Volume 175 Issue 11

Editoral Environment, sustainability and health: the learning curve steepens Recent international strife is showing that a divided, unequal and insecure world is inimical to peace, wellbeing and health. We should be seeking a sustainably ordered world, and not a political New World Order. MJA 2001; 175: 569-570 The dramatic events of September 11, 2001, have compelled a refocusing of minds on wider state-of-the-world issues. Indeed, this refocusing may yet emerge as the silver lining to the cloud of tragedy, trepidation and tension that followed that shocking terrorist episode. Many people, on deeper reflection, are now confronting the question "Why?" — of what underlying malaise is such violence and resentment a symptom? The interdependence, reciprocity and increasing connectedness of the world's nations are now more evident than ever before. We are "globalising". This, in turn, entails an increased flow of information that reveals economic disparities, inequalities of trading regimens, persistence of poverty in many poor populations, and the magnitude and ubiquity of serious environmental deterioration.1 The economic, social and political systems that prevail today have thus heightened the risk of non-sustainability — both by overloading the earth's environmental "carrying capacity" (of humans) and by straining the fabric of social and political cohesion.2 . . . even in the modern, affluent, urbanising world, humankind is dependent on intact life-support systems and is subject to the constraints of environmental carrying capacity. Here, though, there is another tension. Despite the incipient evidence of global-scale environmental damage such as climate change and biodiversity losses,2 and the marked widening of the rich-poor gap over recent decades,1 humankind has undoubtedly done well on various environmental indicators.3 We have manifestly become more efficient at generating material wealth — at creating technology-enriched and comfortable lives — and we have achieved a doubling of average life expectancy over the past century.4 In most countries, fertility rates and infant mortality rates have continued to fall. True, various countries of the ex-Soviet Bloc and of HIV-afflicted Sub-Saharan Africa have experienced recent losses in life expectancy. But, overall, the prospects for the world's health seem good. However, this is where we in the health sector need to get serious about highlighting the significance, and the fundamental determinants, of population health. The world's policy-makers and international agencies are preparing for a major international conference on Sustainable Development, to be held in Johannesburg next September. This will be "Ten Years After Rio" (the United Nations Conference on Environment and Development, held in Rio de Janeiro). Yet, we still have not managed to formulate a clear view of population health as a central criterion of "sustainable development".5 That view would recognise that the prospects for population health are, at least in the long run, largely determined by the conditions and assets of the natural and social environments. Lacking that essentially ecological understanding, we will continue to encounter other limiting, indeed sometimes misguided, views about the significance of population health in the overall schema. The World Health Organization will continue to argue (at least for political reasons) that the population's health is an important input — a resource that enhances economic performance6 (which, in turn, benefits population health7). Others will emphasise that poverty is bad for health, that transnational market forces constrain healthcare for the poor, and that uncontrolled industrialisation poses toxic hazards to local communities. In other settings, however, a more profound argument is now being forged. Through three cycles of scientific assessment, the Intergovernmental Panel on Climate Change (IPCC) has paid steadily more attention to the risks posed to future population health by the continuing change in world climatic conditions.8 Likewise, effects on human health are now a central consideration in the several ongoing international scientific reviews of the human consequences of biodiversity loss, stratospheric ozone depletion, the widespread disruption of ecological systems, and the deregulation of international trade. We have begun to understand that, even in the modern, affluent, urbanising world, humankind is dependent on intact life-support systems and is subject to the constraints of environmental carrying capacity.2 We may achieve some technological alleviation, through developments such as genetic engineering and nanotechnology, but there is no guarantee — and we are rather short of time. The recent international strife has begun to underscore the uncomfortable realisation, for the United States and its Western allies, that a divided, unequal and insecure world is inimical to peace, wellbeing and health. This awareness may, one hopes, prompt serious collective action to avert the various global environmental changes that endanger health and life. Such policy changes will require a broad visionary effort. After all, America's recent rejection of the Kyoto Protocol for reducing greenhouse gas emissions is merely the most notorious of several acts of international policy delinquency. Various myopic governments have preferred immediate national economic growth over the longer-term need for prudent, shared international action in a more equitable world. The US exemplifies this self-serving short-termism, and, in recent years, Australia has sometimes followed suit. However, we are learning that the mere maintenance of economic growth is not what "sustainability" is about.9,10 Our economies should be means to social ends, not material ends in themselves. Further — and this is most important — the human-made economy is embedded within, and is ultimately beholden to, nature's "economy", the biosphere.2 The terrorist attack on New York has shown us that there can be no safe havens in a world riven by environmental stresses, social and political instability, and improvised weapons of mass terror and destruction. The rapid increase in numbers of environmental and political refugees, the outbreaks of slaughter in overpopulated regions (such as Rwanda in 1994), the early, tentative evidence of the impact on health of climate change11-14 — these and other signs tell us that we should now be seeking a sustainably ordered world, not a political New World Order. Our task in this evolving discourse, as health professionals, is to make clear that population health is a central criterion in the sustainability transition.5 Population health should be neither an instrumental policy sweetener nor a sideshow. The long-term good health of human populations is dependent on, and an essential measure of, our stewardship of the natural and social environments.2 Anthony J McMichael Professor National Centre for Epidemiology and Population Health Australian National University, Canberra Butler CD. Inequality, global change and the sustainability of civilisation. Glob Change Human Health 1: 156-172. McMichael AJ. Human frontiers, environments and disease: past patterns, uncertain futures. Cambridge: Cambridge University Press, 2001. Lomborg J. The sceptical environmentalist. Cambridge: Cambridge University Press, 2001. Feachem RG. Globalisation is good for your health, mostly. BMJ 2001; 323: 504-506. McMichael AJ, Smith KR, Corvalan CF. The sustainability transition: a new challenge. Bull World Health Organ 2000; 78: 1067. Bloom DE, Canning D, Sevilla J. Health, human capital and economic growth. Working Group I, Paper 8. WHO Commission on Macroeconomics and Health. Geneva: World Health Organization, 2001 (see www.comhealth.org/docs/wg1_paper8.pdf). Dollar D. Is globalization good for your health? Bull World Health Organ 2001; 79: 827-833. Intergovernmental Panel on Climate Change. Climate change 2000. Impacts and adaptations. Cambridge: Cambridge University Press, 2001. Kates RW, Clark WC, Corell R, et al. Environment development: sustainability science. Science 2001; 292: 641-642. Costanza R, Daly H, Folke C, et al. Managing our environmental portfolio. BioScience 2000; 50: 149-155. Lindgren E, Gustafson R. Tick-borne encephalitis in Sweden and climate change. Lancet 2001; 358: 16-18. Kovats RS, Campbell-Lendrum D, McMichael AJ, et al. Early effects of climate change: do they include changes in vector-borne disease? Philos Trans R Soc Lond B Biol Sci 2001; 356: 1-12. Tulu AN. Determinants of malaria transmission in the highlands of Ethiopia: the impacts of global warming on morbidity and mortality ascribed to malaria [PhD thesis]. London: University of London, 1996. Epstein PR, Diaz HF, Elias SA, et al. Biological and physical signs of climate change: focus on mosquito-borne diseases. Bull Am Meteorol Soc 1997; 78: 409-417. Make a comment

Anthony J McMichael

Editorial Bridging the divide: global inequities in access to HIV/AIDS therapy Australia should take a greater role in reducing the global burden of HIV/AIDS MJA 2001; 175: 570-572 Our recent visit to HIV/AIDS hospital units in Phnom Penh, Cambodia, sharply delineated the contrasting capacity to respond to HIV/AIDS in First World countries, such as Australia, and resource-poor countries. Common to both settings is the relatively young age of those affected, the close attention of loved ones and the dedication of healthcare workers. The contrasts lie in the enormous gaps in quality of healthcare facilities and access to effective HIV treatments. HIV/AIDS may be only one of several major public health issues for these countries, but, probably more than any other issue, it highlights global resource inequities. Over the past decade, Australia has been at the forefront of advances in HIV treatment,1-4 which have provided optimism for many people living with HIV/AIDS. Combination antiretroviral therapy is one of the most cost-effective therapies for a chronic disease in the developed world,5 and most First World countries provide ready access to combination antiretroviral therapy through publicly funded programs. However, 90% of the estimated 36 million people living with HIV/AIDS are in resource-poor countries,6 where access to new HIV treatments is extremely limited: an estimated 0.5% of the global market for antiretroviral therapy is sold in the poorest third of the world.7 Indeed, most people with HIV in resource-poor countries experience inexorable decline in immune function leading to death, just as people in First World countries did before the mid-1990s. If the challenge of the past decade was to develop therapeutic agents to control HIV infection, then the even greater challenge of the current decade is to provide access to effective HIV treatments for people in resource-poor countries. The political commitment to achieve this is growing. Earlier this year, a Declaration of Commitment was signed at the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in New York. This Declaration recognised that "access to medication in the context of pandemics such as HIV/AIDS is one of the fundamental elements to achieve progressively the full realisation of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health".8 The Declaration also set a resource target of US$7-$10 billion per year for HIV/AIDS prevention, care and support initiatives, to be reached by 2005.8 However, expanding access to effective HIV treatments also depends on other factors. Affordability of antiretroviral therapy: Recent endeavours to reduce the price of antiretroviral therapy for resource-poor countries need to be continued. Affordability can be improved through tiered pricing systems (maintaining current pricing levels in industrialised countries to subsidise lower pricing in resource-poor countries), further development of generic production, and use of compulsory licences and other health safeguards of the Agreement on Trade-Related Aspects of Intellectual Property Rights from the World Trade Organization.7 Within these measures, pharmaceutical industry profitability needs to be maintained at reasonable levels to enable continued research and development. Current pricing of some triple combination regimens should make potent antiretroviral therapy cost-effective for many middle-income countries. For example, stavudine-lamivudine-nevirapine, as produced by Cipla, an Indian-based generic producer, sells for A$700 per year, or about 5% of standard pharmaceutical industry pricing. In Brazil, a generic drug program established by the government was followed by 80% price reductions for several component agents of antiretroviral therapy,9 enabling universal access to antiretroviral therapy. Although encouraging, these price reductions are not enough for most resource-poor countries, where annual health budgets are often less than $20 per capita.7 Further, while implementation of antiretroviral therapy is being scaled up, it is realistic to expect that only a minority of people living with HIV/AIDS can be treated. This will necessitate difficult decisions about selecting patients for antiretroviral therapy, which might take into account social criteria (eg, family support and employment status) in addition to biological criteria (eg, symptomatic patients only to be treated). Therapy delivery and monitoring: Simply making antiretroviral therapy "available" is not the whole solution and may be counterproductive.10 Inappropriate antiretroviral therapy use may lead to viral resistance and considerable drug toxicity. Healthcare systems must therefore be developed to deliver and monitor HIV treatments effectively. However, implementation of antiretroviral therapy programs cannot wait for the optimal conditions that exist in industrialised countries. Therapy programs and infrastructure should be scaled up concurrently. Education and training of healthcare workers in antiretroviral therapy and more broadly in clinical management of HIV/AIDS will also be required. Antiretroviral therapy needs to be provided within an integrated system of HIV/AIDS treatment, care and support services. This may be helped by closer collaboration between HIV/AIDS and tuberculosis programs, which have been proposed as a platform for antiretroviral therapy implementation.11 Tuberculosis programs are the clinical entry point for many people with HIV/AIDS, as tuberculosis is the most common AIDS-related illness in resource-poor countries,12 and also have experience in delivering combination pharmacotherapy in resource-poor settings. Establishing referral networks between hospital-based and home- and community-based HIV/AIDS care programs will also improve delivery of a comprehensive package of treatment, care and support. Earlier diagnosis: In resource-poor countries, people with HIV/AIDS generally present with very advanced AIDS-related illness or die before presentation. Although antiretroviral therapy is still effective when commenced late in HIV disease, earlier HIV diagnosis would allow HIV preventive education and other HIV treatments, such as prophylaxis against common opportunistic infections, to be delivered. To achieve earlier diagnosis, rapid scale-up of voluntary HIV counselling and testing services is needed, including routine offering of HIV testing in antenatal clinics in settings with relatively high HIV prevalence. The latter would provide the foundations for preventing mother-to-child transmission and introducing treatment and care strategies, including antiretroviral therapy, earlier to many women with HIV/AIDS. Research on implementing antiretroviral therapy: Priorities should include evaluating pilot antiretroviral therapy programs in resource-poor settings, searching for more cost-effective means of monitoring therapy, and developing simpler therapeutic regimens (preferably, once-daily dosing) to enhance adherence. An example of Australia's contribution to the regional HIV/AIDS response is the HIV Netherlands-Australia-Thailand Collaboration, which has conducted HIV therapeutic research in Thailand since 1996.12 Australia now has the opportunity to contribute to HIV/AIDS research and care in countries such as Cambodia, where the burden of HIV/AIDS is increasingly being felt (Box). HIV prevention: Finally, if the UNGASS commitment to reverse the spread of HIV/AIDS by 20157 is to succeed, a heightened response is required to HIV/AIDS prevention as well as care. Both arms need increased priority and allocation of resources. They also need close interlinking in a broadly based response at national and community levels. However, implementing antiretroviral therapy may enhance HIV prevention through increased incentive for HIV testing accompanied by HIV preventive education. If the HIV/AIDS treatment divide between industrialised and resource-poor countries is to be bridged, we urgently need Australian research, medical, and educational institutions to become more involved, and public and private sector funding to be enhanced. Gregory J Dore Senior Lecturer, National Centre in HIV Epidemiology and Clinical Research University of New South Wales; and Infectious Diseases Physician HIV/Immunology/Infectious Diseases Clinical Services Unit St Vincent's Hospital, Sydney, NSW gdoreATnchecr.unsw.edu.au David A Cooper Professor, National Centre in HIV Epidemiology and Clinical Research University of New South Wales; and Director HIV/Immunology/Infectious Diseases Clinical Services Unit St Vincent's Hospital, Sydney, NSW Acknowledgements We would like to thank Professor John Kaldor and Dr Sean Emery (National Centre in HIV Epidemiology and Clinical Research, University of New South Wales) for their helpful comments on an earlier draft of this article. References Delta Coordinating Committee. Delta: a randomised double-blind controlled trial comparing combinations of zidovudine plus didanosine or zalcitabine with zidovudine alone in HIV-infected individuals. Lancet 1996; 348: 283-291. CAESAR Coordinating Committee. Randomised trial of addition of lamivudine or lamivudine plus loviride to zidovudine-containing regimens for patients with HIV-1 infection: the CAESAR trial. Lancet 1997; 349: 1413-1421. Montaner JS, Reiss P, Cooper D, et al. A randomized, double-blind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients: the INCAS Trial. Italy, The Netherlands, Canada, and Australia Study. JAMA 1998; 279: 930-937. Danner SA, Carr A, Leonard JM, et al. A short-term study of the safety, pharmacokinetics, and efficacy of ritonavir, an inhibitor of HIV-1 protease. European-Australian Collaborative Ritonavir Study Group. N Engl J Med 1995; 333: 1528-1533. Bozzette SA, Joyce G, McCaffrey DF, et al. Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy. N Engl J Med 2001; 334: 817-823. Joint United Nations Programme on HIV/AIDS. AIDS epidemic update: December 2000. Geneva: Joint United Nations Programme on HIV/AIDS, 2000. Attaran A, Gillespie-White L. Do patents for antiretroviral drugs constrain access to AIDS treatment in Africa? JAMA 2001; 286: 1886-1892. Declaration of Commitment on HIV/AIDS: "Global crisis - global action. <www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html> Accessed, Sep 2001. Gottlieb S. US concedes on cheaper drug production in Brazil. BMJ 2001; 323: 12. Horton R. African AIDS beyond Mbeki: tripping into anarchy. Lancet 2000; 356: 1541-1542. Harries AD, Nyangulu DS, Hargreaves NJ, et al. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001; 358: 410-414. Grant AD, Djomand G, De Cock KM. Natural history and spectrum of disease in adults with HIV/AIDS in Africa. AIDS 1997; 11 Suppl B: S43-S54. Kroon ED, Ungsedhapand C, Ruxrungtham, et al. A randomized, double-blind trial of half versus standard dose of zidovudine plus zalcitabine in Thai HIV-1-infected patients (study HIV-NAT 001). HIV Netherlands Australia Thailand Research Collaboration. AIDS 2000; 14: 1349-1356. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia. Annual surveillance report 2001. Sydney: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 2001. World Health Organization, Western Pacific Region. STD/HIV/AIDS surveillance report, no. 10. Manila: WHO, October 1997. Make a comment Australia14 (based on AIDS notifications; total population, 18 million). Cambodia15 (based on an estimated and projected AIDS incidence; total population, 11 million). Back to text

Gregory J Dore · David A Cooper

Conference report Bullfighting in Barcelona Blood, sweat and tears at the International Congress on Peer Review in Biomedical Publication Mabel Chew and Ruth M Armstrong MJA 2001; 175: 573-574

Mabel Chew · Ruth M Armstrong

Year of the volunteer Malaria, malnutrition and MSF This is a personal account of my brief time in Burundi as a volunteer doctor with Mèdecins Sans Frontières (MSF) at the beginning of 2001. Burundi is a small nation in central Africa (bounded by the Democratic Republic of Congo, Rwanda and Tanzania) which has suffered from problems between the Hutu and Tutsi "ethnic groups", similar to those for which Rwanda is better known. Unlike Rwanda, the war between government troops and rebel forces continues in Burundi. MSF has been in Burundi since 1992, providing basic healthcare, nutrition programs, surgical services and epidemiological intervention. In late 2000, a malaria epidemic began in Burundi's highland regions where transmission is normally low, and thus the population largely not immune. Malnutrition rates also increased and MSF rapidly expanded its usual program in an attempt to control these new health problems. David W Evans MJA 2001; 175: 575-576 "Asama." Once again, the first thing I have learnt to say in the local language is "open your mouth". "Asama." Looking along the ward, where the sickest children in the feeding centre are admitted, I can make out enough tiny figures among the overflow of beds and mosquito nets, and mothers with their pots and pans and other children, to know that we will be demanding a lot more open mouths before the morning is over. MSF's therapeutic feeding centre opened a few days before my arrival. Local mud bricks, wood and plastic sheeting, combined with MSF water bladders, piping and generators, have made a 600-bed centre out of this block, next to a regroupment camp from the mid-1990s, when the population was being systematically displaced to "flush out" rebels. It will end up housing over 1000 people when the mothers and siblings, and occasionally fathers, of the malnourished children are included. We start the day's work with the night's admissions. Despite struggling to read the French scribble of the MSF doctor who took the call, it seems that the condition of many of the children has improved from just a few doses of artemether (an antimalarial) and some rehydration. Some, of course, have not responded and it is difficult to reassure their mothers, looking desperately at their children unconscious with cerebral malaria and then hopefully at the Burundian nurse and me, that these children will recover. I explain the basics of our malaria treatment in bad French, which is translated into Kirundi, and the mother smiles. With absolutely no idea of what she ended up hearing, we move on. "Asama." There are about 60 children in this so-called "special care" ward. We need to discharge about 20 to the normal wards each day just to keep the numbers manageable. Every day, admissions seem to increase. Mothers are walking for hours with their marasmic, febrile children to reach the feeding centre here, and every afternoon our minibuses arrive filled with children who present to the MSF supplementary feeding centres throughout the province, but who are too malnourished to be managed with supplementary feeding alone. We know that some children die on the way and, of course, despite all the efforts of the Burundian nurses and MSF workers, some also die after admission. It is hard to consider the beauty of this place alongside the death and illness brought by malaria and war. Taking a break from the ward round, I stand outside with the Swedish nurse whose job it is to manage all this. We stare beyond the adjacent construction site — to be another feeding centre by the end of the week — and remark on the beauty of the clouds as they drift up the mountains to unveil the miniature figures marching through the rice fields below. Then she points out that the stagnant water of these rice fields is probably the source of all this malaria and the mountains here blur with the mountains we see from the United Nations plane on the way from the capital, Bujumbura — the mountains that are almost impossible to cross because of rebel attacks, and where, a week before my arrival in Burundi, rebels stopped a bus from Rwanda and killed everyone on board. This made the international news because an English volunteer teacher was on the bus. I have no idea how many other buses are stopped and their occupants massacred without the incident being reported in the international media. Back on the round, we have a glimpse of what medicine must have been like 150 years ago back in Sydney. Happily, the patient is getting better. So is her mother, who gave birth overnight in her sick child's bed. The other mothers helped her through the early labour, and then the night nurse apparently just parked the medication trolley and popped the gloves on for the delivery. We do our review of malaria treatment and nutrition status for the older child, a baby check on her new brother, a quick obstetrics review of the mother's postdelivery condition, and move on. At lunch we hear that another woman gave birth that morning in one of the transfer minibuses. The visiting epidemiologist from MSF headquarters in Europe is left with the problem of incorporating births into the weekly activity report of MSF's nutritional service. Besides the addition of chips to the usual menu of fried potatoes and boiled potatoes, there is good news at lunch. A 12-year-old girl, who was brought to the local hospital two weeks ago and urgently transferred to the closest MSF surgical service, was back and making a good recovery. She was severely beaten by bandits who stole the goats she and two other children were herding. The other two children, both younger than her, were stabbed to death in the attack. We choose to focus on her recovery. The two other Australians and I can only follow the conversation for so long before the French starts to sound like Kirundi and we sneak off for a quiet anglophone coffee before heading back to work. The afternoon brings seemingly endless queues of children, all apparently identified as having fever since the end of the morning rounds. And so begins the almost impossible challenge of distinguishing malaria from typhus from typhoid from the remaining diseases in the tropical medicine textbook, with only a stethoscope. Then the minibuses begin to arrive. We operate a simple triage system: any child who is unconscious or fitting is seen first. Fearing that we may soon have to resuscitate the Burundian nurse, who has been on admissions all day, all the expatriate medical staff and as many Burundian nurses as can be spared from the wards finish the admissions by torchlight while our logistician gets the generator working for overnight. Many of the children are febrile at admission but almost all the mothers report treatment already with chloroquine. It has been fairly clear since the beginning of the epidemic that resistance to chloroquine is high. No doubt the treatment failure rate contributes to the extraordinary patient overflow in the province's health centres, where triage has become an exercise in crowd control and diagnosing malaria has become guesswork in preference to ordering thousands of thick films made with out-of-date reagents. As we finish the admissions for the day, we hope that the results of MSF's malaria resistance study will soon be available to promote a new national policy with a first-line treatment that actually works. After a dinner of potatoes, most of us head off to the local bar for warm beer and some social time with the Burundian staff. The publican by night is a nutritional assistant by day, and so supplies almost all of the town with nutrients of one form or another. A Burundian version of Tom Waits is singing for beer, but the more beers he drinks the more he seems to sing. I order a soft drink and turn up the two-way radio — the MSF equivalent of the on-call page. Remembering my last call, when the first note reporting a pregnant woman of 38 weeks' gestation with eclampsia and a transverse lie was a joke from one of the other doctors but the 3:00 am postpartum haemorrhage following a cervical tear was not, I lean towards our expat midwife and quietly ask if she objects to being woken up overnight. Reassured by her response, I pass by the hospital before bed. Despite the flicker of the kerosene lamps, the conjunctivae of the woman who had a caesarean that morning seem pink enough and her urine output is good. No-one is in labour. The Burundian night nurse and I decide to treat a newly admitted child for cerebral malaria, despite the mother's insistence that her son was bewitched. At least we can treat malaria. The greatest challenge to sleeping is not so much the bursts of static from the on-call handset, but the MSF pig rooting around outside the bungalow. Plastic sheeting and bamboo muffles only so much sound. I know the pig is roaming the garden at night because the Europeans want him fat for eating as soon as the Australians, apparently the only conscientious objectors to eating one's pets, leave. I don't think about it. You can only focus on one day at a time here. I know that tomorrow we will see the same wizened, marasmic and puffy kwashiorkor faces, as well as a few new children of both expressions, febrile from malaria, but hopefully no children will die overnight. And I hope we can discharge more than we admit. All of us working in these hills at the moment are simply aiming to pass the peak of this epidemic. We'll know we're winning when we start demanding "asama" less often each morning. Authors' details Mèdecins Sans Frontières, Sydney, NSW. David W Evans, BScMed(Hons), MB BS(Hons), Medical Coordinator, MSF Mozambique. Reprints will not be available from the author. Correspondence: Dr D Evans, C/- Mèdecins Sans Frontières, Suite C, Level 1, 263 Broadway, Glebe, NSW 2037 . officeATsydney.msf.org Make a comment Mother and child at MSF therapeutic feeding centre, Burundi. Photograph by Joanna Ladomirska, courtesy of Médecins Sans Frontières, Sydney Population, 6.6 million Total fertility rate, 6.2 babies/woman Life expectancy at birth, 46 years Death rate, 16.36/1000 population Back to text

David W Evans

Year of the volunteer Arrival and departure As the small jet circled the dirt landing strip, I felt apprehensive. The briefing in Nairobi had been very detailed, but hadn't really allayed my fears. I struggled with my emotions and too many unanswerable questions. Why was I going to Somalia in the middle of a civil war, a war about which I knew so very little? What were the risks and what did I hope to achieve? Haydn Perndt MJA 2001; 175: 577-578 The plane touched down and some detail now appeared out of the desert haze. A number of four-wheel-drive vehicles were gathered around the perimeter of the airstrip. There was only one small ramshackle building standing intact. Armed men slouched in torpid menace. The identifying flag of the International Committee of the Red Cross was reassuring. Welcome to Mogadishu. The drive to the hospital of Keysaney, in the north of the divided city, wove through an urban landscape of chaos and destruction. Ten years of civil war had left the country in an anarchic state. Little effective social structure or function remained. As a Red Cross volunteer, I was a member of a flying surgical team responsible for emergency surgical care for victims of the conflict. It all seemed a long way from the island of Espiritu Santo where I'd had my first volunteer experience some years before . . . . . . That had been a very different arrival. The plane had swooped low over an azure lagoon, the island an explosion of vivid green. Coconut trees fringed the single runway. Smiling Melanesian faces welcomed me as I stepped onto the tarmac. I was to work on this dot in the middle of the Pacific for two years, as a medical officer for a 110-bed hospital. The job description read, "A doctor with obstetric and paediatric skills is required to give anaesthesia at the Northern District Hospital. Tropical medicine would also be useful". Having recently completed my specialty training, I was at least happy about the anaesthesia, but knew the other areas would need quite a lot of resuscitation! It proved to be one of the most rewarding periods in my career, the first of many volunteer experiences. I was extremely fortunate to work with a capable and easy-going expatriate surgeon and a shy, but very competent, Ni-Vanuatu anaesthetist counterpart. The theatre sessions were always great fun. I spent my time at the Northern District Hospital doing outpatient clinics, looking after the medical and tuberculosis wards, as well as giving anaesthesia for a fascinating variety of general surgery and emergency obstetrics. "Walking" clinics into "Middle Bush" with a Catholic nun added an extra dimension to my understanding of ambulatory medicine. Consultations took place under the eaves at the end of a thatched "long house" with nearly the whole village looking on. I was reasonably fluent in Bislama (the lingua franca of the 70-island archipelago), and this helped with the medical work and social activities. There was always a feast at the end of a day's clinic. The mountains of "lap-lap" (grated taro, banana or cassava with coconut cream wrapped in banana leaves and cooked slowly in a pit in the ground) were almost as daunting as the numbers of patients. The "Middle Bush" people were surprisingly healthy compared with the town dwellers, whose Western life-style was encouraging the development of the Western diseases of diabetes and hypertension. A rudderless night in a storm off the south coast in the rural health boat "cured" me of any nautical medical inclinations. It was a pity, as this was the only way to see the west coast of Santo. Some months later, I did, however, explore some of this area on foot during a five-day leprosy survey. The two years in Espiritu Santo flashed by. I was very sad when the time came to leave. There were so many good friends and I'd had so many wonderful experiences. But why had I gone to Espiritu Santo in the first place? What had taken me from the security of a "staff" position in a paediatric teaching hospital in Canada to a tropical island on the other side of the world? I still wonder at the serendipity of that initial volunteer opportunity. It was an experience which was to change my life and redirect my professional energies irrevocably. The years have certainly altered my expectations of the challenges and rewards of working in developing countries. I have had the opportunity to visit, live and work in quite a few different countries — over 20 at last count. Mostly, I taught anaesthesia, to medical assistants, nurses, doctors and medical students — in fact, to anyone who was interested. I must confess that I have learned far more than I taught . . . For nearly a decade I was involved in the annual Pacific Anaesthetic Refresher Courses, which took place at the Colonial War Memorial Hospital in Suva, Fiji. The driving force for these courses was a small group of ex-Pacific volunteers who, like me, had been bitten by the "Pacific virus" and wanted to continue helping their Pacific colleagues. Over the years, anaesthetists from almost every Pacific Island nation in Melanesia, Micronesia and Polynesia have attended these courses. The Australian Society of Anaesthetists sponsored and encouraged this activity, with a number of ASA presidents even going to Suva to teach. The courses were so successful that they attracted Australian Government financial support through AusAID (the Australian Agency for International Development) grants. The World Federation of Societies of Anaesthesiologists also helped. The Pacific Society of Anaesthetists has now taken over the running of this annual Continuing Medical Education program, with Australian anaesthetists still volunteering as lecturers and locums. Opportunities for further experience increased dramatically during my eight years on the Education Committee of the World Federation of Societies of Anaesthesiologists. I now became involved in international development work with an energetic and financially well-resourced committee. At times these activities seemed to engulf the other, more sensible parts of my life. What kept me doing them? Opportunities and challenging positions for medical volunteers abound. Websites and professional journals carry tempting advertisements. In general, activities fall broadly into either "service" or "development" roles. The Australian Rotary Interplast (Plastic and Reconstructive) Surgery tours to the Pacific started as a charitable venture. This has become a two-million-dollar, Australian Government-supported aid program. Known as the Pacific Island Project, it now encompasses many specialties, including otolaryngology, orthopaedics, ophthalmology and cardiology, and depends entirely on the time of the volunteer doctors involved. A number of professional colleges and societies have been very proactive in the development area. The Australian Society of Anaesthetists established the first postgraduate training program in anaesthesia for the south-west Pacific in Suva. This led the way for postgraduate training programs in Fiji in four other medical specialties. The Royal Australian College of Surgeons now oversees this AusAID-funded project. The Royal Australasian College of Physicians has been involved for many years in the Master of Medicine programs in Papua New Guinea. Professional organisations have become important partners in the realisation of the Australian Government's regional development objectives. As the small aircraft left Mogadishu for the last time, I reflected on my three months in Somalia. The Flying Surgical Team had worked all over the country, from Berbera in the north, to Merca in the south, as well as behind the rebel lines of an unknown civil war in neighbouring Djibouti. We had operated in derelict hospitals, an old prison and in a desert dispensary. The team had shared some intense experiences. I was privileged to have been part of an international effort to bring peace to Somalia. But there remained so much more to do. Authors' details Hobart, TAS. Haydn Perndt, FFARCS, FANZCA, Anaesthetist, Royal Hobart Hospital. Reprints will not be available from the author. Correspondence: Dr H Perndt, GPO Box 1060-L, Hobart, TAS 7001. Make a comment Population, 9.7 million Total fertility rate, 7.1 babies/woman Life expectancy at birth, 47 years Death rate, 18.35/1000 population Back to text "Middle bush" clinic and Sister Beatrice. Back to text "Ples Blong Katen man" — operating theatre, Santo. Back to text

Haydn Perndt

Crisis The place of infamy Charles Guest MJA 2001; 175: 580-582 Immediate responses to the attacks - Bioterrorism and the new security - Communication, protection and mitigation - We can not be everywhere - "No-regrets" measures - War - Conclusion - Acknowledgement - References - Authors' details - - More articles on Social issues Boston, 18 September Seven days ago, I heard on National Public Radio's 9 AM news that planes had just struck the towers of the World Trade Center. We had only recently arrived in the United States via Honolulu, so I thought of Pearl Harbor. In the week since, many others have recalled the attack of 7 December 1941, living on — in the definitive diction of Franklin Roosevelt preserved in newsreels — as "the day of infamy". The Oxford Dictionary defines "infamy" as the "reputation earned by an extreme, publicly known evil act; public reproach, shame or disgrace". It adds a legal consequence — the loss of rights of a citizen after being convicted of certain crimes. What are the implications of this new infamy for security and public health in the present and near future? Immediate responses to the attacks From one of the doomed jets, passengers had told their families by mobile phone that they would die fighting. So there was communication, but not enough time for intervention by the US Air Force. Yet, there was calm appraisal of the disaster at ground level. US Secretary of Health and Human Services Thompson ordered the activation of the National Disaster Medical Assistance Teams and Disaster Mortuary Operation Response Teams. "It is not down on any map: the true places never are." Herman Melville Heroism took many forms, such as the deaths of fire fighters and police officers during their efforts to save others, and the detailed attention paid to the logistics of rescue efforts by Mayor Giuliani of New York. The disaster immediately promoted a sense of unity among the survivors, those who came to help them, and other people across the United States and many other parts of the world. As people donated blood or money or time in the week following the attacks, compassion became almost competitive. Advertisers in the New York Times vied to "outdo" each other with expressions of sympathy, solidarity and nationalism. Fundraising scams were also reported. The counterterrorist inquiry started immediately, involving thousands of FBI agents and support staff — probably the most intensive investigation of this kind ever conducted in the United States. Osama bin Laden was soon named as the prime suspect. Just as soon, retaliation was on President Bush's agenda, gaining the support of all but one representative in Congress. The feared reprisal attacks and harassment of Arab-Americans in New York and elsewhere began to occur, but perhaps to a lesser extent than was expected. Local environmental investigations were largely unrevealing. The high temperature of the fires that razed the towers of the World Trade Center could have converted the refrigerant freon to phosgene, a highly poisonous gas, but this was not found. Stray sources of radiation among the rubble, another potential hazard, were also not detected. Days of black smoke, much thicker than the air pollution caused by industry, caused some respiratory distress, while many rescue workers, at least in the early urgency of the disaster, failed to wear safety masks, and so may have been exposed to asbestos. (Later, engineers wondered whether the towers would have stood for longer if the ban on use of asbestos had come in after, rather than during, construction of the Center.) Trauma takes its toll, but most of us will be able to put these events into a corner of our lives. A few will experience post-traumatic stress disorder, so, in New York, the world capital of psychotherapy, a surge in that industry may be expected. The trauma, physical and psychological, was exhaustively documented, and there were countless analyses of the way forward. How should the medical community respond to the death and destruction caused by terrorism? Can we move from the infamy of 11 September to constructive action for human health worldwide? Bioterrorism and the new security As a result of the events of 11 September, far stricter guidelines for airports are now in place in the United States. Doubt had been expressed on many previous occasions about the effectiveness of security checks, partly because security is typically run by contractors working for the airlines. This outsourcing of security functions carries a risk that has been widely recognised as intolerable: security and surveillance must be strengthened. This may include more attention to a small proportion of passengers in a "high-suspicion" category, as well as measures that will be applied to the entire travelling public. Some types of security, previously considered unacceptable for reasons of privacy protection, practicality, or expense, will emerge, at least in New York.1 In highly vulnerable and densely populated areas of the city, such as Times Square, options include the widespread use of surveillance cameras, connected to computers with software for face recognition. There will be more police and security officers, with dogs to detect explosives in suspicious bags or packages. Buildings will be reinforced, while heating, ventilation and air-conditioning systems will be secured to prevent the introduction of chemical or biological agents. Traffic and parking will be restricted. The possibility of biological warfare is the chief health concern in plans for the management of catastrophic terrorism. After the events of 11 September, the Centers for Disease Control and Prevention mounted special surveillance programs at New York healthcare facilities for unusual skin lesions that might be indicative of anthrax, plague or smallpox. (Later events showed that this localised approach was not enough.) The establishment of disaster surveillance is not new, following widespread concern about bioterrorism in the 1990s, but how far and how fast should we pursue safety measures? Ideally, the public health approach would focus on prevention of contamination episodes, but terrorism specialists warn that mass screening methods to detect the carriage of chemical or biological agents are not yet available. That leaves the collection and review of information about possible sources, the prevention of acquisition of hazardous material, and the early detection of cases and outbreaks of disease as the principal counterterrorism measures. Communication, protection and mitigation Governments should know where and why scientific equipment (such as that required for microbiology) is used, to reduce the chances of mischief. Public health authorities, including all healthcare facilities, require clear channels of communication with the police and other security agencies. Compliance with the Biological Weapons and Chemical Conventions should be verified worldwide. In Australia, security should be improved at the many places that could be raided by terrorists to obtain biological weapons.2 Existing public health infrastructure (including electronic information systems) should be upgraded, probably without requiring a new bureaucracy, for case and epidemic surveillance. All other aspects of the healthcare system should be reviewed now from the point of view of security. Education and training in the medical aspects of bioterrorism should be a priority. This has started with the development, in 1999, of a training program by the Australian Medical Disaster Coordination Group. Security issues surrounding the 2000 Sydney Olympic Games have also increased our awareness of bioterrorism. However, no country can yet claim to be well prepared. The Clinton administration's campaign to build civil defences against terrorism included the stockpiling of drugs and vaccines. (For example, 40 million doses of smallpox vaccine were to be prepared by 2004.3) The adequacy of these measures is under urgent review. We can not be everywhere The hijacked planes departed from Boston, Dulles and Newark airports, with the mayhem occurring in New York and Washington DC. Soon after the attacks, investigators, following any available leads, searched businesses and homes in New Jersey, Massachusetts, Florida and other states. Follow-up investigations spread to countries where Osama bin Laden's allies in the jihad are known: Egypt, Saudi Arabia, Yemen, Somalia, Eritrea, Afghanistan and Pakistan (to name but a few). As the list gets longer, the likelihood of finding the "true place" (in Melville's phrase) — the base of the terrorists or the trace to their next attack — gets smaller. How far will technology allow the improved tracing of terrorists — or, in the public health sphere, the mapping of diseases and their risk factors? Modern mapping techniques, enhanced by computer-generated imaging, can provide highly sophisticated representations of the distribution of people or diseases. Yet maps yield only partial truths, as Melville suggested. Comprehensive security and public health measures simply can not be implemented everywhere. "No-regrets" measures The technical difficulties of trying to root out terrorists or pinpoint the sources of all disease outbreaks make it essential to work on other fronts, to make more effort with responses that would be worthwhile regardless of whether or not terrorism was involved. Such "no-regrets" measures would have much in common with policies aimed at reducing the health burden caused by degradation of the global environment. For example, climate change threatens the livelihoods of people in poor countries; yet, in rich countries, governments do little to curb the environmentally harmful behaviours (such as the widespread use of private cars and sports utility vehicles) that contribute to global warming. This is but one reflection of the environmental injustice between rich and poor nations. Such inequalities have in turn fuelled a suicidal terrorist anger towards Western success and the hegemony of the United States in particular. The Hippocratic ideal requires that the medical community promote a positive program with a focus on the fundamental causes of terrorism, including such environmental concerns. War War is not the answer to the atrocities of 11 September. "Infamy" seems a fair description, but otherwise the analogy with the attack on Pearl Harbor fails. The identity of the "enemy" was rapidly declared by President Bush, but the retalictory action has not been properly targeted. The population of Afghanistan is not the enemy: most have been oppressed by the Taliban, not in league with it. Afghanistan needs support, not indiscriminate bombing. Bringing the terrorists to justice is the only acceptable form of retaliation. There may be a role for military intervention, but there must be at least as much digging in the civilian trenches to create peace. "The enemy of my enemy is my friend" is an inadequate basis for allegiance in a renewed "war" on terrorism; it will only serve to enlarge a war of hate. ("Wanted dead or alive" was an even more inflammatory phrase, but probably just a Wild West lapse of concentration from President Bush.) Instead of war, international unity, with genuinely shared strategic interests, must be developed. Stronger US support for the United Nations should be a good start. The term "war" is best avoided, even as a metaphor. In the medical arena, as elsewhere, "wars" are rarely won. Consider what has still to be achieved, 30 years after President Nixon's declaration of a "war against cancer". The "wars" on drugs and tobacco will also drag on throughout the new century. Conclusion Building global cooperative strategies to counteract catastrophic terrorism may take decades. The public health system must play its part in the scale-up of disease surveillance systems now, while recognising that we can not be everywhere. Medicine and healthcare represent a locus of vulnerability that should be covered. Removing the causes of terrorism — including an extremism that arises from poverty, hate and envy — will be harder. And increasing our information and security without unjust reductions in the freedom of some populations may be harder still.4We can not predict the time or place of the next strike, but it will happen. We must prepare. Public health surveillance must now have a global network, promoting not only the peaceful purpose of epidemiology, but also the warning, prevention and deterrence of bioterrorism. The epidemiologist classifies health problems according to time, place and person. I have argued here that the place for modern surveillance — not only of terrorism, but also of the risk factors and occurrence of disease — must be expanded, and now is the time. As for the people, government health authorities are necessary but not sufficient: "they" cannot do something about everything. We are all responsible. Postscript, 29 October Bioterrorism in the United States is now a fact: anthrax has been transmitted by mail. After criticism of the failure of intelligence services to prevent the hijackings on 11 September, blame is now cast on health authorities for underestimating the danger to postal workers.5 Will anyone now take bets against the re-introduction of smallpox? Vaccine production has been accelerated. War is also now a fact, but that does not make it right. Our response to this new infamy of terrorism requires, as the Oxford Dictionary noted, a criminal conviction. There has not yet been one. Unilateral declarations of war have been illegal since the adoption of the United Nations Charter in 1945, except under very limited conditions that constitute self-defence.6 The attack on Afghanistan by the United States has exceeded the legitimate use of force. Objections to this war derive not only from the hope for the sustainable, international rule of law, but also from the effect of retaliation, likely to increase the authority of Osama bin Laden and his supporters in some places. Will the US government — now working with the advertising agencies of Madison Avenue on ways to improve the US image abroad — consider that? Acknowledgement Many of the facts recorded above derive from media reports, mainly National Public Radio (WBUR Boston) and the New York Times, September 12-18. References Barstow D. Envisioning an expensive future in the brave new world of Fortress New York. New York Times 2001; 16 September: A16. Robertson AG. Bioterrorism and Australia: where to from here? Aust Mil Med 1999; 8: 18-23. Broad WJ, Petersen M. Nation's civil defense could prove to be inadequate against a germ or toxic attack. New York Times 2001; 23 September: B12. Ignatieff M. Paying for security with liberty. Financial Times 2001; 12 September: 14. Miller J, Stolberg SG. Anthrax: US officials acknowledge underestimating mail risks. New York Times 2001; 25 October: A1. Charter of the United Nations, 1945. Articles 2(4) and 51. Authors' details Department of Population and International Health, Harvard School of Public Health, Boston, MA, USA. Charles Guest, PhD, FAFPHM, Visiting Scholar. Reprints will not be available from the author. Correspondence: Dr C Guest, Department of Population and International Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. cguestAThsph.harvard.edu Make a comment

Charles Guest

Crisis Death in Antarctica Antarctic tourism is flourishing, but Antarctic cruises are often more physically demanding than typical "tropical" cruises. An 82-year-old Antarctic tourist died of probable septic shock secondary to lower respiratory tract infection six days after sustaining a suspected vertebral fracture in a minor fall from an inflatable boat. This case highlights the need for Antarctic cruise ships to be equipped to provide life support and for better screening and education of prospective Antarctic tourists. Paul G Lamberth MJA 2001; 175: 583-584 Clinical record - Discussion - References - Authors' details - - More articles on Travel, aviation and underwater medicine Antarctic tourism has increased rapidly in recent years, possibly because the collapse of the Soviet Union has made available a fleet of icebreakers.1 The combination of cruise ship conditions and the hostile, remote environment portends health risks for travellers. Doctors on scientific expeditions to the Antarctic report dealing with a range of major medical problems, including acute abdomen requiring laparotomy,2 ruptured intracranial aneurysm,3 70% thermal burns,4 and intestinal haemorrhage requiring a multinational rescue operation.5 Although the health needs of workers in Antarctica have been documented, little is known of the requirements of unscreened tourists. I report the death of an Australian tourist on an Antarctic cruise. Clinical record An 82-year-old Australian man boarded a Russian ice-strengthened vessel in Ushuaia, at the southern tip of Argentina, for a two-week cruise to the Antarctic Peninsula. During traverse of the notoriously rough Drake Passage on Day 2, he took dimenhydrinate and hyoscine for motion sickness. On Day 3, he had a minor fall while disembarking from an inflatable boat, leaving him with back pain which he treated with paracetamol and dextropropoxyphene. His only complaint to the ship's doctor (myself) at the time was wheezing induced by the cold air. On Day 5, he missed breakfast and was found lying on the floor of his single cabin. He explained that he had been unable to get up after a fall 12 hours before. I examined him carefully, with the only positive findings being dry mucosae and exquisite localised midline vertebral tenderness elicited at T9. He had a past history of smoking-related chronic airflow limitation, treated with bronchodilators and corticosteroids, and osteoporosis. The working diagnosis was a crush fracture of a lower thoracic vertebra, for which I gave him further analgesia. The following afternoon, subtle disorientation was noted, progressing over four hours to stupor with hypotension, poor peripheral perfusion and tachypnoea. Examination revealed left basal crackles and right-sided wheeze. The right calf had become tender. Intravenous resuscitation with 10% hydroxy-ethyl starch increased his blood pressure to 125/65 mm Hg, and urine output to 40-50 mL/h. Ceftriaxone (1 g) and gentamicin (320 mg) were administered with dexamethasone (4 mg intravenously) in lieu of regular bronchodilator therapy. On Day 8, the stupor persisted. Lung auscultation revealed left basal crackles correlating with a region of dullness to percussion. There was profuse purulent sputum. The patient's insurer agreed to meet the expense of evacuation, but a plan to fly him from the nearby Russian base on King George Island to Punta Arenas in Chile was abandoned when the weather deteriorated. After discussion, the Russian captain's initial plan to leave the patient at the Russian base, which was apparently less well equipped than the ship's hospital, was dropped in favour of returning to Ushuaia at full speed. That evening, the patient developed bilateral ocular deviation to the right, poor peripheral perfusion and periodic respirations. Crystalloid was administered to treat poor perfusion and falling urine output. Lansoprazole, for stress-ulcer prophylaxis, and aspirin, for a probable left leg venous thrombosis, were also given. On Day 9, the patient remained febrile, with normal heart rate and blood pressure. Enteral fluids (2000 mL per day) with sucrose (80 g) and sodium chloride (4 g) were tolerated, with gastric aspirates under 20 mL and normal bowel sounds. That afternoon, his breathing became intermittent, he developed oliguria and bradycardia, and died at 1730 hours. The ship reached Ushuaia 16 hours later. No autopsy was performed, and the body was cremated in Argentina. Discussion The final diagnosis was septic shock secondary to lower respiratory tract infection. The patient may also have had a deep venous thrombosis with possible pulmonary embolism. Contributing factors were chronic airflow limitation, back pain due to a thoracic crush fracture complicating osteoporosis secondary to frequent corticosteroid use, immobilisation and dehydration. Cold air exacerbating bronchospasm probably also contributed, while impairment of balance and cognitive function by anticholinergic medications may have been a factor in the patient's falls. This case illustrates the fundamental principle of incident analysis — a number of seemingly minor factors can combine to produce a disaster that was not predicted from any one precipitant alone.6 The case also raises issues for Antarctic tourism: Medical stocking of ships: As the areas explored can be several days' journey from modern healthcare facilities, there is an argument that ships' hospitals should be able to provide life support for 72 hours. This is not the case on most Antarctic cruise ships, despite travel companies advertising medical supervision as a feature. In contrast, the major "tropical" cruise lines provide advanced medical facilities appropriate to the elderly and infirm nature of many of their clientele. Medical equipment on Antarctic cruises should include intravenous fluids for resuscitation and maintenance and, ideally, a portable ventilator and monitoring device, such as a pulse oximeter. Ships' doctors require a high level of critical care skills to undertake advanced life support at sea. Many ship's doctors now working in Antarctica are Australian emergency physicians. Furthermore, the risks of anticholinergic medications for motion sickness, especially in the elderly, need to be better appreciated. Disturbed balance, sedation and cognitive impairment are a deadly combination in an unfamiliar environment. NASA (the National Aeronautics and Space Administration) advises promethazine for microgravity motion sickness.7 It is believed that promethazine, unlike hyoscine, dimenhydrinate and other common anti-motion-sickness agents, relieves symptoms without impairing adaptation. Therefore, during prolonged exposure, promethazine can be ceased as travellers get their "sea legs". Screening and education of prospective passengers: Factors that increase risk during Antarctic travel include: Moderate to severe reactive airway disease, especially if precipitated by cold air. Caution should be advised for those with chronic airway disease with severe fixed obstruction (FEV1 < 1.0 L/s) or requiring frequent courses of corticosteroids. Decreased mobility or balance problems, because of the need to negotiate steep companionways in heavy seas.8 Conditions with potential complications that would be difficult to treat in a remote environment, such as coronary artery disease, pregnancy and insulin-dependent diabetes. Poorly controlled mental illness. Provision of information on motion sickness, cold environment risks, and hazards such as falls may help passengers look after their own health. Appropriate health and accident insurance should be mandatory. A nihilistic philosophy that requires tourists to accept their own risks does not take into account the impact of illness or injury on other passengers, who may seek legal remedy from the tour operator. Improved surveillance of passengers travelling alone: Passengers in single cabins appear to be at increased risk of adverse events. The failure to detect my patient's predicament until 12 hours had elapsed may have been a crucial factor in his death. A simple system of surveillance would be possible, with passengers on their own reporting to a nominated crew member twice daily. The increase in adventure tourism by the elderly is a significant health challenge. Tour companies should consider developing a standard to equip ships for life support. A well-prepared aeromedical evacuation plan would mitigate this responsibility. Physicians advising prospective passengers should consider the rigorous screening that scientific expeditions apply to participants, and the equipment and training they provide in preparation for medical emergencies.9 Tourists swimming in an active volcano, Deception Island, Antarctic Peninsula. References Prociv P. Health aspects of Antarctic tourism. J Travel Med 1998; 4: 210-212. Priddy RE. An "acute abdomen" in Antarctica. The problems of diagnosis and management. Med J Aust 1985; 143: 108-111. Pardoe RA. A ruptured intracranial aneurysm in Antarctica. Med J Aust 1965; 1: 344-350. Alcorn GB. My Antarctic practice. Med J Aust 1992; 157: 253-258. Poki MT, Semmens K. Intestinal haemorrhage in Antarctica: a multinational rescue operation. Med J Aust 1979; 2: 275-277. Mendick M. What went wrong? Analysis. the little things add up. Flight Safety Aust 2001; 5(4): 14. Cowings PS, Toscano WB, DeRoshia C, et al. Promethazine as a motion sickness treatment: impact on human performance and mood states. Aviat Space Environ Med 2000; 71: 1013-1022. Carter JW. Shipboard medicine on package cruises. BMJ 1972; 1: 553-556. Lugg DJ. Antarctic medicine. JAMA 2000; 283: 2082-2084. Authors' details Department of Emergency Medicine, Canberra Hospital, Canberra, ACT. Paul G Lamberth, FACEM, Emergency Physician, and Consultant, Shock Trauma Service. Reprints will not be available from the author. Correspondence: Dr P G Lamberth, Canberra Hospital, Yamba Drive, Garran, ACT 2606. palamATozemail.com.au Make a comment

