Volume 187 Issue 11

The Journal’s priorities for health care under the new government are clear Curiously, during the recent federal election campaign, the health policy pronouncements of both the Labor and Liberal parties1,2 failed to address one of the major issues with the potential to affect the quality of Australia’s health systems, namely: progressive job dissatisfaction among health professionals. These health care workers must surely be utterly demoralised, for every day they are confronted by the deterioration, indeed, decay, of the systems in which they work and struggle to deliver high-quality care. Of prime concern to the public and health professionals is the systemic deterioration of our public hospitals, burdened as they are with ever-expanding waiting lists, reduced bed capacity, poorly coordinated clinical services, access block and overcrowded emergency departments.3 Add to this the stress of staff shortages, chronic underfunding and dysfunctional management, and it is easy to understand why our public hospitals scored so low in the recent Public hospital report card of the Australian Medical Association.3 This report provides an independent analysis of performance indicators such as bed capacity, access and equity, productivity and funding. Tellingly, all states and territories attracted criticism — not one escaped a pressing need for reform.3 So disturbing is this sorry state of affairs that one fears a repeat of the infamous Bundaberg Hospital scandal.4 Indeed, there has already been a flurry of distressing reports cataloguing near misses and clinical mishaps in emergency departments across the nation.5 General practice also has its share of problems. These include: increasing workforce shortages, especially in rural areas; the burden of red tape; inefficiencies in the interface between general practice and hospitals or community aged care; and numerous other issues related to continuity of care and access.6 And these difficulties will definitely be further stressed by the ageing of our population. With a newly elected Labor government, all Australians look forward to the inherent energy of a new government with a mandate for reform, expecting them to produce the best health system for all Australians. And for this to happen, both the new Health Minister and Prime Minister must be held accountable. The community has wearied of the cynical and perpetual denial of political responsibility and desperately longs for an enactment of Harry Truman’s dictum: “The buck stops here”. But this expectation has to be tempered by the need for plain speaking and honesty. It is deceitful for any government to promise the delivery of a Rolls-Royce health care system, but fund it as though it were an FJ Holden. As to the precise nature of the health reforms the government should pursue, there is a plethora of advice and recommendations.7-10 The Journal has only a few priorities: The present debate about federal–state government responsibility for health services should cease. We need a decision now about whether one level of government or two should be responsible for all Australian health care delivery, and the debilitating and destructive blame game should then cease. Preventive medicine should be given first priority. The inertia in tackling the obesity epidemic is an indictment of the profession and, in particular, the impotence of its public health sector. We desperately need enactment of a national policy with an array of incentives and penalties. In Indigenous health, the momentum engendered by the Northern Territory intervention needs to be sustained, in real partnership with Indigenous Australians. Patients and the public should have a stronger voice in decisions related to health care. To quote Peter Baume, a public health commentator and former Liberal senator and minister: [T]he agenda of the public is more important than the agendas of professionals and the groups that represent them. It would be great to have a system where difficult questions of resource priority were decided before citizen juries, instead of being decided secretly and off stage.11 Finally, changes in health need to involve doctors and return the practice of medicine to its appropriate focus: health care that is enabling and effective.12 Three principles should guide this reform: first, the goal at all times should be ensuring value for patients; second, changes in medical practice should be organised around medical conditions and care cycles; and, third, outcomes and cost should be measured.12 This tripartite approach is necessary to ensure that value for patients is achieved by a move from the current practice paradigm, focused on discrete, uncoordinated and episodic service delivery, to one characterised by integrated and coordinated care, wherein patients actively participate in their own management and are responsible for compliance with care plans.12 The role of organised medicine in Australia is to ensure that health reform is not only realistic, but is realised. It must be said, however, that any cynic, observing the system’s downward spiral, might reasonably question the strength of the profession’s advocacy role and political power. After all, the decline and decay in health care delivery has occurred despite professional protestations. Doctors’ advocacy must become more aggressive, and doctors need to become a politicised profession.13 We have had enough of commissions and inquiries! The time for talking is over. We need action. We need reform. Is the time not ripe for a united and independent task force — one with appropriate professional and consumer representation, which will ensure that the government remains on-task, pursues a reform agenda and reports widely on progress? Is it not time for doctors and other health professionals, who are arguably the only thing our health system has going for it, to question whether they should continue propping up a second-rate system that is jeopardising the quality of care and is increasingly of risk to patients? Doctors and their patients are resolved that the time for change is now. All expect the newly elected government to deliver. And soon.

Martin B Van Der Weyden MD, FRACP, FRCPA

The first 100 days after an election are full of enthusiasm, energy and chaos, and they are crucial to establishing the shape, style and content of the new government’s tenure. The electorate is eager for plans, changes and new ideas, and for election promises to become reality. Early action that is visible and accepted will secure the credibility of longer-term plans. Here, in an open letter to the new Health Minister, we state our hopes for Australian health and health care in that 100-day period Dear Minister, You have come to this task with a raft of policies and initiatives that you and your party have promised to implement, and you probably have a long list of ideas and issues that you want to address, or that others have lobbied for. In a previous issue of this Journal, we put forward eight challenges that we think you will face,1 and you have outlined your own list. Your first 100 days will be crucial, but please don’t rush into action. Take time to consider three fundamental things. First, what health system will be best for Australia in the 21st century, taking into account the health needs of all Australians and how the electorate wants its tax dollars spent? Second, what distinctive role can you, as the federal health minister, play to achieve that system and leave the nation healthier as a consequence of your term as minister? After all, you are accountable to all Australians for precisely such an achievement. Third, you need a strategy, so that your reforms and policies are not just isolated initiatives, but form a coherent plan that will ensure that current problems are addressed and health benefits are maximised. A carefully formulated plan is the difference between just replacing the cracked tiles on an old leaking roof and rebuilding the roof with a better design, updated technology and new tiles. The challenges you face are of two orders: issues that are now causing a huge increase in costs as their incidence grows (examples are chronic disease, childhood obesity, the uptake of new technologies and the workforce crisis), and others that are polity issues (such as the current dual — or should we say duel? — Commonwealth and state–territory funding streams, the public–private mix, and the focus on treatment at the expense of prevention, affordability and equity). It is the polity issues that demand that the “roof”, the protection that our nation’s health care system offers, is redesigned and brought up to date. Without such attention, there will be no sustainable solutions to the other issues that threaten to inundate us; a few new or recycled tiles just won’t do. We urge you to spend your first 100 days, first, planning several high-priority, national concerted actions in the three broad health service policy areas — prevention, community-based care and hospital services — and, second, developing national consensual mechanisms that will address the polity issues robustly and drive the concerted actions. Both these approaches, tackled simultaneously, are essential. United States Government Accountability Office The US Government Accountability Office (GAO) is known as “the investigative arm of Congress” and “the congressional watchdog”. GAO supports Congress in meeting its constitutional responsibilities, and helps improve the performance and ensure the accountability of the federal government for the benefit of the American people. GAO’s work includes oversight of federal programs; insight into ways to make government more efficient, effective, ethical and equitable; and foresight of long-term trends and challenges. GAO’s reports, testimonies, legal decisions and opinions make a difference, for Congress and the nation.2 You have promised a national health and hospitals reform commission, which will meet in the first 100 days of government. While requiring a broader focus than so far described, this commission could give you the expert support and consultative mechanisms needed for comprehensive and robust planning. Your initial success will be measured by the key performance indicators — cooperation and buy-in from the states and territories, non-government organisations, the private sector, health professionals and the public. At the end of 100 days, there must be evidence of a strong developing consensus and growing public confidence that you will stop the blame and cost-shifting of the past and create a new health system to meet national needs. But the gloss of these early glory days will last only if there are long-term commitments of resources to planning, infrastructure (including more effective e-health systems), the workforce, and research and development; to making patients’ experiences and outcomes central to health care decision making; and to monitoring and evaluating the effects of health-policy changes on health, so we know what is working and what is not. This last point is crucial to your long-term success. So we also propose that you establish an office of accountability for health to ensure that you and your partners in health planning and reform can know that agreed outcomes are being achieved, and the public can know that their tax dollars are wisely invested. The United States Government Accountability Office is a good model (Box).2 We offer here two of many reasons why we need the equivalent of the US Government Accountability Office. The cost of medical errors in Australia is over $1 billion annually and could be as high as $2 billion.3 About half of all medical mistakes are preventable.4 The current failure to collect comprehensive national data means that our progress towards better quality and safety remains anecdotal. The Editor of this Journal has spoken out on the failure to clearly enunciate and implement a comprehensive range of relevant safety indicators, mandatory incident reporting and learning systems for mishaps, and an outcome measurement system, stating that “Australians deserve better than this”.5 We agree. The cost of obesity in Australia last year was $21 billion in ill health and disability, premature death and productivity losses.6 Over 3 million Australians are obese, and this could rise to over 7 million people within 20 years if current trends persist unabated and unaddressed.6 The last Australian Schools Health and Fitness Survey was conducted in 1985, and the last National Nutrition Survey in 1995. This means that policymakers are hindered by the lack of current data to inform the development of new policies. Without ongoing measurements and feedback there is no way to evaluate the effect of implemented policies. It is only through repeated surveys, done by the same people using the same survey instrument, that we are able to assess progress and evaluate the success of individual initiatives. The overwhelming impression left from the election campaign is of 6 weeks of piecemeal policies, and local funding commitments that add to the multitude of health programs but do not strengthen or reform the health system. Your task now is to build a better health system that can deliver better health programs more effectively and efficiently. The multiple challenges must be tackled, with a focus on better health outcomes and better value for money. They can only be resolved by a shared national vision, national leadership and national action across a period that may encompass decades, but your actions in the first 100 days and investments in the first 3 years will be critical. This surely is where the Australian Government must play its main role and where a committed Health Minister can make a real difference and leave a lasting legacy. Since 1933, when Franklin Delano Roosevelt tackled the worst effects of the Great Depression in a rush of breathless reform,7 the first 100 days of a new government have provided the test of its leadership and reformist credentials. Australian state government leaders, from Jeff Kennett in Victoria to Geoff Gallop in Western Australia, have adopted this benchmark for achievement. We strongly advise you to embrace this benchmark, and we wish you well in the 100 days ahead.

