Volume 178 Issue 1

The US strain of West Nile virus could enter Australia, but we may be protected by the already present Kunjin virus Australia needs to consider the implications of the recent emergence and spread of West Nile virus in the United States, including the possibility of its spread to Australia. This development also raises questions about Kunjin virus, a subtype of West Nile virus, which already occurs widely in Australia. West Nile virus, a mosquito-borne flavivirus, was known to have a wide geographic range, extending from Africa through the Middle East to southern and eastern Europe and western Asia. The initial outbreak in New York city and adjacent counties in August 1999 resulted in 62 human infections and seven deaths of elderly patients.1,2 Genetic evidence suggests that the virus came from the Middle East. Over the next three years, it spread rapidly in the US, first in the north-east and then more widely, causing disease and deaths in humans, horses and birds.3 Birds, especially crows, were found to be responsible for both spread and maintenance of the virus in a natural cycle with culicine mosquitoes.3,4 By late November 2002, the virus had been detected in 43 states spanning the mainland US, with 3735 reported clinical cases and 215 deaths, almost all among the elderly.5 The virus had also spread to five provinces in Canada, with around 140 cases and two deaths. The speed of its spread was undoubtedly due to the presence of competent mosquito species and a large number of susceptible birds, and especially to a greatly increased propensity to spread in a virgin ecosystem. Before 1996, West Nile virus was known to cause high fever, chills, malaise, headache, backache, arthralgia, myalgia and retro-orbital pain, and, in about 50% of cases, a maculopapular rash,6 but neurological symptoms were uncommon. Since then, severe neurological illness, including encephalitis and meningitis, has been reported more frequently,6,7 together with an acute flaccid paralysis syndrome.6,8 Fatalities have generally been in the elderly. Although human acquisition is nearly always through the bite of an infected mosquito, unusual modes of transmission via organ transplantation,9 blood transfusion9,10 and possibly breastfeeding11 have recently been described in the US. West Nile virus is closely related antigenically and genetically to other members of the Japanese encephalitis serological group of flaviviruses, including Japanese encephalitis, Murray Valley encephalitis (MVE), and St Louis encephalitis viruses, and is almost identical genetically and immunologically to Kunjin virus.12 Kunjin virus, reclassified as a subtype of West Nile virus in 2000, is the most common flavivirus in Australia, occurring widely across northern Australia. Most infections with this virus are asymptomatic, but it causes occasional, mild febrile illness, similar to that traditionally described for West Nile virus, and rare cases of non-fatal encephalitis.13 It is closely related genetically to the West Nile strain in North America,1,2 both being members of West Nile lineage 1. However, unlike Kunjin virus, some recently isolated members of West Nile lineage 1 are known to cause fatal encephalitis in elderly patients,3,6,7 fatal disease in wild birds (in North America)3,14 and domestic geese (in Israel),15 and severe epizootics in horses, with significant mortality.7,13,14 In addition, recent experimental evidence has shown that the New York strain of West Nile virus is considerably more neuroinvasive than Kunjin virus.16 Could Kunjin virus mutate to be as virulent as recent West Nile strains seen in Europe and the US? Kunjin virus has been in our ecological system for many years without any apparent increase in virulence. Several mutations may be required to increase virulence substantially, and there seems little pressure to select for such mutations. Alternatively, could a more pathogenic strain of West Nile virus spread to Australia and, if it did, would it be able to establish itself in competition with Kunjin virus? West Nile virus has been isolated in Sarawak, Malaysia, and is endemic in western India; thus, it could conceivably spread slowly through the region. The virus is believed to have reached New York through carriage on an aircraft of an infected mosquito or an infected traveller with sufficient viraemia to infect a mosquito on arrival in the US. Similar mechanisms could allow its importation into Australia from the US, Europe or Africa. Although current disinsection procedures for aircraft are believed to minimise the first possibility, there is concern that an infected human traveller arriving in Australia might have sufficient viraemia to infect Australian mosquitoes. More information is urgently needed on viraemia levels during infection so that this risk can be properly assessed. Other routes of entry seem less likely. Although a horse infected with West Nile virus was recently imported into Australia from North America, viraemia levels in horses are believed to be insufficient to infect mosquitoes. Introduction of virus through migratory birds is doubtful because of the route and length of migration. Even if West Nile virus is introduced into Australia, it would have to compete with Kunjin virus for vertebrate hosts and vectors. Experience with other members of the Japanese encephalitis serogroup of flaviviruses suggests that they do not interfere with each other's ability to spread,12 despite the induction of cross-reacting antibodies. Thus, West Nile and Japanese encephalitis viruses coexist in western India, and MVE and Kunjin viruses coexist in Australia, while West Nile and St Louis encephalitis viruses appear to coexist in North America, and Japanese encephalitis and MVE viruses appear to coexist in Papua New Guinea. However, antibodies to Kunjin virus neutralise West Nile virus (and vice versa), and Kunjin virus is widely distributed over much of Australia, so it may prove more difficult for West Nile virus to find the susceptible vertebrate hosts it needs to become established or to spread rapidly. There is no treatment or vaccine available for West Nile infection, but people with prior exposure to Kunjin virus should be protected. Similarly, those exposed to other members of the Japanese encephalitis serological group, especially Japanese encephalitis and MVE viruses, may have limited protection against West Nile disease. The current Japanese encephalitis vaccine is unlikely to protect, although more research is needed to confirm this.17,18 Finally, could Japanese encephalitis virus spread in Australia as West Nile virus has done in the US? Japanese encephalitis virus has occurred in the Torres Strait of northern Australia nearly every year since 1995, and entered the Australian mainland in 1998.19,20 As Australia has the appropriate mosquitoes and avian and porcine vertebrate hosts for natural transmission cycles,20 it is likely that Japanese encephalitis virus will eventually become established here. However, the narrow range of bird species used by Japanese encephalitis virus as maintenance hosts (generally herons and egrets), the need for pigs as amplifier hosts, as well as the Australian ecosystem, climate and arid interior, would suggest that Japanese encephalitis virus is unlikely to match the spread of West Nile virus in North America. Migratory birds, wind-blown insects and rapid air transport of infected humans, animals and insects could all bring exotic pathogens into Australia. Identifying potential threats, maintaining aircraft disinsection and mosquito surveillance around major airports, as well as good internal surveillance, are important parts of the protection of human and animal health in this country.

John S Mackenzie BSc, PhD · Roy A Hall BSc, PhD · David W Smith FRCPA

Infectious diseases are still the dominating cause of death Papua New Guinea (PNG) has a population of about 5 million people, 85% of whom live in rural villages.1 Since becoming independent in 1975, PNG has experienced problems common to emerging nations of starting from a subsistence base and simultaneously seeking to achieve economic sustainability and nationhood as well as build systems of governance, defence, transport, communication, education and healthcare. Health system development has not kept pace with changing demands in PNG. Instead, primary health services have faltered, placing a heavier burden of disease on struggling secondary care facilities as opportunities for prevention and early treatment are lost because aidposts have closed or vaccination rates have fallen. Port Moresby, the capital and largest city, has a population of over 300 000. Port Moresby General Hospital (PMGH) is the country's major teaching and referral hospital, with 600 beds. Hospital-based studies of the causes of death and patterns of admissions to PMGH confirm that infections remain the major cause of adult hospitalisation and deaths in hospital, and that HIV/AIDS is now a leading cause of death in adult inpatients. Moreover, there has been no reduction since 1980 in the mortality rate of children under five years, and infectious diseases, predominantly pneumonia, are also the main cause of childhood deaths. Adults: Studies of medical records in the 1980s and again in the 1990s determined causes of death in adults admitted to medical wards and the intensive care unit at PMGH.2,3 The findings of these two studies are summarised in the Box. Malaria, tuberculosis, typhoid and pneumonia were the leading causes of death in patients in whom aetiology was determined. In addition, these same infections were suspected on clinical grounds to be the cause of death in more than half of those dying without confirmation of the cause. A further study in 2000 looking at reasons for medical admissions to PMGH (Dr G Tau, Chief Medical Officer, PMGH, personal communication) found infections remain the most common reason for admission, with tuberculosis being the most common (27%), followed by malaria (23%), pneumonia (15%), dysentery (12%), typhoid fever (8%), and HIV/AIDS (3%). According to statistics of the PNG Health Department, the reported national prevalences of tuberculosis, malaria, typhoid and other infections have not declined in the past three decades.1 Thus, the dramatic recent addition of HIV/AIDS has occurred against a background of no change in the high prevalences of other infectious diseases. As a result of cultural resistance, autopsy rates in PNG are very low, and, at the time of the two studies of causes of death,2,3 autopsy was performed in less than 3% of deaths. Needle autopsy, which, compared with full autopsy, is accurate in 77% of cases, appears to be an acceptable alternative for Papua New Guineans and could be applied to determine cause of death in the large numbers of patients who currently die from undiagnosed causes.4 In addition, better diagnostic facilities in microbiology laboratories would assist in diagnosing and treating infections earlier and more effectively. As economic prosperity increases, non-communicable diseases are becoming more apparent. New diagnostic facilities at PMGH — ultrasound, echocardiography and a private computed tomography facility — have markedly enhanced the ability to diagnose chronic, non-communicable diseases. Even allowing for this enhanced diagnostic capacity, the prevalence of these non-communicable diseases is increasing.1 Children: Reports on child health in rural areas of Papua New Guinea similarly indicate a dominance of infectious diseases. The major infectious diseases causing child mortality in PNG include pneumonia, measles, meningitis, malaria and neonatal sepsis. Between 1960 and 1980 the mortality rate for children under five years of age in PNG fell by an average of 3% per year, from 204 to 122 per 1000 livebirths. No improvement has occurred since then. By contrast, the mortality rate in this age group in East Asia and the Pacific region has fallen by 2.5% per year. The most optimistic figures for the current infant mortality rate, and the mortality rate in children under five years, puts the national rate at 77 per 1000 livebirths and 100 per 1000 livebirths, respectively; this represents no progress during the past decade. According to UNICEF, only four countries in the world have failed to improve the mortality rate among children under five years since 1980: Burma, Niger, Zambia, and PNG. The high child mortality rate is attributed to collapse of health service structure, law and order problems, closure of aidposts, deteriorating roads, and inadequate administrative assistance and support. Vaccine-preventable diseases, such as measles, whooping cough and Haemophilus influenzae infection, still kill children in PNG. Vaccination coverage is low and differs from province to province. According to figures in the National Health Plan, vaccination coverage averaged 64% for diphtheria–tetanus–pertussis and 60% for measles, while, in the Western Province, these proportions were only 30% and 27%, respectively.1 In a highlands province in 1997, coverage was about 33% for immunising doses of any vaccine.5,6 HIV/AIDS: The first case of AIDS in PNG was diagnosed in 1987. HIV in PNG is heterosexually transmitted and equal numbers of men and women are affected. Unprotected sex and a rising incidence of other sexually transmitted diseases and promiscuity have contributed to the rapid rise in cases of HIV/AIDS to epidemic levels. By the end of December 2001, 4700 cases had been reported.7 About A$200 million was committed to healthcare in the 2001 PNG National Budget, including $650 000 earmarked for HIV prevention and care. In addition, $20 million is being put into the National HIV/AIDS Support Project by AusAID. Some antiretroviral therapy is becoming available through UNAIDS. PNG faces the danger of following the experience of African nations, with the potential to lose half of its adult population to this disease. Investing in the future of the nation: PNG manifests the challenges facing many tropical nations where communicable disorders remain major causes of mortality and morbidity, but non-communicable diseases are becoming more apparent. This is in sharp contrast with Australia, where cancer, ischaemic heart disease and stroke are the leading causes of death (27.8%, 20.7% and 9.6%, respectively).8 In PNG, this background of infectious diseases is being overlaid by non-communicable diseases — hypertension, coronary artery disease and diabetes (Dr G Tau, personal communication).1 Declining health service efficiency has meant that HIV/AIDS has now taken hold, placing additional stress on an already skeletal system. The commitment of public resources to the control and alleviation of these problems needs to be seen as an investment in the future of the nation. Those responsible for the administration of healthcare may be encouraged from international experience that control of infectious diseases and lowering child mortality are achievable and worthwhile goals. Australian aid to PNG has been generous, with the estimated total aid to PNG for 2002–2003 being $351.4 million.9 Special attention should now be given to enhancing primary care services provided in the village aidposts and rural district health centres. At the same time, PNG requires continuing support from experienced clinicians and public health experts. It would be wise for Australian aid to support this and related workforce development. Australia has a special relationship with PNG. This should be used to work with PNG in the development and implementation of the PNG National Health Plan. Australian aid must be sensitive to the PNG political environment, and should not be provided without an explicit purpose or without clear accountability for its expenditure. In controlling the spread of HIV, tactics used in other countries to good effect, including the judicious and appropriate use of antiretroviral medications, need to be examined for their applicability in PNG. Admissions and deaths at Port Moresby General Hospital2,3 1984 study2 1994 study3 Total admissions 1242 2353 Deaths in hospital 120 (10%) 168 (7%) Preventable 7 0 Treatable 35 37 Ultimately fatal 31 71 Not determined 47 60 Number of deaths from confirmed infections 59/120 (49%) 80/168 (48%) Definitions Preventable: The cause of death is known and the illness is treatable or curable but the correct treatment was not given. Treatable: The cause of death is known and the illness is treatable or curable, but the patient died despite receiving the correct treatment. Ultimately fatal: The cause of death is known, but the illness is such that, despite treatment, it is ultimately fatal (eg, hepatoma). Not determined: The specific cause of death is unknown because the aetiological diagnosis could not be made.

