Volume 179 Issue 11

compassion n. Pity inclining one to help or be merciful. (The Concise Oxford Dictionary). Doctors resigning and demoralised by forces ranging from heavy workloads to indemnity woes . . . A society conditioned to instant gratification, soaring expectations of modern medicine and technology, often fuelled by media hype (Ooi, page 639; Daniels, page 637) and increasingly cynical about doctors’ true priorities . . . A lucky country that’s materially better off than ever before . . . The latter observation comes from one of our foremost playwrights David Williamson (page 594), yet, as sociologist Hugh Mackay comments, we are “. . . neglecting the most vulnerable people in our society — the aged, the frail, the sick, the disadvantaged, the bewildered”.1 Meanwhile, internationally, the rift between rich and poor nations grows, and the lack of compassion of nations who “have” toward those who “have not” is seen as one of the antecedents to current international insecurity. Is compassion in its death throes two millennia after one man in Jerusalem advocated loving others as oneself, and another in Mecca described “a person’s true wealth [as] the good he or she does in the world”? A flock of white coats hovers above a young man in a hospital bed. The consultant tells the patient that he needs an urgent back operation and the flock moves on. It disperses after the ward round, and its most junior member returns to write up the young man’s medication chart. She is about to dash to her next task when the patient calls out, “Will the operation make me walk again?” The resident hesitates. “That’s unlikely, but it will stop things getting worse.” The patient nods and turns his head away. The resident hesitates again then leaves as her beeper goes off. Fifteen years later, I still wish I’d stayed to ask this man if he wanted to say or ask more. It would have cost me little, despite feeling ill-equipped to handle his pain and the eternal call of ward duties. It might have made no difference to him, but surely we are each responsible for becoming the change we wish to see. M Chew, Deputy Editor A qualified “no” is the answer to this question from contributors to the 2003 Christmas issue of the Journal. Perspectives by emergency physicians O’Reilly et al (page 649) and Fulde (page 651), who make space in their hearts and lives for homeless people visiting their emergency departments, and by Sutton (page 591) and Taylor (page 617), who have worked in developing nations, indicate that many doctors are still motivated by compassion. Furthermore, a recent forum on globalisation, aid and foreign policies, and their impact on health brought together diverse Australian and international experts (Zwi and Reid, page 573) and showed that many of us want to engage in compassionate “big picture” action. Yet all acknowledge the difficulties of practising compassion in an environment that does not seem conducive to it. Bleeding hearts?Certainly not. There are sound, even pragmatic, reasons for healthcare workers to act compassionately. Firstly, it benefits patients. While the benefits of a compassionate approach may be difficult to measure, a systematic review suggests that patients have less pain and recover faster if their doctors show empathy and reassurance.2 Furthermore, homeless patients presenting to a Canadian emergency department, and randomly allocated to receive “compassionate” care (a chat and a snack with a volunteer) re-presented less frequently than those receiving standard care.3 Secondly, doctors are well placed to join informed debate about sociopolitical issues that may impact on health. This is also crucial if our profession is to regain the trust of a sceptical community. The Royal Australasian College of Physicians (RACP) gives its rationale for taking physicians’ views on health and social policy to Canberra: “What doctors must do is show the community that medicine and consumers have overwhelmingly common imperatives and that doctors stand with the community before self interest. . . . lack of trust [that doctors act from concern for their patients] . . . most seriously threatens medicine’s continuance as a profession bound up in ethical values rather than commercial ones”.4 Thirdly, a modicum of compassion would not go astray in medical workforce planning. Part of the remedy for our workforce crises lies in regarding it as “more than a numbers game and . . . [with more] explicit attention to working conditions, incentives and rewards”.5 While compassion might begin at home, a global perspective is also vital. At the inescapable altar of evidence, even certain humanitarian medical interventions (such as vaccination, providing food and safe water) have gained sanction for efficacy, although alternative types of evidence and outcome measures should also be pursued.6 Smith’s editorial in this issue (page 571) argues that the impact of climate change on the health and economies of all in our global village offers rich countries ample incentive to act now for a win–win solution. Ultimately, however, to provide or enable healthcare of any ilk is a moral endeavour7 — we do so because we value human life. How do we regain compassion?Paradoxically, we believe that self-care (as opposed to self-centredness) is one of the keys. Reciprocity (or “getting something back”) is a motivation for altruism,5 and contributors to this issue of the Journal highlight their need for personal and external supports to prevent distress and the erosion of compassion (Smart, page 587; Edwards, page 647). Like it or not, role models are integral to medical training, and medical students and young doctors value attributes such as compassion in their role models, as eminent neurologist Lance attests (page 620). Yet good role models are not plentiful in our hospitals,8 and all of us need both to be and to emulate such models (see Box). Indeed, the World Health Organization has outlined the social accountability of medical schools, which have an obligation to direct their education, research and services toward the community’s priority health concerns.9 Medical schools must be responsive to, and proactive about, societal needs. Our initial and ongoing education should also seek to actively instil a recognition of the social determinants of health, and the place of humane values and ethics.10 The imposition of mechanistic guidelines, audits and regulations on clinical practice, with increasing commercialisation, have contributed not only to de-professionalism, but also to compassion fatigue. Our practice and research should embrace and refine such outcome measures as quality of life and the doctor–patient relationship. Compassionate action may also mean becoming advocates and agents of change for a variety of public health issues, such as more equitable healthcare access. We can do so as individuals by enthusing colleagues, engaging with others in the community and petitioning parliamentarians. We can do so as members of professional bodies (eg, the Australian Medical Association stance on Indigenous health [www.ama.com.au/web.nsf/doc/WEEN-5N5UHZ] and the joint statement by the RACP and the Royal Australian and New Zealand College of Psychiatrists on the health of children in immigration detention centres [www.racp.edu.au/hpu/policy/asylumseekers/detention.htm]). We can do so by supporting national and international coalitions of health, development, social justice and human rights, rather than coalitions of conflict or commercial interests. Examples of the former include Healthy Skepticism (Mansfield, page 644), the Medical Association for Prevention of War (www.mapw.org.au/about.html), and Médecins Sans Frontières. Surely medical involvement in some of these fields represents the ultimate preventive healthcare! . . . and what about a compassionate society?Hugh Mackay also observed in his commentary, “Who could have predicted that, at the turn of the century, Australia would become a less tolerant, less hospitable and less compassionate society?”1 This issue of the Journal celebrates the survival of compassion in medicine, in the face of bewildering societal changes. But we need much more. We need our policymakers to develop evidence-based, targeted strategies against health inequities. We need continued leadership and advocacy from our professional bodies. Above all, we need political leaders who champion compassion and unity rather than fear and division. If you want others to be happy, practise compassion. If you want to be happy, practise compassion — The Dalai Lama.

Mabel Chew FRACGP, FAChPM · Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP, FRCPA

Rich countries must lead the fight against climate change affecting rich and poor in our global village It is nearly a tautology to say that poor people and poor nations generally act with short time horizons or, in the jargon of economics, high discount rates. Anecdote and analysis confirm it. Those who realistically fear potentially severe consequences tomorrow are less concerned about next year. At the family level, these attitudes can be understood as the consequence of natural selection acting on the propagation of genes. High discount rates are necessary to ensure one’s genes survive under short-term stress; when the ground is treacherous and the tiger is following, raising one’s eyes to the horizon is risky to survival, let alone procreation. Although even poor societies and nations generally act with longer time perspectives than their individual members, they too must acknowledge the demands of short-term survival.1 However, many human reactions honed through natural selection no longer serve us well. We crave dietary fat for the nutritional security it once brought, but in modern excess it kills rather than saves us. Equally, the scale of our impact on the environment now has effects on time scales much longer than those of typical human time horizons. The archetypal example is perhaps global pollution leading to global climate change. We are now well into a planetary experiment on the effect of injecting a bolus of warming pollutants, three to four times natural levels, during an instant of geological time. Nothing much happens at first, but analysts say that much more is set to happen unless we mend our ways soon.2 Still, it may be decades before the really bad things happen. Should we care? How much? And should how much we care depend on how poor we are? This issue is illustrated starkly by a graph developed from calculations by Hughes at the University of Edinburgh3 (Box). It shows the ratio of the cost of health and economic damage from local energy-derived air pollution (household indoor pollution from use of poor quality fuels and urban outdoor air pollution) to the cost of damage from climate change.4 A standard low discount rate is applied (3% per year) to convert future costs into the equivalent cost today. The graph shows that, in poor countries, short-term local pollution typically causes three to four times more health and economic damage than climate change. This occurs even though poor countries are expected to experience much more health damage from climate change than rich countries. In contrast, in rich countries, long-term damage caused by climate change is greater, even after discounting, because short-term pollution has been greatly controlled. Many in the climate-change debate argue that, because of the huge stakes involved, developed countries should use lower-than-standard discount rates and act today to reduce the long-term damage. This could even be at the cost of spending less on today’s problems. After all, developed countries can afford longer time horizons and produce most of the climate-changing emissions through their use of fossil fuels. However, it is difficult to put this argument to poor countries, which have many other pressing problems and have benefited little from the burning of fossil fuels that has produced most climate-changing emissions to date.5 However, the graph also reveals potential solutions. It shows the attractiveness of rich countries investing in poor countries to simultaneously reduce both local and global pollution. These “win–win” activities could benefit both countries because of their different discount rates and local impacts. An example is investing in clean household fuels that simultaneously halve the local health impact of air pollution and reduce climate-changing emissions.6 Recognising these “win–win” opportunities helps us set current priorities.7 Unfortunately, the climate-change debate no longer encompasses the option of total prevention. It is nearly certain that, no matter what we do, we are already committed to significant change and, indeed, are already experiencing the first stages. We must start planning how to live with this change. The principal health impacts are expected to include an increase in environmentally related infectious and vector-borne diseases in poor countries.8 However, climate change enhances rather than creates these diseases,9 offering another means of prioritising competing public-health needs. For instance, if climate change will increase malaria, we would benefit from spending more now on reducing the baseline malaria rate before serious climate change begins. This is a practical way to consider the long term, while addressing today’s serious problems.10 Perhaps the most important long-term benefit of the climate-change debate is that it illustrates, more than any other issue, that we live in a global village. Although one can argue, on humanitarian and other grounds, that an easily preventable child death in India impoverishes everyone, everywhere, such arguments do not go far in most policy forums. However, it is incontrovertible that greenhouse gases released anywhere affect us all, everywhere. In addition, no matter how much greenhouse gas we ourselves release, we are all subject to the same global climate and its changes. Thus, we are hostage to each other and will have to find ways to make the necessary decisions together to protect us all, rich and poor. Health and economic damage to nations from energy use * Ratio of cost of damage to nations from local energy-derived air pollution over cost of damage to nations from global climate change.3 † Poor = South Asia and Sub-Saharan Africa. ‡ Middle-income = East Asia, Middle East and Latin America; § Rich = nations belonging to the OECD (Organisation for Economic Co-operation and Development), eastern Europe/former USSR.

Kirk R Smith

Health and foreign policy — unlikely bedfellows? Perhaps . . . Current world interest in the ties between security, poverty, health, human rights, globalisation, and trade was an important backdrop to the symposium on Health and Foreign Policy: Scope for Australian Engagement, held in Sydney on 18–19 September 2003. Whether such a meeting would have taken place before the 2001 attack on the World Trade Center in New York is a moot point. Nevertheless, conference delegates were keen not to focus primarily on the “war on terror”, but rather, on “upstream” issues of social justice, equity, development, conflict prevention and human security. Opening addresses by the Honourable Professor Marie Bashir (Governor of New South Wales) and Kay Patterson (then Federal Minister for Health and Ageing) both stressed the imperatives for closer links between health and foreign policy. The symposium was co-hosted by the School of Public Health and Community Medicine, the University of New South Wales (UNSW), and the Institute for International Health, University of Sydney. The Nuffield Trust, United Kingdom, supported student attendance and brought a dynamic team from the UK to engage Australian academics and policy makers. Nearly 140 people with backgrounds in aid and development, trade, the pharmaceutical industry, non-government organisations, health services, international relations, human rights, and public health met to formulate ideas for better links between these unlikely partners. “There can be no new consensus, no new order, no stability, without tackling the appalling poverty that afflicts nearly a half of the world’s population.” — Tony Blair (quoted by Sir Alastair Goodlad at the pre-symposium meeting in Canberra)1 The symposium followed a key meeting in Canberra organised by the Nuffield Trust with the Australian Department of Health and Ageing, and attended by Australian and British policy makers in health, foreign policy and aid, academics, and Australian Foreign Minister Alexander Downer. Mr Downer stressed that, to deal effectively with issues such as the burden of ill health on economies, HIV/AIDS, sudden acute respiratory syndrome (SARS), and the availability of drugs for common diseases, “global health can no longer be the preserve of national health ministries . . . global health is a foreign policy issue”.2 Governance and capacity building were identified as crucial to ensuring that weak states can deliver health services, are supported to avoid collapse, and can tackle poverty. GlobalisationAt the Sydney symposium, Dr Kelley Lee (London School of Hygiene and Tropical Medicine) defined globalisation as: a set of processes intensifying human interaction across economic, political, sociocultural, environmental and technological realms. These changes are evident across spatial, temporal and cognitive boundaries. As examples, she highlighted the risk of emerging anti-microbial resistance and its accelerated spread as a result of global travel and international trade. Similarly, obesity and related health problems are reaching low- and middle-income countries, associated with rising consumerism and decreasing local food security. Professor Ron Labonte (University of Saskatchewan) described the immense effect of globalisation on health within and between nations, such as the impact of global trade in processed food. He also highlighted the limitations of departing from an “upstream” focus on determinants of health, health promotion and primary healthcare, to more “downstream” responses to disease. Stuart Harris (Emeritus Professor of International Relations, Australian National University [ANU]) drew attention to the inevitability of some health considerations creeping into the foreign policy domain. The SARS epidemic revealed how emerging infections can rapidly, systematically and severely affect trade, tourism and perceptions of risk and safety. Global epidemics of HIV/AIDS, the unfinished agendas of tackling malaria, tuberculosis and child health problems, and the emerging problems of chronic disease, mental health and injuries and violence continue to pose significant challenges. Professor Kalinga Tudor Silva (University of Sri Lanka) highlighted the links between growing globalisation and collective violence. There is mounting concern with how disease undermines economies and weakens states, with potential consequences of instability and violence. International governing structures no longer seem adequate to address such complex challenges. Health and human rightsChris Sidoti (Human Rights Council of Australia) and Elizabeth Reid (Gender Relations Centre, ANU) propelled health and human rights to the centre of the debate. While the right to health is not an absolute right, it is a right to be “progressively realised”. It includes the right to control one’s body and the right to equality of healthcare access. Specific rights often articulated include access to quality maternal, child and reproductive healthcare, healthy workplaces and natural environments, disease prevention, treatment and control (including access to essential medicines), and access to safe and potable water, sanitation, and nutrition. In 1990, the Commission on Health Research and Development (COHRED) described the 10/90 disequilibrium — only 10% of research and development spending is directed to the health problems of 90% of the world’s population. The Special Rapporteur of the Commission on Human Rights argues that the very neglected diseases and the 10/90 disequilibrium are human rights issues. Symposium discussions displayed solid commitment to ensuring better access to basic drugs in developing countries. Delegates also learned and voiced concern that Australia has introduced restrictive policies, especially with respect to reproductive health. For example, partner organisations of the Australian Agency for International Development (AusAID) are prohibited from using funds for “activities that involve abortion training or services, or research, trials or activities which directly involve abortion drugs”.3 The Australian Government has also stopped funding to the World Health Organisation’s Human Reproductive Programme and the Population Council (Dianne Procter, Chief Executive Officer, Australian Reproductive Health Alliance, personal communication). These policies are more restrictive than domestic policies, are in tune with those of the United States, and appear to influence practice and values in recipient countries in ways that arguably conflict with international human rights law. Conference delegates pondered the ethics of applying stringent conditions in foreign assistance while not applying the same standards at home. Humanitarian and development assistanceThe generalised decline in development aid funding was seriously challenged. Despite the internationally accepted benchmark that 0.7% of gross national product (GNP) per capita be spent on international assistance, the US contributes about 0.1% and Australia 0.26%. The UK has recently and dramatically reversed its steady decline in development funding, as described by Dr Julian Lob-Levyt (Department for International Development, UK). The UK commitment to poverty eradication, a more humane globalisation and the United Nations Millennium Development Goals4 were widely applauded. There has been a shift toward humanitarian relief funding directed at addressing instability and collective violence, but this emergency response has limitations, especially in influencing longer-term development. Professor Anthony Zwi (UNSW) elaborated several reasons for the decline in development aid: the end of the Cold War (as the value of propping up client states in the developing world is less apparent in our era), difficulty proving the direct benefits of aid funding, critique of the role of the state, and generalised cynicism about internationalism. That links exist between poverty, sociopolitical instability and inequity seems a logical notion. Yet, as Sue Ingram (Institute for International Health) pointed out, the evidence base for these links and for development assistance as a means to break them is not particularly strong, warranting further research and debate.5 Underlying concerns at the meeting were the rising trends in inequity in health and healthcare. There is disturbing evidence that health sector reform and macroeconomic structural adjustments within a globalising world may have contributed to increasing inequity within and between various countries. Examples include the 10/90 disequilibrium and the negative effect on the household economies of poor countries of having to pay more for healthcare. Various conference delegates expressed concern with AusAID’s stated objective of primarily benefiting Australia,6 given potential and actual conflicts of interest between this objective and the development needs of the poorest nations. Delegates supported proposals endorsed by the Development Assistance Committee of the OECD. These proposals were to ensure that aid is less tied to the country providing assistance and more to the development and poverty eradication needs of the beneficiary country. Towards an Australian global health coalitionThe symposium ended with a call for a much more vigorous engagement by Australian stakeholders in shaping global health issues. All were challenged to rediscover pride in Australia’s contribution to global health, aid, development, and human rights and to put behind the period in which harsh approaches to refugees and asylum seekers had shamed Australia’s international reputation. The meeting concluded with a commitment to take this forward by establishing an Australian coalition on global health, which will promote new thinking and seek an aspirational, progressive content to Australia’s aid program.

Anthony B Zwi PhD, FFPHM · Michael A Reid

The UK’s National Health Service (“the NHS”), with 1.3 million employees, has now become the world’s second largest employer after the army of the People’s Republic of China. How can anyone drive anything that large? The former UK Secretary of State for Health, Alan Milburn, tried doing it for 6 years and, within days of his resignation, was instead defending tobacco industry jobs in his own constituency. At least he wasn’t driven to drink; to us, as newcomers to the United Kingdom trying to make sense of this unwieldy bureaucracy while surviving the deep midwinter, a drink looks pretty good. What NHS managers appear to excel at is meetings. They have dozens of them, often attended by literally dozens. A relic of the Milburn era is a profusion of performance targets, not only for hospitals, but for general practice and primary care as well. Someone has reckoned that across the NHS there are at least 1200 targets. A basket of 34 of them determines whether hospitals and Primary Care Trusts attract no, one, two or three stars — the NHS equivalent of Michelin ratings. These are important drivers, because the star rating determines access to funds — those who do well are rewarded with more public money to do even better; laggards are left to limp along: “The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings”. A great many of the targets relate to the processes of health care and precious few to its outcomes. Waiting lists for elective surgery, and “trolley waits” in accident and emergency departments are part of public discussion in the UK now, while particular institutions are lambasted for poor medical records or general cleanliness. The focus on targets reflects a belief in the benefits of centralisation and a lack of trust in those at the coalface. This has led to demoralised health professionals. Furthermore, the emphasis on process rather than outcome is partly due to a perception that the public is unable to understand more than waiting times. The UK lacks the health consumerism of Australia; while the NHS remains part of the social fabric, there are often low public expectations, and medical issues remain mysterious to most people. The public-health community is driven by a health inequalities agenda, which is remote enough from service delivery to make it irrelevant to the health service. Thus, there is no one to help set priorities to improve public health and prevent the agenda being driven by how care is delivered rather than by what it achieves. While the system is awash with forms and information, it is totally unable to link records. It took long enough to recognise the excess short-term mortality in the paediatric cardiac surgical service in Bristol; there is no hope of routinely measuring clinically important long-term outcomes. Meanwhile, targets are responsible for distorting NHS activity on a day-to-day basis. Hospitals shift their staff around to reduce “trolley waits” during the week when the inspectors from the Commission for Health Improvement are visiting, and accusations of waiting-list fiddling are heard regularly. More profoundly, the orientation of many people in the middle layers of the NHS has undergone an about-face. Instead of attending to problems reported from below about barriers to delivering high-quality care in a timely fashion, the focus of most middle managers is on meeting targets imposed from above, from levels even more remote from the delivery of service. In the early days of the NHS, there is no doubt that doctors called the shots. This lasted for several decades, until the development of Thatcher’s internal market (consisting of large numbers of “business units”, each of which needed a manager); the focus on targets and performance; and, most recently, the clinical governance agenda. Oddly, both doctors and managers feel disempowered and believe that someone else is in charge. So, are the managers themselves part of the problem (it’s not the driver that’s bad, but the transmission that’s broken)? The Tory Party says that managers now outnumber beds in the NHS. Good clinicians from the whole spectrum of health professions have moved sideways into comfortable, well paid administrative roles that could be fulfilled during sociable hours, significantly depleting the ranks of those actually delivering healthcare and making the difficult clinical decisions that this involves. What NHS managers appear to excel at is meetings. They have dozens of them, often attended by literally dozens. If you add up the wages and the travelling times, a single meeting can cost the same as a whole week of clinical care, but rarely will it take a decision that measurably affects anyone’s health. Even when someone is brave enough to try a novel idea, managers further up the line are likely to impose a reorganisation long before enough time has passed to see if the new way is better. And that presupposes that adequate provision was made for a proper evaluation of the initiative, which is all too rarely the case. Not that people are unaware of the problem; the divide between management and the frontline underpins much of the current disaffection and malaise within the NHS. It’s just that solutions to such complex problems don’t come easily.1 Some commentators become despondent, and suggest that the only effective strategy for managing a huge complex machine like the NHS is to muddle through. Meanwhile, on the wards, in the outpatient clinics, and out in the practices, scores of dedicated health professionals and other staff struggle on. There are half the number of doctors per head of population compared with Australia, and the slice of gross domestic product dedicated to the NHS is at least a third less. One does not have to be driven, there is always someone waiting to be seen. Enjoy the sunshine this Christmas; your comrades over here may also be feeling the heat.

Konrad Jamrozik DPhil, FAFPHM, MFPH · Richard F Heller MD, FRCP, FRACP, FAFPHM · David P Weller MPH, PhD, FRACGP, FAFPHM

Overweight and obesity are very common in Australian adults (56%) and children (27%). Rates of overweight and obesity are snowballing and will place greater burdens on health services for the treatment and care of chronic diseases. Prevention is urgently required from health, social and economic perspectives, but the response to date has been inadequate. A long-term, sustained action plan starting with a focus on young people is needed. This should particularly address the “obesogenic” environments causing the epidemic. Although whole-of-government action is required, support from and involvement by parents, carers, community leaders, healthcare professionals, teachers, childcare workers, urban planners, recreation managers, food manufacturers, employers, advertisers, and communicators is essential. The health sector should take the lead, but success will only come from concerted and integrated action across the whole of society. There are now signs of political commitment to addressing overweight and obesity. Doctors should get behind this and help mobilise community support.

John C Catford DM, FRCP, FAFPHM · Ian D Caterson MB BS, PhD, FRACS

Objective: To evaluate clinical measures of obesity for their ability to predict death from cardiovascular disease (CVD) and coronary heart disease (CHD), in parallel with conventional cardiovascular risk factors.Design, participants and setting: Cross-sectional analysis of an age- and sex-stratified sample of 9206 adults aged 20–69 years from Australian capital cities (1989 Australian Risk Factor Prevalence Survey). Blood pressure, fasting serum lipid levels, smoking, history of heart disease or diabetes, and obesity as measured by body mass index (BMI), waist circumference and waist–hip ratio were recorded. These data were linked with the National Death Index to determine causes of death of the 473 survey subjects who had died to 31 December 2000.Main outcome measures: Hazard ratios for the risk factors predicting CVD mortality and CHD mortality.Results: Of the modifiable risk factors, obesity, as measured by waist–hip ratio, is a dominant, independent, predictive variable for CVD and CHD deaths in Australian men and women. Self-reported angina/myocardial infarction in both sexes, and cigarette smoking in women, are also independent risk factors.Conclusions: Obesity assessed by waist–hip ratio is a better predictor of CVD and CHD mortality than waist circumference, which, in turn, is a better predictor than BMI. The recognition of central obesity is clinically important, as lifestyle intervention is likely to provide significant health benefits.

Timothy A Welborn PhD, MB BS · Satvinder S Dhaliwal MSc · Stanley A Bennett PhD, FSS

To the Editor: We read with interest Abraham’s recent article on bodyweight issues facing young women.1 Abraham notes that this group is at risk of extreme weight-loss behaviours, including excessive exercise and use of slimming tablets. However, recent data from our studies show young women’s high risk of substantial weight gain and obesity.2,3 Obesity entails significant health and social costs for young women. There are also likely to be substantial financial costs associated with efforts to manage weight. The low levels of satisfaction with their body and poor self-esteem among young women, in conjunction with their heightened risk of weight gain, make them prime targets for the slimming industry. A number of studies have estimated what obesity costs and its impact on the healthcare system,4,5 and some have estimated expenditure by consumers on weight-loss products.6 However, none have quantified the financial costs of weight management for women. We recently (January 2002) investigated weight-management strategies among a randomly selected, nationwide sample of 445 women aged 18–32 years. Our study was approved by the Deakin University Human Research Ethics Committee. Women reported their use of and expenditure on nine methods “to lose weight, prevent weight gain, or control body shape” in the previous 12 months. Thirty-one per cent of the sample were overweight or obese (body mass index > 25 kg/m2), and 61% had used at least one weight-loss method in the past 12 months. Box 1 shows the proportions using each method. Some women spent more than $3000, with a mean expenditure of $441 per woman among those using a weight-loss method, or $251 per woman across all women in the sample (Box 2). Extrapolating these results to the population of women in this age group, this equates to almost $414 million per annum spent by young women to manage their weight. Thus, young women are investing considerable amounts of money to manage their weight. Increasing rates of obesity suggest that young women’s efforts to manage their weight are ineffective. Promotion by general practitioners of safe, low-cost weight-management strategies — including low-fat healthy eating, as well as walking for exercise — could help alleviate the substantial health and economic costs of obesity and weight control. 1: Proportion of women using weight management strategies 2: Mean expenditure by women using weight management strategies

Kylie Ball PhD · Sari Andajani-Sutjahjo PhD · David Crawford PhD

To the Editor: Shaw and Chisholm described the increasing prevalence of type 2 diabetes in Australia.1 A similar alarming trend exists in China — there will be nearly 1 million new cases of diabetes per year in the 21st century,2 and a total of 290 million people with diabetes by 2010.3 The main risk factor for the development of diabetes in China is obesity. The Chinese are getting fatter.4 As China becomes modernised, people are eating more and exercising less. That eating a healthy diet and becoming physically more active can prevent diabetes is convincingly proven by China’s Daqing IGT (impaired glucose tolerance) and Diabetes Study.5 A total of 577 subjects with IGT were randomised by clinic to either a control group or to one of three active treatment groups: diet only, exercise only, or diet plus exercise. This is the first randomised controlled clinical trial to demonstrate that weight reduction by diet and exercise can significantly reduce the incidence of diabetes in subjects with impaired glucose tolerance.

