sucks, Timmy. Australian Magazine, March 8-9 1997: 10-18. Stewart M. Shoovy Jed. Sydney: Random House, 1997. Marsden J. Dear Miffy. Sydney: Pan Macmillan, 1997. Cantor CH, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond. Med J Aust 1999; 171: 137-141. Sawyer M, Arney M, Baghurst PA, et al. Child and adolescent component of the national survey of health and well-being. Canberra: AGPS, 2000. Centerwall BS. Television and violence. JAMA 1992; 267: 3059-3063. Children's Book Council of Australia. The Children's Book Council of Australia Awards Booklet. Brisbane: The Council, 1997. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association, 1994. Australian Bureau of Statistics. Children, Australia: a social report (1999). Catalogue no. 4119.0 <www.abs.gov.au> Accessed 28 August 2000. Hartnett S. The devil latch. Melbourne: Penguin Books, 1996. Walters C. The killing of Mud-Eye. Brisbane: University of Queensland Press, 1997. Hassan R. Effects of newspaper stories on the incidence of suicide in Australia: a research note. Aust N Z J Psychiatry 1995; 29: 480-483. Martin G, Clarke M, Pearce CM. Adolescent suicide: music preference as an indicator of vulnerability. J Am Acad Child Adolesc Psychiatry 1993; 32: 530-535. National Mental Health Strategy. Achieving the balance: a resource kit for Australian media professionals for the reporting and portrayal of suicide and mental illness. Canberra: Commonwealth Department of Health and Aged Care, 1999. (Received 4 Jul, accepted 12 Sep, 2000) Authors' details Rivendell Unit, Central Sydney Area Health Service, and New Children's Hospital, Sydney, NSW. Kathleen M Bokey, BA, FRANZCP, Fellow in Child Psychiatry; Garry Walter, MB BS, FRANZCP, Acting Director, Child and Adolescent Mental Health Services, Central Sydney Area Health Service, and Clinical Lecturer, Department of Psychological Medicine, University of Sydney. Department of Psychological Medicine, University of Sydney, Sydney, NSW. Joseph M Rey, PhD, FRANZCP, Professor of Child and Adolescent Psychiatry, and Director of Child and Adolescent Mental Health Services, Northern Sydney Health, Sydney. Reprints will not be available from the authors. Correspondence: Dr G Walter, Rivendell Unit, Hospital Road, Concord West, NSW 2138. gwalterATmail.usyd.edu.au Make a comment 1: Psychiatric symptoms and diagnoses in 269 characters* Symptoms Emotional (eg, anxiety) Behavioural (eg, conduct problems) Somatic (eg, conversion symptoms) Psychotic (eg, hallucinations) Cognitive (eg, memory loss) 151 (56%) 126 (47%) 18 (7%) 18 (7%) 16 (6%) Psychiatric diagnosis Adjustment disorder Post-traumatic stress disorder Mood disorder Substance abuse/dependency Personality disorder Psychotic illness Oppositional defiant disorder Delirium Eating disorder Conduct disorder Anxiety disorder Dissociative disorder Mental retardation Dementia Pre-menstrual dysphoric disorder 32 (12%) 22 (8%) 21 (8%) 14 (5%) 11 (4%) 9 (3%) 7 (2%) 6 (2%) 6 (2%) 5 (2%) 3 (1%) 3 (1%) 2 (1%) 2 (1%) 1 (1%) *From Children's Book Council of Australia "Notable Texts -- Older Child", 1996-1998. Eating disorder (from All of me, p. 68) "You said something yesterday about how to fool them. How?" she asked Sharon. "They check everything." "Oh, you can't do it here. When you get home you can. See, you just buy laxatives at the supermarket or the chemist. Then you take a handful before you eat. So you can eat, see, but the food just goes straight through you and you get gastric and you don't put on weight! It works just fine. "Obsessive compulsive disorder (from Checkers, p. 40) Daniel . . . actually laughs at the weird stuff he does, but he can't stop himself doing it. One of his obsessions is with cleanliness. He spends four, five, six hours a day in the shower . . . He spends so much time in the shower he gets all pink and wrinkly . . . He won't go into a new room until he's touched five different types of wood. . . . He gets dressed in a certain order . . . Like I say, I don't know how he survives. Mania (from Hothouse flowers, p. 157) Rose was listening . . . while the good doctor talked. "Manic is when your brain makes you feel fantastic. . . . It makes you want to try things and buy things . . . remember . . . ". He'd held up a box of baby rattles in gloriously bright colours that chimed and sang and chirruped when they were moved. Rose had bought two giant boxes of them and charged them to her father. "It's not really you when you behave like that". Schizophrenia (from The killing of mud-eye, p. 158-159) I waded upstream and downstream looking for transistors. . . . Now they have wired up the rocks and cliffs. Now the voices come from here and over there and here and over there again and in the running river and they tell me to die. They go on and on in a terrible jumble of things but most of all they tell me to die. Back to text 2: Sources of help for 132 characters* with mental health problems Peer Parents or other family member Adults (other than parent) Mental health professional General practitioner 86 (65%) 48 (36%) 39 (30%) 38 (29%) 15 (11%) *From Australian Children's Book Council "Notable Texts -- Older Child", 1996-1998. Back to text 3: Teenage characters who suicided* Character Psychiatric profile Means of suicide Jesse in The house on river Terrace Drug and alcohol abuse, personality disorder, depression Jumping over cliff while intoxicated Robyn in Third day, the frost Eating disorder, depression, post-traumatic stress disorder Explosive device, altruistic suicide(?) Michael in Bad behaviour Depression Firearm Bo in Green monkey dreams Psychotic illness, family history of "madness" Jumping in front of train William in Green monkey dreams Major mood/psychotic illness Self-immolation Ragmar in Green monkey dreams Psychotic illness Self-immolation Linton in The killing of mud-eye Schizophrenia Hanging Larceny in Care factor zero Psychotic illness, drug and alcohol abuse Jumping from balcony Ella in Shade's children No diagnosis Explosion (altruistic motive) Drum in Shade's children No diagnosis Explosion (altruistic motive) * From Children's Book Council of Australia "Notable Texts -- Older Child", 1996-1998. Back to text

Kathleen M Bokey · Garry Walter · Joseph M Rey

Medicine and the Community Healthcare on the Internet Buyers beware Peter M Yellowlees MJA 2000; 173: 629-630 The World Wide Web is becoming a new medium of medical practice. Access to misinformation - Internet addiction - The practice of skullduggery - References - Authors' details - - More articles on Psychiatry Around the world books and other media are focusing increasingly on aspects of healthcare on the Internet.1 A whole series of new jargon terms are evolving, such as "B2B" (Business to Business), "B2C" (Business to Consumer), "D2D" (Doctor to Doctor) and "D2C" (Doctor to Consumer/Patient). While these terms seems to derive more from the business world than the medical, the two worlds are becoming increasingly intertwined. Doctors are more familiar, through their training, with the derivation of other new terms such as "cyberchondria", "cybersex", "technophobia" and "Internet addiction disorders". As a clinician and researcher who is interested in the exciting possibilities of Internet healthcare, I have been encouraging patients to use the Internet to access health information for some years, and also to communicate with me, if they wish, by email. Several patients have effectively self-referred themselves to me, via their general practitioners, after reading my curriculum vitae, which is posted on a website at the University of Queensland (www.coh.uq.edu.au). I also encourage patients to download information about their disorders from the Internet to discuss with me or other doctors or healthcare professionals who might be treating them. I keep a list of what I consider to be good sites on the Web that I can hand out to patients who wish to do research themselves, and who at least want a reasonable start in finding good-quality information from reliable sites. In future, with the increasing prevalence of published e-books in particular, patients will be able to learn how to do structured searches that make it more likely that they will get good-quality health information from the Internet.2 I am confident that the Internet, and in particular the much faster Internet2 that will be with us within two or three years,3 will have a positive overall effect on the way we treat our patients and the way they manage themselves. It is, however, crucial to retain a critical view of any new approaches in healthcare, and to evaluate them carefully, as it is becoming clear that there are some quite marked "side effects" to the Internet. Access to misinformation Patients do need to understand the importance of finding both reliable and valid information,4 and I believe that doctors will increasingly need high level skills in information analysis as a core medical competence. Unfortunately, at present, patients too often gain health information from chat rooms and discussion groups, and this is frequently either wrong or inappropriate. Just as there have been well publicised cases of individuals altering stock market values on the NASDAQ (the American National Association of Security Dealers Automated Quotation system) by aggressively presenting themselves in discussion groups, so cases are arising of cults, religious or otherwise, and other unusual organisations, trying to influence people through misinformation. Patients may heed this information and buy the wrong products or services. Similarly, many health sites promote the sales of unproven treatments, or may in fact be entirely bogus, intended as satire or designed to steer people towards pornographic sales and marketing situations, or the like. Patients are increasingly sending emails to sites that offer medical advice, purported to be from licensed medical practitioners, or seeking consultations by email. It is obviously vitally important that patients know who exactly is the doctor that they are emailing, and I would personally strongly advise against any patients receiving information from an anonymous doctor. As a brief test of potential quality of health "advice" on the Internet, I recently asked a question at a major commercial American health site about the ideal treatment for depression. I received three single-sentence replies from an individual identified only by a number and which were completely contradictory, informing me I should (a) see a psychiatrist, (b) always engage in psychotherapy, and (c) consider medications, without any further details. I believe I would have received a better reply from a women's magazine agony aunt. Some clinically sensible and ethically focused Internet healthcare sites are beginning to emerge. Perhaps the most well known is NHS Direct,5 in the United Kingdom, where symptom-driven decision trees (effectively patient decision-support systems) are backed up by a nursing telephone service which allows symptomatic patients to be triaged and to select either self-care, general practice or hospital treatment options. In Australasia the most comprehensive email consultation site is doctorglobal.com,6 with which I am commercially involved. Patients who access Doctor Global consult a named doctor, whose photograph and biography appear on the site, whose work is audited by a clinical advisory board and who has gone through a formal accreditation process before being allowed to practise through the site. At the moment, mainly because of medicolegal fears and a more restrictive clinical culture, there is no equivalent broad healthcare website in the United States providing real electronic clinical consultations. Internet addiction The concept of Internet addiction disorder7,8 has been around for some years, but cases of patients so affected are becoming increasingly prevalent, and I have treated several (Case 1). Internet addiction disorder is so well described on the Internet that it is even possible to receive treatment online.9 This seems a bit like going to the pub for a few drinks to try to cure one's alcohol dependence, and isn't something that I would instantaneously recommend. Cyberchondria is a syndrome closely related to Internet addiction disorder that is also becoming increasingly common, and which occurs in anxious or hypochondriacal patients who start spending too much time chasing around the Web searching for information which may make them more anxious (Case 2).10 I can see no reason to define cyberchondria as a new form of psychiatric disorder, as it is simply a modern-day approach taken by those hypochondriacal patients who in the past have tended to read too many medical dictionaries. The practice of skullduggery Like it or not, our world will always contain some dreadful people who prey on others, and who will now use the Internet as their chosen access route to victims.11 At least one man has already been imprisoned for "stalking" his ex-girlfriend on the Internet by publicising her name and contact details as someone who prostituted herself for clients wishing to have sadomasochistic sex. There are examples of men who cross-dress on the Internet pretending to be women, and then having steamy cyber-relationships with other men (a seemingly fairly common danger of Internet love affairs), and many instances of paedophiles joining chat rooms to try to meet adolescents. As long as we are aware of these sorts of side effects, or dangers, we can make sure that patients are appropriately warned. Whatever we may think personally of the Internet -- and I am an obvious enthusiast -- it is inevitable that patients will increasingly use it both to find information about their disorders, and to communicate with doctors. There are now several publications that promote the sensible use of the Internet in healthcare and which propose guidelines for medical activities, in particular email use, on the Web.12,13 These should certainly be reviewed by all doctors who intend now, or in the future, to practise, at least in part, in this manner. References Slack W. Cybermedicine. San Francisco: Jossey-Bass; 1997. Yellowlees P. Your guide to e-health. Third millennium medicine on the Internet. Brisbane: University of Queensland Press, 2000 [eBook available from http://www.uqp.uq.edu.au]. Accessed 27 October 2000. About Internet2. <http://www.internet2.edu/html/about.html> Accessed 27 October 2000. Yellowlees PM, Brooks P. Health online: the future isn't what it used to be. Med J Aust 1999; 171: 522-525. NHS Direct. <http://www.nhsdirect.nhs.uk> Accessed 27 October 2000. Doctor Global. <http://www.doctorglobal.com> Accessed 27 October 2000. Young K. Caught in the net: how to recognise the signs of Internet addiction. New York: J Wiley & Sons; 1998. Yellowlees PM. E-therapy: a guide to mental health in cyberspace. [eBook available from http://www.mightywords.com]. Accessed 27 October 2000. Center for On-line Addiction. <http://www.netaddiction.com> Accessed 27 October 2000. Brosnan M. Technophobia: the psychological impact of information technology. London: Routledge, 1998. Gwinnell G. Online seductions: Falling in love with strangers on the Internet. New York: Kodansha Press; 1998. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc 1998; 5: 104-111. Spielberg AR. On call and online: sociocultural, legal and ethical implications of email for the patient-physician relationship. JAMA 1998; 280: 1353-1359. Authors' details Department of Psychiatry, Faculty of Health Sciences, University of Queensland, Brisbane, QLD. Peter M Yellowlees, MD, FRANZCP, Head, and Director, Centre for Online Health. Reprints will not be available from the author. Correspondence: Professor P M Yellowlees, Department of Psychiatry, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane Hospital, Herston, QLD 4029. P. YellowleesATmailbox.uq.edu.au Make a comment Case 1: Internet addiction disorder Mr A was a 25-year-old, highly intelligent university student undertaking a health sciences course. At the age of 22 he had his first bout of severe depression, and was soon diagnosed with a bipolar disorder after a manic episode. This young man also had a very obsessional personality style and started spending many hours every day searching the Internet for information about the biology and treatment of bipolar disorder, sitting up all night and sometimes spending as much as 16 to 18 hours a day on his searches. His inappropriate use of the Internet took over his life and made it impossible for him to continue with his studies, and eventually became a greater cause of disability than his original bipolar disorder. He was successfully "withdrawn" from the Internet by agreeing to move back home to live with his parents, who did not have an Internet connection, and discontinued his university studies for some months while he received treatment for his primary psychiatric disorder. Back to text Case 2: Cyberchondria Mr B was a 28-year-old single man with a five-year history of somatisation disorder. He became fascinated by the Internet, particularly by support groups for people with his type of disorder, and started to spend large amounts of time communicating with other sufferers on the Web. He became obsessed with the need to find a "biological cure" for his disorder and communicated regularly with researchers around the world involved in this area. Treatment consisted of the conventional treatment for his psychiatric disorder, particularly encouragement to use non-biological approaches, as well as reducing the amount of time he spent on the Internet. He was able to do this and, in a very positive postscript to his treatment, while on holiday overseas he organised to see one of the psychiatric researchers he had come to know on the Internet for a second opinion. I organised this appointment for him and he was pleased with the outcome. Back to text