Sirus Naraqi FRACP, FACP · Bairi Feling · Stephen R Leeder PhD FRACP

The outgoing Director-General of the World Health Organization, Gro Harlem Brundtland, has successfully returned health issues to the international arena. The new Director-General will have to cope with reduced control over funding, debate over WHO's mandate, and the relationships between WHO and other organisations. Despite the broad role described in WHO's constitution, many groups see WHO's mandate as narrowly directed at disease eradication. The method of choice for funding health programs has become public–private partnerships. These have the advantages of bringing private money, management expertise and research knowledge to bear on health problems, but rarely consider the health system as a whole, focusing instead on specific diseases. This has the potential to distort resource allocation and priorities. The international community needs to work to strengthen WHO and maintain its broad mandate to achieve the highest possible level of health for all people.

Michael A Reid · E Jim Pearse

Australia is one of the healthiest countries in the world, although we have a long way to go before the health of Indigenous Australians matches that of the population as a whole. In 1999–2000, the Commonwealth Government spent 8.5% of GDP on healthcare, ranking our health spending among the highest in the world. By contrast, many people living in our region are burdened by emerging epidemics, such as HIV/AIDS, diseases associated with economic and industrial development, and problems of communicable disease and nutritional deficiencies. For decades, many Australians have been working towards improving health in these developing countries by providing their knowledge and expertise. While the financial resources for healthcare are largely the responsibility of individual national governments, the international system plays an important role in assisting developing countries to improve their health standards. From our own experiences of working with AusAID and the World Health Organization on two projects to eradicate iodine-deficiency disorders in China and Tibet, we illustrate how health professionals can work with international aid agencies to deliver healthcare and make a difference to the lives of people in developing countries.

Mu Li PhD, MHSM · Creswell J Eastman AM, MD, FRACP

Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was "primary health care" (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own heathcare services. Changes in economic philosophy led to the replacement of PHC by "Health Sector Reform", based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.

John J Hall MTH, FAFPHM · Richard Taylor DTM

Training and education of health workers remains an indispensable part of good health development in resource-poor settings. Many past training programs have failed to achieve significant gains in health outcomes because of poor selection of participants, inadequate methodology, and/or the influence of external factors in the health system or social environment. The solutions lie in better planning of "who" and "what" should be trained; effective methods based on adult learning principles; alternative methods that maximise learner input and locate training as close as possible to the workplace and its problems; appropriate inclusion of the community; and coordination with other health system interventions.