Paul G Lamberth

Crisis So this is Christmas For many, Christmas is a time of religious celebration and joyous family reunions, while for those separated from family and friends it can be a time of great loneliness. For others it can be a time of great grief as loved ones die on our nation's roads. Steven R Doherty MJA 2001; 175: 585-586 On the last "normal" working day before Christmas 2000 many hospital departments were in wind-down mode. Office parties, long lunches and early pre-Christmas drinks promoted an atmosphere of relaxation before the festive season holidays. Emergency departments rarely have such luxuries, although, on this particular day, a buffet was spread out in the tea-room. The local paper that morning screamed out headlines about the carnage on country roads. In the preceding 48 hours, in separate crashes in our area, one woman had been killed and a pregnant woman had been flown to Sydney with spinal injuries. The police were hoping that these would be the last major incidents in our region over the festive season. Just after lunch the emergency physician on duty asked if I could leave intensive care and help in the emergency department. There had been a car accident about 50 km away. Initial reports were that there were three vehicles with three dead, a baby on its way by helicopter, a man in shock at the scene and an elderly couple coming by road. The "unknown male" baby arrived accompanied by paramedics. He was probably about three months old with an obviously fractured humerus, conscious and crying loudly. He had a lot to cry about. His parents were both killed in their small hatchback vehicle. In the newspaper photograph the following day, their car was unrecognisable. He had been in a child restraint in the back seat and appeared to have no other major injuries. However, he was transferred to a paediatric facility because of concerns about occult injuries, and was subsequently ventilated for a closed head injury. The paramedic advised us that the "man in shock" was really a man with a few orthopaedic injuries. The elderly couple had only minor injuries, but one of them had had ischaemic chest pain. The medical retrieval unit then phoned to say that the "man in shock" was being flown to a tertiary centre and wouldn't be coming to us. The elderly couple arrived and I started to assess them. The woman had been driving at the time of the accident. The baby's parents in the car in front never had a chance. An oncoming car just suddenly drifted across the road and drove them backwards. The driver of that vehicle died too. The elderly woman tried to avoid the wrecks, but clipped into them. She had a bruised knee and, after a series of investigations, went home. Her husband's ischaemic pain had settled, but he had a painful and tender neck, although nothing wrong according to his x-rays. Just before the "man in shock" arrived — it seemed he wasn't going to a tertiary centre after all — Santa came in. One of the local general practitioners has traditionally dressed as Santa and brought in gifts, usually of the liquid and chocolate variety, for emergency department staff working over Christmas. I think he realised as soon as he pushed open the resuscitation room doors that he'd come at a bad time. The "man in shock" was the passenger in the car that drifted. He was 22 years old and had open fractures of his right hand and right ankle and a fractured left radius. He had no more serious injuries. He verified the story told by the elderly woman. His brother, who had turned 26 three days previously, had been driving. After the casualties were sorted out the bodies started to arrive. The dead parents had names, the baby had a name. Before the baby's transfer, and long after the others had left, the nurse who had received him into the emergency department was still there, stroking his hair and waiting for the retrieval team. He would never again know the sound of his mother's voice, never again suckle at her breast. Some time before this, the mother of the two brothers had phoned. The police had given her the news. With a broken voice she asked me about her other son. It was some consolation to be able to tell her that he was battered and bruised, but not in any real danger. A female resident, 20 weeks pregnant with her first child, arrived for the evening shift. She wasn't involved with any of the patients, but was upset by the whole event. She asked me if things like this get harder as you get older. I don't know if they do or not. Does experience harden or mellow you? I told her that I believed these events became harder after you had your own children. Your own children give you a perspective on life you never knew existed. You understand the mother's grief on a more tangible level. You understand the changes this baby will face on a more tangible level. The solemn staff went about their work; counsellors were called to see the survivors of the crash and their relatives, as well as the staff. Only a month before I had spoken at the Australasian College for Emergency Medicine annual scientific meeting. I presented on the differences between rural and city trauma. Fatigue, speed and alcohol are all more frequently associated with car smashes in country areas. These vehicles were all doing about 100 km/h, and all undertaking long trips. The baby and his parents were on a journey of 978 km, the two brothers 513 km, and the elderly couple 859 km -- massive distances in anyone's language. At the meeting I also presented 1999 Roads and Traffic Authority (RTA) figures; in New South Wales 572 people were killed and 26 748 people were injured in motor crashes. Sixty-five per cent of fatalities occurred in country areas, where only 30% of the population live (Mike Adams, Traffic Accident Research Unit, RTA). The police and the RTA preach preventive driving all the time. Yet hundreds of people still die on our roads. The incidence increases every holiday season, with Christmas no exception. Perhaps, though, at Christmas, the impact of the road toll, repeatedly tallied on our televisions and in our newspapers, hits harder. In the 2000 Christmas and New Year break, 77 people died on Australian roads, 39 in NSW. Notwithstanding the work of the police and the RTA, the medical profession, and emergency physicians in particular, are in a great position to become more proactive in road trauma prevention. Programs need to be developed, starting with children in our schools, and they need to be repeated at various stages of their progress through school. Indoctrination? Perhaps, but something needs to be done. We need to develop a society that knows the dangers of driving and understands the main contributors to road crashes, most of which are not "accidents". Christmas 2001 is approaching, and sadly the same horror stories will occur somewhere this year. They will keep recurring. For some this will be the real Christmas. A Christmas of tragic loss or painful memories. Are we, as a profession, doing enough to lessen this trauma? Authors' details Emergency Department, Tamworth Base Hospital, Tamworth, NSW. Steven R Doherty, MB BS, FACEM, Emergency Physician. Reprints will not be available from the author. Correspondence: Dr S R Doherty, Emergency Department, Tamworth Base Hospital, PO Box 83, Tamworth, NSW 2340. srdohertATmpx.com.au; sdohertyATdoh.health.nsw.gov.au Make a comment

Steven R Doherty

Asylum seekers and healthcare Asylum seekers in Australia The medical profession can assist by reinforcing the principle of healthcare as a right, and opposing policies that contribute to poor health MJA 2001; 175: 587-589

Mitchell M Smith

table { width: 100%; table-layout: fixed; } table tr td { width: 70%; } table tr td:first-child { width: 30%; } Asylum seekers and healthcare The health needs of asylum seekers living in the community Mark F Harris and Barbara L Telfer MJA 2001; 175: 589-592 Abstract - Health needs of asylum seekers - Access of asylum seekers to healthcare - Caring for refugee patients - The role of healthcare workers - Competing interests - References - Authors' details - - More articles on Social issues Abstract Asylum seekers living in the Australian community, and awaiting the outcome of applications for protection visas, may require medical treatment for a range of illnesses, and are likely to have psychological or musculoskeletal problems as a consequence of traumatic experiences in their own countries. Many require specialist treatment. Some asylum seekers living in the community are denied access to Medicare and can not afford basic medical treatment. This creates suffering in the short term and complications in the long term. Healthcare professionals have an ethical responsibility to provide basic medical care for asylum seekers in Australia. Under the offshore component of its Humanitarian Program, Australia offers 4000 places for refugees each year. In addition, Australia offers places under its Special Humanitarian Program for people in refugee-like situations who have links to Australia. There is also provision for granting refugee status to applicants who apply from within Australia (onshore asylum seekers). In total, the program assists 12 000 people per annum.1 In 1999-2000, the Department of Immigration and Multicultural Affairs (DIMA) received 12 713 applications for refugee status from people onshore.1 In that year, 2458 onshore asylum seekers were granted protection visas: 1684 of these were granted at the completion of the primary stage of processing (which is handled by a DIMA staff member).1 More than 70% of those unsuccessful at the primary stage appealed to the Refugee Review Tribunal, but, in 1999-2000, only 679 protection visas were granted after this second stage of processing.1 The number of protection visas granted as outcomes of successful appeal to the Federal or High Court is not specified on the DIMA website. In the year 1999-2000, 76 protection visas were granted through ministerial discretion, the final stage of appeal.1 (Because of the time delay involved in the various stages of the visa process these figures do not all apply to the same group of applicants.) According to DIMA, at 30 June 2000 there were 6500 applications for protection visas at the primary stage and 7828 at the Refugee Review Tribunal stage.1 With 3622 asylum seekers in mandatory detention at 23 March 2000,2 we estimate that there were over 10 000 asylum seekers living in the community in Australia in 1999-2000. While embroiled in the multistage application and appeal process (which can take from three months to over three years) community-based asylum seekers must remain in Australia. During this period, however, many must survive with no right to work, and no Medicare cover, no pharmaceutical benefits and no welfare support.3,4 Health needs of asylum seekers Several studies have assessed the health needs of refugees. In the United Kingdom, one in six refugees have a physical health problem severe enough to prevent them from going about their daily life and two-thirds have experienced anxiety or depression.5 Not surprisingly, a past history of torture, or the feelings of insecurity experienced by refugees, amplify and extend the duration of their illnesses.6 In addition, postmigration factors such as discrimination, lack of social support and unemployment have been identified as major contributors to anxiety and depression in refugees.7 Children, in particular, appear to suffer prolonged psychological distress after resettlement.8Some asylum seekers present with the physical sequelae of torture or other violent trauma which may not have received adequate medical attention in their countries of origin. These sequelae include malunited fractures, osteomyelitis, epilepsy or deafness from head injuries, or non-specific musculoskeletal pain or weakness.9 In rape victims, in addition to the psychological sequelae of rape, there may be a risk of HIV or other sexually transmitted diseases. The incidence of infectious and nutritional diseases varies between refugee groups according to their country of origin.10 The presence of HIV, hepatitis A and B, tuberculosis or immunisable diseases is of major public health concern.11 However, severe parasitic and intestinal infections are also common. Helicobacter pylori infection is particularly common in refugees from developing countries or those who have spent time in refugee camps.12 In Sydney, a study in 1994 of 40 asylum seekers attending the Asylum Seekers Centre, a charitable organisation which provides education and support for asylum seekers, suggested that most were suffering from psychological and physical symptoms sufficiently serious to warrant medical assessment.13 Thirty reported exposure to premigration trauma, 10 had been subjected to torture, 10 reported gastrointestinal disease, nine musculoskeletal complaints, six gynaecological problems and one had an infectious disease (hepatitis). Smith has described the similarity between the health of asylum seekers and that of refugees resettled in Australia from overseas.4 Their general health problems are complex and compounded by the socioeconomic disadvantage they experience in Australia. Likewise, in the United Kingdom, studies have found that many of the diverse and manifold health needs of asylum seekers overlap with those of "deprived or excluded groups, ethnic minorities or new entrants to the country".14 Access of asylum seekers to healthcare UK and Europe In the United Kingdom, asylum seekers have free access to the National Health Service. They can register with a general practitioner and are exempted from charges for prescriptions and dental and optical care.15 However, many refugees encounter problems registering with a GP,16 with GPs' concerns ranging from the demands on their time to communication difficulties.17 Low consultation rates with primary care doctors have also been reported in Switzerland.18 Apart from GPs' attitudes, other barriers to healthcare access for asylum seekers in the UK include practitioner inexperience with uncommon and complicated health problems; a lack of relevant cultural, health and health service educational material for both asylum seekers and healthcare staff; language difficulties; misunderstandings; and inadequately resourced interpreter and advocacy services. Importantly, a scarcity of government-funded health services for asylum seekers is overburdening non-governmental and voluntary organisations and community groups.16,19 In the words of the Chairman of the British Medical Association Medical Ethics Committee: There has been no real NHS planning for the health needs of asylum seekers . . . No thought has been given to their health needs or the social infrastructure around them and it is possible to see the whole process as an abuse of human rights in itself.20 The outcome of these "system based" shortcomings is "false economy", where many asylum seekers "end up requiring hospitalisation for conditions which could have been easily treated at an earlier stage".21 Australia In Australia, to be eligible for essential medical services through Medicare and the Pharmaceutical Benefits Scheme, asylum seekers with a valid visa must apply for asylum within 45 days of their arrival in Australia. As a result of this "45-day rule" and other governmental restrictions, about 40% of asylum seekers are denied Medicare and work rights.3 If they appeal their case to the Refugee Review Tribunal or the courts (as most asylum seekers do who are unsuccessful), these restrictions can persist for many months to years. Asylum seekers experience a greater burden of ill health, lower socioeconomic status and greater problems accessing affordable and appropriate healthcare.4,13In exceptional circumstances asylum seekers who are denied Medicare and work rights can receive help from the Asylum Seekers Assistance Scheme (ASAS). ASAS is a Commonwealth Government scheme administered by the Red Cross which provides financial assistance and healthcare to a small proportion of eligible asylum seekers.22 In 2000-2001, the scheme assisted 2641 ASAS-eligible asylum seekers. However, the number of community-based asylum seekers "unable to meet their most basic needs" exceeds the scope of the scheme. For example, in 2000-2001, the Red Cross assisted an additional 1475 asylum seekers who were officially ineligible for the ASAS scheme, but unable to meet their most basic needs (ASAS, National Office of the Red Cross, Melbourne). The NSW Health Department charges patients who are ineligible for Medicare for inpatient and outpatient care. At a metropolitan referral hospital, these charges are $695 per day for inpatient care and $80 for outpatient care.23 An assurance of payment is required before treatment is provided (cash, credit card or guarantee from an Australian citizen) (Box 1). When such an assurance of payment is not forthcoming, the patient is to be informed that he or she will receive only the minimum and necessary medical care to stabilise their condition. Persons admitted to a public hospital under ASAS are exempt from paying these fees, but this does not apply to the many asylum seekers who do not qualify for this scheme or fee exemption. In Australia, there have been few studies of access to healthcare of asylum seekers. In the 1994 study of 40 asylum seekers,13 27 expressed concerns about not obtaining treatment for general health problems over the previous 12 months, with 25 citing lack of access to Medicare as the main reason; 21 reported poor access to emergency care and 19 to long term medical care; and 27 reported difficulty accessing dental care. Caring for refugee patients The Victorian Foundation for Survivors of Torture and the West Melbourne Division of General Practice have produced a guide to the care of refugee patients in general practice.24 This emphasises the importance of engaging a professional interpreter and providing adequate education and information to refugee patients, including the cost of prescriptions, investigations and referrals. Key issues to be considered in the assessment include preventive care, chronic conditions for which management may have been delayed or inadequate, dental care, developmental problems, mental health problems, injuries and infectious diseases. The aims in managing refugee patients who may be survivors of torture or other trauma associated with refugee status are:25 To identify patients who may have experienced torture and/or traumatic experiences. To understand the context in which torture and refugee trauma may have occurred, and the impact on the individual, family and community. To assess the physical and mental health problems of torture and refugee trauma survivors. To work with patients to develop a management plan. To be aware of and confident in referring patients to appropriate services. To be aware of the impact of these issues on health professionals. For many refugee patients who were tortured, the torturing was done by medical practitioners, who were forced to do so by the authorities. Not surprisingly, these patients often find it difficult to trust practitioners, especially when there are also language and cultural barriers. The role of healthcare workers Healthcare workers have an ethical responsibility to provide life-saving care for asylum seekers in Australia. However, this responsibility is not always clear cut, and clinicians, in their attempts to provide care in a timely way, are often frustrated by State and Commonwealth health department policies. Patients with physical conditions requiring investigations (such as possible malignancy), subacute conditions (such as extrapulmonary tuberculosis), or those with chronic conditions which may result in acute complications (such as diabetes), face significant barriers to accessing healthcare (Box 2). Very often they rely on charitable organisations and the ingenuity of volunteer healthcare workers to "bend the system". This is becoming increasingly difficult. A case study illustrating the problems of access to healthcare is given in Box 3. Competing interests None declared. References Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed September 2001). Department of Immigration and Multicultural Affairs. DIMA Fact Sheet 82: Immigration detention. http://www.immi.gov.au/facts/82detain.htm (accessed September 2001)] Mares P. Borderline: Australia's treatment of refugees and asylum seekers. Sydney: UNSW Press, 2000. Smith M. Desperately seeking asylum: The plight of asylum seekers in Australia. New Doctor Summer 2000-2001; 74: 21-23. Carey Wood J, Duke K, Karn V, Marshall T. The settlement of refugees in Britain. London: HMSO, 1995. (Home Office research study 141.) Sundquist J, Johansson SE. The influence of exile and repatriation on mental and physical health. A population-based study. Soc Psychiatry Psychiatr Epidemiol 1996; 31: 21-28. Pernice R, Brook J. Refugees' and immigrants' mental health: association of demographic and post-immigration factors. J Soc Psychol 1996; 136: 511-520. Hjern A, Angel B, Jeppson O. Political violence, family stress and mental health of refugee children in exile. Scand J Soc Med 1998; 26: 18-25. Burnett A, Peel M. The health of survivors of torture and organised violence. BMJ 2001; 322: 606-609. Jones D, Gill PS. Refugees and primary care: tackling the inequalities. BMJ 1998; 317: 1444-1446. Burnett A, Peel M. Asylum seekers and refugees in Britain. BMJ 2001; 322: 544-547. Walker PF, Jaranson J. Refugee and immigrant health care. Med Clin North Am 1999; 83: 1103-1120. Sinnerbrink I, Silove DM, Manicavasagar VL, et al. Asylum seekers: general health status and problems with access to health care. Med J Aust 1996; 165: 634-637. Bardsley M, Storkey M. Estimating the numbers of refugees in London. J Public Health Med 2000; 22: 406-412. Connelly J, Schweiger M. The health risks of the UK's new Asylum Act: The health of asylum seekers must be closely monitored by service providers. BMJ 2000; 321: 5-6. Islington Refugee Working Party. Report on questionnaire survey. London: Islington Voluntary Action Council, 1992. Ramsey R, Turner S. Refugees' health needs. Br J Gen Pract 1993; 43: 480-481. Blochliger C, Junghanss T, Weiss R, et al. Asylum seekers and refugees in general practice: problems and possible developments. Soz Praventivmed 1998; 42: 18-28. Woodhead D. The health and wellbeing of asylum seekers and refugees. 2000, London: King's Fund. Available at: http://www.kingsfund.org.uk/ePublicHealth/assets/applets/asar.pdf (accessed October 2001, no longer available). Wilks M. Chairman of the BMA Medical Ethics Committee. The Observer 2001; Sunday June 24. Available at: http://www.observer.co.uk/life/story/ 0,6903,511637,00.html (accessed September 2001). Murshali H. Refugee Council, UK. Australian Red Cross. Asylum Seeker Assistance Scheme. http://www.redcross.org.au/ourservices_acrossaustralia_asas_default.htm (accessed October 2001, updated February 2006). NSW Health Department. Health Services Act 1997. Scale of fees for hospital and other health services. Circular No 99/64. Caring for refugee patients in general practice. Victorian Foundation for Survivors of Torture, on behalf of the Western Melbourne Division of General Practice, 2000. Canberra: Department of Health and Aged Care, 2000. ISBN 0 9585657 4 0. Available at: http://www.racgp.org.au/downloads/20000831refugeevic.pdf (accessed November 2001). Managing survivors of torture and refugee trauma. Guidelines for general practitioners. NSW Service for Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), General Practice Unit, South West Sydney Area Health Service, Centre for Health, Equity, Research and Evaluation (CHETRE), NSW. Sydney: Refugee Health Service, 2000. ISBN 1 876056 12 6. Authors' details University of New South Wales, Sydney, NSW. Mark F Harris, FRACGP, MD, Professor of General Practice, School of Community Medicine. Barbara L Telfer, BPhysiotherapy, MPH Student. Reprints: Professor M F Harris, School of Community Medicine, University of New South Wales, Sydney, NSW 2052. m.f.harrisATunsw.edu.au Make a comment 1: A Medicare card is required for all hospital attendances Back to text 2: An audit of primary care needs of asylum seekers at the Asylum Seekers Centre, Sydney, 2001 Objective and methods: To describe the health problems and access to health services of community-based asylum seekers, we audited the records of 102 consecutive asylum seekers attending the general practice clinic at the Asylum Seekers Centre in Sydney over a 12-month period in 2000-2001. These asylum seekers, whose mean age was 33.5 years (SD, 15.9; range, infancy to 68 years), did not have access to Medicare. Sixty-one per cent were men. Results: Most patients were from Africa, the Middle East and South America. Their diagnoses, in order of frequency, are listed below. There was a history of torture or trauma in 45 of these patients. Psychological, musculoskeletal and cardiovascular problems were the most common. Sixty-seven were prescribed medication, 32 required a pathology test and 20 were investigated by imaging. Twenty-eight patients were referred (most frequently to physiotherapy, eye clinic, gynaecologist, psychologist, diabetes centre, gastroenterologist, urologist, breast clinic or family planning). For several patients there were problems with providing care because of cost or access. This resulted in a significant delay in care over and above what would normally be expected, or in the care not being provided. This included patients requiring hospital admission (5), complex investigation including magnetic resonance imaging, bone scan, angiography (3), subacute or elective surgery (5), dental care (3), referral to allied health (3), specialist medical care (6) and drugs on the Pharmaceutical Benefits Scheme, which are expensive to purchase at full price (6). Arranging bookings for confinement was difficult in most cases — especially so in two. Conclusions: This pattern of morbidity is not surprising given their frequently reported history of torture and trauma. A significant proportion required specialist care and experienced problems accessing hospital-based services, especially inpatient care, as well as difficulty paying for expensive drugs (such as triple therapy for Helicobacter pylori infection, and antipsychotic drugs). Psychological and medical conditions of asylum seekers Psychological, including depression, anxiety, post-traumatic stress disorder 26% Musculoskeletal, including previous injuries/trauma 24% Circulatory, including hypertension, heart disease 18% Digestive, including peptic ulcer 16% Infectious diseases, including TB, HIV, hepatitis B 12% Urological, including urinary tract infections, prostatitis 9% Neurological, including headache, epilepsy 8% Endocrine, including diabetes 7% Pregnancy 6% Female genital conditions 6% Ophthalmological conditions 6% Skin conditions 5% Dental problems, including dental abscess, gum disease 3% Anaemia 2% Ear problems 2% Back to text 3: Case study A 27-year-old man whose case was before the Refugee Review Tribunal had experienced trauma during imprisonment in his country of origin and had sleep problems as a result. He had had abdominal pain, diarrhoea and fever for 3-4 months. He felt constantly tired and lethargic and had lost 9 kg (down to 43 kg). He had been unable to get medical attention because he was not eligible for Medicare. On examination, his right abdomen was very tender and he had an enlarged liver. His haemoglobin level had fallen to 86 g/L (normal range, 120-160 g/L), and he had a lowered white cell count and a raised erythrocyte sedimentation rate of 60 mm/h (normal range, 5-15 mm/h). The provisional diagnosis was tuberculosis or malignancy. He was referred to a senior gastroenterologist, who tried to admit him to hospital for further investigation. However, the hospital would not authorise his admission as he did not have a Medicare card. After multiple entreaties by the doctors involved, the Red Cross lodged an application with the Department of Immigration and Multicultural Affairs for financial coverage of his health costs in a public hospital. This took 5 days to organise, during which time he suffered repeated blackouts at home. He was eventually admitted to hospital a week after the original recommended urgent admission date and investigations confirmed a diagnosis of tuberculosis. He was treated with antituberculosis chemotherapy and has made a slow recovery over 6 months. Back to text

Mark F Harris · Barbara L Telfer

Asylum seekers and healthcare Psychological disturbances in asylum seekers held in long term detention: a participant-observer account Confinement in immigration detention centres for extended periods of time can have severe, psychologically disabling effects on asylum seekers. Aamer Sultan is a medical practitioner who fled persecution in Iraq after providing casualty medical care to Shiite Muslim rebels. He has been detained in the Villawood Detention Centre, Sydney, since May 1999, as his claim for protection under the United Nations Convention has not been endorsed by Australian authorities. He can not be returned to Iraq because Australia currently has no diplomatic ties with Iraq and no international flights go to Iraq. As a health professional and a bilingual Arabic/English speaker, he has acted as a confidant for many detainees. His observations are supplemented by those of clinical psychologist Kevin O'Sullivan, who provided psychological treatment for over 50 asylum seekers during a recent 12-month contract with the same detention centre. Aamer Sultan and Kevin O'Sullivan MJA 2001; 175: 593-596 For editorial comment, see Steel and Silove Abstract - The environment of detention - Refugee assessment process - Cumulative effects on the mental state of asylum seekers - Effect on children - Survey of detainees at Villawood - Conclusions - Authors' details - - More articles on Social issues Abstract The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Most of the asylum seekers detained at Villawood Detention Centre come from developing countries ruled by oppressive regimes with poor human rights records. Many have been victims of State-organised violence, including torture and other forms of inhuman or degrading treatment or punishment, or have family members who have suffered such abuses. Thus, they are at high risk of the range of post-traumatic psychological reactions widely documented among victims of mass trauma and organised violence. These background issues are relevant to the understanding of the impact of detention on asylum seekers' psychological state. The environment of detention On arrival in Australia, most asylum seekers hold strongly to the belief that their applications for protection are legitimate and most are confident that a just society such as Australia will accept the veracity of their claims for refugee status. After transfer to a detention centre, several factors converge to undermine this faith and hence the psychological stability of the asylum seeker. The most threatening aspect is loss of liberty for an indeterminate period of time — detention without trial imposed on people fleeing injustice in a context where no crime has been committed. The average length of detention in Villawood in February 2001 was six months, although the duration varies from individual to individual and, for some, may extend for longer periods of time, with no maximum limit on the period of detention. Lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status, or those who are unable to be deported from Australia (because they are stateless or from countries with no diplomatic ties with Australia, particularly Afghanistan and Iraq). The physical environment at Villawood is intimidating in a number of respects. Each compound is surrounded by multiple layers of high fencing topped and grounded by razor wire. All visitors must pass through high security checkpoints. Within the detention centre, there are multiple daily musters and nightly head counts, which may occur at 2 AM and 5.30 AM. The public address system, which operates almost continuously from 7 AM to 9 PM, is also disturbing. For most of the previous two years, there has been a general dearth of activities, resources, or educational materials, leaving detainees with long periods of unstructured time. Despite recent improvements, boredom, aimlessness and apathy are widespread, particularly among those who have been detained for longer periods of time. At times, we have observed harsh and uncompassionate handling of asylum seekers by staff. Detainees are routinely handcuffed during transportation to and from the facility for medical or legal appointments. Access to medical services sometimes has to be negotiated through correctional centre staff, especially after hours or during security incidents. Detainees may then perceive medical practitioners as being aligned with the detaining authorities and are concerned that this may hinder them in acting in their best interests. Concerns have been raised about doctors authorising sedative medication for containment and removal of detainees rather than for genuine medical reasons. Multiple complaints have been lodged by detainees with the Commonwealth Ombudsman, the Human Rights and Equal Opportunity Commission, and the NSW Health Care Complaints Commission about inadequacies in medical and dental care. Apart from official hearings and interviews, interpreter services are not generally available, leaving detainees with poor English isolated and unable to communicate. During crisis periods, such as when hunger strikes or breakouts occur, detainees have been confined for long periods in their rooms, and denied access to phones, faxes, postal services, and visitors. The rules governing daily life seem arbitrary, changing from time to time, and from one detention officer to another. Some detainees have suffered intimidation and reprisals after acts of advocacy, protest or revolt. Authorities have instituted room searches, confinement in solitary cells, restrictions in receiving visitors, and obstacles to accessing legal representation or medical care. During a hunger strike in July 2000, all electrical power and water supplies to the cell block where the hunger strikers were residing were cut-off, affecting uninvolved women and children. As a consequence of these inhumane actions, the atmosphere at Villawood leads to fear, despondency and frustration. It is within this context that the refugee determination process is undertaken. It is soon apparent to all detainees that their future depends on the procedures established to test their refugee claims, but the complex mechanisms and the legal processes applied are poorly understood by most asylum seekers. Given the context and conditions of their detention, asylum seekers find it difficult to distinguish between the authority of the company managing the detention centre (Australasian Correctional Management) and that of the Department of Immigration and Multicultural Affairs in reaching decisions about their refugee claims. It is a widely held belief by detainees that every action within the detention centre may be observed and may critically influence the outcome of refugee claims. This belief appears to be covertly encouraged by those operating the facility to increase their control over the detainees. Refugee assessment process In their testimonies and at interviews, asylum seekers have to recount in detail the most distressing moments of their lives, testimony that may be treated with doubt, suspicion and incredulity. It is little wonder that memories for details become blurred under such pressure, yet inconsistencies in accounts are often cited as the reason for rejecting a claim. Those people whose claims are rejected at this primary (Department of Immigration and Multicultural Affairs — DIMA) stage can appeal to the Refugee Review Tribunal (RRT). If the claim is rejected by the Tribunal, recent legislation has removed any right of judicial review. The final resort is to appeal to the Minister for Immigration and Multicultural Affairs for humanitarian consideration. Few of these appeals receive compassionate outcomes. (For a summary of the stages of application for protection visas, see Smith.) As the period of detention continues, life is increasingly punctuated by feelings of loss and grief arising from the release of compatriots who have been successful in their refugee claims or the forcible removal from Australia of those who have been unsuccessful. These stresses are combined with the ever-present anxiety about the wellbeing of family members left behind. Some may experience guilt for having left their family to secure their own survival and protection, for not yet being able to work and send money home to assist their family, and for not being able to sponsor them to the safety of Australia. Cumulative effects on the mental state of asylum seekers Our observations suggest that there may be some common themes in the psychological reaction patterns of detainees over time. Each successive stage is associated with increasing levels of distress and psychological disability. Non-symptomatic stage: During the early months of detention, before the primary refugee determination decision, the detainee is shocked and dismayed at being detained, but these feelings are mitigated by an unwavering hope that confinement will be short-lived and that their claim will be upheld. Primary depressive stage: This follows the receipt of a negative decision by DIMA and the realisation by detainees that they face a serious threat of forcible repatriation or detention for an indeterminate period, or both. The clinical presentation is consistent with a major depressive disorder, with the severity closely related to pre-existing risk factors, such as premigration exposure to trauma or personal predisposition to depression. There may also be a reactivation or exacerbation of any pre-existing post-traumatic stress reactions from past abuses (eg, torture, incarceration in political prisons and other forms of persecution). The sense of injustice overwhelms many detainees, who enter a "primary revolt stage" of non-compliance and non-conformity. The nature of the revolt varies: some become protesters (engaging in hunger strikes and other non-violent demonstrations); others become advocates (attempting to raise public awareness about the realities of detention); and some become aggressors (engaging in confrontations, riots, detainee-guard conflict and interdetainee violence). Secondary depressive stage: This typically follows the rejection of the asylum seeker's application by the Refugee Review Tribunal, the ultimate administrative level. The timing of this final rejection may vary, but generally occurs between six and 18 months after first being detained. This stage is associated with a more severe and debilitating depressive reaction, with a greater level of psychomotor retardation and/or agitation. There is a marked narrowing of focus to issues of self-preservation and survival and an overwhelming feeling of impending doom. Whereas before most asylum seekers confided in others about their personal lives and their concerns for family left behind, communication about these issues ceases almost entirely. Some asylum seekers will also enter into a secondary revolt stage that is less aggressive and largely associated with passive, non-compliant resistance and attempts to escape. Many asylum seekers will remain in this secondary depressive stage for the duration of their detention, but a significant number appear to progress to an even more serious state of debilitation. Tertiary depressive stage: At this stage the detainee's mental state is dominated by hopelessness, passive acceptance and an overwhelming fear of being targeted or punished by the managing authorities. Affected detainees become self-obsessed and trapped in their predicament. Ties to other detainees that were once strong become fragmentary and in some cases disintegrate. There is a significant and chronic impairment in concentration, with detainees being unable to perform even simple tasks. The detainee's life can become dominated by paranoid tendencies, leaving them in a chronic state of fear and apprehension and a feeling that no one, including other detainees, can be trusted. Long periods of time are spent alone and some develop frankly psychotic symptoms, such as delusions, ideas of reference and auditory hallucinations. Chronic rage and resentment are directed at the detaining country and the host government. The most disturbed engage in self-stimulatory, stereotypic behaviours, such as repetitive rocking or aimless wandering. Postures and facial expression are consistently downcast and affected detainees may appear to be disengaged or dissociated from their physical environment. Some engage in repeated acts of self-harm or self-mutilation leading to acute hospital admissions. Effect on children Between 10 and 50 children are held at Villawood at any one time. The detention environment, exposure to actions such as hunger strikes, demonstrations, episodes of self-harm and suicide attempts, and forcible-removal procedures, all impact on a child's sense of security and stability. A secondary effect is mediated via the parents, whose ability to provide a caring and nurturing environment is progressively undermined as they pass through the stages outlined above, with risk of neglect and physical abuse of dependent children increasing across the course of detention. Following allegations of child sexual abuse at the Woomera centre, detaining authorities have increased their monitoring of parents at Villawood for evidence of negligence and abuse, leading to parental fears of their children being removed, which has further increased family insecurity. At times, children have also become negotiating pawns in attempts to contain protests within the detention centre. For example, on a number of occasions, the authorities have separated children from their parents to pressure adults to cease their hunger strikes. A wide range of psychological disturbances are commonly observed among children in the detention centre, including separation anxiety, disruptive conduct, nocturnal enuresis, sleep disturbances, nightmares and night terrors, sleepwalking, and impaired cognitive development. At the most severe end of the spectrum, a number of children have displayed profound symptoms of psychological distress, including mutism, stereotypic behaviours, and refusal to eat or drink. Children of parents who reach the tertiary depressive stage appear to be particularly vulnerable to developing a range of psychological disorders. Survey of detainees at Villawood To support some of our participant-observer accounts, in August 2001 one of us (A S) conducted a survey of detainees who had been held for over nine months. Of the 37 people meeting this criterion, 33 agreed verbally to participate in the survey and to allow the results to be reported. The survey consisted of a semi-structured interview based on previous observations. As most of these detainees had been held in Villawood since their arrival in Australia, A S was able to corroborate much of the information from his own longitudinal observations of each participant. The detainees originated from 10 countries, with most being from Afghanistan, Iraq, Iran and the former Yugoslavia. The average period of continuous detention was two years, with the longest period being three years and 10 months. Most were men (85%), and over half were married (55%), with most of these being separated from their spouses on fleeing to Australia. Despite rejection of their refugee claims, over half reported being victims of gross human rights violations before arriving in Australia, enduring abuses such as physical torture (58%) and the murder or disappearance of immediate family members (30%). All but one of the detained asylum seekers displayed symptoms of psychological distress at some time. At the time of the survey, 85% acknowledged chronic depressive symptoms, with 65% having pronounced suicidal ideation. Close to half the group had reached the more severe tertiary depressive stage. Seven individuals exhibited signs of psychosis, including delusional beliefs of a persecutory nature, ideas of reference and auditory hallucinations. Due to the severity of their psychological symptoms, hospitalisation has been recommended for some of these people by the centre health staff, but authorities have not approved this, except in medical emergencies after incidents involving self-harm. A few have been deported without receiving any appropriate care. Conclusions In drawing conclusions, we acknowledge the limitations of our report. A S is faced with the same challenges that other detainees encounter and it might be claimed that he is motivated to advocate not only for others but also for himself. The only counterargument we can offer is our commitment to reporting our observations in what we consider to be as objective and truthful a manner as possible. The observations are broadly consistent with those of other health and mental health professionals who work with detainees, either within the detention environment or on their release from detention. It is therefore difficult to avoid the conclusion that the policy of mandatory detention of asylum seekers is leading to serious psychological harm. Even if many of those who spend long periods of time in detention are not deemed by the strict criteria enforced to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Authors' details Aamer Sultan, MB ChB, Immigration Detainee, Villawood Detention Centre. Kevin O'Sullivan, BSc, PhL, DipClinPsychol, Former Visiting Clinical Psycologist, Villawood Detention Centre. Reprints will not be available from the authors. Correspondence: Dr A Sultan, Villawood Detention Centre, Villawood, NSW 2163. Make a comment Survey of 33 detainees at Villawood Detention Centre Questionnaire items No. of detainees Demographic Information Average period of detention in Australia, 2.1 years Males Females Married Single 28 5 18 15 Premigration trauma exposure History of physical torture Murder or disappearance of immediate family member(s) 19 9 Symptoms during first six months of detention Sleep problems Regular nightmares Loss of libido Anhedonia Feelings of intense bitterness Adoption of a non-conforming approach to detaining authorities Psychological symptoms, requiring psychotropic medication (primarily, antidepressants) 32 32 32 31 26 22 19 Current mental state Chronic feelings of helplessness Bitterness towards authorities Chronic depressive symptoms Chronic headache Impaired memory and concentration Suicidal ideation Stuttering Delusions of a paranoid nature Psychosis 31 30 28 27 25 23 13 13 7 Stage of observed functioning Not symptomatic Primary depressive stage Secondary depressive stage Tertiary depressive stage 1 4 12 16 Back to text

Aamer Sultan · Kevin O'Sullivan

Asylum seekers and healthcare The mental health implications of detaining asylum seekers In the year when we should be celebrating the 50th anniversary of the United Nations Refugee Convention, we appear instead to be ignoring the lessons of history Zachary Steel and Derrick M Silove MJA 2001; 175: 596-599 Abstract - Recent independent inquiries into detention - Research studies - Discussion - After September 11 - References - Authors' details - - More articles on Social issues - More articles on Psychiatry Abstract The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community. Australia is the only Western country that enforces a policy of mandatory detention for asylum seekers arriving without entry documents. This policy is noteworthy given the fact that Australia receives only a small number of asylum applications (12 700 in 1999-20001) compared with most European countries (Germany, 117 650; the Netherlands, 43 900; Belgium, 42 690; France, 39 780; Switzerland, 32 430 in 2000), the United Kingdom (75 680 in 2000), the United States (91 600 in 2000) and Canada (34 250 in 2000).2 On a per capita basis, Australia was ranked 17th out of 21 industrialised countries in terms of the absolute number of asylum applications received during 1999.3 Because of Australia's policy, the possible mental health impact of mandatory detention on asylum seekers is an issue of special relevance to Australian health professionals and the wider public. Sultan and O'Sullivan,4 provide a picture of the daily difficulties and mental reactions experienced by detained asylum seekers in Australia. Their documentation represents a unique convergence between the observations of an "insider" — a medical practitioner detained at Villawood Detention Centre, Sydney, since May 1999 — and those of a mental health professional who has worked in the same facility. We focus here on several key areas raised by Sultan and O'Sullivan: the mental health implications of detaining people who have previously been exposed to trauma including torture; the patterns of mental and behavioural responses manifested by detainees; and the possibility that conditions of detention may act to retraumatise those who are held for indeterminate periods. In assessing these issues, we will draw on the findings of recent inquiries into the policy of detention and also on the small number of empirical studies investigating the mental status of detainees. Recent independent inquiries into detention A comprehensive inquiry undertaken by the Human Rights and Equal Opportunity Commission5 found that mental distress in varying degrees is a common manifestation in detained asylum seekers, with "a large number of detainees experiencing mental health problems". Factors regarded as increasing the risk of mental distress included prior experiences of torture or other forms of persecution in the country of origin, the stresses created by the length and conditions of detention, and the feelings of anxiety and desperation in those whose refugee claims are rejected. The report noted that suicide attempts by asylum seekers are not infrequent, with "numerous examples of detainees attempting suicide or serious self-harm" being cited in incident reports. This inquiry also found "evidence of violence between detainees, especially within families, as well as between detainees and custodial officers", and concluded that there was "considerable tension created by the regime of control necessary to implement the policy of mandatory detention". The evidence suggested that the indeterminate nature of the detention made it considerably more difficult to endure. Of particular concern to the Commission was that there were no formal procedures to identify people who needed specialist care, such as survivors of torture and other forms of extreme trauma, or people at risk of suicide. In a subsequent report, the Commission concluded that the "balance between security and care is undermined by the contractual arrangements between DIMA [the Department of Immigration and Multicultural Affairs] and ACM [Australasian Correctional Management — the private contractor]", and the increasing emphasis on security ("multiple musters, night curfews") can be traced to this imbalance.6 An independent inquiry by the Commonwealth Ombudsman found evidence from credible witnesses about "the inappropriate use of force, unnecessary "trashing" of rooms for no apparent reason and the alleged harassment of detainees by some [ACM] staff".7 The report concluded that "long-term detention of immigration detainees is a source of frustration, despondency and depression often resulting in drastic action being taken by the detainees". Evidence of self-harm, damage to property, as well as fights and assaults, suggested "systematic deficiencies in the management of the detainees".7 A similar set of concerns emerged from a report by members of the Parliamentary Human Rights Sub-Committee.8 According to the report most committee members were shocked by what they saw during their visits to the centres: "the physical impact . . . the double fences, [the] barbed wire". Inside the centres, committee members were struck by the despair and depression of some of the detainees, and "their inability to understand why they were being kept in detention in isolated places, in harsh physical conditions with nothing to do". The Committee found that medical treatment was not always satisfactory, educational facilities were limited and the range of activities was inadequate for the number of detainees. The report also highlighted the negative psychological impact of prolonged detention, pointing out that "those who had been at Woomera [detention centre] for three or four weeks, for example, were notably less tense and depressed than those who had been at Curtin or Port Hedland [detention centres] for a year or more".8 Research studies Several clinical observations have been published about the general plight of asylum seekers in detention in Australia,9,10 with some focusing on specific issues such as hunger strikes.11 More systematic studies are relatively scant, largely because of problems of access to the centres by researchers. A survey in mid-1995 of 17 East Timorese held at the Curtin Detention Centre, in Victoria, for 1-3 months found substantial levels of premigration trauma, including random and unprovoked harassment, torture and physical assaults, and being arrested and/or detained under harsh conditions.12 All 17 East Timorese were found to be suffering from posttraumatic stress disorder (PTSD), 16 were depressed and 11 suffered from severe anxiety. Thompson and colleagues reported a survey of 25 detained Tamil asylum seekers held at Maribyrnong Detention Centre, Victoria, during 1997 and 1998.13 The results were compared with those of a parallel community-based study of Tamil asylum seekers, immigrants and resettled refugees living in New South Wales.14 Detained asylum seekers reported extensive trauma histories: 18 were victims of torture; 23 had witnessed the murder of family or friends; and 22 had been threatened with death at some time. Detained asylum seekers reported exposure to an average of 12.4 (of a possible 16) major trauma categories, compared with 4.8 for asylum-seeker compatriots residing in the community. Compared with the community group, the detainees were more depressed, suicidal, and suffered more extreme post-traumatic panic and physical symptoms. Levels of past trauma exposure did not account entirely for the symptomatic differences across comparison groups, suggesting, albeit indirectly, that the immediate conditions of detention might be contributing to the mental health problems of detainees. Although Australia is the only country that has adopted a policy of mandatory detention, a number of other countries, including the United States and the United Kingdom, detain asylum seekers considered at high risk of absconding or asylum seekers at various stages of the asylum-seeking process.15 In the United Kingdom, a group of 10 detained asylum seekers, six of whom had been tortured previously, were all found to be clinically depressed, manifesting appetite loss and multiple somatic complaints. Four were suicidal, with two having made suicide attempts while in detention.16 Another UK study found high levels of past trauma, including systematic torture, and ubiquitous depressive, posttraumatic stress, as well as suicidal symptoms, in 15 detained asylum seekers.17 The investigators observed that "a profound sense of injustice characterises detainees' views of their reception and treatment . . . detention is seen as punitive, hostile and unfair". Discussion In recording trauma histories, there is always a risk of retrospective bias, particularly when there is potential for gain, for example to advance a refugee claim. However, exposure to past trauma does not, in itself, provide grounds for claiming asylum. The key criterion is proving threat of future persecution. In addition, consistency in reports of trauma across various samples of asylum detainees, corroborated by the indepth investigations of successive commissions of inquiry, makes it difficult to avoid the conclusion that at least a portion of the detained population have been subjected to extreme forms of previous persecution, including incarceration in political prisons and torture. One study found that detainees may have suffered greater levels of threat and trauma than other refugees,13 suggesting that those under most threat tend to leave their home countries in haste, often without documents, thereby increasing the risk of being detained on arrival in Australia. (This conclusion is supported indirectly by statistics provided by the Department of Immigration and Multicultural Affairs which show that over 85% of recent detainees have been found to be genuine refugees fleeing from persecution, an endorsement rate that is higher than that for refugee applicants living in the community.18) Sultan and O'Sullivan's account of past trauma among detainees thus appears to be credible.4 Their observations need to be considered in the light of conclusive evidence that extreme trauma associated with human rights violations constitutes a potent risk factor for a variety of mental disturbances, including PTSD, depression and anxiety.19,20 A consistent dose-effect relationship has emerged from epidemiological studies of refugees, with greater levels of trauma exposure incrementally increasing the risk of mental disturbance.19 In refugees with comorbid disorders, particularly major depression and PTSD, the impact on psychosocial functioning is particularly severe.21 Furthermore, certain forms of trauma, particularly torture and incarceration in political prisons or concentration camps, appear to be particularly injurious to subsequent mental health.20,21 Yet, according to successive commissions of inquiry into detention in Australia, there is no policy in place to systematically assess the psychological needs of detainees who have suffered trauma or to offer them special consideration in relation to early release. The mental suffering of detainees identified by Sultan and O'Sullivan is not only consistent with the findings of recent research studies, but also paints a more complete picture of the way asylum seekers react at particular milestones in the asylum-seeking process.4 The close association between administrative procedures and psychological reactions is particularly worrisome, as it endorses the concern that these procedures, in themselves, act to undermine the psychological well-being of detainees. Although symptoms of depression and PTSD loom large in all recorded accounts, Sultan and O'Sullivan highlight additional features, such as extreme anger and resentment, self-destructive urges, profound social withdrawal, bitterness and alienation, and interpersonal conflict. These accounts of the wider adaptive difficulties triggered by conditions of threat, frustration, dehumanisation and confinement are reminiscent of those observed in survivors of concentration camps after World War II.22 A critical issue is therefore the extent to which the detention environment itself is a direct contributor to psychological distress, either de novo or as a retraumatising influence. There is growing evidence that refugees rendered psychologically vulnerable by past trauma are at greater risk of PTSD if they are exposed to further trauma or adverse conditions.23 For clinicians, there is little doubt that exacerbations of PTSD occur under stress, especially when people are exposed to salient triggers that remind them of the conditions of past trauma. Conversely, it is well accepted that the provision of a safe, supportive and predictable environment is instrumental to recovery for those suffering early psychological reactions to mass trauma.24 Early recovery is important, as there is some evidence that the longer PTSD symptoms persist, the less potential there is for remission.25 These more general observations in the field of traumatology support the contention raised by Sultan and O'Sullivan4 and others10 that environmental, procedural, and legal stressors associated with detention may converge to undermine the mental well-being of detainees, particularly those who have suffered past persecution and trauma. Longitudinal studies are urgently needed to examine more definitively the possible mental health consequences of detention, an imperative supported by a recent public statement by the Australian Medical Association (for a summary of the AMA's statement, see Smith). Of particular concern is the possibility that detention may leave long term psychological scars that may impede the process of acculturation and adaptation when asylum seekers are released into the community — the outcome for a majority of cases. After September 11 We have focused here on the mental health implications associated with the detention of asylum seekers. Elsewhere, we have considered some of the broader human rights concerns associated with detention, and the social and political implications of contemporary refugee policies.26,27 The paradox of contemporary refugee policies has been thrown into stark relief by the world crisis precipitated by the terrorist attack on September 11. On the one hand, there is bipartisan political support in Australia for an international war against terrorism. At the same time, those fleeing from terrorist States are treated as criminals when they reach our shores. Also, in supporting war, we should not forget that one of the most certain outcomes is a large flow of refugees seeking asylum. Yet, our leaders have gone to unprecedented lengths in recent times to deter asylum seekers by confining them in detention centres in economically poor island countries to our north, thereby incurring criticism from the United Nations and other international agencies. Australia is a signatory to the Refugee Convention, a landmark international instrument committing ratifying countries to providing humane protection to persons fleeing persecution worldwide. In the year when we should be celebrating the 50th anniversary of the Convention, we appear instead to be ignoring the lessons of history. In so doing, we risk travelling full circle to the pre-Holocaust era. At an international meeting on the refugee crisis in Europe in 1938, Australia expressed its vociferous opposition to resettling Jews and others fleeing the Nazi terror — all in the name of defending our racial homogeneity and our "way of life". The outcome was the most destructive genocide of all time. Socrates once proclaimed that an unexamined life is not worth living. Are we examining closely enough a national "way of life" that requires, as its cornerstone, the exclusion, punishment and confinement of those fleeing persecution? References Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed November 2001). United Nations High Commissioner for Refugees. 2000 global refugee trends: analysis of the 2000 provisional UNHCR population statistics. Geneva: UNHCR, 2001. United Nations High Commissioner for Refugees The state of the world's refugees: fifty years of humanitarian protection. New York, NY: Oxford University Press, 2000. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account. Med J Aust 2001; 175: 593-596. Human Rights and Equal Opportunity Commission. Those who've come across the seas: The report of the Commission's Inquiry into the detention of unauthorised arrivals. Canberra: HREOC, 1998: 167, 153, 154, 218. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/h5_2_2.pdf (accessed November 2001). Human Rights and Equal Opportunity Commission. 1998-99 Review of immigration detention centres. Canberra: HREOC, 1999: 12. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/idc_review.pdf (accessed November 2001). Commonwealth Ombudsman. Report of an own motion investigation into the Department of Immigration and Multicultural Affairs' immigration detention centres. Canberra: Commonwealth Ombudsman, 2001: 26, 20, 2. Available at: http://www.comb.gov.au/publications_information/Special_Reports/IDCMarch.pdf (accessed November 2001). Joint Standing Committee on Foreign Affairs, Defence & Trade, Human Rights Sub-Committee. A report on visits to immigration detention centres. Canberra: Parliament of the Commonwealth of Australia: 2001: 65-67, 104. Silove D, McIntosh P, Becker R. Risk of retraumatisation of asylum-seekers in Australia. Aust N Z J Psychiatry 1993; 27: 606-612. Becker R, Silove D. Psychiatric and psychosocial effects of prolonged detention on asylum-seekers. In: Crock M, editor. Protection or punishment: the detention of asylum-seekers in Australia. Sydney: The Federation Press, 1993. Silove D, Curtis J, Mason C, et al. Ethical considerations in the management of asylum seekers on hunger strike. JAMA 1996; 276: 410-415. Victorian Foundation for Survivors of Torture. The East Timorese: clinical and social assessments of applicants for asylum. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 23-27. Thompson M, McGorry P. Maribyrnong Detention Centre Tamil Survey. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 27-31. Silove D, Steel Z, McGorry P, et al. Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and posttraumatic stress in Tamil asylum seekers: comparisons with refugees and immigrants. Acta Psychiatr Scand 1998; 97: 175-181. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Bracken P, Gorst-Unsworth C. The mental state of detained asylum seekers. Psychiatr Bull 1991; 15: 657-659. Pourgourides C, Sashidharan S, Bracken P. A second exile: the mental health implications of detention of asylum seekers in the United Kingdom. Birmingham, UK: North Birmingham Mental Health, NHS Trust, 1995: 96. Edmund Rice Centre. Just comment: debunking more myths about asylum seekers. Sydney: Edmund Rice Centre for Justice and Community Education. October 2000. Available at: http://www.erc.org.au/issues/text/se01.htm (accessed November 2001). Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA 1993; 270: 581-586. Van Ommeren M, de Jong Joop T, Sharma B, et al. Psychiatric disorders among tortured Bhutanese refugees in Nepal. Arch Gen Psychiatry 2001; 58: 475-482. Mollica R, McInnes K, Pham T, et al. The dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis 1998; 186: 543-553. Bergmann M, Jucovy M. Prelude. In: Bergmann M, Jucovy M, editors. Generations of the Holocaust. New York: Basic Books, 1982: 3-29. Steel Z, Silove D, Bird K, et al. Pathways from war trauma to posttraumatic stress symptoms amongst Tamil asylum seekers, refugees and immigrants. J Traumatic Stress 1999; 12: 421-435. Silove D. The psychosocial effects of torture, mass human rights violations and refugee trauma: Towards an integrated conceptual framework. J Nerv Ment Dis 1999; 187: 200-207. Kessler R, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Silove D, Steel Z, Mollica R. Detention of asylum seekers: assault on health, human rights and social development. Lancet 2001; 357: 1436-1437. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Zachary Steel, MPsychol, Adjunct Lecturer; Derrick M Silove, MD, Professor. Reprints will not be available from the authors. Correspondence: Mr Zachary Steel, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Level 4, Health Services Building, Liverpool Hospital, Sydney, NSW. z.steelATunsw.edu.au Make a comment