Tsung O Cheng MD

Medical officers (MOs) employed by the Armed Services are, in a sense, both doctors and warriors. The concept of being both a doctor and a warrior is quite difficult for many to grasp. How can someone who has elected to dedicate his or her life to healing be part of an organisation that may enter into armed conflict? How can healing and harming go hand in hand? Nevertheless, they do. The idea of sending MOs to war is not new, as where there is war there is medical work to be done. Indeed, thousands of MOs around the world have shown a willingness to put their own needs aside to achieve a greater good. Furthermore, many advances in medical science that can benefit us all (eg, transfusion, ambulance services, and various surgical techniques) were first realised or developed in the theatre of war. MOs have played a vital role in Australia’s military history. Many have been decorated for their bravery and medical work on the front line, including Major General Sir Neville Howse in the Boer War (awarded Australia’s first Victoria Cross), Sir Edward “Weary” Dunlop in WWII, and, more recently, Captain Carol Vaughan-Evans, who was awarded the Medal of Gallantry for working during a massacre at Kibeho refugee camp in Rwanda in 1995. Others have made the ultimate sacrifice, dying in the service of their country — among them a personal hero of mine, Lieutenant (Dr) George Merz (who was killed by hostile Arabs in 1915, after working tirelessly as both an MO and pilot on many dangerous missions in WWI) and Major Susan Felsche (who died in a plane crash in 1993 while serving with the United Nations [UN] mission in the Western Sahara). Australian MOs continue to serve in wars, peacekeeping missions and humanitarian activities. Since the September 11 attacks on the United States, they have been busier than ever, providing medical support to the Coalition Against Terrorism in Afghanistan, triage and aeromedical evacuation in the wake of the Bali bombings, and a range of medical services in the war against Iraq and the subsequent mission to rebuild Iraq’s infrastructure. Most recently, our medical personnel were again at the front line, supporting the Regional Assistance Mission in the Solomon Islands and providing humanitarian assistance to the people of that country. These awards and activities are high-profile aspects of what it is to be a military MO in the Australian Defence Force (ADF). But there is much more to the job. Here, I will try to separate the myths from the reality of what it really means to be a military MO in Australia. I will outline what is expected of us at home and on operations, draw a picture of the many and varied experiences of service life and try to explain how the inevitable problems that can develop are dealt with. Jack of all trades and moreWhen not on deployment, the military MOs of all three services (Navy, Army and Air Force) are really “jacks of all trades”. They help to ensure that fit, healthy service personnel stay that way. They combine the roles of general practitioners, sports medicine physicians, preventive health experts and occupational health consultants. Some military MOs are involved in specialist areas of medicine, either at unit level or as part of the ADF’s three health centres of excellence — the Navy’s Submarine and Underwater Medicine Unit in Sydney, the Australian Army Malaria Institute in Brisbane, and the Air Force’s Institute of Aviation Medicine in Adelaide. On deployment, an MO’s main purpose becomes keeping people fit enough to carry out their job in extreme circumstances. This includes ensuring that only physically fit people are deployed, preventing casualties, and returning people who become ill to health as soon as possible. It involves providing operational health support, which reflects three concepts: first response (first aid); the “golden hour” for resuscitation (ie, the first hour after injury, when treatment has the greatest chance of increasing survival); the “three hour rule” (for initial wound surgery). Basically, if casualties can survive the first hour, then they have a high probability of surviving three hours,1 which should be time enough for them to be swiftly evacuated (by air, land and/or sea) to a place where they can receive an appropriate, adequate level of care. Based on these three principles, health support is organised into five levels of care: Level 1 (basic first aid), Level 2 (resuscitation), Level 3 (initial wound surgery), and Levels 4 and 5 (more specialised healthcare and rehabilitation provided in major civilian teaching hospitals). Surgical and intensive-care capabilities at our Level 3 facilities in the field are provided by members of the ADF’s Specialist Reserve, who include general surgeons, orthopaedic surgeons, anaesthetists and intensivists. Such reservists are often the unsung heroes who form the basis of our deployed health support. To supply effective support to the ADF personnel involved in the high-risk occupation of waging war, military MOs must be skilled not only in disaster and trauma medicine but also in the detection and management of injury caused by nuclear, biological or chemical attacks. Furthermore, in most of the missions we have been on in recent years, providing humanitarian aid has been an additional priority. However, more than anything, military medicine plays a major role in upholding the morale of a fighting force — an efficient, well equipped healthcare system allows members of the military to do their job in the knowledge that, if injured, they will be well looked after. Unique stressorsAll doctors know that medicine can be a stressful occupation, and military medicine is no exception. However, there are a number of stressors that are unique to this environment. Personal and professional stressorsFirst and foremost, there are the oddities of military life — the discipline, the bureaucracy, the uniforms and the haircuts. This lifestyle doesn’t suit everybody. Then, the ADF is a kind of “extended family”. The people who are your patients are also the friends you eat lunch with, see at the gym or socialise with at the mess. On deployments this is even more of a problem, as you are also living with your patients, who may have difficulty relating to you other than in your role as doctor. Relationships with family and friends can be challenging, as military MOs are often away from home — on courses or deployments or filling in for other people on courses and deployments. Being on very short standby for deployment can make it difficult to plan your life. The unexpected does happen, bringing with it a range of experiences (Box 1). 1: All in a day’s work One Monday morning in April 1999, I was called at 08:30 and told to be at the airport by 13:00 to be deployed to an island off the coast of Malaysia to investigate a fatal F-111 accident. It was an incredibly demanding mission, as the accident location was in a small swamp on a small island in the South China Sea. Aircraft wreckage poses many dangers, and the weather was hot and humid. It took several days to retrieve the bodies of the air crew, and both of the casualties were known to me personally. This took a toll on my physical and mental wellbeing, and I was physically ill before heading out to the site of a morning. But, as the only medical person on the team, I had many responsibilities in addition to my role as an accident investigator. As well as retrieving the bodies, I provided healthcare (including mental health support) to other team members and kept up their spirits. I counselled one of the spouses who visited the site. I liaised with Malaysian military personnel and police to bring the bodies ashore. When we reached Kuala Lumpur, I assisted with the autopsies. When we arrived back in Australia, I had to interview both spouses. Lastly, I organised psychological follow-up for my non-medical team members and, importantly, for myself. Gaining appropriate clinical expertise and opportunities for professional development can also be a challenge. Young medicos may be directed towards senior administrative roles early in their career; the opportunity to specialise may be limited to a few specific fields. All military MOs must have a broad range of skills, but often may have only limited scope to practise and maintain these skills when not deployed. On operations, many of the stresses of military medicine are magnified and others enter into the equation. Living conditions can be less than ideal. Working with unfamiliar cultures that may have different standards of care can lead to difficulties and conflict. Long working hours are often unavoidable, and fatigue takes its toll. War protocolThe Laws of Armed Conflict are the protocols that govern our actions in war. They protect our role as medical personnel and non-combatants, allowing us to do what we do best — tend to the sick and wounded. They also define our use of weapons. Many may shudder at pictures of personnel wearing the Red Cross while carrying guns; however, the Laws of Armed Conflict allow medical personnel to carry weapons to protect themselves and their patients. The Laws also state that it is our responsibility, as MOs, to treat everyone — friend or foe — using medical criteria to prioritise care. This can create a moral dilemma for the treating doctor, who may know that this same person, now a patient, committed almost inhuman atrocities in front of our personnel, as happened in Rwanda. Extreme operation: RwandaMuch of what I have described I have personally experienced in the most extreme operation I have been involved with to date — Australia’s commitment to the UN Assistance Mission in Rwanda.2 After the genocide in that country in April 1994, Australia sent two contingents of 300 peacekeepers to Rwanda from August 1994 to August 1995. As our mission was primarily a medical one — to provide health support to the UN troops and civilian personnel — nearly a third of our deployed personnel were health personnel. Although we were organised primarily to treat fit and healthy UN troops, we were now in a country whose health infrastructure had been largely destroyed in the genocide. Most Rwandan health professionals had either been killed or had fled the country. Consequently about 75% of our efforts were directed towards what was to have been, supposedly, our secondary mission — the humanitarian role. Despite the best efforts of our military training, there was no way we could have been adequately prepared for the influx and range of illnesses and injuries among civilians that we had to try to treat, as best we could, with limited and inconstant resources. We were able to save the life of a young mother who had lost both her legs as well as a pregnancy after stepping on a mine. However, we couldn’t help a young boy from a remote village who presented with a massive tumour of the head and neck. He was one of many we could neither diagnose nor treat. All we could do was advise his mother to take him home to die. So overwhelmed were we by the broad range of exotic medical and surgical conditions that confronted us that the MOs in my contingent had T-shirts made up with a logo that expressed our predicament precisely: instead of “Médecins Sans Frontières”, like our NGO colleagues, we sometimes felt like “Médecins Sans L’Idée” (Doctors Without A Clue) (Box 2). 2: T-shirt logo aptly expressing how overwhelmed we felt during the Rwandan crisis Rather than “Doctors Without Borders” (like our NGO colleagues) we sometimes felt like “Doctors Without A Clue”. It was difficult to come to terms with the harsh reality of trying to manage with extremely limited resources. Further, since our mission was primarily to support the UN troops, we had to give them priority. It felt, at times, as if we had to “play God”, a circumstance that did not sit comfortably with many of us. The fact that many of our Rwandan patients were HIV positive or had full-blown AIDS added to the danger and stress of our working environment. However, all of these challenges would have to be considered less distressing than my contingent’s involvement with the April 1995 massacre at the Kibeho refugee camp and dealing with the aftermath. The members of our medical team who witnessed the massacre felt the terrible frustration of seeing death and destruction before their eyes and of not being allowed to lift a finger to stop it. Even without the massacre, conditions at the camp were extreme — when food was in short supply there, I witnessed people picking corn out of human faeces that was scattered throughout the camp so they that could re-cook it. We worked among the filth and squalor, while talk of a sniper in the camp after the massacre persisted. Practising medicine while wearing a flak jacket, helmet and two pairs of gloves can be quite an experience, let me tell you. Thankfully, our experience at Kibeho ended on a positive note, as we were eventually able to convince the refugees to leave the camp and return home. Support strategiesYou will not be surprised to learn that these stresses do take their toll (Box 3). Military MOs are not immune to developing mental and physical problems, but we are perhaps more likely to ignore such problems in ourselves. On a deployment, we are the primary caregivers, preventive health experts, and often the mental health providers as well, to all personnel, including the health team (and, of course, oneself!). The MO may be the sole doctor at a site of deployment. I know of some who have become so preoccupied with their patients, their duty to fellow team members and their wider responsibilities that they have developed serious medical conditions that they themselves have not always recognised. 3: Post-traumatic stress disorder All personnel involved in war activities are at risk of developing post-traumatic stress disorder. A study of returned personnel from my contingent in Rwanda (of whom 27% were medical personnel) revealed that most subjects had been exposed to potentially traumatic events, such as seeing or handling dead bodies and fearing exposure to a contagious disease, toxic agent or injury.3 Six years after deployment, one in five were still experiencing significant levels of distress, with symptoms of post-traumatic stress disorder and a measurable impact on general psychological wellbeing. However, compared with infantry (who made up 30% of the sample), medical personnel reported lower levels of post-traumatic stress related symptoms and alcohol use — despite no differences between the groups in their levels of traumatic exposure, either in Rwanda or over their lifetimes. A questionnaire completed by 16 nursing officers who served in a different contingent in Rwanda revealed that it was not only traumatic experiences that were perceived as negative aspects of deployment. Other things, such as changing guidelines, having to accept some decisions made by non-medical personnel, the difficulty of interactions with other care organisations, and the lack of usual routine, were also a source of frustration.4 However, on a positive note, nearly all participants in the study felt the experience had changed their lives for the better. However, support strategies exist for helping us through the tough times — our overall military training, medical screening before departure, training with personnel from other services before deployment to develop group cohesiveness, and a willingness to support each other. A strong sense of purpose and an appreciation of the big picture — “we’re here to help, and we’re doing a good job” — and, at times, good old-fashioned MASH-style black humour, are also useful. DevelopmentsThe military has learnt from its experience, and our high operational tempo of recent years has been accompanied by more attention to support for military members on deployment. There is now more focus on adequate preparation for deployment, with appropriate training and medical and psychological screening. Research on personnel returning from deployments has led to improved mental health strategies before, during and after deployment. Personnel are being educated about the support available and encouraged to seek support. To better prepare medical personnel for the clinical aspects of deployment, military health units have entered into strategic alliances with major civilian hospitals in order to expose our personnel to a broader range of clinical experience. A new MO career structure has been developed that incorporates the need for ongoing professional development and specialisation in relevant areas of medicine. We are also exploring the use of technologies such as telemedicine in providing more and enhanced clinical support to deployed MOs. ReflectionsMilitary medicine is a challenging occupation. Although it can be stressful, especially when on deployment, it can certainly provide a fulfilling career for a doctor within an organisation that appears, at first glance, to espouse the philosophical opposite to the profession of medicine. Speaking for myself, my military career has also given me some incredible life experiences, such as flying at the speed of sound in fighter aircraft and travelling on duty to countries all over the world. In addition, I have learnt a lot about myself — my limitations and weaknesses as well as my strengths. Although the very nature of the job means that the health needs of MOs are often considered secondary to the needs of others, this situation can be, and is being, addressed. I look forward to seeing further development in support strategies for military MOs and to my next opportunity to practise medicine on the front line!

Tracy L Smart BM BS, DipAvMed

This is a brief account of my six months in Afghanistan in 2003. I worked as the Médecins Sans Frontières (MSF) project doctor in the western province of Herat, spending alternate weeks in Herat City and in Kushk-e-Kohna, a sparsely populated district some two hours north of the provincial capital by four-wheel drive. I arrived in February, just over two years after the US-backed overthrow of the Taliban. Herat is now controlled by its Emir and Governor, Ismail Khan, who rules beyond the reach of Afghanistan’s central government. With a private army of sixty thousand men and control of customs revenue from trade with Iran, it is no wonder he has not, despite invitation, joined the government of Hamid Karzai. His unchallenged power and the considerable wealth at his disposal have in fact made Herat relatively more stable and prosperous than the rest of the country. It is February, and the winter snows are just thinning as I arrive to work in the mobile clinic in Kushk-e-Kohna, which I affectionately call “Kushk”, or “palace”, in the local language of Farsi. The name clearly harks back to a more prosperous time, for there is no palace to be found in this district of sixty thousand people. The inhabitants have mud-brick houses and live mostly off subsistence farming, growing wheat (Box 1) and raising livestock (Box 2). They have lived like this for generations, and life was little different under the Taliban, although now it is evident that young girls are going to newly built schools. There are only two doctors for the entire population — myself and an Afghan doctor recently recruited by MSF. Dr Mohammad Amin has recently graduated, and is enthusiastic about working with MSF, learning English and broadening his knowledge. Before 2003, locals had to gamble on the only “healthcare” available — drugs sold in private pharmacies by untrained “drug sellers”. And so it is that after a week I begin getting used to the hundreds of patients presenting every day, many having walked for hours, thronging around the makeshift consultation room and desperately pressing to be seen (Box 3). The mobile clinics are situated across the district, with MSF’s base in the district centre of Kooklam. We visit one or two villages each day, staying until dusk. Each clinic is one to two hours’ drive from Kooklam over rough terrain and is visited every two weeks. The crowds are becoming more manageable as we begin using mass consultations to get through the large numbers of patients, seeing thirty at a time and triaging by casting an eye across the crowd to identify the seriously unwell. In so doing, Jodie, the expatriate Australian nurse who is assisting me, spots an unconscious child and distressed father. The four-year-old is clearly very unwell. His head is arched back, and the petechial rash across his upper chest confirms the diagnosis of meningococcal meningitis for us. Without pathology services or a hospital nearby, we treat him with an intramuscular dose of oily chloramphenicol, which will slowly be absorbed over the next week. We urge the boy’s father to take him to Herat City Hospital, but he doesn’t have the four dollars to hire a taxi, nor can he leave his wife and children unaccompanied at home. Afghan culture dictates that any woman must be accompanied by her husband or a male relative, and so her husband stays. I find it difficult to overcome the sense of despair and helplessness in treating an often fatal illness in a day clinic, but hope for some response regardless. It is therefore with joy and surprise that we see little Nazamuddin two weeks later, alive and well, on our return to the village for another round of consultations. I had not seen chloramphenicol used like this before, but am told that it has been used successfully in meningococcal outbreaks in Sub-Saharan Africa. Our feeding program runs concurrently in the old storeroom next door. Forty children are getting supplementary food and standardised medical care today. They receive a corn/soy/bean mix, iron/folate tablets, vitamin A, mebendazole and antibiotics on their first presentation. They are treated for malaria if febrile. Any severely malnourished children (who should really be in a hospital), will at least get some treatment to optimise their chances while remaining at home, and will be seen by us on a fortnightly basis. These children will get oily chloramphenicol, the wonder-drug, when they first present, and a special nutritional supplement, PlumpyNut, of which they are quite fond. It is a so-called “ready-to-use therapeutic food” containing peanut. Jodie oversees the activities, but the Afghan staff have it running like clockwork, undressing and weighing the children, crushing their tablets into a paste, and giving parents cards to pick up the food bags and to record their children’s progress. Our health educator is speaking to the crowds about hygiene and diarrhoea. The outreach workers are busy screening new patients for malnutrition, and occasionally I review one who appears particularly unwell. Tuberculosis seems to occur everywhere. Many patients have bought antituberculous drugs from local pharmacies, taken them for a few weeks, then stopped taking them because of the expense. No-one has been formally diagnosed, and several don’t have TB at all, but the fear of it is great, as they have seen relatives become weak and die. Patients I diagnose can’t go to Herat, where MSF’s directly observed short-course treatment (DOTS) TB program1 has just commenced. So all I can do is entreat them not to buy more TB combination blister packs from Pakistan, telling them that they will get resistant TB and that they should wait for a rural TB program to start (although this is certainly years away). I wish I could offer them the services of our Herat TB program, which is a runaway success — I am heartened to see many patients who were initially brought to us in wheelbarrows now looking completely well. For me, their deep gratitude is humbling and heart-warming. The consultations en masse become an unexpected forum to talk to Afghan women about their mental health. There is one psychiatrist for the entire province of two million people, so discussing mental health is unheard of in this conservative, desperately poor district. When women present in great numbers, all complaining of “body pain”, we decide to see them together to explain the nature of their illness. Body pain, as a complaint, is hardly known in Western countries, yet is a common complaint of southern Asia and the Middle East. Women, and sometimes men, report months or years of head, shoulder, back, leg and arm pain. In a country that has suffered twenty-five years of civil war, it is clear that psychological trauma, grief and personal loss contribute greatly to how this problem manifests.2 I therefore find myself in an unusual position — male, foreign and non-Muslim, yet privy to the private traumas of rural Afghan women. Some have lost husbands, and many, many have lost children. Nasima is heavily pregnant and pleads with me to keep her child alive, as she has lost eight previous children in pregnancy or in the first year of life. In Afghan society, no woman is complete without bearing children. Through her clothes, I feel her abdomen. I feed my stethoscope under her clothing to auscultate, without revealing her skin. Through all this she keeps her headscarf across her face, and speaks quietly from behind her hand. We prescribe what we give all women in late pregnancy: ferrous sulfate, folate, and multivitamins. It is a rural tradition to cut the umbilical cord using the heel of a shoe, with its obvious risk of causing neonatal tetanus. We therefore urge her to visit the MSF clinic in the district centre for her first tetanus vaccine, and advise against the traditional practice. Unfortunately, the four-hour ride by donkey to the clinic is a difficult prospect for a woman eight months pregnant. There are other misconceptions to overcome. Afghan women throw away colostrum, critical for a newborn, giving a child water or tea for two to three days. Such ideas are entrenched, but as expatriates we are regarded somewhat as magicians, and listened to intently. Abdul Rafour, a man in his forties, is being led into our dusty consultation room. He removes his dark glasses, and we realise he has no eyes. His face is a patchwork of scars. He has been a victim, some years earlier, of one of Afghanistan’s ten million landmines. He complains to me of deafness and inability to sleep, and it is soon clear that he suffers from post-traumatic stress disorder and bilateral chronically perforated ear drums. What can I do for him? Nothing at all. I call the next patient in. Today’s drive home takes two hours in a three-car convoy (Box 4), mostly along a dry riverbed. I listen to my portable CD player as I take in the serene vista of the foothills of the Hindu Kush mountain range. There are twelve of us squeezed into the landcruisers: expats and Afghanis, drivers, a translator, a feeding centre supervisor, outreach workers, a health educator, a registrar, a doctor’s assistant and a scooper for the food distribution. We’re all sitting on or around our portable gear: tables, chairs, mats, medication, dressings, height boards and scales. On the way home there is more room, as we have distributed over three hundred kilograms of food during the day. Arriving at our compound (Box 5), we play cards, then volleyball. I fit in a quick snooze and some reading by lantern light until dinner (rice, eggplant, tomato and bread). I go to bed early, to the familiar, vibrant singing of the Afghan staff outside. Afghanistan has given me a profound insight into the challenges of aid work in a country ravaged by twenty-five years of civil war. The US-led attack on the Taliban in 2001 was only the most recent trauma in a long history of terrible conflict. What is emerging now is a tenuous and fragile peace, with ongoing conflicts between rival warlords, guerilla attacks by Al Qaeda and Taliban remnants, and no effective unified government or military force. In this context, the challenges of aid work are only partly medical. Many of the obstacles to bringing health to the Afghan people have to do with politics, security, culture and trust. For Afghanistan, the first incremental steps are being made to tackle the appalling health situation, but there needs to be a foundation of stability, security, economic growth and basic education before significant inroads can ever be made. It is a country with a burden of disease that is mostly preventable, a country poisoned by land mines, and where the fundamental right of access to basic medical care is still an unattainable aspiration for most. Most importantly, if Afghanistan is to leave behind its tragic past, its plight must not be forgotten by the international community.

Brett A Sutton

What it means to be Australian is harder to define than ever in these complex, shifting times I’ve been looking into what it means to be an Australian all my life. As one of a group of young playwrights who came to prominence in the early 1970s, our group mission, in so far as we articulated it, was to investigate the “Australian identity”. In an interview I gave in London in 1973, I was quoted as saying: “There is an awful Australian uniqueness, and for the first time the Australian theatre is getting down to the business of finding out what it is.” A bit of an overstatement, perhaps, but we did see ourselves as exploring the darker side of Australian life, albeit in a satirical way. Australia’s chauvinism, materialism, conservatism and suburban conformity were put under the microscope, but even as I was savaging such tendencies in my plays, I found my country endearing as well as horrific. In those days there was a sense that the whole population shared common characteristics — our black, sardonic humour, our energy, our directness and our hatred of pretentiousness — that could be thought of as typically Australian. Then, at a literary dinner at the start of the 1980s, the articulate, scathingly witty, but sternly moral journalist, David Marr, scolded us all for our preoccupation with “Australian identity”. He said there was no such thing. What we had been calling the “Australian identity” was nothing more than the Anglo-Celtic identity and a male, middle-class, heterosexual version of it, to boot. We were, in fact, a country of many identities: Aboriginal, gay, ethnic, feminist, working class, rural and dozens of others. There was no overall “Australian-ness”, and to claim we were trying to find it was naïvety at best, and arrogance at worst. I slunk away and tried to find reasons to include feminist lesbian Greeks and rural Aboriginals in my plays, but quickly decided that it was probably better that they wrote their own plays, which they promptly did, and Australian theatre has been all the richer for it. The lesson I learned is that when one tries to make sense of a topic like “what it means to be Australian”, one has to tread warily. If you’re one of the 700 000 Australian children being raised in poverty, you’re obviously going to have a very different view of what it means to be Australian than if you’re a futures trader making $500 000 plus at the age of 26. If I were writing about this issue at the start of the 1960s, I could truthfully say that being an Australian meant living in the country with the smallest gap between rich and poor in the world. In 2003, we have one of the largest income disparities of all the industrialised nations. Although the top 30% of income earners in Australia are much better off, in absolute terms, than they were 40 years ago, surveys show they are no happier, and this baffles the science of economics. Writers and artists have been suggesting for thousands of years that happiness is never simply a question of consumption. It also has a lot to do with feeling loved, fulfilled and creative. Some part of human happiness may be bound up with wealth, but the more enlightened economists are now dicovering that it’s relative rather than absolute wealth that counts. Humans as a species are very sensitive to their relative status in a community. We don’t just want to be loved, but also respected and noticed. So part of what it means to be an Australian these days is working longer hours, experiencing more stress and suffering increasing rates of depression in order to purchase the symbols of success which will make one feel respected. Forty years ago, a 120 m2 house was considered quite acceptable for a family. Now it has to be double that size before one feels adequate. The single most important measure in the political governance of most countries remains the rate of growth of gross national product (GNP), implicitly maintaining the fiction that increased consumption equals increased happiness; this despite the fact that galloping GNPs also mean a galloping increase in resource consumption and a galloping rate of increase in pollution and environmental degradation. What it means to be an Australian varies widely. Being a rural Australian last year meant experiencing the worst drought on record, living with more uncertainty and hardship than city Australians, thanks to El Niño. Being an Australian in many areas meant facing major bushfires. If you’re a Muslim Australian, it means being under suspicion; if you’re a female executive, it means not being as well paid as your male counterpart. If you’re second-generation Greek Australian, it means being able to send up your Greek-ness and love it at the same time. If you’re a young Australian, it means working harder and longer and having a more uncertain future than your parents had; and if you’re an Australian over 60 and in good health, it apparently means that you’re happier (as a group) than anyone else. So was the magisterial David Marr right after all? Is the “Australian identity” a fantasy? When I find myself laughing at the truly appalling Kath and Kim, I can’t help feeling that, for all our preening and pretensions on the world stage, there’s still a bit of that awful Australian uniqueness around. And any country that can laugh at its own awfulness can’t be all that bad. One of the really good things about this country is that we remain, by and large, the world’s most successful experiment in multiculturalism. With our Muslims and Aboriginals, we have a long way to go, but there is more intermarriage between ethnic minorities and Anglo-Celts here than in any other comparable country, indicating that the long-lived racial ghettos of America are not going to happen here. I don’t think it’s a matter of the Anglo-Celts absorbing and dominating minority groups, but a genuine interaction in which the social centre of gravity will shift to a new and original position. The personal perspectives by doctors from migrant backgrounds, Yu (page 598), Houssami (page 595) and Santoro (page 600), reflect these changing dynamics. If the world manages to avoid travelling down its present road to long-term disaster, we might well have one of the most interesting countries in the world here, in time. I’m alarmed at the way the world is heading — greed and envy pushing us towards what could be an eventual terrible reckoning. And I’m alarmed that we’re such an enthusiastic little helper in the whole process. But when I look around the world at the other options, I’m still rather glad I’m here and hold an Australian passport.

David Williamson

Finding a niche and fulfilment in Australia When the MJA contacted me about writing a “perspective”, I was initially delighted, thinking that it would be related to my research in breast cancer testing. When the word “personal” entered the discussion, I hesitated, then agreed — I owe that much to my mother, my teachers, and Priscilla. My migrant background has, in many ways, given me a broad perspective of what a community is, and I have grown up comfortable with seizing the best of different cultures. At 38 years of age, I tend to see life as a series of challenges and opportunities, and I feel very fortunate that, in Australia, I have always had sufficient support to make the most of these. My twin brother Hadi and I were born in Beirut, Lebanon, into a relatively wealthy family, the youngest of six children. I guess one could say we had everything — loving parents, private schools, and a huge apartment in the heart of Beirut. There was never any plan to migrate to another country. When I was about 6 or 7 years old, things started to go wrong with my parents’ health. First, my mother, then in her early thirties, developed renal failure that rapidly deteriorated, necessitating a transfer to Melbourne under the care of a Dr Priscilla Kincaid-Smith, with a view to transplantation. She was supposed to return soon after, but never did. Then, within about 8 months, my father suffered a heart attack and died. I was later to hear from my mother about her wonderful Australian renal physician, who had treated her kindly and broken the news of my father’s death to her while holding her hand. Because of my mother’s very favourable experience with her medical care, she naturally wanted to remain where she had received her transplant, and it was decided that we would join her in Australia. It was to be another 3 years before we were re-united with my mother. It was a painful time, and, while we were looked after by various members of my mother’s family, my oldest sister Sahar (then aged only 13 years) had responsibility for taking care of “the twins”. The cost of care for six children during that time consumed nearly all our resources. When I arrived in Sydney, aged almost 11 years, I thought that this was the most wonderful place in the world (and still do), although I could not speak a word of English. There seemed to be an abundance of everything, plus a backyard with pets! In retrospect, being re-united with my mother was what largely influenced my view of my new country. I found most things easy to learn and, having had a bilingual education (I spoke fluent French and Arabic at the time), English was a relatively easy language for me to learn. By the end of my first year at school, I was communicating well, had made a few friends, and was topping my class in science. At school, and to a much lesser extent at university, there was the inevitable taunting, and the occasional “wog” labelling. It rarely affected me, and in many instances I chose to ignore it. My school teachers were very encouraging, and within a few years had put me on the school debating team. Debating was an extremely arduous task, as I still “thought” in Arabic, yet had to express myself in English. My mother, like many people of non-English-speaking backgrounds, had a strong belief that, armed with education, you could do almost anything. She wanted me to do well enough in the Higher School Certificate (HSC) to gain entry into medicine (and of course would talk of why I should become a renal specialist!). I studied hard and expected to do well in the HSC, but was surprised to come first in my school, and gain entry into medicine at the University of Sydney. It feels as if Sydney University has always been a part of my life, from medical school until the present. During my undergraduate days, and through the three postgraduate degrees I subsequently completed at this university, I rarely encountered discrimination and felt generally happy. Yet, until I commenced the clinical years, I was unsure about whether to continue with medical school, as the non-clinical years gave me little indication as to whether I would enjoy providing care for people. Lidcombe Hospital was a teaching hospital at the time, and a great place to learn the art of clinical care. The tutors were enthusiastic, and we had a particularly inspiring medical tutor who seemed to know more medicine than the textbooks. By the time I completed my medical degree in 1987, I was fairly sure I wanted to be a doctor (but one with little interest in kidneys!). I was also sure that I had found the perfect partner. However, having been brought up in a strict Moslem family, boyfriends were not allowed, let alone Italian–Australian ones. We announced our engagement amidst strong (but short-lived) objections from both his family and mine, and my fiancé, along with my mother and siblings, celebrated my graduation in 1988. I completed my internship and a year of residency at Concord Repatriation General Hospital, a wonderful hospital to work in for general medical rotations, especially for unfortunate souls like me who were undecided about specialising. The internship included a secondment to Auburn Hospital, with its culturally diverse community, where I frequently saw Arabic-speaking patients in the emergency department. They genuinely appreciated being able to communicate with their doctor without a third party, and there were occasions when particularly sick elderly patients would grab my hand to kiss it, a gesture of appreciation in many Arab cultures. During my internship, I got married, and managed to celebrate with two wedding ceremonies, a Moslem one and a Catholic one. Early in 1990, I accepted a position as a breast clinician in one of Sydney’s private breast centres (Sydney-Square Breast Clinic) under the mentorship of Dr Joan Croll, one of Australia’s pioneers of mammography. Being able to help women with breast symptoms, who generally felt very vulnerable, and to spend time discussing management options with them, was very rewarding. I was soon convinced that this was the medicine I wanted to practise long term. Around that time, the methods of breast cancer detection were evolving, and our unit was one of the pilot sites for Australia’s breast-screening initiative, as well as one of the first centres to use ultrasound-guided needle biopsy. There was much to learn and do, and clinicians like me who were responsible for “triple testing” of breast abnormalities (by clinical examination, imaging and biopsy) were called “breast physicians”. Life events 1965 Born in Beirut, Lebanon 1972 Mother is transferred from Beirut to Melbourne for a renal transplant 1973 Father dies of a heart attack 1976 Siblings and I migrate to Australia and are reunited with my mother in Sydney 1988 Graduate in medicine from the University of Sydney Marry in two wedding ceremonies (Moslem and Catholic) 1988–89 Internship and residency at Concord Repatriation Hospital 1996– 2002 Medical Director (and, subsequently, Director), MBF’s Sydney-Square Breast Clinic 1997 Graduate Master of Public Health 1998 First child (Nadine) is born 1999 Graduate Master of Education 2002 Move from private practice to NSW Breast Cancer Institute, and the Royal Hospital for Women Complete PhD thesis: Accuracy of mammography and ultrasound in women with breast symptoms Second child (Laura) is born 2003 Graduate PhD Senior Lecturer, Screening and Test Evaluation Program, School of Public Health, University of Sydney I was 30 years old and had worked in multidisciplinary breast services for several years when I was appointed Medical Director of the Sydney-Square Breast Clinic. Although a little anxious about the responsibility, I was eager to do a good job and ensure that we provided a high standard of care to our patients. It was in this phase of my medical career that I first experienced some discrimination. The team of more than 40 staff was generally supportive, but I was aware that a few of my peers did not consider that I had the appropriate profile for the role. It was difficult to ascertain how much of this was due to my youth, my ethnicity, or perhaps my lack of a high profile, compared with that of my renowned predecessor Joan Croll. This was, however, transient. I remained in that role for 7 years, and during that time I combined clinical work with postgraduate study and research in public health, and developed a research profile for the centre in breast diagnosis, particularly in breast imaging accuracy. My research mentor, Professor Les Irwig, changed my life. Not only did he teach me the skills for conducting research, he provided invaluable advice and tolerated my “I give up” tantrums through an MPH and a PhD in clinical epidemiology. Last year, after a short break to have my second child (the baby having arrived a fortnight after I completed my PhD thesis!), I switched from private practice back to the public hospital system. I currently spend half my time at the New South Wales Breast Cancer Institute, working in services that range from a “benign disease” clinic to a “metastatic breast cancer” clinic. I also consult at the Royal Hospital for Women’s breast centre, seeing women with predominantly symptomatic breast conditions. The rest of my time is spent at the School of Public Health at Sydney University, continuing breast cancer research. Maintaining the balance between clinical and academic work is certainly a challenge, but I think the greatest challenge is spending enough time with my family, and making sure that my Australian children grow up with an appreciation of both the opportunities that surround them and their mixed heritage. We live in a part of Sydney that is greatly enriched by Italian–Australian culture, and my children are able to learn Italian at the local school, celebrate Italian fiestas, and visit Casa d’Italia on a regular basis. I think there is less opportunity for them to discover their Lebanese heritage, and I wonder how I can change that — with my busy life I myself have become increasingly distant from it. In a few weeks’ time, I will sit the Public Health Physicians Fellowship exams. I consider my chances of passing to be slim — breast cancer control is but a tiny fraction of the broad field of public health medicine. However, I am optimistic because of the enormous amount of help I am receiving from the public health medicine community, my colleagues at the Breast Cancer Institute, my husband, and Julia, a fellow candidate for the exams, who has been coordinating our study group. At my PhD graduation earlier this year, my husband and oldest daughter (aged 5 years) celebrated with me. My mother was not there, but I think she would have been proud. She passed away many years ago, aged 54 years, 20 years after her transplant. A few weeks before she passed away, she asked me if I had ever met Priscilla Kincaid-Smith (but the answer was no, and I still haven’t met Priscilla).