Christopher J Morgan DTCH, FRACP · Peter W Deutschmann MB BS, MPHC, FRACS

Australia enjoys high standards of healthcare and medical education. However, the same cannot be said for many of the countries in our region. As some of the articles in this MJA issue on Global Health reveal, Australian institutions, professional organisations and health professionals are involved in projects to improve health in poorly resourced countries, particularly through capacity building — assistance with training, education and other resources needed to increase a country's ability to meet its health needs. As there is no readily accessible listing of the involvement of our medical institutions and individuals in this work, we approached the medical faculties of Australian universities and our clinical colleges for their current initiatives in developing countries. What follows is an arbitrary cross-section of these activities. Medical schoolsFaculty of Health Sciences, University of AdelaideTwo general practice academics are establishing a department of general practice in Dharan, in eastern Nepal. They have had extensive previous experience in primary healthcare in Kathmandu, as well as in rural and urban general practice and Indigenous health in South Australia. Since January 2002, they have been at the BP Koirala Institute of Health Science at Dharan, teaching undergraduate students and creating a postgraduate training program in general practice (MD in Family Medicine). This is only the second postgraduate training program established for primary healthcare in Nepal. Adelaide University is providing support, including a teaching visit, a conference presentation and a planned three-month sabbatical exchange to Nepal in 2003. School of Medicine, Flinders UniversityFlinders' Rural and Remote Community Clinical School and Office of Education are assisting in medical education upskilling of Thai doctors, who, in turn, will be involved in a Thai government program aimed at overcoming a shortage of rural doctors. Over 10 years, 3000 extra students will be enrolled in Thai medical schools, and receive their clinical education in rural government hospitals. They will then be bonded to work in their local areas for three years after graduation. In Cambodia, the Director of the Rural and Remote Community Clinical School at Flinders is the delegation leader of an AusAID-funded project aimed at empowering the emerging Cambodian Medical Association to develop an Accreditation and Continuing Medical Education Program for its rural doctors. In East Timor, the Head of the Northern Territory Clinical School has acted as an advisor to the East Timor government on paediatric services and medical education. From 2003, Flinders will be offering a Master in Hospital Management degree in association with Nankai University in China, as there are no formal qualifications in health service or hospital management in that part of China. Finally, the Department of Medical Imaging has been involved in the training of radiologists from several developing countries. Faculty of Medicine, Health and Molecular Sciences, James Cook UniversityThe Faculty is conducting operational research to assist the government of Papua New Guinea (PNG) in investigating disease outbreak, and is also involved in a two-decade longitudinal study of PNG's epidemiological transition from a predominance of infectious to non-communicable diseases. A Lymphatic Filariasis Program in the Pacific Islands (in partnership with national ministries of health) has a strong capacity-building component for a number of countries, including the Federated States of Micronesia, Tuvalu, Fiji and Nieue. The program includes investigation of epidemics, development of improved diagnostic tests and vector control methods, and novel surveillance methods. An additional initiative involving Fiji is a protocol being developed to provide PhD scholarships for staff members of the Fiji School of Medicine. In East Timor, the Faculty is involved in World Health Organization research into intestinal helminths and lymphatic filariasis, including onsite training of laboratory staff in parasitology. University of Melbourne School of Medicine of the Faculty of Medicine, Dentistry and Health SciencesThe School is a founding partner of the International Medical University in Malaysia, and each year takes up to 12 students into third year to complete their training at the University of Melbourne. In a separate arrangement, from 2003, 20 Malaysian students each year will be sponsored by their government to undertake a bridging program before commencing medical studies at the School. Since 2000, one to five students per year have been sponsored by the government of Botswana to enter the Melbourne University medical course, after two years of premedical science at the University of Botswana. Other projects in Indonesia and Malaysia will aid existing and new medical schools in curriculum development, supply curricular materials and foster research collaboration and staff and student exchange. The School has 71 international higher-degree research students and 36 international higher-degree coursework students. Most of the latter are undertaking Master of Public Health degrees funded by AusAID. Finally, the Faculty contributes to an AusAID-funded program in Fiji for the development of postgraduate programs at the Fiji School of Medicine. Faculty of Medicine, Nursing and Health Sciences, Monash UniversityStudents from developing countries undertake postgraduate degrees at the Faculty. The 2001 cohort included students from Bangladesh (3), Cambodia (2), China (1), Fiji (3), India (8), Indonesia (28), Kenya (1), Lebanon (1), Malaysia (32), Mexico (1), Nigeria (2), Pakistan (1), Philippines (1), Sri Lanka (1) and Thailand (4). In addition, the School of Nursing has been managing a $1.2 million AusAID project to deliver the Bachelor of Nursing (Post Registration) by distance education to 40 nurses in eight locations in PNG. In 2000–2001, the Department of Epidemiology and Preventive Medicine delivered a Fellowship Program in the Master of Public Health Services Management to 25 Indonesian Ministry of Health officials. The program was funded by the Asian Development Bank for $1.7 million. In 2001, the Department of Epidemiology and Preventive Medicine, in collaboration with George Washington University (USA), inaugurated a Master of Health Science Management course at the Monash University campus in Malaysia. University of Queensland Faculty of Health SciencesOver the past 20 years, 500 graduates from 30 countries have been trained in the areas of tropical health and nutrition. In addition, to assist with capacity building in community nutrition, 40 Indonesian graduates have been trained in various areas of community nutrition. Links with PNG include bringing medical, nursing and other allied health workers to Australia for short courses, and working with the University of PNG in community medicine and curriculum development. The Faculty has also established close relationships with several medical schools in China (Wuhan, Shanghai and Wenzhuo), including the training of PhD students, whereas student exchanges and PhD training have been used to develop programs for health service delivery in Cambodia. Joint programs with the Queensland Institute of Medical Research include a program for the control of dengue in Vietnam, modelling of different interventions in schistosomiasis control, and a vaccine trial for acute respiratory disease in the Philippines. Faculty of Medicine, University of SydneyThe Faculty has a Masters/Graduate Diploma of Public International Health which was established in 2000 to meet a demand, both in Australia and internationally, for high quality public health training in resource-poor settings. Since 2000, the program has grown from 13 students to the 95 students currently enrolled. Since the course's inception, 42% of the students have come from developing countries, including China (4), Mongolia (2), Vietnam (7), Cambodia (2), Philippines (3), Thailand (2), Burma (1), Malaysia (1), Bangladesh (6), India (1), Nepal (1) and Bhutan (2), sub-Saharan Africa (4), the Middle East (1) and Central and South America (1). This program aims to provide students with skills in public health education, research and practice appropriate for developing countries. Students are trained in areas such as disease priorities, health and development, international health organisations, as well as in epidemiology, biostatistics and social science methods. Students can choose to specialise in areas such as project management, infectious and non-communicable disease control, health promotion, maternal and child health, health and culture. Most of the students from developing countries return to their own countries to provide public health expertise to governments and agencies. University of Tasmania School of MedicineThe School has accepted international students since the 1970s. Most are from Malaysia, with recent smaller numbers from Botswana. Currently, the School admits up to 20 international students into the first year of the medical course. The School formed a medical school partnership with the International Medical University, Kuala Lumpur, Malaysia, in 2000, and currently takes five students per year into the fourth year of the medical program. The School also has a partnership with the Kunming Medical College, Yunnan Province, China, providing elective exchange programs in both directions, as well as postgraduate training and collaborative research. In 2000, two scholarships for study in cardiovascular medicine in the United Kingdom were provided to University of Tasmania graduates from Malaysia and Sri Lanka. The recipients will return to their countries with postgraduate training in paediatric cardiology and management of ischaemic heart disease. Since 1984, a number of students with AusAID or other support have had postgraduate training in cardiovascular medicine, surgery, obstetrics and gynaecology, and through the Menzies Centre for Population Health Research (China, 4; Laos, 2; Thailand, 2; and Sri Lanka, 1). Faculty of Medicine and Dentistry, University of Western AustraliaIn 2000, 114 East Timorese medical students were forced to discontinue their medical studies at Indonesian universities. The university, together with the Committee of Deans of Australian Medical Schools and the colleges, is attempting to help these students complete their training and support the professional development of junior doctors. With the World Health Organization, the Mental Health Epidemiology Unit has organised training courses for over 400 participants from Vietnam, China, Bulgaria and Russia on the International Classification of Diseases and measurement instrumentation in epidemiological research on mental disorders. The Centre of Vision Sciences, Lions Eye Institute and Universitas Airlangga (Indonesia) have developed joint postgraduate teaching programs in Surabaya, Indonesia. Up to 25% of all Indonesian ophthalmologists have attended exchange information programs on practical diagnosis and treatment of eye diseases causing blindness. Clinical collegesAustralian and New Zealand College of AnaesthetistsFellows of the College provide educational support for healthcare in PNG by participating in the Medical Officer, Nursing and Allied Health Project. College Fellows also assist Royal Australasian College of Surgeons/AusAID surgical teams visiting PNG, Fiji and the Pacific Islands, and East Timor. The College provides a Visiting Professor in Anaesthesia and an examiner for the MMed (Anaesthesia) examination at the University of PNG, and awards prizes for the best undergraduate and postgraduate students in anaesthesia. The ANZCA Maintenance of Professional Standards (MOPS) program is available to PNG anaesthetists. At the Fiji School of Medicine, ANZCA provides an examiner for the MMed (Anaesthesia) examination and awards a prize for the best candidate. The MOPS program is also available to anaesthetists in Fiji. Australasian College of DermatologistsCollege Fellows have participated in AusAID's Pacific Islands Project, conducting clinics in Vanuatu, Samoa, Fiji and Tuvalu. College Fellows have also participated in the AusAID-funded Graduate Training Program at the Fiji School of Medicine. The College supports the training of African health officers in dermatology at the International League of Dermatological Societies Regional Dermatology Training Centre in Moshi, Tanzania. Past trainees have been from Uganda and Malawi. Two College Fellows have written a booklet, Skin disease in the Pacific (University of Sydney, 2000), for use in the Pacific Islands, and, in September 2002, two College Fellows conducted a three-day workshop for doctors and nurses in Suva, Fiji. Royal Australian College of General Practitioners For over 20 years, the College has run a conjoint examination with the Malaysian Academy of Family Practice, awarding successful candidates the Fellowship of the Royal Australian College of General Practitioners. The Continuous Home Evaluation of Clinical Knowledge (CHECK) program (a continuing medical education program) is distributed through several developing countries, and it is hoped to extend its reach to incorporate India, Myanmar and Indonesia. The College has had a long involvement with WONCA (the World Organisation of Family Doctors), especially in the Asia Pacific region. It provides strong support to many of the regional family medicine working groups and furthers WONCA's objectives of promoting tobacco control and prevention and management of HIV/AIDS in the region. Royal Australian and New Zealand College of Obstetricians and GynaecologistsTogether with the Pacific Society for Reproductive Health, the College is developing a Continuing Professional Development Program for obstetricians and gynaecologists in Pacific Island countries. The College provides educational input and teaching assistance for the Diploma and Master of Medicine (Obstetrics and Gynaecology) programs at the University of PNG and the Fiji School of Medicine. The RANZCOG supports young gynaecologists in the Asia and Oceania region to attend reproductive health scientific meetings (including the College's own Annual Scientific Meeting) and short-term training placements in hospitals in Australia and New Zealand. The College maintains a register of volunteers and responds to requests for locum and teaching placements in major regional hospitals in PNG and Fiji. From time to time, second-hand medical equipment is channelled to these hospitals. The College provides specialist input for meetings, workshops and health improvement programs run by obstetrics and gynaecology societies throughout Asia and Oceania. Royal Australian and New Zealand College of OphthalmologistsThe College coordinates Fellows' involvement in developing countries in providing both ongoing services and concentrated, practical training programs for ophthalmologists in these countries. In addition, funds have been allocated to provide university and hospital ophthalmology departments in developing countries with 120 free subscriptions to the College's scientific journal, Clinical and Experimental Ophthalmology. The College sponsors ophthalmologists from developing countries to attend and participate in the RANZCO's Annual Scientific Congress, and, in 2002, the International Congress of Ophthalmology in Sydney. A recently acquired laser and other equipment will be available to Fellows for use when working in developing countries, and a travel grant is available for registrars to enable them to attend overseas field trips in developing countries. Registrars have recently worked in Bali, Fiji, Tonga and Western Samoa. Royal College of Pathologists of AustralasiaThe College has active training programs in Hong Kong, Singapore and Malaysia, and has representatives from these countries on its Council. Although there are only 25 forensic pathologists in Australia, the College has a number of initiatives in this field. These include: responsibility for the Forensic Pathology Secretariat of the World Association of Societies of Pathology; initiation of a Diploma in Forensic Medicine designed for overseas graduates who are ineligible for Australasian qualifications; training of graduates from Sri Lanka, Kenya, Malaysia, Tanzania, Taiwan and Fiji in forensic pathology institutions around the country; assistance with forensic investigations in Bosnia, Kosovo, East Timor and Fiji; and establishment of inhouse forensic pathology training at the International Committee of the Red Cross in Geneva (during 2003). A Soft Tissue Tumour Registry, designed to assist with the diagnosis of soft-tissue tumours, operates at an international level, and includes a number of panellists in China. Royal Australasian College of PhysiciansThe College has an Asia Pacific Committee, with members from PNG, Fiji, Malaysia, Singapore, Hong Kong and Thailand. The committee promotes links with the Asia Pacific region, contributes to development projects, undertakes educational initiatives, and maintains a database of activities and College Fellows in the region. For the past seven years, the College has been the lead partner in a major AusAID-funded training project, the PNG - Medical Officer, Nursing and Allied Health Science Training Project. The project is aimed at strengthening the capacity of the PNG National Department of Health and the University of PNG to improve training in medicine, post-basic nursing and allied health sciences. The College annually provides visiting lecturers for the Master of Medicine Program in Malaysia and for educational programs in Fiji. It also contributes to other organisations' projects, including projects of the Royal Australasian College of Surgeons in the Pacific Islands and the Fiji School of Medicine. Royal Australian and New Zealand College of RadiologistsThe College is developing a radiology education centre for the South Pacific, based in Fiji, under the guidance of the World Health Organization and in association with international radiology and radiography societies. New Zealand and Australian radiologists make short visits to Samoa, Vanuatu, Solomon Islands, PNG and Fiji, providing education in image interpretation, management and client focus. The success of the visits is assessed by host country radiologists and radiographers. South Pacific radiologists are encouraged and financially supported to participate in the annual scientific meetings of the College. Further, the College is establishing a program to provide new, second-hand and superseded radiology textbooks to developing countries. Sources include publishers, radiologists, and practices. Australian College of Rural and Remote MedicineThe College supports a number of ongoing collegiate linkages in developing countries, based on providing information and educational resource sharing, as well as organisational and peer support. A current project involves working with the Cambodian Medical Association to strengthen professional development capacity. Initial work, including familiarisation visits, educational resource development and workshops, has been funded by AusAID. Royal Australasian College of SurgeonsIn the PNG Tertiary Health Services Project, specialist medical teams deliver surgical services that would not otherwise be available. Ongoing links between visiting surgeons and local personnel improve medical knowledge and skills in PNG. The Pacific Islands Project involves short term visits by specialists from 12 different specialties to 10 Pacific Island countries: the Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Marshall Islands, Samoa, Solomon Islands, Samoa, Tonga, Tuvalu and Vanuatu. The teams provide clinical service, as well as training for local personnel. The Medical Equipment Maintenance Project covers seven Pacific Island countries, using formal and on-the-job training to improve equipment management practices, equipment reliability, and technical skills for local personnel. Interplast is a collaborative effort with Rotary, the Australian and New Zealand College of Anaesthetists and registered nurses to teach and deliver plastic and reconstructive surgical services to developing countries. The East Timor Project involves the placement of a full-time anaesthetist and general surgeon in Dili, as well as specialist surgical visits. This selection shows what is possible when individuals and institutions apply their resources to work in partnerships with countries with greater needs and fewer resources than Australia. It should serve as a challenge to each one of us, as doctors, to ". . . search and see if there is not some place where you may invest your humanity" (Albert Schweitzer).