Lesley Russell BSc(Hons), BA, PhD · Stephen R Leeder AO, MD, PhD · Bruce K Armstrong AM, DPhil, FRACP · James A Gillespie BA, PhD · George L Rubin FRACP, FAFPHM

The first IAS conference to highlight biomedical prevention was held in Sydney in July 2007 Over 5000 delegates from 133 countries met in Sydney in July for the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, the first major international conference on the biomedical aspects of AIDS to be held in Australia. It was also the first conference in this series to include prevention in its title and to assign a central role to prevention research in the scientific program, alongside basic science and clinical research. Coinciding with the conference was the release of the Sydney Declaration, which calls for 10% of all resources devoted to HIV programming to be dedicated to research1 (Box). The conference provided Australia with an opportunity to benefit from the presence of world-leading scientists from a number of disciplines, as well as to showcase outstanding Australian achievements in HIV research. Clinical research, treatment and careAccording to the World Health Organization, the number of people receiving antiretroviral therapy (ART) worldwide now exceeds two million, which represents 28% of the adults, but only 15% of the children, who urgently need treatment in low- and middle-income countries. Debrework Zewdie (Director, Global HIV/AIDS Program, World Bank, Washington, DC, USA) reported that, as ART rollout continues at a fast pace in developing countries, new challenges are being recognised, including the “brain drain” of health professionals, limited laboratory facilities to monitor treatment, lack of access to the more costly regimens that limit toxicity or act as second-line treatment regimens, the coincident epidemic of tuberculosis fuelled by both the HIV epidemic and increasing resistance to standard antituberculosis drugs, and the need to increase coverage to include the most vulnerable, including injecting drug users (conference abstract MOPL1, available online at the conference website2). The conference highlighted research on new agents and new ways of using existing drugs to improve clinical outcomes. New drugs included etravirine (active against HIV resistant to first-line non-nucleoside reverse transcriptase inhibitors) (abstracts WESS204-1 and WESS204-2), raltegravir (the first integrase inhibitor) (abstract TUAB104), and maraviroc (the first chemokine inhibitor) (abstract WESS104), all of which showed efficacy in Phase III clinical trials. Patients with multidrug-resistant HIV following treatment with existing drug classes can now expect, in well resourced countries, to achieve full viral suppression with the newer agents. Other ART agents in earlier phases of development include apricitabine (abstract WESS203), active against lamivudine-resistant HIV, and being developed by an Australian pharmaceutical company, and PRO 140, a CCR5 monoclonal antibody, which could potentially be administered subcutaneously once weekly (abstract WESS201). The long-standing debate about when to start ART was reignited during the conference. The Children with HIV Early Antiretroviral Therapy (CHER) study in South Africa enrolled 252 infants less than 12 weeks of age and randomly assigned them to start ART immediately or defer therapy for 1–2 years. It was halted after an interim analysis revealed a 75% reduction in mortality in the immediate therapy arm (abstract WESS103). In adults, there is mounting evidence that ART should be initiated earlier than is recommended by the current guidelines (at CD4 T cell counts of 200–350 cells/μL),3 and new analyses of the landmark SMART (Strategies for Management of Antiretroviral Therapy) study4 found that patients who interrupted ART, even with a relatively intact immune system, were at increased excess risk of serious illness such as AIDS-defining conditions, malignancy and death from a number of causes including liver and cardiovascular disease, malignancy and AIDS. After several years in which a cautious approach held sway, the pendulum now seems to be swinging back to earlier initiation of treatment. The immunological rationale for this has become clearer: the newer treatments are less toxic so can be taken for longer without the severe side effects of the older agents, and there is an increasing recognition of the public health benefit of early treatment in reducing infectiousness through viral suppression. Biomedical preventionThere was much to discuss in the field of biomedical prevention, as the past year has witnessed some outstanding successes as well as some major setbacks. In a compelling plenary address, Robert Bailey (Professor of Epidemiology, School of Public Health, University of Illinois, Chicago, USA) reviewed evidence from recent randomised trials of the strong protective effects of male circumcision against HIV acquisition (abstract TUPL101). While urging rapid scale-up in high prevalence settings, Bailey cautioned that circumcision needs to be integrated with broader HIV prevention strategies. Observational studies in Sydney (abstract WEAC103) and Peru (abstract WEAC102) showed no significant protective effect of circumcision in gay men. The MIRA (Methods for Improving Reproductive Health in Africa) trial of female diaphragms in African women was concluded with a finding of no benefit (abstract WESS304). Retention rates were high in this long-term study (abstract TUAC104), but low adherence and reduced condom use in the diaphragm arm may have limited the study’s ability to detect an effect. Similarly, no impact on HIV incidence was seen in a trial of daily acyclovir to suppress herpes simplex virus type 2 conducted among women in northern Tanzania (abstract MOAC104), although adherence may have also played a role in compromising the results of this study. The conference heard new details about the two Phase III trials of cellulose sulfate gel as a vaginal microbicide which were suspended early this year. One trial, conducted in Africa and India, was halted after interim analyses revealed a more than twofold increased risk of HIV seroconversion among women using the gel, for reasons which remain unclear (abstract WESS301). The second trial was stopped, even though no differences in risk had been observed (abstract WESS302). At the other end of the development pathway, a Melbourne-based biotechnology company found that its candidate microbicide, SPL7013 gel, was well tolerated in a penile application safety study, paving the way for trials in sexually active women (abstract TUAC1LB). Preventing maternal HIV transmission continued to advance with the finding from Tanzania (abstract TUAX101) and Rwanda (abstract TUAX102) that fewer than 1% of infants whose mothers received postpartum ART were infected with HIV during the breastfeeding period. Supported by recently issued guidelines from the WHO and the United States Centers for Disease Control and Prevention, provider-initiated testing programs have increased the numbers of people tested in the US (abstract TUSY203) and Botswana (abstract TUSY205), and rapid testing has facilitated the return of results (abstract TUSY203). There is nevertheless ongoing controversy about this approach because of its “opt out” nature, particularly in settings where HIV-related stigma, discrimination and limited access to treatment remain realities. Despite the undeniable importance of sexual transmission of HIV globally, intravenous drug use accounts for 10% of the global burden of HIV infection and is the leading mode of exposure in parts of Asia and eastern Europe. Data from Australia showed low and declining HIV prevalence among intravenous drug users, confirming our success in averting an epidemic in this population (abstract MOAC202) through harm-reduction strategies, particularly needle and syringe distribution. Thomas Kerr (Assistant Professor, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada) also reported a strong relationship between efforts to decentralise the distribution of clean needles and syringes and reduced HIV injection risk behaviour in Canada (abstract MOAC205). However, a powerful presentation by Mauro Guarinieri (Chair of the Global Board of the Global Network of People Living with HIV/AIDS) reminded us that such strategies remain largely unavailable in many regions, and that the emphasis on drug prohibition has led to human rights violations and continues to impede efforts to prevent HIV among people who inject drugs (abstract TUSY303). A safe and effective prophylactic vaccine remains the best hope for HIV prevention in the long term but seems as elusive as ever. Ongoing Phase IIb vaccine studies (abstract MOBS301-4) are investigating candidates that boost cellular immune responses and are expected to work by controlling HIV disease progression in those who become infected. The public health benefits of such vaccines could nevertheless include lower rates of illness, reduced potential for HIV transmission, and prolongation of the time to ART initiation. “Lessons learned” from HIV prevention trials were also shared at the conference, with presentations reporting that willingness to participate in trials does not necessarily translate into participation (abstract TUPDC01), and that providing information to trial participants in a focused, locally appropriate manner and within a continuous informed consent framework improves comprehension and message retention (abstract MOAC303). Susan Kippax (Director, National Centre in HIV Social Research, University of New South Wales, Sydney, Australia) reminded us that there are many areas in which further research is needed, including the meanings attributed to prevention technologies, expectations in relation to their effectiveness, and the impact of new and generally experimental prevention technologies on older, proven ones, such as condoms (abstract TUSY302). Basic scienceHIV immunopathogenesis represents a complex interplay between the virus and the host’s immune response, and presentations from Michael Lederman (Director, Center for AIDS Research, Case Western Reserve University, Cleveland, USA; abstract MOPL102) and Jason Brenchley (Research Fellow, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA; abstract TUSY402) crystallised current knowledge in this area. The pivotal event early in HIV infection is the massive depletion of mucosal CD4 + T cells that results in immunological and physical damage to the gastrointestinal tract, leading in turn to leakage of components from normal gut microorganisms into the blood. These microbial products stimulate the production of inflammatory cytokines from cells of the innate immune system, triggering T cell activation and expansion, and creating a greater pool of target cells to support HIV replication, ultimately resulting in the depletion of CD4 + T cells and lymph node fibrosis. Strategies to prevent immune activation are now being pursued in order to limit this HIV-mediated damage. An area of intense investigation, critical for developing successful microbicides, is mucosal immunity. A study presented by Dr Maddy Hayes (St George’s University of London, UK) demonstrated using human cervicovaginal tissue that a protein with anti-HIV properties could be elicited from these tissues by a mechanism that is independent of triggering known Toll-like receptors in cells of the innate immune system (abstract MOPDA02). This study raises the possibility of inducing endogenous antiviral factors as mucosal stimulants of the innate immune response. In a macaque study, Eric Arts (Assistant Professor, Division of Infectious Diseases, Case Western Reserve University, Cleveland, USA) demonstrated for the first time that a vaginally applied candidate microbicide (abstract PSC-RANTES) could select for a drug-resistant virus (abstract WESS303). Major implications of this study include the possibility that agents with different drug-resistance profiles should be considered for therapy versus prevention, and the importance of using a combination of drugs in topical microbicides to limit the emergence of HIV drug resistance. The session on new drug targets and compounds highlighted novel approaches for inhibiting HIV replication. Orally bioavailable fusion inhibitors have been identified that have mechanisms of action unlike that of enfuvirtide, the first and currently only available drug in this class (abstract MOPDX01). A novel inhibitor, BIT225, developed by an Australian company, specifically inhibits HIV replication in macrophages, which represent a reservoir for HIV (abstract MOPDX06). An exciting HIV gene therapy approach using a “triple-R” vector was also presented by John Rossi (Professor and Chair of the Division of Molecular Biology, Beckman Research Institute, California, USA). This vector expresses a combination of three types of RNA to target essential viral genes and inhibit expression of the CCR5 host cell receptor, which is critical for viral entry (abstract TUPL102). ConclusionsThe Sydney conference provided an important opportunity for delegates from Australia and the region to participate in an international forum. Treatment access is expanding steadily but encountering practical barriers, and prevention science is entering a new era, with results from recent trials raising complex implementation issues. In the absence of substantial increases in investment in both research and community building, the efficacy–effectiveness gap is likely to remain very wide. As we look forward to the 5th International AIDS Society Conference in South Africa, we would do well both to put the Sydney Declaration into practice and to heed the words of Maura Elaripe, of Igat Hope, the national network of HIV-positive people in Papua New Guinea, at the conference opening ceremony: “Talk with us, not about us”. The Sydney Declaration: good research drives good policy and programming — a call to scale up research1* Ten per cent of all resources dedicated to HIV programming should be used for research towards optimizing interventions utilized and health outcomes achieved. The evolution of HIV prevention, treatment, and care over the past quarter century is one of the great successes of medical science. Committed and sustained research efforts have provided the evidence on which approaches to programming are based. These same scientific efforts are now resulting in new prevention technologies and drugs, and new strategies to manage and deliver both. Good research drives good policy. In recent years, resources have dramatically increased for delivery of existing interventions in resource-limited settings. Although funding remains insufficient to meet the increasing need for services, it is imperative that the global community does not lose sight of the future while responding to the immediate crisis. An effective response to HIV/AIDS requires a sustained commitment to ensure that interventions and approaches to service delivery are continuously improved over time. For example, as current first-line antiretroviral regimens become increasingly available in resource-limited settings, there is an urgent need to identify optimum, durable, and well-tolerated standardised first-line and second-line regimens, and to monitor and respond to resistance patterns as they emerge. Outcomes will not necessarily be the same in diverse settings across the globe. Operations research is critical, in addition to basic, clinical, prevention, social, and policy research. We must identify which approaches are effective in the field, which are not, and why. We must also learn how to integrate HIV-specific services with primary, tuberculosis, malaria, prenatal and postnatal, and sexual and reproductive health services. None of these services have been as effectively linked to scale-up of HIV programming as is possible or necessary. Furthermore, greater understanding of the social, political, and cultural barriers that perpetuate stigma and discrimination can contribute to ensuring that governments act in the interests of public health. Operations research will enable rapid implementation of new technologies to prevent, diagnose, and treat HIV infection, and can help to ensure that health systems are strengthened as a result of scaling-up HIV prevention, treatment, and care. Unfortunately, few granting agencies or national health budgets commit designated funds to operations research, and where such funding is available, it is often underused. The Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, allows up to 10% of each grant to be allocated for operations research, but this provision is rarely used by countries and the research community is rarely represented on Country Coordinating Mechanisms (CCMs). The lack of participation on CCMs further reduces the likelihood that operations research will be a priority in funding applications. An ancillary benefit of integrating research into the overall approach to scale-up in the developing world will be an expanding cadre of health-care workers trained in research methodologies and practice. Such research should not be seen as an additional burden on the various funding bodies or ministries of health but, on the contrary, as the only means by which we can refine our understanding of what is and is not effective. Last but not least, all areas of research can further strengthen the efforts of the global AIDS community to confront the absurd theories of AIDS denialists as well as the “magic” cures that continue to confuse policymakers, health-care professionals, and communities of people at risk of and living with HIV/AIDS throughout the world. HIV professionals must continuously build on the evidence base to ensure sound and effective policies and practices in HIV/AIDS prevention, treatment, and care. The undersigned individuals and organisations call on national governments and bilateral, multilateral, and private donors to allocate 10% of all resources for HIV programming to research. We believe that without such funding we will fail to maintain a sustained and effective response to the AIDS pandemic. * As of 15 August 2007, there were 1854 signatories to the Sydney Declaration.