Nehmat Houssami MB BS(Hons), PhD, MPH

Reputation should be neither sought nor avoided. — Lao Zi It always surprises people, especially those with an Asian heritage, when I say that I have never been disadvantaged, in my schooling or my professional life, by being Chinese. I suspect that I am often not believed, but that is my experience. A: J S Y at home in Nanjing, aged 2 years B: Joshua Young Wai, uncle of J S Y, as a junior resident medical officer at Sydney Hospital, circa 1939 My parents met when my father visited Sydney as part of a Chinese government delegation. I was born in Nanjing in December 1934, and in my third year of life my family was disrupted by the Japanese invasion of Manchuria and then China, in those fateful years leading to the Second World War. I came to Australia with my mother and sister, while my father remained in China, serving as part of the Nationalist Government of Chiang Kai Shek. My mother had been born in Australia and was returning to the safety of her home. I came as a refugee — by a regular passenger ship, different to those used by more recent refugees. My maternal grandfather, Young Wai, had left southern China for the Victorian gold-fields in 1867. Shortly afterwards, he worked as a Presbyterian mission worker to the Chinese miners. He was later ordained into the Presbyterian Church and moved to Sydney to start the first Chinese Presbyterian Church (now located in Crown Street, Surry Hills). His eldest son, Joshua Young Wai, was the first Chinese graduate in medicine from the University of Sydney. It was in his household that I grew up. English was spoken at home; we ate Chinese food on weeknights, but at other times we had Australian food. Thus, my experiences may well have been very different to those of other Chinese people in Australia at that time. I guess that my early life may be seen as a privileged one for an Asian growing up in a country known for its “White Australia” immigration policy. I was clearly Chinese, but, at Summer Hill Primary School and then at Fort Street High School, I did not feel different. When I hear about other experiences from contemporaries, I feel grateful for the liberal attitudes and values of my teachers and schoolmates. I had an older sister, but I was the first-born son, and with that came a family obligation, not spoken but clearly understood by me. I cannot recall actively thinking about what I would do in later life, but I knew there was a family expectation, with my uncle being a general practitioner, that I would study medicine. I did what was expected of me, and that, I suppose, was a reflection of my Chinese sense of duty. Fifty years later, I have no regrets. I would still choose medicine, despite the interference of governments into medical practice and the burden of indemnity insurance. Paediatrics was a chance residency term allocation, but luck had me working for Arnold Tink, who helped make that clinical term a life-determining experience. Kids were fun; they were gutsy and brave and very honest. I cannot imagine any other specialty giving me the satisfaction and joy that looking after children and their families has provided over a working lifetime. Healing and harmonyIn the early 1970s, through the Royal Australasian College of Physicians and the Australian Department of External Affairs, I was given the opportunity (as Head of Medicine at Royal Alexandra Hospital for Children) to take part in a graduate teaching program in paediatrics in Singapore and Manila. I returned to both cities over the next 5 years. Being Chinese had not seemed to be a factor in my medical life. However, seeing sick Asian children being cared for in poorly equipped hospitals (albeit by excellent clinicians) made me feel guilty about the inequities of life; the fact that these children were Asian made me identify with them in a way I had not expected. I felt more Asian than I had ever felt before. Seeing the top-class facilities of Singapore today, and their standards of care, makes you realise that money and a government priority can make a difference. I think Singapore is the one country in the world that spends a lot on both defence and health. The move of the Children’s Hospital from Camperdown to Westmead in 1995 allowed the hospital to re-equip with the latest and best technology. Even more importantly, it allowed us to provide not just medical science, but a hospital designed to recognise the importance of light and colour. The gardens, entertainment systems and art programs, including an artist in residence, a music therapist and a drama therapist, were all designed to create a total healing environment for patients and their families and carers. It foreshadowed the awareness of fun and laughter in feeling better and getting better. Now that Singapore equals our technical standards of medical care, I am going back to help them recruit their own community into providing the humanity of care that characterises Westmead Kids. I will help promote fund raising for children’s charities and talk about making healthcare more truly caring. But Singapore is a very special case. In other parts of the world, especially in countries like Vietnam, Cambodia, Laos and the small countries of the South Pacific, the help we expect for our sick children is denied to so many. We in Australia can make a very meaningful contribution to our region through education. This is a relatively inexpensive means of aid with a long term yield of goodwill. I am delighted that so many of our colleagues are giving their services as teachers and mentors to healthcare workers in the more disadvantaged countries of the Asia–Pacific region. To me, the key to a peaceful, harmonious region is through education. Life events 1934 Born in Nanjing, China 1937 The Rape of Nanjing; come to Australia as a war refugee 1959 Graduate in medicine at University of Sydney 1960 Junior Resident, Royal Alexandra Hospital for Children 1967 Membership of Royal Australasian College of Physicians 1971 Head, Department of Medicine, Royal Alexandra Hospital 1978 Chief Executive, Royal Alexandra Hospital 1989 Member, Order of Australia 1995 Involved in planning move of Children’s Hospital to Westmead 1996 Sidney Sax Medal, Australian Health Care Association (for outstanding contribution to health services) Australian of the Year Deputy Chancellor, University of Western Sydney DLitt(honoris causa), University of Western Sydney MD(honoris causa), University of Sydney 1997 Retire from Children’s Hospital Trustee, Art Gallery of New South Wales 2000 Chancellor, University of New South Wales Chair, VisAsia Chair, Australia China Council, Department of Foreign Affairs Chair, Specialist Advisory Committee, NSW Commission for Children and Young People 2001 Companion, Order of Australia 2003 Weary Dunlop Medal, Asialink (for fostering Australia–Asia relationships) Art, culture and toleranceLike so many other medicos, my life has been busy with the hours that I have worked and the burdens of responsibility for my patients and then for my hospital. My solace and my escape have been found in music and the arts. I have actively sought ways of giving something back to these areas that have sustained my sanity and provided so much enjoyment. Having little artistic ability, I volunteered my organisational skills. Over the years, I have served on the National Board of Musica Viva, the Boards of Trustees of the Powerhouse Museum and the Penrith Regional Gallery, and I am currently Deputy President of the Art Gallery of New South Wales and Chairman of VisAsia. VisAsia is the arm of the gallery that promotes an understanding and appreciation of Asian art (www.visasia.com.au). A: J S Y in the orthopaedic ward of the Children’s Hospital at Westmead, 1996 B: J S Y, with staff, visiting Macau Hospital, 1999 I am an enthusiastic collector of ceramics and textiles, especially those of the Asia–Pacific region. I believe that art and culture provide a non-threatening way of introducing different cultures and values to people who may be unfamiliar with them. Understanding and accepting the differences in art and culture make it easier to be tolerant of other differences. Over the years, I have become aware that many young Asian people who live in Australia have little knowledge of, or indeed interest in, their own cultural heritage. I hope through VisAsia, and through the various student organisations in our tertiary education institutes, that these young people may learn something of this heritage and feel some pride in their own heritage as well as that of their new home in Australia. Being proud of your own family heritage helps in building self-esteem, especially when others may question or challenge differences that they see as being of lesser value. I believe the same holds true of young people of other cultural backgrounds, most topically at present, young people of Islamic heritage. Confucius wrote, “If you set an example by being correct, who would dare to remain incorrect?” Being part of your community and giving something back is very much in line with Confucian teachings — it is something that doctors traditionally did when medicine was judged a noble profession. But perhaps I am just becoming more Chinese as I get older.

John S Yu

Two generations of Santoros have served the Italian community of Melbourne for over 70 years My father, Soccorso Santoro, was born near Naples, Italy, in 1902. After graduation in medicine from the University of Genoa and internship at Alessandria, north of Genoa, he was called up for military service in the Battalion of Doctors and Pharmacists. On completing this service, he decided to travel around the world. As he spoke English well, and Italy was an ally of Britain in the 1914–1918 war, he took the sensible precaution of registering his Genoa medical degree in London, which allowed him to practise throughout the English-speaking world. Soccorso Santoro unveiling Dante, Melbourne, 1958 Soccorso Santoro (standing) at the official unveiling of a bust of Dante Alighieri (a gift of the Dante Alighieri Society to the City of Melbourne) in the Treasury Gardens. When Soccorso resigned as President of the Society after nearly 20 years, he received a gold medal “Società Dante Alighieri” for his long service and for promoting the Italian language. In June 1930, my father sailed to Australia on the Orient Line’s “Orama”. He arrived in Melbourne well equipped with the appropriate medical, surgical, obstetric and even dental instruments (his degree gave him the right to practise dentistry, although he never did). He started practice in the “Professional Chambers”, 110 Collins Street, Melbourne, in August 1930. In 1933, he married my mother, and in 1935 I was born. My father’s gross income in the previous year was £761 ($1522), and he stated in his 1935 tax return that as his “. . . practice consists of mainly Italians . . . scattered in all suburbs of Melbourne . . . , [his] average monthly mileage is 1200”. He noted that petrol was 1 shilling and seven pence (15 cents) per gallon (3.5 cents per litre)! My father’s practice was not easy. Most of his patients were working-class Italians, who would occasionally sit on the floor in the corridor outside his rooms, to the surprise of the specialists in three-piece suits and watch chains also practising in the building. My father spent a great deal of time translating for patients and accompanying them to specialists. This was an era of great respect for the family doctor, who was the confidant of many families. Migrants wanted someone who could understand them and their family ties. As their children mixed with local children, family strictness and unity broke down; many children refused to speak Italian and were desperate to be considered Australian. This rejection was upsetting to the older migrants, especially as they relied on the young to interpret. My father took me on home calls to the Italian families around Carlton. They would be roasting coffee or making spaghetti, ravioli, salamis or prosciutto, but all work would cease as the whole family became involved in prolonged conversation with my father about some medical problem. It was unusual for him to complete a home call in under an hour. My father was also involved in the Dante Alighieri Society, which promotes Italian culture and language, and was its president from 1931 to 1959. He was a delegate of the Italian Red Cross and responsible for financial donations, as well as the official doctor of the Italian Consul General in Melbourne and the Italian shipping lines. When war was declared in 1939, my father was interned in a camp at Tatura in Victoria. Through the efforts of my mother, an Australian citizen, he was released after 6 weeks, while other Italians remained for the duration of the war. The conditions were that he report to Kew police station three times a week, not travel more than 40 kilometres from Kew and not go near the beach on Port Philip Bay, as he might signal enemy shipping! He was allowed to continue practice in Collins Street, but no more than two other Italians were to be in his surgery or waiting room at the same time — as a meeting of four was defined as a conspiracy. Any other Italian patients were asked to “go for a walk around the block”. For the same reason, tennis could not be played at our home with other Italians. The prohibition on speaking foreign languages on the telephone restricted history-taking before home visits. Our home was searched for subversive literature, but the complete library of the Dante Alighieri Society, hidden under the house, was not found. Nevertheless, our family was treated with great courtesy by the authorities, and, the few times I visited my father at Tatura camp, I remember Australian soldiers giving me oranges and playing with me. In 1948, my father made his first trip back to Italy (a 96-hour plane flight) to see his family. Back in Australia, he continued to work tirelessly to promote the Italian community. For instance, he mobilised Italian clubs to donate to St Vincent’s Hospital’s building program in 1953 and presented 200 books by Italian authors to Melbourne Public Library in 1956. In 1960, the Italian language was accepted as a subject at the University of Melbourne, and an annual “Dr Santoro Prize” is given to the best student in first-year Italian. In 1960, my father received the honour of “Cavaliere Ufficiale” (Officer of the Order of Merit of the Republic) from the Italian government. In 1961, on a trip to Genoa, he suffered a heart attack and was admitted to the same hospital in which he had studied medicine. In the preceding months, he had contacted many of the 1926 graduates from the Genoa medical school to arrange a 35-year reunion. It was not to be. He died on 10 July 1961, aged 59, having practised in Collins Street for 31 years. Soccorso Santoro 1902 Born Serino Italy 1926 Graduates in Medicine from the University of Genoa, Italy 1927–28 Internship at Alessandria, north of Genoa 1928–29 Military service 1930 Registers as medical practitioner, London, and sails from Naples to Australia 1931–61 General practice, Collins Street, Melbourne 1933 Marries Vida Clancy (a nurse who trained at St Vincent’s Hospital), at St Ignatius Church, Richmond 1935 Attends British Medical Association 103rd Annual General Meeting and 1st Australian Congress (Melbourne); first Italian member of the BMA in Victoria (his copy of the Book of Melbourne Australia 1935, a review of contemporary medical practice written for this conference, is still in my possession) 1940 Interned as an enemy alien at Tatura, Victoria, for 6 weeks 1956 Official doctor for the Squadra Olimpica Italiana, in Melbourne for the 16th Olympic Games 1960 Cavaliere Ufficiale, Republic of Italy 1961 Dies Genoa, Italy, aged 59 years George Santoro 1935 Born Melbourne 1962 Graduate in Medicine from the University of Melbourne 1965–2001 Solo general practice in Richmond, Victoria 1970–2001 Nominated Medical Officer for Italian government, assessing Italian pensions and past work-injury claims 1976–99 Treasurer and President of the Medical Benevolent Association of Victoria 1977 Cavaliere, Order of Solidarity of Republic of Italy 1983 President, Victorian branch of the Australian Medical Association 1983–present Director, Medical Defence Association of Victoria 1984 Cavaliere Ufficiale, Republic of Italy 1983–96 Inaugural President, Italian Medical Society 1986–94 Federal Council, Australian Medical Association 1988–89 Chairman, Lord Mayor’s Fund for Metropolitan Hospitals and Charities 1989–97 Board Member and Chairman, St Carlo Complex for Italian Aged 1990 Member, Order of Australia 1994 Commendattore Order of Merit, Republic of Italy 1994–present Director and Treasurer, Melbourne Division of General Practice 1994–99 Board Member, Faculty of Medicine, University of Melbourne 1996 Current Member of Order of Australia Council (Governor General’s committee for Australian honours) The year after my father died, I graduated in medicine from the University of Melbourne. Internship at Queen Victoria Hospital and locums in a few Italian and Australian practices led me to practise in the inner, (at that time) industrial, suburb of Richmond, where many Italians lived and worked. There was no alternative to solo practice, as few general practitioners spoke Italian, and a non-Italian-speaking partner could not have shared the workload equally. I was on call 24 hours a day to a large group of patients, as my father had been. In this situation, deputising services were a godsend, and, in 1970, I helped develop a service which still operates today. In caring for the Italian community, not only is the capacity to communicate in Italian important, but so is the cultural understanding of illness. “Fire of St Anthony” explains the excruciating pruritis of shingles nicely, while an inability to weed or tend a vegetable garden suggests the shortness of breath of cardiac failure. I enjoyed my numerous home visits, which gave enormous insight into patient care. Taking a detailed medical history often revealed past medical misunderstandings, which had led to inappropriate medications and unhelpful stereotypes, such as “Mediterranean backache” and “Mediterranean gut ache”. I found it best to involve the patient and family and their opinions of the illness, its cause and treatment. Compliance with treatment is increased if combined with traditional management; dietary restriction is relished, as this supports the sick person being the centre of family attention. In my career, I have also found time for community service as office bearer of the Victorian branch of the Australian Medical Association and the Medical Benevolent Association. I also formed the Italian, Greek and Chinese medical societies and was the inaugural president of the Italian Medical Society for 14 years. Many ethnic doctors feel isolated from their Australian peers because of the unusual demands of their ethnic patients. I have a particular interest, as chairman of the board of a home for Italian aged, in the special accommodation needs of ageing migrants. I was very proud to be honoured by both the Italian and Australian governments for my contribution to the health and welfare of the Italian community. Recently, I have been involved with Dr Tony Mariani, current president of the Italian Medical Society, in producing a 300-page book on preventive medicine, in English and Italian, to assist migrants in lifestyle choices. With continuing migration to Australia, there is still much to be done toward compassionate primary medical care. My family’s contribution gives me great pride.