Ruth M Armstrong BMed

Even eight hours after a campfire has been extinguished with sand, it retains sufficient heat to cause a full-thickness burn with contact of one second. Because extinguishing with sand disguises the danger, this is a particular hazard for children. The only safe way to extinguish a campfire is with water.

John F Fraser MRCP, FJFICM · Kelvin L Choo MB BS, FRACS · Roy M Kimble FRCS, FRACS · David Sutch

Objective: To identify the adequacy of first aid care following minor burns in children.Design: Prospective case series.Setting: Emergency Department and Acute Wound Clinic, the Children's Hospital at Westmead (CHW), Sydney.Participants: 109 children who presented with minor burns (10% body surface area or less) to CHW over the five months from 2 November 1998 to 23 March 1999.Main outcome measures: Comparison of the adequacy of first aid delivered by parents and carers, general practitioners, local hospitals, and CHW.Results: Burns included scalds, contact, flame, chemical or electrical burns. Adequate initial first aid had been given by parents or carers in only 24 of 109 cases (22%). The 85 children who presented to medical care after inadequate initial first aid was given by parents or carers included 14 of 14 (100%) who had presented to their general practitioner (GP), 22 of 31 (71%) who had presented to their local hospital, 22 of 38 (58%) who had presented to CHW, and 2 of 2 (100%) who had had first contact with other health professionals.Conclusions: This study shows that there is a need to educate parents and health professionals regarding appropriate first aid for burns.

Rebecca A McCormack MB BS(Hons), RN, GradDipMid · Erik R La Hei MB BS, FRACS · Hugh C O Martin MB BS, FRACS, FRCS

Interest in envenoming syndromes caused by Australian jellyfish has been intense since the deaths in early 2002 of two tourists in Queensland, attributed to the Irukandji syndrome. We review current knowledge of these envenoming syndromes, mechanisms of venom action and therapy, focusing on the deadly box jellyfish, Chironex fleckeri, and the array of jellyfish thought to cause the Irukandji syndrome. Current understanding of jellyfish venom activity is very limited, and many treatments are unproven and based on anecdote. Worldwide media attention recently focused on Australia following the first two known human fatalities attributed to the Irukandji syndrome in Queensland in 2002.1 Jellyfish envenoming represents a major cost to northern Australian communities in terms of public health, leisure and tourism. Management of these syndromes depends on improved understanding of venom action and critical analysis of current therapy. We review the current state of knowledge of envenoming syndromes caused by Australian jellyfish, the mechanisms of venom action and management. We focus on the deadly box jellyfish, Chironex fleckeri, and the array of jellyfish thought to cause the Irukandji syndrome. Information was obtained from a search of MEDLINE, EMBASE and SciFinder Scholar for articles published in English over the period 1966–2002, using the keywords jellyfish, venom, Chironex fleckeri, Irukandji, Carukia barnesi, antivenom, pressure immobilisation bandaging, verapamil and therapy. Chironex fleckeriThe box jellyfish, C. fleckeri, is found in tropical waters of Australia's north, from Gladstone in Queensland to Broome in Western Australia (Box 1 and Box 2). It is most prevalent in summer, although stings have been reported year-round.1 The jellyfish has a transparent box-shaped bell measuring up to 20 cm by 30 cm and weighing up to 6 kg, while the total length of tentacles may exceed 60 m.3 Skin contact with C. fleckeri tentacles can result in dermonecrosis, pain and death, occasionally with alarming speed. Some patients also develop delayed cutaneous hypersensitivity reactions at the sting site.4 There have been 67 human deaths attributed to C. fleckeri, the most recent a six-year-old boy at Yarrabah, near Cairns in Queensland, in 1999.1 However, despite this jellyfish's reputation as the "world's most venomous animal",5 the vast majority of human stings are of little consequence.4 Most are managed with no analgesia, local ice packs or oral analgesia only, and rarely require hospital admission. The mechanism of action of C. fleckeri venom in severe envenoming remains unclear, but the key events appear to be cardiac or respiratory failure, or both.6,7 Some patients with severe C. fleckeri envenoming have been successfully treated by expired-air resuscitation alone,8,9 but fatalities have also occurred due to cardiac toxicity in mechanically ventilated patients.10 The Irukandji syndromeA number of jellyfish can cause the Irukandji syndrome,11 although only Carukia barnesi is conclusively known to do so. C. barnesi is a small carybdeid jellyfish with a transparent bell 1.5–2.5 cm in diameter. The infrequency of sightings or capture of C. barnesi and other small jellyfish that may cause the Irukandji syndrome makes precise knowledge of its geographic distribution problematic. Cases of Irukandji syndrome have occurred from Rockhampton in Queensland to Broome, although prevalence is greatest in the Cairns region. Recently, an Irukandji-like syndrome was reported in Hawaii.12 The Irukandji syndrome most commonly presents with generalised pain, hypertension (often severe), nausea, vomiting, and distress. The similarity of many of these symptoms to decompression sickness can provide a diagnostic challenge in scuba divers. Most patients presenting to emergency departments are treated with opiate analgesia, and about half require admission. A small number require advanced life support, usually because of cardiac failure.13 Catecholamine excess has long been proposed as a significant underlying mechanism in severe Irukandji syndrome.1,3,21 Victims develop symptoms mimicking medical conditions associated with endogenous catecholamine excess, such as phaeochromocytoma. Experiments in ventilated piglets showed a 200-fold increase in serum noradrenalin levels and a 100-fold increase in serum adrenalin levels after injection with crude extract of C. barnesi.22 These experiments quantified for the first time a relationship between experimental envenoming by C. barnesi and a hypercatecholaminergic state. However, there is no evidence of further deterioration in patients with cardiac dysfunction associated with severe Irukandji syndrome treated with adrenalin infusions.11 The mechanism of the cardiac dysfunction is yet to be elucidated. A review of 11 cases of pulmonary oedema developing in patients with Irukandji syndrome suggested that these patients had features of myocarditis.23 In a review of 116 patients with Irukandji syndrome presenting to Cairns Base Hospital in the summer of 2001–2002, 25 had raised serum levels of troponin I.24 Eighteen of these 25 patients had echocardiography, with six showing echocardiographic evidence of cardiac dysfunction. Significantly, no patients developed clinical cardiac failure. It is unclear whether the cardiac dysfunction is caused by a myotoxin or the hypercatecholaminergic state, or a combination. Venom delivery and actionJellyfish venom is delivered into prey or victims by millions of microscopic stinging cells, known as nematocysts. Light microscopy examination of nematocysts recovered from victims' skin is used to identify the envenoming jellyfish, particularly in Chironex stings. Two techniques are used to harvest nematocysts — scalpel-blade scraping of the sting site, and sticky-tape sampling. These tests generally demonstrate good specificity (ie, positive nematocyst identification correlates well with observed clinical syndromes).14 Both methods also appear to have similar efficacy in terms of nematocyst retrieval, although, given the low nematocyst identification rates in the Irukandji syndrome, their sensitivity remains unknown. The rapid onset of systemic symptoms after major jellyfish envenoming by C. fleckeri suggests that venom is "most probably introduced directly into blood vessels".15 Postmortem evidence from the last C. fleckeri fatality demonstrated nematocyst barbs penetrating the vascular dermis.16 C. fleckeri venom has haemolytic, lethal, myotoxic and dermonecrotic effects.17 Current evidence suggests that the venom toxins are proteinaceous and target specific organs. Monoclonal antibodies capable of neutralising C. fleckeri-induced haemolysis did not protect against the lethal effects of venom.18 Several myotoxins, with molecular weights of about 600 kDa and 150 kDa, have been reported in C fleckeri venom.19,20 These toxins showed significant lethality in a mouse model of envenomation and may play a role in human cardiotoxicity.3 We speculate that these and other, as yet unidentified, proteins cause ion flux and transmitter release through altering cell membrane permeability, either through specific interactions with ion-channels or receptors or through non-specific interactions with cell membranes. Treatment of jellyfish envenomingPrevention and first aidThe only reliable preventive measure is to avoid any contact with sea water. Other measures include wearing "stinger suits" or swimming inside "stinger nets" (Box 1), although these do not appear to protect against Irukandji syndrome.13 First aid measures include retrieval of the patient from the water, activation of the emergency medical system, and cardiopulmonary resuscitation, if appropriate. Acetic acid irreversibly inhibits firing of previously undischarged C. fleckeri nematocysts,25 and has greatest acceptance for beachside treatment of jellyfish stings; large amounts of vinegar are placed in prominent positions along swimming beaches in jellyfish-endemic areas. Pressure immobilisation bandagingPressure immobilisation bandaging (PIB) is advocated by Queensland26,27 and national28 authorities for first aid in jellyfish stings, but not by Northern Territory authorities.29 It was first proposed because of its effectiveness in treating elapid snakebite,30 but the link between treatments for snakebite and jellyfish stings is tenuous. Animal models demonstrate that PIB slows entry of snake venom to the circulation by halting lymphatic flow from the venom depot.31 However, in jellyfish stings, nematocysts may be widely distributed on victims' skin, and there is evidence that venom enters the victim's bloodstream directly rather than via lymphatics.16 No animal studies have been performed to demonstrate a beneficial effect of PIB in jellyfish stings, and a recent review found no scientific evidence to support the ongoing use of PIB in this setting.16 Furthermore, a significant amount of venom may remain in discharged nematocysts adherent to the patient's skin.32 An in-vitro model of nematocyst discharge showed that pressure equivalent to PIB caused further venom liberation from previously electrically discharged nematocysts from Chiropsalmus spp.32 Similarly, pressure equivalent to PIB caused additional venom release from naturally discharged C. fleckeri nematocysts exposed to vinegar, in amount similar to the initial firing.33 PIB in jellyfish envenoming thus remains at best unproven, and at worst potentially dangerous. More evidence is required to delineate its role in human jellyfish envenoming. The Australian Resuscitation Council has recently announced a change in advice to a more neutral position.34 Treatment of Chironex fleckeri envenomingAntivenomC. fleckeri antivenom is produced using "milked" venom, obtained by electrical stimulation of C. fleckeri tentacles. The antivenom neutralises the lethal, haemolytic, dermo-necrotic and pain-inducing effects of milked venom and whole-tentacle extracts in experimental animal models.3,5,6,35,36 However, it is less effective in neutralising crude nematocyst venom (obtained by mechanical rupture of nematocysts) compared with milked venom in a mouse model,5 creating doubt as to whether the milked venom used in its production contains all the lethal factors present in native venom. Evidence supporting the efficacy of C. fleckeri antivenom in human envenoming is anecdotal, with several reports of successful use.9,30,37 However, there is also a report of survival in major envenoming in the absence of antivenom.8 C. fleckeri antivenom appears safe to use. It is widely available in C. fleckeri-endemic areas, and is carried routinely by Queensland paramedics. As most patients who are envenomed by C. fleckeri have minimal symptoms, we believe that antivenom should be used only in those with cardiorespiratory instability, including cardiac arrest, or severe pain unrelieved by opiate analgesia (Box 3). VerapamilVerapamil was initially advocated to treat C. fleckeri envenoming on the basis of isolated organ experiments showing that C. fleckeri venom causes arterial constriction, reduced coronary blood flow and bradycardia.38,39 There is experimental evidence that these effects may be due to increased intracellular calcium concentrations in the affected organs.6,40 Two studies reported that verapamil significantly delayed death in experimental C. fleckeri envenoming, perhaps buying time for more definitive therapy.41,42 However, verapamil was associated with increased morbidity and mortality in a pig model of envenoming.6 There are theoretical reasons to be cautious in using verapamil for the potentially unstable patient, as it may potentiate hypotension and induce cardiac dysrhythmias. At best, it can be considered appropriate as experimental treatment for the patient in extremis. Clearly, more evidence is required to determine its role. Treatment of dermonecrosis and delayed cutaneous hypersensitivity reactionsDermonecrosis is a frequent acute complication of serious C. fleckeri stings. While indomethacin and methysergide have been shown to reduce C. fleckeri-induced capillary leakage,43 no animal or human clinical data have identified any agent that reduces long-term scarring. There are case reports of improvement in both acute and long-term cutaneous damage when C. fleckeri antivenom is used,30 but it should be noted that the acute skin changes of C. fleckeri envenoming often resolve spontaneously. At present, acute dermonecrosis is treated as a burn, with specific attention to avoiding secondary bacterial infection.7 Delayed hypersensitivity reactions are a common late complication of C. fleckeri stings, occurring in about 50% of cases, and are usually minor.4 Corticosteroid cream and oral antihistamines are the mainstay of treatment. Treatment of Irukandji syndromeEvidence as to the best treatment for Irukandji syndrome is anecdotal. The relative infrequency of patients with severe illness makes the prospect of high quality evidence unlikely. AnalgesiaNarcotic analgesia is routinely required, but no single agent has met with universal approval. There are several theoretical reasons to avoid pethidine, including potential for norpethidine toxicity and myocardial depression. Antihypertensive agentsPatients are often hypertensive at presentation, although it is unclear if this is due to pain or catecholamine-like effect. Phentolamine has been used to treat hypertension,44 but is rarely used in emergency departments and may not be available in some centres. An agent with a shorter half-life may be more advisable given the potential for cardiovascular collapse. Glyceryl trinitrate has been used15 and may be the first-line agent for hypertension. As cases of echocardiographically proven cardiac dysfunction have occurred, caution should be exercised in avoiding life-threatening hypotension. Treatment of pulmonary oedemaPulmonary oedema is treated in the usual manner, with supplemental oxygen, inotropic support with dopamine and adrenalin, and positive-pressure ventilation. The underlying cause appears to be significant cardiac dysfunction which returns to normal within three to four days. ConclusionsFundamental knowledge of the biology, venomology and toxidromes of medically important jellyfish is severely lacking. Many therapies currently used for jellyfish envenoming are based on anecdote and may be harmful. Formal understanding of the functional components of jellyfish venom may reveal a mechanism of action that is reversible with currently available pharmaceuticals. Alternatively, novel treatments for envenomed humans may also be developed, based on a more thorough knowledge of the mechanism of action of the venom components. 1: "Stinger net" at Palm Cove, Cairns Of all the beaches around Cairns, Palm Cove has the highest incidence of Irukandji syndrome. Stinger nets offer no protection against the tiny causative jellyfish, Carukia barnesi. 2: Distribution of Chironex fleckeri stings and Irukandji syndrome Sites of recent fatalities attributed to Irukandji syndrome (Hamilton Island, Jan 2002; Port Douglas, Apr 2002), and to C. fleckeri envenomation (Yarrabah, 1999). 3: Characteristics of Chironex fleckeri antivenom Derived from sheep serum Carries risk of anaphylaxis, although rare Indications: Cardiorespiratory instability Cardiac arrest Severe pain unrelieved by narcotics Dose: Initial dose is three ampoules, diluted 1 in 10 with normal saline If cardiac arrest, give up to six ampoules as an intravenous bolus Has been given safely as an intramuscular dose by ambulance staff before reaching hospital