Peter M Yellowlees

Medicine and the Media Medicine, the media and monetary interests: the need for transparency and professionalism Ray Moynihan and Melissa Sweet MJA 2000; 173: 631-634 Abstract - Breakthroughs and boosterism - The news business - Cosy relationships - The buck stops...where? - Cash for comment - Evidence-based journalism - References - Authors' Details - - More articles on Social issues Abstract Emerging evidence suggests that media coverage of medicine is increasingly promotional in nature. Recent Australian examples include misleading newspaper articles on an experimental cancer vaccine and a high profile television current affairs segment on a new influenza drug, which failed to disclose the industry ties of a key expert featured in the report. There are widening concerns that this problem in medical journalism may be exacerbated by the growing commercialisation of medical and scientific research, and the increasing ties between researchers, doctors and pharmaceutical or biotechnology companies. Closer links between industry and medicine are being explicitly encouraged both in academia and the health care sector for the mutual benefits they bring. However, these partnerships are the cause of growing unease within medicine. In the United States, rigorous legislation governing research protocols is being proposed, and in Australia new ethical guidelines covering industry-profession relationships are being promulgated. If one of the media's roles is informing the community about the business of health and medicine in a fair and accurate way, a cultural change in medical journalism is required. In November 1999, one of Australia's high circulation newspapers published a prominent story about a new cancer vaccine that had "tripled life expectancy in trials".1 In May 2000 the Australian Press Council upheld a complaint from a leading cancer expert that this report, versions of which were published in sister newspapers across the country, was both misleading and inaccurate.2 While the Australian Press Council made no judgement about the scientific evidence supporting the new vaccine, the finding served as a timely reminder of the need for more scepticism in medical journalism. Yet just two months later, in July 2000, the same vaccine received another round of positive publicity in the nation's leading newspapers, publicity echoing promotional material from the vaccine's proponents.3If one of the media's roles is to inform the community in a fair and accurate way, the reporting of medicine or medical research too often falls short of the mark. A recent study of newspaper and television coverage of medications over a five-year period found many stories tended to overstate therapy benefits, played down potential harms and failed to disclose the relevant industry ties of cited experts (Box).4 The misleading nature of much medical reporting requires urgent attention from both journalists and health professionals. Concern about media reporting raising false hopes, undue anxiety or unnecessary alarm is not new.5 However, the increasing commercialisation of scientific research, and the expanding role of the stockmarket in medicine, are creating powerful new forces. Like many new therapeutic advances, the experimental cancer vaccine featured in the Australian media is promoted by a biotechnology company listed on the stock-exchange: for these companies positive stories may boost share prices and negative stories may send them plummeting. Closer involvement between industry and science, which is being explicitly encouraged in a bipartisan way in Australia,6 may well carry the clear benefits of increased research funding or enhanced commercial opportunities for effective new treatments -- but at what cost? Within medical circles, and in the wider community, there is growing unease that overly cosy relationships may be affecting research integrity and professional independence.7,8 It may be time for the media to offer more critical analysis of the business of medicine, and less thinly disguised promotion of the latest "breakthroughs". Breakthroughs and boosterism At the international Berzelius Symposium, Medicine and the Media, convened in Stockholm in September this year by the Swedish Society of Medicine, many contributions focused on the increasing commercialisation of medical and scientific research. While some conference participants expressed optimism about a growing sophistication in media coverage of medicine, others expressed concern about promotional "boosterism", particularly in media coverage of genetics and biotechnology.9At the conference, Lars Holmgren, from the Karolinska Institute, Sweden, focused on the now-infamous front-page story in the New York Times on Sunday, 3 May 1998. It began with the paragraph: "Within a year, if all goes well, the first cancer patient will be injected with two new drugs that can eradicate any type of cancer, with no obvious side effects and no drug resistance -- in mice."10 The article referred to two agents, endostatin and angiostatin, which have shown significant promise in treating cancer in mice by blocking angiogenesis. It had an international impact, provoking widespread follow-up in other media outlets, and leading to many inquiries from anxious cancer patients about a treatment that had not yet been trialled in humans. As Holmgren explained, the front-page story also had a dramatic impact on the shares of the company developing the agent, which increased in value severalfold the next day. An investigation by the Los Angeles Times11 later showed that the shares in this and other biotechnology companies have since risen and fallen in response to continuing public relations activities and media stories, both positive and negative.12 In a provocative conclusion, Holmgren suggested that the trend towards researchers seeking to attract investors through publicity in the mass media -- often ahead of publication in scientific journals -- had become so prevalent that the high-tech stock index, the Nasdaq, had become a more reliable indicator of scientific developments than journals themselves! The news business If "good news" medical stories are valuable for listed companies, they are also big business for commercial media and increasingly entrepreneurial public broadcasters. Television news and current affairs programs routinely broadcast formulaic "breakthrough" medical stories, and often heavily promote them. As the southern hemisphere flu season got under way this year, a top-rating television current affairs program broadcast an item about Glaxo Wellcome's new influenza product Relenza (zanamivir), described as a "wonder drug" with "miraculous results".13 While brief mentions were made of concerns about cost-effectiveness and a paucity of sufficient trial data in high-risk patients, the presenter's voiceover was upbeat, and reinforced by comments that the drug had been hailed as "the greatest breakthrough ever" in the treatment of influenza. During the day of the broadcast and the following day's trading, the price of shares in Glaxo's Australian partner, Biota, jumped almost 15%. While the television segment was extremely good news for company investors, it serves as another stark example of the malaise affecting much of medical reporting. Like many previous items about zanamivir, the drug's modest benefits were not mentioned.14 Similarly, the evidence of rare but potential serious harm associated with the new drug for those with pre-existing illnesses like asthma were ignored.15 Perhaps most importantly, the television program failed to inform its audience of the links between Glaxo Wellcome and one of the key experts who repeatedly appeared in the segment, despite the company's support for the expert's research on zanamivir being clearly disclosed in the scientific literature.16 Instead, the program chose to describe the specialist as an "independent professor" from an academic institution. This clear failure to reveal the relevant industry ties of a key source is not an isolated instance.4 Cosy relationships While many media stories are failing to report on the potential conflicts of interest of their "experts", the growing ties between industry and academic medicine are generating considerable disquiet. In an editorial in the New England Journal of Medicine in May this year, Marcia Angell, the journal's editor, detailed the dangers of the increasingly "cosy relations" between medical scientists and the drug and device manufacturers providing funds for research, consultancies for advice, and free trips to speak at international conferences.7As an example of the problem, Angell cited the difficulties in finding independent reviewers to write about the treatment of depression, because so many US psychiatrists have links to companies selling antidepressants. "The problem is by no means unique to psychiatry," she wrote. Nor is the problem unique to the United States. Two years ago a leading Australian academic complained publicly of the difficulty in finding independent specialists to sit on regulatory committees, because so many were consultants to drug companies.17 The reason for concerns about the increasingly intricate ties between researchers and industry is not simply academic. Evidence suggests that a range of physician-company interactions (like attending company-sponsored education, or accepting sponsored trips) can carry negative impacts on behaviour.18 As Angell pointed out, "there is now considerable evidence that researchers with ties to drug companies are indeed more likely to report results that are favourable to the products of those companies than researchers without such ties."7 An obvious concern is that corporate funding may sometimes cause bias. More subtly, according to Angell, ties may influence scientific judgements in ways that are difficult to identify. The bottom line is that companies are seen to be buying the goodwill of researchers, "which is a very valuable commodity for drug and device manufacturers".7 The buck stops . . . where? The goodwill of researchers and opinion leaders is a particularly valuable commodity precisely because it can be exploited by a company using the media to promote a new product direct to the public. Having a new product endorsed in newspapers or on television by a purportedly independent authority figure is invaluable. Clearly, the mainstream media must urgently institute routine disclosure of the potential conflicts of medical and health experts, just as medical journals have required for some time. Amendments to journalist codes of ethics may be one route towards this outcome. Similarly, it may be appropriate for media to disclose when a public relations company or another vested interest has been responsible for orchestrating a story.19Community concerns about the ties between doctors and the pharmaceutical industry led the Royal Australasian College of Physicians this year to disseminate new ethical guidelines that cover these relationships.20 Largely accepting the benefits of close commercial relationships, including company funding of research, paid consultancies and sponsored travel, the guidelines recognise the possibility that these relationships may cause conflicts between physicians' responsibilities to their patients, and their own personal gain. Essentially endorsing the multiplicity of industry-professional ties, the guidelines argue that openness to public scrutiny is a sufficient safeguard. But self-regulatory professional guidelines that carry no real penalties are not considered enough in some quarters. Responding to Angell's editorial, the United States Secretary for Health and Human Services, Donna Shalala, recently announced a list of wide-ranging measures to improve ethical conduct in research.21 Included is the possibility of new legislation which would impose fines of up to $US250 000 per clinical investigator and up to $1 million per research institution for violations of ethical research conduct -- such as failing to obtain proper informed consent from research participants. Shalala argued that several recent incidents in the United States, including the much-publicised death of a subject in a gene therapy trial,22 had shaken public confidence in research ethics. One of the reasons that protection for human subjects needed to be strengthened was, according to her editorial, that academic investigators increasingly have commercial links with trial sponsors or personally hold patents over the therapies being trialled, creating potential conflicts of interest and major ethical dilemmas. Cash for comment The recent Australian Broadcasting Authority inquiry into commercial radio, known as the "cash for comment" inquiry, has helped raise awareness of the extent of hidden corporate payments to broadcasters and the way in which those payments can undermine and distort public debate. In a similar distortion of public debate, overly promotional media coverage of healthcare products may help foster false public expectations of benefits, encourage unnecessary or potentially harmful use, and add to healthcare costs. As well, there are concerns such coverage may promote overmedicalisation and discourage the use of effective non-medical interventions. In light of the revelations which emerged from the "cash for comment" inquiry,23 a rigorous and wide-ranging investigation of the nature and extent of commercial links between the medical profession and the pharmaceutical, biotechnology and medical technology companies may now be timely in Australia. In a spirit of openness and disclosure, such an inquiry could also examine the ties between journalists and the medical companies whose products they are charged with reporting on. Evidence-based journalism Enhanced transparency about industry ties is only one strategy for improving the way the media covers medicine. In our view, journalists and media managers could benefit greatly from a heightened understanding of the move towards an evidence-based approach in healthcare. As a recent article in the Australian journalists' professional magazine, The Walkley, noted,24 the media could learn from the questions which are being asked by proponents of evidence-based medicine (eg: What is the evidence to support the claim being made? How strong is the evidence? How does it fit with the existing body of evidence? Are there other, valid conclusions which could be drawn? Have the results been published in a reputable peer-reviewed journal? What interest might the doctor/researcher have in promoting this view?). Strategies for quality improvement will require debates within media organisations, journalist professional bodies and the wider research community. Valuable assistance in those debates may soon come from a group of researchers who are now conducting a randomised controlled trial of various educational interventions for journalists covering health and medicine.25 Similarly, many researchers and journalists, as well as the Australasian Medical Writers Association, are working on educational and other resources designed to improve medical reporting.26,27 In Sweden, for example, medical journalists are encouraged to follow a number of ethical guidelines, including do not arouse false hopes and fears; try to present risks and benefits together; emphasise the uncertain and temporal nature of knowledge.28 Critical, informed and independent journalism will become even more crucial in light of increasing commercialisation, combined with the major, complex changes arising from the new biotechnologies. Media organisations currently face a fundamental choice about how they cover the issue of human health: to act as "cheer squads" for the new products, or to seek out truly independent evaluation of promotional claims in order to better inform the public about the limitations, uncertainties, dangers and costs, as well as the genuine health benefits, of new medical therapies and technologies. References Busfield W. Melanoma vaccine next year. The Daily 1Telegraph, 19 November 1999: 3. The Australian Press Council. Adjudication No. 1081. Re: The Daily Telegraph, 19 November, 1999. Greenblat A. Cancer drug fires up AVT. The Age 20 July 2000: B3; and The Sydney Morning Herald, 20 July 2000: 23. Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications. N Engl J Med 2000; 342: 1645-1650. Leask J, Chapman S. An attempt to swindle nature: press anti-immunisation reportage 1993-1997. Aust N Z J Public Health 1998; 22: 17-26. Wills PJ (Chairman). Health and Medical Research Strategic Review. The virtuous cycle -- working together for health and medical research. Canberra: Department of Health and Aged Care, 1999. Angell M. Is academic medicine for sale? [editorial]. N Engl J Med 2000; 342: 1516-1518. Weatherall D. Academia and industry: increasingly uneasy bedfellows. Lancet 2000; 355: 1574. Swedish Society of Medicine. Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Kolata G. Hope in the lab -- A special report: A cautious awe greets drugs that eradicate tumors in mice. New York Times, 3 May 1998. Jacobs P. Biotech stocks ride roller coaster of publicity. Los Angeles Times 21 March 1999. Ashraf H. British Medical Journal apologises to biotech company [news]. Lancet 2000; 355: 2139. A Current Affair, June 14, 2000. Summary of evidence about effectiveness of zanamivir. National Institute for Clinical Excellence, UK, 1999. <http://www.nice.org.uk/nice-web/Article.asp?a=427> Accessed 14 November 2000. Relenza [US Food and Drug Administration consumer drug information]. <http://www.fda.gov/cder/ consumerinfo/druginfo/relenza.htm> Accessed 14 November 2000. The MIST (Management of Influenza in the Southern Hemisphere Trialists) Study Group. Randomised trial of efficacy and safety of inhaled zanamivir in treatment of influenza A and B virus infections. Lancet 1998; 352: 1877-1881. Moynihan R. Too much medicine? Sydney: ABC Books, 1998: 8. Wazana A. Physicians and the pharmaceutical industry. JAMA 2000; 283: 373-380. Sweet M. Medicines and the media; a journalist's view. Aust Prescriber 2000; 23: 70-71. The Royal Australasian College of Physicians. Ethical guidelines in the relationship between physicians and the pharmaceutical industry. Sydney: RACP, 2000. Shalala D. Protecting research subjects: what must be done? N Engl J Med 2000; 343: 808-810. Greenberg DS. Stricter regulation proposed for US gene therapy trials [news]. Lancet 2000; 355: 1977. Commercial Radio Inquiry. Report of the Australian Broadcasting Authority hearing into Radio 2UE Sydney Pty Limited, Sydney: ABA, 2000. Sweet M. Journalist, heal thyself. Walkley Magazine, August 1999: 15. Oxman A. Evidence-based medicine and medical journalism. Presentation to Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Irwig L. University of Sydney continuing education courses on evaluating health studies. Levi R. Medical journalism: exposing fact, fiction, fraud. Studentlitteratur 2000 Stockholm. <www.studentlitteratur.se> Accessed 14 November 2000. Bengtsson H. The roles of the Medical Journalist. Presentation to Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Authors' Details Ray Moynihan, BA, Journalist, Australian Financial Review, Harkness Fellow in Health Policy, 1998-1999. Melissa Sweet, BA, MA, Journalist, The Bulletin and Australian Doctor. Reprints will not be available from the authors. Correspondence: Mr R Moynihan, 76 Francis Street, Bondi, NSW 2026. ray_128AThotmail.com Make a comment What the media didn't say The relative-risk "gee-whizz" effect A retrospective analysis of 207 United States newspaper (n = 180) and television (n = 37) stories in the period 1994-1998 about three preventive medications (pravastatin, a cholesterol-lowering drug; alendronate, a bisphosphonate for treatment and prevention of osteoporosis; and aspirin, as used to prevent cardiovascular disease) revealed that: 53% of 207 stories did not mention potential harms. 70% of 207 stories did not mention drug costs. 83% of 124 stories which quantified benefits used a "relative" frame only -- an approach that is potentially misleading. 60% of 85 stories that cited at least one expert or study with a relevant "industry tie" failed to disclose that tie. A story reported a randomised controlled trial of alendronate as producing an "almost miraculous" 50% reduction in the incidence of fractured hip. Sounds good? The story did not report the actual rate of fractured hip in untreated patients (2%) or treated patients (1%). The relative-risk reduction of 50% sounds much more impressive than the absolute-risk reduction of 1% -- and, of course, both figures must be weighed against other information, such as the costs and side effects of treatment.4 Back to text