Zachary Steel · Derrick M Silove

Asylum seekers and healthcare Screening for conditions of public health importance in people arriving in Australia by boat without authority Kathleen King and Peter Vodicka MJA 2001; 175: 600-602 Abstract - Methods - Results - Discussion - References - Authors' details - - More articles on Psychiatry Abstract Objective: To determine the prevalence of tuberculosis, hepatitis B carriage and markers of hepatitis C and HIV infection in people detained in immigration reception and processing centres in Australia. Design and setting: Eighteen-month survey of medical conditions of public health importance in people detained at the immigration reception and processing centres at Curtin and Port Hedland in Western Australia and Woomera in South Australia. Participants: 7000 detainees (5742 adults and 1258 children and teenagers aged < 18 years) between 1 January 2000 and 30 June 2001. Main outcome measures: People treated for active tuberculosis; issuing of health undertakings to report to a chest clinic for follow-up of inactive tuberculosis; and confirmation of hepatitis B carrier status or hepatitis C or HIV infection. Results: Eleven people required treatment for tuberculosis (in nine the diagnosis was confirmed bacteriologically), representing a prevalence of 157 cases per 100 000 population. This rate is much higher than the incidence in Australia in 1998 of 4.93 cases per 100 000 population, but comparable with rates in the source countries. Health undertakings were issued to 973 people (13.9%). Of these, 682 (70.1%) were for inactive tuberculosis (26 in association with hepatitis B carriage [16] or hepatitis C infection [10]); and 156, 58 and two health undertakings were for hepatitis B carriage, and hepatitis C and HIV infection, respectively. Conclusions: The health-screening program at immigration reception and processing centres detects significant numbers of conditions of public health importance, enabling treatment and surveillance to the benefit of the people detained and the Australian community. People arriving in Australia by boat without authority are admitted to an immigration reception and processing centre (also known as a "detention centre"), and undergo a protocol-based health assessment. The protocol for entry health assessments at these Department of Immigration and Multicultural Affairs (DIMA) detention centres was devised by a committee with representatives of the Commonwealth Department of Health and Aged Care, DIMA and State and Territory health authorities. The health assessments are concerned with conditions of public health importance only, and identify the minimal health requirements and vaccinations necessary to protect the health of the people detained and the Australian public. The day-to-day healthcare and continuing medical treatment of the people detained are the responsibility of Australasian Correctional Management (ACM), the company that operates and manages DIMA's detention centres. All people detained are given medical examinations to satisfy the requirements for visa application. This examination is used for granting visas in those who are assessed as engaging Australia's obligations for protection under the United Nations Convention relating to refugees. By the time that this assessment is complete and the people are released from detention, they will have completed the full, formal medical examination for the granting of a temporary protection visa.1 An onshore protection visa can be granted even when a medical condition is present. We describe the conditions of public health importance noted in the health assessment process for the possible granting of visas (Box 1; the tinted entries indicate the health examinations included in our study). Methods Our report includes all people receiving medical screening in the immigration reception and processing centres at Curtin and Port Hedland in Western Australia and Woomera in South Australia between 1 January 2000 and 30 June 2001. Chest x-ray examinations were performed at Derby Base Hospital, at Port Hedland Hospital and at Woomera Base Hospital, and x-ray films were read either by chest-clinic physicians or by private radiologists, or both. Medical examinations for granting of visas were performed by medical advisers or approved medical practitioners of Health Services Australia (a government business enterprise contracted to DIMA to provide health assessments). People suspected on clinical or radiological grounds of having tuberculosis underwent full evaluation by sputum-smear and sputum-culture tests. Personnel of State chest clinics were kept informed of all cases of suspected tuberculosis and were involved in the management of all people treated for the disease. Specimens, including Mycobacterium tuberculosis isolates, were sent for testing to laboratories in the respective capital cities (Adelaide and Perth). Sensitivity testing was to World Health Organization reference standards and included tests to rifampicin, isoniazid, ethambutol and streptomycin, with an indirect test for pyrazinamide. Serological testing for hepatitis B surface antigen (HBsAg) and hepatitis C and HIV infection was by standard methods. People with non-communicable diseases, such as cardiomegaly or diabetes, identified by chest x-ray or during the medical examinations were referred to doctors employed by ACM for appropriate investigation and treatment. Likewise, people with evidence of sexually transmitted diseases were also referred to ACM doctors for treatment. All subjects gave their consent to examination and data collection for health assessment purposes. Results In the 18-month period, 7000 people were examined in the three immigration reception and processing centres for the possible granting of a protection visa. There were 5742 adults and 1258 children and teenagers (< 18 years of age) (5916 males and 1084 females). The reported citizenship breakdown was 48% Iraqi, 42% Afghani and 4% Iranian, with the remainder being Sri Lankan, Pakistani, Syrian, Turkish and Palestinian. Seven men and one woman were diagnosed with culture-positive, fully sensitive, pulmonary tuberculosis and treated for infection. Except for one man aged 68 years, all those with active tuberculosis were between 17 and 35 years of age, with five being under 23 years. A 21-year-old man with an abnormal chest x-ray film was found to have peritoneal tuberculosis. Two other men, both 34 years of age, had radiological and clinical indications of active pulmonary disease and consequently were treated for tuberculosis. Both had very abnormal chest x-ray films; one also had an enlarged cervical lymph node and the other had a strongly positive Mantoux reaction (27 mm). Thus, the prevalence of active tuberculosis in this population was 157 cases per 100 000. HIV infection was diagnosed in two people. In two others the test results were indeterminate. In one of those with indeterminate results, a subsequently performed polymerase chain reaction test gave negative results and he is thought not to have HIV infection. In total, 973 people were issued with health undertakings should a visa be granted, with 682 being undertakings to report to a chest clinic for further follow-up of inactive tuberculosis (Box 2). Other communicable conditions diagnosed and treated that do not require a health undertaking include malaria (average, one case per 200 arrivals), chickenpox and other childhood infectious diseases, scabies, headlice, and one case of cutaneous leishmaniasis. Detainees also consult the doctors employed by ACM for treatment of routine infections, most commonly skin conditions (eczema, impetigo and fungal infections), respiratory tract infections, and urinary symptoms. Discussion The medical screening program at the immigration reception and processing centres has resulted in the detection of a considerable burden of disease of public health importance. In Australia, cases of tuberculosis are generally diagnosed soon after the disease becomes active, so that the incidence and prevalence are similar. It is not strictly correct to compare prevalence with incidence. Nevertheless, to provide some comparison, the rate of active tuberculosis of 157 cases per 100 000 population found in our study is significantly higher than the reported incidence of tuberculosis in Australia in 1998 of 4.93 cases per 100 000 population.2 The case-notification rates of tuberculosis in the principal source countries of our study subjects — Afghanistan, Iraq and Iran — in 1999 were 15 cases per 100 000 population, 142 cases per 100 000 population and 18 cases per 100 000 population, respectively.3 The first and last rates are likely not to represent true incidences in those countries. For example, in 1991, Afghanistan reported a rate of 148.9 cases per 100 000 population. Thus, the prevalence of tuberculosis in the detention population is a reflection of its prevalence in the source countries. Both for treating the people detained and protecting the Australian community, it is important to screen for active tuberculosis among people in detention centres. As would be expected, the prevalence of currently inactive tuberculosis is also high in this population. One of the strategies used for the control and surveillance of tuberculosis is the issuing of health undertakings to visa applicants with tuberculosis or abnormal chest x-ray films. The applicant signs an agreement to report to a State or Territory government chest clinic for follow-up within a specified period should a visa be granted. Health undertakings to present to a chest clinic for follow-up and surveillance of inactive tuberculosis were required in 9.7% (682/7000) of people, while, of the total group, 13.9% required health undertakings for tuberculosis or other conditions. This proportion is similar to that of overseas visa applicants (14%) who were considered by the Health Assessment Service in 2000-2001 to require health undertakings (unpublished data). In 1995, visa holders' initial compliance rate with health undertakings was 58% overall.4 Changes to the undertakings system foreshadowed in that report have resulted in higher initial compliance rates of around 70% (unpublished data). The tracing system in case of default, also introduced in 1995, has increased final compliance rates to around 75%. State and Territory chest clinics have indicated that compliance rates by people holding temporary protection visas with health undertakings are similar to those of the general population of visa holders with health undertakings. Procedural changes have recently been introduced to require holders of temporary protection visas to notify DIMA of their current addresses and this should further increase compliance with health undertakings. Hepatitis B carriage occurred in 2.5% (172/7000) of the population examined. This rate is at the lower end of the expected rate, as most of the people detained come from countries where the prevalence of HBsAg carriage ranges from 2% to 7%.5 The prevalence of HBsAg carriage in Australia is less than 2%.5 Hepatitis C infection occurred in 1.0% (68/7000) of the population examined. It is also likely that this is a lower rate of infection than might be expected, but there are no data for prevalences of antibody to hepatitis C in Iraq, Iran and Afghanistan.6 In Australia, the prevalence of hepatitis C infection is less than 1%.6 It is important that people with HBsAg carriage and hepatitis C infection are followed up in the Australian health system and counselled appropriately. HIV infection was confirmed in two people, giving a prevalence of 0.03%. This rate compares with estimated prevalences of 0.15% for Australia and of less than 0.01% for Iraq, Iran and Afghanistan.7 Overall, the health-screening program at the immigration reception and processing centres detects significant numbers of conditions of public health importance, enabling treatment and surveillance to the benefit of the people detained and the Australian community. References Department of Immigration and Multicultural Affairs. Guidelines for medical and radiological examination of applicants for onshore protection visas. Canberra: DIMA, 2000. National TB Advisory Committee for the Communicable Diseases Network Australia and New Zealand. Tuberculosis notifications in Australia, 1998. Commun Dis Intell 2001; 25: 1-8. World Health Organization. Global tuberculosis control. WHO report 2001. Geneva: WHO, 2001. King K, Dorner RI, Hackett BJ, Berry G. Are health undertakings effective in the follow-up of migrants for tuberculosis? Med J Aust 1995; 163: 407-411. National Center for Infectious Diseases, Centers for Disease Control. Geographic distribution of chronic HBV infection [modified June 1, 2001]. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/slideset/ hep_b/slide_9.htm (accessed July 2001). World Health Organization. Hepatitis C: global prevalence (update). Wkly Epidemiol Rec 2000; 75: 3. UNAIDS/World Health Organization. Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. 2000 Update (revised). Available at: <http://www.who.int/emc-hiv/fact_sheets/All_countries.html> (accessed October 2001). Authors' details Department of Immigration and Multicultural Affairs, Sydney, NSW. Kathleen King, MB ChB, FRCPath, Director, Special Health Projects. Peter Vodicka, MB BS, DPH, Director, Health Assessment Service. Reprints will not be available from the authors. Correspondence: Dr K King, Department of Immigration and Multicultural Affairs, GPO Box 9984, Sydney, NSW 2001. kathy.kingATimmi.gov.au Make a comment 1: Medical screening services for people coming to Australia by boat without authority Service Type of service/target population When performed Primary purpose* Examiner Initial triage Initial medical examination On arrival/en route To ensure no immediate medical problems ACM nurse and/or doctor Initial medical examination More detailed medical examination including psychological questionnaire and urinalysis Screening for infectious diseases, if indicated clinically Within a few days of arrival at an immigration reception and processing centre To identify medical history and concerns ACM nurse and/or doctor Malarial screening Those coming from or transiting a malaria-endemic country and/or pregnant If presenting with febrile illness or fever in 1st week To identify public health risks ACM Vaccination Children All children Commences within 1 week of arrival Disease prevention ACM Adults If indicated clinically (eg, spouse with hepatitis B infection) When indicated Disease prevention ACM Tuberculosis screening Chest x-ray and medical examination, 12 years or over or symptomatic Mantoux test, Monitoring for pregnant women Within 2 weeks of arrival To identify public health risks ACM Blood screening Test for HIV and hepatitis B and C, ≥ 15 years Within 2 weeks of arrival Required for granting a visa ACM Continuing medical treatment Day-to-day care Referral to specialists Medical tests as required While in detention Continuing care ACM Medical assessment for granting a visa Complete visa medical examination Consider radiological and pathology test results Before granting a visa Required for granting a visa Health Services Australia Release arrangements Where MOC from DIMA's health assessment service has determined that a health undertaking is required Before granting a visa Required for granting a visa ACM + DIMA case officers Tinted entries indicate the health examinations included in our study. ACM = Australasian Correctional Management. DIMA = Department of Immigration and Multicultural Affairs. MOC = Medical Officer of the Commonwealth. *Additional reasons may exist for conducting medical screening and tests. The results of medical and chest x-ray examinations and pathology tests obtained for health management during detention are made available to Health Services Australia for visa requirements. The results of blood tests obtained to satisfy visa requirements are made available to ACM for health management during detention. Back to text 2: Reasons for issuing a health undertaking Reason Number issued Inactive tuberculosis only* Inactive tuberculosis with hepatitis B carriage or hepatitis C infection Pregnancy† Hepatitis B (HBsAg) carriage Hepatitis C infection HIV‡ Other§ 656 26 45 156 58 4‡ 28 * Includes 57 children under 12 years of age referred for prophylaxis with isoniazid. † Pregnant women who did not undergo radiological examination, and showed no clinical evidence of tuberculosis, but will have a chest x-ray examination after confinement. ‡ Includes two cases with indeterminate results. § Includes typhoid (six cases); paratyphoid (two cases); other gastrointestinal diseases (eg, giardiasis); and sexually transmitted diseases (eg, syphilis, gonorrhoea and chlamydial infection) requiring follow-up. Back to text

Kathleen King · Peter Vodicka

Childhood injuries Preventing children drowning in Australia We need to take a scientific approach to drowning prevention W Robert Pitt and Danny T Cass MJA 2001; 175: 603-604

Danny T Cass

Childhood injuries Drowning and near-drowning in Northern Territory children Karen M Edmond, John R Attia, Catherine A D'Este and John T Condon MJA 2001; 175: 605-608 For editorial comment, see Pitt and Cass Abstract - Methods - Results - Discussion - Acknowledgements - Competing interests - References - Authors' details - - More articles on Paediatrics Abstract Objective: To compare incidences of drowing for children in the Northern Territory (NT) with those in Queensland and the rest of Australia. Design: Descriptive, retrospective, population-based analysis of death and hospitalisation data for drowning and near-drowning. Setting and participants: Children aged 0-14 years resident in Australia from 1983 to 1998. Main outcome measures: Age-standardised average annual incidence of drowning (1983-1998) and near-drowning (1994-1997) in children aged 0-4 and 5-14 years in the NT, Queensland and the rest of Australia. Results: The average annual incidence of drowning and near-drowning from 1994 to 1997 for children aged 0-4 years in the NT (67.82 per 100 000) was significantly higher than for Australia (24.45 per 100 000) (incident rate ratio [IRR], 2.77; 95% CI, 1.40-4.91) and for Queensland (32.55 per 100 000) (IRR, 2.13; 95% CI, 1.05-3.94). The proportion of children aged 0-4 years drowning or near-drowning in swimming pools from 1994 to 1997 was also significantly higher in the NT (83%) than Australia (64%) (difference, 0.19; 95% CI, 0.086-0.30) and Queensland (65%) (difference, 0.18; 95% CI, 0.069-0.29). From 1983 to 1998, the incidence of drowning in NT children aged 0-4 years increased by 0.4% per year (IRR, 1.004; 95% CI, 0.994-1.070), compared with a 5.0% reduction per year (IRR, 0.950; 95% CI, 0.937-0.963) in Australian children. Conclusions: The incidences of drowning and near-drowning in the NT are higher than in the rest of Australia and show no significant decrease. The NT should improve its measures for prevention of childhood drowning. In Australia, childhood drownings are second only to road trauma as a cause of injury death in children younger than 15 years.1,2 Encouragingly, the overall incidence of childhood drowning in Australia appears to be decreasing.1,3 However, drowning death rates are higher in the Northern Territory (NT) than the rest of Australia.1,4-6 There is also some evidence that rates of drowning in the NT are not decreasing as fast as those in the rest of Australia.4,5 However, there are no published studies that compare rates of near-drowning in the NT with rates in the rest of Australia. There are also no published analyses of NT drowning trends. Risk groups for drowning include children aged 0-4 years,1,3 children living in cities with high swimming pool to population ratios,7-10 children living in hot climates,3,8 children living in areas with lack of isolation pool fencing,11-14 and Indigenous children.4,5,7 However, there are no published NT data concerning these risk groups. The proportion of NT children drowning in swimming pools is also currently unknown. This study was designed to determine how incidences of childhood drowning and near-drowning in the NT compare with rates in the rest of Australia and in Queensland (another State with a similar climate and similar numbers of domestic swimming pools per capita as the NT). We aimed to stratify our analysis according to specific risk groups (children aged 0-4 years, children aged 5-14 years, children drowning in swimming pools, and Indigenous children). We also planned to compare the proportion of NT children aged 0-4 years who drowned or nearly drowned in swimming pools with Queensland and the rest of Australia. The study was designed as a descriptive, retrospective, population-based analysis of hospital morbidity and mortality data for drowning and near-drowning, identified by International classification of diseases, 9th revision, clinical modification (ICD-9-CM) codes15 in children aged 0-14 years. Methods Definitions A drowning incident was defined as a non-intentional episode in which immersion of a child in water was followed by death. A near-drowning incident was defined as a non-intentional episode in which immersion of a child in water was followed by admission into hospital and the child subsequently surviving. A case was only included as a drowning or near-drowning if it was identified by specific ICD-9-CM external (E) cause codes (830, 832, 919.0-910.9) or the ICD-9-CM disease code for near-drowning (994.1).15 E-codes classify environmental sites, events, circumstances, and conditions as the cause of injury, and include a code for swimming pool drowning.15 Data collection Mortality and hospital morbidity data for all cases of drowning and near-drowning were obtained from the Australian Institute of Health and Welfare (AIHW). Mortality data were available for 1983-1998, but hospital morbidity near-drowning data were available for 1994-1997 only, because of the introduction of casemix funding and changes in ICD-9-CM coding.16 Population denominators for the NT, Queensland and the rest of Australia were the estimated resident population data for each year published by the Australian Bureau of Statistics (ABS).17 NT Indigenous population data were the estimates of the NT Indigenous population published by the ABS.18 Data analysis Crude incidences of drowning and near-drowning for the NT, Queensland and the rest of Australia were standardised year by year within 0-4 and 5-14 years age groups using the indirect standardisation method and the Australian population as the reference population.19The annual number of cases was assumed to follow a Poisson distribution.20 Changes in annual drowning death rates from 1983 to 1998 were investigated using the Mantel test for trend and a Poisson regression model which included terms for year. NT average annual incidences of age-standardised drowning and near-drowning were compared with Queensland and the rest of Australia using incident rate ratios (IRR) and 95% confidence intervals. An IRR was defined as the ratio of two incidences. The difference between proportions of children drowning or nearly drowning in swimming pools in the NT, Queensland and the rest of Australia was compared using tests of difference between two proportions and 95% confidence intervals. Stata software was used for statistical analysis.21 Ethical approval This study was approved by the Joint Institutional Ethics Committee of the Royal Darwin Hospital and the Menzies School of Health Research. Results Drowning Forty-two NT children drowned from 1983 to 1998. There was no significant change in the incidence of drowning over this period in NT children aged 0-4 or 5-14 years (Boxes 1 and 2). In contrast, rates of drowning in Australian children reduced significantly each year in children aged 0-4 years (Boxes 1A and 2). Rates in Australian children aged 5-14 years also reduced each year, but the Poisson regression rate ratio for trend per year did not reach statistical significance (Boxes 1B and 2). The average annual incidence of drowning in NT, Australian and Queensland children from 1994 to 1997 is shown in Box 3. Near-drowning The NT incidence of near-drowning for children aged 0-4 years was higher than the Queensland rate, but not statistically significant, while the rate for children aged 5-14 years was similar to the Queensland rate (Box 3). Swimming pool drowning and near-drowning The proportion of children aged 0-4 years drowning or near-drowning in swimming pools from 1994 to 1997 in the NT (83%) was higher than in Queensland (65%) (difference, 0.18; 95% CI, 0.069-0.29) and the rest of Australia (64%) (difference, 0.19; 95% CI, 0.086-0.30) (see Box 3 for incidence). Indigenous status In the NT, non-Indigenous children aged 0-4 years had higher rates of drowning and near-drowning (73.19 per 100 000) than Indigenous children (56.63 per 100 000) (IRR, 1.29; 95% CI, 0.53-4.47), although this was not significant. Non-Indigenous children aged 5-14 years also had higher rates of drowning and near-drowning (7.27 per 100 000) than Indigenous children (5.41 per 100 000; IRR, 1.34; 95% CI, 0.81-5.42). Rates of swimming pool drowning in the NT were also higher in non-Indigenous children aged 0-4 years (24.89 per 100 000) than Indigenous children (14.04 per 100 000) but this difference was not significant (IRR, 1.77; 95% CI, 0.91-6.22). Only five of 40 children (13%) aged 0-4 years who drowned in a swimming pool in the NT from 1983 to 1998 were Indigenous. Discussion This study describes the extremely high incidence of drowning and near-drowning in children in the NT. Incidences were higher than in the rest of Australia and showed no significant decrease despite reductions in the rest of Australia. Rates in the NT are among the highest recorded worldwide.3-5Indigenous children in the NT had lower rates of drowning and near-drowning than non-Indigenous children, as well as lower rates of swimming pool drowning, although the differences were not statistically significant. Case numbers of fresh water drownings were too small to allow statistical analysis. Some studies describe rates of drowning and near-drowning in Native American children to be two to three times those of non-Native American children.7,10 However, Australian studies report rates of Indigenous child drowning mortality similar to those reported here.4,5 Reporting of Indigenous status in the NT is accurate, in contrast to other Australian States and Territories.1 Near-drowning urban and rural hospital referral patterns are similar and are unlikely to have contributed to the difference in Indigenous and non-Indigenous rates. Reduced exposure of Indigenous children to domestic swimming pools is a possible explanation. Further prospective research is required to clarify these issues. There are many reports of the high rates of drowning in children aged 0-4 years.1,2,9,11 In our study, children aged 0-4 years in the NT, Queensland and the rest of Australia had rates of drowning and near-drowning 5-10 times higher than children aged 5-14 years. Young children in the NT appeared to be at greatest risk, with rates of drowning and near-drowning nearly three times higher than the rest of Australia and Queensland. Rates of swimming pool drowning in children aged 0-4 years in the NT were more than twice the Australian and Queensland rates and among the highest in the world.2,8,9,11 The proportion of children drowning in swimming pools in the NT was also statistically higher than in Queensland and the rest of Australia. Drowning rescue and resuscitation protocols in the NT are similar to those in the rest of Australia. One possible explanation for the differences between NT and Queensland rates of swimming pool drowning is that Queensland introduced statewide pool fencing legislation in 1992, while pool fencing laws in the NT are still inadequate. All the NT swimming pool drowning deaths reported in this study occurred in pools with non-Australian Standards fencing (NT coroner, personal communication). There is no standard legislation for pool fencing in the NT. Only one jurisdiction (encompassing less than 10% of the population) requires fencing according to Australian Standards. Other reasons for the disparity between NT and Queensland rates of drowning could be differences in exposure to water, differences in exposure to swimming pools, or differences in parental supervision. Further prospective research is needed to investigate the role of these different risk factors. We may have underestimated rates of drowning and near-drowning, as retrospective data were used and case ascertainment relied on coded cause of death/hospitalisation. We may also have under-reported NT rates of near-drowning, as the ratio of near-drowning to drowning in the NT (2:1) was lower than Australia (9:1) and Queensland (9:1). Smaller numbers of NT drowning and near-drowning cases also produced considerable variation in annual NT data. However, statistical analyses, including Poisson regression, enabled analysis of trend over time. In response to this study and other reports, NT injury prevention groups are planning to expand their drowning prevention campaigns. This will include lobbying the NT government to enact isolation/four-sided pool-fencing legislation. More public awareness campaigns are also planned. These will be directed towards the need for effective pool fencing, parental supervision of young children, and cardiopulmonary resuscitation skills, and will include other measures that can assist in preventing drowning in young children. Kidsafe NT also intends to use the information from this study to develop a prospective drowning surveillance system. This system will be used to evaluate drowning prevention interventions and to further investigate NT risk factors for childhood drowning, including the role of swimming pool fencing. Acknowledgements Kidsafe, Child Accident Prevention Foundation of Australia, NT branch, provided the funding for the data extraction by the Australian Institute of Health and Welfare. Competing interests None declared. References Moon L, Rahman N, Bhatia K. Australia's children: their health and well being 1998. Canberra: AIHW, 1998. (AIHW Catalogue No. PHE 7.) Pitt WR. Increasing incidence of childhood immersion injury in Brisbane. Med J Aust 1986; 144: 683-685. Cass DT, Ross F, Lam LT. Childhood drowning in New South Wales 1990-1995: a population based study. Med J Aust 1996; 165: 610-612. Vimpani G, Doudle M, Harris R. Child accident mortality in the Northern Territory. Med J Aust 1988; 148: 392-395. Silva DT, Ruben AR, Wronski I, et al. Excessive rates of childhood mortality in the Northern Territory. J Paediatr Child Health 1998; 34: 63-68. d'Espaignet ET, Kennedy K, Paterson BA, et al. From infancy to young adulthood: health status in the Northern Territory, 1998. Darwin: Territory Health Services, 1998. Spyker DA. Submersion injury epidemiology, prevention and management. Pediatr Clin North Am 1985; 32: 113-125. Pitt WR, Balanda KP. Childhood drowning and near-drowning in Brisbane: the contribution of domestic swimming pools. Med J Aust 1991; 154: 661-665. Geddis DC. The exposure of pre school children to water hazards and the incidence of potential drowning accidents. N Z Med J 1984; 97: 223-226. O'Carrol PW, Alkon E, Weiss B. Drowning mortality in Los Angeles County 1976-1984. JAMA 1988; 260: 380-383. Fergusson DM, Horwood LJ. Risks of drowning in fenced and unfenced domestic swimming pools. N Z Med J 1984; 97: 777-779. Carey V, Chapman S, Gaffney D. Children's lives or garden aesthetics? A case study in public health advocacy. Aust J Pub Health 1994; 18: 25-32. Millner N, Pearn J. Will fenced pools save lives? A 10 year study from Mulgrave Shire, Queensland. Med J Aust 1980; ii: 510-511. Intergov-WA, Intergovernmental Working Party on Swimming Pool Safety. Preschool drowning in private swimming pools. Perth: Health Department of Western Australia, 1988. US Department of Health and Human Services. The international classification of diseases. 9th revision. Clinical modification (ICD-9-CM). 3rd ed. Bethesda, Md: DHHS, 1989. Langlois JA, Buechner JS, O'Connor EA, et al. Improving the E coding of hospitalizations for injury: do hospital records contain adequate documentation? Am J Public Health 1995; 85: 1261-1265. Australian Bureau of Statistics. Population by age and sex, Australian States and Territories. Canberra: ABS, 1997. (Catalogue no 3201.0.) Australian Bureau of Statistics. Experimental estimates of Aboriginal and Torres Strait Islander population 1991 and 1996. Canberra: ABS, 1997. (Catalogue no 3230.0.) Pagano M, Gauvreau K. Principles of biostatistics. 1st ed. California: Wadsworth, 1993. Frome EL, Checkoway H. Epidemiologic programs for computers and calculators. Use of Poisson regression models in estimating incidence rates and ratios. Am J Epidemiol 1985; 121: 309-323. Stata Statistical Software [computer program]. Version 5.0. Texas: Stata Corporation, 1997. (Received 23 Feb, accepted 30 Jul, 2001) Authors' details Territory Health Services, Casuarina, NT. Karen M Edmond, FRACP, MMedSc (ClinEpid), Community Paediatrician. Centre for Epidemiology and Biostatistics, University of Newcastle, Newcastle, NSW. John R Attia, FRCPC, PhD, Senior Lecturer; Catherine A D'Este, PhD, Senior Lecturer. Menzies School of Health Research, Casuarina, NT. John T Condon, FAFPHM, MPH, Research Scholar. Reprints will not be available from the authors. Correspondence: Dr K M Edmond, Research Fellow in Paediatric Epidemiology, London School of Hygiene and Tropical Medicine, 50 Bedford Square, London, WC1B 3DP, UK. karen.edmondATlshtm.ac.uk. Make a comment 1: Age-standardised annual incidence of drowning for the Northern Territory and the rest of Australia, 1983 to 1998 Back to text 2: Drowning trend analysis for children in the Northern Territory and the rest of Australia, 1983-1998 Poisson regression Mantel test for trend rate ratio for trend per year (95% CI) χ2 (degrees per year of freedom) P for trend per year NT children 0-4 years 5-14 years 1.004 (0.994-1.070) 0.981 (0.883-1.078) 0.02 (1) 0.15 (1) 0.895 0.696 Australian children 0-4 years 5-14 years 0.950 (0.937-0.963) 0.911 (0.889-1.067) 53.73 (1) 66.08 (1) Back to text 3: Average annual incidence of drowning and near-drowning for the rest of Australia and Queensland compared with the Northern Territory, 1994-1997 Northern Territory Australia Queensland Number Incidence* Incidence* IRR† (95% CI‡) Incidence* IRR (95% CI) Drowning 0-4 years 16 22.61 3.71 6.17 (1.60-16.68) 5.77 3.92 (0.94-12.48) 5-14 years 1 3.21 0.62 5.26 (0.12-33.48) 0.82 3.91 (0.08-39.28) Near-drowning 0-4 years 32 45.21 20.69 2.19 (1.18-4.37) 26.78 1.69 (0.70-3.52) 5-14 years 7 5.56 2.55 2.20 (1.26-8.30) 5.36 1.03 (0.12-4.14) Drowning and near-drowning 0-4 years 48 67.82 24.45 2.77 (1.40-4.91) 32.55 2.13 (1.05-3.94) 5-14 years 8 6.44 3.61 1.78 (1.21-6.58) 6.12 1.04 (0.12-4.08) Swimming pool drowning and near-drowning 0-4 years 40 56.51 15.65 3.61 (1.70-6.77) 20.69 2.74 (1.24-5.47) 5-14 years 1 3.20 1.03 3.08 (1.75-18.7) 2.63 1.22 (1.29-8.23) * Incidence per 100 000 children. † Incident rate ratio. Back to text

Karen M Edmond · John R Attia · Catherine A D'Este · John T Condon

Childhood injuries Horse-related injuries in children Andrew J A Holland, Gerard T Roy, Valapha Goh, Frank I Ross, John P Keneally and Daniel T Cass MJA 2001; 175: 609-612 Abstract - Methods - Results - Discussion - Acknowledgements - Competing interests - References - Authors' details - - More articles on Paediatrics Abstract Objectives: To identify the frequency, spectrum and outcome of horse-related injuries in children. Design and setting: Retrospective case series of horse-related injuries in children admitted to the Children's Hospital at Westmead (CHW) from January 1988 to December 1999, the John Hunter Children's Hospital (JHCH) from January 1991 to December 1997 and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry from January 1988 to December 1999. Main outcome measures: Circumstances of injury; helmet use; adult supervision; type and number of injuries identified. Results: 232 children were admitted with horse-related trauma, 97 to the CHW over 12 years and 135 to JHCH over seven years, with one death at each hospital. There were six deaths reported to the NPTD Registry over 12 years. The median age was 11 years (range, 1-17). Girls accounted for 65% of those injured and 75% of children were injured while riding. Falls caused the injury in 76.3% of cases. Head and upper-limb trauma accounted for 216 of the injuries (73%). Five out of six children with severe head injuries died. In the CHW group, helmet use was documented in only 24 riders (38%) and adult supervision in 22 (22.9%). Conclusions: Horse-related trauma accounts for a considerable number of deaths and injuries in children in NSW. The use of a Standards-approved helmet for riding or horse-related activities might have decreased the severity of head injuries. In 1788, six horses — four mares and two stallions — arrived with the First Fleet at Botany Bay, New South Wales. The first paediatric equestrian death was reported in 1830.1 Both the equine and human populations in Australia have grown enormously since then, but there have been few reviews of horse-related trauma in this country.2-4 This is surprising given Australia's considerable rural population and the popularity of horse riding as a sporting and leisure activity. Trauma is the most common cause of both morbidity and mortality in children, and motor vehicle injuries are the most frequent cause of such trauma. Although horse-related injuries in children are not as common, the potential for serious injury or death in a young child is high. An adult horse may weigh over 500 kg, gallop at speeds of up to 65 km/h and kick with a force 1.8 times its weight.5 The physical differences between horses and children predispose towards severe injury and are compounded by the potential for unpredictable behaviour in both species. We reviewed the records of children admitted with horse-related injuries to two paediatric tertiary referral centres — one in Sydney receiving children predominantly from an urban and outer urban environment (the Children's Hospital at Westmead [CHW]), and the other in a more rural environment in the Hunter Valley (the John Hunter Children's Hospital [JHCH]). These two hospitals receive most NSW children admitted with horse-related injuries (except those from southern NSW, who may be admitted to Sydney Children's Hospital). These data were supplemented with cases reported to the New South Wales Paediatric Trauma Death (NPTD) Registry. We wished to establish the extent and spectrum of horse-related trauma in children to determine the most effective approach to injury prevention. Methods We performed a retrospective review of children aged under 18 years admitted to the CHW and JHCH, or reported to the NPTD Registry, with horse-related injuries. Data were collected on age, location of injury, whether the child was riding or not riding at the time of the injury, the mechanism of injury, the injuries and surgical intervention required, complications and final outcome. For children admitted to CHW and reported to the NPTD Registry, data were also collected on documented adult supervision and helmet use. In children who died, the cause of death was identified from the coronial postmortem report. CHW admissions: Data were collected from January 1988 to December 1999. Patients were identified retrospectively from the Paediatric Trauma Database compiled by the trauma research nurse at Westmead and the Royal Alexandra Hospital for Children hospitals (subsequently the CHW). In addition, a retrospective medical record search was made for children discharged with "animal-related injury external cause" code categories. JHCH admissions: Data were collected from January 1991 to December 1997. Patients were identified through a retrospective medical record search for children discharged with "animal-related injury external cause" code categories and a search of the John Hunter Hospital trauma database. NPTD Registry: This records all deaths resulting from trauma in children under 16 years of age in NSW that are reported to the coroner. Data were available from January 1988 to December 1999. The police statement and coroner's report, together with the postmortem findings, were reviewed for children who had died after horse-related trauma. Results Horse-related injuries and deaths identified The Box summarises our data on the 236 children who sustained injuries between January 1988 and December 1999. Girls accounted for 65% of those injured and 75% of children who were injured while riding a horse. Falls, or a fall followed by a further injury, was the mechanism in 76% of cases. There was no trend over time for a change in the frequency or type of injury at either hospital, or helmet use at CHW. CHW: There were 97 children with horse-related injuries, representing 6% of children admitted with all play and sporting injuries and 35% of animal-related trauma over the 12-year period. Thirty-four patients (35%) were transferred from a peripheral hospital. One child, a non-riding two-year-old boy, died in hospital. Of those children injured while riding, 24 (38%) were wearing a helmet, 21 (33%) were not, and for 18 (29%) there was no documentation. The location of the injury event was identified in 41 cases: a farm in 26, private land in seven, a riding school or competition in five, and a public highway in three. In 22, adult supervision was recorded; there was no adult supervision in 31, and this was not documented in 44. None of the children not riding were wearing a helmet at the time of the injury, even when involved in activities requiring close proximity to the horse. In four cases the children's feet were caught in the stirrup when the horse bolted and they were dragged along the ground. JHCH: There were 135 children admitted with horse-related injuries, accounting for 8% of children admitted with play and sporting injuries and 48% of animal-related trauma over the seven-year period. One child, a 13-year-old girl, died in hospital. NPTD Registry: There were six deaths from horse-related injuries (including the two mentioned above), representing 8% of the 78 play-related and sporting-related deaths recorded over the 12 years. There was only one other animal-related death reported to the registry. Five of these children were injured on a farm and one during a competition. An adult was present in three cases. Only two of the four children injured while riding were wearing helmets; one of these helmets was seen to fall off before the child struck the ground. In summary, there were significantly more children injured while riding (81% v 66%; χ2 = 6.741; P = 0.009), and more children injured through falls from a horse as opposed to being kicked or trampled (75% v 52%; χ2 = 17.3; P = 0.001), in the JHCH group compared with the CHW group. Further, there was no difference between the age of the children who survived and those who died, but boys accounted for 50% of fatalities, compared with 34% of admissions. Spectrum of injuries The Box (b) compares the injuries identified. Head and upper-limb trauma accounted for 124 and 92 of the injuries, respectively, representing a combined total of 73%. Significantly more patients had head trauma (58% v 34%; χ2 = 16.66; P = 0.001) and torso trauma (25% v 10%; χ2 = 8.588; P = 0.003) in the CHW group; limb trauma (31% v 54%; χ2 = 12.20; P = 0.001) was more frequent in the JHCH group. Major head injury was the cause of death in five of the six children who died, none of whom were wearing a helmet when their heads struck the ground. Of those children admitted to CHW who survived a head injury, 17 were wearing a helmet, 25 were not and there was no documentation for 10. Although there was no significant difference between the initial severity of head injury between children in these groups, no patient who was wearing a helmet at the time of injury, compared with five children who were not wearing helmets, had a long-term neurological deficit. Treatment and outcome One hundred and fifty patients required 174 procedures under general anaesthesia (mostly either limb fracture reduction and fixation or debridement and suturing of a laceration) and three patients had four procedures under local anaesthesia. There were significant adverse outcomes in 23 survivors (10%), eight of which involved a neurological deficit. Discussion The risk of injury while horse riding has been estimated as between 1 per 320 to 1 per 1000 hours of riding.4,6 The variation in reported population-based risk of horse-related trauma of between 18.7 injuries per 100 000 to 9.5 injuries per 1000 population per year illustrates the difficulties of accurate data collection and variable inclusion of non-riding injuries.7 Interestingly, the overall risk of injury from horse-related activity has been determined to be greater than that of car racing or riding a motorcycle, and the rate of hospitalisation from falls from a horse equivalent to that from playing rugby.8-10Our data indicate that horse-related trauma is a significant problem for children in Australia, particularly those living in rural environments. This probably reflects greater exposure to horses in rural areas, together with greater numbers of riders and riding hours compared with children living in an urban environment.11-14 The true scale of the problem is likely to be even greater than our data suggest, as children with minor injuries may not require admission to a paediatric hospital, and we may not have identified all patients.4 Girls accounted for 65% of horse-related injuries in children in this study and three-quarters of those injured while riding, but only 50% of fatalities. This overall female preponderance, a contrast to the situation for most traumatic injuries, is likely to represent the greater participation of girls in horse-related activities.4,6,13,15-17 The equal sex ratio for fatal horse-related injuries in this review resulted from the number of male preschool non-riders injured while in close proximity to a horse. Sex differences in exploratory behaviour patterns would explain this finding.18 Although the risk of injury in children involved in horse-related activities is high, of perhaps more importance is the severity of such injuries and their potential long-term consequences.2,13,15,16,19 In addition to the six deaths over 12 years in NSW, 230 children had sufficiently severe injuries to require hospital admission. While a kick from a horse may cause a lower-limb fracture or soft-tissue injury in an adult, in a child it may result in a compound skull fracture, thoracic trauma or perforated hollow viscus.2,12 Our findings indicate that the social and economic cost of horse-related trauma in children is considerable: a death every two years in NSW, over 200 children admitted with an average length of stay of three days, and 10% of survivors having complications.4 These negative outcomes must be balanced with the positive health aspects of a sporting activity that involves interaction with a companion animal. The challenge is therefore to improve the safety of horse riding. Our data suggest that some fatalities and injuries might be avoided, or their severity reduced, through a combination of increased adult supervision of preschool age children and the use of appropriate safety measures such as a Standards-approved helmet.6,18,20,21 Although the use of Standards-approved helmets is encouraged by both the Pony Club Association of NSW and the Equestrian Federation of Australia (EFA), it is not a legal requirement as it is for pedal and motor cyclists. Further, their use in place of a top hat or traditional riding helmet may even be disallowed when competing at the higher levels (national, international, Olympic, etc) of dressage competition (E Canapini, National Coaching Manager, EFA, personal communication). Compliance with helmet use in this study, although not fully documented, appeared to be poor and reflects published findings.2-4 While the number of patients in our study for whom there were complete data was small, children wearing helmets when riding appeared less likely to suffer long-term neurological sequelae compared with those who were not. We therefore propose that consideration be given to making the use of a Standards-approved helmet for horse riding mandatory. Although it would not be practical to enforce helmet use in rural areas, compulsory use in all styles of competition, in riding schools, and on public highways might have a follow-on effect on farms and in children who become occupational riders as adults.22 We see no reason why children and adults engaged in horse-related activities should not receive the benefits of helmet use that have been shown in cyclists, and which they currently enjoy by law.23 Acknowledgements Dr P Subramaniam provided assistance with the collection of data from the John Hunter Children's Hospital. Mr A J A Holland was supported by a Surgeon Scientist Scholarship from the Royal Australasian College of Surgeons. Associate Professor J Peat provided assistance with statistical analysis. Competing interests None declared. References Cone TE Jr. Playing with horses. Pediatrics 1971; 47: 784. Pounder DJ. "The grave yawns for the horseman". Equestrian deaths in South Australia. Med J Aust 1984; 141: 632-635. Williams F, Ashby K. Horse-related injuries. Edition No. 23. Melbourne: Monash University Accident Research Centre, 1995. Cripps, RA. Horse-related injury in Australia. Edition No. 24. Adelaide: Australian Injury Prevention Bulletin, Flinders University, 2000. Kriss TC, Kriss VM. Equine-related neurosurgical trauma: a prospective series of 30 patients. J Trauma 1997; 43: 97-99. Bixby-Hammett DM. Pediatric equestrian injuries. Pediatrics 1992; 89: 1173-1176. Hamilton MG, Tranmer BI. Nervous system injuries in horseback-riding accidents. J Trauma 1993; 34: 227-232. Nicholls JP. Safety of horseriding. BMJ 1990; 301: 496. Chapman MAS, Oni J. Motor racing accidents at Brands Hatch, 1988/9. Br J Sports Med 1991; 25: 121-123. Buckley SM, Chalmers DJ, Langley JD. Injuries due to falls from horses. Aust J Public Health 1993; 17: 269-271. Aronson H, Tough SC. Horse-related fatalities in the Province of Alberta. Am J Forensic Med Pathol 1993; 14: 28-30. Hobbs GD, Yealy DM, Rivas J. Equestrian injuries: a five-year review. J Emerg Med 1994; 12: 143-145. Christey GL, Nelson DE, Rivara FP, et al. Horseback riding injuries among children and young adults. J Family Pract 1994; 39: 148-152. Thompson JM, von Hollen B. Causes of horse-related injuries in a rural western community. Can Family Physician 1996; 42: 1103-1109. Barone GW, Rodgers BM. Pediatric equestrian injuries: a 14-year review. J Trauma 1989; 29: 245-247. Nelson DE, Bixby-Hammett D. Equestrian injuries in children and young adults. Am J Dis Child 1992; 146: 611-614. Campbell-Hewson GL, Robinson SM, Egleston CV. Equestrian injuries in the paediatric age group: a two centre study. Eur J Emerg Med 1999; 6: 37-40. Lam LT, Ross FI, Cass DT. Children at play: the death and injury pattern in New South Wales, Australia, July 1990-June 1994. J Paediatr Child Health 1999; 35: 572-577. Ingemarson H, Grevsten S, Thoren L. Lethal horse-riding injuries. J Trauma 1989; 29: 25-30. Finch C. Sports injury prevention. In: Ozanne-Smith J, Williams F, editors. Injury research and prevention: a text. Melbourne: Monash University Accident Research Centre, 1995. Rivara FP. Fatal and non-fatal farm injuries to children and adolescents in the United States, 1990-3. Inj Prev 1997; 3: 190-194. Condie C, Rivara FP, Bergman AB. Strategies of a successful campaign to promote the use of equestrian helmets. Public Health Rep 1993; 108: 121-126. Cameron MH, Vulcan AP, Finch CF, Newstead SV. Mandatory bicycle helmet use following a decade of helmet promotion in Victoria, Australia — an evaluation. Accid Anal Prev 1994; 26: 325-337. (Received 2 Jan, accepted 16 Aug, 2001) Authors' details The Children's Hospital at Westmead, Royal Alexandra Hospital for Children, The University of Sydney, NSW. Andrew J A Holland, FRCS, FRACS, Senior Research Fellow, and Clinical Lecturer, Department of Academic Surgery; Valapha Goh, RN, Trauma Research Nurse; Frank I Ross, BAppSc(Nurs), MPH, Clinical Nurse Consultant; Daniel T Cass, PhD, FRACS, William Dunlop Professor of Paediatric Surgery; John P Keneally, MB BS, FANZCA, Head, and Clinical Senior Lecturer, Department of Anaesthesia. The John Hunter Children's Hospital, Newcastle, NSW. Gerard T Roy, FRCS, FRACS, Paediatric Surgeon. Reprints: Mr Andrew J A Holland, Department of Academic Surgery, The Children's Hospital at Westmead, Royal Alexandra Hospital for Children, Locked Bag 4001, Westmead, NSW 2145. AndrewH3ATchw.edu.au Make a comment Children with horse-related injuries admitted to the Children's Hospital at Westmead (CHW), January 1988 to December 1999, John Hunter Children's Hospital (JHCH), January 1991 to December 1997, and horse-related deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry, January 1988 to December 1999 (a) Demographic characteristics and manner of injury CHW survivors (n = 96) JHCH survivors (n = 6) NPTD Registry deceased (n = 134) Age (years) Median 10 11 11.5 Range 1-15 1-17 2-14 Sex Boys 33 (34%) 46 (34%) 3 (50%) Girls 63 (66%) 88 (66%) 3 (50%) Activity Riding 63 (66%) 109 (81%) 4 (67%) Not riding 33 (34%) 25 (19%) 2 (33%) Mechanism Fall 50 (52%) 101 (75%) 2 (33%) Fall plus further injury 13 (14%) 11 (8%) 3 (50%) Kick 28 (29%) 19 (14%) 1 (17%) Bite 0 2 (2%) 0 Trampled 5 (5%) 1 (1%) 0 (b) Details of injuries and number of children affected CHW survivors (n = 96) JHCH survivors (n = 134) NPTD Registry deceased (n = 6) Head injuries Concussion 19 17 0 Skull fracture 18 10 3 Intracranial haemorrhage 8 3 4 Cerebral contusion 7 1 2 Facial fracture 10 4 0 Soft tissue injury 6 10 3 Totals 68 in 56 patients 45 in 42 patients 11 in 5 patients Spinal injuries Cervical spine 1 3 1 Lumbar spine 0 1 0 Totals 1 in 1 patient 4 in 4 patients 1 in 1 patient Torso injuries Liver or spleen 11 1 1 Kidney 5 2 0 Soft tissue 5 3 1 Pulmonary contusion 3 2 0 Haemothorax/pneumothorax 2 5 0 Rib fracture 2 2 0 Pelvic fracture 2 2 0 Myocardial infarction 0 0 1 Hollow viscus perforation 1 0 0 Bladder haematoma 0 1 0 Totals 31 in 24 patients 18 in 14 patients 3 in 3 patients Limb injuries Upper limb fracture 26 58 1 Lower limb fracture 4 14 1 Upper limb soft tissue 2 4 1 Lower limb soft tissue 2 1 0 Totals 34 in 30 patients 77 in 73 patients 3 in 2 patients Back to text