Paul M Bailey FACEM · Mark Little FACEM, MPHTM · George A Jelinek MD, FACEM · Jacqueline A Wilce BSc, PhD

Objectives: (1) To identify the causative jellyfish species by examining skin scrapings in patients presenting to Cairns Base Hospital with marine stings, and (2) to describe clinical outcomes of those with Irukandji syndrome and those in whom nematocysts were identified from skin scrapings.Design and setting: (1) A retrospective case series of 128 patients, identified from Cairns Base Hospital emergency department records with discharge diagnoses of marine stings between 1 July 2001 and 30 June 2002. (2) A prospective study of skin scrapings from 50 patients presenting with marine stings from the same period.Main outcome measures: Number of patients with Irukandji syndrome, their opioid requirements and cardiac findings (where available); identification of causative species from nematocysts isolated from skin scrapings.Results: 116 patients retrospectively identified with marine stings had Irukandji syndrome. Of 50 patients who had skin scrapings, 39 had nematocysts consistent with Carukia barnesi. Symptoms experienced ranged from local pain alone to severe Irukandji syndrome with elevated troponin I levels, changes on electrocardiogram, cardiac dysfunction on echocardiography, and high opioid dose requirements. One patient had an unidentified cnidome on his skin scraping. He developed severe Irukandji syndrome and subsequently died from its complications.Conclusion: This is the first published report of Carukia barnesi being successfully identified from skin scrapings. Most patients with identifiable cnidomes experiencing Irukandji syndrome were stung by Carukia barnesi, which we show causes a wide range of illness, including cardiac dysfunction. Our finding of a cnidome not consistent with Carukia barnesi in the setting of Irukandji syndrome makes it possible that other species of jellyfish may also cause this syndrome.

Truc T Huynh MB BS · Peter Pereira FACEM · Richard Mulcahy FACEM · Paul Cullen FACEM · Jamie Seymour PhD · Teresa Carrette BSc · Mark Little FACEM

To the Editor: Survey data are difficult to publish when response rates fall below 60%. Reminder letters are the most reliable method of improving response rates in postal surveys,1,2 and three to four reminders are needed to achieve the 60% benchmark. The additional benefit of sending five or more reminders appears negligible, suggesting that four is the optimum number to maximise response rates using this approach.1 Our recent experiences suggest that human research ethics committees (HRECs) are seeking to limit the number of reminder letters on the grounds that they could be construed as harassment of research subjects. We recently submitted applications to two HRECs, seeking permission to conduct a multicentre postal survey in our local area. One committee approved the use of a single reminder letter, while the second approved the use of two. We appealed both decisions, citing evidence from earlier studies.1,2 The first committee reversed its decision and subsequently approved use of three reminders; the second committee upheld its decision to allow only two reminders. Thus, our study was effectively restricted to two reminder letters. These experiences highlight two limitations of the ethics review process in Australia. First, the process is highly fragmented and lacks standardisation. HRECs exist as autonomous and independent entities, with varying interpretations of ethical practice. The decisions of one committee frequently undermine those of another. This is frustrating for researchers, who often have to seek permission from two or more committees during the course of a study. Second, the process confers higher status on the rights of study participants than on the methodological demands of science. Whenever there is any actual or perceived conflict between the two, HRECs consistently rule in favour of individual rights. Researchers are reluctant to challenge the decisions of their local committee, as there is no independent review process, and appeals are usually referred back to the original committee. The result is a directive and autocratic process which fails to consider the demands of scientifically valid research. Under current guidelines of the National Health and Medical Research Council, HRECs may endorse procedures that are potentially invasive or intrusive, provided certain conditions are met: the procedures are scientifically justified; there is no acceptable alternative; and reasonable steps are taken to protect individual rights. This certainly provides scope for sanctioning four reminder letters in postal surveys.