Ray Moynihan · Melissa Sweet

Peter Goldsworthy

Medicine and Beyond Life after medicine Ron Elisha MJA 2000; 173: 635-638 Medicine and the Muse There are doctors who devote themselves to their profession, and there are others who escape into alternative careers - George Miller, the film director, and Rob Sitch, the comedian/TV personality/film director, are two famous examples. Then there are those who manage to squeeze two careers into a crowded life. In these personal accounts by novelist/GP Peter Goldsworthy and GP/playwright Ron Elisha, we see these creative writers pursuing a love-hate relationship with the life-and-death demands of medicine. - The Editor By the time I was ready to enter university, 13 years of schooling had equipped me with little more than a bad haircut, the ability to forge my parents' signatures, and a healthy contempt for anyone called "sir". Of the world at large, I knew nothing. Women fell wholly within the realm of terra (read as terror) incognita, the unspoken rules by which society actually operates remained a closed book and, never having been required to decide upon anything more momentous than the timing of a bowel action, I remained a total stranger to consequence. It was with this solid grounding beneath my feet that, on the night before our preferences for university courses were due to be submitted, I reached a spur-of-the-moment decision to opt for medicine. I had no good reason for this, the second most significant choice of my lifetime. Certainly not a rational reason. But, then, rational decisions are made only in retrospect. Alas, some 30-odd years later, I still have no good reason. Medicine, like lava, has consumed everything in its path -- time, energy, intellect, memory, even the very compassion from which the desire to practise it first sprang. Nothing can escape the pervasive imperialism of the medical experience. If it were not so, one would hardly be moved to ask the question "Is there life after medicine?", just as one doesn't think to raise the same question in relation to carpentry, hairdressing or pharmacy. Medicine, even now, remains a vocation -- a calling in the same sense as the priesthood -- something that envelops life rather than being contained within it. Seated behind the desk of the great white healer, held captive before the endless, overwhelming cavalcade of human misery that goes by the polite name of consultation, it is difficult to imagine that there exists within the real world even an atom of contentment, of wisdom or of simple decency. Humanity, it appears, swims within a moral sewer, largely of its own making and always, doggedly, upstream. While the foregoing is demonstrably an exaggeration, it nevertheless represents the perception, the feeling one gets, day after relentless day, from behind that perpetual, immovable, ineluctable desk. It is this feeling, coupled with the lack of conviction that accompanied my original decision, that impels me to write. To see, hear and feel what a doctor sees, hears and feels and not to seek explication, exegesis and catharsis through writing defies comprehension. To bear such witness for 80 hours per week and not to need to escape into the world of writing -- where, for a fleeting, illusory moment, chaos gives way to meaning -- defies credibility itself. Everything I write, regardless of tone, setting or content, is fuelled by the furnace of anger and outrage I feel at what I daily witness as a doctor. Sometimes it is anger directed at the evil that men do, sometimes outrage at the profound sorrow that is intrinsic to human existence, perhaps directed at God or, more precisely, at the self-destructiveness and, ultimately, moral bankruptcy of a human vision that would conceive of a God capable of such infamy. Everything I write is fuelled by the furnace of anger and outrage I feel at what I daily witness as a doctor. The brunt of my anger, however, is borne by medicine itself. For the suffering it has inflicted in the name of progress, for its arrogance in masquerading as a science, for its simplistic reduction of the disease paradigm to a battle between a man and a microbe (social context be damned), for its ham-fisted blundering in ignorance, for its overweening paternalism, for its ultimate impotence in the face of real human suffering and the finality of death. For all these things I cannot forgive medicine. And for its covetousness, its jealousy, its proprietorial imperative, binding its practitioners to a life of servitude at the expense of family, friends, fitness and, at the end of the day, the very writing that might have served as an antidote to its unbending tyranny. For that is precisely the place to which my first love, writing, has been relegated -- the end of the day. When the patients have been seen, dinner eaten, the children bedded, reports written and journals read, it is that tiny scrag-end of night during which -- to the accompaniment of burning eyes and aching back, and with the brain rapidly descending into slumber -- I allow myself the luxury of literary enterprise. The window of opportunity, however, is painfully small, and days or even weeks may pass without a word being writ -- not for want of the creative spark, but for want of time, energy and, in the end, simple consciousness. As the years pass, and with the advent of each new medical torture -- vocational registration, accreditation, amalgamation -- the window grows progressively smaller, to the point where each evening is now a blank wall. And there is no hiatus during the day through which I can indulge my other self in rehearsals or meetings or the kind of schmoozing that actually gets a play on. Patients will insist on getting sick. Time waits for no man. And that's not an actor waiting in the wings, but Death itself. Which means that the only true sense in which there is life beyond medicine is in the sense of the life of the mind, which retains its capacity to traverse the universe even as Mrs Blogg describes the bouquet of her stool. It is this mind-body dichotomy -- the coexistence of the sublime and the ridiculous within the one, tiny space -- that hones the irony of my work. My real work, that is. The great love of my professional life. My writing. And it is the terrible irony central to that work which lifts it above the level of mere diversion, imbuing it with what passes for a semblance of meaning, so that when I sit behind my desk, struggling to retain consciousness through endless tales of dysfunctional body cavities, I can almost convince myself that it's all been worth the effort. Almost. Ron Elisha graduated in medicine in 1975, and has spent most of his career in full-time general practice. He has written stage plays, radio plays, teleplays, screenplays, children's stories, short stories and feature articles. Many of these have been published or produced, both in Australia and overseas (including the USA, the UK, Canada, New Zealand, Israel, France, Belgium and Poland). He has won four Australian Writers' Guild Awards (AWGIES) for best scripts for works for stage and television, including the Major Award in 1982 for the play Einstein. Other highlights of his writing career have been a US tour of Einstein, a trip to London to work on a screenplay with Istvan Szabo and a trip to Paris as a guest of the Comédie Française.

Ron Elisha

Power of One A clinician with a passion for pathology Priscilla Kincaid-Smith MJA 2000; 173: 639-642 As a woman in medicine and as a scientist, Professor Kincaid-Smith has met and overcome some determined obstructionists Hammersmith and the research focus - No place for women - Analgesic nephropathy - The achievements of pathology - References - Author's details Make a comment - - - More articles on History Introduction The early 1950s, when I graduated, were an exciting time in clinical medicine. Penicillin had only just become generally available and it revolutionised the treatment of infectious disease, particularly in a hospital like Baragwanath Hospital, where I spent my early years as a doctor. This 2000-bed hospital across the road from the now-infamous Soweto township outside Johannesburg was to absorb my full attention for the next two years. It was a very exciting place for the residents and registrars, as the wards were full of very ill patients many of whom could now be cured. A dose of penicillin which we would now consider homoeopathic transformed pneumonia into an illness lasting a few days and its mortality fell dramatically. In the same years chloramphenicol did for typhoid fever what penicillin had done for pneumonia, and chloroquine cured most patients with malignant cerebral malaria. The ward balconies were full of patients with advanced tuberculosis and this too became a curable disease after streptomycin became available. Hammersmith and the research focus After three years of working like a galley slave but gaining a huge experience in clinical medicine, I was lucky enough to be accepted at Hammersmith Hospital, London. At that time Hammersmith Hospital was a leader in many fields, notably in cardiology, where McMichael and Sharply-Schafer had pioneered cardiac catheterisation and the Australian, Paul Wood, certainly one of the world's top clinical cardiologists, worked for a time. At Hammersmith the whole attitude was to do research, and improve medical knowledge. It didn't give me the same satisfaction of saving lives, but it was certainly the academic centre of London in the 1950s. At that time the ancient traditions of the London teaching hospitals were a handicap to doing new things and research. Hammersmith was frowned upon as "that hospital next to HMP Wormwood Scrubs, that hospital where they did all those experiments!". I came into contact with some of the most famous names in medicine. Each day seemed more exciting than the last and the rate of learning was exponential. I spent two and a half years in anatomical pathology, but my research interest in hypertension and the kidney stood me in good stead for my future career in the then non-existent field of nephrology. Renal biopsy was in its infancy and Robert Heptinstall, perhaps the world's best renal pathologist, came over regularly from Mary's Hospital to look at renal biopsies with our expert in this field, "Do" Doniach, who was senior pathologist at Hammersmith Hospital. This exposure to living pathology has had a great influence on my career in nephrology, which, although unequivocally clinical, has always kept me close to a microscope and involved in pathology. As a pathology registrar, I spent the mornings doing autopsies, the highlights of which were the attendance at lunchtime of all the top clinicians for a presentation of the findings. This was a no-holds-barred school, with people like John McMichael (Head of Medicine at Hammersmith) and Sheila Sherlock (who published the first major book on hepatology and became a world leader in the field). Nothing was taken for granted: the questioners were a very erudite and exacting bunch of clinicians. Histological analyses of biopsies and surgical specimens were reported on the day they became available. This necessitated many late nights to prepare for the consultant pathologist's overview the next morning, but this one-on-one learning process was excellent. As an early riser I found that I could easily start work about two hours before anyone else arrived, which allowed me to do some research. My first "kidney" paper was published in The Lancet in 1955,1 and I managed quite a lot more in those extra two hours each day. Although I was fully immersed in pathology, I couldn't drag myself away from the wards. After attending ward rounds two or three times a week, my envy of the doctors looking after patients finally drew me back to clinical medicine in 1956. My training was in cardiology -- there was no specialty of nephrology --but, as hypertension was my main research interest and most of my previous research had involved hypertension and the kidney, I became a de facto nephrologist. Another great advantage was that Malcolm Milne was second in charge in the McMichael cardiology unit in which I worked, and he was truly one of the founding fathers of nephrology. Not only did I learn a lot from Malcolm, but we ran the dialysis service for southern England and collaborated with a string of clinical fellows with renal interests, among them Bob Muehrcke (who established renal biopsy as a safe procedure) and Belding Scribner (of dialysis fame). In 1958 Sir John McMichael called me into his office to offer me a junior consultant post at Hammersmith. I was overwhelmed and greatly honoured, but had that week become engaged to Ken Fairley (from Melbourne, who spent four years training at the National Heart Hospital in cardiology with Paul Wood), and neither of us really wanted to bring up a family in England. I sometimes wonder if, had I known what awaited me in Australia, I might not have tried to persuade Ken to stay in England after all. No place for women I had assumed that I would be eligible for a similar post in Melbourne to that offered in what I regarded as the UK's top hospital, but I was very wrong. In the 1950s, in Australia, when a woman married she automatically lost her job. I was not considered for any significant post in a hospital or university in Melbourne. My curriculum vitae was not wanting: I had published several respectable articles, held a postgraduate qualification in pathology, was a member of the Royal College of Physicians, London, and had eight years of first class postgraduate training. I had excellent references. But I was the wrong sex! I was devastated. It seemed that almost all doors were closed to married women. After doing general practice locums to help pay the bills, Sir John McMichael arranged a part-time research position for me at the Baker Institute at the Alfred Hospital, Melbourne. However, Ken and I decided that if I was not wanted in Melbourne perhaps we could be of service in New Guinea, which had almost no specialists in its health service. We applied for and were offered appointments, Ken as a physician and I as a pathologist. We went up to New Guinea to inspect the new hospital in Rabaul and were thrilled with the facilities, but soon discovered that, as a married woman, my appointment could only be temporary. If any man, irrespective of qualifications, applied, he would get the position, and permanent to boot! So it was back to Melbourne, where I was appointed as an honorary physician at the Queen Victoria Hospital, a hospital run by women for women. I also had a part time research position at the Baker Institute and a part time research and teaching appointment in the University of Melbourne, Department of Medicine, at the Alfred Hospital. Eventually, in 1967, I was appointed as first Assistant in Medicine in the University of Melbourne. That was the year in which barriers to employing married women in universities were removed. Analgesic nephropathy It was on my very first day at the Alfred that I encountered my first case of what was later called analgesic nephropathy. I went, as I always had at Hammersmith Hospital, to review that day's postmortem findings. There was no formal presentation and the pathologist seemed somewhat surprised to see me. Demonstrated were the kidneys from three patients. All showed the same lesion, a kind which I had never encountered at the Hammersmith. These had very obvious features: black necrotic papillae with overlying atrophy and with striking hypertrophy in adjacent columns of Bertin (Box 1). On asking the pathologist what this lesion was he replied that it was papillary necrosis, a common complication of renal infection. "Well, it doesn't occur in renal infection in London", I replied, but I don't think he believed me. Although I recognised the lesion as the sign of a specific disease process at that first-ever autopsy attendance in Melbourne early in 1959, it took a bit longer to connect it to analgesic abuse. I had, of course, seen acute renal papillary necrosis in an occasional kidney in England, but the Alfred cases were quite different and more chronic lesions. Phenacetin nephritis had been described in Switzerland as chronic interstitial nephritis in 1953, but there was almost no mention of papillary necrosis in the description, certainly none of pigmented papillae. When I was finally able to get a photograph of one of the Swiss kidneys it was clearly different: the kidney was small and there was a moth-eaten appearance of the papillae, which presumably represented areas from which necrotic tissue had been lost (Box 2). Ken Fairley was working in Bill King's unit at the Royal Melbourne Hospital and it was he who made the connection between the kidneys seen so frequently on the autopsy table in Melbourne and analgesics. Bill King was a busy gastroenterologist and when he encountered patients with renal disease he consulted Ken. Over a relatively short period of time Ken gathered a series of patients with peptic ulcers and impaired renal function who also had a history of a phenomenally high intake of analgesics. When one of these patients passed a small fragment of pigmented material which was processed and turned out to be a piece of renal papilla the puzzle was solved. These patients had analgesic nephropathy, even if the lesions were quite different from those described by Spühler and Zollinger in Switzerland.2 In 1963, at the International Society of Nephrology meeting in Prague, we had great difficulty in persuading our European colleagues to accept our evidence for this new form of analgesic nephropathy. They particularly did not like the large kidneys, which we demonstrated to reduce in size on radiological imaging as papillae were sloughed, with resulting cortical atrophy. This always seemed to me to be the likely pathogenesis of the so-called "chronic interstitial nephritis". They objected even more strenuously to the demonstration that this shrinkage in our cases was often followed by remarkable hypertrophy in Bertin's columns. They stressed the rarity of pigmented papillae and papillary necrosis, both major features of our cases. They argued that what we were describing was certainly not "phenacetin nephritis". We were already calling it "analgesic nephropathy" by then, because it continued unabated if patients ceased taking phenacetin and replaced it with paracetamol. There was strong opposition to this view and almost a denial of any connection between our Australian variety of analgesic nephropathy and their "phenacetin nephritis" with chronic interstitial nephritis. Later, years of careful clinical documentation and animal experimentation showed that it was not the phenacetin but the mixed analgesics that caused the renal papillary necrosis. Phenacetin alone or its immediate metabolite, paracetamol, could be fed to rats in huge quantities without causing apparent damage. But when we fed rats the analgesic powders and tablets then being sold in huge quantities in Australia we quickly reproduced the lesion of renal papillary necrosis, which closely resembled analgesic nephropathy in man, even to the detail of pigmented papillae. The stories of analgesic abuse extracted from patients at that time were incredible. The patients were truly addicted to the analgesics. They appeared to be seeking the mood-altering effects, not the analgesic effects, and it seemed that it was the phenacetin which they missed when taking different combinations. The patients were commonly heavy smokers and found it easier to give up cigarettes than analgesics! In the first group of patients that we studied, as many died of coronary artery disease as of renal failure.3 Extensive premature atheroma was a prominent feature, but we could never quite prove that it was the analgesic abuse and not the smoking that was linked to the atheroma. Renal artery stenosis was another common feature, perhaps also due to smoking, but we did postulate that the huge quantities of aspirin which these patients took may have destroyed the "good" as well as the "bad" prostaglandins and predisposed to severe atheroma. Our wards were full of patients with the analgesic syndrome. In addition to the characteristic renal disease, peptic ulceration, anaemia, premature atheroma and premature ageing, dementia was a frequent finding. Some blamed phenacetin for the impaired cognitive function. Severe and often malignant hypertension was another characteristic feature. Renal failure was of course a major cause of death, but if the patient could be persuaded to give up the analgesic abuse a remarkable degree of recovery could be expected. Nonetheless, when this condition started to feature on dialysis and transplant registries 10 years later, it was indeed a major cause of end-stage renal failure -- most common in Queensland and New South Wales and least common in Victoria, where our studies had been carried out. Gradually the message got across. Long before government regulations were introduced to control sales, people became aware of the dangers of analgesic abuse and the prevalence gradually declined. Analgesic powders and tablets, which were then available free in factories and other places, also disappeared, as did the cardboard boxes in which a gross of analgesic powders or tablets were sold. They had once been a very prominent item in the weekly family supermarket trolley. Over the next 10 years or so, the pharmaceutical companies lobbied long and hard against the evidence that analgesic abuse was a major cause of renal failure. In the late 1970s I happened to be flying interstate, seated in front of two senior executives from one of the many companies whose fortunes were founded on APC sales. From this vantage point, I overheard them vigorously attacking me and what I had said about analgesic nephropathy. I was of course delighted that they thought that I had had such an influence on analgesic sales. Later, the tenor of their discussion was that Australia was a lost cause for advertisement and sale of mixed analgesics, and they began to discuss plans to invade the markets of South East Asia, where there were no controls over either advertising or sales. They were targeting Malaysia in the first instance, and reports of analgesic nephropathy from Malaysia 10-20 years later confirm that their plans succeeded. Advertising had been one of the secrets of the success of analgesic sales and this dated back to the 1920s, when Nicholas in Melbourne commenced manufacture of aspirin after the defeat of Germany in World War I and the collapse of Bayer. History relates that a new manager from the United States had predicted that there were millions to be made from aggressive advertising of analgesics. Thirty years later one would still hear on television programs that "You will need Aspro today". It was not uncommon even in the 1960s and 1970s to see shop windows devoted to advertising a particular variety of analgesics (Box 3). Between 1979 and 1982 all Australian States legislated to control over-the-counter sales of mixed analgesics. This was 20 years after most nephrologists were convinced of the need to do this. The final success came from joint activities by the Australian Kidney Foundation and the Australasian Society of Nephrology, which managed to convince the National Health and Medical Research Council and, in turn, the Government. Progress was painfully slow to those of us struggling with the very common disease which resulted from analgesic abuse. The controls were sensible and effective. Regulations controlled the number of analgesics that could be sold in one pack and did not permit the sale of combinations of aspirin, phenacetin, paracetamol and caffeine. Analgesic nephropathy, which had been such a common clinical condition, gradually faded away. The achievements of pathology Although I now rarely visit the autopsy room, I still look down the microscope every day, peering at all the fascinating things which appear in the urine of patients with renal disease, or examining renal biopsies. I now have a collection of some 20 000 renal biopsies; in many I have known the clinical story as well as the pathology. Nephrology was at first dominated by physiologists and pathology was a very poor relation, but, in my view, pathology has contributed far more to clinical nephrology than physiology. Now pathology, in combination with various immunological techniques applied to biopsy tissue, is certainly at the forefront of advancing knowledge in nephrology. References Kincaid-Smith P. Vascular obstruction in chronic pyelonephritic kidneys and its relation to hypertension. Lancet 1955; 2: 1263-1269. Spühler O, Zollinger HV. Die Chronische Interstitielle Nephritis. S Klin Med 1953; 151: 1-50. Dawborn JK, Fairley KF, Kincaid-Smith P, King WE. The association of peptic ulceration and chronic renal disease and analgesic abuse. Quart J Med 1966; 35: 69-83. Author's details Epworth Hospital, Melbourne, VIC. Priscilla Kincaid-Smith, AC, MD, FRACP, FRCPA, Medical Director and Director of Nephrology; Emeritus Professor, University of Melbourne. Reprints will not be available from the author. Correspondence: Professor P Kincaid-Smith, Epworth Medical Centre, 185-187 Hoddle Street, Richmond, VIC 3121. priscillkATepworth.org.au 1: Autopsy specimen of both kidneys and the aorta in a 43-year-old man The kidneys show bars of hypertrophy on the outer aspect of the right kidney representing hypertrophy in columns of Bertin. The cut surface of the left kidney shows typical features of analgesic nephropathy, with black pigmented papillae, atrophy of cortex over nephrotic papillae and pale areas of hypertrophy in Bertin's columns. The aorta shows extensive atheroma. Return to text 2: Cut section of a kidney with typical features of the "Swiss" variety of analgesic nephropathy The cortex is atrophic. The papillae show small cavities from which necrotic material has been lost. No hypertrophy is seen in Bertin's columns. Return to text 3: A typical 1960s shop window display advertising a popular analgesic Return to text