Gerard T Roy · Valapha Goh · Frank I Ross · John P Keneally · Daniel T Cass

MJA 2001; 175: 613-616 Why medicine? - Why research? - Is research possible in country general practice? - Why Sydney University? - Reflections - References - Authors' details - - More articles on General practice and primary care I was delighted to read this description of research [organised curiosity] as I started my general practice career. Indeed, seeking answers to questions seemed a sensible approach to the whole of life. Why medicine? During my school years I had no career plans other than that I was not going to be a doctor like my father and grandfather, probably for no other reason than to reject what was expected. My wish to become a farmer was discouraged by my parents, as they could see no way for me to have a farm of my own immediately, and anything less was not to be thought of. When I was in my last year at school, my father needed an operation for cancer, and this turned my thoughts to medicine as a career. If I could not be a farmer, then I would be a country doctor. "Research in general practice might best be described as organised curiosity." Dr Tev Eimerl, 19601 In my first year at Melbourne University my father drew my attention to an article in the Medical Journal of Australia and suggested that I read it. The Arthur E Mills Memorial Oration for 1952, "The secret of living", by S W Pennycuick,2 struck several chords with me. His suggestion that the secret of living consists in more than avoiding the ABC of life — accidents, bacteria, and chronic degenerative diseases — fitted in with my feeling that the medical career I wanted was more than one of merely trying to keep people alive. His representation of a life of total security and freedom from fear and want as being akin to a "life of boredom in a zoo" was a vivid image of a life I did not want. But, most of all, I was struck by his suggestion that "To travel hopefully is better than to arrive", or, otherwise expressed, that "Our journey through life has little meaning unless we travel hopefully towards the ideals which we know full well we will never reach". It became my motto. I never met nor heard of Pennycuick again, but he has exerted a powerful influence on my life. Why research? In the fourth year of my medical course, during a microbiology lecture on infectious hepatitis, Professor Sydney Rubbo mentioned a book, Epidemiology in country practice,3 by an English general practitioner, William Pickles, in which Pickles reported on his work in tracing epidemics of infectious diseases through isolated villages in Yorkshire in the 1930s. I did not hear the book reference clearly, so at the end of the lecture I asked Professor Rubbo for the details so that I could get it out of the library. "I'll do better than that", he said, "Come to my office and I'll lend you my copy." After enjoining me to read the book and return it within a fortnight, he added, "And don't just leave it in my office. Make an appointment to see me, and tell me what you think of it." It was a challenge, but not an unkind one; he was a friendly and encouraging man, and a wonderful teacher. I was captivated by the book, and more or less there and then decided that as well as becoming a GP I wanted to do epidemiological research. After graduation I worked as a Junior Resident Medical Officer at the Royal Melbourne Hospital. The Honorary Medical Officer in charge of the medical ward was Dr John Bolton, whose twice-weekly ward rounds were unusual in a number of ways. While there was much talking with (definitely not to or at) the patient, and physical examination was done when needed, there was no medical discussion in the patient's presence. That took place in the side room during afternoon tea, a ceremony presided over by Sister in which everyone, including the lowly students, participated. After discussion, a member of the team was sent back to tell each patient the results of the deliberations. Dr Bolton himself then went around again to make sure no patient had further questions. During one of these ward-round afternoon teas I asked if patients who had had a long history of angina did better after a heart attack than those who did not, reasoning that those with angina might have developed more collateral circulation to prevent some of the damage resulting from the occluded artery. Dr Bolton suggested that I should find out by conducting a small research project using the hospital records. Under his guidance I studied the medical records of 100 consecutive patients admitted with myocardial infarction, correlating the presence of pre-infarction angina with the outcome of their hospital stay. He assisted me in formulating the research questions, in coping with the limitations of hospital records for the research purpose, in revising my rudimentary knowledge of statistics, writing up the results, and having the final paper published. "Shock in myocardial infarction" was my first research paper, published in the Royal Melbourne Hospital Clinical Reports in 1959.4 I disproved my hypothesis, as there was no evidence that a longer history of angina led to less shock or fewer deaths in hospital, but I did find that the overall death rate in hospital following myocardial infarction was an enormous 34%. Is research possible in country general practice? I commenced general practice as a partner in a rural medical group in Traralgon, Victoria, in 1960. I had not forgotten my idea of incorporating research into my professional career. Organising my curiosity described exactly what I wanted to do, and I immediately began keeping a "morbidity index" of all my patients (ie, a listing of patients under the diseases or conditions they had). The first question I addressed with my practice index was "What are the commonest conditions seen in my general practice?". It was soon obvious that these were acute respiratory infections, so I decided to investigate these, conscious that then, as now, there was great controversy about how these should be diagnosed and managed. I started by considering the epidemiology of acute respiratory infections, and presented the results at the 1963 Annual Convention of the Australian College of General Practitioners in Sydney.5 A seminal idea arose at a football match. Several of my friends there had colds of varying degrees of severity, coughing and spluttering amidst the cheering for our team. During the following week some of them came in for a consultation. However, it was not necessarily those who had seemed most sick who came in. It set me wondering, why? It was obviously more than just severity of symptoms that made sick people seek medical attention. What were the other factors? It also made me aware that my research into respiratory infections was biased towards conditions for which the patient sought attention. Were those who didn't consult a GP different? These questions led me into the fascinating realm of the sociology of medicine via David Mechanic's book Medical sociology.6 A statement that particularly caught my eye was: "Studies which begin with known or treated cases of particular disorders risk confusing aetiology with social and psychological processes leading to care unless the relationship between treated cases and untreated cases is known." I did not know this relationship in Traralgon, but hoped that I could find out. Since I had study leave due after five years in the practice, I used it to spend several months in the United Kingdom in 1966, meeting people who were doing the sort of research I now wanted to do. I visited the people I knew of already, and they recommended many others. At the end I reflected ruefully that some of their incisive and critical comments about my own research and ideas had been a little deflating, but that the depth of concern shown for a fellow researcher was encouraging. I was ready to go on. In 1966, the (by now Royal) Australian College of General Practitioners' Council advertised "one long-term Fellowship for conduct of a major research project approved by the College". I applied and was awarded it. From that time onwards my professional life included paid research time. We recruited from our practice 56 families with children, comprising 258 individuals, who were to keep a daily health diary for each family member for a year, and were willing to allow me to access details of all medical attention they received during that time. I was thus able to learn about all illnesses, particularly respiratory infections, including those for which no medical attention was sought. In 1968, I met Basil Hetzel, newly arrived at Monash University as the inaugural Professor of Social and Preventive Medicine. He was most interested in the research I was doing in Traralgon, and extremely supportive, inviting me to use the facilities of his department, the most helpful of which was access to the university computing centre to analyse my results. He also encouraged me to write up my study as an MD thesis, something that had never occurred to me. In the same year, I became Honorary Secretary of the Royal Australian College of General Practitioners' Research Committee of Council, a position I held for nearly 20 years. I was involved in the 1969-1974 RACGP national morbidity survey, which led me into research and development of appropriate classifications and to membership of the World Organisation of Family Doctors Classification Committee. In 1970 I commenced a new project, the Traralgon Health and Illness Survey. This was to be a major undertaking, based on my previous studies but much more representative of the community and more sophisticated. It preceded and in many ways foreshadowed the later triennial Australian Health Surveys that are now undertaken by the Australian Bureau of Statistics, for at that time there was relatively little information about community health status. The survey occupied me for the next three years, and three major articles resulting from it were my first publications in the international arena.7-9 All this time I had been a busy and fulfilled country GP, treating my patients in hospital and in the community. I loved the personal interaction with patients and the continuity of care that led to long-lasting relationships. It surprised me that so much of my research work was now a matter of epidemiological surveys and classification, as I did not see myself as a number cruncher, an academic theoretician. When, after 1974, advertisements began to appear for Chairs of General Practice or Community Medicine in Australian medical schools, I found the idea irresistible. I applied for several, although I felt torn between the challenge of taking up an academic position and the wish to remain in the country. I was going to miss the generosity of a country community and the space. Why Sydney University? I was short-listed for some positions and found the university meetings, and even the interviews, stimulating. I was becoming more and more convinced that I had something to contribute to academic life, and felt that it was a challenge that I wanted. I had not applied to Sydney — too big and brash a city, I thought, and I had no connections there — but that's where I ended up. It started with a phone call answered by my wife, Anne, one morning at home. She was impressed that the man at the other end introduced himself with perfect etiquette as "Richard Gye, Dean of the Faculty of Medicine at the University of Sydney". Did I realise that in phoning a stranger at home one should always introduce oneself with one's first name, Anne asked me when I came in to lunch. No, I replied. On returning the call, I was invited to come to Sydney to share my ideas about teaching general practice in universities. It never occurred to me that this might be an approach inviting me to apply for the Chair there, but I accepted the invitation to visit Professor Gye and his colleagues. One evening he took me to dinner, where we discussed many things other than professional issues. I had not expected to find an eminent neurosurgeon — narrowest of narrow specialties, I thought — an interesting human being, but I did. My formal interview must have gone well (I don't remember much of it), as I was offered the Chair. I had ascertained that, although it was a Chair of Community Medicine, its focus would be general practice. I was fortunate in being able to start a new department and ensure it had a clinical emphasis. To that end, the acquisition of a university general practice was important and rewarding. Here was a base from which we could initiate further research into medical records, respiratory infections, and emergencies in general practice. It was a great disappointment when the practice had to close in 1990 because a high quality teaching and research practice could not be made financially self-sufficient. Teaching came easily to me. It was also "organised curiosity", but in this case there was already an answer to be shared. We built a closeknit team of staff and emphasised experiential learning and small-group interaction. We established a widespread network of teaching GPs in both city and country whose support was invaluable. Our course always rated well in faculty teaching evaluations. My first major research task as an academic was to edit a report of the 1969-1974 RACGP national general practice morbidity and prescribing survey.10 This reinforced my interest in surveys and classifications and the international links that were to develop and provide so much interest and stimulus over the next 20 years, alongside the international friendships and travel in which Anne and I delighted. The evolution of the International Classification of Primary Care11 was one lasting achievement. The 1990-1991 general practice morbidity and treatment survey12 not only updated such information, but led to the continuing national BEACH ("Bettering the Evaluation and Care of Health") survey now contributing to information about Australia's health.13 There was even opportunity for creative activities. I was one of the editors and contributors to the book General practice in Australia,14 one of the last publications of Sydney University Press in 1986. About the same time I initiated and helped edit a video produced by the university about people living with terminal illness. I chose the title, A changed kind of reality, from a quote of one of the participants. We not only used it in our teaching program, but it also won a Penguin award and was broadcast by the Australian Broadcasting Corporation. Reflections I have been very fortunate to have been able to "travel hopefully" and enjoy a life of "organised curiosity", not only in my profession, but with family and friends. It is the people with whom I have been able to share my life and questions who have given me a sense of purpose and achievement, rather than the things I have done. There is still much to be curious about, and much to hope for, in the rest of life's journey. References Eimerl TS. Organised curiosity. J R Coll Gen Pract 1960; 3: 246-248. Pennycuick SW. The Arthur E Mills Memorial Oration. The secret of living. Med J Aust 1952; 2: 261-264. Pickles WN. Epidemiology in country practice. Bristol: John Wright and Sons, 1939. Bridges-Webb C. Shock in myocardial infarction. Royal Melbourne Hospital Clinical Reports 1959; 27: 26-29. Bridges-Webb C. A three-year study of respiratory infections. Med World 1965; May: 381-389. Mechanic D. Medical sociology: a selective view. New York: The Free Press, 1968. Bridges-Webb C. The Traralgon health and illness survey: method, organisation and comparison with other Australian surveys. Int J Epidemiol 1973; 2: 63-71. Bridges-Webb C. The Traralgon health and illness survey part 2: prevalence of illness and use of health care. Int J Epidemiol 1974; 3: 37-46. Bridges-Webb C. The Traralgon health and illness survey part 3: illnesses and their medical and hospital care. Int J Epidemiol 1974; 3: 233-246. Bridges-Webb C, editor. The Australian general practice morbidity and prescribing survey 1969 to 1974. Med J Aust 1976; October 2(Suppl): 1-28. WONCA International Classification Committee. International classification of primary care, ICPC-2. Oxford: Oxford Medical Publications, 1998. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-91. Med J Aust 1992; 157(Suppl): S1-S56. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 1999-2000. Canberra: Australian Institute of Health and Welfare, 2000 (AIHW Catalogue No. GEP 5). Anderson N, Bridges-Webb C, Chancellor A, editors. General practice in Australia. Sydney: Sydney University Press, 1986. Authors' details University of Sydney, Sydney. Charles Bridges-Webb, MB BS, MD, FRACGP, MM, Emeritus Professor of General Practice. Reprints will not be available from the author. Correspondence: Professor Charles Bridges-Webb, University of Sydney, Sydney, NSW 2052. cbridgesATmail.usyd.edu.au Make a comment Short curriculum vitae Qualifications MB BS, University of Melbourne, 1957; MD, Monash University, 1971; MM (ad eundem gradum) University of Sydney 2001; FRACGP, 1971 Present positions Director (part-time), RACGP NSW Projects, Research and Development Unit, 1996- Professor of General Practice (now Emeritus), University of Sydney, 1975- External Clinical Teacher, RACGP Training Program Awards Faulding Prize for Research in General Practice, RACGP, 1967 RACGP Rose-Hunt Medal for service to general practice, 1993 Medical appointments General Practitioner, Deakin Street Clinic, Traralgon, 1960-1975 General Practitioner, Croydon General Practice Unit, University of Sydney, 1976-1990 Academic positions Honorary Secretary, Research Committee of Council, RACGP, 1968-1987 Member, International Classification Committee, World Organisation of Family Doctors, 1972-1999 (Chairman, 1991-1998) Member, NSW Faculty Research Committee, RACGP, 1976- (Chairman, 1983-1985) Member, World Health Organization Working Party to Develop a Reason for Encounter Classification for Primary Care, 1981-1984 Member, National Health and Medical Research Council, 1982-1984 Member, Australian Association for Academic General Practice, 1984- (President, 1989-1991) Member, Quality Assurance Committee, RACGP, 1986-1991 (Chairman, 1989-1991) Member, NSW Government Committee of Enquiry into Services provided by General Medical Practitioners to Country Public Hospitals, 1987 Member, Project Grant Assessment Panel, General Practice Evaluation Program, Commonwealth Department of Human Services and Health, 1994-1996 Criticism Editor, Acute Respiratory Infections Group, Cochrane Collaboration, 1997-1999 Professional interests Research in general practice, with special interest and expertise in classification systems for general practice, dementia and preventive medicine. Development of quality assurance programs for general practitioners, evaluation of quality of care, measurement of clinical patient outcomes, and evidence-based medicine. Personal interests Gardening; cricket and soccer; literature, music and art; philosophy and religion; Australian and medical history RACGP = Royal Australian College of General Practitioners

Charles Bridges-Webb

The research enterprise The Menzies Centre for Population Health Research A unique and supportive local population was a vital ingredient in the Centre's success Terence Dwyer MJA 2001; 175: 617-620 Early days: the Tasmanian Infant Health Survey and Sudden Infant Death Syndrome - The post-SIDS era: taking stock - New directions - Genomics - The future - References - Authors' details - - More articles on Psychiatry I ACCEPTED THE CHAIR IN COMMUNITY HEALTH at the University of Tasmania in 1985 with the intention of setting up a research centre that focused on epidemiological research into preventable causes of disease. While I did not know how the centre would be funded, I was certain that Tasmania would be a very competitive site for such research. Already, valuable epidemiological studies on iodine deficiency, hydatid disease and asthma had been conducted in the absence of significant research infrastructure.1 The "Island State" provided a perfect source population for unbiased selection of cases and comparison samples or controls. Further, the land area and population size (around 500 000 people) made follow-up of cohorts relatively easy. Thus, Tasmania had important advantages for the two major strategies used to search for environmental and lifestyle causes of disease — case-control and cohort studies. Funding from the Menzies Foundation came about through the input of three people — Basil Hetzel, then Chief of the Commonwealth Scientific and Industrial Research Organisation Division of Human Nutrition in Adelaide, who had a close association with the Menzies Foundation; Professor Ian Lewis, Dean of the Medical School at the University of Tasmania and a member of the Menzies Foundation Board; and Eric Wigglesworth, the Director of the Foundation. To determine the likely success of such a centre, the Foundation Board held a three-day workshop attended by representatives of State and Federal health departments and the World Health Organization, notable Australians in the field of public health, and distinguished British epidemiologist Sir Richard Doll. History of the Menzies Centre 1987 Workshop ("Towards a Centre for Population Health Research") in Hobart, Tasmania. 1988 Official opening in January. Collection of Tasmanian Infant Health Survey (TIHS) data began (prospective study on Sudden Infant Death Syndrome [SIDS]). 1990 Designated as a World Health Organisation Collaborating Centre for the Prevention of Cardiovascular Diseases. 1991 Provides prospective evidence confirming importance of prone sleeping position as a cause of SIDS (Lancet 1991; 337: 1244-1247). 1992 Evidence that SIDS death rate was falling after a national campaign on infant sleeping position. 1993 Research helps explain how prone position interacts with other factors to increase risk (N Engl J Med 1993; 329: 377-382). 1995 First follow-up of TIHS cohort searching for early life influences on childhood diseases. Shows that the major decline in SIDS deaths from 1991 onwards is the result of changes in infant sleeping position (JAMA 1995; 273: 783-789) 1997 Contract signed with AMRAD pharmaceutical company. Provides funding for Genetic Epidemiology Unit. 1997-2000 Follow-up of the Tasmanian Infant Health Survey cohort into childhood provides important evidence about early life determinants of risk for osteoporosis, blood pressure and asthma (J Clin Endocrinol Metab 1998; 83: 4274-4279; J Bone Miner Res 1999; 14: 146-151; BMJ 1999; 319: 1325-1329; Thorax 1999; 54: 664-669). 2000 Named "Tasmanian Icon" by State Premier. Core funding doubles. Key events Major scientific achievements. Subsequently, the Menzies Foundation Board decided to support the establishment of an epidemiology research centre, to be named the Menzies Centre for Population Health Research. The Foundation then met with the Tasmanian Premier and Minister for Health, who matched the Foundation's initial contribution of $100 000 per year. Early days: the Tasmanian Infant Health Survey and Sudden Infant Death Syndrome Before my departure from Sydney University, I had been reviewing the data on disease distribution in Tasmania. Sudden Infant Death Syndrome (SIDS), with an annual rate in Tasmania twice the national average, stood out. The head of neonatology at the Royal Hobart Hospital, Neville Newman, convinced me that this should be the subject of a major research effort. The cause had not been clearly identified, and epidemiological research had been limited. With helpful input from Geoffrey Berry, Professor of Biostatistics at Sydney University, we planned the first prospective cohort study on this condition. Preliminary work began just before the decision of the Menzies Foundation to support the establishment of the Centre. The epidemiology research group within the Medical School at the University of Tasmania consisted of one epidemiologist, the research fellow Trevor Beard, and limited support staff. Even with the extra $200 000 that the establishment of the new Centre brought, it would not have been realistic to work on a broad front. It was decided that we would focus most of our effort on the new SIDS research program. The next step was to build an appropriately skilled team. We advertised for another epidemiologist and a biostatistician, but it proved very difficult to attract qualified applicants. It seemed that Australian academics were either not interested in living in Tasmania, or were not confident their careers would flourish there. This problem was compensated for by a stroke of good luck when a young Tasmanian medical graduate, Anne-Louise Ponsonby, became our first postgraduate student, working on SIDS. She put an incredible amount of intelligently directed energy into the SIDS program, and together, with financial help from the Australian Rotary Health Research Fund, we were able to develop momentum in the project. In 1988, we initiated the first full data collection for the cohort study — a huge endeavour that involved measurements each year in 1500 infants and their mothers on three occasions in the first three months after birth. That we could get this work under way was pleasing, but we needed to find well-qualified biostatisticians. Given the previous lack of success with advertising in Australia, I decided to use our international network. Sir Richard Doll referred Michael Jones, a young Master of Science graduate from Oxford, who was recruited to our ranks, and then Laura Gibbons, from the University of Massachusetts, joined us. This relatively small and young team of investigators coordinated the conduct, data management and analysis of the SIDS program. They also assisted with less well resourced but developing areas in cancer and cardiovascular disease. In late 1990 evidence was accumulating from case-control studies that prone sleeping position might be a major cause of SIDS, but the research was retrospective, creating concerns that recall bias might explain the findings. We had the only prospective data in the world and were able to show that the association was equally strong prospectively, ruling out recall bias.2 A number of countries, including Australia, launched campaigns to encourage parents not to place babies on their stomachs in the cot, with astonishing results — the death rate from SIDS in Australia fell from 507 in 1990 to 139 in 1998, with similar falls in a number of other countries.3 While our work was not the only important contribution to the understanding of this major cause of SIDS, it provided an important piece of evidence needed for solving the puzzle. Later, in 1993, our team explained why prone sleeping position seemed to exert a different effect in winter than summer and a different effect across countries.4 Then, in 1995, we provided evidence that showed clearly that the fall in deaths could only be attributed to the changes in prevalence of prone sleeping position.5 This success will undoubtedly rank as one of the major contributions of the Centre in the years to come. It also established the organisation as one which, in its special location, could have a significant impact on international medical science. It was the much-needed platform that would underpin future recognition and opportunities. The post-SIDS era: taking stock The death rate from SIDS fell so rapidly after the prone sleeping position campaign that, by late 1991, it was clear there would eventually be insufficient cases occurring annually in Tasmania for epidemiological research (when we started the SIDS program, there had been an average of 27 cases a year for an extended period, and by 1998 there were only three). While this outcome was tremendously gratifying, it was clear that the research money to support our staff of now approximately 20 would dry up unless we repositioned our research program. This was confirmed by the National Health and Medical Research Council (NHMRC) Regional Grants Interview Committee's decision not to recommend refunding of our cohort study for 1992. We went from triumph to a period of considerable adversity. One of our first responses was to tell the Tasmanian public that we needed its financial and moral support. They responded generously. With a major public fundraising appeal, helped greatly by our Board and new Chairman John Tomlinson, and a timely decision by the United States National Institutes of Health, we were able to continue the study long enough to thoroughly evaluate the impact of the prone sleeping intervention campaign. In 1992, I took some time to review where we were going as an organisation and to think about where our future research opportunities might lie. I visited people like Richard Doll in Oxford, who had provided very helpful mentoring since 1987. I also had discussions with Ken Rothman (author of Modern epidemiology6), and Dimitris Trichopoulos at Harvard. These visits confirmed that, if we were to continue to conduct work of global significance, we would have to search even more thoroughly for gaps in knowledge that might be filled by an epidemiological approach. I was also convinced that we would need to develop stronger working relationships with basic scientists if we wished to use epidemiology to understand aetiology. These strategies were challenging, but all our team had learned a great deal from the SIDS research experience. While overseas, I also upgraded my skills in organisation and management by attending a management course in Salzburg, led by Peter Drucker, one of the world's most prominent management theorists. New directions The perspectives gained during my overseas visit were incorporated into planning from 1992 onwards. The major new strategy we decided on was to follow the Tasmanian Infant Health Survey (TIHS) cohort, now numbering 11 000 infants and children. The focus would be to search for links between early life exposures and later disease, using our extensive database of infant measurements that provided information on more than 450 variables measured during the first three months of life. One disease we looked at was asthma, an important disease for which preventable causes had not yet been identified and for which there was a shortage of good epidemiological data. This investigation would be coordinated by Anne-Louise Ponsonby, with help from David Couper, a biostatistician who had joined us from Seattle. We also increased our activity in research on the development in childhood of risk factors for cardiovascular disease and diabetes. Fitting into this theme was the new program started by a recent recruit from the Garvan Institute in Sydney, Graeme Jones (we were finally starting to see interest in work opportunities from well-qualified Australians outside Tasmania). He had a strong track record in osteoporosis in the elderly, and he used that background to focus on the impact of early-life factors on bone density in childhood. Fortuitously, interest in the "Barker hypothesis", which concerns the impact of fetal development on later disease, was gaining momentum. We were well placed to make an important contribution in this field, and our capacity was greatly enhanced by the addition of Ruth Morley, from the Institute of Child Health in London. Supplemented by smaller research efforts in cancer and adult cardiovascular disease, by 1994 we were able to see evidence that the research program was growing again. Between 1994 and 2000, the team was able to attract 17 new NHMRC grants from 38 applications submitted. This overall level of success was built on the tremendous preparedness of the Tasmanian public to be involved in the research. Response rates for case-control studies in this period were about 90% for cases and 80% for controls sampled from the electoral rolls, with comparable figures for cohort follow-up. In addition to our growing research effort we took on an important role in ensuring that knowledge was transferred to countries with less developed research capacity. The World Health Organization designated our institution as a Collaborating Centre for the Prevention of Cardiovascular Disease (CVD) a decade ago. That role has expanded steadily to the point where the Centre is assisting in studies on CVD in countries including Vietnam, Fiji and Samoa, where CVD and diabetes are producing an unexpectedly high disease burden. Genomics For the first seven years (1988-1995) the Centre focused solely on the environmental and lifestyle causes of disease. Meanwhile, others had been using the deep family pedigrees available in Tasmania to search for genetic causes of diseases following a Mendelian pattern of inheritance. Novel genes or linkages were discovered for several conditions, including multiple endocrine neoplasia and Huntington's disease. These successes were based on special features of Tasmania that are replicated in few other locations, namely (i) a population descended largely from identifiable founder families; (ii) comprehensive genealogical records; (iii) a modern healthcare system capable of identifying disease outcomes; (iv) a demonstrated capacity to involve the population in studies; and (v) organisational structures to facilitate the research. In 1995, David Mackey, a Tasmanian medical graduate and ophthalmologist at the Victorian Eye and Ear Hospital, approached us. He was undertaking important work in Tasmania on the more complex genetics of glaucoma. He wanted a base in Tasmania, and the Walter and Eliza Hall Institute, in Melbourne, was seeking a Tasmanian institution to manage new research and development syndicate funds to support his research. We accepted the role and our interest in the use of epidemiology to find genes for human diseases increased. Then, in 1996, the Australian pharmaceutical company AMRAD approached us about increasing its involvement in gene discovery in Tasmania through the Menzies Centre. We agreed, on the condition that the funding would be for a genetic unit that would employ people who could provide intellectual input to the work from a Tasmanian base. AMRAD signed a contract in 1997 for a five-year grant of $2.5 million, and, in 1998, we attracted Tasmanian molecular geneticist Michele Sale to coordinate the work. With financial and other help we were able to very quickly get projects under way in multiple sclerosis and osteoarthritis, and have continued to develop activity with Cerylid, a spin-off from AMRAD formed to operate its discovery arm. The genomics development has also led to an increase in postgraduate student training at the Centre, with five PhD students currently enrolled. The future During the past 12 months there have been several important developments for the Centre, driven by our very committed Board, chaired by Jean Trethewey, and strongly supported by the Dean of the Faculty of Health Science at the University of Tasmania, Allan Carmichael. The Tasmanian Government introduced an "Icons Program", which supports the Tasmanian Symphony Orchestra and our State cricket team. To this list Premier Jim Bacon added the Menzies Centre, with a commitment to provide $500 000 a year to help our organisation develop its capabilities. This, together with a large donation in 2000 from the United States-based Atlantic Philanthropies Inc, has placed us in a previously unimagined position to recruit more staff and drive our research program. To enable us to undertake these future developments with vigour, the University of Tasmania Council has established the Menzies Centre as an independent company limited by guarantee, remaining within the university structure. In 2002, the Centre will become the "Menzies Research Institute". Already, the Centre has grown to support a staff of 60. The new institute is likely to start 2002 with a budget of approximately $5 000 000 that will see staff numbers increase to more than 100, working on both environmental and genetic causes of disease. A major NHMRC grant of $2 290 000 over the next five years will enable us to study a cohort of Australians first measured as schoolchildren in 1985. They will be followed up for the emergence of adult disease, and it is anticipated this will provide the first direct evidence available on the impact of childhood lifestyle and biology on diseases such as coronary heart disease. A collaboration with similar cohorts in the US and Finland has already been established. A new director of the Cohort Studies Unit, Alison Venn, who has a strong background in this research strategy, has been recruited from the Centre for the Study of Mothers' and Children's Health at La Trobe University to coordinate developments. A large adult cohort study in Tasmania, with a focus on exposures that occur closer to the time of disease development, will also commence in 2002. Both studies will benefit from the input of a now-strong biostatistics group of three staff headed by one of our own PhD graduates, Leigh Blizzard. The level of genetic research activity will expand greatly. Tasmania presents opportunities as good as any in the world for gene discovery, and we intend to take up these opportunities. An increasing number of epidemiological studies at the Centre are focused on finding novel genes or validating candidate genes identified through animal or cell studies, or bioinformatic "data mining". This growth in activity reflects the recognition by commercial and government sources of the opportunities here, as well as the developing capacity of our genetic unit. Increasingly, our "environmental" epidemiologists and biostatisticians are developing their interests and skills in genetic research. This has not only led to the more rapid development of a critical mass for projects on gene discovery and validation, but has also opened up the possibility for in-depth investigation of gene-environment interaction. Projects with this focus are already under way in multiple sclerosis. There is great scope for us to contribute in an internationally significant way to the understanding of gene-environment interactions using Tasmania's unique population and our skill base. In the coming decade Australia will be relying more and more on its medical research institutes to maintain its competitive advantage in a knowledge-based global economy. We are confident that the new Menzies Research Institute will be making its contribution. References King H, editor. Epidemiology in Tasmania. Canberra: Brolga Press, 1987. Dwyer T, Ponsonby AL, Newman NM, Gibbons LE. Prospective cohort study of prone sleeping position and sudden infant death syndrome. Lancet 1991; 337: 1244-1247. Australian Bureau of Statistics. Deaths, Australia, 1990, 1998. Canberra: ABS, 1998. (Catalogue no. 3302.0/3303.0.) Ponsonby AL, Dwyer T, Gibbons LE, et al. Factors potentiating the risk of SIDS associated with the prone position. N Engl J Medicine 1993; 329: 377-382. Dwyer T, Ponsonby AL, Blizzard CL, et al. The contribution of changes in the prevalence of prone sleeping position to the decline in SIDS in Tasmania. JAMA 1995; 273: 783-789. Rothman K. Modern epidemiology. Boston: Little John and Co., 1986. Authors' details Menzies Centre for Population Health Research Terence Dwyer, MD, FAFPHM, Director. Reprints will not be available from the author. Correspondence: Professor T Dwyer, Menzies Centre for Population Health Research, 17 Liverpool Street, Hobart, 7000 TAS. t.dwyerATutas.edu.au Make a comment

Terence Dwyer

Forensic medicine Not murder most foul Suspicious circumstances and inexplicable wounds do not a murder make Alan D Cala and Christopher H Lawrence MJA 2001; 175: 621-622 Break and enter and fatal assault? - Assault with a steel bar? - References - Authors' details - - More articles on Pathology These two unusual forensic cases highlight the value of the autopsy in defining cases of murder. Circumstantial evidence pointed towards foul play and murder investigations were initiated, but correlation of the autopsy findings with the scene of the "crime" showed that one was a death from natural causes, and the other was an accident. Break and enter and fatal assault? An 87-year-old, 54 kg man who lived alone was found dead at his home in Sydney after he failed to maintain regular contact with relatives. The house was locked, and a relative forced entry by smashing a side window. The man was found lying on his back in the lounge room, wearing only a singlet, a flannelette shirt and short socks. It was mid-winter, with a temperature range that day of 5º-15ºC. No working heater was found in the house. The relative called the police, who suspected foul play in view of the scene they witnessed: a deceased, partially dressed man with bruises on his head, trunk and limbs, surrounded by upturned furniture, pulled-out drawers and scattered papers, suggestive of a struggle (Figure 1). The house, however, was secure (apart from the window smashed by the relative) and a wallet containing cash was found near the body (an unusual finding in a "break and enter/robbery"). The man had clearly been dead for many hours: the body was cold to touch, and there was very firm rigor mortis with dependent lividity. He had had a myocardial infarction in 1997, but recently had been well and was not taking any regular medication. At autopsy, 10 separate injuries were found on the body: abrasions on the right cheek, right ear, and right lower chest, and bruises and abrasions on the posterior aspect of both upper arms. A very large abrasion (240 x 110 mm) was noted on the right lateral upper thigh, with other abrasions around both knees. The heart weighed 640 g. The pericardial sac was obliterated by fibrous adhesions. The left ventricular wall thickness was 13 mm (reduced to 6 mm in the affected area by an anteroseptal scar), and the right ventricular wall thickness was 2 mm. The coronary arteries were severely narrowed by calcific atherosclerosis. The aorta and branches also showed severe atherosclerosis. The severe coronary atherosclerosis and left ventricular scarring were indicative of past and possibly recent myocardial ischaemia/infarction, but there was no evidence of an acute myocardial infarction. There were bilateral apical emphysematous changes in the lungs. The stomach lining had numerous superficial jet-black erosions, 2-10 mm in diameter, in the body and antrum (Figure 2). About 20 mL of altered blood was found in the stomach in association with these erosions. Toxicological analysis was negative for alcohol or other drugs. Neuropathological examination showed age-related neurofibrillary changes in the brain and a scar in the putamen. The cause of death was determined to be the combined effects of fatal hypothermia and ischaemic heart disease. Discussion Hypothermia, in which the core body temperature falls to below 35ºC,1 is rare as a cause of death in a temperate city such as Sydney. Those most at risk are thin, elderly people who live alone in poorly heated premises. They have low fat reserves, may be nutritionally and calorically deficient and usually have other significant medical problems. Poor family and social networks may lead to isolation, which can exacerbate the situation by failure to obtain timely medical assistance. Quite often, the scene findings in cases of fatal hypothermia show evidence suggesting a struggle. The premises may be in disarray, and affected individuals may be found under newspapers or furniture. Presumably, once hypothermia has set in, they become confused and disoriented, and attempt to seek warmth in unusual places. They also suffer from "paradoxical undressing", or "hide-and-die" behaviour, thought to be due to a disturbance of the temperature-regulating function of the hypothalamus that causes a feeling of overheating (and resultant attempts to cool down such as undressing) as the body's core temperature drops. The most significant finding at autopsy was the presence of gastric erosions. Although not diagnostic for hypothermia (and not present in all cases), such multiple, superficial, variable-sized ulcers or erosions, found particularly in the body of the stomach, are often seen in cases in which hypothermia is believed to be either the sole cause of death or a contributing factor to death. They are thus highly suggestive of the diagnosis. They may also be seen in cases of "stress" from any cause, for example postoperatively, or following myocardial or cerebral infarction. Other autopsy findings that have been described in fatal hypothermia are pancreatic haemorrhage or necrosis, and cherry-pink lividity, but these are not specific.2 Assault with a steel bar? In a second case, a 37-year-old, 99 kg man with no significant past medical history was found by his wife at about 8:45 am, lying in the back yard of his residence, with a penetrating injury to his right eye. This unusual injury was immediately designated as suspicious by the police, who arranged for a forensic pathologist to attend the scene. The man's usual practice had been to water the garden each morning before leaving for work at 5:30 am. The garden hose was found still running on the ground, and the man's body was almost submerged by the water collecting around him. He was lying on his back with his legs folded underneath him, on the edge of a garden bed. Several sandstone rocks were around the body, and nearby was an 18 mm diameter octagonal steel post that was upright but loose in the ground. The autopsy was conducted later that day. The main abnormality was a complex, patterned, roughly square injury on the right cheek and eye, which was covered with blood and fragments of brain tissue. On the right cheek, close to the nose, was a curved 26 mm full-thickness laceration running obliquely and medially. Two parallel lines of abrasion/laceration, 20-45 mm in length, extended upwards and laterally away from this laceration. On the lower right eyelid was a 'V'-shaped laceration. Dissection of this complex injury showed a 70 mm long haemorrhagic wound track directed upwards, left to right, and front to back. The injury had perforated the posterior wall of the orbit, superficially bruising the lateral wall of the right orbit. The globe of the right eye remained substantially intact, despite the severe injury. There was a penetrating injury to the right inferior frontal region of the brain to a depth of 35 mm, resulting in a wound defect in the brain of 18 mm diameter (Figure 3). Within the wound were several small pieces of dark material, possibly representing corroded metal. The left orbit was fractured, and 300 mL of blood from a subdural haemorrhage was in the anterior right middle cranial fossa. Detailed neuropathological examination also showed evidence of brain swelling, resulting in midline shift of structures from right to left, transtentorial herniation on the right side, and flattening of gyri over the area of the subdural haemorrhage. Duret haemorrhages, indicative of raised intracranial pressure, were present in the pons and midbrain, with some minor haemorrhage in the right uncus. Other injuries, consisting mainly of abrasions, were present on the forearms and thighs. The time of death was estimated to be between 5:00 and 6:00 am that morning, given the degree of rigor mortis, the rectal temperature and degree of skin slippage present. The rest of the autopsy showed no notable abnormalities. Examination of the metal post under a dissecting microscope revealed small strands of tissue and one small hair, possibly from the lower eyelid of the deceased. DNA analysis confirmed that the material on the post was from the body of the deceased. The cause of death was determined to be an accidental penetrating injury of the right orbit and brain by a steel post, with no evidence that the injury was inflicted by another person. Discussion Fatal penetrating injuries to the head are uncommon,3 and mostly due to gunshot rather than stab wounds. Initially, investigating police believed the injury must have been caused by some other person. Suicide was considered highly unlikely. Although the metal post was the obvious weapon to have caused the injury, it was not immediately clear what had transpired to lead to the injury. There was even speculation about the possibility of a tangential gunshot wound. Foul play was discounted after x-rays and autopsy revealed the true nature of the injury and "weapon". The most probable scenario is that while the deceased was watering his garden, he tripped on the hose, fell onto the post, sustained the penetrating injury and died a short time later. References Harrison's textbook of internal medicine. 14th ed. New York: McGraw-Hill, 1998: 97-99. Knight B. Forensic pathology. New York: Oxford University Press, 1991: 380-384. Adams JH, Graham DI. Introduction to neuropathology. 2nd ed. Edinburgh: Churchill Livingstone, 1994: 133-155. Authors' details NSW Institute of Forensic Medicine, Glebe, NSW. Allan D Cala, FRCPA, Forensic Pathologist; Christopher H Lawrence, FRCPA, Forensic Pathologist. Reprints will not be available from the authors. Correspondence: Dr A D Cala, NSW Institute of Forensic Medicine, 42-50 Parramatta Road, Glebe, NSW 2037. CalaAATemail.cs.nsw.gov.au Make a comment Figure 1Figure 1: Upturned furniture in lounge room, suggestive of a struggle (Case 1). Back to textFigure 2 Figure 2: Multiple superficial gastric erosions, suggestive of hypothermia (Case 1). Back to textFigure 3Figure 3: Steel post injury laceration to right frontal lobe of brain (Case 2). Back to text

Alan D Cala · Christopher H Lawrence

q Forensic medicine Dolphin deaths: forensic investigations Forensic pathologists may have an important role to play in investigating the deaths of marine or other mammals Roger W Byard, John D Gilbert and Catherine M Kemper MJA 2001; 175: 623-624 The assessment of wounds in humans is a standard part of forensic pathology practice. Injuries are routinely examined to determine how and when they occurred, and with what degree of force. Careful examination also helps to narrow down the range of possible weapons that may have been used. Injuries are examined in both living and deceased individuals, and opinions are given as to the likelihood that the injuries were accidental, self-inflicted, or inflicted by others. The legal implications of this determination are obviously significant. The following two cases demonstrate an unusual application of forensic pathology involving two deceased dolphins. Case 1: A dead adult male Indian Ocean bottlenose dolphin (Tursiops cf aduncus) was found floating off an Adelaide beach on 11 December 2000. An autopsy revealed a single, lethal stab wound to the ventral thorax between the flippers (Boxes 1 and 2). The stab had penetrated the heart and caused a left-sided haemothorax. Examination of the wound indicated that the weapon was likely to have been a single-edged blade with a maximum width of 18 mm at a distance of 85 mm from the tip. Although three wounds were present in the right ventricle (Box 3), these could have resulted from one thrust with the weapon, with movement of the weapon, the dolphin or the heart causing the three injuries. Given the right-to-left direction of the wound, it could have been inflicted from the left side of a boat if the dolphin had been swimming beside the boat and had angled over onto its left side, thus exposing the anterior thorax. The dolphin otherwise appeared to be in good health, with no evidence of significant trauma or underlying organic illnesses. The presence of regurgitated, partly digested food in the oesophagus may have indicated recent feeding, although stress is known to delay gastric emptying in a variety of species.1,2 Case 2: On 19 May 2001, an immature male common bottlenose dolphin (Tursiops cf truncatus) was found dead on a beach in southeastern South Australia. An autopsy revealed a wound that was similar in appearance to the wound seen in Case 1. The wound was in the ventral thorax between the flippers (Box 4), overlying a cavity in muscle; however, no damage to underlying vital structures was found. Although death was not caused by trauma, we could not determine the precise cause. However, the presence of stomach contents and a small, partly digested squid in the oesophagus may have indicated recent feeding. Sealice activity around the wound suggested that death may have occurred before beaching. Discussion Traditionally, forensic pathologists rarely become involved in non-human cases. In cases of dead marine mammals in South Australia, however, collaboration between the South Australian Museum, veterinarians, National Parks and Wildlife South Australia and the Forensic Science Centre has resulted in an approach that has facilitated the assessment of the significance of wounds and injuries in a non-human population. For example, in a previously investigated case in 1999, forensic examination of an infant dolphin showed that the animal had died after being speared to death (Box 5) and enabled the approximate dimensions of the weapon to be determined.3 In 1998 three other dolphins were found to have been shot. For the dolphin in Case 1, death was attributed to a stab wound inflicted to the heart, most likely by a knife or similar single-edged sharp weapon. This conclusion resulted in the launching of a coordinated search for the perpetrators, with media appeals to the public for help. Although the injury to the dolphin in Case 2 appeared superficially similar, it was not lethal. Thus, forensic examination could determine quite quickly that the injury in Case 2 had not been responsible for death, and may even have occurred post mortem. The significance of the findings in these cases is far from academic, as the penalty in South Australia for killing a marine mammal may be a $30 000 fine and/or a jail term of up to two years.4 Given these penalties, it is likely that anyone charged with such an offence would employ an active legal defence that could easily terminate the case on technical grounds if the examination and subsequent handling of evidence did not follow established guidelines. For this reason, cases of sea-mammal deaths, including the two we describe, have been processed in a routine forensic manner. This means that the examination of each dead dolphin was undertaken in a similar fashion to a standard human autopsy in a suspicious case, including accurate documentation of times, personnel present and possible trauma. The measurement, assessment and recording of injuries was undertaken in the usual manner, with descriptions being recorded in original notes and subsequently transcribed into an official signed report. Specimens that were taken for histological examination, storage for possible future DNA matching and toxicological evaluation were also signed and sealed at documented times and submitted to the Forensic Science Centre so that a formal chain of evidence could be maintained. Biological information, including species verification, was lodged at the South Australian Museum. To date, however, no charges have been laid in the reported cases. Involvement of forensic pathologists in such cases has resulted in the early determination of whether trauma was implicated in the death, and has also facilitated an understanding of the relationship between the mechanism of death and the external injuries. In addition, investigating officers have been given some idea of the type of weapon to look for, material has been secured for possible DNA cross-matching between possible weapons and a particular animal, and wounds have been recorded accurately for possible court presentation if required. In reporting these cases we have demonstrated that a standard branch of medicine, forensic pathology, may be useful in areas other than the assessment of human medicolegal cases, and that pathologists may play an important role in investigating the deaths of marine or other mammals. References Byard RW, Gilbert JD, Brown K. Pathological features of fatal shark attacks. Am J Forensic Med Pathol 2000; 21: 225-229. Knight B. Forensic pathology. 2nd ed. London: Arnold, 1996: 89-90. Gilbert JD, Kemper CM, Hill M, Byard RW. Forensic studies of a stabbed infant bottlenose dolphin. J Forensic Med 2000; 7: 150-152. Fisheries Act 1982 (South Australia). Reprint no. 8. Authors' details Forensic Science Centre, Adelaide, SA. Roger W Byard, MD, FRCPath, Specialist Forensic Pathologist and Clinical Professor of Pathology and Paediatrics. John D Gilbert, FRCPA, Forensic Pathologist. South Australian Museum, Adelaide, SA. Catherine M Kemper, PhD, Senior Curator of Mammals. Reprints will not be available from the authors. Correspondence: Professor Roger W Byard, Forensic Science Centre, 21 Divett Place, Adelaide, SA 5000. byard.rogerATsaugov.sa.gov.au Make a comment Figure 1 Back to textFigure 2Back to textFigure 3 Back to text Figure 4 Back to textFigure 5 Back to text