Stuart C Howell · Susan Quine · Nicholas J Talley

Comment: Howell and his coauthors invite human research ethics committees (HRECs) to standardise their judgements about key aspects of methods, such as response-aiding strategies.1 Their balanced and thoughtful analysis of their experience in securing approval from two HRECs for reminders to enhance response rates to a postal community survey adds to previous concerns about decision-making by HRECs in Australia.2,3 In an era of evidence-based healthcare, there are two main reasons to insist that HRECs only approve protocols for surveys that propose scientifically based procedures to increase response rates. First, applicants are applying empirical insights from previous research in their own practice. Hence, methods are evidence based. Second, applicants are doing their best to ensure the validity of their future data. As eloquently quantified elsewhere, surveys with low response rates are plagued by response bias.4 Indeed, it was recently asserted that, for mailed surveys, "you need an 80–85% response rate to make it epidemiologically significant".5 Fortunately, there is the most rigorous evidence (Level 1) for specific response-aiding strategies for surveys of medical practitioners in Australia.6 Howell and colleagues cite two recent studies of response-aiding strategies in lay surveys. Yet such compelling evidence appears to have been inadequate to secure identical responses from at least two HRECs. That both required Howell and colleagues to apply "homoeopathic" measures to their reminders (sending two rather than the proven four reminder letters) suggests that these HRECs may have been poorly apprised of the relevant scientific literature, unconvinced of its generalisability, or concerned about the acceptability of proposed procedures to research participants. As current National Health and Medical Research Council (NHMRC) guidelines provide a framework for approving research procedures that are "scientifically justified", it seems HRECs would benefit from regular and independent updates about key methodological advances, such as response-aiding strategies, their benefits, risks and harms. I am mindful that such methodological guidance must not add unnecessarily to the copious reading that is already typically demanded of members of HRECs. Perhaps the NHMRC Australian Health Ethics Committee could consider this issue in its next triennium, to commence 2003.

Jeanette E Ward

To the Editor: The recent information that methylphenobarbitone (60 mg tablets) will be unavailable after 1 January 2003 has caused anxiety in patients with epilepsy previously treated satisfactorily with this drug. The suggested substitution of phenobarbitone, primidone or a newer antiepileptic agent seems appropriate. However, patients and perhaps practitioners may assume, as my patients have, that phenobarbitone and primidone are equivalent to methylphenobarbitone on a milligram-for-milligram or a tablet-for-tablet basis. This may not be so. The equivalence is close to 30 mg of phenobarbitone for 60 mg methylphenobarbitone, and probably around 200 mg of primidone for 60 mg of methylphenobarbitone.1 Plasma phenobarbitone concentrations should be checked before and after any changeover. In recent years, several other old, but therapeutically satisfactory, neurological drugs have also been withdrawn from the Australian market (oral neostigmine, several anticholinergic antiparkinsonian agents, ethosuximide and some phenytoin preparations, and the only ergotamine preparation not also containing caffeine). Subject to safety issues, ethics committees usually will not approve a clinical trial of a new drug unless patients who benefit from it are guaranteed supplies until the drug is marketed. Surely similar considerations should apply for patients who have had completely satisfactory long-term responses to marketed drugs. If such drugs must be withdrawn, except for safety reasons, there should be extensive prior consultation with prescribers and patient groups, prescribers should know the situation before their patients discover it from other sources, and there should be a sufficient lead time for everyone receiving the drug to return for another prescription (and for advice) before the drug becomes unavailable (a minimum lead time of six months in the case of drugs subsidised under the Pharmaceutical Benefits Scheme). The withdrawal of useful neurological drugs in Australia has reached the stage where therapeutic options are becoming limited. In the case of drugs required for long-term use, to protect the interests of new patients it has become necessary to consider whether the drug will continue to be available for the expected duration of the patient's therapy. In this regard, the prescriber's only guide may be the track record of the firm which markets the drug otherwise chosen.

Mervyn J Eadie

To the Editor: The recent article by McLean and Higginbotham1 and the accompanying editorial by Melding2 highlight the problems faced by elderly people in aged-care facilities. It is likely that many elderly people living alone in the community are suffering equal, if not worse, pain. At a recent strategic planning meeting, the Australian Pain Society identified this group of people as a high priority for the development of pain management treatment strategies. These strategies are now well into the development process. While it is appropriate for the Journal to focus on medical practitioners' care of these patients, it must be remembered that most direct care for people in aged-care facilities is delivered by nurses and nurse assistants/carers. The Australian Pain Society will be focusing its strategies on non-drug techniques that can be used by this group of healthcare workers. Assessment and documentation of pain-related behaviour, particularly in people with cognitive impairment, is critical if progress is to be made. It is also important to appreciate the contribution in this area from other allied health professionals, such as physiotherapists, psychologists and occupational therapists. These practitioners have much to offer this patient group and have been important contributors to the Australian Pain Society's management strategies. It is hoped that State and federal funding can be made available for nurse educators to deliver these low-tech, non-drug management strategies within aged-care facilities. The two articles quite rightly focus on the regular use of simple oral analgesics, such as paracetamol, and low-dose opioids. Oral analgesics, together with more widespread use of non-drug treatments (eg, exercise, transcutaneous electrical nerve stimulation, hot and cold topical applications, relaxation, distraction, mental stimulation, lifestyle modification) and increased awareness among aged-care workers of the problems and solutions, should lead to an enhanced quality of life for this growing sector of our community.

C Roger Goucke

To the Editor: The articles by Melding1 and McClean and Higginbotham2 highlight the important problem of chronic pain in residential care. We have conducted two studies to investigate factors related to depression in residential care. In our first study, in 1994, we approached a random one-in-two sample of the non-nursing-home population of a Sydney retirement village (n = 1466). We excluded residents who were under 65 years, had severe dementia, were away from the village at the time of the survey, or were too deaf or ill to participate. Of 610 eligible residents, 513 participated (response rate, 84%). Of these, 42.1% lived in hostels and 57.9% in independent living units. In a second, similar study, in 2000–2001, we surveyed residents of three Sydney aged-care hostels (n = 205). Of 159 eligible residents, 148 (93%) participated. In both studies, residents were asked how often over the previous six months they had experienced recurring pain and asked to rate the severity of pain at its worst (see Box). Using the Geriatric Depression Scale (GDS),3 Study 1 found that residents reporting frequent/constant pain were significantly more likely to be depressed (ie, to have a GDS score ≥ 11) than people reporting rare/occasional pain; similarly, people who felt rare/occasional pain were more likely to be depressed than those with no pain (odds ratio, 1.44; 95% CI, 1.13–1.83). In Study 2, there was a non-significant association between frequent pain and depression (odds ratio, 1.47; 95% CI, 0.96–2.24). We implemented pain management programs at each facility. In Study 1, the program was part of a multifaceted intervention for depression,4 but residents could attend whether depressed or not. Based on general practitioner referral, the program provided interdisciplinary assessments by a visiting rehabilitation specialist together with a physiotherapist, occupational therapist and registered nurse from the facility. Consultative psychiatric input was also available. Neuropathic and musculoskeletal pain were the most common reasons for referral. Recommended interventions included drug treatment, exercise and preventive measures. Our impression was that they were well received by residents and GPs. In Study 2, residents with chronic pain were referred to a physiotherapist specialising in pain management and reported that this was beneficial. A clinical psychologist also offered to assist, but residents were reluctant to accept this form of help. Our impression was that psychological assistance would have been better received as part of an interdisciplinary pain management program. Older people in residential care may find it difficult to travel to hospital-based pain management programs. Our experience indicates that it is feasible to conduct pain management programs in residential care. However, improving pain management is not only a matter of pharmacological interventions. If we are serious about achieving adequate standards of pain management in residential-care facilities in Australia, resources should also be devoted to providing accessible interdisciplinary pain management programs and to changing the attitude that pain is an inevitable part of old age. Self-reported pain frequency and severity among residents of aged-care facilities Study 1 (1994) (n = 513) Study 2 (2000–2001) (n = 148) Pain frequency Not at all 230 (44.8%) 54 (36.5%) Rarely/occasionally 115 (22.4%) 52 (35.1%) Frequently/constantly 168 (32.8%) 42 (28.4%) Pain severity* Minimal/mild 58 (20.5%) 27 (28.7%) Moderate 98 (34.6%) 36 (38.3%) Severe/bad as could be 127 (44.9%) 31 (33.0%) *Severity rated only for residents experiencing pain.

Robert H Llewellyn-Jones · Karen A Baikie · Heather E Smithers · Philip D Funnell

To the Editor: In their editorial,1 Hammett and Harris have overlooked one of the most important contributory factors to the increased use of diagnostic tests by community-based practitioners (ie, GPs) — patient demand. It is not unusual for a GP to be faced with a request by a patient to be "tested for everything", or for a specific test that may be quite inappropriate ("I just want my hormones checked"). It takes far longer to explain to the patient that the tests are inappropriate than to give in and sign the appropriate pathology form. And then, if the patient a year later does come down with some obscure syndrome, he or she can come back in the courts and say, "If only the doctor had listened to my request for tests I would be okay now". The frontline GP is in a lose–lose situation, stuck between the Health Insurance Commission and its demands for reasonable levels of testing, the expectations of patients that everything can be detected by a blood test, and the excessively perfectionist ideals of the legal system.