Priscilla Kincaid-Smith

Power of One Service in three careers Peter E Baume MJA 2000; 173: 643-646 Life is full of opportunities, with no time to waste Medicine, 1955 to 1980 - Politics, 1971-1991 - Academia, 1991-2000 - Reflections - References - Author's details Make a comment - - - More articles on Education Introduction The apocryphal story is told of an aged French abbé who planted a tree that would not mature for some decades. When challenged about the wisdom of the action in light of his age, he is supposed to have responded: "There is not a moment to lose." It has been the same for me. So much to do; so little time; so many interesting things; so many choices to be made; so many possibilities at every stage. It just seems impossible to get it all into one lifetime. Some of us are lucky enough to have several quite different careers, so we learn different skills and experience different things. Medicine, 1955 to 1980 My first career, in medicine (see Box 1), was a joy. Those were days when it was good to be a medical practitioner, when doctors were appreciated and medicolegal considerations were not predominant. The patients I saw were interesting people. Their illnesses were challenging, their needs great, their distress real. I was not the first to observe that people sometimes came with "surrogate" problems hiding their real concerns, and that best results were obtained when their underlying concerns were allowed to surface. Treating the "surrogate" problem was sometimes irrelevant. It has always been true in good medical practice that people matter more than do their diseases alone. Politics, 1971-1991 In 1971, I was contacted by the late Don Dobie, MP, an Assistant Minister in the McMahon Coalition Government, who wanted a medical practitioner to contribute to the inescapable forthcoming Medibank debate. This was my introduction to politics. Medical practice had become very busy and demanding for me and my family. Dobie inspired me to stand for Liberal Party preselection. After an unsuccessful tilt at one seat (Berowra, NSW), I was taken in hand by Senator John Carrick (later Sir John Carrick) and then won preselection for a Senate place in NSW. Politics was service to people in a different, more direct way. I worked for people and my office was often the point from which they had their many problems addressed. Of course, I never ceased to be a medical practitioner in the Parliament and I continued to publish in medical journals.1-8 Many people needed medical care while in Canberra. I developed good relations with practitioners in Canberra but still needed to do a fair bit of work myself -- always pro bono, not least because of certain arcane provisions of the Australian Constitution, but the work was certainly varied. People used to wander in and make it clear that they wanted to see the doctor and not the politician. My excellent staff soon got used to this. If colleagues or staffers needed routine referral or wanted pills that they had forgotten, these were organised easily enough. If it was an emergency, this usually required that I speak to one of the first-rate general practitioners or specialists in Canberra -- after a while, this became a well-practised routine. My parliamentary career lasted 17 years (see Box 2). I began on the backbench and soon chaired a Senate Standing Committee which brought in two influential reports. The first report ("Drug problems in Australia -- an intoxicated society?"9) placed alcohol and tobacco centre stage as drugs -- at that time a radical suggestion outside the medical profession. Prime Minister Malcolm Fraser's response was to ask a learned judge to conduct a Royal Commission, which rejected some of our findings. The second report ("Through a glass darkly: evaluation in Australian health and welfare services"10) insisted that what we achieve is probably more important than what we do (although some public servants clearly indicated to the committee that they considered their activity more important than their results). In 1987 a personal crisis came when I was Shadow Minister for the Status of Women, when I supported a Bill seeking equal employment opportunity for women in certain statutory bodies, such as Qantas, in spite of the decision of the Liberal Party to oppose the Bill. When the votes came, a quarter of the Liberal senators supported me (without any lobbying on my part) on the vote. This was a momentous decision for me and my family. But it is not even a footnote to history now. What was pleasing was the mail I received afterwards, most notably a telegram from Carmel Niland, then President of the Anti-Discrimination Board of NSW and now Director-General of the NSW Department of Community Services. Her message read simply: "Thank you. Thank you. Thank you." But the die was cast. I was finished in the Liberal Party. It is true that one is allowed to cross the floor in the Liberal Party of Australia, but my philosophical liberal principles sat poorly with the increasingly dominant radical conservatism of others. It was time again for a change of career. Academia, 1991-2000 Early in 1989, Professor Ian Webster (Head, School of Community Medicine, University of NSW) approached me to say that he believed he could make a greater medical impact in the communities of south-western Sydney, centred on Liverpool, than he could in more affluent parts of Sydney, and that he would go to the south-west if a suitable replacement could be recruited for the campus at Kensington. I was happy to be considered among the candidates for his position. After a public and proper selection process, I was appointed. So it happened that I left the Australian Senate in 1991 to become Professor of Community Medicine at the University of New South Wales. I led a good School with some fine academics and strong programs of teaching and research. We taught to all undergraduate medical students and to graduates in public health, epidemiology, medical ethics, biostatistics, general practice, aged and extended care, general education, drug and alcohol, women's issues, and more. Along the way I was able to pursue research interests in euthanasia,11-21 drug policy22-24 and evaluation.25 It was also possible to do some interesting consultancies and to repay society with some pro bono work. In 1991 I wrote a book, A question of balance,26 urging reform of the drug licensing system in Australia. My proposition was that a better marriage of timeliness and safety in the licensing of therapeutic drugs was required for society to get maximum benefit. These recommendations were accepted in subsequent reforms. I performed other consultancies for the Menzies School of Health Research in Darwin,27 for the NSW and Tasmanian departments of health and for the Commonwealth on disability services.28-30 Each consultancy was commissioned to examine purposes and structure in very different settings. Controversy surrounded my consultancy reports on veterans' compensation31 and on Australian surgeons for the Australian Government.32 In one case the government realised that it had a crazy system and in the other it wanted to know more about surgeons and surgical specialties. Bruce Ruxton (Victorian President of the RSL) wrote an angry letter about the Veterans' Report, and many prominent surgeons and professional bodies were outraged by my report. Over time much of the controversy has abated but few of the recommendations have been implemented. Nineteen colleagues combined to write a book (The tasks of medicine33) under my editorship in 1998. In it, it was possible to outline some personal beliefs and suggest some desirable directions for the future of healthcare. After the cryptosporidium "crisis" in Sydney's water supply in 1998, the NSW government decided that someone with some knowledge of public health should be added to the Board of the Sydney Water Corporation. I accepted the position and really enjoy work on the Corporation Board. Sydney Water may get bad press, but certainly approaches issues with care and prudence. It does serve the society, trying to determine difficult issues fairly. In 2000 I chose to leave the University of New South Wales to allow a younger person to have a turn. To give my successor a fair go, I moved to the university's Social Policy Research Centre as an honorary research associate. (See Box 3 for academic career.) Reflections Each of my three careers has demanded the refinement of quite different skills, but I see a theme of service to others running through them all. My family has a record of public service. One great-uncle (John Jacob Cohen) was Speaker of the New South Wales Legislative Assembly; my grandfather, Frederick Baume, was a New Zealand MP from 1900 to 1910; and several ancestors were medical practitioners. To me, medicine was pre-eminently about helping people; going into Parliament was simply another way of helping people; and teaching was yet another way. In all my medical teaching and writing I have tried to convey the notion that people are more important than their diseases and that the whole person is the proper focus of medical care. Medical practice required the understanding of many concepts, particularly about human structure and function, the learning of a mass of material about particular illnesses, and some fascinating learning about people and their needs. Medical practice might be even better if people realised that all paradigms are provisional and that acceptance of change is one attribute of wisdom. Politics is quite different as regards its skills, but similar as regards the centrality of people. There is a tendency to devalue the skills of politics, but there is a set of communication and brokerage skills peculiar to that trade that must be learned by anyone wishing to do well. People who belittle politics and politicians are usually those who have no personal experience of the political life. Those who have tried politics know just how demanding and difficult it is -- particularly the need to bring others around to your own viewpoint. It is the same in academic life. In a collegial system like a university school, one has to demonstrate leadership, rather than just give orders, if one wants people to follow. The chance to teach eager and bright young people is a privilege. To carry out this task as an agent of a wider society is a trust. To help more mature people gain extra skills is a pleasure too. The university teaching role is something about which I continued to learn throughout all my time in academe. My sister, who taught at high school, constantly showed me how to do educational tasks better. It seems that those of us with more "technical" skills have a lot yet to learn from the educational academics, those who have the technical skills in teaching and learning. Recently, information technology has made a huge difference in what we can offer and do. Universities like the University of Sydney which have developed a growing intranet have pointed out one new and exciting way of improving resources for students. The University of Southern Queensland, at Toowoomba, is also exploring the possibilities of using information technology more imaginatively -- and attracting positive worldwide interest in the process. The intellectual life of a faculty of medicine is interesting too. It was the capacity to think creatively and to challenge and test existing systems of belief that I valued most highly in those doing research in the School of Community Medicine. People have only a limited time to contribute intellectually and they might as well use that time most productively. While "routine" pot-boiler surveys certainly have their proper place in research, it is thinking that forces us to re-examine or modify paradigms that carries most weight. Certainly, this is what I see at the exciting Australian National University. We are all different and it would be churlish to think all people should value the same kind of life trajectory. But for me, the opportunities and rewards have been great, and the chances to serve, sometimes unexpected, have been ones that I have appreciated. Family support has always been important, and I can only thank my parents, wife, siblings and children for their help, counsel and understanding. It has all meant so much and has made much possible. Now let us see what new tasks lie ahead. There is not a moment to lose. References Baume PE, Tracey M, Dawson L. Efficacy of two minor tranquilizers in relieving symptoms of functional gastrointestinal distress. Aust N Z J Med 1975; 5: 503. Messer M, Baume PE. Oral papain in gluten intolerance [letter]. Lancet 1976; 2: 1022. Baume PE. Medicine, men and politics throughout the ages. Aust N Z J Med 1977; 7: 229-238. Baume PE, Alder S, Greig M. Study of one consulting medical practice. Aust N Z J Med 1981; 11: 255. Baume PE. The Kolling Institute -- the first 50 years [editorial]. Med J Aust 1985; 143: 96. Baume PE. Oration. Aust J Physiotherapy 1979; 25: 141-144. Baume PE. Current medical politics and peer review. Australas Radiol 1979; 23: 4. Baume PE. The great equation is wrong. Aust N Z J Psych 1980; 14: 175-178. Senate Standing Committee on Social Welfare (Chair: Senator Peter Baume). Drug Problems in Australia -- an intoxicated society? Canberra: AGPS, 1977. Senate Standing Committee on Social Welfare (Chair: Senator Peter Baume). Through a glass darkly: evaluation in Australian health and welfare services. Canberra: AGPS, 1979. Baume PE, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1995; 161: 137-144. Baume PE. Voluntary euthanasia -- mercy or sin. New Doctor 1995; 63: 13-14. Kuhse H, Singer P, Baume PE, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. Baume PE, O'Malley E, Bauman A. Professed religious affiliation and practice of euthanasia. J Med Ethics 1995; 21: 49-55. Kuhse H, Singer P, Baume P, Clark M. Medical end-of-life decisions: Australia and the Netherlands. Mature Med Can 1998; May/June: 37-38. Baume P. The right to die. Hospital Healthcare 1997; December: 28-29. Yuan ZF, Baume PE. Attitudes of Sydney Chinese to voluntary euthanasia. Aust N Z J Public Health 1997; 21: 106-107. Kuhse H, Singer P, Baume PE, Clark M. "Muddled" commentary on end-of-life study. Aust Doctor 1997, 18 April: 23. Baume PE. The euthanasia study. Quadrant 1997; September: 12. Kuhse H, Singer P, Baume PE, Clark M. Medical end-of-life decisions in Australia and the Netherlands. Geriatrics Aging 1997; 167: 282-283. Baume P. Voluntary euthanasia: letting people decide for themselves. Aust J Ageing 1997; 16: 8. Baume P. Why drug policy reform has not happened. In Touch 1998; 15: 1-2. Baume PE. Overcoming myths, hypocrisy and lies: drug law reform in Australia. New Doctor 1989; 51: 8-9. Baume PE. Drug legalisation. Health System Reform -- Health Outcomes Bull 1989; 1: 4-5. Baume PE. Getting the policy right: recovering the golden rules of evaluation. In Uhr J, editor. Decision making in Australian government: program evaluation. Canberra: Union, 1991: 35-38. Baume PE. A question of balance -- report on the future of drug evaluation in Australia, Canberra: AGPS, 1991. Baume PE. Opportunity and benefit -- report of a consultancy on relations between the Menzies School of Health Research and Aboriginal people. Darwin: Menzies School of Health Research, 1991. Baume PE, Nutbeam D, NSW Health. Achieving accountability for health outcomes in the Australian health system. Sydney: Health Promotion Unit, NSW Health, 1992. Baume PE, Kay K. Interim report: strategic review of the Disability Services Program. Canberra: Commonwealth Department of Human Services and Health, 1994. Baume PE, Kay K. Working solution: strategic review of the Disability Services Program. Canberra: Commonwealth Department of Human Services and Health, 1995. Baume PE, Bomball R, Layton R. A fair go -- report on compensation for veterans and war widows. Canberra: AGPS, 1994. Baume PE. A cutting edge: Australia's surgical workforce 1994. Report of the Inquiry into supply of, and requirements for, medical specialist services in Australia. Canberra: Commonwealth Department of Human Services and Health, 1994. Baume PE, editor. The tasks of medicine: an ideology of care. Sydney: Maclennan and Petty, 1998. Author's details Social Policy Research Centre, University of New South Wales, Sydney, NSW. Peter E Baume, AO, MD, FRACP, Honorary Research Associate, Emeritus Professor, University of New South Wales, and Chancellor, The Australian National University. Reprints will not be available from the author. Correspondence: The Honourable Professor P E Baume, 32/17 Raglan Street, Mosman, NSW 2088. p.baumeATunsw.edu.au 1: Medical career MB BS, University of Sydney, 1959 Residency and registrarship, Royal North Shore Hospital, Sydney, 1960-1962 Member of the Royal Australasian College of Physicians, 1962 Research fellow, Royal North Shore Hospital, Sydney, 1962 Scholarship studies in gastroenterology in the UK (1963) and USA (1964-1965) Royal Australasian College of Physicians, Roche Research Scholarship, 1965 Honorary Assistant Physician, Royal North Shore Hospital, Sydney, 1967-1974 Clinical Lecturer, University of Sydney, 1967-1974. Doctorate in medicine, University of Sydney, 1969 Consultancy 1967-1980. Return to text 2: Political career New South Wales Senator, 1974-1991 Member, Senate Standing Committee on Social Welfare, 1976-1980 Government Whip, 1978-1980 Federal Minister for Aboriginal Affairs, 1980-1982 Federal Minister for Health, 1982 Federal Minister for Education, 1982-1983 Shadow Minister for Education and Youth Affairs, 1983-1984 Shadow Minister for Education and the Status of Women, 1984-1985 Shadow Minister for Community Services and the Status of Women, 1985-1987 Member AIDS Parliamentary Liaison Group, 1985-1991 Return to text 3: Academic career Professor of Community Medicine, University of New South Wales, 1991-2000 Honorary Fellow, Royal Australian College of General Practitioners, 1991 Chair, Drug Offensive Council of New South Wales, 1991-1992 Member, Australian National Council on AIDS, 1991-1994 Foundation Chair, Australian Sports Drug Agency, 1991-1999 Officer of the Order of Australia, 1992 President, Public Health Association in New South Wales, 1992-1994 Commissioner, Australian Law Reform Commission, 1993-1997 Chancellor, the Australian National University, 1994- Member, Harkness Fellowship Selection Committee, 1995-2000 Member, West Committee on higher education financing and policy, 1997-1998 Participant, NSW Drug Summit, 1999 Emeritus Professor, University of New South Wales, 1999 Honorary Doctorate in Letters, University of Southern Queensland 2000 Return to text