Roger W Byard · John D Gilbert · Catherine M Kemper

Medicine and the media Trial of a trial by media In a democratic society, the Press has the right to investigate any issue it chooses, but this right should come with a responsibility for accuracy and freedom from bias Helge H Rasmussen, Peter S Hansen, Yutaka Koyama, Barbara-Ann Adelstein, Anthony J O'Connell and Gregory I C Nelson MJA 2001; 175: 625-628 Rationale for the trial - The trial - Consent - The risks of our trial - Lessons from the obstacles to the trial - Conclusions - References - Authors' details - - More articles on Journalology and publishing Articles in the Sydney broadsheet, the Sydney Morning Herald (SMH), earlier this year reported that some doctors were concerned about the safety, ethics and lack of informed consent of a clinical trial proposed for the management of acute myocardial infarction (AMI). The New South Wales Minister for Health, Mr Craig Knowles, was made aware of the SMH journalists' investigation, and, by the time the articles appeared in the broadsheet, he was reported to have stopped implementation of the trial.1,2 A prominent radio commentator highlighted the serious nature of the perceived problems by asking rhetorically "Do we have to have someone who actually dies before it becomes a scandal?".3The fate of this clinical trial has implications for the conduct of clinical research. Here, we outline the rationale for the trial and the risks for participants in it, and discuss ethical issues related to consent to participate in clinical trials. We also question the ethics of the process that led to the trial being stopped. Rationale for the trial Treatment of AMI with fibrinolytic agents is firmly established. However, its efficacy in achieving the treatment goal of opening the occluded coronary artery is limited and re-occlusion occurs frequently.4,5 Furthermore, many patients have contraindications to fibrinolysis, usually because they are deemed to be at high risk of bleeding. They may also be considered unsuitable for fibrinolysis, mostly because an electrocardiogram does not show the changes associated with proven benefit. AMI remains a common and frequently fatal condition. Recent prospective registry data on 30 402 patients with AMI indicate that the cumulative mortality rate remains high at about 14% while in hospital and about 22% by 90 days after presentation.6Percutaneous coronary intervention (PCI) has been introduced to improve outcomes of AMI. When PCI is used in the treatment of AMI, an angioplasty balloon is used to unblock the occluded culprit coronary artery. A stent is then often deployed to maintain the patency of the artery. Small, randomised trials indicate that PCI is superior to fibrinolyis when performed in heart centres by experienced teams.7,8 However, most patients, even those residing in urban areas, live outside the catchment area of major hospitals. An extension of the benefits of PCI to these patients could be achieved by establishing cardiac interventional units in their local hospitals, but such units would have a low case load. Studies have shown that institutions and operators with a low case load do not achieve better patient outcomes with PCI than with fibrinolysis.9-11 We chose to examine an alternative approach involving early transport of patients to a specialised "Regional Heart Attack Centre". The trial Patients presenting to the Ambulance Service with suspected AMI within the geographic limits of the Northern Sydney Area Health Service, but outside the normal catchment area of Royal North Shore Hospital (RNSH), were to be allocated at random to treatment at their local district hospital or at RNSH. Our trial was to compare two strategies: one based on PCI, backed by facilities at a large centre, and the other based on treatment with fibrinolytics at local hospitals with fewer facilities. Our comparison between the two strategies was to be based on the number of deaths and the number of recurrent non-fatal myocardial infarctions and non-fatal strokes in the two groups of patients during the admission for AMI and six months later. Our trial was designed to determine if there were benefits of a PCI-based strategy at a large centre despite the additional transport time. The potential benefits of such a strategy might be considerable. Careful analysis of registry data on AMI indicated that the hospital mortality rate for patients treated at small centres without facilities for PCI is almost twice as high as that at large centres with facilities for PCI.8,12 Had our randomised, controlled trial replicated these results, it would have indicated that many lives could be saved with centralised care of all patients with AMI in large cities in a few, highly specialised Regional Heart Attack Centres. Because of the urbanised distribution of our population, many patients in Australia would stand to benefit. However, such centralised treatment would require a major change from current practice and have important consequences for resource allocation. (See the Box for a flow diagram of the proposed trial.) In 1997, the RNSH institutional ethics committee requested that we perform a pilot study to document that we could reproduce the published results of PCI on a seven-days-a-week, 24-hours-a-day basis before a randomised study could be considered. The pilot study (Stenting Strategy as an Alternative to Lytic/Medical Therapy in Acute Myocardial Infarction — SALAMI) started on 1 July 1997 and was completed in November 1998. It was confined to patients eligible for fibrinolysis within the RNSH catchment area. No inhospital deaths occurred in 102 patients.13 PCI became our standard treatment at RNSH for all patients with AMI. Subsequent outcomes for patients in a wide age range with virtually no exclusions have remained excellent,14 and much better than expected for the alternative strategy based on fibrinolysis/medical therapy. Despite these good outcomes, the SMH reported that there were concerns about the trial related to risks to participants and lack of fully informed consent. Consent The medical executive officer of a private hospital publicly articulated his concern about consent and was quoted in the SMH as saying: I think the lack of consent is a very fundamental issue of weakness in the trial. I think it is an abrogation of fundamental human rights. I can't imagine how they got it past their ethics committee. What they are saying is that the benefits justify them overlooking that basic human right. I don't know anybody who knew anything about ethics would agree with that.2 A subsequent editorial in the SMH emphasised that "patients should be informed totally about proposed treatments".15 Truog et al hold a different opinion, and maintain that blind insistence on consent can preclude evidence-based improvement in care of acute critical illness and can be viewed as harmful.16 We concur with their judgement. Truly informed consent is difficult to give in any trial, and particularly difficult for patients with an acute critical illness. There is little evidence that informed consent protects patients from exploitation in research. This is highlighted by patients' poor understanding of consent forms and the process of randomisation, even when these decisions apply to elective treatment.16 The understanding of consent has been examined for participants in the PARAGON-B and OASIS-2 studies (which investigated the use of platelet antagonists in unstable angina and non-Q-wave myocardial infarction). Understanding of the benefits of participation was good at 85%. However, only 35% of participants understood the risks and very few (10%) understood that there was an alternative to participation. Not surprisingly, pain was an adverse predictor for comprehension.17 In our proposed trial, pain would be an almost universal feature at the time informed-consent had to be given, and the need to administer reperfusion therapy as early as possible would not allow much time for the informed-consent process. Inevitably, comprehension would have been even worse than in the PARAGON-B and OASIS-2 studies.17 The difficulty with giving informed consent in our trial was illustrated by the articles in the SMH. The paper provided a reasonably accurate account of the trial in the first articles it published,1,2 but we doubt whether the editorialist (unsigned), writing three days later, understood the trial's purpose. Indeed, he/she questioned "why the trial is necessary at all".15 When customary informed consent cannot be obtained, one can choose from three options: Not to conduct the research For life-threatening conditions for which treatment is unsatisfactory not conducting research is unacceptable, as it may deny patients their right to optimal care.18 To change treatment without trial evidence Changing treatment without trial evidence might be applauded as "clinical innovation" and does not require ethics approval. There is virtually no protection of patients from even the most adventurous "clinical innovation".16 For the issues that were to be addressed by our trial, a change in treatment strategy would be based on comparisons between rather than within studies. Regardless of how compelling such comparisons may seem, the superiority of a treatment cannot be established without randomised, controlled trials.19 To have an ethics committee assume the responsibility of giving consent on behalf of patients. The best way to protect patients from exploitation in trials involving patients with acute critical illness is by getting an ethics committee to carefully scrutinise the protocol and agree to assume the responsibility of giving consent in the acute phase of the illness.16 Patients should then be fully informed about their participation and rights as soon as reasonably feasible. This approach is in complete accordance with Australian guidelines on the ethical conduct of research on humans,20 and was adopted for our trial. It was an important feature of our protocol that patients allocated at random to treatment at RNSH would be asked if they agreed to be taken there before the ambulance started its journey. A patient who declined would be taken to the local district hospital and receive standard care. We reject the assertion that they were to be "press-ganged".15 However, there is no pretence that it would have been feasible to obtain patients' truly informed consent. The SMH expressed the view that absence of informed consent in our trial might set "a dangerous precedent".2 This also has no foundation in fact. Proper research for the "Herald investigation" would have revealed that the first and best-known large-scale trial to document efficacy of fibrinolysis was conducted without informed consent. An institutional review board had found that informed consent could not be obtained in patients with AMI.21 Our trial would not have set any precedent. The risks of our trial An institutional ethics committee can not consider a trial unless the risk of the intervention under investigation is reasonable compared with that of existing therapy.22 According to the SMH our trial was a high-risk venture.15 One article stated "it is generally acknowledged by doctors that one in every four heart attack victims will die within the first hour if emergency treatment is not given".2 A cardiologist offered an estimate of what the delays might be: "I would want to know that I wasn't going to be delayed by two hours when I could have had thrombolytic agents in 10 minutes."2 Another cardiologist expressed similar concerns.3 We agree risks would be unacceptable if there were additional delays of two hours and a 25% mortality rate per hour. However, the implication that such risks would be imposed by our trial is not consistent with the facts. Patients with AMI tend not to seek help early, and typically arrive in hospital about two hours after the onset of symptoms.6,23 The pre-hospital cardiac arrests that do occur usually happen before arrival of an ambulance.23,24 New South Wales ambulances are equipped with defibrillators and ambulance officers can provide care for patients with cardiac arrest which is as good as or better than that provided by medically trained personnel.25 A reversible cardiac arrest can be safely dealt with during transport, a conclusion supported by experience with interhospital transfers of patients with AMI,26 including those at particularly high risk.27 It is very unlikely that any trial patient who had a reversible cardiac arrest during transport to RNSH would die. Let us also consider the alleged treatment delays of two hours versus 10 minutes. Transport of patients to district hospitals takes time and the median time to administration of fibrinolytics after patients arrive is up to 45 minutes.6,28 The only transport time difference that matters is that between transport within the catchment area of a district hospital and transport to RNSH. Data from direct transport to the RNSH trauma centre, by-passing district hospitals, show a mean difference of 20 minutes for the most remote area.29 This is less than the difference in in-hospital delays for patients with AMI who arrive within or outside normal working hours and are treated with PCI -- we cannot detect any adverse effects of these delays.14 In fact, outcomes for patients treated during either period are much better than expected for a treatment strategy based on fibrinolysis. Available evidence suggests that the overall risk for patients transported to RNSH is likely to be lower than the risk for patients taken to district hospitals and treated in accordance with established strategies. Lessons from the obstacles to the trial The results of the SALAMI pilot study (which was completed in 1998)13 satisfied the RNSH ethics committee's request for documentation of patient outcome. However, we were then asked to provide a response to complaints lodged with the Australian Federation of University Women Inc Northern Beaches Group, the NSW Health Care Complaints Commissioner, the Australian Medical Association, the NSW Director General of Health, local political leaders, community groups, the National Health and Medical Research Council (NHMRC), and the Cardiac Society of Australia and New Zealand. (Documentation relating to these complaints and our responses is available on request.) The Health Care Complaints Commissioner recommended that the trial be referred to the NSW State Ethics Committee. This committee referred the trial back to the RNSH ethics committee, with long delays occurring in the process. However, approval was eventually given. Complex practical arrangements for implementation of the trial were near completion when the SMH announced that the NSW Minister for Health had decided to refer the trial to "an area ethics committee yet to be formed, which would comply with National Health and Medical Research Council guidelines".2 We emphasise that the RNSH Human Research Ethics Committee had been constituted, and operated, strictly in accordance with NHMRC guidelines. It was also reported that the new ethics committee would meet "in the next few weeks".2 In reality, constitution of an ethics committee is a complex process, and more than four months passed before the new committee had its first meeting. Additional long delays have already occurred in processing our proposal completely, independently of the careful, lengthy deliberations of the original committee. The main concerns expressed by opponents of the trial related to the ethics of the trial, particularly its lack of fully informed consent. However, there are situations in which it is impossible to reconcile the doctrines of informed consent with the practical necessities of research, and depriving patients of the potential benefits of research can, in some circumstances, be considered unethical.22 The guidance for treatment and health policy, which the trial had the potential to provide, might have saved many lives. However, the trial was delayed because of the many complaints lodged about it, and it was ultimately stopped as a direct consequence of the SMH's investigation. The published investigation1,2 misrepresented the trial's rationale, risks and important ethical issues. The NSW Minister for Health acted on the information made available to him. He may have had little choice under the circumstances. However, the end result was that due process suffered. Conclusions In a democratic society, the Press has the right to investigate any issue it chooses, and individuals have the right to lodge complaints with any authority they see fit. However, these rights should come with a responsibility for accuracy and freedom from bias. Society now has a justified expectation of medical practice based on evidence, and processes are in place to ensure the ethical conduct of the necessary research to produce this evidence. These processes may be in need of protection from sensationalism based on suppositions rather than evidence and expertise. The establishment of ethics committees with guaranteed protection from interference, similar to the protection for courts, should be considered. References Ryle G. Radical heart attack fix under fire. The Sydney Morning Herald 2001; 29 March: 1. Ryle G. A trial of the heart. The Sydney Morning Herald 2001; 29 March: 11. Sydney radio station 2UE. Malcolm Elliott 10.10 am, 1 April 2001. Presenter discusses plans to divert emergency heart attack patients to Royal North Shore Hospital. Interview with Dr Ross Walker, Sydney Adventist Hospital. (Transcript available on request.) The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both, on coronary artery patency, ventricular function and survival after acute myocardial infarction. N Engl J Med 1993; 329: 1615-1622 Meijer A, Verheught FWA, Werter CJPJ, et al. Aspirin versus coumadin in the prevention of reocclusion and recurrent ischaemia after successful thrombolysis: a prospective placebo-controlled angiographic study. Circulation 1993; 87: 1524-1530. Rogers WJ, Canto JG, Barron HV, et al. For the Investigators in the National Registry of Myocardial Infarction. Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. J Am Coll Cardiol 2000; 35: 371-379. Gersh BJ. Primary angioplasty reduced rate of death, reinfarction or disabling stroke. Evidence-based Cardiovasc Med 1997; 1: 105-106. Every NR, Lehmann KG. The effectiveness of primary PTCA: does patient risk matter? J Am Coll Cardiol 2001; 37: 1836-1838. Every NR, Parsons LS, Hlatky M, et al. A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. Myocardial Infarction Triage and Intervention Investigators. N Engl J Med 1996; 335: 1253-1260. Magid DJ, Calonge BN, Rumsfeld JS, et al. Relation between hospital primary angioplasty volume and mortality for patients with acute MI treated with primary angioplasty vs thrombolytic therapy. JAMA 2000; 284: 3131-3138. The GUSTO-IIB angioplasty substudy investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activators for acute myocardial infarction. N Engl J Med 1997; 336: 1621-1628. Zahn R, Schiele R, Schneider S, et al. Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? J Am Coll Cardiol 2001; 37: 1827-1835. Hansen PS, Rasmussen HH, Vinen J, Nelson GIC. A primary stenting strategy as an alternative to fibrinolytic therapy in acute myocardial infarction. Med J Aust 1999; 170: 537-540. Koyama Y, Hansen PS, Rasmussen HH, Nelson GIC. August 2001. What are the delays in primary infarct angioplasty when performed after hours and do they influence outcomes? Presented at the 49th Annual Scientific Meeting of the Cardiac Society of Australia and New Zealand. Aust N Z J Med. Abstract. In press. Medicine on trial. Editorial. The Sydney Morning Herald 2001; 2 April: 12. Truog RD, Robinson W, Randolph A, Morris A. Is informed consent always necessary for randomized, controlled trials? N Engl J Med 1999; 340: 804-807. Kucia AM, Horowitz JD. Is informed consent to clinical trials an "upside selective" process in acute coronary syndromes? Am Heart J 2000; 140: 94-97. Grim PS, Singer PA, Gramelspacher GP, et al. Informed consent in emergency research. Prehospital thrombolytic therapy for acute myocardial infarction. JAMA 1989; 262: 252-255. White HD. Thrombolytic therapy in the elderly [editorial]. Lancet 2000; 356: 2028-2030. National Health and Medical Research Council. National Statement on Ethical Conduct in Research Involving Humans. Canberra: NHMRC, 1999: 28-29. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Lancet 1986: 1: 397-401. Foëx BA. The problem of informed consent in emergency medicine research. Emerg Med J 2001; 18: 198-204. Holmberg M, Holmberg S, Herlitz J, Gardlov B, for the Swedish Cardiac Arrest Society. Survival after cardiac arrest outside hospital in Sweden. Resuscitation 1998; 36: 29-36. Norris RM, on behalf of the United Kingdom Heart Attack Study Collaborative Group. Fatality outside hospital from acute coronary events in three British health districts 1994-5. BMJ 1998; 316: 1065-1070. Holmberg M, Holmberg S, Herlitz J, for the Swedish Cardiac Arrest Society. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J 2001; 22: 511-519. Widimsky P, Groch L, Zelizko M, et al. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study. Eur Heart J 2000; 21: 823-831. Straumann E, Yoon S, Naegli B, et al. Hospital transfer for primary coronary angioplasty in high risk patients with acute myocardial infarction. Heart 1999; 82: 415-419. Thiemann DR, Coresh J, Schulman SP, et al. Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000; 101: 2239-2246. Harris R. Forget the golden hour. Proceedings of the First International Conference of the Australasian-Canadian Trauma Society, Darling Harbour, Sydney; March 2001. Abstract. Injury. In press. (Received 25 Jun, accepted 10 Oct, 2001) Authors' details Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW. Helge H Rasmussen, FRACP, DMSc, Professor of Cardiology, Department of Medicine, University of Sydney; Peter S Hansen, FRACP, PhD, Senior Lecturer, Department of Medicine, University of Sydney; Yutaka Koyama, MD, PhD, Interventional Fellow; Gregory I C Nelson, MB BS, FRACP, Director, Cardiac Catheterisation Laboratory, and Coronary Care Unit. Ambulance Service of New South Wales, Sydney, NSW. Barbara-Ann Adelstein, MB BCh, MBA, Medical Director. Anthony J O'Connell, FANZCA, FFICANZCA, Chairman, Medical Advisory Committee, Ambulance Service of NSW. Reprints will not be available from the authors. Correspondence: Professor H H Rasmussen, Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW 2065. helgerATmed.usyd.edu.au Make a comment Flow diagram of the proposed trial of two models of care for patients with acute myocardial infraction. Back to text

Helge H Rasmussen · Peter S Hansen · Yutaka Koyama · Anthony J O'Connell

Medicine and the media Media milking of sacred cows: a heart-stopping tale Were there alternative frames that could have attracted journalistic interest in this trial? MJA 2001; 175: 629-630 In 1897, William Osler advised doctors not to "toy with the Delilah of the press".1 Despite researchers being generally delighted with journalists' translations of their work into news2 (few would disagree with Mae West that it's better to be looked over than overlooked), Osler's counsel sadly retains widespread support in the health professions. For too many, journalists spell trouble. Some who have been bruised by what they consider trite, sensationalised or misleading news reports of their research assume that journalists are mere ciphers for doctors and scientists, providing a sort of popular scientific abstracting service which is falling down in its duty. While the news media may be an arm of the health service in some countries, they play an entirely different role in open societies like Australia. Here, facts frequently serve as pretexts to publish richly subtextual moral tales intended to resonate with readers, retain their loyalty and, in expanding readership, attract greater advertising revenue. Journalists' routines are governed by ambitions to get on the front page and break "exclusive" news that will ripple for days through their rival's news media. When this ambition dovetails with public health and the wider public interest, most are happy to applaud the media as a highly influential force for good. But, when popular news frames are invoked to negatively frame potential advances in patient care or public health, the media can be a powerfully conservative force that can damn progress. Almost by definition, people in the midst of life-threatening medical emergencies, who may be unconscious, in shock, in extreme pain or delirious, surrender their normal sentient ability to consent. Health and medicine are rich with news value.3 Doctors are cast by the news media in many roles:4 for example, as medical miracle workers;5 as sages interpreting issues of contemporary morality; as intrepid, no-stone-unturned disease detectives;6 or as entrepreneurs. Rasmussen and colleagues, who describe their experience with the media in this issue of the Journal,7 perceived their role as just trying to save the lives of patients with acute myocardial infarction (AMI). They aimed to compare the outcomes of transporting patients with AMI to a large centre with facilities for angioplasty and stenting with the conventional wisdom of rushing them to the nearest hospital for standard treatment. These researchers were following the long tradition of those who have sought to improve survival rates through a randomised controlled trial. But reporter Gerald Ryle and his editors at the Sydney Morning Herald judged other news frames to be more compelling. They chose to see the story as one of doctors who, "believing their own omnipotence", "press-ganged" vulnerable people into some dangerous and radical "experiment".8,9 Ryle's reports,8,10 the Herald's editorial,9 and their sequelae voiced by radio commentators, framed the trial as an example of arrogant doctors dicing with patients' lives. The main ingredients of the "story" were the notions that two inviolable conventions were being trampled underfoot. Blind Freddy — or the Herald's editorial writer — knows that transporting a person having an infarct to the nearest hospital without delay, and obtaining patient consent to treatment, are sacrosanct. The transportation issue taps into the same ordinary person's outrage when a local hospital is closed, and politicians explain that patients are better served by travelling the extra distance to a larger hospital. In criticisms of this aspect of the trial, the important question of whether patients might actually benefit by travelling the extra distance was lost. Both the righteous indignation of the accusations that patient consent to involvement in the trial would not be obtained, and the restrained dissection by Rasmussen et al of the folly of that indignation, will cause many heads to shake in disbelief. Almost by definition, people in the midst of life-threatening medical emergencies, who may be unconscious, in shock, in extreme pain or delirious, surrender their normal sentient ability to consent. To describe this as being "press-ganged" was sure to produce popular outrage. Were there alternative frames that could have just as easily attracted journalistic interest in this trial? Opposition had often been voiced in local newspapers, because of implications for local hospitals of the trial's possible success. If it showed important patient benefit, local coronary care facilities may have been downgraded, with all the downstream implications. "Doctors seek to stop life saving heart trial", with an investigation of the motives and interests of local opposition to the trial, might have been another headline that defined the same events with rather different outcomes. Alan Otten, with the Wall Street Journal for 44 years, notes that "Well done investigative reporting produces public outrage . . . Ten-thousand-watt klieg lights turned on a situation focuses the minds of policy makers very fast."11 Ryle's front-page arc lights precipitated ministerial intervention, stopping a trial that may have led to many lives being saved. The sacred cow of the shortest possible ambulance ride remains intact, as presumably does the despair of those hoping to use research to find ways of improving survival rates after AMI. The history of medicine is full of tumultuous episodes where accepted procedures were challenged by innovators and where the orthodoxy stood to lose from the change.12 This episode adds to that litany, but hopefully will not jaundice what is so often a mutually productive relationship between medicine and the media. Simon Chapman Professor, Department of Public Health and Community Medicine University of Sydney, Sydney, NSW Competing interests: None declared. Osler W. Internal medicine as a vocation. [Address given at the New York Academy of medicine, October 19, 1897.] Reprinted in McGovern JP, Roland CG, editors. The collected essays of Sir William Osler, vol. II. Birmingham, AL: Classics of Medicine Library; 1985: 151. Phillips DP, Kanter EJ, Bednarczyk B, Tastad PL. Importance of the lay press in the transmission of medical knowledge to the scientific community. N Engl J Med 1991; 325: 1179-1183. Lupton D. Medical and health stories on the Sydney Morning Herald's front page. Aust N Z J Public Health 1995; 19: 501-508. Lupton D, McLean J. Representing doctors: discourses and images in the Australian press. Soc Sci Med 1998; 46: 947-958. Lupton D, Chapman S. Death of a heart surgeon: some thoughts about press accounts of the murder of Victor Chang. BMJ 1991; 303: 1583-1586. Brown J, Chapman S, Lupton D. Infinitesimal risk as public health crisis: media coverage of a doctor to patient HIV contact tracing investigation. Soc Sci Med 1996; 43: 1685-1695. Rasmussen HH, Hansen PS, Koyama Y, et al. Trial of a trial by media. Med J Aust 2001; 175: 625-628. Ryle G. Radical heart attack fix under fire. Sydney Morning Herald 2001; 29 March: 1. Medicine on trial [editorial]. Sydney Morning Herald 2001; 2 April: 12. Ryle G. A trial of the heart. Sydney Morning Herald 2001; 29 March: 11. Otten AL. The influence of the mass media on health policy. Health Affairs 1992; Winter: 111-118. Porter R. The greatest benefit to mankind. A medical history of humanity from antiquity to the present. London: Fontana,1999 . Make a comment

Simon Chapman

Medicine and the media Clinical research in the emergency setting: the role of ethics committees It is important that discussions and decision-making processes be free, open and transparent MJA 2001; 175: 630-631 Probably because of its mixed history of triumph and abuse, medical research has always been regarded with a combination of awe and suspicion. Not surprisingly, research into innovative technologies and dangerous illnesses arouses particular anxieties, and sometimes public controversy. The complexities associated with clinical research in the emergency setting are illustrated by the story recounted in this issue of the Journal of the trial proposed by investigators at Sydney's Royal North Shore Hospital (RNSH) to compare two models of care for patients with acute myocardial infarction (AMI).1 While fibrinolysis has been standard treatment for AMI since the mid-1980s, evidence has suggested that coronary artery angioplasty with stenting produces better outcomes. However, the latter treatment requires advanced technology and skills, limiting its availability. Accordingly, it was proposed to conduct a randomised trial to compare outcomes for patients with AMI of transport to the nearest regional hospital for "conventional" treatment versus transport to RNSH for possible angioplasty. . . . the scientific questions are well founded and the answers are likely to carry significant implications for medical practice around the world. Two major issues were recognised from the outset: Patients assigned to RNSH would often experience increased transport times to hospital; and It would be difficult to obtain patients' fully informed consent. The first issue is important because delays in initiating treatment after AMI increase the risk of death. The second issue of difficulty obtaining informed consent is encountered in research involving interventions for acute, life-threatening illness, because of shortness of time and the inevitable stress associated with the life-threatening circumstances. Both these issues were taken up by the RNSH ethics committee that meticulously examined the study. After examination of preliminary data, the committee accepted the arguments of the investigators that the benefits of stenting would exceed any increased risk associated with transport delays. It was also decided that it was acceptable to delay provision of detailed information about the trial until the patients arrived at RNSH, even though, in reality, this would often exclude alternatives. Despite complaints provoked by concern within the medical community, approval was eventually granted, but before the trial could begin the Sydney Morning Herald published an article questioning this decision.2 A storm of publicity followed and, months later, the trial has still not commenced. There are several points raised by this case on which there is widespread agreement. In the emergency setting, as elsewhere, rigorous testing is important to identify the most effective treatments and to exclude ineffective, risky or unnecessarily expensive ones. However, the gravity and urgency of the circumstances will often limit the extent to which patients can make carefully considered judgements about whether to participate. Often compromises need to be found. It is the sometimes unenviable job of the responsible ethics committee to attempt to find such a compromise, after considering all the issues and balancing possible risks and benefits. In this case, the scientific questions are well founded and the answers are likely to carry significant implications for medical practice around the world. However, whatever decision is ultimately reached it is unlikely to find acceptance by all protagonists. The complexity of the issues emphasises the importance of the ethics committee process. As with the courts, public confidence in the outcome of ethics committee deliberations depends on a belief that it is fair, free from interference and takes into account all relevant issues. The RNSH ethics committee appears to have acted with propriety and professionalism, but, like other ethics committees, its deliberations are not open to public scrutiny. In addition, it is possible that it did not consider issues affecting other hospitals within the region — for example, the interests of private providers of angioplasty and their patients who could be disadvantaged by the study. The absence of the need to justify decisions in contentious cases, and of a defined appeals process for most committees, creates an appearance of arbitrariness and peremptoriness. The role of the media, which the investigators found so disturbing here, also raises important issues. Medical research is a matter of public interest, and ethics review is not a mere technical function, but a means by which the community ensures that research proposals are adequately evaluated and supervised. Press coverage may be of variable quality, and may itself represent undeclared vested interests. However, as cumbersome and inconvenient as the process may be, if a study has sufficient merit and the review process has been sufficiently robust it is unlikely that public debate and critical reflection will ultimately prevent it from proceeding. This imbroglio provides several important lessons. There are no short cuts to the solution of difficult ethical problems and complete consensus may never be possible. What is most important is that discussions and decision-making processes be free, open and transparent. For these reasons, the tendency for ethics committees to keep their deliberations secret, in the mistaken belief that this is necessary to protect intellectual property, should be reassessed. Promising new models for ensuring public accountability and sharing of experience of committee processes should be examined, such as open access to meetings, chat rooms and the concept of the health ethics archive.3,4 In addition, care must be taken to ensure that current efforts to streamline ethics review processes in the interests of cost and efficiency do not erode the democratic, decentralised nature of the system. In the case of the RNSH trial of treatment for AMI, the investigators should be encouraged to continue dialogue with their interlocutors until the best possible compromise can be reached. Paul A Komesaroff Director, Monash Centre for the Study of Ethics in Medicine and Society Melbourne, VIC Competing interests: None declared. Rasmussen HH, Hansen PS, Koyama Y, et al. Trial of a trial by media. Med J Aust 2001; 175: 625-628. Ryle G. A trial of the heart. Sydney Morning Herald 2001; 29 March: 11. The Institutional Review Board — discussion and news forum. <http://www.irbforum.org> (accessed November 2001). Health Ethics Archive. <http://www.ethics-archive.org> (accessed November 2001). Make a comment

Paul A Komesaroff

Fitness and fads The epidemiology of dog walking: an unmet need for human and canine health Adrian E Bauman, Schroeder J Russell, Susan E Furber and Annette J Dobson MJA 2001; 175: 632-634 Abstract - Main findings - Further interpretation using DogEpi concepts - Authors' details - - More articles on Psychiatry Abstract Objective: To describe the prevalence of dog walking in New South Wales, and to identify potential health gains if more dogs were walked. Design: Cross-sectional analytical survey. Setting and participants: 894 adults in NSW in 1998 (among the owners of approximately two million domestic dogs in NSW who were potential participants in dog-walking behaviours). Interventions: None yet. Main outcome measures: Dog walking hours per week; other DogEpi concepts to illustrate the public health gains include the DAF (dog attributable fraction), and the BBR (benefits to bites ratio). Results: The response rate to the survey was 74%. 46% of households in NSW had a dog and, overall, dog owners walked 18 minutes per week more than non-dog owners. However, more than half of dog owners did not walk their dogs, and were less likely than non-owners to meet recommended levels of physical activity sufficient for health benefits. If all dog owners walked their dogs, substantial disease prevention and healthcare cost savings of $175 million per year might accrue. Conclusions: There are potential benefits of dog walking for human health; currently, among dog owners, much of this benefit remains to be realised. There are also likely benefits for canine health. Dog walking should be promoted through national strategies recommending "Walkies for all by the year 2010". About half of all homes in Australia have a pet, with dogs being the most prevalent, reported in about 40% of all households; these rates are similar to United States estimates for dog ownership.1,2 Although most dogs are loved and well cared for by their owners, a key question is whether dogs might improve human health. The notion that dogs might promote good health has been explored elsewhere, with studies of the psychological companionship and supportive role of dogs, and the use of "dogs as therapy" for older, institutionalised adults.3,4 Other, small-scale studies have associated dog ownership with lower blood pressure, or even reduced re-infarction rates, among people with coronary heart disease.5,6 One area which has been less studied is the concept of dog walking, which provides physical activity for both dogs and people. Some surveys have proposed that people who own dogs are more active than those who do not,5,7 although this is not always the case.2,8 Nonetheless, this area has received much less attention than other pet-related research. This article focuses on the epidemiology of dog walking, which generally has been ignawed by researchers, and eschewed by epidemiologists. Hence this report cuts to the bone and unleashes an incisive public health argument for increasing dog walking in Australia. The primary research question was whether dog owners were more active than non-dog owners. In addition, the potential benefits of increased dog walking were estimated, using innovative DogEpi concepts. Methods This study was based on two population-based physical activity surveys carried out in New South Wales in March and November 1998.9 Respondents were adults, randomly sampled from the Electronic White Pages. Questions were asked about dog ownership, and the amount of time the respondent had spent walking his or her dog in the previous week. Standard physical activity questions about walking and moderate and vigorous physical activity in the previous week were also asked.10 The study variables were total time engaged in dog walking, any walking and total physical activity. Respondents were considered to have achieved "recommended levels of physical activity" for health benefit (150 minutes of at least moderate activity a week), based on the US Surgeon General's report.11 Analyses were carried out with SPSS,12 and included bivariate comparisons of proportions and means, and adjusted odds ratios using forced-entry logistic regression models to adjust for possible confounders. Results Main findings Of the 1208 adults approached, 894 (74%) responded. They were aged 25-64 years, with a mean age of 44.4 years (95% CI, 43.9-44.9 years). Almost half (45.6%) were male, 75% were married or had a partner, and 28% reported some tertiary education. Overall, 47.1% achieved the US Surgeon General's recommended 150 minutes of total physical activity per week, and 27% achieved this only through walking. About 46% of the sample reported that they had a dog at home. Among dog owners, the mean reported time allocated specifically for dog walking each week was 0.95 hours (95% CI, 0.77-1.13 hours per week), which was less than half of the average of two hours in total from all types of walking reported by dog owners each week (see Box). Among dog owners, 59% reported no dog walking, 26% reported up to 2.5 hours per week, and 15% reported at least 2.5 hours per week. The Box shows the mean time spent in physical activity according to dog ownership status. Those who owned dogs walked only 0.3 hours (about 18 minutes) more per week than non dog-owners. However, those who owned dogs and walked them less than one hour per week walked less, in total, than non dog owners (P = 0.01). Only those who walked their dogs for more than an hour per week walked significantly more or were significantly more active in total than non dog-owners. Further, the median number of walking sessions per week was 3.0 for both dog owners and non-owners (P = 0.98). All dog-walker categories were slightly less likely to reach the 150 minute per week "health-enhancing" threshold, except for those who walked their dogs for 2.5 hours. For overall physical activity, similar proportions of owners and non-owners achieved 150 minutes of total activity per week (46.9% and 47.3%, respectively), and dog owners who did not walk their dogs were significantly less likely to meet the guidelines. Only those who walked their dogs for at least an hour a week were more likely (odds ratio, 1.89) than non-owners to achieve sufficient physical activity for health benefits (Box). Further interpretation using DogEpi concepts This section describes innovative interspecies epidemiological approaches to understanding the data. DogEpi concepts are not meant to hound researchers, nor meant to be a golden (standard) retriever of epidemiological wisdom, but they are descended from the litter of current epidemiological thought, some of which is scatological. Firstly, the notion of dog walking to total walking ratio (DWTWR) and dog walking to total physical activity ratio (DWTPAR). The DWTWR, which is the percentage of all walking that was dog walking, was 22.9%. For 12% of the population, dog walking was half of their total walking. As a percentage of all physical activity, the DWTPAR was 13%, with 9% of the population doing at least half their total activity as dog walking. More important is the DAF (dog attributable fraction), which is an epidemiological estimate of the proportion of disease which might be prevented if all of the dog owners walked their dogs for at least 150 minutes per week. If this occurred, the population prevalence of sufficient physical activity would increase from 47% to 71%. Such an increase in physical activity would be about 5-10 times as great as most population-level interventions designed to promote activity.9 From this level of change in dog walking, and assuming a population-attributable risk of 18% for physical inactivity and coronary heart disease (CHD),13 it can be estimated that the maximal DAFcardiovascular is about 9% of the total burden of CHD. Other estimates of the DAF for diabetes and colon cancer, along with other health benefits of being active, including reduced doctor visits and medication costs, could be estimated in addition to this cardiovascular DAF. Direct healthcare cost savings can be estimated for specific increases in physical activity levels.13 A conservative estimate suggested that A$36 million might be saved annually for coronary heart disease for every 5% increase in the prevalence of adults who are "sufficiently active".13 Thus, if all dog owners walked their dogs more, this would be a 24% increase, resulting in direct healthcare cost savings of around $175 million per year. These savings would accrue rapidly, as cardiovascular risk reduction occurs sooner following the initiation of physical activity than after smoking cessation or dietary change.14 Nonetheless, it is important to calculate the other benefits and also the potential adverse effects and costs of keeping dogs as pets in Australia. The benefits of mental health improvement and stress reduction may be considerable, but are not used here in order to provide a conservative estimate of overall dog benefit. The adverse effects include the risks of zoonoses, but these are low. One public health issue is dog bites, which are estimated to cost $1.5 million in Victoria in direct healthcare costs.15 This is clearly an overestimate for the risks of dog walking, as only a quarter of dog bites occur in open space, roads or paths.16 However, we can use this overestimate to calculate a preliminary population health benefits to bites ratio (BBR) for the increased risk of dog bites and the risk reduction for heart disease to estmate the potential benefits versus risks of dog walking. We find that, even if only half of dog owners increased their dog walking to 150 minutes per week, then the resulting national savings of $87.5 million, divided by national dog bite costs of around $7 million, would give a very favourable cost benefit to bites ratio. Discussion In general, dog owners are not more active than non-owners, unless they practise regular, sustained dog walking. This article identifies the human health benefits of dog walking, and points to the need to encourage those with dogs to walk them more. It is possible that adults in the household other than the survey respondent also contributed to the time dogs are walked, so, from the canine perspective, our data could be an underestimate. Nonetheless, it would be a useful health-promotion strategy for inactive non-dog owners to acquire a dog in order to initiate regular moderate walking. There are reciprocal benefits for canine health -- from the dog's perspective, the amount walked is generally "never enough". This may be one way in which dog and human health might be improved, providing a biologically plausible explanation for the xeno-transmission of mortality gradients shared between pets and their owners, and described recently in the British Medical Journal.17Dog walking is an important potential benefit of dog ownership. As about half of adult Australians are physically inactive, and the public health benefits of being active are comparable to those of smoking cessation,18 dog walking should become widely recommended by human and canine health advocates alike. We should paws then, put our best feet forward, and take "man's best friend" for a walk more often. We advocate a campaign to promote "Walkies for all by the year 2010". Acknowledgements We thank NSW Health for data collection. Competing interests None declared. References Beck AM, Meyers NM. Health enhancement and companion animal ownership. Ann Rev Public Health 1996; 17: 247-257. Headey B. Health benefits and health cost savings due to pets: preliminary estimates from an Australian national survey. Soc Indicat Res 1999; 47: 233-243. Robb S, Stegman CE. Companion animals and elderly people — a challenge for the evaluation of social support. Gerontologist 1983; 23: 277-282. Francis GM, Turner J, Johnson S. Domestic animal visitation as therapy with adult home residents. Int J Nurs Stud 1985; 22: 201-206. Anderson WP, Reid CM, Jennings GL. Pet ownership and risk factors for cardiovascular disease. Med J. Aust 1992; 157: 298-301. Friedmann E, Thomas SA. Pet ownership, social support and one year survival after acute myocardial infarction in the Cardiac Arrhythmia Suppression Trial (CAST). Am J Cardiol 1995; 76: 1213-1217. Serpell J. Beneficial effects of pet ownership on some aspects of human health and behaviour. J Roy Soc Med 1991; 84: 717-720. Simons LA, McCallum J, Simons J. Pet ownership and future health. Med J Aust 1997; 167: 231-232. Bauman AE, Bellew B, Owen N, Vita P. Impact of an Australian mass media campaign targeting physical activity in 1998. Am J Prevent Med 2001; 21: 41-47. Armstrong T, Bauman A, Davies J. Physical activity patterns of Australian adults (AIHW Catalogue No. CVD 10). Canberra: Australian Institute of Health and Welfare, 2000. US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Washington DC: Department of Health and Human Services, Centers for Disease Control and Prevention, 1996. Statistical package for the social sciences [computer program]. Version 10. Chicago, Ill.: SPSS Inc, 2000. Stephenson J, Bauman A, Armstrong T, et al. The costs of illness attributable to physical inactivity. Canberra: Commonwealth Department of Health, 2000. Blair SN, Kohl HW III, Barlow CE, et al. Changes in physical fitness and all cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995; 273: 1093-1098. Watson W, Ozanne-Smith J. The cost of injury to Victoria. Report No. 124. Melbourne: Monash University Accident Research Centre, 1997. Ashby K. Dog bites. Hazard no. 26. Victorian Injury Surveillance System. Melbourne: Monash University Accident Research Centre, 1996: 7-13. Moloo J, Waller JL, McKeown RE, et al. Xenotransmission of the socioeconomic gradient in health? A population based study. BMJ 1998; 317: 1686-1686. Mathers C, Vos T, Stevenson C. Burden of disease and injury in Australia. (AIHW Catalogue no. PHE 17). Canberra: Australian Institute of Health and Welfare, November 1999. (Received 15 Oct, accepted 2 Nov, 2001) Authors' details School of Public Health and Community Medicine, University of NSW, Sydney, NSW. Adrian E Bauman, PhD, FAFPHM, Professor of Public Health; Susan E Furber, PhD, Senior Lecturer. Strathfield, NSW. Schroeder J Russell, Canine Walking Advocate. School of Population Health, University of Queensland, Herston, QLD. Annette J Dobson, PhD, Professor of Biostatistics. Reprints: Professor A E Bauman, Epidemiology Unit, Hugh Jardine Building, Locked Mail Bag 7017, Liverpool BC 1871, NSW. Make a comment Walking and total physical activity time, and percentages meeting recommended physical activity levels, according to dog ownership and dog-walking status Total hours Achieved 150 minutes per week Category Number Walked per week (mean [95% CI]) Physical activity per week (mean [95% CI]) By walking only By total physical activity Adjusted odds ratio†(95% CI) Non-dog owner 484 1.7 (1.4-1.8) 3.3 (2.9-3.6) 121 (25.1%) 229 (47.3%) 1.0 (reference) Dog owner* 410 2.0 (1.8-2.2) 3.5 (3.1-3.8) 105 (29.7%) 191 (46.9%) 0.95 (0.72-1.23) Does not walk dog Walks dog up to 1 h/week Walks dog 1-2.5 h/week Walks dog > 2.5 h/week 240 33 73 61 1.3 (1.0-1.5) 1.3 (0.9-1.7) 2.2 (1.8-2.5) 5.0 (4.3-5.6) 2.5 (2.0-3.0) 1.9 (1.3-2.5) 4.1 (3.4- 4.8) 7.0 (6.0-8.1) 39 (16.3%) 5 (15.2%) 16 (21.9%) 45 (100%) 76 (31.7%) 9 (27.3%) 45 (61.6%) 61 (100%) 0.55 (0.39-0.77) 0.45 (0.2-1.01) 1.89 (1.1-3.1) n/a * Data on dog-walking time were missing for three dog owners. † Odds ratios for meeting the recommended physical activity guidelines, adjusted for age, sex, education, marital status. n/a = not available. Back to text

Adrian E Bauman · Schroeder J Russell · Susan E Furber · Annette J Dobson

Fitness and fads Estimating historical changes in physical activity levels Garry J Egger, Neeltje Vogels and Klaas R Westerterp MJA 2001; 175: 635-636 Abstract - Methods - Results - Discussion - References - Authors' details - - More articles on Psychiatry Abstract Objective: To compare activity levels between a simulated "historical" lifestyle and a "modern" lifestyle to try to validate earlier estimates of secular changes in activity. Design: Triaxial accelerometers (TRACMORs) were used to measure activity levels in a "historical" group of seven male actors who were paid to live like early Australian settlers at a theme park north of Sydney (eg, minimising the use of modern technology) for a week. Results were compared with those from a group of seven "modern" sedentary office workers. Results: Activity levels were up to 2.3 times greater in the historical group than the modern group. Calculations based on body weight and energy expenditure suggest the difference is the equivalent of walking up to 16 km per day more in the past than today. Conclusions: These findings accord with two previous estimates of changes in daily activity levels over time and suggest that recent public health guidelines for increasing physical activity may be inadequate. An inactive lifestyle has been linked to a range of diseases, many of which are mediated through obesity.1 Intuitively, it seems apparent that average activity levels have decreased with modern industrial development and have mirrored the worldwide rise in obesity. Proxy measures of inactivity, such as the sale of motor vehicles and television viewing time, show a clear relationship to the development of obesity in the presence of a declining food intake. For this reason, some obesity experts suggest that the modern phase of the obesity epidemic (from 1980 onwards) is probably mediated more by inactivity ("sloth") than overconsumption ("gluttony"). However, the quantitative dimensions of a change in physical activity are difficult to estimate.2 If they could be (even roughly) determined, they might provide valuable information against which to assess modern physical activity guidelines for weight loss and maintenance. A "back of an envelope" calculation suggested an average decline in energy expenditure in the United Kingdom from the years after World War II to 1995 of around 800 kcal/d.3 At an energy cost of around 50 kcal/km for a 70 kg man,4 this suggests a decline in activity levels equivalent to walking about 16 km less per day. More recently, a comparison of activity levels of hunter-gatherer populations with those of individuals in modern Western societies suggested that the average daily difference may be equivalent to walking about 19 km.5 In an attempt to validate these estimates, we recently mocked up a small experiment for a lifestyle television production (Burke's Backyard). Our experiment was designed to compare activity patterns in Australian settlers of 150 years ago with modern-day sedentary office workers. We then attempted to calculate differences in terms of distance walked daily to compare with the previous estimates. Methods Movement levels were monitored in two groups of men by use of a triaxial accelerometer (TRACMOR, Maastricht University, Maastricht, the Netherlands) worn around the waist during waking hours. This has recently been validated against doubly-labelled water,6 and is regarded as one of the most sophisticated modern ambulatory measurement monitors. The device measures movement in activity units on three axes (forwards, sidewards and upwards), and includes even relatively minor movements such as fidgeting and upper-body actions. Seven male actors aged 30-60 years who work at "Old Sydney Town", a historic theme park north of Sydney set around the early 19th century, were selected to represent a historically active group. The men are paid to play the role of early Australian soldiers, convicts and settlers for about eight hours every day. They agreed to wear a TRACMOR during waking hours for one week, and were asked to avoid the use of modern technology as much as possible when they were not working at the park during the week. In an attempt to further authenticate this process, five of the men lived on the premises in convict huts for up to four days and nights. A second group of seven male modern sedentary workers, aged 30-60 years, including accountants, information technology personnel, doctors, a taxi driver and an entertainer, were also given TRACMORs to wear during waking hours, and were asked to continue their normal lifestyle over the course of a week. All records were downloaded into a computer program developed by the developers of the TRACMOR at Maastricht University in the Netherlands for analysis of results. Results The mean activity level (arbitrary units) for the historical group was 88 533 (95% CI, 33 697-143 369; range, 62 204-129 924), compared with 54 920 (95% CI, 32 019-77 821; range, 38 322-70 399). Thus, the historical group were on average 1.6 times more active than the modern group. However, the task was taken more seriously by some in the historical group than others (eg, some still used cars and televisions to some extent during the week). Hence, the two main outliers in the group, who kept rigidly to the experimental requirements, may provide a better reference point for calculations. These two individuals (with activity levels of 129 924 and 125 800 units) were 2.3 times more active than the modern group. Using estimates derived from energy expenditure tables (see Box), it was calculated that the difference in activity levels between the means of the two groups was equivalent to walking about 8 km per day. However, when the two outliers in the historical group were compared with the mean of the modern group, the difference was equivalent to walking about 16 km per day. Discussion A difference in daily activity levels equivalent to walking 8-16 km per day between previous and modern times represents a huge secular change in daily energy expenditure. At the upper level, this coincides roughly with previous estimates.3,5 It probably also accords with the levels of movement required for foraging for survival throughout most of human evolution. Anthropological evidence suggests that early humans, like modern hunter-gathers, may have transported tools, weapons and game over a daily range of about 15 km.8 Given their other daily tasks, this would have added up to a substantial daily energy use which was rarely, if ever, likely to be exceeded by food intake over an extended period, thus reducing the chances of energy imbalance. As a result, human populations, up until the past 2-3 decades, have not been significantly overweight. The growth of time-saving and time-using technologies,9 however, means that these activity levels are unlikely ever to be reached without conscious effort. In the presence of an abundant (and energy-dense) food supply, obesity, at least at the population level, is almost an inevitable consequence of modernisation. More telling are the implications this has for physical activity recommendations for optimal health and weight management. Recent government recommendations suggest an added daily energy requirement of 30 minutes of accumulated mild- to moderate-intensity activity.10,11 However, for a 96 kg sedentary office worker, such as in this study, this would account for perhaps an extra 200 kcal/d, which is 300-800 kcal (the equivalent of walking 5-13 km) short of the 500-1000 kcal difference estimated here. These findings support the suggestion that, if the evolutionary perspective (which has dominated almost all of human existence) is indicative of requirements for optimal health, an increase in activity levels up to three times those recommended in modern guidelines may be necessary.5 Supporting this, data from the United States Weight Control Registry, a database of people who have lost more than 14 kg and maintained this for at least five years, have shown that people who achieve the greatest benefits are consciously active for up to 80 minutes a day.12 This is about three times greater than current recommendations.10,11 These figures are based on people who have been previously obese, and maintenance of weight loss may be more difficult than prevention of weight gain. Nevertheless, it is an awesome task, in the absence of a major environmental change, to expect these activity levels to be met in our society. The figures presented in this study should be interpreted with caution. Although we used a validated modern movement-sensing device,13 the results involve only small numbers under artificial conditions. In their present form, they merely add support to other attempts to calculate human activity levels over time and provide an indication of the activity requirements needed to correct these secular changes. References Powell KE, Blair SN. The public health burdens of sedentary living habits: theoretical but realistic estimates. Med Sci Sports Exerc 1994; 26: 851-856. Prentice A, Jebb S. Obesity in Britain: Gluttony or sloth? BMJ 1995; 311: 437-439. James WPT. A public health approach to the problem of obesity. Int J Obes Relat Metab Disord 1995; 19: S37-S45. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 2000; 32 (9 Suppl): S498-504. Cordain L, Gotshall RW, Eaton SB. Physical activity, energy expenditure and fitness: an evolutionary perspective. Int J Sports Med 1998; 9: 328-335. Bouton C, Verboeket-van de Venne WP, Westerterp KR. Physical activity assessment: comparison between movement registration and doubly labelled water. J Appl Physiol 1996; 81: 1019-1026. Movahedi A. Simple formula for calculating basal energy expenditure. Nutr Res 1999; 19: 989-995. Gowlett J. Mental abilities of early man: a look at some hard evidence. In Foley R, editor. Hominoid Evolution and Community Ecology. New York: Academic Press, 1984; 167-192. Bowden S, Offer A. Household appliances and the use of time: the United States and Britain since the 1920s. Econ Hist Rev 1994; XLVII: 725-748. United States Surgeon General. Physical activity and health: a report of the Surgeon General. US Department of Health and Human Services. Atlanta: Centers for Disease Control, 1996. Egger G. National physical activity guidelines for Australians: scientific background report. Canberra: Commonwealth Department of Health and Aged Care, 1999. Klem ML, Wing RR, McGuire MT, et al. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997; 66: 239-246. Westerterp K. Pattern and intensity of physical activity. Nature 2001; 410: 539. (Received 25 Sep, accepted 22 Oct, 2001) Authors' details Deakin University, Melbourne, VIC, and GutBusters Pty Ltd, Sydney, NSW. Garry J Egger, MPH, PhD Adjunct Professor of Health Sciences. Masstricht University, The Netherlands. Neeltje Vogels, BBiolSc Student; Klaas R Westerterp, PhD, Professor of Human Energetics, Department of Biological Sciences. Reprints will not be available from the authors. Correspondence: Professor G J Egger, PO Box 313, Balgowlah, NSW 2094. eggergjATozemail.com.au Make a comment Calculation of distance equivalents Activity units measured by the TRACMOR are not readily convertible to energy units (kilocalories). However, an estimate of relative differences in activity levels can be made by assuming a total daily energy expenditure 1.4 times that of resting metabolic rate for the men in our modern group.5 With an average weight of 96 kg and age of 44 years, a mean resting metabolic rate of about 2000 kcal/d can be estimated.7 Therefore, total energy expenditure would be 1.4 x 2000 = 2800 kcal/d, of which 800 kcal represents daily physical activity. As activity counts in our historical group ranged from 1.6 times those of the modern group on average to 2.3 at the extremes, this implies a total daily physical activity level in this group of 1280-1840 kcal/d, or a net difference of about 500-1000 kcal/d between the groups. Using energy values for walking of 0.716 kcal/kg per kilometre (or about 61 kcal/km for a 90 kg man),4 this implies a net difference between the groups equivalent to walking about 8-16 km per day. Back to text