Lisa Maher PhD · Gilda Tachedjian BSc(Hons), PhD · Jennifer F Hoy FRACP · Iona Millwood PhD · Rebecca J Guy BAppSc, MAppEpid · Nick M Walsh MB BS, MPH · John J Zaunders BSc, PhD · Anthony Jaworowski BSc(Hons), PhD · John M Kaldor PhD

For the first time, there is a real opportunity to deal comprehensively with the shameful situation of Indigenous communities in Australia — but the commitment needs to be huge The girl undergoing a health check in a remote community in the Northern Territory has a delightfully cheeky grin. Recently arrived from a town camp on the outskirts of Alice Springs, she is in the care of a woman unrelated to her. About 9 years old, she pops up everywhere, desperate for attention. The health check reveals that she has ringworm, dental problems and a perforated eardrum from a chronic middle-ear infection. She also has a heart murmur brought on by an earlier bout of rheumatic fever. It is vital that she undergo an echocardiogram as soon as possible. A boy aged 5 years is brought in by his mother, who is 36 weeks’ pregnant and has had no antenatal care. He and his mother have been camping rough. Although he is not here for a health check, the opportunity is taken to give him one with his mother’s consent. Although he looks happy and healthy, he is found to be anaemic and is given iron injections as well as the vaccinations he has missed. A boy of about 14 seems depressed, although this has not previously been diagnosed. The only male adults he has to model himself on are dependent on drugs and alcohol. He frequently plays truant from school. He is on a slippery slope, and much needs to be done if he is not to slide into disaster. There is so much promise for these Indigenous children, but it will only be fulfilled if their living conditions are fundamentally changed. Health crisis in a land of plentyIt is remarkable to contemplate that in parts of Australia, there is a health crisis that is in some respects more devastating than anywhere else in the world. The Australian Medical Association has called the state of health and lack of health services endured by Aboriginal peoples and Torres Strait Islanders a national tragedy and a national shame. The former president of the association, Dr Mukesh Haikerwal, wrote earlier this year: “I think we are being kind in that assessment.”1 The figures for renal and coronary heart disease among Indigenous peoples could well be the worst in the world. For instance, Indigenous Australians are three times more likely to have a major coronary event than other Australians, and 1.5 times more likely to die after such an event.1 Through my two decades of involvement with the health of Aboriginal communities, I have watched in frustration as health levels improved only marginally and self-esteem and pride were destroyed. When the “sit-down money” arrived each fortnight, in the form of numerous government handouts, many communities went into self-destructive alcohol binges for 3 or 4 days, during which time women and children were abused, children did not go to school and remained hungry. Those of us working in the field of Indigenous health have watched this happening and have tried to influence the outcome, but despite this, both the health of Indigenous peoples and the level of their education have continued to show great disparity with the rest of the population. We all know that social factors such as overcrowded housing, lack of education and limited employment opportunities, along with environmental health issues such as lack of clean water, washing facilities and functioning septic systems, all influence health outcomes of individuals and the community. These factors, combined with a cycle of welfare dependency, lead to a loss of pride and low self-esteem. Substance (particularly alcohol) misuse is a direct result. Therefore, any targeted medical strategy must have a broad focus and address all these wider issues which have an impact on the health of individuals. Some good things have been done, but not on a scale to make a real difference — until now. Massive interventionThe Australian Government’s Northern Territory Emergency Response2 is without precedent in Australia. It is the largest and most significant whole-of-government initiative yet carried out in this country. The government set up the Northern Territory Emergency Response Taskforce (Box) to provide advice and to oversee the implementation of the emergency measures. The intervention has three broad objectives: stabilisation to protect children and secure their communities; normalisation of services and infrastructure; and in the longer term, sustainability, bringing Indigenous Australians fully into line with the choices other Australians enjoy. The government committed $587 million for the stabilisation phase in the 2007–08 financial year. This is for urgent and immediate actions. It includes over $83 million specifically for improving child and family health, with $205.8 million for employment and welfare reform and the balance for promoting law and order, enhancing education, supporting families and for housing and land reform.2 On 18 September 2007, the government announced further funding of $740 million to highlight its long-term commitment, bringing the total committed so far to $1.3 billion. This includes $100 million over 2 years from the 2008–09 financial year for more doctors, nurses, allied health professionals and specialist services.2 When the response was announced on 21 June 2007, many were concerned about its motivation and methods.3 Was this not paternalism or yet another attempt to dominate Indigenous communities? Well, while it is still early days in an intervention to which the Australian Government has committed itself for at least 5 years, I have seen how this response is already bearing fruit and believe everyone with concern for Indigenous health should continue to support this initiative. We cannot let this opportunity go. For instance, the introduction of strict controls over alcohol consumption had a huge impact almost immediately. An Indigenous woman told me that, for the first time she could remember, she had had a week of sleeping peacefully. A sharp reduction in the physical abuse of women and children has also been seen. The Chair of the Northern Territory Emergency Response Taskforce, Dr Sue Gordon (Box), reports that in communities across the NT, women are talking about the positive effects of alcohol bans in reducing violence, abuse and antisocial behaviour. The same thing is probably happening with levels of child sexual abuse — the horror which sparked off this emergency response — although it will only be when more trust has been built up that we will be able to explore this more fully. A comprehensive program of health checksOne of the pillars of the initial phase of the Northern Territory Emergency Response from a health point of view is the health checks to be carried out on up to 17 000 children aged 15 years and under in 73 target communities. By 19 October 2007, medical teams had already completed checks on more than 3200 children. The findings of these checks are sobering, and underline the need for the intervention. We already knew that the children in many of these communities had very high rates of chronic diseases, but have found that the situation is even worse than the official picture. The Indigenous population has a burden of disease up to six times higher than in the non-Indigenous population.4 Probably 80% of the Indigenous children have middle-ear diseases. Intestinal parasites and skin infections are rife. An absence of water for washing — taps don’t run, toilets don’t flush, there is no soap — has led to skin hygiene so poor that pathogens thrive. This in turn contributes to the devastating levels of renal disease and heart disease, the latter particularly associated with rheumatic fever. Type 2 diabetes is also increasingly common in children.5 Of course, painting a full picture of the burden of disease is only the start. It must lead to a massive increase in treatment resources, and, beyond that, to a transformation of these communities. Only the synchronous rollout of many measures will be truly effective. This will take a lot of time and a lot of money. Fortunately, the government is committed to this initiative for at least 5 years. Step by stepStrategies in the stabilisation and normalisation phases of the initiative include: voluntary health checks available for all children aged under 16 years in target communities; development of a range of special services for children and their families who have suffered trauma from physical, sexual and emotional abuse or neglect; increased police presence to guarantee safety and security for community members; implementation of alcohol-management plans; a focus on getting children to school; support for and an extension of the current nutrition programs for Indigenous children; establishment of crèches in communities; funding for new housing and renovations; a focus on creating real jobs within the communities and incentives to develop local businesses; the appointment of government business managers in each community; government assistance to the Northern Territory Government to expand child-protection services and increase the number of safe houses; changed welfare payment rules to ensure money meant for children is spent on them, including quarantining welfare payments to parents or carers if children do not attend school; a licensing program for community stores to ensure families have access to a range of healthy foods; acquiring 5-year leases over the main townships to ensure the job is done quickly; and opening up communities by changing the permit system so that people can visit common areas within them. A well resourced primary health care system — enough doctors, health workers and nurses — is integral to long-term sustainability. Further, interventions to manage the diseases identified by both the child health checks and data from the Northern Territory Government will need to be implemented. Talks have already started about this. I would like to think that extensive treatment programs will be underway within a year to deal with the ear, dental, cardiac and renal problems. Along with educating children and parents about the importance of personal hygiene, we need to make this feasible. Installing taps that work will make a huge difference. However, a sustainable solution will require much more than this, and the key will be education. That is the only way out of poverty, and away from the debilitating system of government handouts. Pride has to be restored to shattered communities. Seize the opportunityThis intervention is not going to be perfect; there will be many problems to overcome, but it gives us a tremendous opportunity. Of course, some people, particularly those with vested interests (like those making money out of selling alcohol), will feel threatened. Others will claim the response is paternalistic. To them, I have two things to say. First, in many of these communities, there is a complete breakdown of normal mores. It is not paternalistic to be firm about what is not acceptable. Second, the ultimate aim is to restore these communities, their resources and self-esteem to the point where they are in charge of their own destinies. I believe this initiative offers a real chance to restore the health not just of the rural and remote Indigenous communities of the NT, but of Australian society, wounded by these enormous disparities. It is up to us to seize this one-time opportunity to finally solve a problem that has been decades in the making. We dare not let the momentum be lost. Northern Territory Emergency Response Taskforce2 The Taskforce was established to advise the Australian Government on how best to protect Indigenous children in the Northern Territory, oversee the Northern Territory Emergency Response Taskforce Operational Group, and promote public understanding of the issues involved. It is made up of people with experience in areas such as medicine, government, the law, education and business. Its members are: Dr Sue Gordon AM (Chair), a magistrate in the Perth Children’s Court and chair of the Australian Government’s National Indigenous Council. Major General Dave Chalmers AO, CSC (Operational Commander), who has considerable organisational and command experience, notably in East Timor and as commander of the joint taskforce that provided humanitarian relief to Sumatra after the 2004 Boxing Day tsunami. Dr Bill Glasson, ophthalmologist and former president of the Australian Medical Association, who has worked on a voluntary basis in a number of Aboriginal communities and in East Timor. Roger Corbett AM, member of the Reserve Bank of Australia Board and former chief executive of Woolworths. Miriam Rose Baumann AM, principal of St Francis Xavier Catholic School in Daly River, a member of the National Indigenous Council, and chair of the Aboriginals Benefit Account Advisory Committee. Dr Peter Shergold AC, secretary of the Department of the Prime Minister and Cabinet. Paul Tyrrell, chief executive of the Northern Territory Department of the Chief Minister.