Warwick Carter

In reply: As Murray notes, appropriate test ordering belongs firmly in the domain of quality care and clinical accountability. In his seminal article on clinical leadership of healthcare system improvement, Berwick lists appropriate use of testing and therapy as the first challenge facing people who wish to improve healthcare systems in the developed world.1 Murray also identifies the paucity of structured educational programs aimed at providing junior medical staff with the skills to exercise "knowledge and judgement" in test ordering. The Royal Australasian College of Pathologists is seeking to address this deficiency through the development of educational modules on test ordering. It is unlikely, however, that education alone will curb the increase in test ordering in Australia. Educational programs for junior medical staff are notoriously resource-intensive and difficult to sustain. In addition, they rarely provide the point-of-care guidance that seems to be more effective in sustainably modifying behaviour. Such guidance may require test-ordering software that provides guidelines for ordering and feedback of individual performance, or the use of structured test-stratification programs such as that described by Stuart et al.2 Improved education, supervision and point-of-care guidance will prove ineffective if fears of litigation continue to drive the behaviour of clinicians. As Carter points out, concerns about litigation must be considered in any program aimed at improving practice. However, although litigation related to missed diagnosis is a recurring theme, this may relate more to time pressures rather than a failure to perform investigations. Indeed, many malpractice suits result from failure to adequately check and act upon the results of the barrage of tests ordered. Attempts to reduce medicolegal risk by ordering all conceivable tests may increase practitioners' risk unless they have extremely well-designed follow-up systems. It is important that clinicians not sacrifice high-quality, evidence-based investigation and treatment in an attempt to minimise perceived litigation risks. By testing inappropriately, clinicians may in fact expose themselves to greater risks of litigation, as their patients are exposed to the risks of the tests themselves, the chance of false-positive results and inappropriate treatment, and the failure to follow up on investigation results. It is unfortunate, and an indictment of our current reimbursement system, that the financial realities of community practice make it difficult for clinicians to take sufficient time to communicate with patients about the appropriateness of an investigation or treatment. If we continue to allow this to become the way we practise, we will continue to see a diminution of our professional role as we become merely booking agents for tests. As Berwick says, "Efforts to reform the health system from the outside can help motivate and set the stage for improvement. Yet, if clinicians do not wish to make specific changes in their own work to better meet society's need for better outcomes and lower cost, no-one outside the health system can be clever enough or powerful enough to make them do it."1

Rohan J H Hammett · Roger D Harris

To the Editor: While agreeing that sensible utilisation of pathology tests in emergency departments (EDs) is important, we are concerned that the article by Stuart et al1 might be misinterpreted to justify wholesale reductions in important diagnostic microbiological tests, particularly blood cultures. Stuart and colleagues imply they could safely reduce the number of blood cultures by 80%.1 Other local data have suggested a minority of blood cultures in the ED influence patient management.2 Confirmation of aetiology will be denied for patients by "rationalisation" of blood cultures in EDs. Although most pathogens are susceptible to broad-spectrum anti-microbial agents, widespread empiric prescribing of such agents in an era of increasing antimicrobial resistance is unwise. A recent Australian study evaluating blood cultures found that a third of patients with positive blood culture results were not clinically suspected to be bacteraemic.3 Furthermore, the Journal recently reported the emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA),4 and increasing resistance in Streptococcus pneumoniae.5 Missing MRSA or multidrug-resistant pneumococcal bacteraemia will result in adverse patient outcomes. What about missed cases of meningococcal disease, or typhoid fever, with their associated public health costs? Paradoxically, amid emerging antimicrobial resistance, we may become less aware of the problem. Furthermore, what about the infection control costs required to control the resultant outbreaks of multidrug-resistant organisms? Empiric broad-spectrum antibiotic prescribing, driven by failure to undertake important microbiological investigations, is bad medicine: It teaches everyone to guess the microbiological diagnosis, and, if you do not test, who can prove you wrong? Perhaps only when the patient presents to the tertiary referral hospital with therapeutic failure and evolving multisystem organ failure. It logically extrapolates to all patients getting vancomycin plus meropenem to ensure covering MRSA and resistant gram-negative bacilli. It inevitably drives resistance, which is increasing rapidly. It has never been subject to rigorous scientific scrutiny with cost-effectiveness studies. Moreover, the study by Stuart et al1 provides no data on readmission rates, lengths of stay, adverse events and rates of missed or incorrect diagnoses; the ED setting studied has limited generalisability; and United States guidelines, which may be inappropriate in the Australian healthcare context, were used to develop the diagnostic testing protocol. Might not reducing the ordering of some microbiological tests cause "spiralling therapeutic empiricism"? Might not the overall healthcare budget growth accelerate because of increased prescribing of expensive broad-spectrum antimicrobials?

Iain B Gosbell · Peter J Collignon · John D Turnidge · Christopher H Heath · Joan L Faoagali

To the Editor: The rate of growth of pathology and radiology testing over the last decade has surpassed the average growth of most other medical services.1 Pathology Medicare items processed per capita between 1996–97 and 1998–99 demonstrated the largest increase (8%) of all item types. The interventional program for reducing diagnostic testing reported by Stuart, Crooks and Porton shows promise in addressing this increase in the emergency department, and has significant potential across other hospital departments.2 The program's focus on initiating behavioural change among test-ordering staff as a precursor to effecting significant long-term reduction of test use is important. Views differ as to the reasons for excessive clinical testing among hospital staff. Medicolegal issues, level of experience, fear of the consequences of inadequate testing and the desire to diagnose within a single presentation have been previously described.3 These issues were dealt with to some extent via the described educational component of the authors' intervention program and seem to explain the apparent sustainability of the intervention. The authors report a "40% decrease in ordering of tests in the emergency department, with test utilisation falling from a mean of $39.32/patient to $23.72/patient." Other measures reported include reduced time taken for result review, with a resultant availability of additional resources for "other critical areas of service delivery". An assertion is made that "improvements to quality care" are "likely". Issues relating to improvement in quality of care, however, still remain: Although "no adverse patient outcomes relating to underutilisation of investigations" were identified, what follow-up was performed to ascertain "adverse outcomes"? What proportion of patients for whom further testing was requested via a general practitioner or outpatient clinic did not follow through with these investigations? Is there the potential for sufferers of undiagnosed chronic disease to develop more serious disease, requiring eventually more expensive therapies? What is the cost of patients' attending GPs and outpatient clinics for further investigations? Are the investigators' "evidence-based list of clinical indicators for ordering . . . tests" appropriate and are they rigid enough to prevent operator bias? Test utilisation measured by cost was the primary outcome measure for this study. Based on this measure, the results appear promising; however, important quality-of-care issues need investigation before more widespread implementation is considered.

Peter Gambell

In reply: Our intervention1 was developed following concerns with the quality of test ordering in our department, and resulted in a significant improvement in the checking and documentation of test results. Quality of care is also influenced by test over- and underutilisation. The study demonstrated a marked reduction in test ordering and accorded with the current estimates for test overutilisation.2 Test underutilisation was monitored using established mechanisms for reporting critical incidents (including missed or incorrect diagnoses) and patient complaints, as well as feedback from staff, general practitioners and other departments and hospitals. Patient outcome factors (eg, readmission rates, length of stay) were confounded by the dramatic onset of access block during the intervention period, making retrospective comparisons unreliable. The intervention is unlikely to have increased GP and outpatient referrals, as the previous practice of the department had been to refer patients having non-urgent tests (where the result was not immediately available) to a GP or outpatient clinic for follow-up of the test result. The department did not have the resources to ensure all patients attended for follow-up of the test result, raising medicolegal concerns and quality-of-care issues. The intervention, by deferring the ordering of non-urgent tests until after review, has the potential to reduce test duplication and the ordering of inappropriate (specialised) tests by junior emergency department staff. In addition, this process allows the patient's condition to be reviewed to determine whether further or alternative testing is required. Gosbell and colleagues speculate on the potential adverse outcomes that may follow from a reduction in the routine ordering of blood cultures. Blood cultures change patient management in only a fraction of cases, and the clinical situations where this occurs have been defined.3 A major concern is the high rate of false positive results and the consequent economic and social cost of additional unnecessary testing, treatment and prolonged hospital stay.4 As with any clinical tool, the use of blood cultures must be supported by evidence-based guidelines rather than based on expert opinion. The widespread use of blood cultures to limit the prescribing of broad-spectrum antimicrobial agents and development of disease resistance needs to be subjected to scientific examination and a cost–benefit analysis. If, as Gosbell et al seem to argue, the value of blood cultures lies predominantly in their public health role, the public have a right to be informed of the evidence used to substantiate the "test-all" approach being advocated to allow proper debate on the opportunity costs to public health.

Peter J Stuart

To the Editor: In advocating the use of questionnaire measures for outcomes for patients with depression or anxiety in clinical practice, Hickie, Andrews and Davenport advised that "for physicians who work predominantly in academic, specialist or administrative settings, the arguments for routine outcome measurement are obvious".1 The arguments are not at all obvious for clinicians. What is obvious is the divide between clinical practice and academia. The claim that there is now "an urgent need" to promote such questionnaires for general practitioners is difficult to understand. The historical and professional resistance to the use of such "instruments" is for good reason. They are unwieldy and unreliable. The oldest measure of outcome, known to clinicians but overlooked by academics, is to ask the patient "Are you feeling any better?", and to evaluate outcome using clinical skill and expertise. The key to understanding this peculiar proposition is to be found in the final sentence of the article, in its reference to the move for governments to "support major service innovations in primary mental healthcare". Those who produce, administer and measure such innovations will not, of course, see themselves unrewarded for their valued efforts to improve healthcare outcomes in the community. The poor GP will be burdened with yet another clinically irrelevant activity. Hickie and colleagues will no doubt press on regardless. There is a hint of insight, however, in the professorial obiter dictum that these measures would not be "the prime concern for the treating clinician". The "health services planning and other research benefits" of collating clinical data is a nice idea. It is hard to see its relevance to general practice based treatment of psychiatric disorder. If it is true that one out of three general practice consultations are driven by some psychiatric problem, then GPs will have a lot of forms to fill out, won't they?

Anthony Dinnen

In reply: It is pleasing to note that a senior psychiatrist is looking at the practicality of general practitioners (GPs) measuring the clinical outcome of patients with mental disorders. However, Dinnen's concerns may be groundless. For example, the Kessler Psychological Distress scale (K10) consists of 10 simple questions that patients can complete in two minutes in the waiting room and doctors can then score by summing 10 numbers between one and five.1 This takes less time than writing a progress note. The websites www.gpcare.org, www.beyondblue.org.au and www.mentalhealth.gov.au1-3 are the simplest places for doctors to familiarise themselves with the proposed outcome measures and with other new initiatives for better outcomes in mental healthcare. For the K10, the website1 advises GPs that if, after treatment, a patient's score remains above 25 the GP should review the patient and consider seeking a second opinion from a psychiatrist. In a specialist clinic (St Vincent's Hospital, Sydney) the average K10 score of a cohort of patients was 26.1 before treatment and 21.7 after treatment (indicating the effect of sound treatment). Nevertheless, the scores of a fifth of patients remained above 25 after treatment. Psychiatrists might therefore familiarise themselves with the measure so they understand when a GP refers a patient for a second opinion "with a K10 score above 25 after treatment".

Gavin Andrews · Ian B Hickie · Tracey A Davenport

Re: "The effectiveness of coordinated care for people with chronic respiratory disease", by Smith BJ, McElroy HJ, Ruffin RE, Frith PA, Heard AR, Battersby MW, Esterman AJ, Del Fante P and McDonald PJ, published in the 4 November issue of the Journal (Med J Aust 2002; 177: 481–485). The correct credentials and title for Peter A Frith are MB BS, FRACP, Director, Respiratory Medicine, Repatriation General Hospital, Daw Park, SA 5041. The web version of the article was corrected on 18 December 2002.