Garry J Egger · Neeltje Vogels · Klaas R Westerterp

Fitness and fads Quick weight loss: sorting fad from fact David C K Roberts MJA 2001; 175: 637-640 Abstract - How to recognise a fad diet - Why fad diets "work" - Our metabolic flexibility has limits - Low carbohydrate diets - High carbohydrate, very low fat diets - Other types of fad diets - How to advise patients - Acknowledgements - References - Authors' details - - More articles on Nutrition Abstract This article reviews popular diets for their ability to produce effective weight loss. Most of the "evidence" for fad diets is based on anecdotal findings, theories and testimonials of short term results. The most prominent elements of fad diets are those of ritual and sacrifice. These diets offer quick and painless weight loss while allowing consumption of favourite or tasty foods, but place severe restrictions on certain other foods or food categories. Fad diets often work in the short term because they are low-kilojoule diets in disguise; that is, energy intake as a result of the diet is lower than the person's requirements. Successful long term weight loss depends on the consumption over a long period of time of less energy than is expended. The ideal approach is to increase physical activity while modifying eating behaviour to achieve a nutritionally balanced intake. As the desire for instant thinness continues to be a feature of our society, so is the appearance of new and not-so-new fad diets. The Journal published an article in 1999 reviewing substances used in weight loss; the authors concluded that most had no evidence to support their action.1 An excellent review of popular weight-loss diets has been published elsewhere by Anderson and co-workers.2 In this article, I review popular diets for their ability to produce effective weight loss, and provide additional information to assist practitioners in distinguishing fad from fact. As a nation, we are fat. According to the latest National Nutrition Survey,3 64% of Australian men and 47% of women are overweight or obese. The situation is getting worse rather than better — the proportion of overweight or obese adults has increased since 19834 by about 52% for men and 34% for women. Personal efforts to address the overweight problem, while common, are apparently not working. One in three Australians claim they are on some type of "diet",3 yet energy intake has increased and physical activity levels have decreased.5 Mathematical modelling suggests that weight loss is a simple matter, with limited inputs and outputs to be controlled.6 Yet most people who successfully lose weight return to their old eating habits, and within two years regain most of the lost weight.7 The methodology and design of reported weight-loss studies have been questioned,8 especially in studies involving long term follow-up. Weight loss can be a treatment effect (weight loss to improve diabetes control) or it can be an outcome of some other treatment (medication used to produce weight loss), making randomised controlled trials difficult to interpret. The lure of rapid weight loss promised by each new popular diet is undoubtedly compelling. A survey in the United States found that more than one in five dieters used fad diets.9 Fad diets feed into the psyche of people who seek to look better and feel better with the minimum of effort. Sensible eating for weight loss often does not appeal to people who feel they are already doing the best they can. However, very simple dietary changes, followed diligently, can often produce effective weight loss at a rate that can be maintained over the longer term.10 Conversely, when weight loss is too fast, changes in body composition, especially the loss of lean body mass, can compound the problem of overweight in the longer term. One large study reported an overall increased risk of major weight gain in the long term (at 6 and 15 years) in those who undertook weight-loss attempts (dieting) at baseline.11 However, these findings do not rule out the potential success and benefit of weight-loss programs which aim to encourage permanent changes in behaviour. How to recognise a fad diet To the aware practitioner, fad diets are relatively easy to spot (Box 1), but they can be quite convincing to the lay person. They offer a quick solution to a long term problem. The author or promoter presents what appear to be scientifically valid explanations or references to support the dieting theory. The promoter may be tertiary educated, although frequently has no formal nutrition or dietetic qualifications.12 The theory behind the weight loss approach is often explained using scientific terminology that simplifies or expands upon the biochemical and physiological facts that provide the evidence to support the claims. However, the validity of the scientific support is often questionable. Most of the "evidence" for fad diets is based on anecdotal findings, theories and testimonials of short term results. The most prominent elements of fad diets are those of ritual and sacrifice. The ritual aspect is to always include, say, grapefruit daily but never add sugar to your beverage (sacrifice). These diets offer quick and painless weight loss while allowing consumption of favourite or tasty foods, but severely restrict certain other foods or food categories. Why fad diets "work" Fad diets often work in the short term because they are low kilojoule diets in disguise (Box 2); that is, energy intake as a result of the diet is lower than the person's requirements. This is the only way to lose weight — to consume less energy than the body needs. No magic ingredients, strange food combinations or pseudoscientific formulas will alter this metabolic fact. The rate of weight loss (which reflects shifts in water equilibrium as well) varies depending on the relative proportions of the three major nutrients in the diet — carbohydrate, fat and protein. The macronutrient composition can also affect appetite: high-protein diets can suppress appetite, as can ketosis, which results from severe carbohydrate restriction.7 Because energy from food comes only from these nutrients (and alcohol), the number of dietary permutations and combinations is limited. Thus, most diets can be categorised into three main types: low carbohydrate with the emphasis on high protein; low carbohydrate with the emphasis on high fat; and high carbohydrate with an emphasis on low fat. To complete the picture, some fad diets promote one food or a very limited range of foods, while others may be based on individual characteristics such as blood type or personality, or on an unproven physiological concept (such as cleansing "toxins" from the body). Fad diets are generally nutritionally unbalanced and lack essential nutrients.13 They have the potential for health risks. A major problem is that the unfounded nutritional theories espoused with these diets undermine sound nutrition education and public awareness of the importance of healthy long term eating combined with regular physical activity. Our metabolic flexibility has limits The primary objective in effective weight loss is to lose fat and not lean body mass (muscle). From a biochemical point of view, this means encouraging the body to use fatty acids for energy with minimal reliance on glucose as an energy source, except for those tissues with an obligate requirement for glucose, such as red blood cells. With limited carbohydrate in the diet, once carbohydrate (glycogen) stores have been used the only source of glucose available to the body is that derived from the carbon skeletons of amino acids. In this situation, and in the absence of sufficient dietary protein, body protein (lean body mass) is catabolised to provide glucose. Muscle mass will therefore decline markedly on a very low carbohydrate, restricted protein diet. The ideal weight-loss diet should provide enough carbohydrate to prevent net protein catabolism, enough good quality protein to meet the normal needs of protein turnover, and enough fat to meet essential fatty acid requirements. Low carbohydrate diets Low carbohydrate diets have a long history. The Greek Olympians are said to have eaten high meat, low vegetable diets to improve athletic performance.7 The modern popularity of low carbohydrate diets has been influenced by the seeming "failure" of low fat diets because of a misunderstanding that energy intake is not important and that you can eat as much low fat food as you like and still lose weight.12 Furthermore, low carbohydrate diets appear to work, as they produce rapid weight loss in the first week.7Because the body's demand for glucose is constant, body glycogen stores are mobilised in the early phases of a low carbohydrate diet, and for each gram of glycogen lost two to four grams of intracellular water are lost (intracellular water maintains isotonicity). Consequently, there is greater water and hence weight loss in the early days of this type of diet. Water equilibrium is re-established in the second and subsequent weeks, so that, in the longer term, weight loss simply reflects the energy deficit. Energy-nitrogen balance studies have demonstrated that the greater weight loss on a low carbohydrate, high fat diet is accounted for by losses in body water.7 If carbohydrate restriction is severe (for example, less than 60 g), ketosis can result, which decreases appetite and causes nausea, but can also cause hyperuricaemia as ketones compete with uric acid for renal tubular excretion.7 Popular low carbohydrate, high protein diets include the Zone Diet,14 the Carbohydrate Addict's Diet,15 and the Sugar Busters! diet.16A popular low carbohydrate, high fat diet that has been around since the 1970s is the Dr Atkins diet.17 Low carbohydrate, high protein diets As with other low carbohydrate diets, high protein diets result in initially rapid weight loss. If continued, they produce weight loss because they are also low kilojoule diets. There is also evidence that higher-protein diets are more satiating. People feel fuller and eat less after a meal with a high protein content (31%-54% energy).18-20 A low fat, higher-protein diet (25% of energy) has also been found to produce a significantly reduced energy intake and greater weight and fat loss over six months compared with a low fat diet with 12% energy from protein.21 However, energy restriction is responsible for the weight loss. An additional problem of high protein diets is the extra solute load placed on the kidneys owing to greater production of nitrogen waste products, particularly in situations of high water loss from perspiration or inadequate fluid intake contributing to dehydration.7 In the long term, very high protein diets may increase the risk of osteoporosis in people with inadequate calcium intake by increasing calcium excretion.7,22 Low carbohydrate, high fat diets Popular for many years, the Dr Atkins diet17 allows protein-rich foods such as meats, fish, chicken and eggs, but also encourages fatty foods like butter, cream, fats, oils and salad dressings in large amounts. The key principle of the diet is to develop ketosis, which is seen as a dieting advantage because loss of ketones in the urine is regarded as wasting "usable" energy. The early stage of the diet restricts carbohydrate to no more than 20 g per day to achieve this. However, the actual energy value of urinary ketone losses is insignificant compared with the energy deficit of around 30 MJ required to lose one kilogram of fat. The daily loss of energy from ketones rarely exceeds 2%-3% of the total energy requirement.23 After ketosis is established, small amounts of carbohydrate (up to 60 g per day) are allowed back into the diet, provided urinary ketone losses are maintained. Common consequences of following this type of diet include dehydration, diarrhoea, weakness, headaches, dizziness and bad breath. Over the longer term, such a diet can increase the risk of atherosclerosis — one study has shown that this diet increases serum cholesterol levels and may increase the risk of coronary heart disease by more than 50% with long term use.2 This type of diet also does not include sufficient fruits and vegetables for good health and promotes the misconception that energy intake is not important. High carbohydrate, very low fat diets High carbohydrate diets for weight loss can be consistent with healthy eating if they recommend high fibre intakes and provide sufficient essential fatty acids and fat-soluble vitamins. However, if lean meat and fish and low fat dairy products are allowed only in tiny amounts (eg, as "condiments" only), there is the risk of inadequate intakes of calcium, iron, zinc and high quality protein. The Pritikin diet,24 for instance, recommends that fat intake be less than 10% of energy intake, which is likely to be unpalatable for many people used to a Western diet and is close to the lower limit of our requirement for essential fatty acids. The Pritikin diet is also quite low in protein in one of its forms (Maximum Wt Loss), so the quality of any protein present becomes important. A US study of popular diets has demonstrated that diet quality (measured by dietary variety and intake of five food groups, fat, saturated fat and sodium) is higher in high carbohydrate diets and lowest in low carbohydrate diets.25 The same study showed body mass index is lower in people following high carbohydrate diets and highest in people on low carbohydrate diets. Other types of fad diets Over the years, an array of "one food" diets have been promoted, such as the rice diet, banana diet, and the grapefruit diet. These types of diet are potentially dangerous, nutritionally unbalanced and unscientific, and encourage poor eating habits and food faddism. Some diets base their theories on unproven information about physiology and metabolism, such as that which suggests that blood type influences the best food pattern for you,26 and diets that suggest excess weight is caused by liver dysfunction and not energy imbalance.27 How to advise patients Successful long term weight loss depends on the consumption over a long period of time of less energy than is expended (Box 3). The ideal approach is to increase physical activity while modifying eating behaviour to achieve a nutritionally balanced intake.10Energy needs for weight loss are best established by determining the energy needs of the person at their desired weight and then providing for a weekly energy deficit of about 30 MJ, or 4.2 MJ (1000 kcals) per day. This usually means a suggested energy intake of around 5 MJ (1200 kcals) per day for a woman and up to 8 MJ (1900 kcals) per day for a man. All foods should be allowed, with an emphasis on fibre-rich carbohydrate foods (cereals, breads, fruit and vegetables), fish and other seafood, lean meat and low fat dairy foods, with small amounts of unsaturated fat as oil or margarine. Behaviour modification to help control impulsive eating is also useful. The eating plan should be based on the principles of the Australian Guide to Healthy Eating.28 Increased and regular physical activity adds substantially to the success of weight loss programs, so regular physical activity should be encouraged.29 Acknowledgements I wish to thank Ms Toni Irwin (APD), Dietitian/Nutritionist, for her help and assistance in the preparation of this article. References Egger G, Cameron-Smith D, Stanton R. The effectiveness of popular, non-prescription weight loss supplements. Med J Aust 1999; 171: 11-12. Anderson JW, Konz EC, Jenkins DJ. Health advantages and disadvantages of weight-reducing diets: a computer analysis and critical review. J Am Coll Nutr 2000; 19: 578-590. Australian Bureau of Statistics and Commonwealth Department of Health and Family Services. National nutrition survey: selected highlights, Australia. Canberra: ABS, 1997. (Catalogue no. 4802.0.) National Heart Foundation of Australia. Risk factor prevalence study No. 2. Canberra: NHF 1983. Armstrong T, Bauman A, Davies J. Physical activity patterns of Australian adults. Results of the 1999 National Physical Activity Survey. Canberra: Australian Institute of Health and Welfare, 2000. (Catalogue no. CVD-10.) Kozusko F. A setpoint based dieting model. Math Comput Model 1999; 29: 1-7. Denke M. Metabolic effects of high-protein, low-carbohydrate diets. Am J Cardiol 2001; 88: 59-61. Lean ME. Is long-term weight loss possible? Br J Nutr 2000; 11 Suppl 1: s103-s111. Jeffery RW, Folsom AR, Luepker RV, et al. Prevalence of overweight and weight loss behavior in a metropolitan adult population: the Minnesota Heart Survey experience. Am J Public Health 1984; 74: 349-352. Goodrick G, Poston WS, Foreyt J. Methods for voluntary weight loss and control: update 1996. Nutrition 1996; 12: 672-676. Korkeila M, Rissanen A, Kaprio J, et al. Weight-loss attempts and risk of major weight gain: a prospective study in Finnish adults. Am J Clin Nutr 1999; 70: 965-975. Stein K. High-protein, low-carbohydrate diets: do they work? J Am Diet Assoc 2000; 100: 760-761. Fisher MC, Lachance PA. Nutrition evaluation of published weight-reducing diets. J Am Diet Assoc 1985; 85: 450-454. Sears B, Lawren B. The Zone — a dietary road map. New York: Harper Collins, 1995. Heller RF, Heller RF. The carbohydrate addict's diet. The lifelong solution to yo-yo dieting. London: Reed International, 1992. Steward HL, Bethea MC, Andrews SS, Balart LA. Sugar Busters! London: Random House, 1998. Atkins R. Dr Atkins' new diet revolution. New York: Avon, 1992. Stubbs RJ. Macronutrient effects on appetite. Int J Obes Relat Metab Disord 1995; 19 Suppl 5: s11-s19. Stubbs RJ, Ritz P, Coward WA, Prentice AM. Covert manipulation of the ratio of dietary fat to carbohydrate and energy density: effect on food intake and energy balance in free-living men eating ad libitum. Am J Clin Nutr 1995; 62: 230-237. Stubbs RJ, Harbron CG, Murgatroyd PR, Prentice AM. Covert manipulation of dietary fat and energy density: effect on substrate flux and food intake in men eating ad libitum. Am J Clin Nutr 1995; 62: 316-329. Skov AR, Toubro S, Ronn B, et al. Randomized trial on protein vs carbohydrate in ad libitum fat reduced diet for the treatment of obesity. Int J Obes Relat Metab Disord 1999; 23: 528-536. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. JAMA 2001; 285: 785-795. Friedman RB, Kindy P Jr., Reinke JA. What to tell patients about weight-loss methods. 1. Diets. Postgrad Med 1982; 72: 73-80. Pritikin N. The Pritikin permanent weight loss manual. New York: Grosset and Dunlap, 1981. Kennedy ET, Bowman SA, Spence JT, et al. Popular diets: correlation to health, nutrition, and obesity. J Am Diet Assoc 2001; 101: 411-420. D'Adamo P. Eat right for your type. London: Century, 1997. Cabot S. The liver cleansing diet. Sydney: Women's Health Advisory Service, 1996. Population Health Division, Commonwealth Department of Health and Aged Care. Australian Guide to Healthy Living. <http://www.health.gov.au/pubhlth/ strateg/food/guide>. Accessed 7 November 2001. Population Health Division, Commonwealth Department of Health and Aged Care. National physical activity guidelines for Australians [brochure]. Available at <http://www.health.gov.au/pubhlth/publicat/document/physguide.pdf>. (Received 4 Oct, accepted 31 Oct, 2001) Authors' details School of Health Sciences, University of Newcastle, Newcastle, NSW. David C K Roberts, BSc, PhD, Foundation Professor of Nutrition and Dietetics Reprints will not be available from the author. Correspondence: Professor D C K Roberts, School of Health Sciences, University of Newcastle, Newcastle, NSW 2308. david.robertsATnewcastle.edu.au Make a comment 1: Common features of fad diets Promises of rapid weight loss Elements of ritual and sacrifice Magical food or food combination Unlimited foods of some type Rigid menus or monotonous food choices Jargon and scientific half-truths Lack of good scientific evidence Lack of acknowledgement of physical activity needs Back to text 2: How to assess weight loss diets — GP checklist Does the diet promote a new fact or newly discovered secret? Does the diet involve purchase of a commercial product? Is there a promise of rapid weight loss? Has the diet been independently tested and results published in a reputable journal? What are the credentials of the author or promoter? Will the diet result in only small quantities of carbohydrate foods being eaten? Does the diet promote adequate intakes of the main food groups: fruit and vegetables, cereal foods, low fat dairy foods, lean meats? Is there an overemphasis on dietary fat or any one food type? Is the energy-balance equation recognised and physical activity promoted as an important part of this? Back to text 3: Features of an appropriate weight-loss diet Considers the individual's current habits, preferences and risk factors. Sets realistic weight loss targets (0.5-1 kg/week). Has a minimum daily intake of 5000 kJ (1200 kcal) for women and 6500 kJ (1500 kcal) for men. Has carbohydrate intake in excess of 150 g per day. Includes foods from each of the food groups. Emphasises dietary fibre. Recommends increased physical activity. Is based on change of life-long eating habits. Back to text

Bites and stings Outbreak of caterpillar dermatitis caused by airborne hairs of the mistletoe browntail moth (Euproctis edwardsi) Caterpillars may be an under-recognised cause of skin and eye reactions. We report a four-month outbreak of recurrent papulourticarial rash among staff and visitors at a community centre. The cause was eventually diagnosed as airborne hairs from caterpillars of the mistletoe browntail moth (Euproctis edwardsi), which infested a eucalypt tree growing in front of the centre. To our knowledge, this is the first clear case of airborne caterpillar hairs causing dermatitis in an indoor environment. Corrine R Balit, Helen C Ptolemy, Merilyn J Geary, Richard C Russell and Geoffrey K Isbister MJA 2001; 175: 641-643 Clinical records - Discussion - Acknowledgements - References - Authors' details - - - More articles on Informatics and computers Lepidopterism refers to adverse effects from moths and butterflies (Lepidoptera), the most common arising from skin and eye contact with caterpillar hairs or spines.1 The pattern of reaction varies between caterpillar types.2 Caterpillar dermatitis can result not only from direct contact with the caterpillar, but also from airborne caterpillar hairs.3,4 Caterpillar dermatitis is probably far more common than previously realised.1,3,5-10 Patients often present with a rash of unknown origin, and the association with caterpillar exposure is often not recognised. We report an outbreak of caterpillar dermatitis related to an infestation of the caterpillar Euproctis edwardsi (Family: Lymantriidae), commonly known as the mistletoe browntail moth. The infestation occurred at a community centre, where staff and visitors experienced dermatitis and skin irritation for several months before caterpillar dermatitis was diagnosed. To our knowledge, these are the first clear cases of dermatitis caused by airborne caterpillar hairs in an indoor environment. Clinical records In February 2001, the Wentworth Public Health Unit, Sydney, NSW, was contacted about a local community centre where both staff and clients had been experiencing skin reactions and irritation. Seven of the 14 employees of the centre were affected, as were about 5% of clients seen at the centre. The reactions began in November 2000 and appeared while people were at the centre. They would settle or resolve while people were away from the centre on weekends and holidays and recur on their return to work. The skin reactions comprised a papulourticarial rash. Clinical effects in six patients are shown in Box 1, and further details of one patient in Box 2. The centre had been sprayed against a variety of pests on several occasions, without benefit. Each time, the pest control company reported no visible evidence of insects in the centre. Many staff sought medical advice, and various treatments were prescribed, including topical corticosteroids and oral antihistamines, with no benefit. The site was inspected by the Environmental Health Officer of the Population Health Unit (H C P). In front of the centre was an ironbark tree (Eucalyptus sideroxylon) which contained a mistletoe plant and, at its base, a large clump of caterpillars (pictured above). The tree was growing adjacent to the mail box, about 3 m from the front door of the centre and the window of the upstairs lunchroom, and 10 m from the intake vent of the air-conditioning system. Caterpillar samples were identified at the Department of Medical Entomology, Westmead Hospital, Sydney, as E. edwardsi, commonly known as the mistletoe browntail moth. Caterpillar-like hairs were also identified in samples of dust from inside the centre. Based on reports of successful use of sticky tape to sample affected areas for nematocysts in jellyfish stings,11 this method was tried on three affected individuals. Transparent sticky tape was applied to the affected area and then placed onto a glass slide. Caterpillar-like hairs were identified from two of the three people thus tested (Box 3). The caterpillars were treated with insecticide and removed along with the mistletoe, according to the recommendations of the environmental health officer. Although the officer also recommended re-inspection of the tree and removal of any mistletoe regrowth the following spring, the centre eventually removed the tree completely. The building was thoroughly cleaned to remove all caterpillar hairs. Follow-up of people at the centre a month later showed significant improvement in their conditions. Occasional episodes of skin irritation in two people were successfully treated by immediate application of sticky tape to the affected areas. Follow-up after six months revealed no further reports of irritation. Discussion This is the first case series that clearly demonstrates dermatitis resulting from airborne caterpillar hairs in an indoor environment. Although the cause of the dermatitis was not identified for months, once found treatment was straightforward — removal of the caterpillars and their food source to prevent re-exposure. We also demonstrated the usefulness of the sticky-tape technique in diagnosing, as well as treating, caterpillar dermatitis by removing caterpillar hairs from the skin.1E. edwardsi is reported to be the most important cause of caterpillar dermatitis in Australia.1 It occurs from Queensland to South Australia and is widely distributed in south-eastern Australia.12 Its food source is usually Amyema species of mistletoes.1 The incidence of caterpillar dermatitis peaks between December and March,3 with two generations of the moth each year, in early summer and autumn.1 The fully grown caterpillar is about 4 cm long and has golden tufts of spicules on its back. These spicules easily separate from the caterpillar, causing irritation on skin contact. The most common reaction is a papulourticarial rash, usually on exposed skin, but possibly more extensive if clothing is contaminated.1 The hairs are small enough to become airborne and affect people without direct contact with the caterpillar. In patients presenting with skin reactions and dermatitis of unknown cause, particularly recurrent rash, a careful history of location and seasonality is required. Caterpillar dermatitis should be considered in the differential diagnosis and can be confirmed by identifying the source of the caterpillar or its hairs. Microscopy of sticky-tape samples from the affected area may aid diagnosis. The use of sticky tape has been reported previously as a treatment option in caterpillar exposures, to remove fine hairs that may cause ongoing symptoms.5 This is the first report demonstrating the use of sticky tape as a simple and effective diagnostic tool. Once the source of exposure has been removed, treatment of caterpillar dermatitis is essentially symptomatic and supportive. Patient 1 allowed several treatment options to be assessed. Most effective was topical aspirin paste, with improvement within hours. Topical aspirin has previously been reported to be effective for histamine-induced rash.13 The paste is made by adding a few drops of water to a soluble aspirin tablet and applying it to the affected area. A topical preparation containing lignocaine offered some symptomatic relief but did not shorten the duration of symptoms. A topical hydrocortisone cream produced no noticeable change. Outbreaks of caterpillar dermatitis are not uncommon and may be difficult to diagnose. Sticky-tape sampling of the affected area may aid diagnosis. Topical aspirin paste appears an effective treatment, and topical lignocaine preparations and oral antihistamines may provide partial symptomatic relief. Acknowledgements We thank Dr James Isbister (Royal North Shore Hospital, Sydney, NSW) for providing digital images of the sticky tape slides and Mr Stephen Doggett (Department of Medical Entomology, ICPMR, Westmead Hospital) for taking the clinical photograph. We also thank Judith Kirby and all the staff at the NSW Poisons Information Centre for their support and assistance. References Southcott RV. Lepidopterism in the Australian region. Records of the Adelaide Children's Hospital 1978; 2: 87-173. Isbister GK, Whelan PI. Envenomation by the billygoat plum stinging caterpillar (Thosea penthima). Med J Aust 2000; 173: 654-655. Thompson JI. Mistletoe brown tail moth - a skin irritation caterpillar. AGFACTS. Sydney: NSW Department of Agriculture, 1984. Southcott RV. Some harmful Australian insects. Med J Aust 1988; 149: 656-662. Dunlop K, Freeman S. Caterpillar dermatitis. Australas J Dermatol 1997; 38: 193-195. Scholz A, Russell R, Geary M. Investigation of caterpillar dermatitis in school children. NSW Public Health Bull 1993; 4: 65-66. Blair CP. The browntail moth, its caterpillar and their rash. Clin Exp Dermatol 1979; 4: 215-222. Cleland JB. Papulo-urticarial rashes caused by the hairlets of caterpillars of the moth (Euproctis edwardsi Newm.). Med J Aust 1920; 1: 169-170. McKeown KC. Australian insects. An introductory handbook. Sydney: Royal Zoological Society of NSW, 1942. Lee D. Arthropod bites and stings and other injurious effects. Sydney: School of Public Health and Tropical Medicine, University of Sydney, 1975. Currie BJ, Wood YK. Identification of Chironex fleckeri envenomation by nematocyst recovery from skin. Med J Aust 1995; 162: 478-480. Musgrave A. Harmful moth caterpillars. Aust Museum Mag 1941; 7: 391-396. Yosipovitch G, Ademola J, Lui P, et al. Topically applied aspirin rapidly decreases histamine-induced itch. Acta Derm Venereol 1997; 77: 46-48.(Received 14 Jun, accepted 27 Sep, 2001) Authors' details NSW Poisons Information Centre, The Children's Hospital, Sydney, NSW. Corrine R Balit, BPharm, Pharmacist. Wentworth Population Health Unit, Sydney, NSW. Helen C Ptolemy, BAppSci, Environmental Health Officer. Department of Medical Entomology, ICPMR, Westmead Hospital, Sydney, NSW. Merilyn J Geary, DipAppSci, PestContCert, Laboratory Manager; Richard C Russell, MSc, PhD, Director, and Associate Professor, University of Sydney, NSW. Department of Clinical Toxicology and Pharmacology, Newcastle Mater Misericordiae Hospital, Newcastle, NSW. Geoffrey K Isbister, BSc, MB BS, Toxicology Registrar. Reprints will not be available from the authors. Correspondence: Ms Corrine R Balit, NSW Poisons Information Centre, The Children's Hospital, Locked Bag 4001, Westmead, NSW 2145. CorrineBATchw.edu.au Make a comment 1: Details of six people who developed a papulo-urticarial rash at the community centre Patient (sex, age in years) Affected areas Duration of rash Sticky tape sample 1. Staff (M, 24) Arms, legs Recurrent, Nov-Feb Positive 2. Staff (F, 26) Face, legs, hands, stomach Recurrent, Nov-Feb Negative 3. Staff (F, 38) Arms, chest, neck Recurrent, Nov-Feb Positive 4. Staff (F, late 30s) Arm, chest, face Recurrent, Nov-Feb Not available 5. Visitor (F, 23) Neck, chest, face, arms 5 days Not available 6. Visitor (F, 32) Neck, chest 24 hours Not available F = female. M = male. Back to text 2: Severe reaction to caterpillar hairs (Patient 5) A 23-year-old woman developed a moderately severe reaction after visiting the community centre for an hour. She had a past history of atopy, asthma and mild atopic dermatitis. On examination, exposed areas were affected, including the forehead, face, neck, upper chest and lower arms. The reaction began as an itchy red area within six hours of exposure, and over the next 24 hours developed into a papulourticarial rash with intense pruritus (pictured 24 hours after exposure). Initial dizziness and light-headedness were the only systemic effects. A number of treatments were tried in different affected areas, including topical hydrocortisone (1%), a topical combination of lignocaine, bufexamac and chlorhexidine, topical aspirin paste, and sedating and non-sedating antihistamines. Areas treated with aspirin paste showed marked improvement over four hours. Topical lignocaine and sedating antihistamines provided symptomatic relief, but other treatments produced minimal responses. The rash cleared completely over five days. Back to text 3: Caterpillar hairs from Patient 1 Sticky-tape sample from an area of papulourticarial rash in Patient 1, showing a human hair (centre) surrounded by numerous smaller, caterpillar-like hairs (original magnification, x 20). Inset shows a control slide of hairs from the caterpillar Euproctis edwardsi (original magnification, x 40). Back to text

Corrine R Balit · Helen C Ptolemy · Merilyn J Geary · Richard C Russell · Geoffrey K Isbister

The "jack jumper" ant (Myrmecia pilosula) is a major cause of anaphylaxis in Tasmania. We describe four deaths attributed to stings by this ant between 1980 and 1999. All victims were men aged 40 years or over with significant comorbidities; two were taking angiotensin-converting enzyme inhibitors, which may increase risk of severe anaphylaxis. Three victims had known ant-sting allergy, but only one carried adrenaline, which he did not use. Another believed he was protected by previous attempts at hyposensitisation with whole ant-body extract. There is potential to prevent deaths by careful education of people with known allergy, prescribing of adrenaline for auto-injection and development of an effective hyposensitisation therapy. Simon G A Brown, Qi-Xuan Wu, G Robert H Kelsall, Robert J Heddle and Brian A Baldo MJA 2001; 175: 644-647 Clinical records - Discussion - Acknowledgements - References - Authors' details Of 89 described species of bull ants (genus Myrmecia), 88 are found only in Australia.1 Stings are frequent, and allergy is common, especially to Myrmecia pilosula in Tasmania,2 rural Victoria,3 the Adelaide Hills of South Australia and southern New South Wales. Peptide allergens thought to account for most M. pilosula IgE-specific reactions have been identified, cloned and named Myr p I, II4-9 and III. Stings by M. pilosula caused 21%-25% of the 324 cases of anaphylaxis treated with adrenaline in the Royal Hobart Hospital Emergency Department between 1990 and 1998, compared with 13% caused by honeybee stings (Brown, unpublished data). M. pilosula is well known to local people, and recognisable by its size and coloration (Box 1A). It moves in short jerks and jumps, leading to the names "jumper ant", "hopper ant", "jumping jack", and "jack jumper". Nests are defended aggressively and range from a single hole to large mounds a meter in diameter with multiple entrances, typically surrounded by a scattering of fine gravel. Another less common but well-recognised local bull ant is the "inchman" (Box 1B). Our field trips in Tasmania have revealed this ant to comprise one species, identified as Myrmecia forficata by CSIRO (the Commonwealth Scientific and Industrial Research Organisation) Entomology, Canberra. Other species are seldom encountered and unlikely to be a common cause of stings. We present clinical details of four deaths attributed to M. pilosula stings between 1980 and 1999 in southern Tasmania (population, 223 00010). Cases were identified from a manual search of diagnoses in the hospital's forensic register. Immunological methods are shown in Box 2. The study was approved by the Royal Hobart Hospital Ethics Committee. Clinical records Patient 1 In 1989, a 49-year-old man woodcutting in bush told his companions he had been stung by a jack jumper ant. Because of known allergy to these stings, he took two antihistamine tablets. He was left alone for 15-20 minutes and was dead when his companions returned. Past history included hypertension treated with enalapril. Autopsy revealed cardiomegaly, acute on chronic pulmonary congestion and "unusually fluid blood". The pathologist discounted ant-sting anaphylaxis as "exceedingly rare". Tissue from a suspected forearm bite was negative for snake venoms (Dr Struan Sutherland, Medical Consultant, Commonwealth Serum Laboratories, Melbourne, VIC, personal communication). Tests for serum tryptase and venom-specific IgE were not available in Australia at that time. Patient 2 In 1995, a 62-year-old man was thought to have been stung by a jack jumper ant while fishing. He subsequently developed tongue and lip swelling and breathlessness. When a paramedic arrived 20-30 minutes later, he was in cardiac arrest. Resuscitation was unsuccessful. Past history and allergies were not recorded. Autopsy revealed severe oedema of lips and tongue, oedema of the upper airways, extreme lung congestion, diffuse severe atherosclerosis with occlusions of 50%-75%, and marked hypertensive left ventricular hypertrophy. Toxicological screening revealed a blood alcohol level of 0.21 g/100 mL and no other drugs or substances. Serum tryptase level in blood taken three days after death was 2.73 µg/L (reference range [RR], < 2 µg/L). IgE specific to M. pilosula venom was detected by IgE antibody-binding studies (uptake of radioactive label, 15.2%). Reactivity to other venoms was not tested. Patient 3 In 1995, a 40-year-old man reported being stung by a "bull ant" (a term commonly used by local people, including some medical practitioners, when referring to M. pilosula) outside his home in a beachside suburb of Hobart. He injected himself with promethazine (50 mg) and continued to drink alcohol. Some time later, he was noted to be slurring his words and to fall over when going to the bedroom. The precise timeframe was difficult to determine from available records. He was found dead in bed in the early hours of the morning. Past history included obstructive sleep apnoea and progressively worsening systemic allergic reactions to "bull ants", for which he was prescribed intramuscular antihistamine and an adrenaline puffer. The medical records did not mention whether "bull ant" referred to M. forficata or M. pilosula. He was known to be a heavy alcohol user and was also prescribed diazepam and fluoxetine. Autopsy results were unremarkable apart from a fatty liver. Toxicological screening revealed a blood alcohol level of 0.22 g/100 mL and non-toxic concentrations of diazepam and fluoxetine. Serum tryptase level in blood taken three days after death was 2.72 µg/L (RR, < 2 µg/L). Tests for venom-specific IgE revealed high radioactive label uptakes for M. pilosula (31.7%) and the other Myrmecia species tested (M. tarsata, 42.1%; M. simillima, 39.8%; M. pyriformis, 39.6%; M. gulosa, 37.0%; and M. nigrocincta, 24.5%). Patient 4 In 1999, a 65-year-old man working in his backyard in Hobart complained that he had just been stung on the knee by a jack jumper ant, feeling immediately unwell, itchy and short of breath. An ambulance was called, and he collapsed. A paramedic crew arrived five minutes later, when he was found to be deeply cyanosed with no palpable pulses. He had a generalised urticarial rash and was making an occasional respiratory effort without any movement of air. Cardiopulmonary resuscitation was commenced, but bag-valve-mask ventilation was ineffective. Electrocardiogram demonstrated idioventricular rhythm. Paramedics administered a total of 13 mg of adrenaline, but at no stage was a pulse detected. On arrival in hospital 50 minutes after the arrest, laryngoscopy revealed marked laryngeal oedema and a gum-elastic bougie was required to achieve intubation. Resuscitation attempts were ceased shortly thereafter. Past history included allergy to M. pilosula, with unconsciousness on several occasions. Fifteen years earlier, hyposensitisation was attempted with crushed whole-ant preparation. Since then he had been stung once, with what his family recalled to be a less severe reaction, leading him to believe he was protected from further stings. He also had a history of atrioseptal defect repair, chronic atrial fibrillation and impaired left ventricular function. Medications at time of presentation included warfarin, digoxin, bumetanide, carvedilol and fosinopril. Autopsy revealed considerable oedema of the larynx, aryepiglottic folds and adjacent pharyngeal tissues. The lower airways were clear, indicating that aspiration had not occurred. There was no significant coronary artery disease, but there was marked dilatation of the tricuspid and mitral valves and all cardiac chambers. Serum tryptase level in blood taken four hours after termination of resuscitation was 51.6 µg/L (RR, < 12 µg/L). IgE specific to the venoms of M. pilosula and honeybee was detected (radioactive label uptakes, 10.1% and 2.7%, respectively). IgE uptakes to three synthetic venom peptides, Myr p I-III, were 0.4%, 3.2% and 1.0%, respectively. No significant IgE reactivity with European wasp or other Myrmecia venoms was detected. Results of inhibition and immunoblot studies are shown in Box 3. Discussion It has been argued that deaths caused by sting anaphylaxis are under-reported because of lack of circumstantial evidence and the frequent absence of diagnostic postmortem features.15-17 This may be compounded by lack of awareness, as suggested by our first case. IgE specific for M. pilosula venom was detected in the three patient sera tested. In Patient 3, binding of IgE to all tested venoms probably represented true immunological cross-reactivity, as the patient was unlikely to have been exposed to all these ant species, which are found in geographically disparate areas. Cross-reactivity between different Myrmecia venoms is well recognised7 and may lead to anaphylaxis after the sting of a species not previously encountered, which should be made clear to patients. Consequently, the third death may have been caused by the inchman ant, M. forficata, rather than the jack jumper, M. pilosula. Postmortem findings supported anaphylaxis as a cause of death in all patients except Patient 3. In about half the deaths caused by anaphylaxis, no cause of death is evident at autopsy.17 In Patient 3, the apparent long interval between the sting and death, along with the significant comorbidities, raises the possibility that death was caused by a combination of moderately severe anaphylaxis, intoxication (alcohol, benzodiazepine and antihistamine) and obstructive sleep apnoea. Although the median time from sting to cardiac arrest in fatal cases is 15 minutes, significant delays of several hours may occur.18,19 Serum mast-cell tryptase level was markedly raised in Patient 4, but only marginally raised in the other two patients tested. The reference range for the technique used in 1995 was < 2 µg/L,11 and levels do not increase after death.20 Baseline tryptase levels are raised in some people with sting allergy because of underlying mastocytosis.21 Using 10 µg/L as the cut-off level, postmortem serum tryptase level has 86% sensitivity and 88% specificity for predicting death caused by anaphylaxis.22 Tryptase level is not raised in many anaphylaxis cases, despite raised histamine levels,23 and tryptase may not enter the circulation until 30 minutes after exposure, peaking 1-2 hours after exposure if the circulation remains intact.24 Tryptase half-life is two hours with an intact circulation, increasing to four days after death.24 In Patient 4, the clear-cut reactivity of IgE antibodies with whole venom was not replicated with synthetic peptides. While whole venom produced 80%-90% inhibition of IgE binding, synthetic peptides at much higher concentrations produced only 35% inhibition. Immunoblotting results suggested that the peptide components separated by gel electrophoresis also had low reactivity to IgE in this patient's serum. A review of serum from 273 people allergic to M. pilosula venom reveals that, of those with positive reactions to whole venom, 19% show little or no reactivity with Myr p I or Myr p II. Immunoblotting with some of these sera demonstrated four previously unidentified IgE-binding bands with molecular weights 11.7, 16.9, 25 and 43.5 kDa (Wu and Baldo, unpublished data). These findings have significant implications for immunotherapy. In the absence of further data on interactions with T-cell epitopes, it cannot be assumed that these synthetic peptides will be effective substitutes for native venom immunotherapy. Notably, we did not identify deaths of young healthy individuals. This repeats the pattern observed for bee and wasp sting allergy,15,19 and is consistent with the observation that adult males tend to have more severe reactions to bee stings.25 All victims in this series were men aged 40 or over with significant comorbidities. Two of the patients used angiotensin-converting enzyme (ACE) inhibitors, combined with a β-blocker in one case. These drugs may have contributed to the deaths or may simply have been a marker of underlying conditions that determined outcome. ACE is a kininase; inhibitors of this enzyme can trigger severe anaphylaxis in patients undergoing venom immunotherapy,26 possibly because of decreased breakdown of vasodilator kinins activated during anaphylaxis or compromise of compensatory activation of the renin-angiotensin system.27 In addition, β-blockers may both impair the endogenous adrenergic stress response and counteract and imbalance the effect of exogenous adrenaline. Interestingly, patients with severe venom allergy have reduced activity of the renin-angiotensin system, despite normal kininase activity.28 Drugs that selectively inhibit the angiotensin II-1 (AT1) receptor, such as losartan, may have less deleterious effects than ACE inhibitors. In patients undergoing haemodialysis, losartan may be associated with a lower incidence of anaphylactoid reactions than kininase inhibitors,29 but no data are available on anaphylactic reactions to external allergens. Three of the victims had previously sought medical attention for ant-sting allergy. In contrast, larger (and probably more representative) studies of sting-allergy deaths show that a minority of victims have a previous history of systemic sting allergy.16,19 Despite the known histories of sting allergy, only one of the victims had been prescribed adrenaline, which was not used. Another patient believed he was protected by previous immunotherapy with crushed whole ant-body extract. This technique has been shown to be no better than placebo in the only rigorously conducted trials available — for bee and wasp sting allergy30,31 — and is no longer available for the treatment of jack jumper venom allergy. The optimal duration of immunotherapy is also unknown — indefinite continuation has been recommended for those with a history of severe reactions, such as Patient 4.32 These cases illustrate that the severity of reactions in allergic individuals can be unpredictable. There is potential to prevent deaths by careful patient counselling, prescribing of adrenaline for auto-injection and development of an effective hyposensitisation therapy. Currently available synthetic allergens may not reproduce enough of the immunological activity of M. pilosula venom to produce hyposensitisation. Therefore, we are currently conducting a trial of hyposensitisation therapy using native M. pilosula venom. Acknowledgements The authors thank Dr Catherine Morgan (Emergency Medicine Department, Royal Hobart Hospital) for her assistance with the manual search of the hospital forensic medical register. This work was supported by a grant from the Royal Hobart Hospital Research Foundation. References Ogata K, Taylor RW. Ants of the genus Myrmecia Fabricus: a preliminary review and key to the named species (Hymenoptera: Formicidae: Myrmeciinae). J Nat Hist 1991; 25: 1623-1673. Clarke PS. The natural history of sensitivity to jack jumper ants (Hymenoptera formicidae Myrmecia pilosula) in Tasmania. Med J Aust 1986; 145: 564-566. Douglas R, Weiner J, Abrahamson M, O'Hehir R. Prevalence of severe ant venom allergy in southeastern Australia. J Allergy Clin Immunol 1998; 101: 129-131. Ford SA, Baldo BA, Weiner J, Sutherland S. Identification of jack-jumper ant (Myrmecia pilosula) venom allergens. Clin Exp Allergy 1991; 21: 167-171. Donovan GR, Baldo BA, Sutherland S. Molecular cloning and characterization of a major allergen (Myr p I) from the venom of the Australian jumper ant, Myrmecia pilosula. Biochim Biophys Acta 1993; 1171: 272-280. Donovan GR, Street MD, Tetaz T, et al. Expression of jumper ant (Myrmecia pilosula) venom allergens: post-translational processing of allergen gene products. Biochem Mol Biol Int 1996; 39: 877-885. Street MD, Donovan GR, Baldo BA, Sutherland S. Immediate allergic reactions to Myrmecia ant stings: immunochemical analysis of Myrmecia venoms. Clin Exp Allergy 1994; 24: 590-597. Street MD, Donovan GR, Baldo BA. Molecular cloning and characterization of the major allergen Myr p II from the venom of the jumper ant Myrmecia pilosula: Myr p I and Myr p II share a common protein leader sequence. Biochim Biophys Acta 1996; 1305: 87-97. Donovan GR, Street MD, Baldo BA. Separation of jumper ant (Myrmecia pilosula) venom allergens: a novel group of highly basic proteins. Electrophoresis 1995; 16: 804-810. Australian Bureau of Statistics. 1996 Census of Population and Housing. Basic Community Profiles State of Tasmania (Greater Hobart and Southern Statistical Divisions). Data summaries available online [Cited 2001 Nov 04]. Available at <http://www.abs.gov.au/ausstats> Enander I, Matsson P, Nystrand J, et al. A new radioimmunoassay for human mast cell tryptase using monoclonal antibodies. J Immunol Methods 1991; 138: 39-46. Fisher MM, Baldo BA. Mast cell tryptase in anaesthetic anaphylactoid reactions. Br J Anaesth 1998; 80: 26-29. Donovan GR, Street MD, Baldo BA, et al. Identification of an IgE-binding determinant of the major allergen Myr p I from the venom of the Australian jumper ant Myrmecia pilosula. Biochim Biophys Acta 1994; 1204: 48-52. Tovey ER, Ford SA, Baldo BA. Enhanced immunodetection of blotted house dust mite protein allergens on nitrocellulose following blocking with Tween 20. Electrophoresis 1989; 10: 243-249. Harvey P, Sperber S, Kette F, et al. Bee-sting mortality in Australia. Med J Aust 1984; 140: 209-211. Mosbech H. Death caused by wasp and bee stings in Denmark 1960-1980. Allergy 1983; 38: 195-200. Pumphrey RS, Roberts IS. Postmortem findings after fatal anaphylactic reactions. J Clin Pathol 2000; 53: 273-276. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30: 1144-1150. Sasvary T, Muller U. Fatalities from insect stings in Switzerland 1978 to 1987. Schweiz Med Wochenschr 1994; 124: 1887-1894. Yunginger JW, Nelson DR, Squillace DL. Laboratory investigation of deaths due to anaphylaxis. J Forensic Sci 1991; 36: 857-865. Ludolph-Hauser D, Rueff F, Fries C, et al. Constitutively raised serum concentrations of mast-cell tryptase and severe anaphylactic reactions to Hymenoptera stings. Lancet 2001; 357: 361-362. Edston E, van Hage-Hamsten M. Beta-tryptase measurements post-mortem in anaphylactic deaths and in controls. Forensic Sci Int 1998; 93: 135-142. Lin RY, Schwartz LB, Curry A, et al. Histamine and tryptase levels in patients with acute allergic reactions: An emergency department-based study. J Allergy Clin Immunol 2000; 106 (1 Pt 1): 65-71. Schwartz LB, Yunginger JW, Miller J, et al. Time course of appearance and disappearance of human mast cell tryptase in the circulation after anaphylaxis. J Clin Invest 1989; 83: 1551-1555. Roberts-Thomson PJ, Harvey P, Sperber S, et al. Bee sting anaphylaxis in an urban population of South Australia. Asian Pac J Allergy Immunol 1985; 3: 161-164. Tunon-de-Lara JM, Villanueva P, Marcos M, Taytard A. ACE inhibitors and anaphylactoid reactions during venom immunotherapy. Lancet 1992; 340: 908. van der Linden PW, Struyvenberg A, Kraaijenhagen RJ, et al. Anaphylactic shock after insect-sting challenge in 138 persons with a previous insect-sting reaction [see comments]. Ann Intern Med 1993; 118: 161-168. Hermann K, von Tschirschnitz M, Ebner von Eschenbacj C, Ring J. Histamine, tryptase, norepinephrine, angiotensinogen, angiotensin-converting enzyme, angiotensin I and II in plasma of patients with hymenoptera venom anaphylaxis. Int Arch Allergy Immunol 1994; 104: 379-384. Saracho R, Martin-Malo A, Martinez I, et al. Evaluation of the Losartan in Hemodialysis (ELHE) Study. Kidney Int 1998; 68 Suppl: S125-S129. Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978; 299: 157-161. Muller U, Thurnheer U, Patrizzi R, et al. Immunotherapy in bee sting hypersensitivity. Bee venom versus wholebody extract. Allergy 1979; 34: 369-378. Golden DBK, Kwiterovich KA, Kagey-Sobotka A, Lichtenstein LM. Discontinuing venom immunotherapy: Extended observations. J Allergy Clin Immunol 1998; 101: 298-305. (Received 26 Jun, accepted 15 Oct, 2001) Authors' details Department of Emergency Medicine, Royal Hobart Hospital, Hobart, TAS. Simon G A Brown, FACEM, Director. Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW. Qi-Xuan Wu, MB BS, MMed, Research Assistant. Office of the State Forensic Pathologist, Royal Hobart Hospital, Hobart, TAS. G Robert H Kelsall, FRCPA, Director of Forensic Pathology. Department of Immunology, Allergy and Arthritis, Flinders Medical Centre, Adelaide, SA. Robert J Heddle, FRACP, PhD, Director of Allergy. Research Laboratory, NSL Health Limited, Melbourne, VIC. Brian A Baldo, PhD, Research Director. Reprints will not be available from the authors. Correspondence: Dr Simon G A Brown, Department of Emergency Medicine, Royal Hobart Hospital, GPO Box 1061L, Hobart, TAS 7001. Simon. BrownATutas.edu.au Make a comment 1: Common bull ants (genus, Myrmecia) of Tasmania A B A: The "jack jumper" ant (Myrmecia pilosula) is 10-12 mm long and jet black, except for yellow or orange mandibles and leg tips. B: The "inchman" ant (Myrmecia forficata) is 15-20 mm long with a purple-brown body and black abdomen. Although other Myrmecia species appear similar, M. forficata appears to be the only such species found in appreciable numbers in southern Tasmania. Back to text 2: Immunological methods Immunological studies were performed at the Molecular Immunology Unit of the Kolling Institute of Medical Research, Sydney, NSW, during each forensic investigation. Serum tryptase levels: Tryptase released from mast cells was measured in postmortem serum by radioimmunoassay (reference range, < 2 µg/L in 1995; and < 12 µg/L in 1999, because of reagent changes).11,12 IgE antibody-binding studies: Patient IgE specific for venom was measured by incubating patient serum with venom-coated nitrocellulose discs. IgE that bound to the discs was measured using 125I-labelled anti-IgE, and results expressed as percentage uptake of the radioactive label. Uptake > 2% was considered positive.7 Inhibition studies: The specificity of patient IgE for synthetic venom peptides was investigated as described previously.7,13 Patient serum was pre-incubated with whole venom or synthetic venom peptides to neutralise specific IgE. Remaining venom-specific IgE was then measured by uptake to venom-coated discs as described above, and compared with levels in serum that was not pre-incubated. Percentage inhibition of IgE due to the venom or peptide was calculated. Immunoblot: To investigate specificity of patient IgE further, venom components separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) were transferred to nitrocellulose and then probed with patient serum. Binding of patient IgE to venom components in the gel was detected using 125I-labelled anti-IgE and autoradiography.5,14 Back to text 3: Inhibition and immunoblot studies in Patient 4 Inhibition of IgE binding by Myrmecia pilosula whole venom and synthetic venom peptides Whole M. pilosula venom was a potent inhibitor of IgE binding. Of the purified peptides, only Myr p II caused significant inhibition, which was markedly less than that produced by whole venom. Immunoblot studies (not shown) No binding of patient IgE to venom components separated by SDS-PAGE and transferred to nitrocellulose was identified initially by autoradiography. However, after 2 weeks of film exposure, bands previously noted to represent Myr p II9 became visible. No binding to other bands was apparent. Interpretation These findings suggest that the synthetic peptides and separated venom components do not account for the total allergenic activity of M. pilosula venom, as represented by IgE binding. Back to text