William J H Glasson FRACO, FRCOphth, FRACS

The Aboriginal Medical Services Alliance sees the Australian Government’s recent intervention to protect Indigenous people, the Northern Territory Emergency Response, as an opportunity to improve primary health care. Despite its serious reservations about other aspects of the intervention, the Alliance considers that sustained improvements in primary health care can be achieved via genuine engagement of government with Aboriginal communities The view portrayed to mainstream Australia in the introduction of the intervention was that an emergency response was essential because nothing in the Northern Territory was working. However, Aboriginal community-controlled health services (ACCHSs) in the NT have been collaborating for some time with the federal Office for Aboriginal and Torres Strait Islander Health and the NT Department of Health and Community Services, to reform and expand the delivery of primary health care services. A challenge and opportunity for these existing services has been, and continues to be, to harness the intervention’s child health checks to ongoing efforts to develop comprehensive primary health care services for Aboriginal communities in the NT. In recent years, before the intervention, there was progress in dealing with key identified inadequacies in primary health care and related health services. Remedies included: initiatives related to needs-based planning, with delivery of more equitable and increased primary health care funding; training, recruitment and retention of the health workforce and planning for comprehensive, regional primary health care services; development of state-of-the-art information technology systems for patient information and access to records; and development of high-quality-care initiatives based on key performance indicators. These changes have been recognised as leading to the current improvements in the life expectancy of Aboriginal people and the reduction in the rates of some chronic diseases.1,2 The Northern Territory Emergency Response and its effectsThe emergency intervention came from left field. The health component, like the intervention as a whole, got off to a bad start. Individual health checks on children were not recommended in the Ampe akelyernemane meke mekarle: “little children are sacred” report,3 but the Australian Government initially talked about compulsory forensic examinations of all children to ascertain a level of sexual abuse. This would have been a form of assault if carried out, and it is likely that no doctor would have agreed to participate in such a process. Thankfully, this never occurred. As with other parts of the intervention, it appears not to have been properly thought through. Within a week, the Minister for Health had publicly given guarantees that the checks would be voluntary and would be carried out by a procedure already being used throughout Australia —Medicare item 708, Aboriginal and Torres Strait Islander child health check.4 Developed in collaboration with ACCHSs, the health checks, if properly done, contribute to children’s health in a broad and holistic manner. Nearly 1000 of these checks had been completed in the NT before the intervention. If providers had suspicions of sexual abuse or neglect they would refer the children to the appropriate person or authority, as was already their mandatory duty, but it was recognised that the health checks were not designed to detect child abuse. Unfortunately, the initial suggestion of compulsory sexual examinations generated widespread fear and misinformation about the health checks. It has taken much work to explain to Aboriginal communities that these were the same checks that were already being done by ACCHSs. The only reason they had not already been provided to all Aboriginal children was a lack of resources. Another concern that was raised in some quarters was the cost of doing the health checks. It could be argued that the $83 million could be better spent on other priorities. While this may be true, there was little room to discuss doing anything else with the money. The Australian Government had already decided that the checks would be done and had allocated the necessary funding. Undertakings by Aboriginal medical servicesThe Aboriginal Medical Services Alliance Northern Territory (AMSANT) decided that it was important to engage with the process of children’s health checks for two reasons. First, without the full cooperation of and engagement with existing ACCHSs, the health checks would not be done as well, would not reach as many children, and would not be properly coordinated with the systems and ongoing responsibilities of ACCHSs. ACCHSs across the NT had begun providing the checks, so this part of the intervention was seen as an opportunity to do them much more quickly and with a commitment to ensuring that the necessary follow-up was available. An average of 67% of children across the NT have been brought by their families to have a health check by the visiting teams in the more than 40 prescribed communities that have been visited so far. The second reason for AMSANT to engage with the health checks was to enable it to continue to work with the Department of Health and Ageing to secure the longer-term needs of the primary health care system. This has led the Department to commit an additional $100 million over 2 years for improving comprehensive primary health care in the NT. The total current expenditure on Aboriginal primary health care in the NT is about $80 million a year. Therefore, an additional $50 million a year is a substantial commitment. An improved primary health care system can sustainably and routinely deliver better health care for children. Since the intervention began, AMSANT and its members have lobbied effectively for an improved and more participatory process. As a result, the Australian Government has worked constructively with AMSANT in planning the details of the follow-up programs. In contrast to the previous approach of offering health checks in the absence of adequate services to provide subsequent treatment, we have the opportunity here to significantly expand primary care and specialist follow-up. The key barrier to the successful implementation of the Australian Government’s initiative is the workforce shortage. In particular, further teams of nurses, general practitioners, ear health workers and others are needed to ensure apprpriate follow-up. It would be unacceptable for deficiencies in the workforce to prevent the children who have been checked from being followed up. The intervention has provided an opportunity for health professionals from mainstream Australia to work in the NT, and we hope they will return to work again with our dedicated teams in the bush. Continued support from various peak health professional associations and the Australian Government is required for this recruitment process now and into the future. The futureThe health checks and an improved primary health care system are now clear potential benefits of the intervention. Also, the additional police and other improved services have been needed and are welcome. Some other aspects of the intervention are less likely to be positive and others are likely to be harmful. In particular, its initial implementation was profoundly disempowering to many Aboriginal people in an environment where disempowerment and loss of identity lie at the root of community dysfunction. The medical profession knows that lack of control of life circumstances can contribute significantly to worse health outcomes. This could be a very damaging effect of the intervention, particularly in the light of the already large gap in life expectancy between Aboriginal and Torres Strait Islander peoples and other Australians (17 to 20 years’ difference). It is also vitally important that the racially discriminatory aspects of the intervention, such as the welfare changes and the forced prohibition of alcohol, be repealed, as there is a clear and well established relationship between the protection of fundamental human rights and population health.5,6 Welfare reform may have merit, but any reform needs to be applied to all welfare recipients across Australia or targeted at particular people who are identified as not acting appropriately with their children. The discriminatory quarantining of income of Indigenous people is also not in the spirit of the Australian Government’s stated aim of encouraging individual responsibility. Similarly, alcohol reform is desperately needed, but the measures the intervention has imposed — forced prohibition in certain places and the need to record takeaway alcohol purchases of more than $100 — have no evidence to support them, are unevenly applied and do little to reduce the supply of alcohol. The need to reform the Community Development Employment Projects, in which an estimated 7500 Aboriginal people in the NT are employed in community-controlled projects funded by block unemployment benefit grants, is widely accepted. To scrap them altogether will rob many of meaningful work, self-esteem and confidence, and diminish the capacity of Aboriginal organisations and communities. This may add to, rather than diminish, social dysfunction. The medical profession has been aware for a very long time of the importance of education to improving the health of populations. The need to fund adequate preschool, primary school and secondary school places for Aboriginal children across the NT is paramount, but this has largely been ignored up to now. The small amount of new funding allocated by the NT Government to education is just a fraction of what is needed to ensure that all Aboriginal children can access all tiers of education. Additional housing is also urgently needed. Chronic overcrowding contributes to poor health outcomes and places children at risk of sexual abuse. The additional $780 million for housing currently offered is a welcome new investment, but will probably not be enough. AMSANT’s experience with the intervention’s child health checks is instructive for other aspects of the intervention. It has required refocusing an initial highly inappropriate measure (compulsory checks for sexual abuse) so that an existing appropriate service (the health checks under Medicare) can be advanced and so that an improved, sustainable primary health care system will ensure the capacity and resources for proper follow-up. A similar rethinking, focused on child protection, is required for other aspects of the intervention. Crucially, this can only occur through a process that achieves genuine engagement of Aboriginal communities as well as the support and cooperation of both the federal and NT governments. This, after all, was the central thrust of the “Little children are sacred” report. For the sake of the children, we must continue to pressure governments to adopt its recommendations.