George R Santoro AM, MB BS, FAMA

During the 20th century Australians have benefited immensely from improvements in their general health and life expectancy. Our average life span has increased by 25 years, and even in the century’s dying decade we managed to gain another two years!1 As with many success stories, there have been numerous contributors, but there is no doubt that basic medical research has played a prominent part. Indeed, the interplay between basic research and advances in medicine is succinctly captured by the phrase “from bench to bedside” or by the term “translational highway”2 — an autobahn for taking basic research advances and transferring these into clinical practice. The powerhouses of basic research in Australia are our universities and research institutes. Their financial underpinnings are the competitive grants provided by both government and non-government organisations. In 2002, for example, the National Health and Medical Research Council’s expenditure on health research and development was $276 million. Of this, the universities received $190 million (69%) and the medical research institutes received $74 million (27%).3 Since 1995, the Christmas issue of the Journal has regularly featured Australian medical research institutes, beginning with portraits of the Walter and Eliza Hall Institute in Melbourne and the John Curtin Institute of Medical Research in Canberra, and featuring most recently the Menzies Centre for Population Health Research in Hobart in 2001 (now the Menzies Research Institute). This year, we sought to explore a different avenue. In 1998, the then Minister for Health, Dr Michael Wooldridge, empowered a prominent committee chaired by Peter Wills, then Chairman of the Garvan Institute of Medical Research, Sydney, to review health and medical research in Australia and report on strategies for these efforts in the first decade of the 21st century. In its final report,4 the committee identified a number of issues including: the need to sustain and expand an effective health and medical research sector underpinned by innovative and high impact basic research; a greater need for research that contributes directly to the health of the people and the healthcare system; and the need for links between research and industry to capitalise on the potential commercialisation of research findings.4 In short, the report recommended an increased emphasis on “bench-to-bedside” research, focused on the health and economic wellbeing of the nation. To gain some perspective on the vitality of this research in Australian medical research institutes, we recently conducted a poll of institute directors (see Box). Their responses are given on the following pages. What inferences can we draw from this snapshot? Survey of Medical Research Institutes in Australia The directors of Australian medical research institutes were contacted in September 2003 and asked : “Most Australian medical research institutes have been operative for more than 25 years and the theme we wish to pursue is . . . what has come out of [name of your institute] that has been translated into population health or clinical practice; ie, what has made it from ‘bench to bedside’? We want you to restrict these to two major impacts.” Twenty-eight research institutes were approached and we accepted 22 submissions (Australian Capital Territory, 1; New South Wales, 5; Northern Territory, 1; Queensland, 2; South Australia, 1; Tasmania, 1; Victoria, 9; and Western Australia, 2). Firstly, it is apparent that “bench-to-bedside” research is alive and well in Australian medical research institutes, and is wide-ranging in its scope. It includes public health advances relevant to South-East Asian and Australian Indigenous communities, clinical advances in areas such as assisted reproduction and cancer, and improved treatments for chronic disorders, such as diabetes or visual impairment in older people. Secondly, this research is achieved by teamwork between clinician–scientists and scientists working together in a collegial spirit. Thirdly, and most importantly, it takes time. Finally, it is apparent that our research institutes are increasingly forging closer links with industry. However, there is one overriding message — that success in basic research cannot be solely developed from imposed priorities and schemes. Research is driven by human imagination, inquisitiveness, insight and a generous sprinkling of serendipity. For, as observed by the Nobel laureate Albert Szent-Gyorgi, “. . . research means going out into the unknown with the hope of finding something new to bring home. If you know in advance what you are going to do or even to find there, then it is not research at all: then it is only a kind of honorable occupation.”5 In short, basic research has two defining features: uncertainty and surprise.6 As long as these twin principles are treasured in our medical research institutes, meaningful “bench-to-bedside” research will continue to advance the practice of medicine. Australian Capital TerritoryEradication of smallpoxIn 1988 Frank Fenner of the John Curtin School, along with Donald A Henderson of the Johns Hopkins University School of Hygiene and Public Health and Isao Arita, Director of the Kumamoto National Hospital, Japan, were awarded the Japan Prize for Preventive Medicine in recognition of their international team effort in eliminating smallpox from the world. This feat is one of the greatest accomplishments of modern medical science. Fenner’s work at the John Curtin School on pox viruses (ectromelia, myxoma and vaccinia) through the 1950s, 60s and 70s had uniquely qualified him to lead the WHO smallpox eradication team which announced to the World Health Assembly in 1980 that the disease had been eradicated worldwide. Doherty and Zinkernagel with their Nobel prize medals. Discovery of MHC restriction In the early-to-mid 1970s, Peter Doherty and Rolf Zinkernagel, working on the response of mice to viruses discovered a major property of the immune system — major histocompatibility (MHC) restriction. In order for T lymphocytes to destroy cells infected by foreign invasion, their receptors must simultaneously recognise on the cell’s surface a complex of foreign antigen and a self molecule, one of the MHC antigens. Their discovery revolutionised our understanding of how the immune system works and won Doherty and Zinkernagel the 1996 Nobel Prize for Physiology or Medicine. MHC restriction has many clinical implications for organ transplantation and for the treatment of diseases involving the immune system. Peter Jeffrey, Public Affairs Manager, JCSMR Western AustraliaFolate supplementationPerhaps the longest established and best known research from the Institute that has had an enduring impact on health is the case–control study of neural tube defects conducted in Western Australia in the early 1980s by Carol Bower and Fiona Stanley.7 This showed that maternal dietary and supplemental folate intake around the time of conception protected against neural tube defects in the offspring. Further international studies showed that 70% of neural tube defects could be prevented by folate intake. Based on these findings, the Institute, in collaboration with the WA Health Department, embarked on a health promotion project in 1992, the first in Australia and one of the first in the world. There was an increase to 30% of women taking folic acid supplements periconceptionally, and a 29% fall in neural tube defects in WA. FunhalerA more recent contribution from the Institute addresses a major problem for children with asthma, who typically show poor adherence to prescribed frequency and technique of inhaled medication. The Funhaler (Visiomed Group Ltd, Australia), invented by the Institute’s Paul Watt, is a small volume spacer device incorporating an incentive toy module. A pilot study showed that the Funhaler reduced problems in giving children asthma medication, improved child and parental adherence to the medication regimen and created a more positive attitude towards treatment.8 A recent grant from the US National Institutes of Health (US$700 000) supports further study of the device, which is due to be launched throughout Australia by the end of 2003. Fiona Stanley, Director, TICHR AlphaCor artificial corneaStarting in 1990, polymer chemistry research by Traian Chirila and Celia Hicks resulted in the world’s first soft artificial cornea, now marketed by the WA company, Argus Biomedical Pty Ltd. Hundreds of novel polymers were formulated and tested for physical characteristics, including optical clarity, tensile strength and elasticity as well as biocompatibility in tissue culture and after implantation in animals. Novel chemical methods were developed to create a porous outer rim into which human cells would grow and establish a firm bond. This porous outer rim was co-polymerised with the same polymer materials under differential conditions to create an optically clear centre via an interpenetrating network. Human trials of the novel artificial cornea started in 19979 and CE-Mark European approval was followed in 2002 by FDA approval in the United States. Laser-induced surgery and central retinal vein blockageIn the early 1990s, Ian McAllister, Ian Constable and Dao-Yi Yu began developing a method to bypass the outflow from blocked retinal venous circulation, which commonly causes rapid loss of vision in older people with hypertension. After experiments in animals, Ian McAllister realised that a very powerful laser was required to break the structural barrier (called Bruch’s membrane) between the retinal and overlying choroidal circulation. In addition, rupture of the obstructed retinal vein was required to create an anastomosis between the two circulations and this was best achieved with a Yag cutting laser.10 Further experiments and observations identified a group of patients with incomplete central retinal vein occlusion for trials. Case–control studies showed that a successful shunt could be achieved in about two-thirds of the target population, and that visual acuity markedly improved as a result. This procedure has been taken up in a number of centres around the world. A randomised controlled clinical trial is under way in four Australian locations. Ian J Constable, Director, Lions Eye Institute VictoriaMobilising myelopoiesisBasic research at WEHI and LICR has had a profound impact on cancer treatment. Don Metcalf’s tenacious research at WEHI over three decades transformed understanding of blood cell production and haemopoietic diseases. He and his colleagues, including Nic Nicola (WEHI) and Tony Burgess (then at WEHI, later at LICR), purified two of the hormones involved in white blood cell production. Known as colony-stimulating factors (CSFs), these hormones (GM-CSF and G-CSF) accelerate white blood cell regeneration in patients undergoing chemotherapy or radiotherapy and have helped treat over 3.5 million patients worldwide.11 During the first clinical trials of CSFs at the Royal Melbourne Hospital (directed by George Morstyn, LICR), Uli Duhrsen (WEHI) and the team made the unexpected observation that CSFs mobilise blood stem cells into the bloodstream, a discovery which led to bone marrow transplantation being replaced by blood stem cell therapy.12 The CSFs are now finding new applications in in-vitro fertilisation and treatment of Crohn’s disease. Suppressing autoimmunityIan R Mackay, Head of the Clinical Research Unit at WEHI, formally defined the concept and key features of autoimmune diseases in a book co-authored by Frank Macfarlane Burnet in 1963.13 Despite considerable scepticism about the concept, Mackay pioneered the treatment of autoimmune (lupoid) hepatitis with the immunosuppressive drugs, azathioprine and prednisolone. This approach continues to be the gold-standard for immunosuppression and has saved the lives of countless patients with autoimmune hepatitis and other autoimmune diseases. Suzanne Cory, Director, WEHI Antony W Burgess, Director, LICR Concepts and conceptionAlan Trounson, together with Carl Wood and his colleagues from Monash University Department of Obstetrics and Gynaecology, pioneered studies of in-vitro fertilisation and other reproductive technologies for the management of human infertility. Building on the work of Edwards and Steptoe in the UK, they integrated ovarian stimulation into the routine IVF protocol,14 providing multiple oocytes for fertilisation. When combined with the capacity to freeze embryos these technologies contributed to improved IVF success rates.15 The Monash group also developed the conditions necessary for oocyte donation to become a routine procedure and extended the capacity for IVF to women without ovaries.16 The ability to biopsy a blastomere from an embryo17 and determine its genetic status18 has enabled preimplantation genetic diagnosis to be successfully performed for fertile couples with a history of genetically based disease. Y Chromosomal defectsIn 40% of infertile men the cause of the spermatogenic defect is unknown, but the observation of small Y chromosomes in some of these men suggests a genetic cause. Scientists from the Institute, together with colleagues at Charles Drew University Los Angeles, further defined the deleted regions of the Y chromosome causing azoospermia or severely reduced sperm counts.19 These observations, together with others, showed that some Y chromosome deletions did not completely prevent sperm production, raising the possibility of using intracytoplasmic sperm injection (ICSI). The Institute’s scientists, together with colleagues at Monash IVF, demonstrated transmission of Y chromosome deletions from father to son by the use of ICSI.20 They also developed a routine clinical test to screen men with sperm counts less than 5 million/mL, enabling genetic counselling for couples where the man has a Y chromosomal deletion. Current estimates indicate that 3%–8% of men with idiopathic infertility have a Y chromosomal disorder. David M de Kretser, Director, MIRD Murray Esler and Gavin Lambert performing noradrenaline spillover measurements to quantify sympathetic nervous system activity in a patient during head-up tilting. Noradrenaline in heart failureIn the 1980s scientists led by Murray Esler developed a unique radiotracer technique for neurochemical quantification of sympathetic nervous system activity and measurement of the spillover of the sympathetic neurotransmitter, noradrenaline, from individual organs. With this advance they were able to isolate neurophysiological mechanisms in heart failure. At that time the accepted view was that the failing heart was functionally and anatomically sympathetically denervated and β-adrenergic blocking drugs were said to be contraindicated. An innovative series of research projects at the Baker showed that in many patients with heart failure the sympathetic nerves of the heart were, in reality, stimulated at an exceedingly high level.24 A prospective study of patients with severe heart failure showed that the cardiac sympathetic tone was the strongest predictor of death.25 This research provided the pathophysiological evidence for the use of β-adrenergic blocking drugs in cardiac failure. The renin–angiotensin system (RAS) in diabetesOver the last 15 years it has become apparent that blockade of the RAS plays a central role in diabetic nephropathy, the leading cause of endstage renal disease in the developed world. Basic research, including that of Mark Cooper’s group, showed that, despite RAS suppression, intervention with angiotensin-converting enzyme inhibitors or angiotension II antagonists could reduce the functional and structural manifestations of diabetic nephropathy.26-30 Over the last decade the underlying molecular and cellular pathways whereby angiotensin II promotes renal injury have been unravelled and may provide new targets for further renoprotection. This basic research was the impetus for three landmark studies exploring blockade of the RAS in type 2 diabetic patients with incipient and overt renal disease. More recently, research has linked the RAS to other diabetic complications involving the retina, heart and vascular system. Multicentre clinical trials are now investigating the benefits of interrupting the RAS for diabetic complications at these extrarenal sites. Garry Jennings, Director, BHRI Linking research with health outcomesOver the past 15 years the Institute’s major achievements have involved the development of appropriate and sustainable technologies to prevent or control infectious diseases in resource-poor regions. Immunisation programsIn the early 1990s the Institute pioneered the introduction of routine hepatitis B immunisation in Lombok, Indonesia, and demonstrated the feasibility of implementing universal hepatitis B vaccination without damaging other vaccine programs. This was the first demonstration of the usefulness of hepatitis B vaccination in a developing country’s immunisation program,21 and contributed to the models used now by Global Alliance for Vaccines and Immunization and the Gates Foundation to support universal hepatitis B immunisation in the world’s 70 poorest countries. Harm reductionSince 1989 the Institute has championed the application of harm-reduction approaches to mitigate the impact of HIV and hepatitis C infection, and has played a major role in driving the acceptance and implementation of these approaches, especially in South-East Asia.22 Cheap sustainable diagnosticsThe Institute has led the development of cheap and sustainable CD4 cell assays23 to support the widespread implementation of antiretroviral drug therapy to treat HIV infection in developing nations. It has also developed, and is now commercialising, new technologies for the diagnosis of hepatitis E and hepatitis A infections. Steven L Wesselingh, Director, Burnet Institute Cellular therapiesThe stem cell biology program at Peter Mac, a major node of the National Stem Cell Centre, is studying fundamental properties of stem cells in adult tissues and using their unique biological properties in novel cellular therapies. The stem cell facility at Peter Mac has good manufacturing process (GMP) accreditation and is licensed by the Therapeutic Goods Administration. It has been used for stem cell therapy in several patient groups, including Australia’s first clinical trial with ex-vivo expanded haematopoietic stem and progenitor cells for breast cancer patients after repetitive high-dose chemotherapy. A significant reduction in neutropenia and platelet transfusion requirements was demonstrated in these patients. The Peter Mac propagated mesenchymal stem cells (MSC) to treat a non-union fracture of the ulna. This pioneering proof-of-principle procedure was the first use of prospectively isolated autologous MSC in a clinical setting. Characterising cancerIn about 5% of cancer patients, extensive clinical workup fails to reveal the primary carcinoma. Researchers at Peter Mac are using microarray-based gene expression profiling, a method of molecular diagnostics that may assist in diagnosing and treating this kind of cancer. Metastatic tumours have been shown to maintain gene expression patterns that are consistent with tissue of origin. Clinically plausible prediction of the origin of the metastatic tumour has been made in numerous cases of carcinoma of unknown primary, suggesting that the test will facilitate clinical management. David Bowtell, Director of Research Division, PMCI In-situ gene expression In the 1980s, researchers John Coghlan, Jennifer Penschow, Geoffrey Tregear and Hugh Niall developed the technique of hybridisation histochemistry using oligonucleotides for detection of in-situ gene expression in tissues.31,32 The Institute holds patents on this technique, which is now widely used for the diagnosis of viral and infectious diseases and in research. Fortifying bone with ForteoA peptide comprising part of human parathyroid hormone (PTH[1-34]) was recently approved by the US Federal Drug Administration for the treatment of osteoporosis. Marketed by Eli Lilly & Co as Forteo, or teriparatide, it is the first approved agent for the treatment of osteoporosis that stimulates new bone formation. Hugh Niall and Geoffrey Tregear played a pivotal role in the discovery and development of PTH(1-34). Working initially at the Massachusetts General Hospital, Boston, and then at the Howard Florey Institute in the 1970s, they were the first in the world to isolate and sequence parathyroid hormone.33 They subsequently synthesised parathyroid hormone fragments and established that the amino terminal 1–34 region of the sequence had full biological activity.34 Forteo is the peptide originally designed and synthesised by Tregear. Frederick A O Mendelsohn, Director, HFI InhibinA major focus of the Institute has been reproductive endocrinology, particularly the relationship between the hypothalamus, anterior pituitary and the gonads. The most significant outcome of this research was the first isolation, purification and characterisation of a new gonadal hormone, inhibin. Inhibin acts as a feedback signal regulating the secretion of follicle stimulating hormone (FSH) by the pituitary. This achievement was the result of collaboration between scientists as Prince Henry's, Monash University, St Vincent's Institute of Medical Research and La Trobe University. The major impact on clinical practice came with the finding that concentrations of inhibin were markedly elevated in the serum of patients with ovarian granulosa cell tumours or mucinous epithelial cancers.35-36 The marker commonly used for ovarian cancer diagnosis and monitoring, CA125, is not especially helpful in these two types of ovarian tumour. Work at the Institute has shown that combining inhibin and CA125 measurement can diagnose 95% of ovarian cancers.37-39 Inhibin measurement is now standard practice in following up patients with ovarian granulosa cell tumours. Research on inhibin has also clarified the mechanisms involved in the hormonal changes in women as they approach the menopause, and has indirectly led to the realisation that measurements of FSH and oestrogen are of little value in the assessment of perimenopausal women. Henry G Burger, Emeritus Director, PHIMR Automating amino-acid sequencesSt Vincent’s Institute has a long heritage of studying protein structure and function. The founding director, Pehr Edman (1957–1972), discovered how to sequence the order of amino acids within proteins and ways to automate this process.40 Protein sequencing enabled characterisation of proteins for diagnostic (eg, radioimmunoassay) and therapeutic use, as well as the unravelling of protein mutations in genetic diseases such as phenylketonuria and thalassaemia. Salmon calcitonin, for example, was sequenced using the Beckman commercial version of Edman’s automated sequencer by Hugh Niall (who had been a student of Edman) and then synthesised by Sandoz (now Novartis) for widespread therapeutic use in Paget’s disease. Obtaining amino acid sequence using Edman’s technology has been a necessary step in cloning many recombinant molecules used as drugs, such as growth hormone, tissue plasminogen activator and erythropoietin. Calcium and cancerJack Martin and his team discovered parathyroid hormone-related protein (PTHrP), a hormone secreted by cancers that causes the syndrome known as humoral hypercalcaemia of malignancy41 and contributes to bone metastasis. This discovery established a molecular explanation for this common clinical syndrome, and led to its accurate diagnosis by radioimmunoassay and immunohistochemistry for PTHrP. A humanised monoclonal antibody against PTHrP is now in Phase III clinical trials, having been developed by Chugai as a result of proof of principle supplied by this Institute’s research. Protein kinases as drug targetsBruce Kemp has made pivotal discoveries about the structure and function of protein kinases, particularly the amino-acid sequences used by kinases to interact with their substrates. Most recently these have been applied to adenosine monophosphate-activated protein kinase (AMPK), which Kemp and colleagues purified and sequenced.42 This is an enzyme involved in fuel metabolism that is activated by drugs that increase insulin sensitivity, including metformin and the glitazones.43 The Institute’s intellectual property in this area has been licensed to Mercury Therapeutics and Aventis, who are searching for new drugs that activate AMPK. The pharmaceutical industry has the protein kinases as one of its three top targets for drug development. Thomas W H Kay, Director, SVIMR TasmaniaSIDSBy the 1980s sudden infant death syndrome (SIDS) had become the commonest cause of death in postneonatal infants in Australia and some other developed countries. However, little was known about its causes or prevention. As early as 1944, it had been proposed that placing a baby prone (on the abdomen) might increase risk.44 Despite the gradual accumulation of retrospective evidence from case–control studies of an association between prone position and SIDS,45,46 concerns about recall bias (particularly at a time when many hospitals advised prone sleeping) limited the acceptance of sleeping position as a cause. Prospective data were needed. The Menzies team reported the first prospective evidence, obtained from the Tasmanian infant cohort, in the Lancet in 1991,47 confirming a higher risk for infants sleeping in the prone position. This research work led to a rapid policy response. A national meeting in July 1991 provided a new recommendation that healthy infants should not sleep prone. SIDSAustralia incorporated the finding into health education advice to new parents. In Australia the number of SIDS deaths declined from 507 in 1990 to 101 in 2001 (rate, 1.93 to 0.41) — a fall of about 80%.48,49 Similar successful campaigns occurred internationally. Subsequent research at the Menzies Institute has continued to inform international policy and contributed to a continued decline in SIDS deaths.50 Terence Dwyer, Director, MRI South AustraliaCause and prevention of discitis after discographyFor more than 50 years discography has been used to confirm a diagnosis of internal disc disruption and the presence of normal discs adjacent to the level of an intended spinal fusion. Discitis following discography is a serious complication and, although the presence of infection is occasionally confirmed, numerous authors have suggested that it is caused by a chemical or aseptic process. Fraser, Osti and Vernon-Roberts showed that the injection of a single Staphylococcus epidermidis into an intervertebral disc in a sheep was sufficient to produce radiographic, macroscopic and histological discitis, but that organisms could not be isolated from the lesion after 6 weeks.51 They found also that in 7 patients with discitis no bacteria were isolated from the 3 biopsied 6 weeks after discography but bacteria were isolated in 3 of the 4 biopsied within 6 weeks. These findings indicated that discitis after discography is initiated by needle-tip infection, but the causative bacteria are rapidly eliminated after the inflammatory destruction of the plate of bone separating the avascular disc from the richly vascular bone marrow of the vertebral body. Changing from a single needle lacking a stilette to stiletted needles and a two-needle technique reduced the incidence of discitis from 2.7% to 0.7%. Combining the two-needle technique with a single prophylactic dose of broad spectrum antibiotic effectively prevented discitis in a follow-up study. Barrie Vernon-Roberts, Director, Institute of Medical and Veterinary Science QueenslandThe Institute for Molecular Bioscience was formed in 2000 by the amalgamation of the Centre for Molecular and Cellular Biology (which focused on mammalian cell and developmental biology) and the Centre for Drug Design and Development (which focused on pharmaceutical development), both at the University of Queensland. Inflammation and painIn the past 6 years researchers at the IMB have discovered three candidate molecules to treat rheumatoid arthritis, chronic pain and neuropathic pain. The first orally active small molecule C5a-receptor antagonist (an anti-inflammatory drug which blocks an important component of the complement system) was designed and developed by David Fairlie and Steve Taylor and has progressed to Phase II clinical trials for rheumatoid arthritis patients.52 The molecule was licensed to the spin-off company Promics to undertake full development. Model of the inflammatory protein C5a and a small molecule C5a receptor antagonist. Antagonist (yellow) mimics a key turn conformation (red) in human C5a (white). A molecule, CVID (a conotoxin from Conus catus, a fish-eating marine cone snail on the Great Barrier Reef), which blocks N-type voltage-gated calcium channels, was discovered by Paul Alewood and Richard Lewis.53 The molecule, which has the potential to alleviate neuropathic pain, was licensed to AMRAD and Phase I/II clinical trials have been successfully completed in cancer patients with pain refractive to morphine treatment. Another molecule from cone snails, MrIA (a conotoxin from Conus marmoreus), was discovered by the Lewis and Alewood team.54 It is a potent blocker in vitro and in vivo of the reuptake of noradrenaline by the noradrenaline transporter and has shown excellent efficacy in preventing chronic pain in rats. It is now under pre-clinical development by the spin-off company Xenome. John J S Mattick, Director, IMB Controlling dengue in VietnamBrian Kay, head of mosquito control at QIMR, realised that the copepod predator of young mosquito larvae, Mesocyclops, had enormous potential for dengue fever control in Asia. Mesocyclops inhabit freshwater ponds and lagoons, but, from surveys in Vietnam, were also found in water storage containers (eg, concrete tanks, jars, wells).55 Brian Kay inspecting water storage tanks in central Vietnam. In 1989, Kay began working with Vu Sinh Nam from the National Institute of Hygiene and Epidemiology, Hanoi, to develop community-driven programs for dengue vector control, using new sampling technologies, key container prioritisation and Mesocyclops. Nine years later they reported the first eradication of Aedes aegypti without insecticide, in the 400 households of Phan Boi.56 By 2002 the program had expanded to 6 communes (11 675 households) in 3 other provinces.57 At the project’s completion, local leaders committed themselves to maintaining and expanding dengue control, supported by the national dengue budget. To date 40 of 46 communes (93 111 households and 386 544 people) are free of Ae. aegypti, and all 46 have no further reports of dengue and dengue haemorrhagic fever. Vaccine to prevent rheumatic feverMichael Good, Michael Batzloff, Colleen Olive and Sri Sriprakash have been developing a vaccine to prevent group A streptococcus (GAS, Streptococcus pyogenes) infection and its associated diseases such as rheumatic fever. GAS is a serious problem in developing countries58 and in Indigenous communities of developed countries including Australia.59 The vaccine is based on a conformational peptide antigen from the conserved region of the M-protein.60 In preclinical studies the peptide was immunogenic in inbred mice. In outbred mice, the peptide was conjugated to the carrier protein, diphtheria toxoid, and formulated with the human-compatible adjuvant alum. Mice immunised with this formulation had significantly enhanced survival following challenge with several GAS serotypes.61 We have used our peptide in combination with several experimental intranasal adjuvants in outbred mice to induce a local mucosal immunoglobulin-A response capable of significantly reducing GAS colonisation of the throat following intranasal GAS challenge. We are now planning to commence the “Good Manufacturing Process” production of our peptide-conjugate/alum formulation for Phase I human clinical trials. Michael F Good, Director, QIMR Brian Kay, Director, Australian Centre for International and Tropical Health and Nutrition Northern TerritoryScabies and skin health: Scabies and complicating streptococcal pyoderma are major causes of morbidity in Indigenous communities in central and northern Australia. The templates for communities to develop their own skin-health programs have resulted from a mix of clinical, public health and laboratory initiatives leading to evidence-based best practice. The first molecular genetics studies ever undertaken on scabies mites were specifically directed at determining whether current dog and human scabies infections are separate epidemics.62 This research enabled the focus of programs to be on prevention and treatment of scabies in children — rather than targeting the dogs. Community-based healthy skin programs have resulted in large decreases in both scabies and streptococcal pyoderma, and current initiatives are directed at sustaining the programs.63,64 Reversing Indigenous renal failureAboriginal people in many remote parts of Australia are experiencing an epidemic of diabetes, cardiovascular disease and end-stage renal disease. The introduction of a systematic pharmacotherapy program over several years on the Tiwi Islands (NT) addressing albuminuria, hypertension, dyslipidaemia and diabetes was associated with a marked fall in rates of renal failure and natural death, reversing a consistent historical trend for both to increase. Rates of the combined endpoints of renal failure and natural death per 100 person-years were 2.9 for the treatment group and 4.8 for the control group.65 Current challenges are how to resource and sustain such activities within the day-to-day clinic activities. Improving dietary quality in remote Aboriginal communities: Poor nutrition in remote Aboriginal communities is linked to high rates of obesity, diabetes and cardiovascular disease. Two well evaluated community-based intervention programs to improve the quality of diets through improved quality of foods in the communities’ local stores have been accompanied by a marked reduction in risk markers for vascular disease across the adult populations. The focus of the Minjilang Nutrition Program66 and the Looma Healthy Lifestyle Program67 has been to reduce the high consumption of sugar and fat, and to increase consumption of fresh fruit and vegetables. Kerin O’Dea, Director Menzies School of Health Research New South WalesDeveloping microsurgeryEarl Owen returned to Australia in 1967 from postgraduate studies in the UK where he had been involved in developing surgical techniques for whole-organ transplantations. An appointment to the Children’s Medical Research Institute from 1967–1970 as the James Fairfax Surgical Research Fellow provided him with the opportunity and resources to develop his expanding interests in the field of microsurgery. This had evolved from his appreciation of the importance of surgical repair of blood vessels and nerves in transplant survival.68 He designed or modified a range of instruments and magnifying devices which facilitated these procedures. His enthusiasm and skill in promoting the advantages of microsurgical techniques led to their rapid widespread adoption in Australia and internationally, particularly in the disciplines of plastic and reconstructive surgery. Gene therapyIn 1995 the Institute and the Children’s Hospital Westmead created a Gene Therapy Research Unit, based on a longstanding interest within the Institute in the use of retroviral gene vectors in biomedical research. Directed by Dr Ian Alexander, the unit has established a gene-vector production unit which is unique in Australia. In March 2002 in conjunction with the Hospital Necker in Paris, this unit and the Immunology Department of the Hospital treated a child with X-linked severe combined immunodeficiency by transducing the infant’s haemopoetic stem cells with a normal copy of the mutant gamma-c subunit of the interleukin receptors.69 This has resulted in a successful reconstitution of the T cell compartment and the patient remains free of infection 18 months later. While gene therapy is far from being routine clinical practice, there is no doubt that it will play a major role in future therapy of a range of diseases from single gene defects to cancer. Peter B Rowe, Director, CMRI l-Arginine and vascular adhesionResearch by Mark Adams, David Celermajer and Wendy Jessup, in a collaboration between the Institute and the Department of Cardiology at Royal Prince Alfred Hospital, found that l-arginine reduces human monocyte adhesion to vascular endothelium and endothelial expression of cell adhesion molecules.70 Subsequent clinical studies showed that oral l-arginine improves endothelium-dependent dilatation and reduces monocyte adhesion to endothelial cells in young men with coronary artery disease.71 This research has translated into the clinical use of oral l-arginine as a treatment in patients with intractable angina. A surrogate marker for advanced atherosclerosisLen Kritharides and co-investigators are developing non-invasive tests for the presence of vascular disease. Using samples obtained from patients undergoing bypass surgery and coronary angiography, they found that coronary arteries release a number of molecules into the blood stream. One of these is haptoglobin, a protein not normally measured in patients with atherosclerosis,72 but which is present at elevated levels in the circulation in patients with advanced coronary disease. This non-invasive test has the potential to identify the presence of vulnerable atherosclerotic plaques before their rupture. Philip J Barter, Director, Heart Research Institute Diabetes and obesityIn 1973 a small team led by Les Lazarus at the Garvan developed the low-dose intravenous insulin infusion method to treat a major complication of diabetes, ketoacidosis.73 This has saved the lives of innumerable Australians and has been taken up around the world. Over the past 20 years, the diabetes research team, including Ted Kraegen, Lesley Campbell and Don Chisholm, has made major contributions to our understanding of the impact of lifestyle on type 2 diabetes. They were one of the first groups to show that exercise training improves whole-body insulin sensitivity.74 They were also one of the first to unravel the impact of dietary lipids on insulin sensitivity75,76 and to show that fat deposition in specific regions plays a key role in the development of insulin resistance.77 These findings have made major contributions to the management of this extremely complex and common human disease. Breast cancerGarvan scientists led by Professor Rob Sutherland carried out an extensive series of studies which helped elucidate the mode of action of the breast cancer drug, tamoxifen.78 Garvan scientists pioneered research demonstrating the role of the cell cycle regulatory protein cyclin D1 in development and progression of breast cancer.79 Recently, this research was judged by the international ISI Essential Science Indicators as one of the top 20 advances (and most cited papers) in breast cancer in the past decade. Further work has confirmed this molecule as an adverse prognostic marker and therapeutic target in breast cancer. John Shine, Executive Director, GIMR Established 3 years ago, the ANZAC Research Institute is one of Australia’s youngest medical research institutes, located on the campus of Concord Hospital and affiliated with the University of Sydney. Its primary research focus is on ageing. Hepatic pseudocapillarisation and cardiovascular diseaseDavid Le Couteur’s observations that ageing is accompanied by obliteration of endothelial pores that allow the liver to metabolise circulating macromolecules80 has led him to a novel approach to examining the liver and postprandial hyperlipidaemia as pivotal elements linking ageing and cardiovascular disease. Genetics of neurodegenerationGarth Nicholson’s discovery of the gene for hereditary sensory neuropathy81 provides an elegant and unique neurogenetic model for classical sensory neuropathies of leprosy and diabetes which both feature painless damage to joints and extremities. Hormonal male contraceptionRecently published work by David Handelsman first proved the efficacy of a hormonal male contraceptive using a prototype combination depot.82 This proof of principle has been adopted by a collaboration between two major multinational pharmaceutical companies, Organon and Schering, to develop a marketable product. David J Handelsman, Director, ARI New antiviral strategies for herpesThe herpes virus periodically reactivates from dormancy and is transported down sensory nerves to skin causing genital lesions. WMI virologists including Tony Cunningham, Russell Diefenbach and Monica Miranda first showed that the virus is transported down these nerves as two components, the inner core and outer (glyco) proteins, subsequently assembling at the nerve terminus. Transport along microtubules (the “railway tracks” of the nerve) was found to be mediated by the interaction of a virus core protein (US11) with a cellular protein, kinesin.83,84 The exact regions of the interaction were mapped and patented as a drug target. A collaboration with Pharmacia is now seeking small molecule inhibitors of this interaction as a new drug strategy for herpes. First success in herpes simplex vaccinesThe first success in vaccine development for genital herpes by GlaxoSmithKline (GSK) has just been reported. This development was partly guided by, and depended upon, key discoveries by WMI scientists, Tony Cunningham and Zorka Mikloska, who showed that the immune control of herpes lesions was mediated by an early influx of CD4 and later CD8 lymphocytes. Both cell populations secrete interferon gamma, which controls viral transmission from nerve to skin and viral mechanisms for evading immune control. The key viral stimulant for CD4 lymphocytes was glycoprotein D (gD).85 The GSK vaccine incorporated gD and an adjuvant to stimulate these mechanisms. This proved 75% successful.86 Refined advice for those at genetic risk of melanomaCancer researchers at WMI, led by Richard Kefford and Graham Mann, have been unravelling melanoma susceptibility genes. They confirmed that the major melanoma gene, CDKN2A (“p16”), is located on chromosome 9p, and went on to perform the largest analysis of mutations in this gene in 132 Australian families.87 WMI researcher Helen Rizos and her team have established the importance of p14ARF, an alternate product of the CDKN2A gene, in the genesis of melanoma, and have recently described a number of highly novel functions of this molecule in regulating the cell cycle at several key points.88,89 Collaborative research between WMI and Nicholas Hayward of the Queensland Institute of Medical Research, together with the members of the international Melanoma Genetics Consortium, has enabled this genetic information to be translated into clinical guidelines for managing those at high risk of developing melanoma, including the use of genetic testing.90,91 Anthony Cunningham, Director, WMI

Martin B Van Der Weyden

Big clinical breakthroughs begin with basic science The 2003 Nobel Prize in Medicine or Physiology was awarded to a chemist, Paul Lauterbur (US), and a physicist, Peter Mansfield (UK), for their discoveries concerning magnetic resonance imaging,1 while the Nobel Prize in Chemistry was awarded to two medical graduates: Peter Agre (US) for the discovery of water channels and Roderick MacKinnon (US) for structural and mechanistic studies of ion channels.1 The prizes were awarded for seminal discoveries that have had major impacts on medicine and biology. The fascinating story of these discoveries illustrates the value of pursuing basic science research and how breakthroughs at a fundamental level can lead to revolutionary advances in medical care. The Nobel Prize in MedicineBackground to magnetic resonance imagingMany atomic nuclei possess the property of spin. When placed in a magnetic field they wobble (precess) on their axis, like a spinning top near the end of its twirl. The precession frequency is directly proportional to the strength of the magnetic field in which the nuclei are immersed, and lies in the frequency range of radio waves. When radio waves at the same frequency as the nuclear precession are applied to a sample, resonance energy transfer takes place and the nuclei become “excited”. Hence, radio waves can be used to detect (observe) atomic nuclei based on their characteristic absorption frequency. This discovery by the groups of Bloch and Purcell in the US led to their award of the Nobel Prize in Physics in 1952. Nuclear magnetic resonance (NMR) is extraordinarily useful in biology and medicine for two reasons. Firstly, because the nuclear spins are observed with radio waves, biological samples can be studied in a non-invasive and non-destructive way. Radio wave photons have about 1/1011 of the energy of x-ray photons, so they produce no radiation damage to biological samples. Secondly, the absorption frequency is precisely determined by the local magnetic field of the nucleus in an atom in a molecule. Since it is possible to measure changes in this field to better than 0.01 parts per million, chemical compounds are able to be identified even in complex mixtures. The incredible precision with which one can determine the frequency of nuclear resonance, and hence the local magnetic field experienced by a nucleus, means that we can (for example) distinguish a hydrogen atom in a methyl group of an alanine side chain in a protein from one in a methyl group of valine in the same protein. The Nobel Prize for Chemistry was awarded to Richard Ernst (1991) and Kurt Wüthrich (2002) for the development of techniques to use NMR to determine protein structure. Remarkably, this is possible within living cells; so metabolism can be followed in real time in a totally non-invasive way. Both of these features make NMR ideal for medical imaging. The discovery of magnetic resonance imagingIn the early 1970s, Paul Lauterbur (at the State University of New York at Stony Brook, US) surmised that if one could vary the magnetic field across a sample in a defined way then it should be possible, by measuring the frequency at which a given ensemble of nuclei were precessing, to determine the exact location of the ensemble in the sample. Lauterbur’s first images were of a “phantom sample” of two tubes of water located within a larger tube of heavy water (ie, water in which the hydrogen atoms are replaced with deuterium atoms).2 Heavy water is chemically almost identical to water and to the eye is indistinguishable. But deuterium nuclei are very different from hydrogen nuclei, so they give no signal when radio waves at the frequency absorbed by hydrogen are applied. By applying a graded magnetic field across the entire sample, Lauterbur reconstructed an accurate cross-sectional image of the two water-filled tubes (Box 1a). At the time this seemed a rather esoteric experiment, but it was a wonderful model to use for the human body, which is essentially a series of water-filled tubes (eg, arteries) and containers (eg, organs) located within a larger water-filled tube (ie, the body walls). Lauterbur’s water-filled tubes were geometrically simple, making it relatively easy to solve the mathematics required to reconstruct the images from the radiofrequency output. Although Peter Mansfield (at the University of Nottingham, UK) was working on a different physical system, it was he who was responsible for sorting out the complicated mathematics required to derive images rapidly from NMR spectrometers, thereby making magnetic resonance imaging a feasible clinical application. He also developed the technique of very fast gradient variations (so called echo-planar scanning) that enabled very rapid imaging.3 The journey from the first images of tubes of water to the installation of the first magnetic resonance imaging (MRI) scanner in a hospital required a huge amount of research and development both in the private and public sector, but it only took about 10 years. This involved mathematicians, physicists, engineers, computer scientists, biomedical scientists and medical practitioners in one of the best modern examples of “translational research”. It is estimated that in 2002 about 60 million MRI examinations were performed throughout the world. MRI has had a major impact on many aspects of clinical practice; probably most notably in neurology (Box 1b). The Nobel Prize in ChemistryBackground to water and ion transport in the bodyAll cells, from bacteria to plants and animals, are surrounded by a lipid membrane that forms a barrier between the inside of the cell (where most of the important events such as gene transcription and metabolism take place) and the extracellular environment. The maintenance of a stable intracellular environment is crucial for cell survival. The first barrier of defence is the lipid membrane, which is largely impermeable to water and water soluble substances, such as ions. Equally important, though, is the ability of cells to interact with the outside world; to respond to stresses imposed from the outside and to communicate with other cells. This is achieved by having proteins embedded in the lipid membrane that can selectively allow the passage of water or ions into or out of the cell. Discovery of aquaporinsWe now know that channels that permit the selective flow of water across cell membranes (aquaporins) are present in almost all cells, but they were only definitively identified 15 years ago. Why did it take so long for them to be discovered? In a sense it was because they are so difficult to measure and because they are so common. Often the easiest way to identify something is to compare two similar objects (in this case, cells) and then determine what it is that is different between them. This of course was not possible for water channels, as almost all cells have them. In the late 1980s, Peter Agre, while working on the rhesus blood group antigens at Johns Hopkins University, US, serendipitously discovered a new membrane protein that he called CHIP28 (channel integral membrane protein of molecular weight 28k). At the time he had no idea what it did.4 Previously and independently, Gheorghe Benga and his group in Romania5 had shown that the water transport inhibitor p-chloromercuribenzoate is selectively bound to a protein in red blood cell membranes. Subsequent studies showed that this was a glycosylated form of CHIP28. After extensive analysis of the CHIP28 protein Agre’s group recognised that it must form a channel in the red blood cell membrane. The crucial experiment they performed was to over-express the new protein in another cell type (the Xenopus oocyte); they found that the cells became much more permeable to water.6 Since then, Agre and colleagues have shown that there is a whole family of genetically related aquaporins in almost every cell type,7 with some also permeable to glycerol and urea. In addition to all fluid transporting epithelia, one obvious place where water channels serve a crucial function is in the kidney, where they permit the reabsorption of hundreds of litres of water that pass through the renal glomeruli each day.7 Discovering the channels was one thing, but how do they work? How can these channels allow the passage of water at a very high rate but not allow the passage of hydrated protons (ie, hydronium ions, H3O+)? This question was answered by Agre in collaboration with Fujiyoshi’s group in Kyoto and Engel’s group in Basel when they solved the structure of aquaporin-1 using electron microscopy (Box 2, a,b).8 Structural basis of ion selectivity in potassium channelsIn contrast to water channels, those that selectively allow the transmembrane flux of ions, such as sodium, potassium or calcium, were first implied in a functional assay and theoretical simulation over 60 years ago, and genes encoding for ion channels were first cloned over 20 years ago.9 We now know that there are hundreds of different ion channels in human cells. Despite extensive analysis of ion channel function, one of the most intriguing conundrums has been how these proteins allow the selective passage of one type of ion at very high rates, while preventing the passage of all others. In the mid 1990s, after electrophysiological measurements combined with molecular biological manipulations of ion channel proteins initially made in Christopher Miller’s laboratory and later in his own laboratory at Harvard University, Roderick MacKinnon realised that the only way to answer this question was to determine the structure of an ion channel using x-ray crystallography. Determining the structure of membrane proteins is extraordinarily difficult, and many people suspected it would not be possible for an ion channel. However, in 1998, MacKinnon and his team (having moved to Rockefeller University) succeeded in crystallising the bacterial potassium channel, KcsA;10 and, just as they had hoped, the structure provided the answer to the riddle of how potassium channels permit the selective passage of potassium ions at a high rate (Box 2, c,d). Furthermore, the combination of x-ray crystallography, electrical measurements and mathematical simulations enabled them to make fundamental predictions about how the channels select ions and open and close to regulate their passage.11 The selectivity of ion channels and the exquisite control of their opening and closing is central to the role they play, for example, in neurotransmission and controlling the heart beat. Indeed, recently it has been shown that even subtle mutations in the genes that encode ion-channel proteins are a potent cause of diseases including epilepsy and cardiac arrhythmias.12 The meaning of the PrizeThe stories behind the discoveries that lead to the award of a Nobel Prize are always fascinating, while the act of singling out individuals among many who have contributed to a field of research is frequently controversial. However, this should not distract from the real message behind the Nobel Prizes in Medicine or Physiology and Chemistry, which is that pursuing basic science research has enormous practical value. Discoveries made regarding the fundamental properties of molecules, whether by physicists, chemists or biologists, can and do lead to major advances in medical care. Particularly at a time when researchers in Australia are under pressure to pursue applied research at the expense of basic science, this year’s Nobel Prizes provide a potent reminder of the importance of fundamental research. 1: Magnetic resonance imaging a) Lauterbur’s first published image of a section of a water phantom. Left: model of the phantom. Right: the reconstructed magnetic resonance image (reproduced from reference 2). b) Modern magnetic resonance sagittal section of a human head. 2: Ion channels a) Ribbon diagram showing structure of aquaporin-1 (water channel). b) Model illustrating mechanisms of water permeation in a water channel. The positive charge on the wall of the channel repels hydronium ions, thereby excluding them from crossing the transmembrane region (from reference 8, reproduced with permission of Nature Publishing Group). c) Structure of the KcsA potassium channel. The channel is a tetramer, but only two subunits are shown, illustrating the cavity and the narrow selectivity filter region formed by the pore helices, labelled ‘P’ (from reference 11, reproduced with permission of Nature Publishing Group). d) Model illustrating K+ permeation. The orientation of the pore helices is such as to produce an electronegative well in the cavity, which attracts K+ ions. The narrow selectivity filter region is just the right diameter to accommodate dehydrated K+ ions. K+ permeation occurs in single file. As one K+ ion enters the selectivity filter it repels the K+ ion ahead of it (from reference 10, reproduced with permission of the American Academy for the Advancement of Science).

Jamie I Vandenberg MB BS, PhD · Philip W Kuchel MB BS, PhD

Along with its new graduate-entry medical program, the University of Sydney has introduced the Combined Degree (Research) Program which allows students to graduate with an MB BS and PhD. The program includes 2–3 years of full-time research between Years 2 and 3 of the 4-year MB BS program. The program aims to produce clinician–scientists committed to continuing research that reflects their experience of clinical practice. Eight women and 23 men have enrolled since the program began in 1998, with the first cohort graduating in 2003. The students have been active in helping to develop the program and establishing a society and other student support networks.