Simon G A Brown · Qi-Xuan Wu · G Robert H Kelsall FRCPA · Robert J Heddle · Brian A Baldo

Although responsibility for health is national, the means to fulfil that responsibility are increasingly global. MJA 2001; 175: 648-651 3 AM. The phone falls to the floor as I grope around in the dark. "We have another one for you, boss", the voice says, with the schadenfreude that the night doctors feel when summoning the on-call staff. "What, another snakebite ?" I wonder what the poor man was doing getting bitten at that hour. It has been a tough night for the emergency doctors. Patients look up hopefully at the first sign of a doctor, while others complain to triage. There is some blood on the floor in the main room; the smell of sweat hangs thick in the air. The interns gesture tiredly in the direction of the resuscitation room. "There is a transfer letter somewhere," they tell me. It is a pithy statement of fact, even for Papua New Guinea. "Thank you for taking K, who is 12 years old. He was bitten by a snake at 6 PM. We have no tet tox or penicillin. We have no antivenom. Yours truly." I'm not sure if they mean to tell me that they have thought of these things, or they are hoping we will provide some for them. Although Australian snakebite mortality rates have fallen more than tenfold since the introduction of the first antivenom 70 years ago1(see Box 1), our nearest neighbour, Papua New Guinea (PNG), has not been so fortunate. Not only do they share with us snakes that are among the most toxic known, but in some areas the snakebite rate is one of the highest in the world.2 Moreover, the consequences of snakebite in PNG are particularly severe; 36% of envenomed patients seen at Port Moresby General Hospital (PMGH) will require ventilation3(see Box 2). In an ironic twist, Gajdusek, whose work on kuru among the Fore people underlies contemporary understanding of "mad cow disease" (which has received much funding and international attention), also reported that snakebite was the commonest cause of death in some of these villages.4 At the same time, the cost of a single ampoule of Australian polyvalent antivenom (CSL Limited), the type most frequently used in PNG,5 at over A$1200, represents approximately half the per capita annual gross domestic product (Anna Leina, Officer in Charge, Pharmacy Department, Port Moresby General Hospital, personal communication). Consequently, even the nation's premier medical institution, Port Moresby General Hospital (PMGH), is frequently without antivenom.6 This situation, unthinkable in Australia, has forced some healthcare centres into managing death adder bites with prolonged pressure bandaging to save scarce antivenom supplies.7The child is not well. Held up by his tired parents, his eyes are heavy from fatigue and from the neurotoxin that is taking over. He is still breathing, with some effort. He does not care that saliva spills from his chin onto his T-shirt. He will need to be ventilated soon, but not yet. His blood does not clot. I have learned not to ask the lab to tell me how long it takes; once I called for missing results only to be told that they couldn't give me a clotting time, as they were still waiting. It has been a steep learning curve for me. The refrigerator in the emergency department has contained two ampoules of sea snake antivenom for a few years now. No-one at the hospital has ever heard of anyone being bitten by a sea snake. The paediatric ward staff tell me they do not have any polyvalent antivenom, but I run across to make sure. It would not be the first time they have tried to save some antivenom. Pharmacy is locked, but I checked there earlier in the day. The nurses in intensive care eye me suspiciously. "We are full, boss." It has been just over a hundred years since Calmette successfully developed the first antivenom, using cobra venom from Indo-China, now Vietnam.8Unfortunately, little has changed regarding antivenom availability for snakebite victims in this region during the past century. The global burden of this eminently treatable condition is estimated at approximately 100 000 deaths each year,9 about a tenth the mortality attributable to malaria. Most of these deaths are concentrated in the Indo-Pacific region,10 where the poor (or absent) access to antivenom for most people results in snakebite mortality orders of magnitude greater than that in Australia (see Box 3). Indeed, tragically, although the burden of snakebite on the local people stimulated Calmette's original studies at the Vaccine Institute in Saigon (now Ho Chi Minh City),11 no snake antivenom was made in Vietnam for the next 100 years. There were five snakebites today and two yesterday — unusual even here. There are over 100 snakebite victims seen each year at Port Moresby General Hospital and we had received 20 ampoules of antivenom in the year 2000. There are seven ventilators. I try again to wrest an ampoule of antivenom from the intensive care ward by telling the staff that this patient might not need to come up to their ward if he had some. They honestly do not have any. I try all the tricks. Neostigmine sometimes helps if the snake was a death adder. I know that over 90% of bites are from taipans, but it is worth a try. I wonder if the scientists who theorised about cholinergic neurotoxins ever thought that it would come to this. It has been said that as the horses used to produce antivenoms for other snake venoms were the same ones used for the taipan antivenom, the antivenoms might have some activity against other snakes. Perhaps the sea snake antivenom might yet be useful. . . We recently proposed a global strategy for snakebite control and procurement of funding to overcome the inequality of antivenom supply.12 This comes amid an acute crisis in antivenom availability for Africa13 and a long-standing undersupply in the Asia-Pacific region14-16(see Box 3). Echoing Nossal's call to awaken the global conscience to the resource constraints facing childhood vaccination,17 we note that the greatest barrier to the widespread availability of antivenoms is not technical, but rather the mobilisation of enough resources. Fortunately for childhood vaccination, the establishment of the Global Fund for Childhood Vaccines by the William H Gates Foundation represents an unprecedented opportunity for infectious disease control by a systematic change in vaccine procurement methods.18 This change recognises that while "responsibility for health is national . . . the determinants of health and the means to fulfil that responsibility are increasingly global".18,19 A similarly coordinated international strategy is required to tackle the neglected issue of snakebite. We propose a comprehensive program that builds on the resources and relationships acquired by the Children's Vaccine Initiative20 and on World Health Organization (WHO) policy initiatives towards securing global access to essential drugs.21 It would employ strategies such as that adopted by the Pan American Health Organization's revolving fund, which emphasises sustainability by long-term government commitment before donor-supported expansion.22 This International Snakebite Initiative (ISI) would recognise that antivenoms are, like vaccines, international public commodities usually manufactured by the same companies facing the same pressures of economics.18 This is already recognised implicitly by the inclusion of antivenoms in the WHO's essential drug list.23 The ISI would require an interdisciplinary and multisectoral partnership maintaining national responsibility and aiming, where possible, for antivenom self-sufficiency. In addition to procurement, it would facilitate the development of new antivenom technology and adjuvant therapies. It would also encourage sustained primary-prevention programs, sponsor research and implement appropriate first-aid methods, ongoing snakebite injury surveillance and improved clinical education tools such as regional snakebite management guidelines. I intubate the boy, leave the intern with the bag, and go back to intensive care and give the staff the bad news. They tell me again that there are no ventilators. I ask which patients' wantoks (relatives) are staying with them. I tell them that we need the ventilator for a child and that they will have to help. I disconnect a patient's ventilator and attach the bag to his tube, explaining to his relatives,"This is how you breathe for him. If you stop, he does not breathe." The lesson is easily understood. We transfer the boy from emergency to intensive care and the other patients' relatives look at us impassively. As highlighted by the reduction in Australian snakebite mortality over the past century, dedicated venom and antivenom research and production saves lives and alleviates suffering. Unfortunately, the global tendency to privatise government-owned antivenom manufacturers,13,24 unleashing free market forces in countries with poor pharmaceutical regulation, threatens the humanitarian task of international snakebite control.13,14,16,25 For example, fake antivenoms are widely sold in Nigeria, and in many countries only charlatans or traditional healers are available to manage snakebite.13,14 These difficulties, combined with the cessation or reduction in antivenom production by traditional manufacturers, such as Aventis Pasteur, have precipitated escalating snakebite mortality in Africa.13Locally, efforts to enhance antivenom availability in PNG through calls for direct or indirect price subsidies16,25 have been ineffective.12,16,25,26 This reflects the general difficulty of facilitating access to essential drugs by appeals to charity or corporate social responsibility.21 Commercial disinterest in this class of pharmaceuticals is clearly evident in the apparent recent withdrawal of the incumbent snake antivenom manufacturer from the United States market.27 This has handed a monopoly to the new producer, which is now selling the most expensive antivenom in the world.14 We therefore argue that a new and more sustainable approach to antivenom procurement is required. Our proposal places antivenoms within global initiatives to secure access to essential drugs, particularly immunotherapeutics, in partnership with donors, the public sector and the pharmaceutical industry.21 Despite these challenges there is room for optimism. The chosen theme of PNG's 25th anniversary of Independence last September was "Walking together", or Raka hebou in Motu and Wokabaut wantaim in Tok Pigin. This theme resonates strongly with our aspirations for regional and global partnerships for snakebite control. Australia, with its distinguished record in antivenom research and development as well as in the Children's Vaccine Initiative, has the potential to play a leading role in the ISI. Countries with a high burden of snakebite, such as PNG and Vietnam, have well-organised national health systems effectively participating in global vaccination programs and disease eradication.28 Australian medical staff assist with snakebite management in regular regional toxinology teaching workshops and courses,29 and by international hospital-based, exchanges, sponsored by Australian institutions.30 Indeed, in the very week of PNG's Silver Jubilee celebrations, two such snakebite workshops were held at PMGH by one of us (K D W). Nevertheless, the need for global snakebite control is urgent and "action plans express no outrage".31 Unless affluent nations like Australia rise to this challenge, variations on our tragic scene will be replayed daily throughout the Asia-Pacific region for want of a 19th-century therapy. Acknowledgements We thank Professor Emeritus Sir Gustav Nossal, Professor Graham Brown and Dr Gabrielle Hawdon of the University of Melbourne, Dr Gertrude Didei of the Port Moresby General Hospital, Dr John Reeder of the Papua New Guinea Institute of Medical Research, and Professor David Warrell, University of Oxford, for their critical review of the manuscript. We are grateful to Dr Forbes McGain for the use of his photograph. Thanks also to CSL Limited and Boucher and Muir for sponsoring K W's trip to Port Moresby and to the ongoing Medical Officer, Nursing and Allied Health Training Project, for its support of A C's part in the registrar exchange program with PMGH. We acknowledge the continuing support of the Victorian Department of Human Services for the work of the Australian Venom Research Unit. Competing interests None declared. The preparation of this article received no specific funding from any organisation. References Winkel KD. Strychine, ammonia and gunpowder for snake bite — the end of an era. Med J Aust 2001; 174: 607. Lalloo DG, Trevett AJ, Saweri A, et al. The epidemiology of snake bite in the Central Province and National Capital District, Papua New Guinea. Trans R Soc Trop Med Hyg 1995; 89: 178-182. Warrell DA, Lalloo DG. Snake bite and its treatment in Papua New Guinea. In: O'Shea M, editor. A guide to the snakes of Papua New Guinea. Madang, Papua New Guinea: Christensen Research Institute, 1996. Gajdusek DC. Urgent opportunistic observations: the study of changing, transient and disappearing phenomena of interest in disrupted primitive human communities. In: Ciba Foundation Symposium 49 (new series), editors. Health and diseases in tribal societies. Amsterdam: Elsevier, 1977. Trevett AJ, Lalloo DG, Nwokolo NC, et al. Venom detection kits in the management of snakebite in Central Province, Papua New Guinea. Toxicon 1995; 33: 703-705. Dyke T. In the tail of the taipan. A personal view of snakebite and serum sickness. Med J Aust 1995; 163: 614-615. Oakley J. Managing death adder bite with prolonged pressure bandaging. In: Handbook, Millennium 2000, the 36th PNG Medical Society Symposium. Port Moresby, Papua New Guinea: PNG Medical Society, 2000: 24. Calmette A. Propriétés du sérum des animaux immunisés contre le venin des serpents; thérapeutique de l'envenimation. C r hebd Seanc Acad Sci Paris 1894; 118: 720-722. Chippaux J-P. Snake bites: appraisal of the global situation. Bull World Health Organ 1998; 76: 515-524. WHO/SEARO guidelines for the clinical management of snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999; 30 (Suppl 1): 1-85. Calmette A. étude éxperimentale du venin de Naja tripudians or cobra capel. Ann l'Institute Pasteur 1892; 6: 160-183. Cheng AC, Winkel KD. Call for global snakebite control and procurement funding [letter]. Lancet 2001; 357:1132. Theakston RD, Warrell DA. Crisis in snake antivenom supply for Africa [letter]. Lancet 2000; 356: 2104. McNamee D. Tackling venomous snake bites worldwide [news]. Lancet 2001; 357: 1680. Currie B, Vince J, Naraqi S. Snake bite in Papua New Guinea. PNG Med J 1988; 31: 195-198. Currie B. Medicine in tropical Australia: the quality and price of snake antivenoms [letter]. Med J Aust 1993; 159: 284. Nossal GJV. Awakening the global conscience: Who will benefit from new vaccines in the 21st century? Immunol Cell Biol 1997; 75: 584-586. Mahoney RT, Ramachandran S, Xu Z-Y. The introduction of new vaccines into developing countries II. Vaccine financing. Vaccine 2000; 18: 2625-2635. Jamison DT, Frenk J, Knaul F. International collective action in health: objectives, functions and rationale. Lancet 1998; 351: 514-517. Muraskin WA. The politics of international health. Albany: State University of New York, 1998. Scholtz M. WHO's role in ensuring access to essential drugs. WHO Drug Infor 1999; 13: 217-220. Freeman P. The PAHO revolving fund: history, operations and contribution to speeding vaccine introductions. Geneva: Children's Vaccine Initiative, 1999. Essential drugs: WHO Model list, 11th revision. WHO Drug Infor 1999; 13: 245-258. Sutherland SK. The sale of Commonwealth Serum Laboratories: wither antivenom research? Med J Aust 1992; 157: 731-732. Cheng AC, Ratcliff A, Adhikari P. Snake anti-venom in Papua New Guinea. Fellowship Affairs 2000; 19: 26. Sutherland SK. Medicine in tropical Australia: the quality and price of snake antivenoms. Med J Aust 1993; 159: 284. Galli R. The antivenin is safe, but its future is uncertain. West J Med 2001; 175: 91-92. Temu P. Health Secretary's message to the 2000 medical symposium. In: Handbook, Millennium 2000, the 36th PNG Medical Society Symposium. Port Moresby, Papua New Guinea: PNG Medical Society, 2000: 6-9. White J, editor. Clinical toxinology short course. 2001 handbook. Adelaide: University of Adelaide Faculty of Health Sciences, 2001. AusAID. Papua New Guinea program profiles, 1999-2000. Canberra: Australian Agency for International Development, 2001. Einternz EM. International aid and medical practice in the less-developed world: doing it right. Lancet 2001; 357: 1524-1525.(Received 19 Jul, accepted 1 Nov, 2001) Authors' details Duke University Medical Center, Durham, NC, USA. Allen C Cheng, MB BS, Fellow in Infectious Diseases. Department of Pharmacology, University of Melbourne, VIC. Kenneth D Winkel, MB BS, PhD, Director, Australian Venom Research Unit. Reprints: Dr K D Winkel, AVRU, Department of Pharmacology, University of Melbourne, VIC 3010. kdwATunimelb.edu.au Make a comment 1: Snakebite fatalities in Austrlia, 1910-1989 Back to text 2: A young snakebite victim requiring assisted ventilation in the Intensive Care Unit, Port Moresby General Hospital, in September 2001. This patient recovered after receiving two ampoules of Australia-New Guinea polyvalent snake antivenom (CSL Limited). Photograph by Dr Forbes McGain, Fellow, Australian Venom Research Unit. Back to text 3: Reported or derived snakebite mortality rates and the quality and status of antivenom supply, by country, in the Asia-Pacific region, excluding the Indian subcontinent9,10 Country Estimated snakebite mortality* Antivenom quality and supply Burma 100 Reasonable quality, limited supply Vietnam 80 Good quality, very limited supply Papua New Guinea 20 Imported high quality, limited supply Taiwan 2.5 Good quality, uncertain supply Australia 0.2 High quality, excellent supply Thailand 0.2 Good quality, excellent supply Japan No data Good quality, good supply East Timor No data Imported reasonable quality, little supply Malaysia No data Imported from Thailand China No data Quality and supply uncertain Indonesia No data Low quality, very limited supply Philippines No data Low quality, uncertain supply * Per million population per year. No data available for Cambodia and Laos. Many of the data reflect historic patterns and are subject to significant reporting bias. Where it is likely that the rate is an underestimate, such as for Myanmar (Burma), the figures presented here incorporate appropriate adjustments. The comparative assessment of quality combines measures of potency, clinical efficacy, pyrogenicity and acute allergic reaction rates. Back to text

Allen C Cheng · Kenneth D Winkel

Bites and stings Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri Gerard M O'Reilly, Geoffrey K Isbister, Paula M Lawrie, Greg T Treston and Bart J Currie MJA 2001; 175: 652-655 Abstract - Methods - Results - Discussion - Acknowledgements - Conflict of interest - Reference - Authors' details - - More articles on Insects, bites and stings Abstract Objective: To determine the immediate and delayed effects of jellyfish stings, and correlate these with microscopic identification of jellyfish nematocysts. Design: Prospective study of patients presenting with jellyfish stings. Participants and setting: 40 people presenting with jellyfish stings to the emergency department of a teaching hospital in tropical Australia between 1 August 1999 and 31 July 2000. Main outcome measures: Clinical diagnosis (sting by Chironex fleckeri, "Darwin carybdeid" or other jellyfish, or "Irukandji" syndrome); clinical severity; delayed hypersensitivity; and sticky-tape sampling and microscopic identification of nematocysts. Results: Patients were aged 2-50 years, with eight aged under 15 years; 23 were male. Presentations were consistent with C. fleckeri sting in 28 cases, Darwin carybdeid sting in five, and Irukandji syndrome in four. Sticky-tape sampling was done in 39 patients and was positive for C. fleckeri nematocysts in 23 and for non-C. fleckeri nematocysts in six, with nematocysts not detected in 10 (including all four with Irukandji syndrome). All microscopically confirmed C. fleckeri stings had typical clinical presentations. None of the stings were life-threatening, and no antivenom was given. Delayed hypersensitivity reactions were seen in 11 of the 19 patients (58%) followed up after stings positive for C. fleckeri nematocysts. Conclusions: Although most jellyfish stings presenting to Royal Darwin Hospital were caused by C. fleckeri, severe envenomation was rare. There was a strong association between clinical features and sticky-tape identification of nematocysts. Delayed hypersensitivity was common after C. fleckeri stings. Box jellyfish stings have historically been an important cause of mortality and morbidity in coastal tropical Australia.1-3 The most common cause of sting presentations to the Royal Darwin Hospital (NT) is the major box jellyfish Chironex fleckeri (Class Cubozoa; Order Chirodropidae)4-6(Box 1A). It is responsible for most severe cases of jellyfish envenomation.1-4 Clinical manifestations include immediate local pain with visible linear tentacle marks and, in severe stings, systemic effects with cardiorespiratory arrest possible within minutes.1-4,6-8 However, fatalities are rare, and the clinical spectrum is not evident from published case reports, which mostly present fatal or near-fatal cases. In addition, it is not clear whether delayed hypersensitivity, which has been reported after other jellyfish stings, is a feature of C. fleckeri stings.1The "Irukandji" syndrome has been associated with stings by Carukia barnesi (Class Cubozoa; Order Carybdeidae)9,10 (Box 1C), although other jellyfish may cause a similar syndrome.11C. barnesi has rarely been found in the Northern Territory (P Alderslade, Curator of Coelenterates, Museum and Art Gallery of the Northern Territory, Darwin, NT, personal communication), and the Irukandji syndrome is less common than in far north Queensland.10,11 Other jellyfish species appear to cause some stings in the Darwin region.1,4 These include the "Darwin carybdeid",1 a four-tentacled jellyfish larger than C. barnesi, which appears to cause less severe skin damage than C. fleckeri. We conducted a prospective study of all jellyfish-sting presentations to Royal Darwin Hospital over 12 months in 1999 and 2000. Our aim was to determine the immediate and delayed effects of all marine stings, and to correlate these with microscopic identification of jellyfish nematocysts using the sticky-tape sampling technique.6 Methods The study included all patients who presented to the Royal Darwin Hospital after a jellyfish sting between 1 August 1999 and 31 July 2000. The study was approved by the Joint Institutional Ethics Committee of the Royal Darwin Hospital and the Menzies School of Health Research. Patients were assessed and treated in the Emergency Department according to the Royal Darwin Hospital protocol12(Box 2). Clinical and demographic details were entered prospectively, along with details of hospital management, on a standardised form. Details included investigations (eg, electrocardiography [ECG]), type and effect of analgesia (topical [ice], oral [eg, aspirin or codeine], or parenteral [morphine or pethidine]) and whether C. fleckeri antivenom was administered. The clinical diagnosis was classified as typical or not typical of C. fleckeri sting according to known features (immediate and persistent local pain, linear sting marks and absence of generalised pain, which is seen in Irukandji syndrome).1,3,11 Sticky-tape sampling During the initial presentation, the sting site was sampled for nematocysts using the sticky-tape technique developed in Darwin.6 Transparent sticky tape was applied to the site and then transferred to a microscope slide for examination at x 100 to x 400 magnification. This allows nematocysts of C. fleckeri to be distinguished from those of other jellyfish on the basis of morphology (Box 1B and 1D). Presence of C. fleckeri or other jellyfish nematocysts was determined by one of the authors (P M L) and verified by another (B J C). Follow-up We telephoned patients about three weeks after initial presentation to ask about persistent or delayed effects, especially emergence of a pruritic rash at the site of the initial sting. Results Forty patients presented to Royal Darwin Hospital with jellyfish stings in the 12-month study period. They were aged two to 50 years (median, 21 years), with eight aged under 15 years; 23 were male. Seasonal variation in stings is shown in Box 3. Of the 40 stings, 28 (70%) were clinically typical of C. fleckeri, and 12 (30%) were not typical. Four of the latter were consistent with Irukandji syndrome (minimal local erythema, and delayed systemic symptoms, especially pain), and five with Darwin carybdeid sting (less severe skin pain and markings, with some "overlap" Irukandji features, such as abdominal pain). A typical C. fleckeri sting is shown in Box 4A. Sticky-tape sampling Sticky-tape sampling was done in 39 patients and was positive for nematocysts in 29 — C. fleckeri in 23 and carybdeid-appearing nematocysts in six. Sampling was negative for nematocysts in 10 patients, including all four with Irukandji syndrome. Correlation between microscopic findings and clinical presentation is shown in Box 5. All microscopically confirmed C. fleckeri stings had typical clinical presentations. Of the six patients with carybdeid-appearing nematocysts, five had presentations consistent with Darwin carybdeid envenomation, while one was more consistent with C. fleckeri. Management None of the 40 patients had documented arrhythmias on ECG, or pulmonary oedema. None was treated with pressure-immobilisation bandages or C. fleckeri antivenom, and there were no deaths. Of the 23 patients with stings positive for C. fleckeri nematocysts, one required parenteral analgesia and nine oral analgesia. In five, pain responded to topical ice alone, and eight required no pain relief. None of these patients required admission. Maximum length of tentacle marks was 5 m, followed by 4 m; both patients had severe local pain. Three of the patients with Irukandji syndrome and one stung by an unidentified jellyfish (no nematocysts detected on sticky-tape sampling) required admission for analgesia. Follow-up Twenty-nine patients were followed up, including 19 whose stings were positive for C. fleckeri nematocysts. Of these 19, 11 (58%) had delayed hypersensitivity reactions. These comprised an itchy red maculopapular rash dotted along the initial tentacle contact points consistent with papular urticaria, occurring 7-14 days after first presentation (Box 4B). These reactions resolved spontaneously in seven patients and after treatment with oral antihistamine and topical corticosteroid cream in four. Discussion This is the largest prospective study of C. fleckeri stings to date. Most previously published cases describe fatal or near-fatal stings, and some authors quote mortality rates up to 20%.13 Our study does not support this high mortality rate and showed that most stings were not severe, consistent with previous Northern Territory findings.5-7Although most C. fleckeri stings are minor and not life-threatening, the potential exists for severe systemic envenomation and even death. It is a concern that, despite considerable public education, eight of our cases were in children. The last 10 deaths from C. fleckeri envenomation in the Northern Territory were all of children, most recently a three-year-old girl from a remote Aboriginal community in February 1996.4 In January 2000, a five-year-old boy died soon after a jellyfish sting near Yarrabah, in north Queensland, presumed to be from C. fleckeri.14 In the past, considerable attention has focused on the use of antivenom in C. fleckeri envenomation.3,8,15-17 Indications have been cardiac arrest and arrhythmias, analgesia or cosmesis, although evidence supporting the efficacy of antivenom remains limited.7 None of our patients received antivenom, as none had cardiac toxicity, and severe local pain was controlled with appropriate analgesia. Nevertheless, it is crucial that antivenom is available for early use in life-threatening situations with arrhythmias or cardiorespiratory arrest. None of our patients had pressure-immobilisation bandages applied. These bandages are not recommended in the Northern Territory, as they potentially increase nematocyst discharge and are unlikely on theoretical grounds to prevent venom absorption.7,12,18 Delayed skin eruptions have been reported after jellyfish stings, although C. fleckeri has not been specifically implicated.19-21 These eruptions typically occurred at the site of the original sting after five days or more, and were pruritic and painless.1 Their histological features were generally consistent with delayed (type IV) hypersensitivity reactions.20 They are likely to be a response to retained foreign material, such as nematocyst thread or other cellular substances injected into the dermis, but specific antigens have not been identified. In our study, over half the patients followed up after stings positive for C. fleckeri nematocysts had delayed skin eruptions clinically resembling papular urticaria, similar to those reported after other jellyfish stings.19-21 This confirms that delayed cutaneous hypersensitivity reactions are common after C. fleckeri stings. Corticosteroid cream, with or without systemic antihistamines, may help relieve symptoms of delayed reactions.1,7 Correlation of sticky-tape sampling with clinical presentation suggests that there were no false-positive identifications of C. fleckeri nematocysts. The false-negative rate is unknown. However, as the test was negative for nematocysts in only three cases that appeared clinically typical of C. fleckeri envenomation, correlation with clinical findings appears good. While all the non-C. fleckeri nematocysts detected were carybdeid in appearance, degenerate C. fleckeri nematocysts may sometimes appear similar. Further description and classification is needed of the Darwin carybdeid and other local jellyfish yet to be identified. Clinical features of most of the carybdeid nematocyst-positive stings differed from those of both C. fleckeri stings and the Irukandji syndrome. The Darwin carybdeid appears to cause local pain from tentacle marks, but this pain is less severe than in C. fleckeri stings. The Darwin carybdeid also causes some "overlap" systemic symptoms, similar to those of a mild Irukandji syndrome. Two earlier stings with these features were confirmed to be caused by the Darwin carybdeid through capture and examination of the jellyfish, as well as microscopic identification of nematocysts1 (Currie BJ, unpublished data). Finally, although life-threatening envenomation is uncommon, we should continue to pursue public education and prevention policies vigorously. Deaths from severe C. fleckeri envenomation will inevitably occur while people, especially children without protective clothing, enter tropical waters in Australia. Acknowledgements We would like to acknowledge support from the Cooperative Research Centre for Aboriginal and Tropical Health; from the National Health and Medical Research Council Centre of Clinical Excellence grant to the Northern Territory Clinical School, Royal Darwin Hospital; and the staff of the Emergency Department, Royal Darwin Hospital, particularly Carole Mansfield and Marg St Leone. We would also like to acknowledge Phil Alderslade (Northern Territory Museum, Darwin) for assistance and for the photograph of the Darwin carybdeid. Conflict of interest There was no specific funding for this study and no conflict of interest. References Williamson JA, Fenner PJ, Burnett JW, Rifikin JF. Venomous and poisonous marine animals. 1st ed. Sydney: University of New South Wales Press, 1996. Williamson JA, Callanan VI, Hartwick RF. Serious envenomation by the northern Australian box-jellyfish (Chironex fleckeri). Med J Aust 1980; 1: 13-15. Williamson JA, Le Ray LE, Wohlfahrt M, Fenner PJ. Acute management of serious envenomation by box-jellyfish (Chironex fleckeri). Med J Aust 1984; 141: 851-853. Currie BJ. Clinical toxicology: a tropical Australian perspective. Ther Drug Monit 2000; 22: 73-78. Currie BJ, Khanh DM, Alderslade P, et al. Jellyfish envenomation in the Northern Terrritory of Australia. Toxicon 1992; 30: 501. Currie BJ, Wood YK. Identification of Chironex fleckeri envenomation by nematocyst recovery from skin. Med J Aust 1995; 162: 478-480. Currie B. Clinical implications of research on the box-jellyfish Chironex fleckeri. Toxicon 1994; 32: 1305-1313. Lumley J, Williamson JA, Fenner PJ, et al. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust 1988; 148: 527-534. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904. Little M, Mulcahy RF. A year's experience of Irukandji envenomation in far north Queensland. Med J Aust 1998; 169: 638-641. Fenner PJ, Williamson JA, Callanan VI, Audley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Currie B. Box-jellyfish in the Northern Territory. N T Dis Control Bull 1998; 5: 12-14. Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. In: Tintinalli JE, Ruiz E, Krome RL, editors. Emergency medicine — a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996: 868-873. Lill J. Fatal sting. Box jellyfish kills boy, 5. The Cairns Post 2000 Jan 25: 1. King GK. Acute analgesia and cosmetic benefits of box-jellyfish antivenom. Med J Aust 1991; 154: 365-366. Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Management of a major box jellyfish (Chironex fleckeri) sting. Lessons from the first minutes and hours. Med J Aust 1992; 156: 655-658. Holmes JL. Marine stingers in far north Queensland. Australas J Dermatol 1996; 37 Suppl 1: S23-S26. Pereira PL, Carrette T, Cullen P, et al. Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Med J Aust 2000; 173: 650-652. Reed KM, Bronstein BR, Baden HP. Delayed and persistent cutaneous reactions to coelenterates. J Am Acad Dermatol 1984; 10: 462-465. Pierard GE, Letot B, Pierard F. Histologic study of delayed reactions to coelenterates. J Am Acad Dermatol 1990; 22: 599-601. Burnett JW, Cobbs CS, Kelman SN, Calton GJ. Studies on the serologic response to jellyfish envenomation. J Am Acad Dermatol 1983; 9: 229-231.(Received 20 Apr, accepted 13 Aug, 2001) Authors' details Royal Darwin Hospital, Darwin, NT. Gerard M O'Reilly, MB BS, Emergency Registrar; currently, Emergency Registrar, Alfred Hospital, Melbourne, VIC. Geoffrey K Isbister, BSc, MB BS, Emergency Registrar; currently, Toxicology Registrar, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Hospital, Newcastle, NSW. Greg T Treston, DTMH, DIMCRCS, FACEM, Director of Emergency Department; currently Consultant, Emergency Department, John Flynn Hospital, Tugun, QLD. Menzies School of Health Research, Darwin, NT. Paula M Lawrie, BSc, Technical Officer. Bart J Currie, FRACP, FAFPHM, DTMH, Head of Tropical Medicine and International Health Unit; and Professor in Medicine, NT Clinical School, Darwin, NT. Reprints will not be available from the authors. Correspondence: Professor B J Currie, Tropical Medicine and International Health Unit, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811. bartATmenzies.edu.au Make a comment 1: Common Northern Territory jellyfish and their nematocysts Chironex fleckeri A. B. Nematocysts from C. fleckeri (original magnification, x 400; sticky-tape preparation; no stain). "Darwin carybdeid" C. D. "Darwin carybdeid" nematocyst (original magnification, x 1000; eosin stain). Nematocysts from C. fleckeri are usually elongated ellipses (cigar-shaped), while those from carybdeid (four-tentacled box-jellyfish) species are usually less elongated and more lemon-shaped or round. Back to text 2: Protocol for hospital treatment of Chironex fleckeri stings in the Northern Territory 1. If necessary, attend to airway, breathing and circulation and give oxygen. 2. Apply vinegar to the stings for at least 30 seconds to inactivate remaining nematocysts. 3. If patient is unconscious or has life-threatening cardiac or respiratory decompensation or significant arrhythmia, administer at least one ampoule of antivenom intravenously (20 000 units per ampoule, diluted 1:10 with an isotonic crystalloid solution such as Hartmann's solution or isotonic saline, given over 5-10 minutes). In a life-threatening situation where response remains inadequate, up to three ampoules may be given consecutively. 4. Cardiopulmonary resuscitation should be continued in a patient with ongoing cardiac arrest until after further therapy with antivenom (at least six ampoules total dose if available) and consideration of cardioactive drugs. 5. For non-life-threatening stings (no cardiac or respiratory decompensation), use ice-packs for initial pain relief, together with oral or parenteral analgesia if necessary (pethidine, 1 mg/kg up to 50 mg adult dose initially, or morphine, 0.1 mg/kg up to 5 mg initially, but can be repeated). For pain not relieved by ice-packs and narcotic analgesia, administer one ampoule of antivenom intravenously as above. Back to text 3: Jellyfish sting presentations to Royal Darwin Hospital, 1999-2000 Back to text 4: Chironex fleckeri stings A. Severe sting on Day 2. B. Hypersensitivity reaction seen 10 days after a sting. Back to text 5: Correlation between clinical presentation and nematocyst identification in 39* jellyfish stings Nematocyst appearance Presentation Chironex fleckeri Other jellyfish† Not detected Typical of C. fleckeri (n = 27)* 23 1 3 Not typical 0 5 7 "Irukandji" syndrome (n = 4) 0 0 4 Other (n = 8) 0 5 3 * Nematocyst sampling was not performed in one patient with a typical C. fleckeri presentation. † All non-C. fleckeri-appearing nematocysts were consistent with carybdeid nematocysts, although degenerate C. fleckeri nematocysts may sometimes look similar. Back to text

Gerard M O'Reilly · Geoffrey K Isbister · Paula M Lawrie · Greg T Treston · Bart J Currie

Hazards and help in communications The personal digital assistant: a new medical instrument for the exchange of clinical information at the point of care Personal digital assistants can provide a portable, integrated platform for point-of-care clinical reference, patient management and data communication. Clinical reference programs allow the user to access information from the Internet and guidelines. Patient management programs allow doctors to access and store clinical information. Wireless technologies have potential for rapid exchange of clinical laboratory results and efficient "electronic patient handovers". Thus, these devices provide the potential for true continuity of care across the healthcare system. Robert A Wilcox and Ralph R La Tella MJA 2001; 175: 659-662 Applications of PDAs in clinical practice - Palm OS PDAs - Security issues - Choosing a PDA for medical practice - Conclusion - Competing interests - References - Authors' details - - - More articles on Infectious diseases and parasitology The use of mobile "evidence carts", consisting of evidence-based medicine (EBM) and medical reference material stored in laptop computers or paper inventories, increases the extent to which evidence is incorporated into patient care decisions.1 However, "evidence carts" cannot be readily taken on bedside rounds or home visits.1 Doctors need a mobile instrument that can provide access to EBM and other clinical data resources at the point-of-care. Recent advances in computer technology have produced efficient, powerful and very compact computers called personal digital assistants (PDAs) (see Box 1 for illustrations of typical models), which have the potential to fulfil many of these demands. PDAs offer built-in appointment, memo and address books, but are capable of much more than just personal information management. They can run a wide range of programs, document readers, databases and calculators. Many programs and data files can be found on the Internet, available at no charge ("freeware"), a nominal charge ("shareware") or commercially. These resources allow PDAs to function as sophisticated reference, organisation and communication devices. PDAs have several important features that distinguish them from desktop and laptop personal computers (PCs). PDAs turn on almost instantly and crash less frequently. Palmtop PDAs use handwriting recognition systems or on-screen keyboards to allow text input via a stylus on a touch-sensitive screen. PDAs can connect to PCs to exchange programs and data. This process is referred to as "hot-synching" and is commonly accomplished via a "cradle" device connected to the PC. Many PDAs also use wireless infrared transceiver ports to directly communicate with compatible PDAs and printers (a process known as "beaming"). Some PDA models can also use compact flash or other memory cards for direct data exchange. Two major operating systems (OS) exist: Windows CE and Palm. Windows CE seeks to be a miniaturised version of the Microsoft Windows OS used on PCs, but will not run Windows 95/98/2000/NT software. It allows efficient file transfer into many programs running under Windows and is popular within the business community. In contrast, the Palm OS has become the defacto standard for medical professionals. Thousands of Palm OS medical programs, databases, medical textbooks and medical web-sites are available. As more than 75% of all PDAs use the Palm OS, most PDA medical software developers concentrate on creating applications for these PDAs. Consequently, we will focus primarily on reviewing Palm OS PDAs and the applications of most value to medical professionals in Australia. Applications of PDAs in clinical practice Point-of-care prescribing When medication is given to a patient, four major processes occur: prescribing, transcribing, dispensing and administration.2 Most doctors are involved in prescribing and transcribing, and some are involved in all four stages. Dosing errors or inappropriate drug choice can cause predictable adverse drug reactions. These events are common in hospital and community practice.3-6 A recent study conducted by the United States Institute of Medicine reported that medication errors cause an estimated 7000 fatalities annually, exceeding the number of US workplace-related deaths.7 Many doctors are surprised to learn that most adverse drug events are primarily caused by physician error,3 and that many of these errors result from a problem with point-of-care drug knowledge.8In the US, drug databases have been developed by "eProcrates".9 These deliver clinical drug information on Palm OS PDAs. The "ePocrates qRX" drug database is used by more than 300 000 medical professionals worldwide.9 Several major US teaching hospitals, such as Stanford University and Duke University, supply PDAs preloaded with ePocrates qRx to their physicians in the hope of improving prescribing and reducing adverse drug events.9 This initiative was supported by a survey of 870 users of ePocrates qRx, in which 50% of respondents were of the opinion that using ePocrates prevented at least one adverse drug event per user per week, with the added benefit of improved physician drug knowledge and a reduction in the time required for drug selection.10 Currently, there is no comprehensive PDA-based pharmacopoeia covering medications used within the United Kingdom, Europe or Australasia. However, many Australasian doctors will find ePocrates qRx valuable, albeit with the drawbacks of differing drug nomenclature and availability than in the US. A PDA version of the Australian Medicines Handbook (AMH) is in development and MIMS on PDA is scheduled for release in February 2002. Document managers Document managers are applications used to create an electronic text library on the PDA. The Palm OS stores text in "doc" files, which are read and sometimes composed in various "doc readers".11 Among the more popular shareware doc readers are TealDoc12 and iSilo.13 Documents-to-Go14 includes a document and spreadsheet reader and editor that allows conversion of Microsoft Word and Excel files to doc format. Similarly, Wordsmith15 allows the free transfer of fully formatted word-processor files between PCs and PDAs and replaces the standard Memopad of the Palm OS with a searchable memo and document-handling application. Doctors can thus create documents or take pre-existing medical protocols from their PCs and convert them to the doc format. Hundreds of useful doc and smaller "memo" files can be downloaded from medical PDA text file repositories.16-20 Database managers Database managers are another important group of applications for organising medical data. These programs allow the user to design data entry forms for tasks such as tracking patients, comparing normal and abnormal laboratory results, or comparing similar diseases. Database files are ideal for rapid medical reference instead of laboriously searching through doc files. Popular database programs include JFile,21 TealInfo12 and HandDbase.22 HandDbase is particularly powerful because of its "relational" database features. For example, this allows clinicians to construct a patient-tracking system with links to drug details, differential diagnoses and medical procedures and protocols. The use of PDAs for point-of-care database entry has been successfully trialled in emergency medicine,23 clinical audits,24 clinical trials25 and for clinical encounter and procedure logbooks.26-28 Furthermore, patients themselves have been provided with PDAs to document their own symptoms in real time.29,30 Medical electronic textbooks Medical electronic textbooks (e-texts) have been published for PDAs, usually based on US medical publications. The most popular titles include the 5 Minute Clinical Consult, Harrison's Principles of Internal Medicine Companion Handbook, the Merck Index and the Washington Manual of Medical Therapeutics.17-19,31,32 Web clipping "Web-clipping" programs allow capture of web page content for use on a PDA. PDA users choose medical sites they wish to review regularly. When the user activates the program, the PDA connects to the Internet through a desktop PC during hot-synching or via a mobile phone-modem connection. The PDA then saves the web pages for later viewing. The most popular freeware web-clipping program for Palm OS is AvantGo.33 Some useful sites include medical news updates and reviews (eg, Medscape34), journal abstracts (eg, British Medical Journal35) and EBM web pages (eg, the Centre for EBM in Oxford36). The Palm OS offers considerable flexibility as a communications tool with the addition of the Eudora Internet kit. With this kit and any infrared, modem-enabled phone, one can send and receive email and access web "Palm Query Applications" (PQAs).37 PQAs are essentially web-clippings or scaled-down versions of useful web sites which can be rapidly accessed. Some useful PQAs for physicians are available at EmedHome.38 These include journal articles and clinical protocols. Medical calculators Medical calculators help doctors make better decisions, give better advice to their patients and avoid calculation errors. Hundreds of medical calculators are available, and some programs consolidate several calculators to a single PDA application (Box 2). Clinical organisers Doctors are constantly striving to be efficient coordinators of patient care. In group practices or during hospital ward rounds, the PDAs of each team member can be synchronised and patient information beamed in an efficient "electronic handover". In addition, several excellent patient management applications have been written (see Box 3 for a typical screenshot).46-48 Palm OS PDAs Within Australia, three major companies market Palm OS PDAs: Handspring, Handera and Palm. Comparisons and reviews of each model can be found at "PDA-Buzz".49 The Handspring PDAs use a proprietary "Springboard" expansion slot that allows addition of modules with extra memory, some pre-packaged medical books, and devices such as cameras, modems and phones. However, Springboard expansion modules are quite expensive and can only be used in Handspring PDAs. In contrast, Handera PDAs use industry-standard "compact flash" data storage cards, and Palm 500/505 PDAs use the smaller industry-standard "multimedia cards" and "secure digital" cards. Handera pioneered software allowing programs to be run directly off a compact flash card, making these PDAs ideal for large applications and e-texts. Furthermore, the entire memory can be saved and restored from the card independently of "hot-synching", and card readers are available to allow direct PC connection independent of the PDA.50 Palm and Handera PDAs also use multimedia cards and secure digital cards to allow addition of devices including digital cameras, modems, phones and Bluetooth radios. Handspring have recently released an adaptor Springboard that allows their PDAs to use compact flash cards.51 However, the Handera 330 retains the unique advantage of possessing expansion slots for multimedia, secure digital, and compact flash cards.52 The Bluetooth wireless technology is a particularly exciting development for PDAs. It provides high-speed, reliable, short-range radio links between PDAs, PCs, mobile phones and other devices.53 Bluetooth wireless technology has built-in security encryption and authentication, and could potentially fulfil an important role as an in-hospital communication and data exchange system for confidential patient information. Security issues Security of confidential patient information on PDAs is a significant concern. These devices are small and can be easily misplaced or stolen. Consequently, physicians should address security issues before entering confidential patient information. There are a number of security programs that provide password control of confidential files.12,16 Although individual PDAs are easy to secure, it must be remembered that the PDA contents are usually replicated on every PC with which the PDA is hot-synched. Protection for this hot-synched data is essential. One solution may be the distribution of clinical updates, laboratory and pathology results via compact flash, secure digital or multimedia cards, or via encrypted broadcast data systems, thus removing the requirement for hot-synching. Doctors at Cedars-Sinai Medical Center in the US have recently reported a successful trial of secure remote access to clinical data repositories using encrypted transmission and wireless PDAs.54 Choosing a PDA for medical practice There are a number of important factors to consider when choosing a PDA for medical practice. Physical size: The device should fit into a pocket or easily clip onto a belt. Battery life: Efficient point-of-care computing demands a battery life at least as long as your medical workday. Most PDAs have battery lives of 2-8 weeks, with colour displays depleting batteries about twice as fast as monochrome screens. Screen clarity: Current PDAs offer very high-resolution screens; nevertheless, clarity can depend on the software applications used. Both Handspring and Palm offer colour screens. Colour can improve screen clarity, but is currently used by few medical applications. Adequate memory: Medical applications, especially e-texts, tend to be large (1-5 MB). Thus, 8 MB memory should be considered the minimum for a PDA. Many medical users will soon find they require the memory expansion slots. PC synchronisation: Choose a PDA which can easily synchronise with your PC. Newer PCs may require USB (universal serial bus) synchronisation docks and cable connectors. Some useful resources for use of PDAs in medical practice are listed in Box 4. Conclusion PDAs will soon take full advantage of wireless communication technology. These PDAs will integrate the electronic medical records, medical references, EBM and guideline implementation and allow coordination of clinical communications. Thus, with increased use of PDAs by doctors, there should be improvements in the quality and continuity of patient care. Australian doctors can help achieve these gains by actively participating in the development and use of these devices. In the near future, many doctors will find their PDA to be an essential medical instrument, as indispensable as their stethoscope. Competing interests Ralph R La Tella is the editor-in-chief of The Guide to Handheld and Palmtop Computing Resources for Health Care Professionals and receives payment for this publication. Neither author has received any remuneration from any personal digital assistant hardware or software developer, manufacturer or retailer discussed in this article. References Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the "evidence cart". JAMA 1998; 280: 1336-1338. Anderson J, Jay S, Anderson M, Hunt T. Evaluating the potential effectiveness of using computerized information systems to prevent adverse drug events. Proc AMIA Annu Fall Symp 1997, Nashville, Tenn, USA. Available at: <http://medicine.ucsd.edu/f97/d004258.htm>. Accessed 20 November 2001. Bates D, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 1993; 8: 289-294. Bates D, Cullen D, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995; 274: 29-34. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: 1200-1205. van den Bemt P, Egberts A, Lenderink A, et al. Risk factors for the development of adverse drug events in hospitalized patients. Pharm World Sci 2000; 22: 62-66. Koln LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on Quality of Health Care in America. Washington DC: The Institute of Medicine. National Academy Press, 1999. Available at <http://books.nap.edu/html/to_err_is_human/exec_summ.html>. Leape L, Bates D, Cullen D, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274: 35-43. ePocrates [website]. <http://www.epocrates.com/>. Accessed 13 November 2001. Rothschild JM, Lee TH, Taran B, et al. Survey of physicians' experience using a handheld drug reference guide. Proc AMIA Symp, 4-6 November 2000, Los Angeles, CA, USA. Available at <http://www.amia.org/pubs/symposia/D200652. PDF>. Accessed 20 November 2001. Strietelmeier J, Clark J, Brandwein E. DOC readers for Palm OS PDAs review. <www.the-gadgeteer.com/docreaders-review.html>. Accessed 13 November 2001. Tealpoint software [website]. <http://www.tealpoint.com>. Accessed 13 November 2001. iSilo [website]. <http://www.isilo.com>. Accessed 13 November 2001. DataViz [website]. <http://www.dataviz.com>. Accessed 13 November 2001. Blue Nomad software [website]. <http://www.bluenomad.com>. Accessed 13 November 2001. Tucows Downloads [website]. <http://www.tucows.com>. Accessed 13 November 2001. Palmgear [website]. <http://www.palmgear.com>. Accessed 13 November 2001. Handango [website]. <http://www.handango.com>. Accessed 13 November 2001. Handheldmed [website]. <http://www.handheldmed.com>. Accessed 13 November 2001. MemoWare — the PDA document repository [website]. <http://www.memoware.com>. Accessed 13 November 2001. Land-J Technologies PalmOS apps [website]. <http://www.land-j.com/palmapps.html>. Accessed 13 November 2001. DDH software [website]. <http://www.ddhsoftware.com>. Accessed 13 November 2001. Lal S, Smith F, Davis J, et al. Palm computer demonstrates a fast and accurate means of burn data collection. J Burn Care Rehabil 2000; 21: 559-561. Curl M, Robinson D. Handheld computers in clinical audit: a comparison with established paper and pencil methods. Int J Health Care Qual Assur 1994; 7: 16-20. Breitfeld P, Weisburd M, Overhage J, et al. Pilot study of a point-of-use decision support tool for cancer clinical trials eligibility. J Am Med Inform Assoc 1999; 6: 466-477. Garvin R, Otto F, McRae D. Using handheld computers to document family practice resident procedure experience. Fam Med 2000; 32: 115-118. Hammond E, Sweeney B. Electronic data collection by trainee anaesthetists using palm top computers. Eur J Anaesthesiol 2000; 17: 91-98. Rosenthal M, Wolford R. Resident procedure and resuscitation tracking using a palm computer. Acad Emerg Med 2000; 7: 1171. Peters M, Sorbi M, Kruise D, et al. Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain. Pain 2000; 84: 181-192. Jamison RN, Raymond SA, Levine JG, et al. Electronic diaries for monitoring chronic pain. Pain 2001; 91: 277-285. CollectiveMed — Medical software, PDA hardware and books [website]. <http://www.collectivemed.com>. Accessed 13 November 2001. Franklin Electronic Publishers [website]. <http://www.franklin.com/estore>. Accessed 13 November 2001. AvantGo — Mobile solutions for today's business [website]. <http://www.avantgo.com>. Accessed 13 November 2001. Medscape [website]. <http://www.medscape.com>. Accessed 13 November 2001. Electronic BMJ (British Medical Journal) [website]. <http://www.bmj.com>. Accessed 13 November 2001. NHS research and development. Centre for evidence-based medicine [website]. <http://cebm.jr2.ox.ac.uk>. Accessed 13 November 2001. Palm Asia Pacific [website]. <http://www.palm.com.au>. Accessed 13 November 2001. eMedHome — emergency medicine's home page [website]. <http://www. emedhome.com>. Accessed 13 November 2001. StacWorks [website]. <http://www.stacworks.com>. Accessed 13 November 2001. Pocket-Doc.com [website]. <http://pocket-doc.com>. Accessed 13 November 2001. Spiro's Palm page [website]. <http://pages.sprint.ca/Spiros/general3.html>. Accessed 13 November 2001. MedMath [website]. <http://mail.med.upenn.edu/~pcheng/medmath/index.html>. Accessed 13 November 2001. MedRules [website]. <http://pbrain.hypermart.net/medrules.html>. Accessed 13 November 2001. STAT cardiac risk [website]. <http://www.statcoder.com/cardiac.htm>. Accessed 13 November 2001. STAT GrowthCharts [website]. <http://statcode.hypermart.net/growthcharts.htm>. Accessed 13 November 2001. PatientKeeper [website]. <http://www.patientkeeper.com>. Accessed 13 November 2001. WardWatch hospital ward round aid [website]. <http://www.watch.aust.com/pilot/wardwatch>. Accessed 13 November 2001. Medtopia [website]. <http://www.medtopia.com>. Accessed 13 November 2001. PDABuzz reviews [website]. <http://www2.pdabuzz.com/Reviews>. Accessed 13 November 2001. Lexar Media — the digital film company [website]. <http://www.digitalfilm.com>. Accessed 13 November 2001. Handspring [website]. <http://www.handspring.com>. Accessed 13 November 2001. HandEra [website]. <http://www.handera.com>. Accessed 13 November 2001. The official Bluetooth wireless info site [website]. <http://www.bluetooth.com>. Accessed 13 November 2001. Duncan R, Shabot M. Secure remote access to a clinical data repository using a wireless personal digital assistant (PDA). Proc AMIA Symp, Los Angeles, CA, USA, 4-6 November 2000. Available at <http://www.amia.org/pubs/symposia/D200798. PDF>. Accessed 20 November 2001. Medical software for handheld, palmtop computer and PDAs [website]. <http://www.medicalsoftwareforpdas.com/>. Accessed 13 November 2001. Arizona health sciences library. PDAs for health care providers [website]. <http://educ.ahsl.arizona.edu/pda/index.htm>. Accessed 13 November 2001. Washington University Medical Palm Initiative [website]. <http://medicine.wustl.edu/~wumpi/>. Accessed 13 November 2001. pdaMD.com [website]. <http://www.pdamd.com>. Accessed 13 November 2001. Healthy Palmpilot [website]. <http://www.healthypalmpilot.com>. Accessed 13 November 2001. Peripheral Brain [website]. <http://pbrain.hypermart.net>. Accessed 13 November 2001. Medical Piloteer [website]. <http://www.medicalpiloteer.com>. Accessed 13 November 2001. Doctor'sPalm.com [website]. <http://www.doctorspalm.com/index.htm>. Accessed 13 November 2001. The virtual medical center [website]. <http://www.geocities.com/HotSprings/Spa/6134/doctor.html>. Accessed 13 November 2001. The pediatric pilot page [website]. <http://www.keepkidshealthy.com/pedipilot.html>. Accessed 13 November 2001. Pediatrics on hand [website]. <http://pediatricsonhand.com>. Accessed 13 November 2001. (Received 24 May, accepted 10 Sep, 2001) Authors' details Department of Medical Biochemistry, Flinders Medical Centre, Bedford Park, SA. Robert A Wilcox, MB BS, BSc(Hons), PhD, Registered Medical Officer and Medical Researcher Ashfield, NSW. Ralph R La Tella, BSc(Hons), Health Information Consultant Reprints will not be available from the authors. Correspondence: Dr R A Wilcox, Department of Medical Biochemistry, Flinders Medical Centre, Bedford Park, SA 5042. wilcwhitATozemail.com.au Make a comment 1: Examples of personal digital assistants Handera 330 Handspring Visor Pro Palm m505 Back to text 2: Medical calculators for personal digital assistants ABG Pro: Calculates arterial blood gas and acid/base status.39 DoseCalcPlus: Calculates the dose of paediatric drugs based on the patient's weight.40 Doser: Calculates drug infusion rates in various units (mg/kg/min, etc).41 MedMath: A freeware program for calculating various equations used in medicine (eg, body mass index, creatinine clearance rate).42 MedRules: Calculates various clinical prediction rules (eg, pre-operative cardiac risk).43 RiskyDisky: Uses predictive models to calculate the risk of female breast cancer.17 STAT cardiac risk: Automates the latest update of the Framingham Heart Study prediction scores.44 STAT Growth Charts: Calculates the growth percentiles of children.45 Back to text 3: A typical screenshot from "WardWatch",47 a PDA patient management application Back to text 4: Resources for medical users of personal digital assistants The 2000 Guide to Handheld and Palmtop Computing Resources for Health Care Professionals55 A guide to medical resources for all PDA platforms, compiled by La Tella, coauthor of this article (downloadable for a small fee). Explanatory notes accompany each product, often with actual screen shots of the application. PDAs for Health Care Providers56 A webpage providing links to health-related resources for Palm OS and Windows CE PDAs from the Arizona health services library. Additional sites containing reviews and downloads of medical software for PDAs: Tucows PDA16 Palm Gear17 Handango18 Handheld Med19 Washington University Medical Palm Initiative57 pdaMD58 Healthy Palm Pilot59 Peripheral Brain60 The Medical Piloteer61 Doctor's Palm62 Physics Palm Pilot Pages63 Pediatric Pilot Page64 Back to text