John D Boffa MB BS, MPH · Andrew I Bell FAFPHM, FACRRM, DRANZCOG · Tanya E Davies FACRRM, FRACGP, DRANZCOG · John Paterson · David E Cooper PhD

Has the federal government’s intervention in Aboriginal communities taken a respectful, tolerant, partnership approach? The timing of the federal government’s intervention to protect little children in the Northern Territory has been viewed by some with cynicism. And well it might be. The intervention needs to be seen in the broader context of what could be called the “white blindfold” view of history. The white blindfold obscures the benefits that modern Australians have inherited as a consequence of European colonisation of this country. It hides any understanding of how dispossession of the Aboriginal first nations has resulted in the poverty, illness and violence that the government is now, belatedly, seeking to rectify. The current neoliberal ideology also prevents understanding of the mechanism of how dispossession and marginalisation have caused the spiritual, mental, social and physical dis-ease that we see at present. In not understanding the causal links, the government is not able to properly arrive at a workable solution. In fact, the approach being trialled stands a good chance of making the underlying problem worse. Work by Marmot1 and Wilkinson2 and insights from de Botton3 and Freire4 throw light on the background and mechanisms whereby the process of colonisation and the ongoing situation of Indigenous people in Australia today translate into physical and mental illness and social discord. The argument, most simply put, is that inequalities, especially overt economic and social inequalities, cause people lower in the pecking order to feel inferior. Even worse, the “lower orders” feel disrespected by their “superiors”. It is the perception of disrespect, manifest in many minor ways, and perhaps not even consciously expressed and received, that drives the sense of inferiority. Through neurological, endocrine and immunological networks, disrespect and inferiority become internalised as immune suppression, inflammation, and acute and chronic illness. Externally, they emerge as substance misuse, risk-taking, violence and social discord. The foundation social determinants of health are social equality and respect. In today’s Australia, particularly in relation to Indigenous people, these are fragile, tenuous, or perhaps even lacking. The logical solution is to create a more equal, tolerant and respectful society. That doesn’t mean handouts and welfare. It does mean working in a respectful manner and offering a partnership approach to helping with economic and community development. The most respectful approach involves listening to community leaders. After all, it is the leaders who have been struggling with the problems for a long time and may have some ideas about locally applicable solutions. Has the federal government’s intervention taken a respectful, tolerant, partnership approach in seeking to improve the lot of children in the NT? No one can claim that it has. From the outset, the intervention has been styled as strong, decisive action. The situation has been framed as an emergency. Consultation with Aboriginal leaders has come later and has been approached in the vein of “this is how you are going to do what we want”. In the federal government’s haste to be seen to be responding to the Ampe akelyernemane meke mekarle: “little children are sacred” report,5 there has been talk of children being forensically examined and uncertainty about what will happen. Scared parents are disturbed by these developments and by the stories of older people who still hold clear memories of the stolen generations — another thing obscured by the white blindfold. Are Aboriginal leaders and the communities they lead feeling respected? The intervention is not implementing any of the recommendations of the “Little children are sacred” report. There are moves to change rules of access to Aboriginal land and there is talk about changing the Aboriginal Land Rights (Northern Territory) Act 1976 (Cwlth). The links between such changes and saving little children are not well spelt out. It is not clear what impact these aspects have on economic development. How does this leave Aboriginal people feeling? In 1989, the National Aboriginal Health Strategy was developed by Aboriginal leaders in partnership with government. It recommended that $2.5 billion be spent nationally over 5 years to achieve improvements in Aboriginal health. In fact, only $232 million was allocated over the 5 years. Since then, Aboriginal health leaders have repeatedly called for adequate funding. In the NT, calls to establish the Primary Health Care Access Program have, until recently, received a muted response from all levels of government. Now, in the lead-up to a federal election, between $0.6 and $1.3 billion has suddenly become available to save Aboriginal children. How do you think Aboriginal people are feeling about that? The other collateral damage is occurring among the doctors, nurses and Aboriginal health workers who, for years, have been doing their best in a resource-poor environment to treat the sick and improve health. How do they feel about this sudden flood of resources that is bypassing the services they are working in, and the unspoken implication that perhaps they haven’t been doing their job well enough? Not that this new bucket of money is not recognised as potentially useful. People are only too aware of the need. As the local analogy goes, the steamroller is coming through: no point lying in the road and getting squashed — let’s run alongside and see what falls off. Maybe we can even nudge it in a more appropriate direction. The key question is whether the government’s intervention will be effective. The answer depends mainly on one’s definition of “effective”. If we were to define effective as creating healthier, more economically robust and socially cohesive Aboriginal communities in the NT, then I am not confident that the present approach can deliver that. This is because the current approach is essentially disrespectful of Aboriginal people and is further marginalising their leadership. In other words, the fundamental social determinants of NT Aboriginal health are being undermined. Were the intervention to be reconfigured and the money invested in a way that supported Aboriginal leaders to build their own capacity and to develop a community response, then I would be much more confident that long-term good will come from it. Community building projects that have been run in other Australian jurisdictions have demonstrated that this approach works — for example, the Windale Community Renewal Scheme in New South Wales.6 There is, besides, an established primary health care sector operating in the NT which, with adequate funding, would be well positioned to do more of what it is already doing. The political will to take action has obviously been present. There is bipartisan support for it to continue. What will be most interesting will be to see what happens once the election is over and the process of governing the country for the next 3 years begins. Will the federal government continue in the same disrespectful manner or will it be open to a change in approach that might truly make a difference?

Peter W Tait MB BS, FRACGP

Coercive reconciliation: stabilise, normalise, exit Aboriginal Australia. Jon Altman, Melinda Hinkson, editors. Melbourne: Arena Publications, 2007 (ix + 342 pp). ISBN 978 0 9804158 0 3. In June 2007, in response to a Northern Territory report on Aboriginal child sexual abuse, the Australian Government declared a national emergency, with interventions aimed at protecting Aboriginal children. While few deny the need for action to address the problems in Aboriginal communities, the sheer scale of the intervention has left many confused. We now have, in one volume, a series of 30 (mainly critical) essays about various aspects of the intervention, written by knowledgeable commentators, many of whom are Aboriginal. One overriding theme that emerges from the essays is that a lack of community engagement means that the intervention is destined to fail, with potentially disastrous results for Aboriginal people. Tom Calma states that the “. . . fundamental elements of good Indigenous policy . . . engagement, participation and accountability” are missing. Raimond Gaita argues that “No plausible description of the plight of the Aboriginal communities can justify . . . the lack of consultation and the reckless disregard for the consequences of the intervention”. He asks: “Could such disrespect be shown to any other community in this country?” He believes not, suggesting that “. . . Aborigines and their culture are still seen from a racist, denigrating perspective”. John Sanderson (former Australian Army Chief and Western Australian Governor) suggests that the intervention ignores the known effects of cultural and social disempowerment on physical and mental health. Some suggest that the child health checks, at least, may be worthwhile. However, as Ian Anderson points out, the health checks were initially going to be mandatory and forensic, but were appropriately changed to be wellness-focused and voluntary. As the Government had already started to roll out Medicare-funded Indigenous child health checks, this aspect of the intervention is just window-dressing — other components of the intervention will have bigger and more worrying effects. After reading the essays, the reader must be concerned about the potentially devastating impact on Aboriginal health and wellbeing of this perhaps well intentioned, but ultimately ideologically driven, intervention. The medical profession has a responsibility to be informed about what is happening. This book will help — it should be widely read.