Brian J Smith MB BS, PhD · Heather J McElroy BSc(Hons) · Richard E Ruffin MD, FRACP · Adrian R Heard MPH, BSocAdmin · Peter A Frith MB BS FRACP · Malcolm W Battersby MB BS, PhD · Adrian J Esterman BSc(Hons), MSc · Peter Del Fante MB BS(Hons), MSc(Public Health) · Peter J McDonald MB BS, FRACP

In Nepal, a 28-year-old security guard presented with a seven-year history of peripheral joint pain and clubbing of the fingers and toes (Box, Figure A). He had first noted swelling of his wrists and metacarpophalangeal joints at the age of 16 years, and later his ankles and knees were also affected. The joints were intermittently painful, particularly after he consumed alcohol. The clubbing had developed insidiously. He reported that his brother had similar swelling of the fingers and toes. He also reported excessive perspiration, erectile dysfunction and diminished libido. The skin of his scalp and face was greasy and thickened, with corrugations on the scalp and deep nasolabial folds. Both knee and ankle joints were swollen, red and warm. The patient had no abnormal respiratory, cardiovascular or gastrointestinal symptoms. A full blood count, liver and thyroid function tests, blood sugar level, and serum levels of electrolytes, urea and creatinine were all normal. The erythrocyte sedimentation rate was raised (46 mm/hour). Tests for antinuclear antibodies, including antibodies to Scl-70 (associated with scleroderma) and rheumatoid factor, were negative. The synovial fluid was a clear straw colour with normal viscosity, lymphocyte count and protein level. A chest x-ray was normal, but x-ray of the wrist showed periosteal elevation and periosteal reaction at the distal end of the radius (Box, Figure B). The patient showed typical features of primary hypertrophic osteoarthropathy1 (also known as pachydermoperiostitis). This diagnosis is made after excluding the secondary form of hypertrophic osteoarthropathy that is associated with a variety of disorders, including intrathoracic malignancies, suppurative lung disease, and congenital heart disease.1 A: Clubbing of fingers and toes. B: X-ray of wrist, showing periosteal elevation and periosteal reaction at distal end of radius.

Rabindra N Das MD MRCP · H R Rahu MB BS DMRD · Rajesh Biswas MB BS MD

Timothy Murrell was the Foundation Professor of Community Medicine at the University of Adelaide, a position he held from 1975 to 1994. A seventh-generation Australian, born in Adelaide on 8 April 1933, he was educated at St Peter's College and the University of Adelaide Medical School, graduating in 1958. After a year as Resident Medical Officer at the Queen Elizabeth Hospital in Adelaide, Tim worked with the Commonwealth Department of Territories from 1960 to 1964 as a District Medical Officer. Stationed in New Guinea at Goroka, Wabag and Kundiawa, he investigated the aetiology and epidemiology of pigbel, a gangrenous intestinal disease that predominantly affected children in the highlands. His survey, case work and reports led to measures that significantly reduced mortality from the effects of the disease and ultimately enabled the development of a vaccine. This formed the substance of his MD thesis in 1966. From 1965 to 1966, Tim was a lecturer at the University of Adelaide Faculty of Medicine, after which he spent two years studying under an Australian Nuffield Fellowship at the General Practice Research Unit at Guy's Hospital, London. On returning to Adelaide, he pioneered teaching general practices as well as general practice teaching units in Highbury and at Modbury Hospital. He introduced community medicine to the undergraduate curriculum, integrating general practice with public health and the teaching of doctor–patient communication. Tim regarded himself as a "human ecologist". Accordingly, his publications on sudden infant death syndrome, multiple sclerosis, Dupuytren's contracture and breast cancer stemmed from his lateral thinking on observations of his general practice patients. In 1978, he received the WHO Staff Society Medal for his pioneering work on pigbel, and in 1992 was awarded a Visiting Fellowship at Corpus Christi College, Cambridge. His publications, career and personal papers can be viewed in the manuscript section of the National Library of Australia, Canberra ("Papers of Timothy Murrell, MS 9304"). Tim was very involved with his extended family, as well as various charities, schools, sports and gardening. He was thrilled to learn that he was to be made a Member of the Order of Australia in the 2002 Queen's Birthday Honours List, only to die suddenly from the sequelae of a heart attack on 15 August, a few weeks before the ceremony. Tim is survived by his wife Patricia and children David, George, Thomas and Melinda.

Dedee Blackburn Murrell MA BMBCh FAAD · Robert G Moorhead FRACGP DipCM

Modernising Australia’s drug policy. Alex D Wodak and Timothy Moore. Sydney: UNSW Press, 2002 (103 pp). ISBN 0 86840 482 9. The discussion of illicit drugs policy is littered with controversy, stoked by strong feelings on both sides and full of assertions that fundamental morality is at stake. Those who support prohibition and have a clear view of law enforcement as the answer need not read this book, as they will find little to relate to. The authors have a long record of challenging the current international philosophy of prohibition, stemming as it does from the muscular nationalism of Teddy Roosevelt, who convened the Shanghai Conference in 1909. That policy has been honed and developed with US leadership in successive international treaties of 1912, 1926, 1961, 1971 and 1988. Richard Nixon’s invention of the politically potent “War on Drugs” in 1972 is given attention in its Australian incarnation “Tough on Drugs”. The book is readable, rather than scholarly, and tells of the folly of this ideological commitment in terms of failed outcomes. Its assertions are not referenced, but the authors speak from a position of authority after years of contributing to the debate. It is an easy read. The book urges the separation of cannabis markets from heroin and cocaine, but is critical of half-hearted decriminalisation when legalisation, with regulation, taxation and health advice about cannabis, would be far more appropriate. The rationale is compelling. It argues clearly that the major problems for society from illicit drugs — crime, corruption, disease and overdose deaths — are primarily the consequences of prohibition rather than the drugs. Misleading advocacy and misuse of naltrexone are well discussed. There is little coverage of cocaine and amphetamines. Although occasionally repetitive, it is worthwhile reading for all concerned citizens, including politicians, medical practitioners and parents. It is good value as a paperback entry to a difficult area of public policy. David G PeningtonEmeritus Professor, and Past Chairman Victorian Premier's Drug Advisory Council Melbourne, VIC

David G Penington

A world of risk The world should focus far more of its health efforts on preventive activities, say researchers from the World Health Organization’s Comparative Risk Assessment Collaborating Group. The group undertook the mammoth task of comprehensively reviewing data from published studies and other sources (eg, government reports and international databases) on 26 potentially modifiable risk factors for disease, splitting the entire world into 14 epidemiological regions based on geography and adult and child mortality. The contribution of each risk factor to mortality and disease burden (expressed as disability-adjusted life-years [DALY]) was calculated. Results differed with epidemiological area, but overall, the leading causes of global burden of disease were childhood and maternal underweight (9.5% of the total DALY), unsafe sex (6.3%), high blood pressure (4.4%), tobacco (4.1%) and alcohol (4%). The researchers said the contribution of these risk factors is much higher than has been previously thought, and targeting them will produce substantial health gains. Lancet 2002; 360: 1347-1360 Gender and mortality In the rural Malawian community of Lungwena, 1–2-year-old boys are twice as likely to die as girls of the same age. A prospective study followed 795 pregnant women until their children turned three. Of 767 live births, 100 infants and 47 1–2-year-olds died during follow-up (mortality rate of 202/1000 in the first three years). After controlling for possible confounders such as maternal age and HIV status, family wealth, proximity to a health centre, immunisation status and nutritional status, the relative risk of a boy dying between the ages of nine and 35 months was 2.0. Causes of post-infancy death included malnutrition (14 of 47 children), malaria or anaemia (10), respiratory infections (4), diarrhoea (4) and a possible accident (1). The researchers said sex biases in child mortality have not previously been thought to be a big issue in sub-Saharan Africa, possibly because larger studies have masked male-biased mortality in some regions and female-biased in others. Arch Dis Child 2002; 87: 386-387 Birth and death The traditional cut-off point of six weeks postpartum for defining pregnancy-related death may need to be extended following the findings of a Nepalese study. Researchers analysed prospective data on 6101 women who had 7325 pregnancies while in the placebo group of a micronutrient supplementation trial in Sarlahi, Nepal, between 1994 and 1997. The women’s relative risk of death was highest during labour and the week after giving birth (37.02). During pregnancy and the first six weeks postpartum the relative risk was 2.21, and extending the period out to 12 weeks produced similar results (RR, 2.26). This suggests that many pregnancy-related deaths are not being counted as such and that WHO figures for maternal mortality (515 000 annually, mainly in the developing world) may be an underestimate. Bull World Health Org 2002; 80: 887-891 It’s curtains for sandflies A study conducted in Venezuela suggests that controlling cutaneous leishmaniasis in urban areas may be a matter of window dressing! The disease is common in Venezuelan cities, where woodland and domestic animals act as reservoirs, and sandflies are the vectors. In the city of Trujillo (2913 inhabitants in 569 households), intervention houses received polyester mesh curtains impregnated with lambdacyhalothrin (12.5 mg/m2) to hang loosely at the windows. Control houses received non-impregnated curtains. After the impregnated curtains were hung, the numbers of sandflies caught in overnight light traps was markedly reduced (a mean of 13 less sandflies per night in intervention than control households). The incidence rate of cutaneous leishmaniasis changed from 4% overall in the 12 months before the study to zero in the intervention group and 8% in the control group in the 12 months after the curtains were hung. BMJ 2002; 325: 810-813 Iron and infection While the developmental effects of iron-deficiency anaemia have a devastating effect globally, some studies have suggested that children given iron develop more infections. A recent systematic review found that this is not the case. The researchers identified 28 randomised-controlled trials of iron supplementation in a review limited by methodological heterogeneity and non-uniform definitions of clinical outcomes. The occurrence of malaria and other infectious illnesses was not affected by iron administration, but children given iron did have a slightly increased risk of diarrhoea (0.05 more episodes/child year). The diarrhoea was not thought to pose a major public health problem and the study could not determine if it was of infective or irritative in origin. BMJ 2002; 325: 1142-1152