Robert A Wilcox

Hazards and help in communications Books as carriers of disease In the early years of bacteriology, librarians, microbiologists and public health physicians were much exercised by the question of whether books could transmit infectious diseases. Mark J Ferson MJA 2001; 175: 663-664 Surveys and experiments on transmission - Attempts to sterilise books - Public health responses - Australian responses - Acknowledgements - References - Authors' details - - More articles on Public and environmental health Given the current concern about transmission of anthrax spores via the mail, it may be instructive to revisit early research on whether books can transmit other infectious diseases. As the theory of spontaneous generation gave way to ground-breaking discoveries in the new science of bacteriology by Pasteur, Lister, Koch and others,1 it was perhaps not surprising that this question was posed at an 1879 meeting of librarians in Chicago.2 Although there was no evidence that bibliophiles had ever expressed a "fear of books as vehicles of pestilence",3 the question seemed to exercise greatly the minds of librarians, microbiologists and public health physicians, and numerous articles were published on the subject in medical and library journals over the succeeding 60 years. These articles sought to determine whether books could transmit infectious diseases and how library books could best be sterilised without damage. Surveys and experiments on transmission An early survey of United States boards of health elicited some notable and bizarre cases of infectious diseases acquired from books.4 These included scarlet fever transmitted by a book in which a young sufferer had inserted strips of his peeling skin as bookmarks, diphtheria in two children acquired through handling school books from a farmhouse where six cases of the disease had occurred 42 years previously, and smallpox in a man who borrowed books from a circulating library in a neighbouring town affected by a smallpox epidemic.4An 1896 issue of The Lancet drew attention to a French study demonstrating isolation of streptococci, pneumococci and Corynebacterium diphtheriae, but not Salmonella typhi or Mycobacterium tuberculosis, from books soiled with the secretions of infected patients.5,6 However, the obviously cynical author felt that fear of contagion would be insufficient to drive readers to buy rather than borrow books.5 A later study found that washings from library books which had been borrowed by people with tuberculosis failed to transmit infection when inoculated into the peritoneal cavity of guinea pigs.7 Attempts to sterilise books A 1911 report sought alternatives to gaseous methods of disinfection, which are unable to penetrate closed books, and to steam, which damages books. Immersing books for 20 minutes in petrol containing 2% carbolic acid sterilised all inoculated cultures of C. diphtheriae, S. typhi, Escherichia coli and Staphylococcus aureus, but did not reliably destroy the infectivity of books contaminated with sputum containing M. tuberculosis.8 Thankfully, the author provided a recipe for a mixture of essential oils to hide the strong odours of petrol and carbolic acid and, perhaps rather obviously, exhorted the reader "to keep . . . the book until dry away from the fire". The following year, an evidence-based review was published, drawing on references in English, German, Italian and French.9 On balance, formalin vapour was concluded to be ineffective, as the gas cannot penetrate the pages of a closed book. The author was unable to replicate the results of the previous study on petrol and carbolic acid, but supported earlier studies showing that the application of hot, moist air (78º-80ºC and 30%-40% humidity) to closed books for 32 hours destroys non-sporing bacteria and mycobacteria without injuring the books. For those not requiring immediate results, several studies found that storing books for a month in a warm, dry room minimised risk of transmission of tuberculosis,7,10 streptococci11,12 and staphylococci.12 Finally, there was concern about the lack of knowledge of virus survival, with a clear statement that books used by a smallpox sufferer should be burned.13 Public health responses In Britain, the government introduced specific provisions into public health legislation through the Public Health Act Amendment Act 1907. This required that a library book borrowed by a member of a household with a notifiable disease be returned to the local authority for disinfection or destruction, with failure to do so attracting a fine of up to £2. These provisions were continued in later versions of the Public Health Act and remain in force today. As the local authority was required to compensate the library for destroyed books, there was some incentive to disinfect them. However, well after introduction of the legislation, discussion continued among members of the Society of Medical Officers of Health as to whether books could transmit infectious diseases,14,15 with much difference of opinion. Australian responses In Australia, public health legislation does not specifically refer to libraries but does mention books. Regulations in the Victorian Health Act 1890 for preventing spread of contagious diseases require that "The room occupied by the patient . . . in all cases, whenever possible, all hangings . . . shall be removed, together with books . . . and sunshine and fresh air in current allowed full play."16 On the other hand, 1896 guidelines provided by the New South Wales Department of Public Health for householders concerned about diphtheria or scarlet fever stated that the "only articles which must always be burnt are books, papers and toys; they cannot be safely disinfected".17,18 Public health laws of the other States made no reference to books. This lack of official guidance did not prevent libraries making their own rules about the handling of books borrowed by individuals with infectious diseases. The clearest manifestation of this concern was the fashion for private lending libraries, particularly in Melbourne, to promote themselves as "hygienic" (Box) because of their practice of placing books in cabinets with formalin vapour (Dr Richard Travers, Rheumatologist, Royal Melbourne Hospital, VIC, personal communication, Sep 2001). This was despite the fact that formalin vapour had already been shown to be an ineffective disinfectant of books. By the 1950s and 1960s, the proliferation of public libraries had largely killed off private lending libraries, and the declining risk of infectious diseases and consequent public interest meant that the concept of books as transmitters of disease was no longer worthy of serious consideration. Acknowledgements I wish to thank Brenda Heagney and Donna Mendrawi of the History of Medicine Library of the Royal Australasian College of Physicians, Sydney, for assistance in obtaining historical references. References Lechevalier HA, Solotorovsky M. Three centuries of microbiology. New York: Dover, 1974. McClary A. Beware the deadly books: a forgotten episode in library history. J Library History 1985; 20: 427-433. Winterich JT. A primer of book-collecting. Revised edition. New York: Greenberg, 1935: 114-120. Reinick WR. Books as a source of disease. Am J Pharm 1914; 86: 13-25. Books as disseminators of disease. Lancet 1896; 1: 180. From our own correspondent. Paris. Lancet 1896; 1: 388. Kenwood H, Dove EL. The risks from tuberculous infection retained in books. Lancet 1915; 2: 66-68. Beebe WL. Carbo gasoline method for the disinfection of books. J Am Public Health Assoc 1911; 1: 54-60. Nice LB. The disinfection of books. Bull Med Library Assoc 1912; 1: 61-66. Smith CR. Survival of tubercle bacilli in books. Am Rev Tuberculosis 1942; 46: 549-559. Balmain AR. Recovery of Streptococcus scarlatinae from experimentally infected books. Lancet 1927; 2: 1128. Smiley HE. Books — shall they be sterilized? Rhode Island Med J 1933; 16: 5-6. McCartney JE. Infection by books. Lancet 1925; 2: 212. Society of Medical Officers of Health. Home Counties Branch. Public Health 1923-24; 37: 265-266. Society of Medical Officers of Health. North Western Branch. Public Health 1923-24; 37: 295-296. Cole HS, Morris H. The Health Act, The Infant Life Protection Act, The Margarine Act, with regulations, notes of English cases and index. Melbourne: Charles F Maxwell, 1894. Department of Public Health, New South Wales. Suggestions to householders for the prevention of scarlet fever (or scarlatina), on the domestic isolation and disinfection, and on the law on infectious diseases. (Public Health Act, 1896, part III.). Sydney: WA Gullick, Government Printer, 1898. Department of Public Health, New South Wales. Suggestions to householders for the prevention of diphtheria, on the law on infectious diseases, and on isolation and disinfection. (Public Health Act, 1896, part III.) Sydney: WA Gullick, Government Printer, 1898.(Received 23 Oct, accepted 29 Oct, 2001) Authors' details South Eastern Sydney Public Health Unit, Sydney, NSW. Mark J Ferson, MD, FRACP, FAFPHM, Director, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW. Reprints will not be available from the author. Correspondence: Dr M J Ferson, South Eastern Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. fersonmATsesahs.nsw.gov.au Make a comment Bookplate for Stinton's Hygienic Library, Moonee Ponds, Melbourne, VIC, circa 1940s. Back to text

Mark J Ferson

Christmas offerings Carols in the wind John E Marley, Paula Searle, Nicole L Chamberlain, Deborah R Turnbull and Catherine M Leahy MJA 2001; 175: 656-658 Abstract - Methods - Results - Discussion - Contributions - Competing interests - Acknowledgements - Authors' details - - More articles on Administration and health services Abstract Aim: To compare mood and emotional responses to music played on pipe organs and pipeless (digital) organs. Design: A two-organ (pipe v. digital) crossover study. Setting: St Theodore's Anglican Church, Adelaide. Subjects: 43 non-musician volunteers. Main outcome measures: Changes in mood and emotions measured by the Profile of Mood States. Results: Both instruments produced significant reductions in the emotions commonly experienced during the Christmas season: tension-anxiety, depression-rejection, anger-hostility and fatigue. There were no significant changes for vigour or confusion-bewilderment, and no significant differences between the mood-altering effects of the two instruments. Conclusions: Pipeless organs are as effective as pipe organs in inducing beneficial mood changes. From supermarkets to cathedrals, carols and organs are part of Christmas. Music affects emotions, and listeners agree on the types of emotions experienced.1,2 Listening to music may invoke a range of responses, from a pleasant, relaxed mood to intense emotions aroused on hearing a beautiful musical phrase3 or a children's carol service. Music decreases heart rate, respiratory rate and Profile of Mood States4 scores, indicating relaxation and mood improvement.5 In a US study, a randomised trial of guided imagery and music conducted over 13 weeks, music positively affected mood scores and reduced serum cortisol levels in healthy adults.6 This suggests music may have another important application: treating stressed adults in the pre-Christmas period. Organ music is usually played on the occasion of important life events such as weddings and funerals. For the many people who attend Christmas church services, the experience would be incomplete without the resounding tones of the organ. Associations with tradition, and the instrument's rich tonal range and volume, are part of what gives the organ its ability to produce powerful emotional responses. The sound of a pipe organ is produced from distinct generators (pipes), numbering from tens to thousands. Many pipes work together and their sounds meld in acoustic space. Pipe organs are expensive to install and maintain. In pipeless (digital) organs, sound is synthesised from digital sampling of the tones produced by traditional organ pipes made by famous pipemakers. The sound diffuses from a few loudspeakers and sounds similar to that of a pipe organ. However, signals conveyed to the speakers, and sounds corresponding to many notes, can cause beats with power nodes and antinodes, which may be unpleasant. Electrical beats are different from in-air acoustical beats produced by organ pipes. A greater number of speakers can produce spatialisation similar to the sound produced by pipe organs.7 Comparing natural and emulated orchestral instruments, it has been found that a fundamental property distinguishing natural instrument tones from their emulated counterparts is the presence of two partially independent sources of variability, such as the natural complex harmonics of strings with the resonance patterns of wood. This endows the music of natural generators with richness of texture and enduring interest.8 Organists tend to have strong views about the superiority of pipe organs over pipeless ones. However, most people listening to organs at Christmas are not organists — would their emotional experience be the same whether the sound was produced by a pipe organ or a digital organ? In the spirit of scientific curiosity we set out to explore whether non-musicians experienced similar mood and emotional responses on hearing a digital organ compared with a pipe organ. Would cash-starved parishes be depriving their parishioners of the full Christmas experience if they invested in electronics rather than wind? Methods Participants Healthy volunteers aged 16 years and over were recruited by advertisement from the University of Adelaide and the general community during the pre-Christmas period in 1999. Expert musicians were excluded, as it was thought they might spend the time trying to guess which instrument they were listening to rather than responding to the music itself. The only other exclusions were people with moderate to severe hearing impairment, "tone-deafness" or a known aversion to organ music. A minimum sample size of 30 subjects was needed. A pilot study was conducted by playing a CD of organ music to volunteers to determine the time taken for them to become restless. As a result, 25 minutes of music was chosen for the main study. Study design Our study was carried out at St Theodore's Anglican Church, Adelaide. The design was a crossover study, with subjects randomly allocated to one of two groups. The groups were then randomly allocated to hear either the pipe organ on the first visit, followed by the digital organ on the second, or the digital instrument on the first, followed by the pipe organ on the second. Each group attended at the same time each week (either 6 pm or 7 pm) and listened to only one instrument at each visit. Visits were separated by one week to allow memory of and response to the first instrument to fade. In order to standardise the test conditions, organs of similar size specifications were played in the same building. Subjects were seated at the back of the church facing away from the instruments, so that they were "blind" to which instrument was being played at each session. St Theodore's Church is a large, resonant building with good acoustics, uniform throughout. The same music was used at each test session using similar registrations (for a list of the pieces played, see Box 1). A professional organist who was not familiar with either instrument performed the music, after a standard amount of familiarisation time on each. The instruments used were a pipe organ built by Waters of Adelaide and an Ahlborn Galanti pipeless organ (specification for both organs available from corresponding author on request). Mood scale Before and after each recital, subjects completed the Profile of Mood States.4 This includes 65 adjectives describing feelings and moods, to which participants indicate their response using a five-point scale. The emotions measured are tension-anxiety, depression-rejection, anger-hostility, fatigue, vigour, and confusion-bewilderment. Statistical methods We calculated the differences between pre- and post-listening mood scores and compared the differences between the digital and pipe instruments using t tests (after checking for normal distribution). As carryover effects were found to be not significant, we were able to pool data over the two periods for each instrument. Pre- and post-music mood scores were compared using a one-sample t test for each of the instruments and for both instruments combined. Data were entered and managed in a Microsoft Access database, and the SPSS statistical package was used for all analyses. Ethical approval was given by the University of Adelaide Committee on the Ethics of Human Experimentation. Results Forty-three subjects completed the study, of whom 23 were women (mean age of participants, 39 years; range, 22-71 years). There were no significant demographic differences between the two groups. When the results for both instruments were analysed, either separately or combined, we found that our listeners experienced significant reductions in tension-anxiety, depression-rejection, anger-hostility and fatigue; however, there were no significant changes in scores for vigour or confusion-bewilderment, and no significant differences between mood changes induced by the pipe organ compared with the digital organ (see Box 2). The time at which the music was played did not significantly affect mood scores (data not shown here). Curiously, however, the group that attended at the later time of 7 pm recorded lower vigour scores (mean, -2.1875) after listening to the digital organ, while the 6 pm group had higher vigour scores (mean, 1.1538) after listening to the same instrument (P = 0.024). The 7 pm group showed no change in fatigue scores (mean, 0.0625) after listening to the digital organ, while the 6 pm group had lower fatigue scores (mean, -2.346) after listening to the same instrument (P = 0.041). After completing the last profile at the second session, subjects were asked, without prior warning, to indicate which instrument they thought was being played at that session. Responses were no better than would be expected from random guessing, indicating that subjects could not distinguish between the two types of organ ( κ = 0.009; P = 0.48). Discussion Music played on both pipe and digital organs produced predictable and desirable mood and emotional responses. It may be that greater changes would have been seen had subjects been "pre-stressed" by stressors such as Christmas shopping or finding a parking place in the Christmas rush. We considered it unnecessary to include a control group not exposed to music, as the ability of music to alter mood is well documented. Both instruments proved equally beneficial in reducing the distressing emotions commonly present in the pre-Christmas period. However, our results suggest that feelings of confusion and bewilderment (such as those accompanying present-choosing) are, alas, likely to persist; and, while fatigue may be reduced by listening to music, listeners may not experience increased vigour. The argument that real pipes are essential for non-musicians to experience beneficial mood and emotional responses to music should now be laid to rest. So, while organists may continue to fight to the death on this issue, financially challenged parishes can safely install pipeless organs without jeopardising the Christmas experience for their parishioners or, presumably, their Christmas collections. Organ music can be highly recommended as a good treatment for pre-Christmas mood disorders. Contributions JM (an inept but enthusiastic organist) conceived the study, PS provided organization and administration, DT psychological knowledge, CL musical expertise and NC statistics. Competing interests The Pipeless Pipe Organ Company loaned equipment for the study. Acknowledgements Mark Joyner played the music. Patrick Brislan, of the Elder Conservatorium of Music, University of Adelaide, gave invaluable expert advice. References Gregory A. Cross-cultural differences in perceiving the emotional content of music. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Collier G. Towards a model of music and emotion. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Sloboda J. Music structure and emotional response: some empirical findings. Psychology of Music 1991; 19: 110-120. McNair D, Lorr M, Droppleman L. Profile of Mood States. San Diego, California: EdITS/Educational and Industrial Testing Service, 1971. Chlan L. Psychophysiologic responses of mechanically ventilated patients to music: a pilot study. Am J Crit Care 1995; 4(3): 233-238. McKinney C, Antoni M, Kumar M, et al. Effects of guided imagery and music therapy on mood and cortisol in healthy adults. Health Psychol 1997; 16(4): 390-400. Bazzanella L, Debiasi G. Electronic organ's sound spatialisation with special regard to plenum and tutti perception. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Carterette E, Kendall A. Acoustical analysis of natural and emulated orchestral instrument signals. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Authors' details Department of General Practice, University of Adelaide, Adelaide, SA. John E Marley, MD, FRACGP, Professor of General Practice; Paula Searle, BTeach, BEd, Research Officer; Nicole L Chamberlain, BSc (Hons - Statistics), Statistician; Deborah R Turnbull, PhD, MPsych(Clin), Senior Lecturer; Catherine M Leahy, BA(Hons - Psychology), BMus(Composition), Research Officer. Reprints will not be available from the authors. Correspondence: Professor John E Marley, Department of General Practice, University of Adelaide, Adelaide, SA 5005. john.marleyATadelaide.edu.au Make a comment 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/> Fr Peter Thompson playing the pipe organ at St Theodore's Anglican Church, Adelaide (photo courtesy of Wendy Newbury). 1: Music played Trumpet Voluntary (Clarke) Air from the Water Music (Handel) Rondeau from Abdelazar (Purcell) An Old English Melody (Wesley, arranged by Floyd) Canon in D (Pachelbel) Back to text 2: Comparison of mood scores of 43 listeners (determined by the Profile of Mood States4) before and after listening to pipe organ or pipeless organ music (mean differences, with 95% CIs; two-tailed significance) Back to text

John E Marley · Paula Searle · Nicole L Chamberlain · Deborah R Turnbull · Catherine M Leahy

Christmas offering Bloodletting and leeching: instruments of healing or torture? "The danger of a large bleeding is less than the danger of the disease."1 MJA 2001; 175: 665 This aphorism, quoted in a 19th-century medical text, typified the approach of many doctors to disease at that time. Essentially, the message was to bleed, and bleed, and bleed again, for a wide variety of illnesses and complaints, ranging from epilepsy and pneumonia, to "bastard pleurisy" and hydrocephalus.1 Venesection was also sometimes coordinated with astrological events, resulting in complex "bleeding charts" being formulated based on celestial cycles.2Instruments for venesection consisted of peculiarly shaped lancets called phlemes (Figure) which were wielded enthusiastically by doctors. For example, one patient in France was bled over 64 times in eight months,3 and sailors suffering from fever in the West Indies had up to 70 ounces of blood taken at the first sitting, with 250 ounces being drained off over three to four days. To add to patients' misery, bleeding was often accompanied by "purging and puking",2 with the use of medications such as epsom salts, ipecacuanha and blue vitriol to induce diarrhoea and vomiting. If blood could not be drained directly from severed veins, leeches in huge numbers were also applied, resulting in a lucrative trade in these small creatures. In one year in 19th-century France, over 40 million leeches were applied to increasingly pallid patients.4 So prevalent was the use of leeching in medicine that the art of healing was, on occasion, referred to as "leechcraft".5 Despite George IV being bled more than 100 times before his 30th birthday,2 royal casualties were not unknown. It is believed that both Emperor Leopold II of Austria and one Prince Schwartzenberg were hurried off to early graves by excessive venesecting.6 Although bleeding had been advocated by no less a figure than Hippocrates, it was left to barbers to perform the task in the Middle Ages, as it was deemed too menial for doctors. Subsequently, surgeons evolved to perform these duties. Rows of patients were often bled at the same time in special "bleeding houses".2 Early texts provide clear descriptions of how to perform venesections, including the use of "a proper bandage of silk, linen, or woollen cloth", and the provision of "wine or some other cordial" to revive those who may have fainted.7 In addition, regional venesections were also prescribed for particular conditions. Recommended areas included under the tongue, the eyes, the penis and the haemorrhoidal veins around the anus. In the event of poor blood flow, presumably because of high levels of circulating adrenaline, "immersing the parts in warm water was recommended".7 There is no doubt that doctors confidently and unquestioningly bled patients and themselves for many centuries. The fact that bleeding undoubtedly and obviously not only worsened some patients' conditions, but also actually caused illness, serves as a salutary reminder of the fallibility of our profession. Roger W Byard Forensic Pathologist Forensic Science Centre, Adelaide, SA References Laennec RTH. Disease of the chest. 4th ed. London: Longman, 1834: 222-226. Newman A. The illustrated history of medical curiosa. New York: McGraw-Hill, 1988: 43-48. Hastings P. Medicine — an international history. London: Ernest Benn, 1974: 56. Lyons AS, Petrucelli RJ. Medicine — an illustrated history. Melbourne: Macmillan Co, 1979: 513. Johnson's dictionary. 7th ed. London: Harrison & Co, 1786. Grossinger R. Planet medicine. Berkeley: North Atlantic Books,1985: 209-211. Encyclopaedia Britannica. 3rd Ed. Vol XVIII. Edinburgh: Bell and MacFarquar,1797: 116-119. Make a comment 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/> A series of 18th- and 19th-century bleeding knives (phlemes), some of which were used in veterinary practice Back to text

Roger W Byard

Christmas offering Conference baggery MJA 2001; 175: 666 No, the title is not in error. I will not describe activities in the Iron Lady's Cabinet, nor what you imagine goes on in closed committees at English conferences. I refer to the bags provided to conference-goers, ostensibly to contain their notes and the papers provided by the conference, but useful for concealing all the free giveaways from the exhibits section. Some remnant of my Scottish background makes it difficult to throw away conference bags. My recent clean-up still left eight of them, too useful to throw away. Many of them have all sorts of useful features and pockets for modern essentials: laser pointers, computer disks, mobile phones — even pen and paper. Indeed, I and my family like them for everyday use. Conference planners buy them with part of the budget from our registration fees; this can waste resources. But a good bag that people keep and use will remind participants of a great conference for a long time. Envelopes or plastic folders are appropriate for one-day events, but not for a three-day event with multiple sessions and heavy abstract books. At one public health conference they gave out a calico bag, intended as a statement about resource use, but so weak that it tore during the first day. Sponsors splash their names and logos across the bag for maximum exposure, at least during the conference. But no one will take it home and become a walking advertisement. The title of the conference in large print also decreases subsequent use. Who wants to proclaim one's profession to passers by, or, worse, to inform everyone in the bus, train, street or the waiting room about attending a conference in some exotic location? They will not recognise that it was off-season, and the beaches were freezing, or the snow had melted. During the conference, when walking to and from the hotel, or at important sessions in the ethanol dispensary, such printing proclaims that one is a visitor, likely a good mark for pickpockets and muggers, or at least to restaurant and shop owners, who use more subtle ways of removing one's currency. Among the hundreds or thousands of identical bags floating around it is easy to pick up the wrong one. Organisers can be bedevilled by lost bags, while participants search desperately for their precious slides or disks. Better ways of identifying otherwise identical bags must be found. One conference organiser found a pallet of simple small backpacks through a disposal sale. They were identified with a large tag, with names printed large. The tag could be flipped inside the bag when leaving the building. The quality control on manufacture was faulty, and some of the zips failed quickly, but one or two of them survived vigorous use for some years. I currently carry a bag from a recent conference in Finland. It is sturdy, with useful pockets, and a discreet logo on the front that is suitably anonymous to outsiders. There is a drug advertisement under the flap, but the company probably gets some additional recognition from my seeing it over a long time. My portable computer fits in a bag from another conference, the title of which is printed in an unobtrusive colour only legible from close up. I doubt that the hotel cleaners who pick up most bags after conferences use more than a few. Perhaps conference organisers could choose bags that will be more extensively used, ensuring remembrance of good conferences, and reducing waste from the early disposal of otherwise functional bags. James A Dickinson Professor of Family Medicine Department of Family and Community Medicine Chinese University of Hong Kong, China Competing interests: I have no conflict of interest, except that I hope to get better and more useful bags from the next conference I attend. Regrettably no-one has provided any funds for this piece of research (but I would not be averse to donations from bag companies in the future). A = Broad shoulderstrap, padded with helium balloons to reduce weight B = Strain gauge overload alarm C = Electronic homing beacon for locating lost bag D = Programmable reminder system, synchronised to conference sessions E = Pockets for easy access to floppy, Zip, mini and compact disks F = Discreet logo G = Recycling unit with trapdoor dump to get rid of unnecessary gimmicks H = Sound- and radiowave-proof pocket for mobile phone I = Main pocket matched to the size of the conference documents J = GPS system to locate hidden seminar rooms K = Space blanket for keeping warm in frigid airconditioning L = Identification label M = Optional CPAP attachment to prevent snoring while sleeping in lectures GPS=global positioning system; CPAP=continuous positive airway pressure.

James A Dickinson

Letters The mystery of GP research output? MJA 2001; 175: 667 To the Editor: Askew et al ask why there is not more general practice research.1I think they would have come close to the answer had their analysis of publication rates by workforce sector included the relative rates of government salaried employment. The proportions of each group in salaried work are approximately: General practitioners, 18% (of whom only 2% are government employees); Physicians, 56%; Surgeons, 26%; and Public health physicians, 90%.2 While the Primary Health Care Research, Evaluation and Development (PHC-RED) program is a laudable and exciting strategy, it is hard to imagine that it will achieve much change in the rate of general practice research until research activity becomes part of the formal "job description" for a large proportion of GPs, as it is for many of our specialist colleagues. Of course, the incursion of corporatisation into Australian general practice will introduce important issues in regard to the amount of research undertaken and the nature of the research performed, as it has for Australian universities. As yet, PHC-RED has not developed a view as to how it might handle such influences. Phillip Gray General Practitioner, Central Queanbeyan Medical Centre, Focal Point Arcade, 25 Monaro Street, Queanbeyan, NSW 2620. gray.qbnATeffect.net.au Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77-80. Medical masterfile [database]. Sydney: Australasian Medical Publishing Company, 2001.

Phillip Gray

Letters Australian general practice at a fork in the road: which way forward? MJA 2001; 175: 667 To the Editor: There are a number of deceptions current in the debate over doctors in Australia. Unfortunately, some of these are expressed in your editorial of 16 July 2001.1You fail to acknowledge there are two classes of doctors, as has been the case in Australia for decades — consultants (the princes), doing very well, and general practitioners (the paupers), struggling to survive. You comment that there is "a new phenomenon . . . dispirited doctors". In Australia, consultants are certainly not dispirited (they have never had it so good). However, there are dispirited GPs, who are grouping together in corporations to solve their economic and social problems. Where, Dr Van Der Weyden, have you been hiding? All of a sudden you would have us believe there is a fork in the road for GPs. In reality, there is no fork — just the steady downhill journey that has gone on for years. Instead of supporting and fighting for an increase in the insulting rates of rebate paid to GPs, you are critical of the very reasons GPs are entering the corporate structure. The statement in your editorial that received the greatest hoots of laughter from my fellow GPs was the classic remark "second, there is the challenge of general practice research and education, which has received little attention in the corporatisation debate". Research has never received attention in general practice, and was certainly not a concern before the move to corporatisation. As you yourself have stated, GPs received a mere 1.6% of the National Health and Medical Research Council's research projects over the years 1996 to 2000. Certainly, such lack of funding has stifled what should have been a rich and flourishing research culture, but what has been done about it? Percy S Rodgers General Practitioner, 2/133 Wilson Street, Brunswick, VIC 3056 Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63.

Percy S Rogers

Letter Australian general practice at a fork in the road: which way forward? (In reply) MJA 2001; 175: 667 In reply: Despite Rogers' views to the contrary, disillusionment and disenchantment are pan-profession phenomena. Like general practitioners, consultants are unhappy with the deteriorating hospital conditions and working environment1 that are their lot. Further, I am not moved by Rogers' worn view of the profession as "them" (specialists) and "us" (GPs). Most modern GPs consider general practice a specialty. To qualify as a specialty, a branch of medicine needs to have a unique body of knowledge and techniques which are sustained and expanded by its members. Unfortunately, general practice lags behind other specialties in these requirements.2,3 It is depressing that the call for general practice to develop and enhance its educational and research programs occasioned "the greatest hoots of laughter" from Rogers and his fellow GPs. This destructive ethos persists in general practice, to its own detriment. In my editorial,4 I suggested that the trend to corporatisation in general practice presents an opportunity to address the lack of time, lack of critical mass and lack of recognition that are barriers to effective research in this field.5 If GP corporatisation simply replicates the current culture and barriers to research on a larger scale, what is the gain? Rogers' question "what has been done about it [research]?" reflects a passive approach — "important, but not my problem", "someone should do it, but not me". Unless research and education become the business of every GP, general practice as a specialty is in danger of disintegrating into multiple craft groups, not necesarily medically based. Such a development is certainly not a cause for hoots of laughter. Martin B Van Der Weyden Editor, The Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059. Perkins RJ, Petrie KJ, Alley PG, et al. Health service reform: the perceptions of medical specialists in Australia (NSW), the United Kingdom and New Zealand. Med J Aust 1977; 167: 201-204. Van Der Weyden MB. Promoting an evidence base for general practice [editorial]. Med J Aust 1999; 171: 60-61. McAvoy B. General practice research. Aust Fam Physician 2001; 30: 175-176. Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63. Kljakovic M. Flourishing research in academic general practice. NZ Fam Physician 1998; 25: 35-40. Make a comment

Martin Van Der Weyden

Letter Economy class syndrome: a forgotten lesson MJA 2001; 175: 669-670 To the Editor: The editorial by Gallus and Baker,1 and subsequent correspondence which speculated about prolonged calf pressure contributing to causing deep vein thrombosis,2 reminded me of an undergraduate lecture in 1948 about pulmonary embolism in people who slept in deck chairs in London air raid shelters during World War II. This lecture was given by Simpson, then a lecturer in forensic medicine (and later a respected authority in this specialty), who reported a significant increase in deaths from pulmonary embolism (to 24) in September and October 1940, soon after serious night air-attacks on London began.3 This compared with only four in September and October 1939. Twenty-one of these 24 deaths occurred in, or soon after leaving, air raid shelters. The pople who died were mostly elderly, obese and often had varicosities of the leg veins. A typical case was that of an overweight, 60-year-old woman who complained of numb legs and swollen ankles after sitting for 10 hours in a deck chair — she dropped dead in the street while walking home, eight minutes after leaving the shelter. Autopsy showed multiple small pulmonary embolisms and small tags of very fresh antemortem clot in the tibial veins. Simpson concluded that the process was mainly mechanical (calf compression causing obstruction, stasis, oedema and thrombosis), as sleeping in deck chairs causes compression of calf veins against the front edge of the chair for many hours. He proposed that people in air raid shelters should therefore be given provision for lying down. Indeed, by the time his letter was published, in December 1940, he noted that the number of cases of fatal pulmonary embolism were already decreasing, coinciding with the provision of bunks in the shelters. Stasis remains the precipitating factor in Virchow's triad of thrombus formation (abnormal blood flow [stasis], endothelial injury and hypercoagulability). Venous flow rate while lying down slows to half on standing and a third on sitting,4 even before calf compression is added. In 1940, civil authorities acknowledged the cause of an excess of cases of fatal pulmonary embolism and preventive measures were implemented, with documented success within two months. In 1954, Homans reported venous thromboembolism "probably due to sitting travel" by air and car.5 In 1988, calf pressure in cramped seating was blamed by the originators of the popular but restrictive term "economy class syndrome".6 In the 1990s, and in relation to the 2000 Olympic Games, a host of cases of flight-related pulmonary embolism were reported.1 But, in 2001, it seems the evidence for a causative effect must still be considered "circumstantial".1 Lloyd K Morgan Retired General Practitioner, PO Box 150, Lorne, VIC 3232 Gallus AS, Baker RI. Economy class syndrome [editorial]. Med J Aust 2001; 174: 264-265. Slonim L. Economy class syndrome Med J Aust 2001; 175: 176 Simpson K. Shelter deaths from pulmonary embolism. Lancet 1940; 2: 744. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for thromboembolic disease: a case-control study. Chest 1999; 115: 440-444. Homans J. Thrombosis of the deep leg veins due to prolonged sitting. N Engl J Med 1954; 250: 148-149. Cruickshank JM, Gorlin R, Jannett B. Economy class syndrome. Lancet 1988; 2: 497-498. Make a comment

Lloyd K Morgan

Letter Improving the treatment of leg ulcers MJA 2001; 175: 670 To the Editor: The article by McMullin emphasises the importance of compression in the treatment of ulcers.1 External pressure equal to that inside the veins will collapse varicosities, which can easily be seen by standing in a swimming pool with water up to the chest. As one cannot spend one's life standing in a pool, it seemed to me that there should be some way of duplicating this in a more convenient form. After some experimentation, I have found a reasonably easy way is to use two sphygmomanometer cuffs, with the tubes connected by suitable plastic tubing, and containing enough water to about 3/4 fill one of the bladders. An insert is put in the canvas of one, to enable it to be worn around the waist (theoretically it should be at the height of the heart, but in practice there seems little difference if it is worn at waist height), and the other is wrapped around the ankle with the ulcer (see Box). The leg cuff is applied first, while still empty, over whatever dressing is preferred on the ulcer, and maybe a layer of cotton wool, as the cuff material can be rather coarse. Then the waist cuff is put on; this contains the water, which can be felt running down and expanding the lower cuff. The importance is that the pressure exerted will balance that in the veins, cannot exceed this, and will vary according to whether one is standing, sitting, or lying down, when water will run back into the upper cuff. As an ophthalmologist I don't get to treat many people with leg ulcers, but I have had vein problems myself for a number of years, with periodic small ulcers, none of which have ever grown to any size, and have healed in four weeks, most in rather less time, with the above management. Obviously, I don't claim it will cure everyone, but it does provide a more scientific pressure which is equal all round the leg, and balances the venous pressure at all times. In my case the pressure, when standing, works out at 66 mm Hg. Even if there is arterial insufficiency, the pressure is only that which is in the veins. No doubt, a purpose-made appliance which is easier to apply and covers a larger area could be produced. Graeme W Johnson Ophthalmologist, 4th Floor, 39 East Esplanade, Manly, NSW 2095. grapamATnsw.bigpond.net.au McMullin GM. Improving the treatment of leg ulcers. Med J Aust 2001; 175: 375-378. Make a comment Device for applying appropriate and even pressure in the management of leg ulcers A: The two connected sphygmomanometer cuffs, one extended to allow it to fit around the waist. B: The device as it is worn. Back to text

Graeme W Johnson

Letter Taenia solium and neurocysticercosis MJA 2001; 175: 670-671 To the Editor: A 37-year-old Australian-born white woman presented on Christmas eve with a focal seizure with secondary generalisation. This had developed on a background of bifrontal headaches for which she had been taking ibuprofen. She was in otherwise good health, with no previous history of seizures, head injury or meningitis. On examination there were no focal neurological signs. Fundoscopy findings were normal. Computed tomography (CT) of the brain showed a small contrast-enhancing lesion, radiologically suggestive of a brain tumour. Therapy with phenytoin and dexamethasone was started, and she was referred for neurosurgical assessment. A magnetic resonance imaging (MRI) scan showed an 8 x 12 mm-enhancing nodule in the right posterior frontal cortex with surrounding oedema (Figure). She underwent excisional biopsy of the lesion, and histopathological examination showed a cysticercus cyst, the encysted larval form of Taenia solium, associated with an intense surrounding inflammatory reaction. Further questioning of the patient revealed that she was a frequent visitor to South-East Asia, where this organism is endemic in some areas.1,2 She remains well and seizure-free at follow-up. T. solium (pork tapeworm) is associated with two distinct infective states in humans: asymptomatic intestinal infection by an adult tapeworm, and cysticercosis, which is associated with clinical disease. Ingestion of eggs in contaminated food or water by an intermediate host, typically pigs but sometimes humans, leads to the development of cysticercosis, as seen in our patient. Humans acquire intestinal infection with the adult tapeworm by ingesting encysted larvae (cysticerci) in undercooked meat.1-3 Epilepsy is the most common presentation.1,2,4 The findings of cysticerci outside the central nervous system (such as in the posterior chamber of the eye, palpable within subcutaneous tissues, or as calcified nodules on plain x-rays) and the detection of anticysticercal antibodies in plasma or cerebrospinal fluid may assist in diagnosis of neurocysticercosis, and subsequently prevent unnecessary neurosurgery. However, patients with a single cerebral lesion or those with only calcified lesions are commonly seronegative.1-3 Stool examination for tapeworm eggs is insensitive, but may identify patients with intestinal infection.2 Whether treatment with praziquantel or albendazole improves long term outcome remains controversial.2,5 In cases of encephalitis, subarachnoid, spinal or ocular involvement, symptoms may worsen secondary to an inflammatory reaction around degenerating cysts. Co-administration of corticosteroids ameliorates some of this effect. Surgical treatment is reserved for patients with hydrocephalus.1-3 Neurocysticercosis is uncommon in Australia.5 Our case reminds us of the risks of infective diseases posed to travellers and migrants. It also highlights the importance of considering infective causes such as cysticerci, bacterial abscesses, toxoplasmosis and cryptococcomas in the differential diagnosis of space-occupying lesions seen on central nervous system imaging. Anthony T Zimmermann,* William S Jeffries † * General Medicine Advanced Trainee, Repatriation General Hospital, Daws Road, Daw Park, SA, 5041 † General Physician, Lyell McEwin Hospital, Elizabeth, SA atzimmATausdoctors.net Garcia HH, Del Brutto OH. Taenia solium cysticercosis. Infect Dis Clin North Am 2000; 14: 97-119. Garg RK. Neurocysticercosis. Postgrad Med J 1998; 74: 321-326. Pluschke M, Bennett G. Orbital cysticercosis. Aust N Z J Ophthalmol 1998; 26: 333-336. White AC Jr. Neurocysticercosis: a major cause of neurological disease worldwide. Clin Infect Dis 1997; 24: 101-115. Hellard ME, Street AC, Johnson PDR, et al. Detection of an aberrant motile larval form in the brain of a patient with neurocysticercosis. Clin Infect Dis 1998; 27: 391-393. Make a comment Magnetic resonance imaging (MRI) scan of the patient's brain MRI scan: axial section, T1-weighted image with intravenous contrast. Lesion clearly visible. Back to text

Anthony T Zimmermann · William S Jeffries

Letter Eye exposure to squashed spiders MJA 2001; 175: 671 To the Editor: I read with great interest the letter from Isbister and Balit describing ocular reactions to squashed daddy longlegs spiders.1 As an arachnophile, I think it is a great pity that people go around squashing these harmless beasts that are very efficient at catching and eating real pests such as mosquitoes and flies. Living in a house that is well populated with daddy longlegs, I would like to enlighten readers on my own method of removing these harmless spiders from the house without harming either myself or the spider. This is the "open fist" method. The spider can be easily caught by placing the hand over and around the spider, leaving a small amount of space in the "open fist". It can then be removed from the house and released into the garden. I have used this method successfully on at least 20 occasions without suffering any bite or reaction. Long live daddy longlegs! John E Stuart Paediatrician, John Hunter Children's Hospital, Locked Bag 1, Hunter Mail Centre, NSW 2310. jstuartATdoh.health.nsw.gov.au Isbister GK, Balit C. Eye exposure to squashed spiders [letter]. Med J Aust 2001; 175: 391-392. Make a comment

John E Stuart

MJA 2001; 175: 672 To the Editor: In these days of increasing globalisation of medicine, it is refreshing to realise that there are some uniquely antipodean case scenarios. I wish to report two patients who presented to the emergency department with multiple injuries caused by a single kangaroo. Although there have been previous reports of kangaroos causing injury, this is usually in the passive capacity as an immovable obstruction to a moving vehicle.1 I do not believe there have been any reports of a single kangaroo causing injury to two people at the same time by actively inflicting injury, resulting in a need for hospital treatment. Patient 1: A 32-year-old man intervened in a fight between his dog and a grey kangaroo. The dog escaped, but the kangaroo then turned on the man, inflicting several deep abrasions to his chest, trunk and back, and a bite to his left forearm. X-rays revealed no underlying fractures, and the skin abrasions were treated conservatively. Prophylactic antibiotics and a tetanus booster were administered, and the patient was discharged. Patient 2: While driving past, a 50-year-old man saw the attack described above. He stopped to assist, and grabbed the tail of the kangaroo to distract its attention. The man was thrown to the ground, and sustained bruising to the right shoulder and upper arm. X-rays revealed no fracture, but the arm was immobilised in a sling for symptomatic relief of pain. The kangaroo escaped without injury. These two cases should serve as a warning that intervening in fights between animals poses the risk of injury, and that one kangaroo is easily capable of injuring two humans at the same time. Caution is required if approaching these animals in the wild. Alan E O'Connor Emergency Physician, Emergency Department, The Canberra Hospital, Yamba Drive, Woden, ACT 2606 Alan. O'ConnorATact.gov.au Whittle IR. Beware of boomerangs and kangaroos. Med J Aust 1980; 2: 347. Make a comment

Alan E O'Connor

Christmas competition Competing interests: MJA Christmas Competition MJA 2001; 175: 574 The entries for this year's Christmas competition arrived in a slow trickle, leaving us wondering whether many of our readers may have had their creative powers sapped by recent world events or the forced conformity of corporatised practice. Quality, however, is what we are about, and this was not lacking. Fresh from the excitement of the recent federal election, MJA editorial staff were in the mood for a bit of a poll, especially when we discovered that the contenders were much more lively and altogether better looking than their political compatriots. Barnabas Bako's "Seahorse" won the Snapshot category with a healthy majority. However, the Vignette category will remain a hung parliament, with Steven Doherty's "So this is Christmas" and James Dickinson's "Conference baggery" running head to head, even after the distribution of preferences. All three winners will receive a refreshing prize from the MJA's famous cellar. As the highs and lows of the coming year unfold remember that we at the MJA would love you to put finger to keyboard to share your quirky images and reflections with us. Contributions for next year's Christmas competition will be gladly received all year round. Make a comment

Snapshots An unusal case of immobility Kevin Ho-Shon Radiology Registrar John Rusli Radiologist Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW MJA 2001; 175: 586

Kevin Ho-Shon · John Rusli

Snapshots Cockroach bladder! David I Chadban Radiology Registrar Department of Radiology, Concored Repatriation Hospital, Sydney, NSW MJA 2001; 175: 620

Rodney H Strahan

Snapshots Seahorse Barnabas Bako Radiology Registrar Department of Radiology, The Children's Hospital at Westmead, Sydney, NSW MJA 2001; 175: 628 The young girl was restless and crying. This study was requested by the surgical team to further evaluate the distended abdomen and unusual bowel sounds. The problem soon became clear - the child had a seahorse in her belly! Further careful questioning revealed that the family had recently visited the aquarium, and had spent a long time in the seahorse section. Another brilliant diagnosis! Make a comment

Barnabas Bako

Snapshots Traumatic false aneurysm in the popliteal artery of a child Dorothy J Radford Deputy Director of Cardiology The Prince Charles Hospital, Brisbane, QLD MJA 2001; 175: 658

Dorothy J Radford