David J Scrimgeour

It remains unclear how federal government intervention measures in Indigenous communities in Central Australia will create sustainable, safe and nurturing communities There are none among us who would question the sanctity of our children. Children lie at the core of Aboriginal existence and of our survival. Furthermore, there are none among us who would not welcome any just measures to protect our children. Child protection and survival remain central to the fight for Aboriginal rights, identity and cultural continuity. Yet now we bear witness to a moment in time when the very foundational principles on which Aboriginal existence are built — community, culture and collective rights — have been shaken, demonised and exposed to a level of scrutiny unparalleled in recent times. In no place has this been felt more acutely than in Central Australia. In 2006, revelations offered by the Alice Springs Crown Prosecutor outlining an accumulated dossier of abhorrent cases of child sexual abuse in Central Australia were met with immense public horror.1 The response was understandable, but failed to acknowledge that the dossier echoed the voices of Aboriginal communities’ repeated calls for action over the span of several decades — voices that had been ignored. The response, from public commentary and an increasingly vocal anti-Aboriginal-rights sector, was swift and damning, editorialising the suffering of Aboriginal communities. In many respects, a new (or rekindled) language emerged, the language of “Aboriginal deficit”. The media were awash with claims of “paedophile rings”, of a culture that “accepted and protected” the raping of children, of “customary law being used as a shield to protect abusers”.2,3 The inference was that all Aboriginal men are “perpetrators”, all Aboriginal children are abused, and that these abuses — fuelled by alcohol, petrol and kava — are compounded by social dysfunction that is largely the consequence of a “primitive” and “barbaric” culture. Public commentary allowed the seeds of change to be sown, change that “required” a “new paternalism”, “normalisation” or “mainstreaming”; that called for the closure of “unviable remote communities”; that touted the “failure of self-determination”; that required an end to “political correctness gone mad” and the “pouring billions of dollars down the toilet”.4,5 Unfortunately, such language has been used to justify blatantly discriminatory policy. In response to public reports, the Northern Territory Government initiated an investigation into the issues of child sexual abuse. These issues were recorded, collated and considered within the Ampe akelyernemane meke mekarle: “little children are sacred” report.6 The ill health and profound disadvantage of Indigenous Australians, particularly of Indigenous children, is well documented, persistent and inadequately addressed. Aboriginal and non-Indigenous professionals and advocates have long called for necessary long-term commitment to and adequate resourcing of health, housing, education, employment and development. Communities have long demanded support for structures for civil society; sustainable environments; respect for cultural diversity; investment in social and human capital; access to high-quality, appropriate child and adult education; and equality of opportunity in the face of enormous disadvantage. Reams of recommendations have been listed, skimmed, ignored and filed — any number of which, if put into practice, could have made a sustainable difference on the ground for Indigenous Australians. The “Little children are sacred” report, irrespective of its integrity and worthiness, joins a disturbingly long list of reports whose recommendations have been largely ignored. In comparison, however, it may well stand out as one of the most blatantly bastardised of all Aboriginal health reports, in that the federal government has “delivered” the NT intervention, in rhetoric, as a means of protecting Aboriginal children. Yet, despite claims that the report guided and was the impetus for the federal government’s intervention, surprisingly few of the report’s recommendations have been considered or implemented. In fact, many commentators have suggested that the report has been used as a shield to force the imposition of an existing federal government agenda to dismantle any semblance of collective and individual rights, native title, and self-determination among Australia’s first people.7 The announcement of the NT intervention was met with an almost audible collective sigh of despair across much (but not all) of Aboriginal Australia. In an instant, another weight was placed on Aboriginal communities, spelling a potential end to the progress made in generations of struggle for acknowledgement and recognition of Aboriginal people’s right to have some control over the future of their families and communities. This is not to suggest that communities are not supportive of an array of intervention targets. Indigenous communities have long called for improved policing; measures to reduce alcohol-related harm; enhanced educational and vocational opportunities; and improved infrastructure, health services and community safety. In fact, in discussions with communities directly involved in the intervention in the NT, there remains strong support for any just and appropriate measures that deliver these. Yet there remains enormous confusion and concern over other elements of the intervention that seem unconnected to child health, such as compulsory land acquisition by the federal government; the abolition of entry permits for Indigenous communities and of Community Development Employment Projects programs; the appointment of government business administrators to “run” Indigenous communities; and the potential threat of community asset-stripping. Further, the legislation covering the NT intervention places unparalleled control of Indigenous affairs in the hands of the Minister (or his designated delegate), and is largely discretionary and, in critical elements, poorly defined. Unfortunately, we also bear witness to a moment in time when Parliament has allowed the passage of racially discriminatory legislation. The most fundamental of all questions remains: will the intervention actually make children safer? Unfortunately, there has been little public or professional debate on this issue. The federal government has largely polarised public discussion, reducing complex issues to narrow, unsophisticated arguments with little recognition of the inherent complexity of the causes and consequences of abuse, in all its forms — particularly in the context of profound disadvantage, marginalisation, trauma, grief and loss, and generations of governmental inaction and under-resourcing. Public debate has been dampened. In simplistic terms, the line is that “you are either with us or against us”. To fail to support the package in its entirety is to either be a child abuser or to accept and support child abuse. Yet, as professionals and citizens, it is our inherent responsibility to question the how, even if we agree with the why. In the weeks and months following the announcement of the NT intervention, it has become clear that decisions were made in a policy and strategy vacuum. Activities have been poorly coordinated, poorly planned, and liable to change and backtracking. This has fuelled confusion and paranoia, and created enormous concern about the squandering of desperately needed resources, which are being used largely to install the bureaucracy rather than provide services.8 Worse still, the current approaches are undermining successful programs already in place in communities. The long fought-for resourcing and community actions required for healing, protecting and nurturing Indigenous children are being de-funded and ridiculed. Child health checks are already occurring; vaccination rates are generally high in Central Australia; many communities already have complete bans on alcohol; families voluntarily submit to “income management programs”; communities have established their own child protection services (because of the failure of government departments), and have progressed towards improved partnerships with police and child protection agencies, who, by their own admission, lack the capacity to adequately respond to reported cases of abuse. Labelling the intervention as the response to a crisis that could not wait a single day longer to be rectified is a fallacy. The government has had countless offers of guidance to better direct the intervention elements, the child health checks, the necessary follow-up and long-term health and social needs. Yet these offers have been ignored. The most worrisome elements of the intervention may lie in the likely and unintended consequences. Communities remain deeply concerned that there will be direct casualties of the intervention, casualties that communities can ill afford, but that the government considers necessary and acceptable “collateral damage” — worsening poverty, suicide and unemployment (particularly of Aboriginal men); disempowerment; the creation of an atmosphere of fear, in which complaints of abuse are less likely to be reported; and a “one size fits all” approach that frames all Aboriginal communities as dysfunctional, all Aboriginal people as abusers, and all Aboriginal children as abused. It remains unclear how any of the intervention measures will create sustainable, safe and nurturing communities, or whether they will protect Aboriginal children at all, particularly in the face of decades of under-investment in the basic building blocks of healthy societies. Despite the likely negative consequences, the intervention may offer opportunities to improve health and social outcomes and promote safer communities, but it remains to be seen whether this potential can be realised. The opportunity exists to focus our attention on the needs and priorities of our young people, to use best-practice models of health promotion and care for Aboriginal adolescents, and to make their safety and development a national priority. However, without a focus on healing, mental health and support for Indigenous youth, both now and over the long term, the intervention is likely to fail. As a society, we must ask ourselves whether the current interventions will empower communities and support them appropriately, in a spirit of collaboration and respect, to adequately deal with the causes, triggers and consequences of abuse. Marginalisation, poverty, disempowerment, colonisation and trauma are the upstream contributors to psychological, physical and sexual abuse in the present. Yet the current policy is likely to deliver the very same things, and, as a consequence, risks perpetuating dysfunction and abuse. The government has yet to explain how the removal of Aboriginal people’s right to control or participate in decision making and implementation will promote their survival and protection. The likely success or failure of the NT intervention may well rest on what mainstream Australia sees as Aboriginal people’s place within contemporary Australia. Are Aboriginal people simply an echo of a past worth forgetting, a relic of a barbaric and uninformed culture? Are we only good as footballers, athletes or performers in opening ceremonies? What of Aboriginal Australia’s aspirations for its own future, or is this something that a globalised community can ill afford to consider? The current policy approach rests on a false underlying assumption that all Australians must share the same values and aspirations. The success or failure of the intervention may also depend on what we consider that Indigenous people offer contemporary Australia. Strength in diversity, wisdom, connectedness, humility and survival against the greatest of odds . . . in any other context these attributes would be regarded as national treasures, as a collective identity worth nurturing, building and embracing. Yet, in 2007, these qualities of our Indigenous people seem to be unrecognised or even disdained. A nation and its people are judged on how they treat their most vulnerable, disadvantaged and marginalised. The significance of our current federal government’s refusal to ratify the United Nations Declaration on the rights of indigenous peoples9 has not been lost on Aboriginal people and their advocates.10,11 On the one hand, the government purports to be taking action to protect vulnerable Aboriginal children, yet on the other, it fails to support any national or international requirement or responsibility to recognise and acknowledge native title, cultural integrity, self-determination, and preservation of Indigenous knowledge and sovereignty, as set out in the UN Declaration.9 It is our responsibility, then, as individuals, professionals and as a nation, to ask how our government’s stance on these issues can coexist with the stated aim of protecting our most vulnerable, our children, our future.