Peter E Baume

Medicine and the Community A swimming program for children with asthma Does it improve their quality of life? Colleen P Wardell and Clair Isbister MJA 2000; 173: 647-648 Methods - Results - Discussion - References - Authors' details - - More articles on Paediatrics Introduction The Asthma Foundation of NSW started the Asthma Children's Swimming Program in 1964. Previously, it was observed that many asthmatic children tended to be excluded from sport and often had difficulty learning to swim in available "learn to swim" programs. They were generally not physically fit. Many were mouth breathers, often with some chest deformity and chronic rhinitis. Even when adequately medicated, respiration was inefficient, with decreased movement of the diaphragm, and nasal obstruction and recurrent ear and throat infections. Many had low body fat, giving poor insulation against cold water pool conditions, which appeared to aggravate wheezing and exercise-induced asthma. Yet some of Australia's Olympic swimmers of the time (such as Dawn Fraser and Jon Henricks) were asthmatic, which suggested that asthma need not be a barrier to physical fitness. The value of swimming for asthmatics was supported by articles in medical journals1,2 and anecdotal evidence. It was a low weight bearing exercise, potentially life saving, easily supervised, and suited to individual tuition and practice. A swimming program also presented an educational opportunity to teach about health and asthma and efficient breathing. Logically and physiologically, swimming appeared the most suitable exercise relevant to respiratory and overall well being. The program developed by the Asthma Foundation of NSW modified the teaching methods of the day to meet the special needs of asthmatic children (Box 1). By 1994 the program had expanded from one to 36 pools throughout metropolitan and rural NSW. In those 30 years about 25 000 children were taught by 2000 volunteer instructors. This kind of growth, based on the voluntary involvement of unpaid instructors and parents of asthmatic children, is itself a measure of success. The anecdotal evidence of those involved in the program is that it improves health, reduces the frequency of asthma attacks and improves the children's quality of life. The NSW Department of Sport and Recreation had acknowledged the value of the program, and included it as an extension course for AUSTSWIM instructors. In 1994, the Asthma Foundation of NSW allocated $10 000 for an evaluation of the swimming program. That study was a retrospective survey involving a limited statistical analysis and a qualitative evaluation of the effect on the whole child.3 In this article we present the main findings of that evaluation, a full report of which is available from the Foundation.4 Methods Asthma is a multifactorial condition with many variables, including severity, seasonal incidence, and multiple trigger factors, such as allergy, climate, and infection. Medical treatment and school and home management differed, as did the geographic distribution of pools. Under these circumstances, it was not possible to assemble a suitable control group for a case-control study. After studying the relevant literature, we concluded that a quality-of-life study by means of questionnaires administered to parents and volunteer instructors was the most appropriate method. Two rural and three metropolitan swimming groups were selected for the study. Children were randomly selected from those who had attended for over one year (to avoid a seasonal influence on results). Three questionnaires were prepared: two for parents and one for instructors. The first parental questionnaire related to the child's condition on entering the program, and the second to the child's condition at the time of the study. They both asked for information about hospitalisation and doctor's visits; physical signs such as mouth breathing, snoring, and chest deformity; general health; other illnesses and allergies; peak flow readings; severity of asthma; school attendance and performance; height and weight; and participation in other swimming classes and sport. The instructor's questionnaire asked about their participation, how and why they did voluntary work, and their observations on the children and the program. Results One hundred and twenty-three sets of questionnaires were distributed to parents, and 87 sets were returned. However, it was found that one rural swimming group had not adhered strictly to the swimming instruction method and had to be excluded, leaving 73 sets for the survey. These were for 38 boys and 35 girls, with an average time of 2.4 years in the program. The main quantifiable results are shown in Box 2. Asthma medication and medication dosage were highly variable in this group of children. Parents of half the children reported a change in medication since starting the swimming program, with two-thirds showing a decrease. Almost all parents who answered the questionnaire were satisfied with the program and reported that the changes in the children had improved the quality of life of the whole family. Appreciation was expressed for the program, the value of the year-round availability, the individual tuition, and the caring attitude of the volunteers. Also valued was the opportunity to discuss common problems with other parents of asthmatic children, and the asthma education provided. Instructors had joined the program for many reasons and some had stayed over 25 years. They enjoyed their participation, and felt that they were rewarded by the children's achievements and the improvement seen in their general health and attitudes. They commented that many children were timid and anxious at first, and needed much coaxing. This made the children's eventual success and increase in confidence and self-esteem even more rewarding for the instructors. It was often noted that children who could swim before joining the program were breathing inefficiently. When this was corrected they swam longer distances with greater ease. Discussion The results of this study suggest that the program has achieved its purpose and justified its continued demand. For many people the program can improve quality of life and asthma management, and reduce medication, visits to doctors, and hospitalisations. Peak flow meter readings taken at every session have been a useful guide for the instructor regarding the child's possible need for pre-swim medication. Huang et al claim improvement in peak flow readings in a swimming program for asthmatic children conducted in the USA,5 but our study did not find significant change in this variable. Instead, the program produced more general improvements in psychological and physical wellbeing. The acquisition of a lifelong sporting skill provides a psychological boost and assists in developing self-esteem and confidence to take part in other activities. The long term commitment and enthusiasm of the volunteer instructors was most impressive and made one appreciate the special value of these people who gave their time and care. For 1999 it was calculated that, had normal hourly rates for swimming instructors been paid, the cost would have been nearly $500 000. A recent report shows that the cost of asthma to the community is $585-$728 million per year.6 Yet here is a program using volunteers, with no government support, which can improve children's health and reduce medication, hospitalisation and visits to doctors, with consequent reduction in parent absenteeism from employment, all of which should result in economic benefits. We hope that others will be encouraged to establish and evaluate programs designed to assist the overall health of people with a specific illness. References Jones RS, Buston MG, Wharton MI. The effect of exercise on ventilatory function in the child with asthma. Br J Dis Chest 1962; 56: 78-86. McEthenney RR, Petersen KH. Physical fitness for asthmatic boys. A co-operative pilot study. JAMA 1963; 185: 142-143. Meyer J. Using qualitative methods in health action research. BMJ 2000; 320: 178-181. Wardell CP, Isbister C. Report on thirty years of the Asthma Children's Swimming Program. Sydney: Asthma Foundation NSW, 1994. Huang S-W, Veiga R, Sila U, Reed E, Hines S. The effect of swimming in asthmatic children -- participants in a swimming program in the City of Baltimore. J Asthma 1989; 26: 117-121. National Asthma Campaign. Report on the cost of asthma in Australia. Canberra: National Asthma Campaign, 1992: 8. Authors' details The Asthma Foundation of New South Wales, Sydney, NSW, 2065. Colleen P Wardell, BA, Swimming Program Co-ordinator; Clair Isbister, FRACP, DCh, Medical Adviser for the Asthma Children's Swimming Program. Reprints will not be available from the authors. Correspondence: Dr C Isbister, 142 Wentworth Street, Blackheath, NSW 2785. wardelljandcATbigpond.com 1: The Asthma Children's Swimming Program A committee of three specialist clinicians, two thoracic physiotherapists, an Olympic swimmer with asthma and a professional swimming coach designed a swimming program to meet the special needs of asthmatics. The principal differences from a general "learn to swim" program were: the use of indoor heated pools to give a controlled environment, thus reducing the chance of inducing asthma symptoms weekly swimming sessions held all year a minimum admission age of four years, considered desirable for adequate coordination, concentration, and understanding eligibility for the program required parental application, supported by a medical certificate stating details of the child's asthma and current medication the presence of a responsible adult carer, to give pre-swim medication if required pre-swim breathing exercises peak flow meter readings before and after swimming individual tuition, allowing each child to learn at his/her own pace no flotation aids except kickboards strong emphasis, starting at the first lesson, on correct controlled breathing coupled with correct swimming actions An instructor's manual was prepared describing the swimming method, and including information about asthma. Volunteer swimming instructors are trained in the method and in asthma first aid. The program has been operating continuously since 1964 and has expanded to many additional locations. For information about the current swimming program or a copy of the current version of the swimming instructor's manual, contact the Asthma Foundation of New South Wales, Suite 1, 82 Pacific Highway, St Leonards, NSW 2065. Return to text2: Reported changes in children's condition after participating in the Asthma Children's Swimming ProgramNo. of repliesChangesAsthma severity7150% showed improvementNumber of trigger factors72No significant changeMouth breathing7113% showed improvementSnoring7118% showed improvementChest deformity717% showed improvementNumber of other illnesses73No significant changeChild's enjoyment of program7397% enjoyed lessonsSwimming proficiency7390% showed improvement; 63% rated good or betterContinuing swimming7389% intended to continue after leaving the programSelf confidence7277% showed improvementPeak flow readings30No significant change Number of visits to doctor7346% overall reductionNumber of hospitalisations7364% overall reductionSchool absence due to asthma (above kindergarten age)5874% reported less absenceAsthma management7367% reported improvementUnderstanding of asthma7378% reported improvementFeeling disadvantaged by asthma7381% reported improvement Return to text

Colleen P Wardell · Clair Isbister

Bites and Stings Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered Peter L Pereira, Teresa Carrette, Paul Cullen, Richard F Mulcahy, Mark Little and Jamie Seymour MJA 2000; 173: 650-652 Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - More articles on Emergency medicine Abstract Objective: To evaluate whether applying pressure equivalent to that of pressure immobilisation bandages (PIB) causes release of additional venom from discharged jellyfish nematocysts. Design: In-vitro experiment -- the venom beads released from electrically activated Chiropsalmus sp. nematocysts were viewed under direct microscopy before and after applying 40 mmHg pressure (replicating the pressure of PIB); and saline washings of discharged nematocysts before and after applying pressure were tested for toxicity (time to ventricular standstill after injecting into live prawns). Results: Applying 40 mmHg pressure caused the venom beads to visibly increase in size, consistent with pressure expressing further venom from the discharged nematocysts. First washings of the nematocyst shafts before compression produced ventricular standstill in prawns within 60 seconds (n = 3); second washings did not produce standstill during 540 seconds of observation (n = 3); and washings after applying 40 mmHg pressure showed a return of toxicity, with ventricular standstill in all prawns within 180 seconds (n = 3). Conclusion: Discharged nematocysts are by no means empty and harmless. Applying pressure results in further release of nematocyst venom. The currently recommended practice of applying PIB in the initial treatment of patients stung by a jellyfish may exacerbate the envenomation, and thus should not be recommended. Introduction The application of pressure immobilisation bandages (PIB) in the first-aid treatment of jellyfish envenomation remains controversial. It is currently recommended by the Australian Resuscitation Council,1 by the Queensland Surf Life Saving Association2 and the Queensland Ambulance Service,3 but not by authorities in the Northern Territory.4,5 The evidence to support the use of PIB is anecdotal,6 and its use is a direct extrapolation of PIB use in elapid snakebite. In snakebite, its beneficial effects have been proposed7 and supported by published case reports.8,9The effect of PIB is to retard the dissipation of snake venom into the circulation by impeding lymphatic flow. This protects target tissues by confining the toxin to the affected limb until the patient is treated with antivenom. In snakebite, the venom is released into the tissues and the delivery apparatus (the snake's fangs) does not remain at the bite site. By contrast, in jellyfish stings, the venom is delivered by specialised cells (nematocysts) which have barbed shafts that adhere to the skin. Unless the nematocysts have entirely discharged their venom, applying pressure (as with PIB) has the potential to worsen the envenomation. Our anecdotal experience is that patients with jellyfish stings whose first aid includes PIB have more severe and prolonged symptoms. Furthermore, no scientific evidence supports the use of PIB in the treatment of box jellyfish stings.10 We designed an experiment to test the hypothesis that applying direct pressure to discharged nematocysts releases further venom. Methods Tentacles from live Chiropsalmus sp. (a closely related species to the box jellyfish Chironex fleckeri) were collected and placed on human amniotic membrane, which in turn was placed over the open end of a glass cylinder (4.5 cm in diameter and 5.5 cm in depth). To cause the nematocysts to discharge, we applied a 6 volt, 3 ampere direct current charge across the tentacles for two seconds. Such electrical augmentation is currently used to collect venom from jellyfish for antivenom production.11 After removal of the tentacles, the membrane was inverted, leaving the nematocyst bodies lying within the cylinder and their penetrating shafts directed externally through the membrane. An aneroid sphygmomanometer (bladder removed) was then attached to the other end of the cylinder (Box 1) to apply pressure to the discharged nematocysts. We used a pressure of 40 mmHg, as pressures of between 40 and 70 mmHg from PIB have been found to obstruct lymphatic flow in simulated snake envenomation.12 Through a dissecting microscope (x 100 magnification) small beads of clear fluid were noted on the tips of the shafts (Box 2). With constant visualisation of these beads, 40 mmHg pressure was applied, and a subjective estimate was made as to whether the pressure altered the size of the beads. To confirm the nature of these beads, the shafts from the discharged nematocysts were washed repeatedly with 2 mL of isotonic saline. The first washing was after activation of the nematocysts (A); the second (B) further cleaned the nematocysts; and the final washing (C) occurred after pressure was applied (and released). Live adult prawns (Penaeus mergenensus) were then injected with one of the three washes (0.2 mL intramuscular injection into the second abdominal segment) and their heart rate was observed every 30 seconds for a period of 10 minutes. The time to ventricular standstill was recorded as a measurement of toxicity. Each solution was administered to three prawns. Statistical analysis Statistical analysis was performed using SPSS.13 Differences in the mean time to cardiac death for prawns in each of the three treatments were determined using a balanced one-way analysis of variance with type I sums of squares. Differences between the means of the treatments were determined using least significant difference (LSD) post-hoc analysis. Results The venom beads, viewed under direct microscopy, visibly increased in size on applying 40 mmHg pressure. The heart rates of the nine prawns at time zero (before injection of the washings from the nematocyst shafts) were not statistically different (F2,6 = 1.895; P = 0.230), but there were significant differences between time from injection of the washings to ventricular standstill for the three different washings (F20,65 = 8.53; P < 0.001) (Box 3). Solution A: In the three prawns administered the first washing, ventricular standstill occurred within 60 seconds of injection. Solution B: All three prawns administered the second washing were unaffected by this inoculum during 540 seconds of observation, apart from a minor reduction in heart rate at 60 seconds for one prawn. Solution C: The third washing (after applying pressure), although not as potent as the first washing, caused ventricular standstill within 180 seconds in all three prawns. Discussion Our experiment shows clearly that further venom is expressed by applying pressure (equivalent to that of PIB) to discharged nematocysts. Furthermore, direct visual examination revealed an increase in bead size related to the amount of pressure being applied. This suggests that our simulated PIB caused mechanical expression of nematocyst contents rather than nematocyst reactivation, in which a triggered quantum of venom would be expected. We showed that Solution A (with venom from initially activated nematocysts) produced the anticipated ventricular standstill when injected into prawns. The relatively innocuous nature of Solution B, which did not produce any ventricular standstill, shows that Solution A had effectively cleaned the nematocyst of any substantial amount of venom. Solution C showed a return of toxicity after 40 mmHg pressure was applied. Thus, pressure applied to discharged nematocysts of Chiropsalmus sp. results in further venom being released. Vinegar, presumably through a chemical process, is a potent inactivator of nematocysts' firing mechanism. Not discounting this important function, its role in first aid is limited to inactivating undischarged nematocysts. Any inference that it has a continuing protective effect with discharged nematocysts is probably incorrect, as further expression of venom from discharged nematocysts appears to be mechanical rather than triggered. Given that the physical processes behind nematocyst discharge in all jellyfish are similar, and that nematocyst discharge operates similarly, there is sufficient reason to believe that the use of PIB on any jellyfish sting site may exacerbate the envenomation, irrespective of whether vinegar has been applied. Until evidence to the contrary is available, we recommend that applying PIB is not part of the management of this life-threatening condition. An amended first-aid protocol for jellyfish stings is given in Box 4. References Envenomation -- jellyfish stings. Australian Resuscitation Council. Policy Statement No 8.9.6. Melbourne: Australian Resuscitation Council, July 1996. Fenner P. The marine stinger guide -- dangerous jellyfish and other sea creatures in Australia. Identification and treatment. Brisbane: The Surf Life Saving Association of Australia, Queensland State Centre Inc, 1985. Case management guidelines for poisoning, envenomation, cuboidal jellyfish. Revised May 1998. Queensland Ambulance Service -- clinical practice manual. AL 10, Guideline A 12-6. Brisbane: Queensland Ambulance Service, May 1998. Currie B. Box-jellyfish in the Northern Territory. Northern Territory Disease Control Bulletin, Sept 1998; 5(3): 12-14. Currie B. Clinical implications of research on the box-jellyfish Chironex fleckeri. Toxicon 1994; 32: 1305-1313. Williamson J, Fenner P, Burnett J. Principles of patient care in marine envenomations and poisonings. In: Williamson JA, Fenner PJ, Burnett JW, Rifkin JF, editors. Venomous and poisonous marine animals -- a medical and biological handbook. Sydney: University of New South Wales Press, 1996. 98-118. Sutherland SK, Coulter AR, Harris RD. Rationalisation of first-aid measures for elapid snakebite. Lancet 1979; 1: 183-185. Sutherland SK, Leonard RL. Snakebite deaths in Australia 1992-1994 and a management update. Med J Aust 1995; 163: 616-618. Currie B, Fitzmaurice M, Oakley J. Resolution of neurotoxicity with anticholinesterase therapy in death adder envenomation. Med J Aust 1988; 148: 522-525. Little M, Mulcahy RF. A year's experience of Irukandji envenomation in far north Queensland. Med J Aust 1998; 169: 638-641. Barnes JH. Extraction of Cnidaria venom from living tentacle. In: Russell FE, Saunders PR, editors. Animal toxins. London: Pergamon Press, 1967: 115-129. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation. Med J Aust 1994; 161: 695-700. SPSS [computer program], version 9. Chicago, Ill: SPSS Inc, 1999. (Received 3 Jul, accepted 19 Sep, 2000) Authors' details Department of Emergency Medicine, Cairns Base Hospital, Cairns, QLD. Peter L Pereira, MB BS, FACEM, Director of Emergency Medicine, and Director of C-Airmed; Paul Cullen, BMed, FACEM, Staff Specialist; Richard F Mulcahy, MB BS, Staff Specialist; Mark Little, DTM&H, FACEM, MPH&TM, Staff Specialist. School of Tropical Biology, James Cook University, Cairns, QLD. Teresa Carrette, BSc, Senior Researcher; Jamie Seymour, BSc(Hons), PhD, Lecturer. Reprints will not be available from the authors. Correspondence: Dr P L Pereira, Department of Emergency Medicine, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870. peter_pereiraAThealth.qld.gov.au 1: The experiment Pressure of 40mmHg applied to discharged nematocysts across an amniotic membrane to simulate pressure immobilisation bandages applied to jellyfish stings. Return to text 2: The discharged nematocysts Beads of clear fluid on the shafts of the nematocysts (original magnification x 100) after applying pressure. Return to text 3: Heart rate v time after injection Effect of the three injected solutions on the heart rate of prawns, showing time to ventricular standstill. Solution A = first washings of discharged nematocysts; Solution B = second washings; Solution C = washings after applying 40 mmHg pressure to the discharged nematocysts. Return to text 4: Proposed first-aid management of cuboidal jellyfish stings (including species of Chironex, Chiropsalmus, Carukia and any jellyfish causing "Irukandji" syndrome) Ensure rescuer safety Resuscitate patient as necessary Apply vinegar concomitantly (pour onto the site for at least 30 seconds) Gently apply a vinegar-soaked dressing Do not apply pressure immobilisation bandages Transport patient to the nearest medical facility Provide supportive management as required Return to text