Brian D Power BMedSc(Hons) · Andrew J White BMedSc(Hons), MB BS, PhD · Ann J Sefton AO, PhD, DSc

In 1978, when I was a Fellow in Ophthalmology at the Johns Hopkins Hospital in Baltimore, I went to a seminar given by one of the senior faculty (Maurice Langham) about work he was doing on an unusual disease called onchocerciasis. Although I must have learnt about onchocerciasis at medical school and during my ophthalmology training, it was such an esoteric tropical disease in small print that it had made no perceptible impact on me. Actually, onchocerciasis is a fascinating disease. It is also called river blindness, as those who are affected live along rivers and streams. It affects about 20 million people; 99% of these live in Africa, with a few in Latin America (see Box 1).1 In endemic areas, half will become blind before they die and, at any one time, some half a million people with onchocerciasis are blind. Onchocerciasis has had a devastating impact in Africa. All but the poorest of the poor have abandoned the endemic areas. In the worst affected villages, everyone is infected by the age of 14 or 15 years.1 People go blind in their 20s and 30s, just when these subsistence-farming families are raising children. Once blind, parents often need to be led to their fields by their young children. This has a devastating effect on all aspects of the villagers’ lives. There have been various attempts to treat and control onchocerciasis. During the Second World War, tens of thousands of Australian and American soldiers fighting in the Pacific islands were afflicted with lymphatic filariasis. Wartime drug development led to the discovery of diethylcarbamazine (DEC) that would halt the progression of, and sometimes cure, filariasis. After the war, DEC was tried on some people with onchocerciasis and was found to have a temporary holding effect.1,2 DEC was better than nothing, but its use was limited, as many infected people had a severe reaction to the treatment caused by the sudden death of billions of microfilariae, the so-called Mazzotti reaction.3 Sleeping sickness or trypanosomiasis is almost invariably fatal. During the First World War a drug called suramin was developed in Germany that could save some people with sleeping sickness, although it was very toxic. It was tested and found to be effective against onchocerciasis, but 2%–3% of those treated died and so it was not widely used.4 The World Health Organization had started a major program to control onchocerciasis by spraying breeding sites to control the black fly vectors. This program started in 1974 in 11 countries in West Africa. Breeding sites in rivers and streams were “bombed” each week with the aerial application of larvicide. This was an effective, if slow and expensive, method of controlling the disease in open savanna but, because of problems with aerial access, it could not be used in rainforest areas. This was the state of play as I listened to Langham in Baltimore describe the human studies to treat onchocerciasis he had recently done in Africa. After the lecture, I suggested some clinical trials he could do. It seemed so simple to me then: get a small team of two or three people and a bit of equipment to examine people and do a prospective randomised trial. I had had great lab training at the Royal Melbourne Hospital under Peter Morris (later Professor Sir Peter Morris), and I had had an extraordinary experience of working in the field with Professor Fred Hollows when I travelled throughout outback Australia on the National Trachoma and Eye Health Programme. I little suspected how much I still had to learn, but Langham proposed that I should do the study and offered to help me put it together. Within a few months I was starting a study in Liberia and another in Guatemala. I teamed up with a young infectious diseases doctor, Bruce Greene, who was at Hopkins and later went to Case Western University in Cleveland. This was the start of a very successful collaboration. As there were only a few ophthalmologists working on onchocerciasis, I was soon appointed to a WHO Scientific Working Group on Filariasis that included onchocerciasis. In the 1970s, WHO had started a drug-screening program under their Special Programs for Training and Research in Tropical Diseases. Pharmaceutical companies could send interesting compounds to be tested in WHO-supported laboratories in selected universities to see if their new drug had an effect against some of the targeted tropical diseases. In 1983, I was asked to chair a new WHO Scientific Working Group on Onchocerciasis Chemotherapy. Since the Second World War, major drug companies have scoured the world looking for new antibiotics, many of which came from fungi. In 1978, a Japanese scientist collected a fungus species that was to revolutionise the treatment of onchocerciasis from beside a golf course in Kawano, Japan — I have been told it was from beside the fifth fairway. This fungus made a compound that was called in the lab MK 933. Later, it was called ivermectin. It was not good as an antibiotic, but it was a very potent killer of parasites. It went to a WHO test laboratory where it created some interest, but then it disappeared. It was the pharmaceutical firm Merck and Co. that developed ivermectin and started to market it for veterinary use. It is now a worldwide product used to treat heartworm in dogs, and a whole range of parasites in sheep, cattle, horses, pigs and other animals.5 Dr Mohammed Aziz worked for Merck. He was originally from Bangladesh, and had worked in Africa with WHO where he learned about onchocerciasis. He insisted that MK 933 be tried in onchocerciasis. Once the veterinary product was successfully launched, he got his way, and he did a small pilot study in Senegal.6 The results were published in the Lancet and picked up by the New York Times, Le Monde and other newspapers. This was the first time that I, and others in the field, had heard of this drug. The study was somewhat unusual. The results seemed to be too good to be true. How could any drug kill the microfilaria without producing the intense Mazzotti reaction we saw with every other drug that killed microfilaria? This did not fit with any conceivable clinical, laboratory or theoretical explanation at the time. Besides, the study patients were only lightly infected, the investigators had not worked on “oncho” before, the study was funded by a drug company, and it was published simultaneously in the newspapers and the scientific literature. Maybe it was just wishful thinking, or artefact. Soon a series of parallel, randomised clinical trials were planned to more fully evaluate this very exciting new drug. These studies started after some further patients were treated in an open dose-ranging study. Bruce Greene and I undertook a study in Liberia. We treated men who had become heavily infected with onchocerciasis while working as rubber tappers on a plantation. In this controlled trial, 10 men received ivermectin, 10 received DEC, and 10 took placebos. We were very anxious for the first few days, as we expected to see similar reactions to those seen in patients treated with DEC. Some animal studies suggested even worse reactions were possible with ivermectin. Maybe some people would even die. We were elated six months later when our results showed that ivermectin was at least as effective as DEC, but safer.7 The two other parallel studies came up with similar results.8,9 Subsequently, one partial answer emerged for the lack of a Mazzotti reaction. It seems that, rather than killing the microfilariae in the tissues, the microfilariae are paralysed and then pass through the lymphatic system and die in the lymph nodes. We went back to Liberia and this time treated 300 people, men and women, to test different doses. We followed this group for 2 years. A tiny tablet of ivermectin cleared the microfilariae almost completely and people’s skin and eye signs improved dramatically.10,11 The adult worms were not affected, so ivermectin needed to be given once every year. By August 1987, Merck had enough data to register ivermectin for use in onchocerciasis. The chairman of Merck, Dr Roy Vagalos, announced that his company would provide the drug at no cost to treat anyone with onchocerciasis, anywhere in the world, for as long as it was needed.12 This was an unprecedented and extraordinarily generous and courageous decision. Although Merck was selling huge amounts of ivermectin to treat animals, there were some 20 million people with onchocerciasis, and maybe 40 million who would need treatment. Treatment had to be continued for at least 10 years. This was a huge commitment when each pill was worth US$3. However, Vagalos knew that if Merck did not do something, this breakthrough treatment could never be afforded by those who lived beyond the end of the road, the poorest of the poor. Ivermectin was now freely available. But how could it be distributed to the millions who needed it? There were other questions to be answered: for example, would ivermectin have rare but serious side effects? And what would happen if pregnant women inadvertently took a tablet? We then started another study of 30 000 people in Liberia to assess the community acceptance and safety, and to work out distribution strategies. We monitored every person, every month, investigating and documenting all births and deaths. We kept track of people as they moved, we caught and examined the biting black flies, and we thoroughly examined all the children. This huge study was very successful and confirmed the safety of ivermectin: it could be distributed to nearly everybody in the community.13,14 We showed that by treating the whole community we could reduce transmission and the incidence of new infection in children.15 Initially, the dose of ivermectin was adjusted for each individual’s weight, so everyone had to be weighed, but later work showed that height could be used instead.16 If children could walk under the stick, they got one pill; if they were too tall, they got two. By 1989, when our last Liberian study was finishing, several government and non-government organisations coordinated by WHO had started delivering ivermectin in pilot projects. Although Merck would deliver boxes of ivermectin to the national port, it still cost between 5 cents and $5 a tablet to get the ivermectin up-country and into people’s mouths. A lot of work was done to develop cost-efficient ways of community-based distribution. To supervise the distribution of the donated ivermectin, Merck created the Mectizan Expert Committee.1,17 This joint committee was based at the Jimmy Carter Presidential Centre in Atlanta and included representatives from WHO and Merck, and other experts. I had the privilege to serve on this committee in the early 1990s. In 1990, a Houston software developer, John Moores, read an article about ivermectin in the Houston Chronicle. He was so taken by this story that he started a foundation to support this work. I was also fortunate to be on the Board of the River Blindness Foundation and eventually John Moores gave US$25 million to the Foundation. It became clear that a lot more money would be needed to distribute ivermectin in the 28 African endemic countries. The River Blindness Foundation, the Carter Centre and other non-government organisations convinced the World Bank to start a special program to distribute ivermectin in Africa, worth about $300 million.18 Another smaller program was set up for the six endemic countries in Latin America. In 2002, nearly 50 million doses of ivermectin were given away free: over four million doses a month, treating about 100 people every minute. Despite local disturbances and civil war, ivermectin distribution programs are active in 25 of the 27 endemic countries and currently reach 45% of the “Ultimate Treatment Goal”, the total number of people required to be treated (see www.mectizan.org). The number treated each year continues to increase at an almost exponential rate, and progress is closely monitored by the Mectizan Expert Committee, WHO and non-government organisations. The commitment and strategies are in place to reach everyone who needs treatment and to eliminate onchocerciasis by the year 2020. Success has many parents, and failure only one. Obviously, many people were involved in the ivermectin story, but it has been a great thrill to be one of them and to have been a part of what must be one of the most significant breakthroughs in tropical medicine in the past 25 years. 1: Onchocerciasis endemic areas Two onchocerciasis control programs provide onchocerciasis control in 30 endemic countries in Africa. (OCP — Onchocerciasis Control Program — initial area of vector control; APOC — African Program for Onchocerciasis Control — World Bank and WHO supported ivermectin distribution; OPEA — Onchocerciasis Elimination Program for the Americas — ivermectin distribution in Latin America). Reprinted from Reference 19 with permission. 2: Onchocerciasis fact file Cause Onchocerca volvulus, a filarial worm. Transmission Various biting black flies. Main African vector is Simulum damnosum. The flies breed along the river banks and in the rapids and fast-flowing streams. A female fly bites an infected person to take a blood meal, and becomes infected with a tiny microscopic worm – a microfilaria – that is less than a third of a millimetre long. Over a week or so, these microfilariae develop into infective larvae and can be transmitted when the fly bites another person. Life stages After entering the body, the infective larvae grow to become adult male or female worms. The males are only 5 cm or so long, but the females may be up to a metre long. The adult worms are wrapped together in a nodule like a ball of string. The worms reproduce sexually and the female releases tens of thousands of microfilariae every day. As the female can live for 10 years or so, she literally releases millions and millions of microfilariae. The microfilariae migrate throughout the host’s body, especially to the skin and the eye. In the skin they wait to be taken up by another black fly to continue the life cycle. If this does not occur within 18 months or so, the microfilariae die. There is no inflammatory response to live microfilariae, but dead or dying microfilariae provoke an intense local response. Disease manifestations Subcutaneous nodules (adult worms often attach to bones or joints) Skin changes: severe pruritus and rash, maculopustular reaction, pigmentary changes, atrophy Eye changes: microfilaria in cornea, anterior chamber and retina; uveitis; sclerosing keratitis; chorioretinal atrophy Liberian rubber tappers from one of the early onchocerciasis drug studies. Bruce Green (left) and Hugh Taylor standing at the back.

Hugh R Taylor AC, MD, FRANZCO

Shall quips and sentences and these paper bullets of the brain awe a man from the career of his humour? — Shakespeare, Much Ado About Nothing (II.iii.260) In 1993, when interviewing me for the archives of the Royal College of Physicians, Dr Max Blythe suggested that I write my autobiography. Never reluctant to take pen to paper, I put this suggestion to my family. Their answer was unequivocal — “No, Dad, no. Nothing exciting has ever happened to you. You’ve led a charmed life”. However, as a person who even enjoys filling in questionnaires, I found it hard to resist the invitation of the Editor of the Journal to reminisce about my decision to undertake a medical career, the mentors who guided me and the influences in my chosen pathway to become a clinical investigator. Why medicine?I wanted to be a doctor from the age of 12 years; why, I am not sure. I had no medical forebears but admired an uncle by marriage, Justin Markell, a physician at St Vincent’s Hospital and a keen skier. As a boy I read everything medical I could lay hands on — “The Citadel”, “Viewless Winds”, “The Story of San Michele” and “The Healing Knife” come to mind — and many other books about the history and challenges of the medical life. I found their messages stirring and thought that this was the life for me. I have never regretted my decision. As a medical student I was fortunate in my introduction to clinical work at the Royal Prince Alfred Hospital (RPAH). Frank Mills, debonair and charming, was a kind and understanding tutor in surgery. Keith Harrison, our tutor in medicine, was a first class clinician, caring and courteous. The senior physicians included dedicated teachers such as Archy Collins, C G McDonald, Tom Greenaway and Bill Morrow, all of whom were later knighted, and Professor Lambie, who improved our history taking and physical examination with the rigour of the Scottish discipline he imposed. Cotter Harvey ran the only specialist medical unit in RPAH, the Thoracic Unit, which was of world standard. The pathway to researchAfter graduation I knew that I wanted to undertake research work. My uncle, Justin Markell, exclaimed “Why would you want to do research? You don’t have any deformity or handicap. You could go into practice.” I approached Hugh Ward, Professor of Bacteriology, to discuss my aspirations. When Sir Howard Florey visited Sydney, Professor Ward introduced Henry Harris, another recent graduate, and me to him as possible candidates for a research career. Florey advised us to work in the Physiology Department of Melbourne University and then to do the honours course in physiology at Oxford. Henry Harris followed this advice, and eventually succeeded Florey as Director of the Sir William Dunn Institute in Oxford. I did fly to Melbourne, but was not excited by the work in progress. It was not until I met Peter Bishop, newly returned from London and setting up the Brain Research Unit in the Department of Surgery, University of Sydney, that I focused my research ambitions on neurophysiology. Peter was an enthusiast and transmitted that enthusiasm to others. I have written elsewhere about his influence on the development of neurology in Australia.1 It is necessary not only to make a discovery but to repeat the findings at intervals to prevent the results from sinking into oblivion and to deter others from going through the same motions. While in Peter’s laboratory I kept in touch clinically by seeing patients at the Northcott Neurological Centre, Cammeray, under the guidance of George Selby. George was a superb clinician and teacher who patiently imparted his art, which stood me in good stead when I departed for the then customary 2 years of postgraduate training in London. Marking timeOn returning from Queen Square (now The National Hospital for Neurology and Neurosurgery) in 1956, I looked for an appointment combining clinical work with research. There were none. I was appointed Superintendent of the Northcott Neurological Centre and an Honorary Assistant Physician to the Sydney Hospital. I was one of a group of young specialist physicians who were astounded when informed that we could not conduct a clinic in our own speciality but had to rotate throughout all the clinics so that we could work in our own speciality clinic for 6 months every three years or so. We naturally rebelled against this mad manifestation of entrenched antagonism to specialisation until it was conceded that we could all work for a half day each week in our speciality, provided that we ran a general medical clinic on another half day and took fourth year students on physical examination 2 other half days in the week. As all hospital work was honorary this left three days a week to earn an income. Having completed training in neurology, I had thought that I might reasonably be asked to lecture in this discipline. I gave a series of lectures in physiology at Sydney University but the task allocated to me at Sydney Hospital was to give lectures to nurses on hygiene. The neurological topics were covered by the senior general physicians. When the opportunity arose for Sydney Hospital to be rebuilt on the Prince of Wales site at Randwick, the main teaching hospital of the new University of New South Wales Medical School, my spirits rose. They were dashed when the honorary staff voted by a small margin in favour of the status quo. I decided to jump ship. Sir Kenneth (“Bob”) Noad, senior physician at Sydney Hospital, kindly wrote to Dr Raymond Adams in Boston on my behalf and supported my application for a Lilley Travelling Fellowship. Dr Adams was the Bullard Professor of Neuropathology and Chief of the Neurology Service at the Massachusetts General Hospital. I was accepted to start there in August 1960. There were 2 events worth recording in my four years as an “Honorary” before going to Boston. Bob Noad had looked after four members of a family with epilepsy that he passed on to my care. They had myoclonic jerks and falling attacks with cerebellar signs, known then as the Ramsay Hunt syndrome (a form of familial myoclonic epilepsy). Bob Noad and I reported the family in Brain.2 This experience aroused my interest in myoclonus, which I was later able to investigate in Boston. The second was the suggestion by George Selby that we analyse the case histories of patients with migraine headache. The resulting article3 was published in 1960 and is still quoted today. That work started me on the headache road. My wife Judy and I arrived in Boston with our daughter Fiona in September 1960. While I was working in the centrally heated comfort of the Massachusetts General Hospital, Judy trudged through the snow of a cold New England winter, dragging one reluctant daughter and pregnant with another. While in Boston I followed up my interest in myoclonus, working and publishing with Ray Adams on a group of patients with myoclonus after hypoxia, and on the cause of myoclonic falling attacks (Box 1).4 I completed another interesting project with Dr Robert Schwab, who ran the Parkinson’s disease clinic at the Massachusetts General Hospital, on the relationship between action and resting tremors and cogwheel rigidity.5 Neurological grand rounds were held in the Ether Dome, where ether was first used as a general anaesthetic in 1846 (Box 2). Foremost among the clinicians were Raymond Adams, Miller Fisher and Maurice Victor. From Boston, I applied for the position of Chairman of Neurology at the Prince Henry and Prince of Wales Hospitals, which were to become the teaching hospitals of the Medical School of the University of New South Wales. To my great joy I was appointed. There are many legacies of the year in Boston — a lasting friendship with Raymond Adams, one of the great neurologists of the twentieth century, continuing contact with my colleagues in training at the Massachusetts General who went on to chair most of the major neurology departments in the US, honorary membership of the American Neurological Association, being a foundation member of the editorial board of Annals of Neurology and becoming the proud father of our second daughter, Sarah. Re-entryThe task of creating a teaching hospital out of a rundown infectious disease hospital (Prince Henry) and a collection of wooden huts dating back to the First World War (Prince of Wales) was challenging. The great merit of Prince Henry was that it was a very happy hospital, superbly situated between the Pacific Ocean and Botany Bay with its own golf course. I set up a modest laboratory in a disused ward where our work on the neurophysiology of movement disorders began. In investigating reflex actions we discovered that it was the vibration wave set up by percussion which was the essential trigger for tendon jerks, and this led to the discovery of the tonic vibration reflex, which had important clinical implications, and which led to collaboration with Karl-Erik Hagbarth in Sweden, who had recently discovered the same phenomenon. Studies on the mechanism of spasticity and the control of movement were carried out with David Burke, David Gillies, Colin Andrews, Carlo Tassinari (visiting from Marseilles) and Peter Ashby (from Toronto). I have summarised the early motor studies and their clinical implications in the Wartenberg Address that I gave to the American Academy of Neurology in 19806 and in my book on clinical neurophysiology in which I collaborated with Jim McLeod.7 I wish that the findings were more widely known to guide clinical neurologists today. It is necessary not only to make a discovery, but to repeat the findings at intervals to prevent the results from sinking into oblivion and to deter others from going through the same motions. David Burke and Simon Gandevia later joined Ian McCloskey in founding the Prince of Wales Institute of Medical Research. The motor program, which started in a disused ward and moved to a basement under the EEG Department and then to an abandoned operating theatre at Prince Henry Hospital, now resides in handsome villas on the Prince of Wales site at Randwick. Headaches and serotoninMy interest in headache was reignited by observations made in 1959 and 1961 by Federigo Sicuteri in Florence and by a group at the Montefiore Hospital in New York in 1960. It appeared a paradox that a serotonin antagonist, methysergide, could prevent attacks of migraine and yet an infusion of serotonin itself could ease the headache. We had the good fortune to have a biochemist at Prince Henry Hospital, Herta Hinterberger, who was an expert amine chemist, to teach Don Curran (our first Research Fellow), and then Michael Anthony (our second), the mysteries of estimating serotonin (5-hydroxytryptamine, 5-HT) in blood. We found that serotonin was discharged from blood platelets at the onset of migraine headache. An intravenous infusion of serotonin would constrict cranial blood vessels and relieve the headache (Box 3).8 These and other of our observations on blood vessels in migraine came to the attention of Dr Patrick Humphrey in the Glaxo laboratories in England. He set out to find an analogue of serotonin that had its beneficial effects without its side effects of chest tightness and lightheadedness. At the time of our early studies, there were only 2 receptors known for serotonin. Now there are at least seven main groups with many subdivisions. Patrick Humphrey came up with a substance that was active at the B and D subtypes of the serotonin1 receptor and named this sumatriptan. This and the other triptans developed later have proved to be highly effective agents in cutting short or preventing the development of migraine headache. It is gratifying that our observations qualify us to be godfathers to the triptans. Our initial concentration on the vascular aspects of migraine was carried on by Ewan Mylecharane, pharmacologist, with Paul Spira, John Duckworth, Michael Welch (from the UK and US) and Jusef Misbach (from Indonesia) who quantified the effects on the monkey cranial circulation of various vasoactive agents and their antagonists with a potential use in migraine. Geoff Lambert took over the pharmacological reins in 1978 as the emphasis in migraine research moved to determining the cerebral mechanisms that could underlie vascular changes and be of significance in the genesis of migraine. Some of the headache research team are shown in Box 4. Peter Goadsby and Richard Piper joined the team as BSc(Med) students in the early 1980s, followed by Rick Adams and Sandrino Zagami as Higher Degree candidates. A series of papers established the way in which the cerebral circulation of cat and monkey could be controlled by brainstem structures,9 thus filling a gap in the hypothesis of migraine mechanisms.10 Peter Goadsby continued research as a PhD and MD candidate investigating the pathophysiology of migraine, including a collaborative study of peptide neurotransmitters with Lars Edvinsson of Lund, thus forming our second Swedish connection. Peter later accepted an invitation from the Wellcome Foundation to set up a research department at the National Hospital, Queen Square, London. He joined me as a co-author for the sixth edition of my headache book,11 which outlines the research that has led to the current hypothesis of the mechanism of migraine. We have participated in many therapeutic trials including the triptans. Two early publications are worth mentioning. Don Curran and I conducted a double-blind controlled trial of amitriptyline for chronic tension headache in 1964,12 which has been accepted as a main line of treatment since then. Michael Anthony and I13 reported in 1969 on a successful open label trial of phenelzine for migraine patients resistant to other treatment which opened the door for the use of monoamine oxidase inhibitors when all else had failed. Odd neurological syndromesIn parallel with the research programs, our clinical work grew apace. We had close relationships with our neurosurgical colleagues under the leadership of Alex Gonski. Among the routine case load unusual problems appeared from time to time.14 We studied patients with phaeochromocytoma15 to define the headache and “funny turns” of this disorder, as well as benign sex headache, “neck–tongue syndrome”, visual hallucinations and paroxysmal dystonia.16 The arrival of Dr Peter Drummond, an experimental psychologist, brought a new dimension to our group’s studies of the autonomic nerve system. He worked out the part that the sympathetic nervous system played in facial flushing and the mechanism of the unilateral flushing in harlequin syndrome17,18 and clarified the nature of autonomic deficits in migraine and cluster headache. There are always new diagnostic and therapeutic challenges arising from our patients’ histories. Recent examples are the red ear syndrome19 and the “blip” syndrome.20 EpilogueSurely neurologists must have one of the most exacting and exciting occupations in the world. I have been fortunate in being able to set up the first Academic Department of Neurology in Australia and being appointed a Professor of Neurology rather than Professor of Medicine. The struggle to have neurology regarded as a discipline separate from general medicine has been long, hard and eventually rewarding. I want to emphasise that the research described here is very much the result of a team effort, and I regret that I have not had enough space to record all of it or to mention here all those that have been involved. I am indebted to my wife Judy for so many things, not least for her tolerance of my deskbound habits. I have been shielded from the uglier side of paperwork and helped over the years by three wonderful secretaries — the late Margaret Kendall, Patricia Miller and Carol Flecknoe. New techniques of studying cerebral function and dysfunction are granting us deeper insight year by year. I have no wish to be young again, but would not object to a 20 per cent discount so that I could observe further into the future. I am cheered by the fact that bright eyes and brighter minds are carrying on the exploration of the unknown. 1: Myoclonus In 1960, the cause of myoclonic falling attacks was not understood. Our investigations established that it was not the violence of the myoclonic jerking that caused the fall, but the following period of silence in all muscle groups. (a) Myoclonic jerk and falling attack. (b) Sharp and slow wave seen in an electroencephalogram (upper trace) and myoclonic jerk followed by a silent period in an electromyogram (lower trace). Reproduced with permission from Brain.4 2: The Ether Dome of the Massachusetts General Hospital. Dr Miller Fisher on my right and Professor Raymond Adams on my left during a lecture visit in 1989. 3: Serotonin and migraine Our investigations of migraine in the 1960s clarified the role of serotonin and paved the way for others to find serotonin analogues that would be safe and effective in treating and preventing migraine. (a) Levels of platelet serotonin in a migrainous patient. The injection of reserpine releases serotonin from body stores. Platelets discharge serotonin at the onset of a migraine headache, whether spontaneous or induced. Both spontaneous and induced headaches were relieved by intravenous infusion of serotonin. Reproduced with the permission of the Editor of Archives of Neurology. (b) The vasoconstrictor effect of intracarotid serotonin on the superficial temporal artery pulsation. The upper trace in each pair shows respiratory function, the lower, arterial pulsation. Reproduced with the permission of Karger Publishers (New York, Basel). 4: Members of the headache research team, 1987, in front of the Clinical Sciences Building, Prince Henry Hospital. From left to right: (front row) Professor Michael Anthony, Professor James Lance, Mr. Mark Hellier (Technical Officer), Mr. Basil Daher (Biochemist); (middle row) Mrs Patricia Miller, Mrs Francine Skane (Secretaries), Mr Paul Charalambous (Histology Technician); (back row) Dr Geoff Lambert (Pharmacologist), Dr Peter Goadsby, Dr Alessandro Zagami (Research Fellows), Mr John Duckworth (Technical Officer).

James W Lance MD, FRCP, FRACP

Medical simulation is a relatively new teaching modality suitable for medical education at all levels, although its long-term benefits have not yet been validated. Simulation allows the participant to practise diagnosis, medical management and behavioural approaches in the care of acutely ill patients in a controlled environment. Simulators have achieved widespread acceptance in the fields of anaesthesia, intensive care and emergency medicine. More recently, team training for pre-hospital and within-hospital multidisciplinary medical response teams has become popular. The increasing number and diversity of courses at “CASMS” parallels the evolution of simulation centres into regional clinical skills centres elsewhere. Such centres are likely to become a cost-effective means of achieving greater consistency in medical skill acquisition and may improve patient outcomes after medical crises.

Richard H Riley MB BS, FANZCA · Amanda M Grauze RN, GradDipEd(Higher · Neil H Trewhella CSM, BHSc (Prehospital Care) · Claire Chinnery BN, RN · Ross A Horley

A long and proud history of health education in the Fiji Islands started in 1885 with the founding of the Suva Medical School, which became the Central Medical School in 1929 and the Fiji School of Medicine (FSM) in 1961. Today, FSM provides training in medicine and a wide range of other healthcare disciplines, including dentistry, pharmacy, physiotherapy, radiography, medical laboratory technology, dietetics and environmental health. Students come not only from the Fiji Islands, but from all Pacific Island countries (a population of about seven and a half million people). A particular problem has been that formal postgraduate training and continuing professional development have not been available for its graduates, forcing many Pacific Island practitioners to undertake specialist training overseas, with many choosing not to return to the Pacific. Thus, the Pacific Island countries and FSM itself have been heavily dependent on transient expatriate practitioners for delivery of care and medical education. Valuable though the contribution of such expatriates has been, it cannot substitute for local graduates. To address these and other issues, a Fiji School of Medicine Development Plan was developed in 1994 and endorsed by the Government of Fiji. A major recommendation was that “an effective postgraduate training program, and preferably one utilising the resources of Fiji and the Pacific Island countries, is the key to the revitalisation of FSM.” This was followed in 1995 by a meeting on Yanuca Island in Fiji, sponsored by the World Health Organization, involving consultants and government representatives from all Pacific Island countries. This meeting recommended establishing diploma and masters courses in anaesthesia, internal medicine, surgery, obstetrics and gynaecology, child health and population health. The Fiji government then requested, in discussion with the Australian Agency for International Development (AusAID), that FSM be included in the bilateral program of assistance between the two countries. In May 1997, AusAID appointed the Royal Australasian College of Surgeons (RACS) to manage the 5-year project with a budget of A$5.5 million, in partnership with the Royal Australasian College of Physicians and its Division of Paediatrics, the Australian and New Zealand College of Anaesthetists, the Australian Society of Anaesthetists, the Royal Australian and New Zealand College of Obstetrics and Gynaecology and the Universities of Otago and Melbourne. The aim of the project was to establish a postgraduate training program at FSM, involving local curriculum development to make it more relevant, and to reduce (although probably not eliminate) the need for doctors to travel to other countries for specialist training. Each of the five disciplines was to offer a 1-year diploma, giving a theoretical and practical background sufficient for providing care in Pacific Island countries with populations too small to support fully trained specialists. This diploma would also act as the introductory year for a 3-year masters program for those showing particular aptitude, and who wished to proceed to full specialist practice in larger Pacific Island countries. Selection into the diploma program would require a minimum 3–4 years’ experience after graduating from medical school, and support from the relevant Pacific Island Country authority. Progression from the diploma to the masters program would depend on achievement of a high standard during the course and examination. The FSM faculty was strengthened by the appointment of additional staff in each of the five disciplines, one of whom was appointed Coordinator of Postgraduate Studies (W B). These were supported by long-term advisers from Australia or New Zealand to interact with local staff in each of the five disciplines. Advisers spent full-time attachments in Suva for 18 months to 3 years, depending on the state of development of the specialty. The project was launched on 5 May 1997. The appointment of long-term advisers and local counterparts followed rapidly, and teaching began formally in all disciplines in 1998. In anaesthesia, a pre-existing diploma established with the help of the Australian Society of Anaesthetists was adapted to the more practically oriented and problem-based format used in all five disciplines. In paediatrics and obstetrics and gynaecology, FSM was able to build on diplomas from the University of Otago, which had been offered through the distance mode. In surgery, informal postgraduate teaching and course development had commenced in 1996. The agreed format for the curriculum was a series of modules designed to provide detailed learning objectives, with core and reference materials to allow the trainees to adopt a problem-solving approach to learning and clinical practice. The content was clearly defined at the diploma level in recognition of the fact that this might be the only formal training for trainees, in particular, from the smaller Pacific Island countries, and emphasis was given to the need for life-long learning and continuous professional development. At the masters level, subspecialty teaching was provided by visiting medical staff from Australia and New Zealand, who spent 2-week periods at FSM for direct teaching and to help develop the modules. A specific requirement for each masters trainee was the completion of a research project, supervised by staff in the discipline and the Research Director at FSM. In Suva, trainees in the diploma and masters program undertook clinical duties at the Colonial War Memorial Hospital. Diploma candidates from other Pacific Island countries were able to undertake their initial studies in their own country, provided there were adequate local facilities and clinical and academic supervision, with the last three months of the course undertaken in Suva for intense supervision and preparation for the examinations. Masters candidates are all trained in Suva, with an additional 3–4 months on attachment in Australia or New Zealand. Distance learning for postgraduate education and continuing professional development is a major issue. In 2002, FSM identified “flexible learning”, a process that is learner-focused, and, with the help of the University of the South Pacific and Professor Ian Rouse of Curtin University, is developing a Resource Centre that will collate all paper-based and electronic-based resources, improve delivery of internal services and coordinate workshops on flexible learning for staff at FSM. Distance learning should become more widely available in the future, as more and more FSM-trained specialists in general return to their own environments. GraduatesIn 1999 the University of the South Pacific, a distinct entity which awards MB BS degrees to FSM graduates, approved the awarding of a Master of Medicine (MMed) degree after review by independent external reviewers, and subject to a further review in the final year of the first cohort (2001). This was completed satisfactorily in August 2001, noting that the programs were “soundly based and well balanced in terms of targeted acquisition of appropriate expert knowledge, technical capacity, life-learning skills and problem solving ability”. It was noted that the academic level of the MMed degree was rightly set at a level which was equivalent to other MMed degrees in the South-East Asian area. The diploma remains an award made by FSM itself. By the end of 2002, 74 diplomas had been awarded (anaesthesia, 16; internal medicine, 13; obstetrics and gynaecology, 8; paediatrics, 17; surgery, 16; community and hospital practice, 4) and 14 candidates had completed the Master of Medicine degree (anaesthesia, 1, internal medicine, 3; obstetrics and gynaecology, 4; paediatrics, 2; surgery, 4). Of these graduates, 68 with diplomas and 12 masters graduates were practising in Pacific Island countries. ConclusionsWithin 5 years the FSM postgraduate training project, established with funds provided by AusAID, has facilitated the development of a viable and now largely self-sustaining program for postgraduate medical education for the Pacific Islands. All strategies for implementation have been fulfilled, although continuing support from authorities and individuals from countries such as Australia and New Zealand will be necessary if these achievements are to be sustained and advanced. A memorandum of understanding is under discussion between FSM and AusAID to facilitate such support.