Alex Brown BMed, MPH, FCSANZ · Ngiare J Brown BMed, MPHTM, FRACGP

Lands of shame. Helen Hughes. Sydney: The Centre for Independent Studies, 2007 (xv + 237 pp). ISBN 978 1 864321 35 7. Lands of shame was the blueprint for the Howard Government’s “national emergency” intervention in the Northern Territory. In spite of its influence, I would not recommend Lands of shame to anyone desirous of gaining an insight into the history of Indigenous policy, because of its simplistic generalisations and ideological bias. According to Hughes, poverty in remote Indigenous communities is a legacy of the “Coombs socialist homeland model” introduced 30 years ago. Elements of this model included communal property rights, the apparent use of customary law and other “separatist policies” designed to resurrect “hunter–gatherer economies”. Hughes’ description of the evolution of Indigenous policy is incongruous with the history of my home state of Queensland. Many of Queensland’s remote Indigenous communities are former reserves that were established during the protectionist era that preceded the 1970s. Far from being hunter–gatherer economies, the reserves were akin to Dickensian workhouses that left little room for human dignity, let alone the sanctity of family life. I can still remember the first time that I visited one of the former reserve communities, and a colleague pointed out to me the old dormitory where young children were once forced to live. Years later, the inevitable pain that would have been suffered by the children’s parents still makes me shudder. Arguably, such indignities offer a far more plausible explanation for the contemporary social problems of some remote Indigenous communities, than communal land tenure. Yet this history is largely overlooked by Hughes. Hughes’ greatest flaw is her failure to comprehend the immorality of writing a manifesto for Indigenous people in the absence of a meaningful dialogue with us. Hughes routinely dismisses the Indigenous leadership as corrupt “Big Men”, with only Noel Pearson (who conveniently shares her ideological position) spared rebuke. Her apparent view of respectful engagement with Indigenous people as superfluous makes Hughes no better than those she condemns. Indeed, the very lack of empathy that enabled bureaucrats to remove Indigenous children into dormitories is a disturbing, though unacknowledged, presence throughout the entire book.

Nicole Watson

Initiatives to prevent access block should be aimed at long-term structural changes to bed availability to meet the needs of a complex and ageing population; current management practices are creating a growing mismatch between supply and demand The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the emergency department (ED) where their total ED time exceeds 8 hours.1 Simply put, access block is the absence of flow at a system level, not just the ED. In United States literature, access block is referred to as “overcrowding”. How does flow stop?In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 14% decrease in the number of public hospital beds between 1992 and 2002.2,3 In the US, the number of medical and surgical beds declined by 18% from 1994 to 1999, while ED attendances increased by 15%.4 During this time, there have been concomitant decreases in inpatient length of stay and more day procedures and day admissions.5 However, in the United Kingdom, after a period of decline, the number of multiday admissions per 1000 residents increased in 2002 and 2003. This was thought to be the result of postponed demand related to illnesses for which there were waiting lists, and to the increasing burden of chronic disease. In 2003, 30% of the multiday admissions could be attributed to just 20 International classification of diseases, ninth revision (ICD-9) diagnoses, and a third of these were attributable to chronic heart disease.6 CapacityCapacity decisions in hospitals are generally made without the help of quantitative model-based analyses.7 Hospital managers have been stimulated to reduce the number of beds and increase the occupancy rates to improve operational efficiency. Modelling is usually based on average bed occupancy. However, this model is not capable of describing the complexity and dynamics of the patient flow. This is known as the flaw of averages. A formula has been described that can be applied to almost every queuing system.8 It shows the relation between the expected number of patients in the system, EB(t), the average length of stay (μ), and the unscheduled need, described by the Poisson process, λ: EB(t) = λμ For example, at an intensive care unit (ICU), five patients arrive per day on average. The average length of stay is 6 days. The parameters of this queuing system are: λ = 5 and μ = 6. Using the above formula, the expected number of patients at the ICU is 30. If management decides to size the unit on this average bed number, operational problems will occur on a regular basis. The probability (Pi) that more than 30 beds are occupied at any time is easily calculated according to the formula: Pi = e-λμ(λμ)i/i! where e = expotential and i = the number of beds occupied. In this example, Pi = 0.45 (ie, need will exceed capacity 45% of the time).9 It has been shown that a high degree of reserve capacity (up to 30%) is required to avoid high rates of surgery cancellations because of unavailable beds downstream.10 However, most health policy experts believe that a 15% capacity buffer is adequate, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more.11 Ageing populationIt is projected that between 1996 and 2016, the general population in Australia will increase by 21% or 3.1 million, the number of people over the age of 65 years will increase by 59% or 1.3 million, and those over the age of 80 years will increase by 76% or 368 000.12 The effect of the ageing population on access block is twofold. As noted earlier, there is already a relative decrease in access to residential care beds in the community, especially beds designated for high-dependency patients, in the face of a significant growth in the number of people seeking placement.13,14 It has been shown that incidence rates of institutional aged care double for each 5-year interval from the age of 60 years.15 The general effect of illness and ageing must also be considered. In one study, undertaken between 1990 and 2004, while there was a 54% increase in the total number of ED patients, there was a disproportionate increase of 198% in the number of patients aged over 70 years, including a 671% increase in the number of those aged over 90 years. The time taken to manage patients increased with age, with older patients (aged over 70 years) being 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less), and older patients’ average length of stay was 6.9 times longer. There were 3.3 times more younger patients than older patients, but older patients occupied 9.8 times more ED bed-days.16 Preventing avoidable hospitalisationsIn response to unprecedented and sustained increases in demand for health care services that were placing significant pressures on hospitals, the Victorian Government committed $582 million as an initial investment over 4 years from 2001–02 to 2004–05 to implement the Hospital Demand Management Strategy. Of this allocation, $150 million was invested to develop new approaches to caring for patients known to have a high risk of deterioration in their health, and thus preventing avoidable hospital use in the future. These new approaches to patient care were developed, implemented and evaluated through a program called the Hospital Admission Risk Program (HARP). Many patients with complex and chronic illnesses were treated as hospital outpatients or in the community. These programs have shown good initial outcomes with HARP patients experiencing 35% fewer ED attendances and 52% fewer ED admissions, and 41% fewer days in hospital.17 There are, however, some emerging data that question the sustainability of the early gains of these programs, in the face of age and worsening disease.18 The federal–state divideIn Australia, health care is funded by both federal and state governments. Public hospital funding is largely provided by the state, and primary and subacute care is funded by the federal government. Aged care provides a good example. The federal government has responsibility for residential aged care. In the absence of adequate residential capacity for the aged, patients are inappropriately accommodated in public hospitals. Solving this problem will require a combined approach to stop the “buck passing” between the federal and state governments.19 OutcomesAccess block is not an inconvenience. It is not a problem of EDs. Access block is an illness, and not a benign illness. It has a morbidity and mortality rate and a growing literature about it. A search in MEDLINE (1950 to Week 2 of October 2007) using the keywords access block, crowding and overcrowding identified 163 articles. This Journal alone has published 26 articles in recent years. We know that access block causes ambulance diversion,20 independently predicts increased inpatient length of stay21,22 and increases patient mortality.23,24 One study reported 43% more deaths in an overcrowded cohort compared with a non-overcrowded cohort of ED patients, with the effect more profound in the older population. Another showed a linear relationship (R2 = 0.95) between the degree of overcrowding and 7-day mortality.24 There is a high correlation between overcrowding and patients who leave an ED without treatment. Another report showed a 0.665 correlation between increasing overcrowding and the rate of patients who left before being treated.25 While most of these patients are not in the high-acuity triage categories, tragic consequences can nevertheless arise. In the case of one patient who died of infective endocarditis after being discharged from an ED, the coroner concluded that “it has to be recognised that as a matter of common sense, in an environment of severe overcrowding the potential for error on the part of medical practitioners, especially in a setting where a decision has to be made as to whether a patient should be discharged or not, will inevitably exist”.26 A previous editorial in this Journal proposes two solutions — reduce hospital demand and optimise bed capacity.27 I would propose that we acknowledge the limitations of the first strategy as our population ages and requires increasing community support. As shown earlier, bed capacity needs to be able to meet surge requirements and not the average need. While ED and inpatient reforms have and will deliver some gains, the problem we now face is bed stock. ED overcrowding is not caused by patients in low-acuity triage categories who present to the ED and are able to be quickly discharged. These patients are dealt with through a variety of “streaming” processes (eg “fast track” or “likely discharge” models of care). It is patients who need hospital admission who drive the system into ED cubicle block and overcrowding.

George Braitberg FACEM, FACMT, DipEpiBiostats

Objective: To determine characteristics and outcomes of patients who did not wait to see a doctor in emergency departments (EDs).Design and setting: Population-based outcome study using probabilistically linked ED and Western Australian death records, with ED records from all seven Perth public hospitals that have EDs from 1 July 2000 to 30 June 2003.Main outcome measures: Rates of “did not wait” (DNW) presentations, overall and for individual hospitals; characteristics of DNW patients; mortality rates among DNW patients at 2, 7 and 30 days.Results: DNW rates varied from 2.6% to 6.3% (average, 4.1%) and were generally lower in tertiary teaching hospitals. DNW patients had conditions of lower urgency, predominantly Australasian Triage Scale category 4 (67.1%) and 5 (23.4%). The DNW rates in these categories were 5.8% and 10.6%, respectively (P < 0.001). Patients referred by health care providers had lower DNW rates (0.5%; P < 0.001). DNW patients were more frequently male (4.4% v 3.8%; P < 0.001), and young to middle-aged adults (15–44 years; 5.8%; P < 0.001). Patients with a higher than average DNW rate were more likely to arrive by private transport (5.0%; P < 0.001) or with police (5.8%; P < 0.001), re-present for review (8.6%; P < 0.001) or have social or behavioural problems (7.7%; P < 0.001). Most patients (91.9%) did not wait on only one occasion. The 30-day mortality rate among DNW patients was significantly lower than for patients seen by a doctor and discharged (0.14 v 0.20%; P = 0.026), and for all patients seen in the ED (1.28%; P < 0.001).Conclusions: Patients who did not wait for medical assessment in Perth EDs had conditions of lower acuity and had lower mortality rates than those who waited for assessment.