Peter L Pereira · Teresa Carrette · Paul Cullen · Richard F Mulcahy · Mark Little · Jamie Seymour

Bites and Stings Envenomation by the billygoat plum stinging caterpillar (Thosea penthima) Geoffrey K Isbister and Peter I Whelan We report the first case of envenomation by the billygoat plum stinging caterpillar, Thosea penthima Turner (Limacodidae). The sting, on the forearm, caused immediate burning pain and local wheal formation. Pain radiated up the arm and there was severe "crushing" chest pain lasting four hours. The local pain persisted for 10 hours and required opiate analgesia. (MJA 2000; 173: 654-655) Clinical record - Discussion - Acknowledgements - References - Authors' details - - More articles on Insects, bites and stings Introduction Stings and itchy reactions from contact with caterpillars are common in Australia, but few people seek medical attention. Injuries from moths and butterflies (Lepidoptera), known as lepidopterism, include penetration, inhalation or ingestion of any part or structure of moths or butterflies from any stage in their life cycle.1 By far the most common injury (or reaction) results from skin or eye contact with the hairs of caterpillars (the larval stage).1,2The clinical effects of lepidopterism can range from mild, itchy reactions to localised burning pain, occasionally with regional and systemic involvement. The extent of the clinical effects depends on the caterpillar species, the type of urticating hair, the site of exposure and individual sensitivity. There are two major types of urticating caterpillar hairs: Itchy caterpillars have non-venomous hairs that cause localised itchy reactions and dermatitis3,4 produced by mechanical irritation and foreign-body reactions.5 Stinging caterpillars have hollow spines with a poison-secreting cell at their base. The spines enter the skin and break off, injecting venom and causing severe local reactions, occasionally with systemic effects.1,5 Here we describe a significant sting by the billygoat plum stinging caterpillar, Thosea penthima Turner (family Limacodidae) (Box 1), from northern Australia. Reports of lepidopterism in Australia are rare,1,2,6-8 and there have been no previous reports of stings by this caterpillar. Clinical record In December 1999, a 29-year-old woman presented to a Darwin rural health clinic after a caterpillar sting. The caterpillar had dropped onto her right forearm while she was outdoors. There was an immediate sharp sting, followed by increasing pain radiating up the right arm. After 30 minutes the pain in the arm was severe, and "crushing" chest pain developed. The caterpillar was collected and later identified as T. penthima Turner by one of us (P I W). The patient had no history of allergy or previous exposure to stinging caterpillars. There was localised reaction at the site, but the size and appearance of the lesion were not documented. The patient's blood pressure was 110/70 mmHg and heart rate 48 beats/min. An electrocardiogram (ECG) showed sinus rhythm and no abnormalities. She was given 20 mg of oral promethazine, two paracetamol/codeine tablets (1 g/60 mg) and ice was applied locally. Over the next four hours the chest pain resolved, but the local pain radiating up the arm to the shoulder continued. A repeat ECG showed no change. The patient was then transferred to Royal Darwin Hospital with continuing pain. On arrival, six hours after the sting, the patient had continuing severe pain at the sting site radiating to the right shoulder. A 5 cm x 8 cm raised area on her right forearm (Box 2) was centrally pale with surrounding erythema and tender to touch. There was no axillary lymphadenopathy. The blood pressure was 95/60 mmHg and heart rate 60 beats/min. The patient was given two doses of 2.5 mg morphine intravenously over one hour and ice was applied. The pain gradually resolved over three hours and the local swelling and surrounding erythema decreased. She was discharged 10 hours after the sting. Followed up by telephone, she reported an irritating, red rash at the sting site that lasted a week. There was complete resolution. Discussion In Australia, two families of moths, Limacodidae and Nolidae, have larvae with poisonous spines.1T. penthima, which occurs across northern Australia, belongs to the Limacodidae family of cup moths.9 Its larvae are dorsally/ventrally flattened and discoid shaped, and yellow and light green in colour. A number of protuberances along the body support the poisonous spines (Box 1).6 In the Northern Territory, T. penthima is found at least as far south as Mataranka (400 km south of Darwin). Its food sources in the Darwin region are Planchonia careya ("cocky apple") and Terminalia ferdinandiana ("billygoat plum").6,10There are few records of the effects of Australian stinging caterpillars.1,2,6-8 The only records of stings by billygoat plum stinging caterpillars are by us.2,6 Most people with stings experienced sharp pain and had a raised white wheal that resolved over 5-30 minutes.6 In one case, a sting on the thigh caused a painful burning sensation that increased over 15 minutes, with associated muscle ache, and lasted for 90 minutes. Most stings from other Australian caterpillars have occurred in entomologists collecting larvae or in investigators who have stung themselves experimentally.1,6-8 Three species of the genus Doratifera (Limacodidae) have been reported to cause stings similar to T. penthima.1,6-8 A sting from Uraba lugens (the eucalyptus leaf "skeletoniser") (Nolidae) causes local pain and a wheal, sometimes for up to three weeks.1 Most reports of stinging caterpillar envenomations involve the North American caterpillar Megalopyge opercularis (Megalopygidae).11-13 Stings by this caterpillar cause severe local pain, erythema and swelling, often with pain radiating up the limb;11,12 systemic effects have been reported less commonly.13 One study of caterpillar envenomations showed that radiating pain and systemic effects were more common with M. opercularis (35.2%) or Simine stimulea (45.5%), the saddleback caterpillar (Limacodidae).11 The sting in our patient caused more severe acute effects than previously reported in Australia.1,2,6-8 The initial severity of the chest pain prompted investigation for angina. Although pain radiating from the sting site has been described previously,11 chest pain has not previously been associated with caterpillar envenomation. The severe regional pain and chest pain in our patient suggest a systemic toxin effect. Chest and muscle pain is well described in stings by the jellyfish Carukia barnesi (Irukandji syndrome)14 and it is postulated that these effects are due to toxin-mediated catecholamine release. Studies have shown that components of some caterpillar venoms can cause endogenous mediator release,5 which may be the mechanism of the reaction seen in our patient. Although most of the stinging caterpillars in Australia, including T. penthima,6usually cause only minor local effects, our patient's experience shows that the more severe reactions seen with caterpillar envenomation in other parts of the world can also occur here.11 Prevention of stings relies on recognition and avoidance of plants that these caterpillars feed on. Acknowledgements We thank Dr Bart Currie, Menzies School of Health Research, Darwin, for offering advice and reading the manuscript; Dr E D Edwards, Australian National Insect Collection, CSIRO, Canberra, for species identification; and Mr Geoff Davis, formerly Medical Entomology Branch, Territory Health Services, for supplying the photograph of T. penthima. References Southcott RV. Lepidopterism in the Australian region. Records of the Adelaide Children's Hospital 1978; 2: 87-173. Southcott RV. Moths and butterflies. In: Covacevich J, Davie P, Pearn J, editors. Toxic plants and animals: a guide for Australia. 1st ed. Brisbane: Queensland Museum, 1987: 243-256. Mulvaney JK, Gatenby PA, Brookes JG. Lepidopterism: two cases of systemic reactions to the cocoon of a common moth, Chelepteryx collesi. Med J Aust 1998; 168: 610-611. Dunlop K, Freeman S. Caterpillar dermatitis [review]. Australas J Dermatol 1997; 38: 193-195. Kawamoto F, Kumada N. Biology and venoms of Lepitdoptera. In: Tu AT, editor. Insect poisons, allergens and other invertebrate venoms. Chapter 9. New York: Marcel Dekker Inc, 1984: 291-330. Whelan P. Stinging and itchy caterpillars in the Top End of the NT. 1st ed. Darwin: Northern Terrritory Health Services, 1994: 3-4. Southcott RV. Some harmful Australian insects. Med J Aust 1988; 149: 656-662. Lee D. Arthropod bites and stings and other injurious effects. Sydney: School of Public Health and Tropical Medicine, The University of Sydney, 1975: 193-214. Common IFB. Moths of Australia. Melbourne University Press, 1990: 299-303. Clark M, Traynor S. Plants of the tropical woodland. Darwin. Conservation Commission of the Northern Territory, 1987. Everson GW, Chapin JB, Normann SA. Caterpillar envenomations: a prospective study of 112 cases. Vet Hum Toxicol 1990; 32: 114-119. Stipetic ME, Rosen PB, Borys DJ. A retrospective analysis of 96 "asp" (Megalopyge opercularis) envenomations in Central Texas during 1996. J Toxicol Clin Toxicol 1999; 37: 457-462. McGovern JP, Barkin GD, McElhenney TR, Wende R. Megalopyge opercularis: observations of its life history, natural history of its sting in man, and report of an epidemic. JAMA 1961; 175: 1155-1158. Little M, Mulcahy RF. A year's experience of Irukandji envenomation in far north Queensland. Med J Aust 1998; 169: 638-641. (Received 7 Jun, accepted 14 Sep, 2000) Authors' details Royal Darwin Hospital, Darwin, NT. Geoffrey K Isbister, BSc, MB BS, Emergency Registrar. Territory Health Services, Darwin, NT. Peter I Whelan, AM, BAgSc, Senior Medical Entomologist. Reprints will not be available from the authors. Correspondence: Dr G K Isbister, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Misericordiae Hospital, Locked Bag 7, Hunter Region Mail Centre, NSW 2310. gsbiteATbigpond.com 1: The billygoat plum stinging caterpillar, Thosea penthima Turner (Limacodidae)Return to text 2: The sting site, a 5cm x 8cm raised white wheal on the right forearm, was tender to touchReturn to text