Gordon J A Clunie DSc(Edin), FRACS · Eddie McCaig DSM, FRACS · Wame Baravilala MRCOG, FRANZCOG

In the pregnant pause between when the conductor bows to the audience, and then turns, raising his baton, to face more than 100 musicians with their instruments poised, it can feel as if time has stopped. The anticipation of a whole concert of magical music to follow, the culmination of much concentrated work, gives way to relief mixed with excitement as the sound that follows is full and impressive. The surprise is that this talented troupe are all doctors. Where else would you find such a large group of doctors from all fields of medicine coming together every year from all corners of Australia, to focus intensely on the same thing for 3 days — not only playing for free, but actually paying to be there? These doctors have more than medicine in common — they share a love of music. The combination of music and medicine is nothing new. There are prominent examples dating back many centuries. Thomas Campion (1567–1620), English poet and musician, studied both law and medicine and worked as a doctor in London from 1606.1 The French composer Hector Berlioz (1803–1869) was originally educated in medicine,1 while Russian composer Alexander Borodin (1833–1887) studied medicine and helped found a medical school for women in 1872.1 Musicologist Albert Schweitzer (1875–1965) studied medicine in Strasbourg and worked as a medical missionary, returning regularly to Europe to give organ recitals to fund his hospital in Africa.1 Fritz Kreisler (1875–1962), violinist and composer, withdrew from music briefly to study medicine and to work as a medical officer in the Austrian army before returning to music fully in 1899.1 Flautist Jean-Pierre Rampal (1922–2000) left medical school to pursue his musical career,1 and conductor Zubin Mehta (1936- ) was another to abandon his medical studies, when he left India to pursue his musical studies.1 The Australian Doctors’ Orchestra under the baton of Keith Crellin in Perth, 2003. How we startedThe concept of combining medical and musical talents countrywide was the dream of Australian plastic surgeon and violinist Miklós Pohl, who was intrigued by the disproportionate number of doctors playing at the chamber music camps he attended. He saw the formation of a doctors’ orchestra as an exciting prospect, and his idea was welcomed with great enthusiasm by other musically talented medicos. Much planning preceded the first concert of the Australian Doctors’ Orchestra (ADO) in Melbourne in 1993. This concert featured Melbourne general practitioner, William Kimber, who received a standing ovation for his performance of Beethoven’s Piano Concerto No. 3 in C minor. Since the resounding success of our first concert, we have featured professional musicians as soloists in our annual concerts. They enjoy working with us, and are taken aback at our dedication, energy and enthusiasm. It makes a difference when you are choosing to play music, simply for fun. We have attracted a variety of renowned and notable artists, who are keen to fit us in between their commitments worldwide. We have been particularly fortunate to have British-born and trained Christopher Martin as conductor and artistic director. He recently retired after 20 years as senior lecturer in strings and conducting at the University of Melbourne. He works wonders to achieve cohesion from such a large and diverse group of doctors, drawing out the best possible performance in a very short time. He also chooses our music, and always seems to get it right — it is quite a feat to satisfy so many concerned and compulsive medicos! Our challenge is to satisfy him. We have often sympathised with him, especially at first rehearsals, as he tears his hair out, throws his baton down, and shakes his head as he gets over his initial concern that his choice of music might have been too ambitious. Somehow, he is always smiling at the end of each performance, and he keeps coming back for more. We have also had the privilege of working with Nicolette Fraillon (currently conductor of the Australian Ballet Orchestra) in 2002, and Keith Crellin (artistic director of the Adelaide Youth Orchestra) in 2003. Each conductor brings something of herself or himself to the orchestra, broadening our experience. Tony Prochazka, Cosmetic Surgeon, Sydney, NSW. Principal Cello. “I made a conscious decision 10 years ago not to pursue music as a career. I don’t regret that decision, but occasionally feel wistful about what might have been. Playing music forces you to make artistic decisions all the time. I’m certain that my artistic experience from music guides me in the aesthetic judgements I am required to make on behalf of my patients.” David Backstrom, Visiting Medical Officer, Royal Brisbane and Women’s Hospital, Qld. First Violin. “The most memorable musical moment in my life was probably the very first rehearsal piece of ADO in Melbourne 1993 — Mozart’s Il Seraglio overture. I was a founding member of the ADO. When asked about the oldest member, I think I was the only one willing (or silly enough) to volunteer my age!” James Lie, Rural General Practitioner, Albany, WA. First Violin. “All this music has a positive impact, even though I’m very busy. It makes me happier. My wife and son also play musical instruments. We do lots of after hours musical things as a couple or as a family. My patients also love my participation in music. They are always asking when and where I will be performing again.” Anita Green, General Practitioner, Darwin, NT. Principal Horn. “I work part-time to fit in music and family commitments. My most memorable musical moment was playing Sculthorpe’s Kakadu at Nourlangie Rock at sunset, and my favourite piece of music is Shostakovich’s 5th symphony; it has brilliant horn parts and laughs at authority — a strong Australian trait.” How it worksEach year, we meet for three days of rehearsals which culminate in our annual concert. The venue for our rehearsal period and concert alternated between Melbourne and Sydney for 5 years, after which we went to Adelaide, followed by Hobart, Brisbane, and, this year, Perth. Melbourne will be our host city in 2004, followed by Canberra in 2005. There are now over 500 doctors and medical students on the database, which has gradually grown as more and more people become aware of ADO, mainly by word of mouth. Invitations are sent to all, but only just over 100 participate each year. Our record was 170 players in Sydney in 2002, when we celebrated our 10th anniversary. It was a welcome achievement to have as many as 125 players in Perth this year. A hard core of players makes up about half of the orchestra; other players come and go. A few keen veterans have played in every one of the 11 years of our existence. About 3–4 months before the annual concert, we are sent the music scores as well as a practice compact disc. This recording helps us familiarise ourselves with the music, and allows us to play along in orchestral rehearsal at whatever times suit our schedules. When we meet, we have tremendous fun during the rehearsals, especially on first playing together something that we have only practised with the recording. However, the fun can be mixed with some initial doubt and trepidation, when facing unforeseen challenges just 2 days before the performance. It all gains momentum as we rehearse all day Friday, Saturday and the morning of Sunday, in preparation for the concert on Sunday afternoon. We soak in the uplifting spirit as the time of our concert looms closer. The sense of achievement is great, and it takes us a while to come down after such an adrenalin rush. Every performance has been recorded and videoed, so that players can keep a memento of their experience. In 2003, we also produced a CD of our performance. The orchestra donates all profits from its performances to a different medical charity each year. Apart from sacrificing time away from their work, all players pay a subscription fee, and meet all of their own costs, including those for travel and accommodation. Any sacrifices on our part are well compensated for by the sheer thrill of being part of such magic. A local organising committee in the host city works closely with the chosen medical charity to add corporate sponsorship to these funds wherever possible. This means that most of the door takings are passed on to the nominated charity. Many multi-talented doctors also take the opportunity to showcase their other skills, so that we don’t have to employ anyone else to organise the orchestra. The ADO was incorporated in 1998, and is coordinated with the assistance of a large team of doctors on national and local committees. Apart from a president and vice-president, treasurer and secretary, we also have librarians, a website manager (www.ado.net.au), database manager, publicity officer, video producer, photographer, stage manager, program editor, entertainment and social event organisers, and a master of ceremonies, in addition to many other willing helpers. Phillip Antippa, Cardiothoracic Surgeon, Royal Melbourne Hospital, Vic. Principal Viola. “Music is an integral part of my professional life. I never operate without music, be it classical or other. My favourite composer is Shostakovich and certainly my most memorable moment was playing his 11th Symphony at National Music Camp in 1985.” Rowan Thomas, Anaesthetist, St Vincent's Hospital Melbourne, Vic. First Violin and Concertmaster. “Playing music helps me relax. My association with professional musicians reminds me of a few fundamental truths — the best car to own is one that gets you from A to B, and if you can eat and are warm, there is not too much to worry about.” Cathy Fraser, General Practitioner–Psychotherapist, Sydney, NSW. Flautist, Leader of the Woodwinds. “The need to practise means something else has to go, and that usually can't be work, so it can mean less time eating, exercising or even sleeping! My favourite piece is Samuel Barber’s Adagio for Strings because it moves me more than any other piece of music.” Ti-wan Ng, Paediatrician, Perth. Double Bass player. First time player in 2003. “Music provides an escape from medicine and the chance to create something beautiful. Medicine is not intrinsically very creative. My most memorable musical moment was a night in Florence, listening to a recital in a small church which was raising funds for restoration work.”

Catherine Fraser MB ChB, FACPsychMed, MGPPsych

Do the media promote, for the sake of entertainment, unrealistic hopes and exaggerated fears of doctors? modern ambivalence towards the medical profession is strongly promoted by the lay press. In Britain, at least, and I suspect in most countries, press interest in medical matters has never been greater. Whether the press has merely responded to a demand, or has actually created the demand, is a question that I cannot answer; I think that there is probably a dialectical relationship. The supply created the demand, and the demand created the supply. No one will now ever be able to say which came first. But that there has been an increase in interest is undoubted. If you compare the newspapers of the 1950s with those of today, you will immediately notice the difference. I once calculated that an assiduous reader of the Daily Telegraph alone would read more than 2000 articles per year relating to health, surely more than anyone could assimilate into a sensible intellectual framework. And although I myself have benefited personally from the great increase in interest in health matters in newspapers, in that my career as a journalist was founded on it, I nevertheless lament it as a cultural phenomenon; for at a time when newspapers maintain fewer and fewer foreign correspondents, and report on foreign news ever more scantily, it seems to me to represent a response, or possibly an invitation, to an involution of people’s interests in the world beyond themselves, and to an unhealthy (I use the word metaphorically) self-absorption. Be that as it may, interest in medical affairs is here to stay, at least until we suffer a real social cataclysm, if we ever do. And because newspapers thrive on the sensational, they give a very skewed idea of what medical practice is actually like. You never see an article telling you that little Miss Jones had her appendix out yesterday and is recovering without complications, or that Mr Smith has taken his antibiotics, and his infection is now waning. While these facts are important to Miss Jones and to Mr Smith, they are definitely not news, however representative of the world they may be. Having written for several newspapers for a number of years, I think I can discern a pattern in their reporting. It has two fundamental poles: the miracle cure and the murderously incompetent, or just plain murderous, doctor — a dialectic enlivened by occasional reports of medical threats to the survival of the whole of humanity. This reporting is essentially frivolous. Perhaps it is futile to complain of it, but our newspapers have become a branch of the entertainment industry. Modern technology has, more-over, heightened the tendency to frivolity; speed of information is far more important than its veracity or wider significance (in any case, it will all be forgotten tomorrow). Editors often seem more interested in whether authors can turn out an article of reasonable coherence by 4 pm than in whether the article has any other value. In vain do authors plead for more time to research a subject so that what they write will be more authoritative. Access to the internet enables almost everyone to appear as if they know something about almost any subject; and in the kingdom of the ignorant, the man with one fact to hand is king. The twin poles of medical reporting — miracle cure and murderous doctor — promote undesirable emotions in the population. On the one hand, unrealistic hopes are aroused, such that death itself comes to seem an anomaly, and the fundamentally democratic nature of human life — “one man, one death” — is forgotten. On the other hand, unreasonable fears are likewise aroused; the fact that it is not surprising that there should be incompetent or wicked members of a profession that contains many thousands of men and women (because that is what human nature decrees) is lost sight of. A report of incompetence or wickedness is soon generalised, so that the most blameless practitioners find themselves tarred with the same brush. Officialdom reacts similarly, although with a slightly different motive, namely to exert power and control over the independent corporation of doctors. When it was revealed in Britain that a Liverpool pathologist had taken organs from deceased babies for research without asking the parents’ permission, there was an outcry, obviously promoted by newspapers, and the administrators of some hospitals decreed that every drawer and every cupboard in every room should be searched for hidden body parts. A friend of mine had his outpatient clinic interrupted by three men in suits searching for babies’ organs in his desk drawers (they did not find any). Unrealistic hopes are just as harmful as exaggerated fears. They actually increase human misery by disguising the inevitable limitations of existence, which have to be accepted if they are not to be psychologically debilitating and deforming. This, surely, was the fundamental point made by the social philosopher, Ivan Illich. His books Medical nemesis1 and Limits to medicine2 were published about a quarter of a century ago, just as I was qualifying, and rather irritated me at the time. Had I joined the medical establishment only to become, in Illich’s famous words, “a major threat to health”? I was annoyed, but since then have calmed down and now see the wisdom in what he was saying, even if he over-egged his pudding. An exaggerated belief in the technological powers of medicine can deprive people not only of the ability, but even of an awareness of the need, to cope with the inevitable ups and downs of human existence. They come to view the problems inherent in life — all existential fluctuations — as matters susceptible to medical management. Books such as Listening to Prozac3 encourage them to believe that our understanding of neurobiology is now so great that we can switch moods on and off like taps, to produce any temperature we like, at the touch of a prescription. The supposition is that it is normal to be happy all the time, and that any deviation from constant bliss is a pathological condition. Doctors may be flattered to be considered so powerful and important, but in any case, will find themselves constrained to prescribe medication that they know in their hearts to be perfectly useless and in some cases harmful. How else will they get patients who believe that there is a pill for every ill out of their consultation rooms? Macbeth’s physician was right: we can’t pluck out a rooted sorrow with some sweet oblivious antidote. Rooted sorrows are an inevitable part of human existence, we are not made for constant bliss. Medicine is a noble endeavour, but a limited one. Its advances are taken for granted the moment they are made, and new sorrows rush in where old ones have departed. That is why medicine will always be able to relieve sufferings, but will never be able to abolish suffering itself.

Anthony Daniels

To the Editor: Mental health literacy of the general public is suboptimal, and knowledge and attitudes about some mental illnesses, such as schizophrenia and substance use disorders, are particularly poor.1 The media have been implicated in contributing to overall low levels of mental health literacy, with studies showing that mental illness is commonly portrayed negatively and linked with crime.2,3 However, few studies have considered whether particular mental illnesses are especially likely to be “framed” in the context of crime. In 2000, we undertook a survey of media reporting of mental illness and crime. We retrieved 13 389 Australian media items on mental health or illness from 515 sources during the year 2000 (all national metropolitan daily and Victorian suburban and regional newspapers and all national radio and television networks). We extracted detailed information from a random sample of 1126 items, identifying the mental illness that was the item’s predominant focus (co-morbidity is not typically reflected in reporting) and whether this was mentioned in the context of crime.4 Overall, only 71 of the 1126 items (6.3%) referred to mental illness in the context of crime. However, a substantial proportion of items on schizophrenia (9 of 57, 16%) and substance use disorders (13 of 117, 11%) did so, as did 33 of 311 items (11%) about mental illness in general. By contrast, only a small proportion of items on depression (7 of 218, 3%) and other disorders (9 of 146, 6%) referred to crime, while none of the items on eating disorders (29), dementia (133), or stress (115), did so. Examples of media references to mental illness in the context of crime included: A teenager accused of a fatal stabbing was described as “psychotic, mentally retarded, displaying signs of schizophrenia [and] hearing voices” (The Australian 2000; 15 Nov: 4). A man was referred to as a “paranoid schizophrenic” and “lunatic” in association with attempted murder (ABC Television World at Noon 2000; 16 Nov: 12:19 h). A woman charged with “a spate of armed robberies” was described as “fighting a drug addiction” (Radio 3AW News 2001; 8 Jan: 13:02 h). It was encouraging to find that relatively few items referred to mental illness in the context of crime, but confronting that those that did were disproportionately about schizophrenia and substance use. Studies that have considered the extent to which people with these disorders contribute to crime statistics suggest that public perceptions of them as criminally dangerous are exaggerated,5 and the media may have a role here.

Catherine Francis PhD · Jane E Pirkis PhD · David R Dunt PhD · R Warwick Blood PhD · Philip M Burgess PhD

Objective: To assess the importance of cancer “breakthroughs” reported in the popular media 10 years after their publication.Study design: Questionnaire-based survey in 2003 of expert opinion on the importance of all alleged cancer “breakthroughs” in cancer research or treatment reported in news articles in The Sydney Morning Herald between 1992 and 1994.Main outcome measures: Assessment of each “breakthrough” by an expert in the relevant cancer subspecialty on seven measures of current importance.Results: 31 unique reports of alleged cancer “breakthroughs” were identified, and experts responded to questionnaires on 30. Thirteen of these 30 reports (43%) were judged as not having been supported by further research in the following decade, with three (10%) having been refuted, while 16 (53%) were judged to remain potential breakthroughs, but more research was required. Eight “breakthroughs” (27%) had, or would soon be, incorporated into practice.Conclusion: Cancer research findings reported in newspapers as “breakthroughs” are often not true breakthroughs but may be important for ongoing research. Consumers are likely to be receiving an overly optimistic picture of progress in understanding and treating cancer.

Ethel S Ooi MB BS · Simon Chapman PhD

The AdWatch section of the Healthy Skepticism website (www.healthyskepticism.org/adwatch.asp) aims to improve medical decision-making by illuminating the techniques used in drug advertising. AdWatch draws on 20 years of dialogue about drug promotion plus ideas from many disciplines, especially logic, psychology and marketing. A small group known as Healthy Skepticism . . . has consistently and insistently drawn the attention of producers to promotional malpractice, calling for (and often securing) correction. These organisations [Healthy Skepticism, Médecins Sans Frontières and Health Action International] are small, but they are capable; they bear malice towards no one, and they are honest. If industry is indeed persuaded to face up to its social responsibilities in the coming years it may well be because of these associations and others like them.1 Graham Dukes (Professor of Drug Policy Studies, University of Oslo, Norway) The quality of care delivered by doctors and our consequent incomes depend on our decision-making skills in the face of information and promotion of variable quality. However, few doctors have much training in the basic sciences for decision-making, such as logic and psychology. A database of 2178 references on drug promotion compiled by the World Health Organization provides evidence that many doctors are more vulnerable to being misled than they realise.2 Healthy Skepticism is an international organisation based in Australia that aims to improve health by reducing harm from misleading drug promotion. In October 2003, Healthy Skepticism launched AdWatch, a monthly webpage that explains the techniques used in drug advertisements.3 The story of Healthy Skepticism’s predecessor, MaLAM (the Medical Lobby for Appropriate Marketing), was told in the 1997 Christmas issue of the Journal.4 This update describes the ideas behind the transition from MaLAM to Healthy Skepticism and the launch of AdWatch. From MaLAM to Healthy SkepticismIn the 1980s, open letters from MaLAM achieved improvements in advertising and some drugs were withdrawn.5 During the 1990s, there were fewer obviously inappropriate drugs to target. Although many serious problems with misleading promotion persist,6 they are more subtle and thus less amenable to open-letter campaigns. To understand these problems better, we developed a stronger multidisciplinary team with expertise in medicine, marketing, psychology, pharmacy, pharmacology, statistics and logic.7 We were inspired to change our name to Healthy Skepticism by a 1963 speech from drug advertising executive Pierre Garai.8 Garai urged doctors to stop blaming drug companies for misleading drug promotion and argued that the quality of drug promotion depends on the quality of medical decision-making; “. . . indeed, [if] candor, accuracy, scientific completeness, and a permanent ban on cartoons came to be essential for the successful promotion of [prescription] drugs, advertising would have no choice but to comply”. Garai challenged doctors to accept responsibility for improving their decision-making and to develop healthy scepticism. We accept that effective promotion is a mirror to our souls, reflecting how we really make decisions. The image it reveals differs from what we would prefer to believe about ourselves. However, accepting our human limitations is the best first step towards improved medical care. Consequently, we accept Garai’s challenge, but we feel that blaming the targets of promotion for human vulnerability to promotional techniques is not helpful. Many techniques have been effective in fooling many of the people much of the time for centuries;9 others are products of recent sophisticated research on ways to increase sales.10,11 We prefer to focus on changing the current system in which misleading promotion leads to inappropriate prescribing and higher profits for drug companies, thus funding more misleading promotion. This vicious cycle harms patients and may reduce incomes for doctors and drug companies in the long run. The concept of healthy scepticismThere were two schools of extreme scepticism in ancient Greece. The Pyrrhonian Sceptics suspended judgement on all claims, including the Academic Sceptics’ claim that nothing could be known for certain. Moderate healthy scepticism started with the 16th century theologian Castellio, who advocated accepting reasonable beliefs rather than aiming for certainty.12 In the 1990s, a US business academic developed a questionnaire for measuring scepticism.13 She characterised sceptics as slow to accept claims or form judgements, but keen to ask questions in pursuit of knowledge and understanding, and found that sceptical auditors were more effective and efficient at detecting problems in company accounts. Thus, healthy scepticism involves selectively accepting claims that are justified by good evidence or argument, while resisting those that are not. Understanding misleading promotionFrom Aristotle onward, logicians have observed many types of misleading arguments, which are now called fallacies.9 Psychologists have studied similar concepts, calling them heuristics, biases and influence techniques.14,15 We prefer the term shortcuts. These are quick and easy processes for reaching conclusions that are correct only when common assumptions are justified. For example, “newer is better” is usually a reliable shortcut for choosing the best vegetables or computers, but often unreliable when choosing drugs. It is common to assume that most new drugs are superior, but only about 3% of new drugs offer real advances.16 It is normal to use shortcuts when faced with inadequate time, skills or resources to examine the evidence fully, or when the evidence required is not available. Some common shortcuts are listed in the Box. Drug companies are skilled at influencing prescribing by triggering the shortcuts that doctors rely on. For example, the “experts know best” shortcut underpins company-funded education. Drug companies also carefully choose visual and verbal images that appeal to our normal desires for power, respect, wealth, speed, simplicity, security and sex.10 There is evidence that advertising can be effective at influencing behaviour despite being given little attention.11 Subtle messages that might be rejected if carefully considered can sneak “under the radar” to create links between the indication, the product and the motivation. Repetition strengthens these links so that the product moves up the mental agenda to be the first to come to mind during decision-making. Promotional techniques are tools for good or ill depending on how they are used and what they are used for. Shortcuts often lead to correct conclusions, and desires can be appropriate. It is not possible to advance good causes without using promotion. To be successful at advancing the aims of Healthy Skepticism, we have to use the same techniques that we want people to be more sceptical about. However, we aim to use promotion honestly. This article uses all the shortcuts listed in the Box and appeals to most of the desires listed above. Developing healthy scepticism with AdWatchHealthy scepticism is difficult to promote because most people are confident that they already have an optimal amount. It is common to believe that only other people are susceptible to being misled. Dispelling this illusion of unique invulnerability is the key to improving discrimination between misleading and justified claims.15 One effective method for dispelling this illusion is to mislead people and then show them how they have been deceived. In one study, hospital pharmacists used the techniques of drug company representatives to mislead medical students and then explained the techniques.17 After the intervention, the students were less certain about the value of interactions with drug company representatives. We hope AdWatch will produce similar benefits by explaining the logical, psychological and pharmacological techniques used in drug advertisements. We will also use feedback from visitors to the AdWatch section of the Healthy Skepticism website (www.healthyskepticism.org/adwatch.asp) for dialogue with the companies responsible for the advertisements, the Medicines Australia Code of Conduct Committee and the government regulatory agencies. We have started with advertisements targeting Australian general practitioners but hope to develop editions for specialists and for other countries. Initial feedback to AdWatch from general practitioners, specialists, pharmacists and members of the public worldwide has been positive. An Australian doctor commented: “Unfortunately [the advertisement] had me sucked in for a period, but no longer.” Commonly used shortcuts for choosing therapies Newer is better. Experts know best. If there is mechanism for how it works, it works. If my peers are using a therapy, so should I. If the manufacturers give gifts, I should support them in return. If I see changes after prescribing a therapy, that therapy must be the cause.

Peter R Mansfield BM BS

All crew on deck. But keep the emotions stowed away Every doctor knows the feel of a medical emergency. You’re sitting at the nursing station when the patient in Bed 4 has an arrest. You’re in the middle of performing a routine procedure on a patient when the patient’s blood pressure plummets. You’re sitting in the emergency department when an ambulance paramedic commands your attention — “Two multitraumas, doc. They’re pretty bad.” Any normal person would be anxious or afraid or despairing, but you can’t afford to be. Your attention is focused on the problem at hand. You run through the possibilities and formulate a plan of attack. The fact that the person in front of you is likely to die in front of you is only another element in the equation. You can’t let emotions get in the way, or you’ll be less efficient and less likely to succeed. You are working in a surreal, glassy atmosphere, temporarily detached from your emotional life. That’s what is required in an emergency. For most of us, though, emergencies are rare events, or at least have been since we left our intern and resident days behind. But, for the staff of emergency departments, emergencies are an everyday affair. What effect does this have on the staff? Does the frequent need to switch off their emotions change them in some way? Does it alter their relationships with patients? Does it affect their private lives and families? No one doubts that exposure to traumatic events can have a profound impact on an individual. Post-traumatic stress disorder (PTSD) is well characterised and understood. People who experience PTSD often say that their most disabling symptom is a kind of “psychic anaesthesia”, which may manifest as a constricted emotional responsiveness. They complain that they have lost the ability to fully engage with other people or fully enjoy normal activities. Emergency department staff are not generally thought to suffer PTSD, but it may be pertinent to ask whether they experience some of the typical features of the disorder. Do they suffer a heightened general anxiety? Do they experience flashbacks of their work experiences? If so, we know very little about it, as there is almost no published material on the subject. In this issue of the Journal, four very different articles explore death in the emergency department from an individual perspective. Edwards (page 647) shares with us a very personal perspective on his experiences as an emergency physician. Using a uniquely Australian analogy, Edwards says he copes with deaths in the emergency department by donning a “Ned Kelly suit of armour”. As he looks back over his responses to a series of deaths, he wonders if his armour has remained a useful tool or become a prison. The metaphor of the man of iron is particularly apt given that the original suit was eventually to prove fatally flawed. Articles by O’Reilly et al (page 649) and Fulde (page 651) examine the care of homeless people in the emergency department. They present case histories of homeless patients who had become well known to emergency department staff and eventually died. Both pieces examine the question of what sort of relationship emergency staff can have with this kind of patient. Both play on the tension between the fantasy that the emergency staff were the homeless men’s “family” and the reality that the men had no family at all. Humour is a tried and true defence against emotional trauma, and Fatovich’s satirical study into the mortality of anonymity is as dark as it is funny (page 653). For all of these contributors, the feeling of having to switch off emotionally when dealing with a crisis is probably all too familiar. Every doctor has experienced the same feeling from time to time, but what can it do to you if you feel like that all the time?

Christopher J Ryan MB BS, FRANZCP · Robert P Dowsett BM BS, FACEM

Don your armour, but beware of the chinks I was recently showing my two young children around the grounds of my former high school, when I was reminded of our old school sergeant — the onsite caretaker of the school. He was a large man who would often drop unannounced into a classroom, stay for a couple of minutes taking in part of our lesson, and then leave. As pupils we had to stand on his entry and stand on his leaving — a somewhat distracting ritual for the pupils and teacher. The school sergeant would grab just a snapshot of our lives and learning, and leave. As I reflected on this, I began to think that his somewhat disconnected life with the pupils had similarities with emergency physicians’ relationship with death in the emergency department. Death is unfortunately part of the job of an emergency physician. The death I deal with is usually stark, sudden and shocking. It is often ugly — we are confronted with battered and bruised bodies, which we then further assault with pieces of plastic that protrude from various parts of the person. Having to tell relatives that their loved one is dead is never an easy task. Often what makes it even harder is that these relatives were talking to the patient just a few hours before, when the person appeared completely well, or, even worse, were present when the life-shattering event happened. A recent example was the case of a young woman who had been walking down the road hand in hand with her boyfriend when he was hit by a car. We were unable to resuscitate him in the emergency department. Having to break this news to the girlfriend, who was brought in uninjured a little later by ambulance, was not a task I relished. I spent as much time as I could with her, which on that typically busy evening probably amounted to no more than 10 minutes, and then left her with our social worker. I had a number of other sick patients to review, bed managers pressuring me to clear the department to make beds available for other patients lying on ambulance trolleys, as well as all the paperwork to do for the unfortunate young man who had just died. I was reminded of my school sergeant: I had popped into this young woman’s life — at a time of the most acute anguish and stress — and then rapidly moved on. I did in fact have to walk past her a few more times during the course of the shift while she was sitting with the social worker, but I made no more real contact with her. Despite feeling for her I had to move on — there were more patients to see. Back in 1997, I was part of a medical disaster team deployed to the scene of the Thredbo landslide. Our team was the last to be deployed, and our role was to deal with the medical needs of the over 1000 rescue workers and also to certify the remaining victims once they had been extracted from the crushed lodges. I was taken on a tour of the site — a tangled, flattened mess of concrete and metal — and was struck by the number of simple personal items of the victims that were still strewn around: books, photographs, toothbrushes and the like. This really brought home to me that the victims had had their lives so violently and unfairly taken from them and their loved ones. However, when I had to certify the last four victims — all cold, stiff and crushed — I performed this with perfunctory precision. In order to deal with these aspects of my work, I have developed something like a Ned Kelly suit of armour — an outer hard shell that protects me from the bullets of misery, anguish and stress of people sick and dying; a mask that prevents too much eye contact, and therefore emotional connection, while at the same time preventing the emotion within me from escaping and being seen in the raw. This piece of armour protects me by putting some emotional distance between me and the patients I am dealing with, and allows me to face the onslaught that working in an emergency department often is. But this Kelly suit concerns me. Does it mean, by definition, that the system and specialty in which I work requires that I don the suit to work effectively, or have I put it on myself because I have become somewhat hardened to the human tragedy I deal with? And, more importantly, whatever the answer to this “chicken or egg” type of question, how is this affecting me elsewhere in my interactions with patients as well as my day-to-day interactions with family and friends? I think a major reason most people go into medicine is because they like people and want to help them, and for me that drive is still there. However, the increasing workload and demands of the emergency department mean that I often feel unable to spend the appropriate amount of time with patients. At times I have to “cut to the chase” with them, and may therefore appear a little brusque or callous. That is certainly not my nature and was not how I started out as an idealistic intern. Does this mean I bring this armour and attitude home with me? Having two children under five certainly requires a lot of time, patience and understanding. I hope that I take the armour off when I am with them, but I can never be 100% sure. Having children has been both a help and a hindrance for my work. I certainly have a lot more understanding of the problems of parents, and I interact more naturally with my paediatric patients than I did before having children. But dealing with the death of a child is a lot harder now. I recall a 6-month-old boy in cardiorespiratory arrest who was brought in a couple of years ago. We worked on him for some time, but our efforts were ultimately unsuccessful. During the resuscitation I could not help noticing that this boy’s fair hair and looks reminded me of my son, who was around the same age at the time. I had to really fight back the tears as I ran the resuscitation, which I knew was going badly. In the past I did not have such an emotional reaction when resuscitating children. So perhaps that shows that the Kelly armour does have some chinks in it. Death in the emergency department constantly reminds me about the fragility of life, and the need to try to live life to the full and to spend as much time as possible with those who are close to you. The other day, a normally healthy 40-year-old woman was brought in after, as the jargon would say, “a witnessed cardiac arrest at home with bystander CPR”. We were unable to resuscitate her. The bystander attempting resuscitation was her 12-year-old son. Many of the patients I see now are in their 70s — the same age as my parents. Fortunately, my parents are both still active and healthy, but when that 70-year-old arrest is called through by the ambulance service on our “bat phone”, I can’t help but think sometimes that one day the patient could be one of my parents. I recently watched the broadcast of the singer Slim Dusty’s funeral, and although I didn’t know the man, I know his son, who is an emergency physician. The service was a very powerful one — one that had tears washing down my cheeks. They were tears of sadness for my colleague and his family, but also, in a tiny way, tears of joy for me, because it showed me that the Kelly armour was removable. They were tears of true and raw emotion. I was reminded again of school and some lines of a Les Murray poem I had studied: The man we surround, the man no one approaches simply weeps, and does not cover it, weeps not like a child, not like the wind, like a man and does not declaim it, nor beat his breast, nor even sob very loudly — yet the dignity of his weeping holds us back from his space, the hollow he makes about him in the midday light, in his pentagram of sorrow, and uniforms back in the crowd who tried to seize him stare out at him, and feel, with amazement, their minds longing for tears as children for a rainbow. (Les A Murray, An Absolutely Ordinary Rainbow.1 Reproduced with permission from the author.)

Keith D Edwards MB BS, FACEM

The human aspect of medical care that statistics ignore Historically, hospitals have acted as a refuge for the sick, the frail, the elderly and the infirm. In some instances, hospitals have been the last option for the less fortunate members of our society seeking help. Hospital emergency departments (EDs) are now one of the few agencies available 24 hours a day to assist people in crisis. But the ED is often stretched to the limit providing its services to all and sundry — encapsulated in the story of a composite patient, “Harry the Hobo”. It is a difficult working environment, in which the prevailing orthodoxy of economic rationalism focuses attention on funding measurable outputs. But our experience suggests that some “outputs” are difficult to measure and, indeed, shouldn’t be measured. At last year’s ED Christmas party, someone noticed that Harry hadn’t yet appeared in the ED. Harry always dropped in during Christmas week. In fact, it was in late November of that year that he had last visited. Some Good Samaritan passer-by had alerted the ambulance to a seemingly unconscious old man lying against the wall in an alleyway. When brought into the ED, he was immediately recognised by the triage nurse. “Harry, what have you been up to this time?” She knuckled him in the sternal area, to check his level of consciousness, and Harry roused with a “F... off!” before slipping back into oblivion. He reeked of stale beer, and pieces of his last meal were spattered down his front, making the hospital gown he was wearing almost unrecognisable. But his tweed cap remained glued to his head, and his brown jacket and socks were on, the latter recognised more by odour than colour. “Put him on that trolley in the corridor there”, the nurse directed the ambulance staff. No observations were done. Why would you? This was Harry. The ED on that night in November was bursting. There were no beds in the hospital, but no one bothered any more to ask why. The only reason the department was not on ambulance bypass was that every other hospital was on bypass already. To move to bypass would create “gridlock”, a consequence that could not be contemplated. So Harry wasn’t very welcome that night. Mind you, he had been only begrudgingly welcome for some years. He was a source of frustration nowadays. Years ago, when his name came up on the screen, the cry of “there’s a good patient for the Intern” would come up. On this occasion, the Emergency Consultant was beckoned by the Nurse in Charge to come and “get rid of him”. Harry’s history notes arrived, or at least the last two volumes of them. Harry’s presentations actually seem to have shortened as the years have passed. His diagnoses have included chronic “burnt-out” schizophrenia, head injury from falls and assaults, atypical chest pain that had been investigated relentlessly, atrial fibrillation for which he was once taking warfarin, haematemesis, melaena and alcoholic liver disease. But few of these have been active components of his presentations in this, his eighth decade of life. Mostly he wakes from his ethanol-induced stupor, and shouts a few expletives relating to his desire for the bottle (urine) and for sandwiches and a cup of tea. On this occasion, he was rehydrated with normal saline. As he had no fixed abode, and given that it was 11 pm, Harry slept on his trolley overnight and left in the morning. His cap stayed on throughout. Over the years, Harry has spoken to many psychiatric triage nurses and many social workers. He used to stay in a men’s boarding house, but was evicted on multiple occasions. Now he sleeps “rough” and his patient registration details record him as being of “no fixed abode”. With no living or caring relative, no general practitioner that he bothers to visit, and no regular publican to have a yarn to, he has nominated the hospital as his next of kin. His most frequent ED diagnosis these days is loneliness. Harry may be lonely, but he is not alone in this regard. For people at the margins of society, the local ED can be a place of solace. Maybe this is more pronounced since the reduction of institutionalised accommodation for people with chronic psychiatric conditions, maybe not. Either way, no manner of community follow-up and support networks can fill the void of loneliness. So into the ED comes a group of people seeking aspects of attention that are often disregarded when assessing clinical workload. They may be young or old, male or female. One study of “unnecessary” ED attendances at a tertiary hospital in Melbourne found that 41% of repeat attenders were homeless.1 They may present with atypical chest pain, a conscious collapse in front of the triage nurse, a request for a repeat script for “sleeping tablets”, or a rash of 6 months’ duration. In the waiting room they may chat to fellow patients or catch up on the football displayed on the television. Often they “entertain” the security guards. Once they “break through the department gates” they may get a trolley, where they can choose to sleep or sit up and observe all the activity around them. The place is warm and active. The frowns or firm words of the staff don’t seem to bother them. Being woken up does though, and their colourful vernacular adds to the liveliness of the work environment. A warm cup of tea, some carrot-filled sandwiches, even a shower and some clean striped clothes from the cupboard — these are some of the “perks” of a visit to the ED. This type of patient challenges doctors and nurses alike. They are an ever-present nuisance, a source of frustration. Trolley space, nursing and medical assessments, food and toileting — these resources are already heavily stretched but nevertheless expected to repeatedly cater to the needs of Harry the Hobo and those of his ilk. Medical care is now heavily regulated and constantly measured. In the ED we must measure waiting times, length of stay, complaints and adverse events, which are then benchmarked against key performance indicators. Workload indices, such as attendances adjusted for casemix, need to be calculated. Patient satisfaction surveys are scored and the results compared with those of other health services. Registries keep a record of outcomes for trauma and other diseases, and various surveillance agencies monitor the incidence of injury and infectious disease. Staff morale is measured by staff turnover, staff satisfaction surveys, and days lost due to sick leave. On the basis of these numbers, management is rewarded or punished and hospitals survive or perish.2-5 With all these measurements and management reviews being conducted, surely a proportionate degree of funding and resources is being allocated to providing “tender loving care” to Harry the Hobo and others like him. Well, no, it isn’t. How do we begin to incorporate such care packages into our workload indices? Should we begin by measuring the vocabulary score? — that is, how many expletives were uttered that we really didn’t wish to hear. Or maybe by Harry’s aroma score and its effects on the environment we work in? Surely showering time, undressing and redressing time are easily measurable. Department “warmth” consumed by the patient might be difficult to measure, as would the pleasure felt by the patient in being recognised by staff. At the very least, though, we should have an index for the number of carrot sandwiches consumed. In mediaeval times, the burden of care for the “not unwell but merely unfortunate” fell on the Church. In 19th century Europe, the mass urbanisation associated with the Industrial Revolution increased the marginalisation of the dispossessed, with the concurrent expansion of multiple secular charities.6 Today, the “Salvos” and the Red Cross Society are just two of the many organisations that serve the so-called “castoffs” of modern-day society. And, despite the economic rationalism of the 1980s and 1990s, health services have attempted to maintain some flexibility in catering for those “consumers” who do not fit neatly into an “illness category”. The ED provides 24-hour access and, thankfully, can refuse admission to nobody. For many people it serves as a refuge, a source of basic comforts and basic human values. It becomes their family. We cannot and should not even attempt to measure the delivery of this service. Indeed, any measure would devalue its true worth to the beneficiaries themselves and to the staff who provide it. One could imagine a situation in which hospitals might adjust the “loneliness score” or manipulate the “compassion index” to maximise income. But the service that is being provided is one of human kindness and compassion — the basis of a civilised society. This human aspect of medical care should be acknowledged and celebrated, rather than measured. Harry the Hobo did eventually visit the ED on Christmas Eve. He had been found cold and unconscious, and on this occasion wasn’t moving his left side. In addition, it appeared that he had subsequently aspirated and now was in respiratory distress. It was clear that this would be Harry’s last visit. He was taken inside immediately, and when the treating nurse saw the tweed cap beside him on the trolley, she realised who this dying man was. The cubicle was quiet and respectful, and the doctor and nurse applied some oxygen, delivered some hydration, and ensured that Harry was comfortable. He died several hours later. Harry was at home with his family for Christmas.

Gerard M O'Reilly MB BS, FACEM · Alfredo Mori MB BS, FACEM, FFAEM · Peter A Cameron MB BS, MD, FACEM

Why do some “frequent flyers” of the ED gain a permanent place in our hearts? Recently, the death of a homeless man who had lived in a bus shelter next to our inner-city emergency department (ED) for a quarter of a century made national and international headlines.1,2 Here, I present the story of this man’s relationship with the ED and also describe our involvement with two other homeless men. Then, I ponder why it is that patients like these can make such an impact on the healthcare workers who come in contact with them. Karl, the bus-stop manAlthough Karl did not present as a patient every day, we saw him in the ED every day, as he used our waiting-room toilet as his own. We found him to be a very quiet, private, polite, kind and gentle man. The nuns and hospital staff (especially the nurses and social workers) would give him tea, biscuits and sandwiches when he visited, but rarely did he accept other offers, such as assistance in securing alternative accommodation. He lived in a corner of a nearby bus shelter, and neither he nor the shelter could be considered pleasing to the discerning nose. We repeatedly tried to coax him into the ED for a clean-up and a new set of clothes. On the odd occasion he did accept the offer of a clean-up — notably on Christmas Eve in 1993, when the hospital notes document that the nurses handwashed his clothes when he wouldn’t part with them. He even allowed us to trim his beard a little, and we did think he looked rather like a Santa Claus. Perhaps it was because of his Christian background that Christmas was the only time he ever seemed to truly relax and enjoy being in the presence of the ED staff. Perusal of Karl’s medical record reveals only seven official attendances, including three overnight admissions under my name. In spite of a past history of alcohol misuse, his health problems had been limited to chronic venous insufficiency, swollen legs, cellulitis and scabies infestation. During one admission, an ED registrar had asked jokingly, “Is it Karl’s birthday?” (in fact, we didn’t know his date of birth, and never did find out). On another occasion, during winter, I had admitted him overnight simply because the outside conditions were harsh and he was fearfully cold. In September 2002, Karl was found dead, of natural causes, in his bus shelter. The outpouring of sympathy for this unassuming man, who had become such a “fixture” in the life of the ED, was amazing. Even in death, his life was an enigma. From what could be pieced together from the locals — people whose children he had helped to catch the bus, shop owners and waitresses from whom he had bought or had received gifts of coffee and food (including bacon sandwiches — his favourite), nuns who crossed the road near his bus shelter on the way to and from their convent (whom he uniquely acknowledged by accepting their gifts and offering a smile and ever-so-rare words), and the nurses whom he had looked out for in the dark as they returned home after working a late shift — it became apparent that he had had a daily routine, a circuit. But he had never let us get to know him and never revealed anything about his history. We felt he was a loner by choice and we respected that choice. Unlike other homeless people we saw in the ED, he was never seen to be intoxicated, rude or aggressive. Karl was a man who spoke with his eyes rather than with words. When he died, many of us truly grieved for this kindly, silent, bearded figure. Harry, the newspaper manAnother younger, homeless man evoked a similar feeling of loss upon his demise — this time, the death actually occurred in our ED. I have written of his case previously,3 partly because of its general medical relevance but also because I found myself, like many others in the ED, emotionally affected by it. Harry was a scrawny, wiry man of 40-something who looked a great deal older than he actually was. We frequently saw him in the streets around the hospital. Any greeting of “Hullo” or “Good morning” that we gave him was returned with gusto. We knew him as the man who sold newspapers. We thought this was his way of earning a little more money, as we knew that he drank. He never talked about himself and never asked for a handout. I remember clearly the morning he was brought into the ED by ambulance, having had a witnessed collapse. Quickly it became evident that he was critically ill — he had septic shock secondary to cavitating pneumonia (Box). However, once we had reversed his profound hypoglycaemia (0.7 mmol/L) and commenced to warm him up from his hypothermia (33.5°C), he just kept apologising to us for being a trouble. Over the subsequent hours, we tried to save his life, and did successfully bring him through a broad complex tachycardia. All the ED staff, including non-healthcare staff, were focused in their concern for him, with everyone requesting frequent updates. Unfortunately, we lost him following an arrest. Although he put up an amazing fight, advanced resuscitation, including defibrillation, could not save him. The ED staff went quiet in their grief. Many, including myself, shed a tear. We knew this patient and he had expressed his appreciation of our efforts — even as he was dying. It turned out that he, like Karl, had been a loner. Before he died, he asked us to contact his only friend — the newsagent who supplied him with papers, basic accommodation and the sincere care that only a friend can provide. There were no relatives and there was no past we could piece together. His absence from the neighbourhood haunted us long after his death. “John”, the “scratchie” man“John”, a street person with drug use issues, is one of our most frequent attendees currently. He is highly intelligent, very manipulative, and almost totally non-compliant with antibiotic therapy for a septic knee and sundry other complaints. Even when coaxed to stay in the ED for treatment once difficult intravenous access has been established, he manages to escape several times a day on crutches or on one of our wheelchairs (generally by using the ruse that he is going out for a “smoke”). On one such outing, he bought a lottery “scratchie”, and on his return asked a nurse to check whether he had won anything. For a while there, we all thought he had scratched himself $50 000; he was festively congratulated and we were all very happy for him. When it turned out that an unfortunate minor technicality meant that he just missed out on his prize, the ED staff immediately passed the hat among themselves so they could buy him another couple of scratchies. DiscussionMany homeless and disadvantaged people use the ED as their main point of access to healthcare and social care.4-6 Outside normal working hours, calling in at an ED may be the only practical option available to them. The three cases described here illustrate the bond that can develop between ED staff and the homeless people who visit at irregular times. ED staff will know which of their regular visitors are living “rough”, either by their address (“no fixed address”, multiple changing addresses, or homeless shelter address cited in the medical record), or by talking to other staff or the patients themselves. Maybe it is because EDs are always available and the staff will, with each presentation, listen to the homeless person’s issues, talk to them and try to work out something for them, that there develops a caring bond between the homeless and ED staff. Why do we care? I have mused often about this question and have asked my staff for their thoughts on the matter. The demanding work of an ED tends to attract staff with certain qualities in common. One is our need for gratification — we want to do things and see results, despite the difficulties. This is not necessarily an easy task — many (but not all) homeless patients are “hard work”. They may present to the ED in a confused or demented state; they may be anxious or plain scared. Some fight to reject any care offered to them; others, because of their personalities, mental-health and/or substance-use disorders,7,8 may be overtly rude, aggressive, and verbally and/or physically abusive to all around them. At times we get frustrated and upset, but over time we get to know each of their names and their individual needs. We are persistent, trying over and over again to help them. With each new presentation, both “sides” may begin their “games” anew. Whether the homeless to us, or we to them, become familiar or even “family”, I think all ED staff, on the whole, feel privileged to be in a position to offer not only core healthcare but also comfort and help to homeless people. This is, I believe, why we are so sad and reflective when we lose one of them. Chest x-ray of Harry, showing cavitating pneumonia

Gordian W O Fulde FRACS FRCS FACEM

The pros and cons of anonymity For a small proportion of the patients who attend an emergency department, no name can be elicited. Of the 51 628 attendances at the Royal Perth Hospital Emergency Department in the 2001–02 financial year, 84 (0.163%) were made by 78 patients who were recorded as having no name. I hypothesised that unknown people would have a worse outcome (in particular, a higher death rate) than those with a name. I present here a descriptive analysis of a study I conducted to test my hypothesis. Of the 78 unknown patients who attended the emergency department, 56 (72%) were male (mean age, 32.9 years; range, 2–76 years; median, 31 years). Subsequently, patient names were able to be assigned to 36 (43%) of the 84 attendances. There were six deaths (7.1%) in the 84 attendances without a name, compared with 840 deaths (1.6%) in the 51 544 attendances with a name. This represents an odds ratio for death in the unknown group of 4.6 (95% CI, 2.0–10.7). (This figure, calculated by Woolf’s method, is based on the number of attendances. An alternative approach is to use the number of patients. Preliminary data for the latter also indicate a statistically significant result.) Of the six unknown patients who died, five were male (mean age, 38.3 years; range, 25–52 years). Four of the deaths were a result of trauma, and two were from medical causes. Of the six deaths in the unknown group, five occurred in the subgroup who were subsequently identified (effect size, 11.5%; 95% CI, 6.9%–16.1%). Review of these findings has led me to consider a prospective trial wherein patients attending the emergency department without a name would be randomly allocated to either receive a name or remain nameless. As the data clearly suggest that having a name is protective, an ethics committee will need to consider whether a permanent name change by deed poll is required to maintain this protective effect. On the other hand, the protective effect of having a name appears to be a “one off” benefit, as patients who are subsequently identified are more likely to die. I recommend that hospitals adopt the evidence-based approach of ensuring that patients remain unknown throughout their hospital stay in order to improve their outcome. Further study is required to determine whether the lives of these patients will be in danger once they resume their identity.

Daniel M Fatovich MB BS, FACEM

To the Editor: In 1964 the Journal published an article by Barnes which solved the mystery of a distressing illness that was affecting many Queensland beachgoers — Irukandji syndrome.1 In a remarkable piece of detective work, Barnes had captured a small (25 mm bell) jellyfish and demonstrated, by allowing it to sting himself, his 9-year-old son and the on-duty lifeguard, that this jellyfish caused Irukandji syndrome. All required inpatient care. This jellyfish was named Carukia barnesi in his honour, and has been known as the “Irukandji jellyfish”. Many now believe that more than one jellyfish is responsible for Irukandji syndrome. Significantly, in the 40 years since Barnes’ discovery, no other jellyfish causing Irukandji syndrome has been identified. Here we present evidence of an identified unnamed jellyfish causing Irukandji syndrome. This information is further to a case we have previously reported, of a 24-year-old woman who developed Irukandji syndrome after being stung while snorkelling on the Great Barrier Reef.2 By the time she arrived in the emergency department she was in severe pain, had hypertension and tachycardia, and had clinical and echocardiographic signs of left ventricular failure. She was intubated 24 hours after being envenomed, and required inotropic support for 72 hours and ventilation for 8 days. Her troponin level peaked at 72 μg/L (normal, < 0.7 μg/L) and her echocardiogram demonstrated severe cardiac dysfunction, with a cardiac index of 1.7 L/min/m2. She recovered fully and was discharged home 14 days after admission. At the time, a 2 mm piece of tentacle (Box [a]), and one nematocyst (species-specific stinging cell; Box [b]), was collected from underneath the pressure immobilisation bandage on the sting site. Although we were confident that this tentacle did not come from C. barnesi (Box [d]), we were unable to identify the jellyfish. One of us (J S) has been reviewing collections of jellyfish. In the Queensland museum collection he examined a small, unnamed jellyfish (Box [c]) which was morphologically different to C. barnesi. This “new” jellyfish had gastric cirri (absence of gastric cirri is a specific characteristic of the genus Carukia) The nematocyst from our patient (Box [b]) matched the nematocysts from the Queensland museum specimen (Box [e]). We have thus identified an unnamed jellyfish whose sting resulted in life-threatening cardiac failure associated with Irukandji syndrome. This case confirms that more than one jellyfish is responsible for Irukandji syndrome. We propose that C. barnesi should no longer be known as the “Irukandji jellyfish” but the “Barnes jellyfish” in honour of its discoverer. A piece of tentacle and a nematocyst from the patient, compared with a tentacle from Carukia barnesi and with nematocysts from an unnamed jellyfish

Mark Little FACEM, MPHTM · Jamie Seymour BSc(Hons), PhD

To the Editor: The Irukandji syndrome can cause severe hypertension (over 220/110 mmHg)1 and has caused two fatalities from cerebrovascular haemorrhage.2 There is no first aid treatment for the severe pain or hypertension, so developing an effective prehospital treatment is a priority. The venom from the jellyfish that causes Irukandji syndrome (Carukia barnesi) is a sodium-channel agonist which causes massive release of noradrenaline.3 Intravenous magnesium sulfate has proven to be an effective treatment for the symptoms of Irukandji syndrome,4 but requires in-hospital monitoring. We investigated the use of sublingual glyceryl trinitrate spray (GTN), which is a vasodilator, in three sting victims, in whom it appeared to effectively control hypertension. Three patients with clinically confirmed Irukandji syndrome were given one puff of GTN sublingually for hypertension. Blood pressure (BP) was checked every minute for 5 minutes (by electronic sphygmomanometer). Further puffs of GTN were given every 5 minutes, with the aim of reducing the diastolic pressure below 100 mmHg. The treatment and clinical course of each patient is described. Patient 1 was a 43-year-old man with severe Irukandji syndrome (adrenergic symptoms, severe low-back and muscular pains) who presented 40 minutes after Carukia barnesi envenomation on an island in the Whitsundays. Despite being given 10 mg morphine intravenously, his BP was 200/112 mmHg. One puff of GTN was given, and after 5 minutes his BP was 180/120 mmHg; another puff reduced it to 170/110 mmHg, and 10 minutes after a third puff it was 160/100 mmHg. After transfer to a mainland hospital, his clinical course was stormy. His hypertension was poorly controlled by intravenous magnesium and he required intravenous nitrates and morphine. Patient 2 was a 49-year-old man with pain (for which 10 mg morphine and 50 mg promethazine were given intramuscularly), adrenergic symptoms and a BP of 182/110 mmHg 25 minutes after Carukia barnesi envenomation on a Whitsunday Island. One puff of GTN reduced his BP to 170/96 mmHg within 5 minutes; a second puff reduced it to 140/90 mmHg at a further 5 minutes. His BP remained at this level until he was transferred to hospital an hour later. Patient 3 was a 33-year-old woman with pain (treated with 10 mg morphine and 50 mg promethazine given intramuscularly), adrenergic symptoms and mild hypertension (143/98 mmHg) 35 minutes after Carukia barnesi envenomation on the same Whitsunday Island. She was given three puffs of GTN, which reduced her BP to 130/80 mmHg after 30 minutes. None of the three patients had pre-existing hypertension, or took medication. GTN reduces hypertension by vasodilation, and is now recommended for hypertension from dysreflexia in patients with spinal injury,5 in whom similar high levels of serum catecholamines occur. Further assessment of GTN use in patients with Irukandji syndrome is necessary, but we believe it should be considered as prehospital treatment under medical guidance. It is currently the recommended treatment by Ambulance Officers in the Queensland Ambulance Service.6

Peter J Fenner MD · Morris Lewin FACOG

Background: The numbers 4, 14 and 24 are associated with death for Cantonese-speaking Chinese people, as the words for these numbers sound like the words for “death”, “must die” and “easy to die”, respectively. A previous study in the United States investigating psychological stress engendered by fear of the number 4 found more cardiac deaths in Chinese and Japanese people, compared with white Americans, on the 4th day of the month.Objective: To determine whether more cardiac deaths occur in Hong Kong Chinese people on the days of the month with “deathly connotations” (4, 14 and 24).Design: Analysis of mortality data (1995–2000) of the Chinese population of Hong Kong from the Census and Statistics Department of the Hong Kong Government for these three days of the month, compared with the remaining days, according to both the Gregorian and Lunar calendars.Results: There were 17 346 cardiac deaths registered under ICD-9 codes 410–414 in 1995–2000. The mean (+ 1 SD) of the cumulative number of cardiac deaths on each day of the month was 587 (+ 30) for the Gregorian calendar or 573 (+ 24) for the Lunar calendar. The mean number of deaths on the 4th, 14th and 24th day of the month was not significantly different from the mean number of deaths on the remaining days of the month.Conclusion: Our study of Hong Kong Chinese people does not support the concept that more cardiac deaths occur in Cantonese people on the 4th, 14th and 24th day of the month.

Nirmal S Panesar BSc PhD · Noel C Y Chan · Shi N Li · Joyce K Y Lo · Vivien W Y Wong · Isaac B Yang · Emily K Y Yip

Objective: To test for the presence of sex-based differences in perception (the notion that men and women “think” differently, and that differences in perception are biologically based) among healthcare professionals.Design: Prospective survey.Setting and participants: 90 medical personnel at a tertiary care hospital in Newcastle, NSW.Intervention: Healthcare professionals were shown two pictures that could be interpreted as depicting either a young or an old person, and a word that could be seen as geometric shapes.Main outcome measures: The effects of sex, age, seniority, and specialisation in relation to the first impression of the image, the ability to change one’s perception, and the speed of perception.Results: Contrary to popular opinion, male physicians were more likely to perceive the older figures, and just as likely as women to be able to change their perception. Surgeons and junior staff were more likely to see, as well as being faster to form, an impression requiring abstract thought, and were more able to change their perceptions.Conclusions: Traditional sex stereotypes do not apply to medical personnel, but other age-based stereotypes, and professional rivalries (medical versus surgical) may have some empiric basis.

Balakrishnan (Kichu) R Nair FRACP, FRCP · Stephen R Mears DipIM · Karen I Hitchcock BA(Hons), BMed · John R Attia MD, PhD, FRCP(C) · Steven J Bowe MMedStat

We’ve downsized and upgraded, We’ve amalgamated too. We’ve splurged, and surged, and urged, and merged From here to Timbuktu. There’s just one little problem, With all that we’ve been through, We can’t remember what it is That we were trained to do. (Anonymous administrator) The hospital system the world over is in turmoil. The burgeoning cost of healthcare is ignored by governments more concerned with weapons of mass destruction than trivial matters such as the health of the nation. Even the perpetual smile on the faces of the Public Relations Department personnel has become fixed into a risus sardonicus. Is there no cause for optimism? Of course there is. When things look particularly grim, we should never neglect the past. There is always the option to look back to the future. As patients increasingly turn to alternative medicine, we suggest embracing a combination of the ancient philosophies, such as feng shui (a belief that energy can either flow or stagnate according to the shape of one’s surroundings, determining success or failure in any endeavours), and the contemporary, holistic approach to medicine. Holism is the concept that, in the function of complex systems, the whole is greater than the sum of its parts. Until now, hospital medicine has lacked a holistic approach. Indeed, it might be suggested that hospital administration has adopted the opposite approach, in which the whole is less than the sum of its parts. Consequently, in this article we propose a hybrid model for changes to the hospital milieu, incorporating practices inspired by ancient philosophies and holism, in the pursuit of improved healthcare delivery for patients, clinicians and administrators alike. This model will be known as the Hospital Intergenerational Transcultural Solution, or “HITS”. Hospital AdministrationBefore HITSThe Hospital Administration’s main role is to write a Mission Statement. This should not be confused with the Vision, which is in the realm of the Almighty (see Box). The Vision, usually shared by a select few, transcends the immediate tangible concerns of clinicians and, indeed, transcends reality. Mission Statements resound with platitudes, even though it is widely acknowledged that platitudes are the last resort of the intellectually destitute. For example, the standard children’s hospital Mission Statement aims to “improve the health and wellbeing of all children”. The major advantage of such statements is that it is impossible to argue with their sincerity and impossible to evaluate them. After HITSIt has been said that leaders are born and not made. But why not both? The genetically modified administrator (GM-A) of the future will have all genes for empathy deleted and replaced by genes for transcendental obfuscation. All members of the executive will be dressed along the lines of the Raelian cult, pending the first successful cloning of an administrator. For the inner spirit to escape the confines of the daily routine, the hospital boardroom will be refurbished with futons and a small but tasteful jacuzzi in the corner. The Vision will be placed in the hands of a new Department of Iridology. Finance DepartmentBefore HITSThe modern Finance Department aims to correct the archaic notion that a hospital’s primary role is patient care, and re-direct it to revenue raising. The MD should defer to the MBA. When revenue raising proves too difficult, the modern Finance Department turns its hand to revenue recycling: each department bills other departments for services rendered, ensuring the circulation of imaginary money to the extent that rational budgeting is impossible. This cleverly hides the fact that the Finance Department is incapable of rational budgeting. Any clinical department hoping to achieve an increase in its working budget is advised to read Beckett’s Waiting for Godot. After HITSAs all hospital departments will be created equal, there will be no need for a Finance Department. Instead, there will be a Community Chest, shared on the basis of harmony and mutual goodwill. Over the Chest will be a framed photograph of the Director of Finance, clad in saffron robes, with a garland of rose petals. Candles and incense will be available for purchase, all profits going to the Community Chest. A barter system will be introduced for staff. For example, staff may elect to be paid in kind with offers of coronary artery bypass graft surgery instead of long service leave. In an innovative strategy, patients will be charged on a step-by-step basis once they enter the hospital. Those in wheelchairs or on trolleys will be charged per wheel rotation. This is considered a revolutionary approach to finance. Service Improvement UnitBefore HITSPreviously known as the Quality Improvement Department, the Department of Continual Improvement, or the Department of Perpetual Audit, this fashionable construct of redeployed middle management thrives despite the fact that none of the quality improvements can be quantified. Put simply, Quantity begets Quality. After HITSThe Service Improvement Unit will confine its activities to helping executive staff play better tennis. Public Relations DepartmentBefore HITSPublic Relations is believed by those working there to be the most important department in the hospital, responsible for Corporate Image, which necessitates changing the hospital logo with bewildering frequency and pestering the press to a greater extent than the press pester anyone else. After HITSThe PR Department will be painted beige to emphasise calm, belying the turmoil of bed shortages. A glass “ideas box” will be situated on each Departmental member’s desk, and emptied annually, if necessary. Photographs of the smiling “Fundraiser of the Month” will become mandatory screensavers on the computers in all departments. SummaryOur advocacy of the introduction of HITS to the hospital represents an attempt to meet the needs of the modern patient and adhere to the expectations of clinical governance using a root-cause analysis approach in a no-blame culture. Notwithstanding these ever-present administrative mantras, we would implore you to embrace the concept of holism whole-heartedly. Academic and General Misinformation, and Staff Re-Education 1: Current operational model of devolved responsibility

Dominic A Fitzgerald MB BS, PhD FRACP · David Isaacs MD, FRACP, FRCPCH

Quotes from MJA contributors in 2003 Ever since the Medical Journal of Australia was first published in 1914, the library-like atmosphere that usually pervades our premises (reflecting the quiet industry within) is occasionally shattered by an exclamatory outburst. Such fractures of the usual peace and quiet can be perpetrated by any of our editorial staff, and can signify joy, indignation, solid agreement, pure amazement or other sundry emotions. Outbursts usually occur on reading a submission to the Journal — be it a manuscript, a peer reviewer’s report or other form of correspondence. The general effect is to make the working day all the more enjoyable! This year, the Journal’s new, modern open-plan office has facilitated a sharing of these moments. Here, we share with you a selection from our discerning collection of putative, causative agents in the hope that you, too, will gain some measure of sonorous pleasure in the reading of them. The quotes are real life and presented in raw form, although we could not curb our habit of arranging (and rearranging) material being considered for publication in the Journal. Further, in deference to our journalistic colleagues, we have chosen not to reveal our sources. Some of you may recognise that a few of these excerpts are already in the public domain. In acknowledgement of the good sense of the penultimate quote, and our admiration for all statisticians, we leave any analysis of these data to the experts. Lastly, we wish to thank all of you for your contribution to the Journal. You are all esteemed by us, whether you be an author, reviewer or reader. What’s in a title?“Adverse event reporting in clinical trials: regulatory tail wags the research ethics committee dog, distracting the latter from more useful activity” Gender issues“Most women live in an environment that is also populated by men.” “Seven of the nine patients who developed neurological sequelae were female and the rest of them were male.” All in a day’s work“My apologies for the delay in getting this [economist’s review] back to you but it really is about time that you guys worked out a cure for the common cold.” “I am not sleeping until I get a draft revision to you. I have not heard from my co-authors as yet. I will keep you posted. Time: 3.30 am.” Making a statement . . .“Cardiac arrest is more successfully treated in Chicago or Heathrow airport, or an American Airlines or Qantas jet, or in a Boston post office, than in the vestibules, corridors or general wards of Australia’s premier hospitals.” “Declaring war and prescribing drugs are decisions dependent on information. If that information is incomplete or inaccurate there can be calamitous consequences.” “The Academic Clinician is well recognised to be a breed on the verge of extinction internationally, and this sort of program is the last great hope for ensuring its survival.” ArbitrationOn occasion, the Journal’s editorial committee asks a reviewer to help us out when an author and responder are at odds . . . the exercise generally proves fruitful! “In both of his letters, the author uses analyses which aren’t correct. In fact, his second letter misses the [critic’s] point entirely, since he repeats his error. The responder [critic] adopts the correct method. The story may be recast this way: Author: 1 + a = apple. Responder: The correct method is to compare like with like. If you compare dissimilar things, you get a third, uninterpretable thing; 1 + 1 = 2. Author: Don’t look at me. When I contacted my source, I was given the information I got. Oh, and by the way, I also found that 1 + b = orange. I will venture to say that arguments made on the basis of faulty statistics are themselves faulty. I would suggest that the author seeks professional statistical assistance to clarify his analysis.” End-note“The conclusions end on a note that is remote from the key of the paper (to use a musical analogy)”.