Geoffrey K Isbister · Peter I Whelan

Christmas Offerings MJA 2000; 173: 659-660

Brian J Fotheringham

Christmas Offerings De-skilling me softly: a cautionary ballad MJA 2000; 173: 661 To the tune of "My darling Clementine" Once were doctors, we were doctors practising psychiatry, Many long years spent preparing for this complex specialty. Yet vital skills were clearly lacking post-FRANZCP; Some sought more training and supervision in intensive therapy. This for patients that politicians crudely scorned as "worried well", Though some outwardly successful, their private lives an empty hell. Chorus: Oh psychiatry, dear psychiatry, shame what they have done to thee, Evidence-based undertreatment, protocols for you and me. Abe's1 parents both were war survivors for whom a hug felt like a shark, His wife and colleagues fear his rages; his son swaps needles in the park. Sue's1 father scorned her, uncle raped her, mother feared her infant cry, A PhD, gym and many lovers, constant achievement keep Sue alive. My old consultant taught his interns such patients need skilled care for years, Perverse enactments, somatic crises, destructive mood swings, holiday fears. (Chorus) College leaders in New Zealand mock this profligate waste of time, College leaders in Australia want us to toe the Kiwi line. With SBE,2 McKay3 and Tolkien,4 all government consultancies Farewell depth of understanding, hail the glib technocracy. Costed guidelines, sector funding, managers loom at the door, Now are doctors health providers, integrated to the core. (Chorus) Psychologists and health diplomates give CBT5 and strategies, GPs prescribe medication and short-term "cures" for anxiety. The New Psychiatrist does brief assessments then supervises from afar, Coordinating treatment modules, schizoid omniscience so bizarre. Short-term treatments deemed "world's best practice", just deliver and you'll score Academical promotion, fancy titles, gongs galore. (Chorus) Group therapy died when they closed outpatients, CL's6 been slashed, will it survive? Complex skills lost or devalued by economic triage, political guile. Dollars galore for administrators, publicity, consultancies, Those least skilled in treating patients design and guide health policy. Though Abe and Sue need long-term treatment, such skills dismissed as "luxuries", Health-strategy oligarchy's newspeak is "evidence", "community". (Chorus) Soul-death, despair, basic trust, self-hatred, these DSM7 cannot define, Only thoughtful understanding of patients' "I" and "you" through time. But Canberra has plans and timelines at whose behest ambitions soar, Though psychic pain crosses generations, demo projects this truth ignore. Dare you oppose their naive hubris they'll dismiss it as elitist greed, Those bureaucrats and academics who've never heard a psyche bleed. (Chorus) With platitudes and stats aplenty they'll prove how great a job they've done, Then off they'll go to some bigger office or a salary package in the sun. High talk of ethics, academic standards, yet which professor rose to protest When these were crudely violated, 3198 was the first test. How my heart is sick with anger, for Abe and Sue have been betrayed, Bio-psycho-social wisdom has become a glib charade. (Chorus) From Maimonides, Osler and Bleuler, to Engel and Oliver Sacks, To know the patient as a person guided wise doctors more than stats. Interns now learn from their elders treatment's just a recipe, Don't spend too much time with patients, call them "clients" and you'll see That there's no need to understand what shapes a life from womb to grave, The less explored their loves and traumas, faster the throughput, more money saved. (Chorus) Once were doctors, we were doctors practising psychiatry, Now the tame, generic workforce of the health bureaucracy. Understanding loss and illness or mind-body takes too much time, Sacrificed to symptom checklists, rating scales and stats so blind. Acronyms and showcase projects, Australia's mental health strategy, Dictated by the performance values of global markets ideology. (Chorus) Edwin Harari Psychiatrist North Carlton, VIC "Abe" and "Sue" are false names of actual patients. Solomon, Buckingham and Epstein report (1993), subtitled "A consultancy report for the Mental Health Workforce Committee on medical workforce financing arrangements". McKay report (1996), "Issues and options. Optimum supply and effective use of psychiatrists; a project for the National Mental Health Strategy". Tolkien report (1994), "A model for matching the available workforce with the demands for services". Cognitive behaviour therapy. Consultation-liaison psychiatry. Diagnostic and Statistical Manual. Item 319, introduced in the Medical Benefits Schedule of fees in November 1996, limiting the rebate for psychiatric treatment.

Edwin Harari

Christmas Offerings MJA 2000; 173: 662-663 Introduction The proprietary names of new drugs not only lack imagination but, via the mindless assemblage of concatenated consonants, resemble the loser's board in a last round of Scrabble. Disenfranchised consonants, particularly Xs, Zs and Qs, appear in drug names with as much logic as their appearance in a cup of alphabet soup (albeit my second favourite after soup de jour). While prescribing doctors require no scientific proof that there has been a secular change to idioglossia, I explore this proposition scientifically, using the proprietary names of two classes of psychotropic drugs. Methods The database for my study was the list of oral antipsychotic and antidepressant drugs in the 1998 MIMS Annual.1 The proprietary names for all currently listed "older" and "newer" (ie, pre- and post-1990) drugs were examined for the relative frequency of vowels and consonants. (See Box for names compared.) Results Quantitative analyses I surveyed a total of 33 psychotropic drug names, but was unable to demonstrate a difference between "old" and "new" drugs by the chi-squared test (chi-squared = 0.008; df = 1; NS). It was time for a post hoc ad hoc ergo propter hoc hypothesis, viz., that there had been an increase in specific letters, such as V, I and Z. The latter (ie letter) analysis predictably revealed shifts, with the most notable changes being -- for the consonants -- a distinct increase in the representation of Cs (from 2% of the letter distribution in the "old" drugs to 5% in the "new" drugs) and, even more distinctly, increases in Xs (from 0 to 7%) and Zs (from 1% to 6%). For the vowels, Is had decreased from 6% to 1%, while Os had increased from 6% to 13%. I undertook a validity check by making a comparison with the distribution of these letters in Scrabble, where Cs = 2%, Xs = 1%, Zs = 1%, Is = 9% and Os = 8%. Thus, the older drugs had a distribution of those letters in accord with our Scrabble control, while their current distribution was quite out of kilter and thus, QED, seriously discordant with the English language, the games we play, the rules of sport and the Olympic ideal. Qualitative analyses I read the lists to all hospital support staff cleaning the doctors' corridor in spring 2000, with each (n = 2) asked to assess each drug name for resonance, melodiousness, assonance and assiness. Against expectation, they unanimously rated the "newer" drugs far higher. Post hoc analysis determined, however, that both were non-English-speaking, but they did express thanks for trying to talk to them in their own language. I then undertook a second study involving all unit registrars who had expressed (at their appointment interview) a keen interest in undertaking research if offered a position. These 23 registrars were similarly required to rate each drug set on the evaluative parameters. All three respondents rated the older psychotropic drug names as more attractive, with one noting that it was not the price -- but the excess of Xs -- that prevented her prescribing the new atypical antipsychotics, so rejecting the "null" hypothesis that "nothing succeeds like XS". Discussion My study demonstrated an increased use of discordant consonants in proprietary names for two psychotropic drug classes. Z is climbing up the alphabet, but its appeal is questionable, as any parent knows who has asked their child to eat a zucchini. The only Z that ever had any style belonged to the graffiti artist Zorro. But Zs for drug names? Perhaps a hypnotic? Zizzzz, or even Zizzzzzzzzzzzzzz. X has risen from near x-tinction, C is coming in, and O is on the rise as a leavening vowel. Current analyses allow the confident prediction that "XOCZ" will be the proprietary name to be launched next. But do we want the alphabet-ordered also-rans (the Xs, Ys and Zs) to run? Why not capture the beauty of the English language? How truly evocative then are the names for the new "atypical antipsychotic" drugs -- Clopixol, Clozaril, Risperdal and Zyprexa, which my computer spell-check renders as Claypool, Closure, Dispersal and Pyrexia. Surely, they lack the majestic evocation of the older drug names. Again my spell-check assists us -- Largactil "reframed" as "LargeAction", Anatensol as "Intensely", Navane as "Nirvana", Stelazine as "Stabilize", Anafranil as "Unafraid", Endep as "Endow" and Surmontil as "Surmountable" provide a subliminal message of hope, action and therapeutic success, like the lovely and pleasing word "placebo". Are the "new drug names" not building to treatment resistance? What's in a name? In the old days, lots. The alcohol deterrent drug Antabuse evocatively told us a story. It was anti-abusers and self-abusing, belonged to the right (ie left) end of the dictionary in being close to AA (so assisting prescribing doctors), and was nicely balanced in its mix of vowels and consonants. A fine achievement for a drug that made you vomit. Another example is the hypnotic, Halcion. Only when there was no wind and the waters were quiet and tranquil could the albatross take off, the so-called "halcyon days". Thus was the prescriber encouraged to prescribe Halcion for tranquillity, for wind and for plane phobia. But now we have drugs like Xanax (presumably a computer-driven palindrome). What next? A drug labelled ZZQQZZ? You wouldn't even accept that as a number plate. The rumbelow conjunction of compounding consonants presents the medical profession with a number of deceptively important problems. First, the written equivalent of "Chinese whispers". A handwritten script for Zantac may emerge, after some pharmacist confusion, as one for Zactin, or Zestril, or Zarontin. Second, we are now ankle deep in xenoglossia -- being required to understand a language we have never learned. Third, where is the placebo effect in offering a patient a new wonder drug named "Prozolox"? Fourthly, where is the appeal? What respectable canine, after years of eating affiliative, affirmative and affectionately labelled "Pal", would take a chunk out of a tin labelled Zbra or Quale? What are the marketing and advertising sections of the pharmaceutical companies doing? We know that recognition and verbal learning relate to the pleasantness and association value of words,2 with such research empirically establishing the high appeal of words like "caress", "Christmas", "comfort", "delight", "flower", "kindness", "pleasure" and "sunshine". Presuming that those companies wish us to use their product, are their marketing divisions out to lunch on this issue? If so, and before they get back from lunch, should we in the medical profession not show some leadership? Perhaps to get the ball rolling, I could offer some suggestions for the next "Drugs R Us" company that appreciates gratuitous advice. A search for appealing words can take many roads. James Joyce held that "cuspidor" was the most beautiful word in the English language, but, despite his genius, his inability to call a spittoon a spittoon confirms that beauty is in the eye of the beholder. We need, then, an author "of the people", someone who could sit comfortably with the "man on the Clapham bus". Barbara Cartland! Dame Barbara once listed the 12 "most beautiful" words in the English language as ecstasy, love, God, divine, pure, innocent, rapture, moonlight, shimmering, radiance, magical and mysterious. What an evocative list, and not a Q, X or Z to be seen! But, returning to psychiatry, we need psychotropic drug names that invoke the domain and the suggested impact, increase compliance, have a placebo component and make us all feel good. Cartland provides a semantic base for a thesaurus search. For an antidepressant, recognising that others have stolen Cartland's suggestion of "ecstasy", why not "Cloud9" or "BlissPill"? For anti-manic drugs, why not "Glidedown" or "Asymptote", and perhaps "Astoic", "Flatline" or "Earthbound" for a mood stabiliser. For antipsychotics, if not "SangFroid" (which might be misconstrued as "Sane Freud"), why not "Equanimity", or "Anodine" or "Chillout"? For an anxiolytic, "C-Rene", "Care-less" or "Earthed", perhaps. Of course, such concerns also hold for other classes of drugs. One of the most successful drug releases in the past decade was that of Viagra. But, as a treatment for erectile dysfunction, it has quite the wrong connotation. Viagra rhymes with Niagara. As in Niagara Falls. An unfortunate choice. How about "PeckUp" (note the neat diffusion into "Pickup" -- suggesting both a tonic and the means of acquiring a partner for the night). It would have been a real sales winner if the naming had been more prescient. I rest my case. References MIMS Annual. Sydney: MIMS Australia, 1998. Silverstein A, Dienstbier RA. Rated pleasantness and association value of 101 English nouns. J Verbal Learning Verbal Behav 1968; 7: 81-86. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Gordon B Parker, Professor, and Head. Reprints will not be available from the author. Correspondence: Professor G B Parker, School of Psychiatry, Prince of Wales Hospital, High Street, Randwick, NSW 2031. g.parkerATunsw.edu.au We appreciate your comments. Psychotropic drug names compared Oral antipsychotic drugs: Old: Anatensol, Largactil, Melleril, Navane, Neulactil, Orap, Serenace, Sparine, Stelazine New: Clopixol, Clozaril, Risperdal, Zyprexa Oral antidepressant drugs: Old: Allegron, Anafranil, Deptran, Endep, Nardil, Parnate, Pertofran, Prothiaden, Surmontil, Tofranil, Tolvon, Tryptanol New: Aropax, Aurorix, Cipramil, Efexor, Luvox, Prozac, Serzone, Zoloft Return to text

Gordon B Parker

Christmas Offerings Olympic couch potatoes MJA 2000; 173: 664 The Sydney Olympic Games were captivating. Hordes of people flocked to the torch relay, the sports stadiums and entertainment venues. When not out and about, most of us spent a considerable amount of time glued to the action on television, a pastime not without potential complications. During the Games, my wife, a pharmacist at a large teaching hospital, reported that a newly admitted patient had been given a diagnosis of "TV vegetation". Was this a new syndrome, comprising stiffness, visual impairment, insomnia and blunted mind, the culmination of countless hours of TV viewing? Had the condition been described in Atlanta or Barcelona? Was SOCOG about to be bombarded with compensation claims? Had the consultant been too frivolous and abusive of medical terminology, or was he "sharing the spirit" and participating appropriately in the Olympic banter? None of the above. The patient, a young intravenous drug user, had "tricuspid valve vegetation", and had been admitted with a high fever and renal failure. He eventually made a full recovery. Garry Walter Acting Director Child, Adolescent and Family Mental Health Services Central Sydney Area Health Service, Sydney, NSW

Garry Walter

Christmas Offerings The Internist MJA 2000; 173: 664 There used to be a General Physician Of eminent commanding disposition. His morbid knowledge was completely awesome, From ventral to the lateral and dorsum. There was no system he could not expound on, Nor any body part he was unsound on. Inspection, palpation, percussion, auscultation Were basic to routine examination. The brain, the heart, the kidney, lung or colon, Or any joint or organ that was swollen. Each viscus with a membrane, duct or lumen Would stimulate his medical acumen. But nowadays Physicians have decided That multisystem medicine's misguided, Thereby opting for a demarcation And introducing strict sub-specialisation. Now patients with a medical condition, In seeking out a competent Physician, No longer have the slightest comprehension Of whom they should consult for intervention. For folk without approved medical training, I proffer information thus pertaining, Whereby they may indulge, even rejoice in, A doctor whom they may have little choice in! Len Green Radiologist, Bondi Junction Radiology Rose Bay, NSW

Len Green

Matters Arising Australian general practice: the need for leaders and vision An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 668

James A Dickinson

Matters Arising R&D in general practice: time to move forward An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 668-669

David P Weller

Matters Arising The current situation of general practice An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 669

Letters What a louse! MJA 2000; 173: 603

Paul Prociv

Letter A possible case of intestinal myiasis due to Eristalis tenax MJA 2000; 173: 652 To the Editor: A 42-year-old woman living in rural South Australia presented with a history of passing actively swimming "fish-like creatures" with her stool. There were no other symptoms (apart from a sense of revulsion). Specimens brought in by the patient were cylindrical larvae about 2.5 cm long with a "tail". Based on the characteristic morphology, they were identified by our local pathologist as "rat-tailed maggots", or larvae of the introduced drone fly (Eristalis tenax). The patient saw one to three of the larvae on about five occasions over a 2-week period, whereupon they spontaneously ceased to occur. She remained asymptomatic. There was nothing to suggest that the patient had a low standard of hygiene. The specimen, apparently passed with stool, was identified as a "rat-tailed maggot", or larva of the introduced drone fly (Eristalis tenax). Infestation of live humans or vertebrate animals with larvae of Diptera (fly) species is known as myiasis -- for part of their life cycle, the larvae feed on dead or living tissue or the ingested food of the host.1 Pseudomyiasis is the term used for deposition of maggots on faeces immediately after they are passed. Recognition of dead larvae in stool also comes into this category, as host infestation has not been established. A few patients with intestinal myiasis with drone fly larvae have been described previously, with the mode of infestation presumed to be consumption of water or food contaminated with fly larvae or eggs.2,3,5 Life stages of Eristalis tenax: (a) larva; (b) pupa; and (c) adult fly. The rat-tailed maggot usually breeds in drains, sewage pools, and other stagnant water. Although the larvae live on decaying organic matter, they must breathe air. For this, the breathing tube (the tail) is extended or contracted depending on the depth of the liquid in which they are feeding. Our patient had a septic toilet system. It is possible that the maggots could have bred in the tank and travelled upstream to the toilet bowl. The tank, however, was 10 metres away and appeared normal when opened and inspected, and no other family members noted the maggots in their stool. Doubts have been expressed about the theory that accidentally ingested fly larvae could survive in the environment of the gastrointestinal tract. Zumpt proposed an alternative kind of intestinal myiasis due to Eristalis tenax called "rectal myiasis".1 Flies, attracted to faeces, may deposit their eggs or larvae near or into the anus, and the larvae then penetrate further into the rectum. The larvae may then feed on faeces at this site, as long as the breathing tube reaches towards the anus. Although our patient had no symptoms, anal pruritus or discomfort has been described in other reports.4,5 Phillip B Whish-Wilson General practitioner PO Box 1118 Mount Barker, SA 5251 Zumpt F. The problem of intestinal myiasis in humans. S Afr Med J 1963; 37: 305-307. Lakshminarayana CS, Kanchana MV, Janakavalli R, Mallika M. Intestinal myiasis due to Eristalis tenax. J Indian Med Assoc 1975; 65: 234-235. Aguilera A, Cid A, Regueiro JM, et al. Intestinal myiasis caused by Eristalis tenax (letter). J Clin Microbiol 1999; 37: 3082. Hall MC. A note regarding myiasis, especially that due to syrphid larvae. Arch Intern Med 1918; 21: 309-312. Cookson HA, Oldroyd H. Intestinal infestation by larvae of a drone fly. Lancet 1937; 2: 804.

Phillip B Whish-Wilson

Letters Chromomycosis MJA 2000; 173: 656 To the Editor: A 38-year-old man presented with a hyperkeratotic, crusting lesion on his right knee which had been present for 17 years and had not responded to treatment (Box 1). The lesion developed in 1983 after he knelt on wood chips while cutting wood in scrub country to the west of Mackay in Queensland. The lesion had slowly increased in size and persisted despite various attempts at therapy. When it was about 1 cm in diameter, local excision was offered, but, as the surgeon was not able to guarantee the lesion would not recur, excision was not performed. In January 1996 a biopsy was taken. The report read "pseudoepitheliomatous hyperplasia" of the epidermis. In the dermis there was a "granulomatous inflammatory reaction in which there were collections of pigmented yeast bodies". The histological diagnosis was chromomycosis (chromoblastomycosis) (Box 2). Chromomycosis organisms are round, thick-walled brown cells, 5-12 mm in diameter, usually occurring in dermal microabscesses. After one month's culture, Cladophialophora carrionii (also known as Cladosporium carrionii) was isolated. By 1999, when the patient presented, he had been treated sequentially, without success, with ketoconazole (200 mg daily for six months), fluorocytosine (dose unknown) and terbinafine (250 mg daily). In October 1999, he was given itraconazole 100 mg daily. This dose was increased to 100 mg twice daily in November 1999 and was continued until May 2000, by which time the total dose of itraconazole administered was 54 g. (The patient was 179 cm tall and weighed 114 kg.) The drug has been well tolerated, with no abnormality of blood film or liver function. There has been a slow but steady healing of the knee lesion (Box 3). Chromomycosis (chromoblastomycosis) is a chronic mycotic infection of the cutaneous and subcutaneous tissues. It is diagnosed by the presence in the tissue of phaeoid (Greek phaeios, "dusky") muriform cells and by isolation and identification of the pathogenic fungus. The muriform cells represent an intermediate vegetative fungal form arrested between yeast and hyphal development. The dusky colour of these muriform cells results from a melanin pigment.1 The lesions produced by the infection are nodulo-verrucous. The fungal genera that can cause this infection (Cladophialophora, Fonsecaea, Phialophora, Rhinocladiella) live as saprophytes in soil and in decaying wood and vegetation. Infection is caused by inoculation, but the injury may be so minor as to go unnoticed and may have occurred years before the slow-growing lesion is noticed. It occurs most commonly on the feet or legs, but, in Australia, the upper limbs are more commonly involved. Cladophialophora carrionii infection is a common cause of chromoblastomycosis and, although the infection can be contracted from many environments, it is particularly prevalent in arid and semi-arid areas, most often in tropical and subtropical zones. It has been reported from North, Central and South America, Cuba, Jamaica, Martinique and many other countries, including India, South Africa, and Madagascar, as well as Australia and Northern Europe. It has occurred as an imported infection in the United Kingdom.2 Chromoblastomycosis is frustratingly difficult to treat, but it is becoming increasingly evident that itraconazole is the treatment of choice, at least for infections with Cladophialophora spp., partly because itraconazole accumulates in the skin and subcutaneous tissues owing to its lipophilicity.3 In adults the dose of itraconazole is 200 mg or more per day for as long as required (the dose is continued for a period two to three times longer than that required to obtain negative culture results).4 George R Crowe Plenary Physician, Pioneer Valley Private Hospital PO Box 8877, Mount Pleasant, QLD 4740 Michael Martin Pathologist, Central Queensland Pathology Laboratory Mackay, QLD Acknowledgements: Dr Brian Reid, Dermatologist, Townsville; Dr Andrew O'Neill, Mackay; Mr John Atkinson, Librarian, Mackay Base Hospital; and Ann James, Janssen-Cilag Australia. Guerrant RL, Walker DH, Weller PF. Tropical infectious diseases: priciples, pathogens and practice. London: Churchill Livingstone, 1999: 621-623. Champion RH, Burton JL, Ebling FJG. Textbook of dermatology. 5th ed. Oxford: Blackwell Scientific Publications, 1992: 1205-1206. Strickland GT. Hunter's tropical medicine. 8th ed. Philadephia: WB Saunders, 1999: 573. Borelli D. A clinical trial of itraconazole in the treatment of deep mycoses and leishmaniasis. Rev Infect Dis 1987; 9 Suppl 1: S57-S63. 1: The lesion The lesion on the knee when the patient presented in 1999. The lesion first developed in 1983 after the patient knelt on wood chips. Back to text 2: Chromomycosis organisms Photomicrograph (haematoxylin-eosin, original magnification x400) of skin biopsy in 1996, showing two Cladophialophora spores in a microabscess (arrow). Back to text 3: Healing after 17 years Treatment with itraconazole in late 1999 resulted in steady healing of the lesion. Back to text

Letters Setting the (medical) record straight MJA 2000; 173: 670 To the Editor: The electronic health record is a concept which has been receiving growing community support. The recommendations of the National Electronic Health Records Taskforce were endorsed at the Australian Health Ministers Conference in July 2000. The Taskforce proposes establishing a national health information network (Health Connect). Healthcare providers would enter event summaries into patient records. The data could then be exchanged online. The report recommends that patients (or "health consumers") have access to their own records and control who can view them. This technology has the potential to improve patient care, but requires careful planning. A recent patient encounter highlighted a problem with our present medical records. A 31-year-old woman was admitted to a nearby hospital with fever, a productive cough, and pleuritic chest pain. A chest x-ray confirmed right lower-lobe consolidation. Blood cultures revealed Streptococcus pneumoniae with intermediate penicillin sensitivity. Her condition responded well to intravenous penicillin and a week of intravenous ceftriaxone with the "hospital in the home" (HIH) program. The discharge diagnosis was pneumococcal lobar pneumonia complicated by bacteraemia. Two days after discharge, she presented with the same symptoms, this time to our hospital, giving a history of her previous illness and admission. She was again febrile, but, interestingly, her chest x-ray was now clear. Her sputum cultured Streptococcus pneumoniae with an intermediate sensitivity to penicillin. An extensive septic work-up was otherwise unremarkable. Given the relapsing course, she was again treated with intravenous ceftriaxone with the HIH program. We found this recurrent febrile illness puzzling. The answer became apparent when she wasn't recognised by the HIH staff who had treated her previously. A sister visiting from overseas had become ill and used our patient's Medicare card to receive free treatment at the neighbouring hospital. The sister made a complete recovery. The real card owner then developed similar symptoms. To avoid detection she chose our hospital and used her sister's recent history as her own, not realising that the two hospitals shared the same HIH program. Thus, there had been two different patients with separate illnesses using the same Medicare card! For the second user of the card, this precipitated a prolonged inpatient stay with unnecessary investigations and treatment. This case highlights one vulnerability of our data recording system. There are few safeguards to verify patient identity on admission and, once recorded, data are filed permanently. Are more rigorous checks, such as a photo ID on Medicare cards, warranted? Is the loss of patient privacy outweighed by savings to the taxpayer, given that ultimately the cost of such exploitation of our system is borne by us all? Alan C Young Respiratory Registrar Peter W Holmes Deputy Director Department of Respiratory Medicine, Monash Medical Centre 246 Clayton Road, Clayton, VIC 3168

Alan C Young · Peter W Holmes

Letters Incongruous infants: facial features in old paintings MJA 2000; 173: 670 To the Editor: The following quote is from Sinclair's Human growth after birth: The head of the new-born baby is relatively large. This is reflected in the finding that in the infant the ratio of vertical head height to total height is 1:4, whereas in the adult it is 1:7.5. This difference was not appreciated by many well-known early European painters, and it is common to find representations of the Virgin and Child in which the baby has the chubby outline typical of his age but the proportions typical of an adult.1 I thought it would be interesting to test this statement. Most paintings of the Virgin and Child show the Virgin seated and the Child in various postures, making it impossible to measure their total height. However, we do know that the ratio of head length (vertex to chin) to forearm length (elbow to wrist) is 2:1 in the newborn, 7:4 at the age of two, and 1:1 in adults. Also, the ratio of upper head length (vertex to eyes) to face length (eyes to chin) is 4:3 in the newborn and 4:5 in adults.1 Using paintings reproduced on postcards and in the Time-Life series of art books,2 I made the appropriate body measurements of the Virgin and Child from 41 works painted between 1225 and 1619 CE. Allowing for about 10% variation in the normal ratios I obtained the following results: The head : forearm ratio for the Virgin was normal in 29 of 40 measurements; less than normal in 9; and greater than normal in 2. This ratio for the Child was normal in 12 of 41 measurements; less than normal in 25; and greater than normal in 4. The upper head : face ratio for the Virgin was normal in 18 of 43 measurements; less than normal in 15; and greater than normal in 10. This ratio for the Child was normal in 11 of 43 measurements; less than normal in 30; and greater than normal in 2. However inaccurate my measurements may be, measuring from a picture with the figures at various angles, the results do show a consistent pattern over the centuries. The artist tends to underestimate both the head : forearm ratio and upper head : face ratio in the Child. The ratios for the Virgin were also outside the normal range in many of the examples measured. Artists down the ages have always distorted the anatomical shape of their figures if they felt a better image would result. Artists who lived during the period surveyed would have had the example of the stylised and distorted forms of Byzantine art constantly before them, in the churches and monasteries in which they painted their works. When all is said and done, how important is anatomical accuracy in the production of an otherwise wonderful work of art? John E Gault Physician 203 View Street, Bendigo, VIC 3550 Sinclair D. Human growth after birth. 2nd ed. Oxford: Oxford University Press, 1973: 102-105. Time-Life Library of Art series. Time-Life International (Nederland) b.v.

John E Gault

Letters The cough that packed a punch: is boxing a risk for tuberculosis transmission? MJA 2000; 173: 671 To the Editor: The medical community is spearheading the movement for the banning of boxing as a health risk.1-3 Chronic traumatic encephalopathy, or dementia pugilistica, which is attributed to boxing is one of the associated hazards. We report a possible additional and hitherto undescribed health hazard of boxing. A 34-year-old male prison inmate identified himself as having been in close contact with someone with sputum-smear-positive, culture-positive, pulmonary tuberculosis. The inmate provided a detailed account of his contact with the index case, stating that they had sparred and boxed almost daily for three months. This involved close contact, to the point where they were cheek-to-cheek. The boxing ring was in a well-ventilated area in the prison-yard. The exposure took place between February and May 2000. The inmate underwent Mantoux testing by the two-step technique4 in May and June 2000. He tested Mantoux negative at the time. However, when Mantoux testing was repeated in August, he responded with a 10 mm lesion. His chest x-ray was normal. As he had a cough, his sputum was examined for acid-fast bacilli, but findings were negative. Preventive therapy with isoniazid was initiated. The inmate had been in the same prison since August 1999. There were no other inmates with infectious tuberculosis, apart from the index case, during the period under review. We believe that the mode of transmission of Mycobacterium tuberculosis was during boxing sessions, and propose hyperventilation and forced expiration as the direct mechanisms. One other Mantoux conversion was identified, but the mode of transmission was presumed to be shared air-space during transportation in a van with recirculated air in a confined cabin for over six hours. It should be noted that the affected inmate did not travel with the index case, at any time. This case only came to light because the exposure was so specific, and because the index case and the Mantoux conversion both occurred during periods of incarceration. Anyone acquiring a similar infection in the community would have had multiple contacts, and therefore several probable transmission modes -- this may be why this mode of transmission has not previously been proposed among community contacts of people known to have tuberculosis. Boxing is unlikely to be a major cause of tuberculosis transmission, but may make a small contribution to tuberculosis notifications among young male adults.5 Michael H Levy Director, Population Health Corrections Health Service, PO Box 150, Matraville, NSW 2036 Craig Gater Health Services Manager Australian Correctional Management, Junee, NSW mhlATcmed.wsahs.nsw.gov.au Brain damage in boxers [comment]. Med J Aust 1970; 2: 709-710. Bowden SC, Walsh KW. Boxing: time for action. Med J Aust 1985;142: 282. Moxon J. Boxing injuries. BMJ 1992; 305:1438. Wang PD. Two-step tuberculin testing of passengers and crew on a commercial airplane. Am J Infect Control 2000; 28: 233-238. Global tuberculosis control -- WHO report 2000. Geneva: Communicable diseases, World Health Organization, 2000.

Michael H Levy · Craig Gater

Letters Ulcerative "nintendinitis": a new kind of repetitive strain injury MJA 2000; 173: 671 To the Editor: A previously well 9-year-old girl presented to our clinic with a punched-out lesion in the centre of her right palm. There was no history suggestive of other systemic infection, vasculitis or ischaemia. Clinical examination was unremarkable, except for a 6 mm ulcerated area with a surrounding thin rim of erythema in the centre of her right palm (see Figure (a)). On questioning, the girl revealed that two cousins were visiting for the summer vacation, and had brought with them a Nintendo 64 (Nintendo Co Ltd, Kyoto, Japan) game, Mario Party. She had never played this game before. On the evening of the day when she had played her first game, lasting two hours, the girl complained to her mother of the hand blister. When asked, the girl admitted that she was so engrossed in the game that she used her palm to press the joystick repeatedly and enthusiastically (see Figure (b)). Treatment consisted of abstinence from playing the game and applying an antiseptic cream twice daily. The lesion took 14 days to heal, and left a scar. The Nintendo company has sold more than a billion video games worldwide to date, and since its launch in 1996 Nintendo 64 has proved one of the most popular interactive software games.1 The realistic images and three-dimensional graphics are so captivating that players often spend many hours glued to the game. There have been reports of Nintendo playing causing daytime enuresis (three boys aged 3.5, 5 and 7 years),2 faecal incontinence (a 6-year-old),3 epilepsy (a 13-year-old)4 and soreness of the right thumb ("nintendinitis" in a 35-year-old).5 All these patients were noted to be deeply engrossed in the interactive games and their pathologies all resolved following abstinence from playing. We believe that this is the first reported case of hand ulceration caused by playing Nintendo 64. The multilingual consumer information booklet for Nintendo 64 carries a warning of the risks of epilepsy, repetitive strain injury and motion sickness. The parents of our patient had not read the leaflet and were unaware of these potential complications. Parents should warn their children not to use too much force during games and should limit duration of play. We recommend that any medical practitioner who sees a patient with an unusual hand injury, epilepsy or motion sickness should ask, "Do you play any interactive computer games?". Indeed, we recently encountered a child with diabetes who spent so much time playing these interactive games that lack of exercise resulted in abnormally raised blood glucose levels. T H H Guan Koh Senior Neonatal Paediatrician, Department of Neonatology Kirwan Hospital for Women PO Box 187, Thuringowa, QLD 4817 kohtAThealth.qld.gov.au Nintendo home page <http://www.nintendo.com/corp/ history.html (accessed October 1999). Schink JC. Nintendo enuresis. Am J Dis Child 1991; 145: 1094. Corkery JC. Nintendo power. Am J Dis Child 1990; 144: 95-99. Hart EL. Nintendo epilepsy [letter]. N Engl J Med 1990; 322: 1473. Brasington R. Nintendinitis [letter]. N Engl J Med 1990; 322: 1473-1474. (a) Ulceration of the right palmBack to text (b) Hand position when playing Nintendo 64 gamesBack to text

Snapshots Triple vision MJA 2000; 173: 646 Axial T2-weighted magnetic resonance image of the orbits. The "third eye" is a (histologically-proven) dermoid cyst in the superolateral aspect of the left orbit. David C Wong, FRANZCR Gail Durbridge, MSc Radiology Department The Wesley Hospital Auchenflower, QLD

David C Wong · Gail Durbridge

Snapshots Biting back pain MJA 2000; 173: 658 The patient's vertebral osteophytes appear to be about to bite the calcified abdominal aorta. Geoffrey J Coltheart, FRACS Sawyers Gully, NSW

Geoffrey J Coltheart

Snapshots A new kind of cave painting MJA 2000; 173: 658 This photograph confirms that Indigenous Australians were in the distal oesophagus well before European settlement. The photograph was taken at upper gastrointestinal endoscopy. It shows a segment of Barrett's epithelium (dark pink) just above the lower oesophageal sphincter. The lighter pink areas are residual islands of squamous epithelium. The "hand print" reminded me of Indigenous cave paintings in the outback. Brian Jones, FRACP Hornsby, NSW

Brian Jones