Ann T Gregory MB BS, GradDipPopHealth

a female practitioner with young children working part-time in the country faces many challenges. One particular morning I was looking forward to a 7 am paediatric journal club meeting to be held by teleconference. There are only six a year, and they are sponsored by the Royal Australasian College of Physicians and chaired by Michael Williams from Mackay in Queensland. They are well organised, well presented and packed with information. The night before the meeting I was feeling very positive about it. Why? I’d remembered the date and time of the meeting for a start, the pre-reading material had arrived and I’d read through it, the kids seemed to understand the pre-telephone meeting talk and I had a cloth nappy folded up ready on our home-office desk next to the phone. Everyone knows telephone meetings require minimal background noise — a remote possibility in a dedicated room in a hospital, but impossible in a “reality” home like ours, with polished floorboards and young children. So I always try to remember a folded up (clean) nappy to put over the mouthpiece of the telephone in an attempt to keep our family decibels out of the meeting. Coincidently, that night I’d also had a phone call asking if I would speak on the radio about a local charity that had donated items of equipment to the hospital. At 6.50 am things were still going well. All the kids were up, had eaten breakfast and were toileted (thus decreasing the possibility of any, “Mummy, I’m hungry” or “Mummy, I need a wee” requests over the next hour). I’d even washed the dishes (it doesn’t take long to learn that Weetbix left on plates quickly turns to cement). The children and I had another pre-telephone meeting talk — they were reminded that, for the next hour, all they had to do was be “quiet friends.” When I dialled the teleconference number, a polished adult voice told me to enter the account number and pin number. My husband had been away for five days so it was great to hear another adult voice, even if it did turn out to be a prerecorded message! I entered the numbers and was told I would be switched through to the conference. Several minutes of soft classical music passed but still no conference. I hung up and dialled again. This time, I was in luck. The meeting was informative and the kids were good, so I was really enjoying the education. Suddenly, during discussion of a paper reviewing meningococcal meningitis, there was a terrible din outside. Our three kelpie working dogs had found a kangaroo on the front verandah. Why, at the time of a medical telephone journal club meeting? There had never been a kangaroo on the verandah before. Of course nature took over and the dogs chased the kangaroo. Very soon they were all caught up with kids’ bikes, toy jumbo trucks and the wheelbarrow in the carport. The dogs barked at the kangaroo and the children yelled at the dogs. I doubted that the folded nappy could contain the noise and was about to hang up, when thankfully the kangaroo disappeared. There were no more hiccups. Immediately after the conference I returned the nappy to the cupboard and headed for the toilet — to find no toilet paper —explaining one of the “quiet friends” activities! As I collected more paper, the phone rang. It was the radio station. They needed to pre-record their interview now. It really wasn’t the ideal time. I hadn’t thanked the children for their efforts during the phone meeting; I hadn’t warned them that for this particular phone call I needed “silent friends;” I hadn’t received the faxes giving me the complete background information; and I still had the toilet roll in my hand — but I agreed to proceed. The interview started well, but before long world war house broke out. The four children, who now sounded like 44 children, were sick of being “friends” and needed my attention. I asked the interviewer to stop the tape while I settled the warriors. I was under a bit of pressure. There was no button on our phone to give the caller soft classical music, and I’d put the folded nappy away, so I tried gentle cajoling, explicit body language and my best “cross mum” frown. (Isn’t it a relief we have telephones in our homes and not videoconferencing?) I tried to explain that I was on the radio, but they are country children. Puzzled, the eldest spoke up, “Mum you’re not at the rodeo, you’re on the phone.” Finally they settled and the interview was continued. When it was all done, still feeling a little hassled, I apologised again to the interviewer for the children fighting. “Oh, no problem,” she replied, “It’ll be great on the regional news!” and hung up.

Susan M Gorton

Doctors are often criticised for failing to communicate adequately with their patients and for using medical jargon. But what about “patient speak” — those words that are nearly what we thought we meant? This collection of medical mispronunciations has been carefully recorded in a notebook (yes, one from a pharmaceutical company) kept in the top drawer of a suburban general practitioner's desk, and edited over dinner by the medical members of the family: we share them with you for the festive season. The obituary gland seems a sad place to start. Moving down the ophagus tube, past the broccoli, a fundoapplication may help. You may recognise the psychiatric nerve, but what about the haricot veins? The introverted uterus is a little shy, but the crucial ligaments are obviously important. Platinums and playtex are everywhere. (Pituitary gland, oesophagus, bronchi, fundoplication, sciatic nerve, varicose veins, retroverted uterus, cruciate ligaments, platelets.) Having sorted out the anatomy, the various ailments are next. There are many inflations in the vocabulary. Does the human Pavarotti virus affect the vocal chords? What organs are involved with a hippopotamus or a helicopter? (Inflammations, human papillomavirus, hypothalamus, helicobacter.) For the surgeons, we need help with the biblical hernias and erupted spleen. It may be a little more difficult to decide which specialist to refer a fractured zygote, a utopic pregnancy, bunyips, painful anodes and the occasional Arnold Curarie. (Umbilical hernias, ruptured spleen, fractured zygoma, ectopic pregnancy, bunions, nodes, Arnold Chiari malformation.) We could probably send the pigsty, cellutosis, cradle crop, scarytosis, and ectopic eczema to the dermatologists (if they are not at a conference in Barcelona or Melanesia), but who treats septic ulcers? (Stye, cellulitis, cradle cap, solar keratosis, atopic eczema, basal cell carcinoma, melanoma, peptic ulcers.) The respiratory physicians, with their stereophone can move from sleep apathy to bronchial ecstasy, but should postnatal drips and reproductive coughs go to them or the obstetricians? Even more confusing are Alka Seltzer's disease, tetanus and tendonitis, which are not what they seem. The physicians could investigate grout, osteoferocious and facetious anaemia and handle a myocardial infraction. And for the lawyers — is needless dysplastic syndrome considered as incompetence or a minuscule tear? (Stethoscope, sleep apnoea, bronchiectasis, postnasal drip, productive cough, Alzheimer's disease, tinnitus, gout, osteoporosis, pernicious anaemia, myocardial infarction, dysplastic naevus, incontinence, meniscal tear.) Then there are the things that doctors do to patients which make one wonder about informed consent. If you seduced the patient into pornography what would you expect? A tubal litigation may follow, or perhaps swifter justice with a lumbar punch. Monograms and egg, lettuce and fried tomatoes are common investigations, but who wants the Geiger counter or MI5? If the patient asked for the locum, or, worse still, for the results of their own autopsy, how would you respond? They may be better going to the physioterrorist, or just to the choir practice. (Induced, colostomy, tubal ligation, lumbar puncture, mammogram, E/LFT's, glucometer, MRI, local anaesthetic, biopsy, physiotherapist, chiropractor.) But the best mispronunciations of all are the muddled medications. The metropolis tablets are real blocker beaters, and others prefer the condominium lifestyle, but on a bad day it may be necessary to retreat to Nimbin for a bit of peace and quiet. We could go there in the Valiant, filling up with Caltex on the way, but hopefully avoiding an argument when the map reading leads us astray. (Metoprolol, beta blockers, Coumadin, Nemdyn ointment, Valium, Caltrate, Augmentin.) The medical profession has all sorts of alternative remedies, for Anzacs and aristocrats and perhaps even the odd pessowary. These include marzipan, genetic tablets and those well-known urinal tablets, and Laminex, but there is less demand for the repulsive tablets. (Zantac, Aristocort, pessary, temazepam, generic, Ural, Lasix, Prepulsid.) In our spare time we could join the local music scene with a microphone, or go on a picnic with the transistor patch and the Mortein, taking Ventolin noodles and Caviar tablets for lunch. Or we could take up walking and ease the aches and pains afterwards with Catacomb ointment, Denturub or Aquarius cream. At the opposite ends of the spectrum are the libido and the celibacy tablets. Taken along with some clandestine erotics, who knows what galactic splendour may result? (Micropore, Transiderm patch, morphine, Ventolin nebules, Karvea, Kenacomb, Dencorub, aqueous cream, placebo, Celebrex, Canesten, Aurorix, Largactil, Plendil.) On that note, now that you are completely confused by trying to be bilingual, get out the Kleenex, sit back and hope it all goes into remittance. (Nitrolingual, Keflex, remission.)

Catherine E Yelland FRACP · Stephen D Yelland FRACGP

It was one of those times when you agree to help a friend and don’t realise what you are letting yourself in for. I have known Keith for about six years through our shared love of rock climbing. We saw each other frequently at the sport climbing walls in Hong Kong and, as frequently happens in Hong Kong with the expatriate community, friends come and go, leaving the people left behind to close ranks. After a few years, Keith and I became climbing partners and a regular team in the climbing community. Keith had left the high-flying world of corporate finance to establish an adventure racing company in South-East Asia. In a way, adventure racing is an offshoot of triathlons. The competitors race in groups of two to four over a number of days in a number of different disciplines including mountain biking, running, swimming, rope skills, orienteering, caving and problem-solving exercises. At the level Keith was catering for, the racers were usually amateurs who limped back to their high-pressured jobs the day after the race had finished. As a doctor for 20 years and an anaesthetist for 14 years, Keith asked if I would volunteer to be the medical coordinator for a two-day race he was organising in an area called Yangshou in southern China. This area is famous for its magnificent limestone monoliths towering above the rice paddy fields. With such a glorious backdrop for two days (as well as an all-expenses-paid trip), how could I refuse? Frankly, my expectation of the trip was that I would be washing and dressing innumerable “gravel rashes”, with the most difficult problem being how to splint a fractured forearm or ankle in a remote location with none of the normal hospital facilities. This proved to be a very poor under-estimation of the two days. The first day started quietly enough (at least from the medical standpoint). The race started with a run, leading up to a 9.6 metre (yes, 9.6 metre) bridge jump into a river, a swim over to the riverbank and a bicycle leg. After checking that the same number of people who jumped into the river climbed out, I was given a mountain bike and told to ride 10 kilometres via a short cut to the next checkpoint before the competitors arrived. Within minutes of arriving at the checkpoint I received a call that a competitor had fallen off his bike and landed in a paddy field: back on my bike and off to find the victim. After some time, I arrived at one of the outlying villages and found a crowd of locals swarming around a foreigner leaning up against a chicken coop. He was conscious but unable to remember his accident, and was amnesic for at least five minutes around the time of his fall. He was able to remember that his first name was John, but was unable to recall his surname, or exactly where in Hong Kong he lived. His racing partner volunteered that John had failed to negotiate a tight corner and had fallen over the handlebars and landed headfirst in a ditch below the road. The total height of the fall was about 2 metres. Fortunately he had been wearing a bicycle helmet. The physical examination was unremarkable apart from a superficial graze on the top of his head and multiple small abrasions to his torso. The neurological examination was normal, and there was no spinal tenderness detectable after he was “log rolled”. The next step was to arrange his evacuation to the nearest medical facility for re-evaluation and treatment. There were no soft or hard collars available, so I rolled a towel up and wrapped it around his neck as an improvised soft collar until it could be replaced, but the question of transport was tricky. The village’s remoteness precluded four-wheeled vehicle access, and the villagers themselves either walked or rode motorbikes in and out of their farms along the walking tracks between their crops. Helicopter or fixed-wing evacuation was not a realistic option in this area of China. I contacted Keith by radio and asked for a motorbike to evacuate John out of the area. The idea of a patient with potential head and spinal injuries being evacuated sitting behind a local farmer on the back of his motor bike is not something covered by the medical textbooks but, in this situation, improvisation was mandatory. The motorbike’s progress was slow as I walked alongside in case John lost consciousness and fell off. Thirty minutes later we reached a dirt road and were met by one of the local doctors who drove John and me to Yangshou hospital. Surprisingly, Yangshou hospital has a CT scanner, and after initial assessment by one of the doctors John received a CT scan of the head and cervical region. This proved to be normal and he was discharged soon after to sit out the rest of the race in the hotel room. The cost of the hospital treatment and CT scan? US$36! The rest of the race injuries included a race official sustaining a puncture wound to the palmar surface of his left hand from a stone spike in a limestone cave. This required a second trip to Yangshou hospital, intravenous antibiotics, a tetanus injection, and a flight back to Hong Kong for an emergency operation. There were also several cases of heat exhaustion requiring intravenous fluids and, oh yes, washing and dressing of innumerable “gravel rashes”.

Keith B Greenland MBBS, FANZCA, FHKCA, FHKAM

A 51-year-old man presented with non-healing ulceration at the site of a tattoo on his right leg. Some 8 years previously, in celebration of the victory of his favourite team, Carlton, in the Australian Football League Grand Final, he and a friend both had a picture of a stylised Carlton footballer tattooed on one of their legs. The tattooist did not have a navy blue pigment (the team’s colour) to tint the jersey, but improvised with another source of pigment. The patient reported that about a year before presentation he had developed painful ulceration at the site of the tattoo. The ulcer had progressed and showed no signs of healing. Curiously, the ulceration had occurred at precisely the time when the club was undergoing a dramatic deterioration in its fortunes, as scandal and poor on-field performances saw the team fall to the bottom of the AFL ladder. My patient was just one of the many Carlton supporters who had become very disillusioned. At presentation, there was a granulating ulcer within the tattoo that corresponded to the navy blue areas of the figure (Box), with mild surrounding inflammation. After discussion with the patient, it was decided to excise the ulcer and perform a skin graft. The graft suffered partial loss, associated with a Pseudomonas infection. The wound eventually healed, although at 1 year follow-up the patient complained of occasional itch and mild swelling in the graft. Histology of the excised ulcer showed a dense lymphocytic infiltrate and multinucleated giant cells forming occasional granulomas, consistent with an immune response to the pigment. Black and yellow pigment was seen throughout the dermis and in histiocytes. DiscussionA delayed immune response to tattoo pigments is well described. Generally this takes the form of a granulomatous reaction with swelling and irritation in the affected areas. Ulceration is unusual. A delayed immune response can occur after laser treatment, or may be the first manifestation of systemic sarcoidosis. It can also begin spontaneously several years after having a tattoo, as happened in this case. But an immune rejection of a club’s colours by a disillusioned football supporter has not previously been contemplated as a cause of tattoo rejection.

Anthony J Penington MB BS, FRACS

Computed tomography (CT) scan of the abdomen and pelvis was performed for staging of prostatic carcinoma in a 50-year-old man. The “X” is formed by the two ureteric jets in the bladder in this intravenous contrast-enhanced CT of the pelvis.

David C Wong FRANZCR

It’s not Harry Potter or 007. It’s the Wicked Witch of the West coming to town at this time of the year. She was first detected by this 3D CT reconstructed image!

Bit Lock Wong

Frequently, I call on colleagues for help with a radiological diagnosis. This time I received assistance from a higher authority! The image is a non-contrast axial computed tomography scan of the brain, showing haemorrhage into the central pons.

Chris J O’Donnell FRANZCR

We received an appendix in our anatomical pathology laboratory and were struck by the resemblance of the luminal contents to our wide brown land.

Alison M Skene FRCPA · Alastair J Veitch FRCPA · Piero L Nelva BappSci

A 46-year-old man presented to the ED after waking up to find a plastic golf tee embedded in his right thenar eminence (Figure a). His memory of how it got there was rather foggy. The tee was removed under nitrous oxide sedation (Figure b, c) and the wound was irrigated. There was no apparent neurovascular or tendon injury. The patient was given oral antibiotics and discharged, for follow-up at the Hand Clinic.

Timothy C Green MBBS FACEM

For the past 2 years, I have lived and worked in the Solomon Islands. I have found time to grow a variety of plants in the garden my wife and I share with our hosts, including tomatoes, lady’s fingers and bitter gourds. Among my contributions to the collective table was this unusually and amusingly shaped radish, with fingers resembling a human hand.

JG Chethan Kumar MB BS, MD

To the Editor: Random-digit dialling is commonly used to select samples in telephone surveys. It has been used as a method of selecting survey samples for a diverse range of topics ranging from chronic pain to lesbian health issues.1,2 However, the method has come under criticism in recent years, primarily on the basis that a large number of residents are systematically excluded from the sample. We have recently completed a study where we compared random- versus fixed-digit dialling in telephone surveys. Our protocol was as follows: “random-digit” dialling — a randomisation protocol was developed to identify the digit (ie, finger) to be used in dialling for each attempted telephone contact; “fixed-digit” dialling — the same digit (ie, the index finger of the right hand) was used in all contact attempts. We found that, in both fixed- and random-digit dialling, we were repeatedly contacting the same individual. Thus, we believe that neither method is optimal in controlling for sample bias in telephone surveys. We recommend that, in future, researchers pay more attention to methods for selecting telephone numbers than to methods for selecting a finger to dial with.

Stuart C Howell BA (Hons) · Guy D Eslick MMedSci (Clin Epi)

Carrots sprouted unplanted in my garden, presumably from compost, but instead of long, symmetrical, uniconical down-growths, they spread laterally through the barely penetrable virgin clay to produce nutritious but commercially incorrect deformities — some anthropomorphic. Potential cannibalistic nightmares inhibited my appetite, and the “hand of fate” spent two months desiccating on the laundry windowsill before it was returned to the compost.

Lloyd K Morgan

When a 46-year-old man presented with chest pain, the key to the diagnosis was in his ECG tracing — the one on his thoracic CT scan, that is!

Andrew Bonura BSc(med) MBBS

Among the many “freebies” given to doctors by drug companies, I find “post-it” notes particularly handy. I stick ’em on my desk, in my diary, on my computer, on the fridge, on the dashboard . . . everywhere. Life is much more organised for their existence. And they are such innocuous little darlings . . . or are they? During the past year, I was informed that a young sportswoman hospitalised with severe septic arthritis of the right knee, but otherwise healthy, had been inadvertently prescribed a “novel antipsychotic”. The apparent reason for the error was that the surgical resident, weary at the end of a long shift, had transcribed on to the drug chart the names of the patient’s antibiotics (jotted down on a “post-it”) plus the name of the antipsychotic (advertised by the pharmaceutical company at the top of the “post-it”). It could have been messy. The hospital’s Risk Management Unit, in damage control, was back-pedalling fast. After all, these new antipsychotics, although better tolerated than the older variety, are not devoid of side effects — some potentially nasty. What happened to the patient? Fortunately, no adverse events occurred. Still hopping? — yes. Hopping mad? — thankfully no, and perhaps less likely to be with an antipsychotic “on board”.

Garry J Walter PhD, FRANZCP

In the O. R. I’m cold as hell wearing blue cotton apparel. At least the patient’s wrapped up well by a Bair Hugger and drapes; tucked away from the Antarctic duct spilling an icy stream of air at target range — you can guess where: upon me, huddled in the chair placed with ignorance or intent beneath its thin-lipped, hissing vent. My hands are numb, and nose runny, though the surgeons’ lamp is sunny; his voice sweet as red-gum honey. Insulated by gloves and gown he wants the temperature turned down. “Too hot in here!” I must delete whatever words seem indiscreet: these guys keep me on easy street. It’s even easier to see nobody has considered me. What’s also tough is, currently, professional indemnity costs rising like a tsunami. There is no excess fat to burn. Insurance takes half what I earn. Yet, for a while, I must persist. Another day, another list; another reason to exist since this is all that I can do: my “recherche du temps perdu”.

Philip J Armstrong FANZCA

I arrived in a dusty hot town to start a locum, and was greeted effusively by the resident dog, an enormous part-Alsatian. We became instant friends, but I realised, as he scattered the waiting-room patients the next morning, that this dog was not friends with everyone. He used his Houdini talents to escape and accompany me everywhere, and caused consternation when I entered the High Dependency Unit of the local hospital. He got into the hospital by hurling himself at the front glass doors. When I went for my evening walks, he amused himself by attacking the hubcaps of passing cars. His reputation was legendary — he had attacked every citizen of the small town, and regularly bailed up elderly ladies in their backyard dunnies. Pedestrians all carried stout sticks, and small children wore rubber boots if they wished to play in the park. Dr X, his owner, had been approached by the police, the dog-catcher, a deputation of citizens, even by the Mayor, but he had declared to everyone that if his dog came to harm, he would leave town — and that was that! I walked through the park one hot dry evening, trying to pretend that the dog had nothing to do with me. He did his usual thing — ran up to a small boy and bit him on the calf of his rubber boot. The boy gave a small scream, and went on playing. An elderly man rose from one of the seats, his stick held in front of him. The dog snarled obligingly. “That dog of yours . . .” he started. “Oh no, not my dog!” I protested. “That dog just shows you what is wrong with health services in country New South Wales. We have got to put up with that dog in order to keep our doctor in the town. If the doctor goes, the hospital goes, the chemist goes, and we are left with nothing. NOTHING!” The dog gave a hideous yellow grin. He had quite a sense of humour. I had already noticed his proclivity to break into the consulting room when a Pap smear was in progress. “Yeah” said the receptionist the next day. “Dr X will leave town if they try to poison his dog again. They shouldn’ta thrown them 1080 baits over the back fence.” I was soon gone and, I suppose, forgotten, but a drug rep told me that about a year later the dog had died under mysterious circumstances. Dr X had removed himself and his family instantly to the Eastern Suburbs of Sydney. This story has a happy ending. I travelled through the town recently. They have a new doctor. The council has built a new surgery and residence for him, and the old surgery is now a town museum, well frequented, with rooms out the back for the visiting drug and alcohol and women’s health nurses. The Country Women’s Association converted the waiting room to a mothers and babies restroom. The new doctor doesn’t speak much English, but everyone is very happy. The hospital is running and the aged-care hostel is packed. The little children can once more run around in thongs. And last but not least, old ladies can sit in their dunnies, confident of a happy outcome!

Robyn L Pogmore MB BS

This patient was sighted hanging around in the x-ray department. He was unable to give a history, so total body x-rays were performed. Although he seemed to be holding up well, he was advised against travelling by plane at any time in the near future.

Name Withheld

To the Editor: Are we doctors, physicians, MDs, MBs or what? In the past 50 years or so, the address form “doctor” seems to have lost much of its meaning. Of course, academics holding non-medical doctorates in Australia have long nursed a grievance that graduates in medicine have no rightful claim to the title. Perhaps so, but, like it or not, it was thrust upon us at graduation as a courtesy title, and there is no doubt that in the 50s it was of value to patients in establishing the status of their medical advisers. The rightfulness of the use of the title “doctor” by medicos is supported by antiquity, although divinity, law and music might claim precedence over medicine in using the title. The ancient word “doctore” can be translated simply as “teacher”, and the title, or its equivalent, was so used in Roman and ancient Greek times. There is a reference to the term in its medical sense in a quote from Chaucer (c 1386) in the Oxford English Dictionary: “WiÞ vs Þere was a Doctur of Phesike”.1 At present in Australia we have dentists, veterinary surgeons and others who identify themselves as “doctors”. And then there are legions of PhDs in such diverse disciplines as demography, political science, nursing, economics, leisure industries, and so on. In Australia, where we have inherited much of our general medical culture from the United Kingdom, surgeons are often addressed as “Mr” (a legacy of the days of the barber-surgeons) within their hospitals, but “Dr” by their patients. In North America, where medicos acquire the letters “MD” on graduation, “physician” seems to be the generic term in professional circles, while for journalists, “a doctor” or “an MD” are interchangeable identifiers. We could anticipate that any trend away from “doctor” to “physician” in Australian medical literature to follow the US example would meet with strong opposition from internists protecting the integrity of their “physician” status conferred by the Royal College. Understandable opposition to the adoption of “MD” as a generic identifier could be expected from holders of Australian MDs gained by thesis. So is it time for a title change? Change would not be unprecedented. The University of Sydney changed the qualifying degrees from MB, ChB (1882) to MB, ChM (the by-laws being altered in 1884 so that the latter degree was conferred on those who elected to receive it). The first degree in surgery was changed again to BS in 1922 but remained optional until 1974.2 Several Australian universities have recently made radical changes to the content and duration of medical-school courses. Perhaps the indefinite term “an MB” could be adopted as a surrogate for the popular US term “an MD”. Perhaps a new, uniform Australian medical identifier will evolve. Or perhaps we will just muddle on, letting sleeping dogs lie and confusion continue. This seems to be the probable outcome, as good reason rarely prevails in the minds and hearts of men.

Dennis D Arnold MB BS, FRCS, FRACS · Thomas KF Taylor DPhil, FRCS, FRACS

To the Editor: Patiens in Latin refers to someone who is suffering. However, in the real world the word “patient” also, ironically, takes on elements of the more conventional meaning of the word in its adjectival form. A person becomes a patient when he becomes ill. From that moment onwards he begins to comprehend the indubitable reason for being tagged as a “patient”. He patiently bears the ride to the doctor’s office and waits with a dutiful patience, in a room appropriately dubbed the waiting room, until he is called into the consulting room. Like a zombie, he patiently waits in the consulting room, obeying the dictates of the nurse to either stand on a weighing scale or sit on a chair for blood pressure measurements, while he patiently answers a volley of insipid questions about his health. In between, he waits patiently, with a thermometer perched precariously in his mouth, as the nurse stares at her watch or waits for the thermometer to beep. Then he patiently submits to the discomfort of donating blood or the indignity of providing urine or sputum samples. Ultimately he gets the golden opportunity to understand the real meaning of patience as he patiently waits for the doctor to arrive. The doctor, knowing full well the patience of patients, takes his time to arrive at the clinic. Steadfastly ignoring calls from the clinic, he works diligently on grant proposals/lectures/administrative matters until finally, unable to quench persistent calls, he dashes out to see his patient patients. Now that the interminable wait is finally over, the patient patiently submits to an expert examination. He patiently describes his symptoms (again) and patiently listens to what the doctor has to say. The need to draw on a seemingly immense reserve of patience does not cease once the patient leaves the doctor’s surgery. After patiently waiting at the pharmacy for his prescription, he patiently takes the medicines according to the doctor’s orders. He then patiently waits for the medicines to take effect. Therefore, calling a sick person a “patient” is particularly apt. It becomes slightly complicated when the terms “inpatient” and “outpatient” are used. Does a lack of patience eventually turn a patient patient into an inpatient? When all’s said and done, it is always better to be a patient patient than an impatient patient who tries the patience of potentially impatient doctors who rely greatly on the potential patience of patients.

Biji T Kurien

To the Editor: The 25th Australian Conference of Health Economists was held in Canberra on 2–3 October 2003. This conference used to be held in shabby university seminar rooms, with dry biscuits and instant coffee. This year it was held in a modern facility — the SAS Visions Theatre at the National Museum — with all the usual conference embellishments, including brewed coffee and fresh pastries, plus an evening dinner at the lakeside restaurant within the museum. The conference was sponsored by Medicines Australia; Pfizer Pty Ltd; Bristol-Myers Squibb Australia Pty Ltd; AstraZeneca Pty Ltd; Sanofi-Synthelabo Australia Pty Ltd; Schering-Plough Pty Ltd; Bayer Australia Limited; and Merck Sharp & Dohme (Aust) Pty Ltd.1 Why are those traditional sponsors of medical gatherings, the pharmaceutical companies, subsidising the health economists’ conference? The immediate explanation is simple. Applications to the Pharmaceutical Benefits Advisory Committee for listing of a drug on the Pharmaceutical Benefits Scheme must now include a formal cost-effectiveness study. This requirement has generated a boom in this narrow technical aspect of health economics. Thirteen of the 32 papers presented to the conference reflected this area of interest.1 But are we seeing something more fundamental here? Are the canny pharmaceutical companies directing their largesse away from the once autonomous doctors to the dry bean counters who now make the real decisions? Or have the economists proved one of their own famous maxims wrong by demonstrating that there is such a thing as a free lunch?

William Coote