Jacqui Hall MB ChB, FACEM · George A Jelinek MD, FACEM, DipDHM

Objectives: To assess changes in emergency department (ED) activity and visits to EDs that could have been managed by general practitioners (GP-type visits) in the Christmas and New Year holiday period compared with the rest of the year.Design and setting: Retrospective descriptive and analytical comparison of New South Wales ED visits in the holiday period and the rest of the year; data were obtained from the NSW Emergency Department Data Collection database for the period 2001 to early 2006. More detailed information in 2005–2006 allowed GP-type visits to be assessed in this period only.Main outcome measures: The change in the number and percentage of weekly ED visits during the holiday period.Results: Between 2001 and 2006, average weekly counts of ED visits increased by 9% (95% CI, 7%–11%) during the holiday period. The holiday increase was largely accounted for by visits that were less urgent, and for patients who were not admitted, did not arrive by ambulance, had a shorter treatment time and arrived between 08:00 and midnight. In 2005–2006, average weekly counts of GP-type visits increased by 21% (95% CI, 15%–28%) compared with 8% (95% CI, 4%–12%) for ED visits overall. However, GP-type visits accounted for only 39% of the additional holiday visits. GP-type visits increased mainly for adults and more in urban than rural areas.Conclusions: The Christmas and New Year period is the busiest time of year for NSW EDs. However, only some of the additional holiday visits can be attributed to GP-type visits. Improving access to GPs, but also to broader hospital and community-based health care services over the holiday period, should be considered for managing the excess demand.

Wei Zheng MPH · David J Muscatello MPH · Adam C Chan MB BS(Hons), FACEM

Emergency departments are under pressure. Chronic staff shortages, access block and other problems are increasingly affecting the ability of medical and nursing staff to treat patients On 23 September 2007, The Age (Melbourne) reported a leaked letter to the Victorian Health Minister from Dr Andrew Buck, an emergency registrar, who described compromised patient care in the overcrowded and understaffed emergency department (ED) at Monash Medical Centre in Melbourne.1 News of a miscarriage in its ED waiting room on 25 September shifted the focus to Royal North Shore Hospital in Sydney, initiating scores of complaints in the media from patients and clinicians about treatment provided in New South Wales public hospitals.2 A fatal cardiac arrest occurred in the waiting room of the Canberra Hospital ED on 5 October. Meanwhile, an identical event occurred in the Royal Perth Hospital ED.3 These events patently demonstrate that pressures facing these departments are shared nationwide, and that chronic staff shortages and access block are increasingly affecting the ability of medical and nursing staff to treat critically ill patients in a timely manner.4 The effects of overcrowding and overwork on patient outcomes have been well described. A study in 2006 found that presentation to the ED during periods of high bed occupancy was associated with higher mortality at 10 days, translating to an estimated additional 13 deaths per year.5 Numerous studies have described the association between clinician’s fatigue and stress with adverse outcomes for patients. The wellbeing of doctors and their clinical practice are affected by making mistakes and the increasing public scrutiny of health care.6 The qualitative effects of working in chronically stressful ED environments on workforce morale and retention have been less well examined. Despite evidence that overcrowding and overwork harm both patients and clinical staff, few measures have been introduced to combat the pressures or to address the issues at a system level. Recent media criticism and public scrutiny has caused me, along with many of my colleagues, to reflect on my choice to practise and train in emergency medicine. I have worked in several EDs during the past 6 years: large and small, rural and metropolitan. I can honestly say that there is no other clinical job that provides the exhilaration and satisfaction of a good day spent working in the ED. Unfortunately, a bad day in the ED can leave you very flat indeed. There are so many reasons why emergency medicine appeals to me as a specialty. Above all, it is always interesting. We deal with all sorts of people and all sorts of problems, often finding ourselves in the thick of human tragedy or triumph. We are the medical jacks-of-all-trades, which means that we have something to offer when faced with any kind of clinical problem, often providing a bridge between other disciplines. We are “safe hands” in the hospital, possessing resuscitation skills to save the lives of critically ill patients, and medical and procedural skills to initiate early treatment. We work with our minds, our hands and our hearts to a degree not shared by any other single specialty. We have the ability to do enormous good for our patients and their families. Emergency departments have a special quality. The nature of the work makes multidisciplinary teamwork a necessity. Nurses, doctors, allied health professionals and clinical support staff work, and socialise, together more closely in an ED than in most other departments. Emergency medicine attracts competent, quick-thinking and personable clinicians, who not only care for their patients, but look after each other too. An ED nurse told me recently that the only thing that kept her coming to work each day in the face of public criticism was that she loves her colleagues and did not want to let them down. I share her sentiment and her pride. Despite the many positive features, emergency medicine is struggling to attract and retain clinical staff. Obvious disincentives include shift work, which continues into consultant life; limited access to private billing, resulting in low pay compared with other specialties; and the lengthy and difficult training program. Work intensity has increased, with more patients presenting for treatment, and admitted patients staying longer in the ED while waiting for an inpatient bed to become available. This includes many agitated psychiatric patients. Staff who feel that they are unable to provide timely and high-quality care to their patients become burnt out and take time out from the discipline, entrenching chronic workforce shortages and creating further stress for those left behind. Emergency medicine is very exposed at the “front-end” of the hospital system, and has therefore become overtly political, subjecting staff to regular media attack and reactive, knee-jerk policy implementation. As our doors are always open, EDs are increasingly caring for those who have nowhere else to turn — the homeless and indigent — who present with uncontrolled chronic, often preventable, conditions and have limited or no access to appropriate outpatient treatment or social supports. It is difficult for ED practitioners to feel valued in the current climate. Negative media reports have given patients and families implicit permission to criticise and even abuse clinical staff. There have been verbal and physical assaults against ED doctors and nurses after the recent publicity, and colleagues report that they increasingly feel emotionally and physically frightened at work. Reliance on locum and overseas-trained staff to fill medical and nursing vacancies has increased. Not only is there resentment of the pay differential, but reliance on casual staff potentially affects teamwork and delivery of patient care. Clinicians also feel undervalued by colleagues in other hospital-based disciplines who do not recognise or respect their unique skill set. It is commonplace for a junior doctor from an inpatient team to speak down to an emergency consultant or advanced trainee. While the “ED versus the world” mentality that ensues may enhance clinical teamwork, it can too easily slide into “ED versus ED” as stress levels increase, damaging workplace cohesion and the quality of patient care. Emergency medicine is at a crossroads. It is vital that steps be taken to improve workforce recruitment and retention, and to better manage escalating workloads. These measures must deal with education and training needs, industrial conditions, availability of hospital beds, and provision of appropriate primary, community and outpatient care. Staff-to-patient ratios recommended by the Australian Medical Workforce Advisory Committee in 2003 should be adopted.7 Emergency clinicians should be valued and supported in providing the best possible care for their patients.

Clare A Skinner MB BS, MPH, BA(Hons)

To the Editor: We report a case of successful resuscitation after cardiac arrest associated with obstruction of the airway by chewing gum. In December 2005, in Port Hedland, Western Australia, a 57-year-old electrician was found unconscious by workmates 5 minutes after he was seen working normally. He was not breathing and had no pulse. Bystander cardiopulmonary resuscitation (CPR) was commenced immediately and an ambulance arrived within 3 minutes. Cardiac monitoring showed the patient was in ventricular fibrillation. Direct-current defibrillation was performed three times, resulting in reversion to ventricular tachycardia, rapid atrial fibrillation and, within minutes, spontaneous reversion to sinus rhythm. The time from ambulance dispatch to arrival at Port Hedland Regional Hospital was less than 15 minutes. Rapid transport to hospital enabled prompt assessment of the patient, who was found to be maintaining sinus rhythm with left bundle branch block but no ST segment changes. Following the return of spontaneous circulation and consciousness, the patient’s Glasgow Coma Score and oxygen saturation unexpectedly deteriorated. On rapid sequence intubation, chewing gum was found lodged in the patient’s larynx; it was removed, and intubation completed. An urgent computed tomography scan found no intracranial cause for the deterioration in his condition. The patient was transferred to a tertiary centre by the Royal Flying Doctor Service. There was a rise in the patient’s troponin level after the cardiac event, but normal coronary arteries with globally depressed ventricular function were seen on angiography, and an ejection fraction of 30% on echocardiography, suggesting an underlying cardiomyopathy. An implantable cardiac defibrillator was inserted. The patient recovered, with a diagnosis of hypoxia associated with myopathic cardiac arrest complicated by laryngeal obstruction from chewing gum. He suffered a moderate hypoxic brain injury during the event and underwent a short period of inpatient rehabilitation, before returning to work within 6 months. He had no significant sequelae 18 months after the cardiac event. There have been previous reports of sudden death due to airway obstruction by chewing gum in children and one recent report of adult death, but no reports of successful resuscitation after cardiac arrest and hypoxia associated with chewing gum obstruction.1,2 There have also been reports of delayed problems with ventilation due to migration of previously aspirated chewing gum.3 While it is unlikely that the chewing gum airway obstruction was the primary event in this case, given the finding of cardiomyopathy, we believe that the laryngeal obstruction contributed to the patient’s secondary deterioration. This case demonstrates the importance of CPR training in the community, rapid paramedical and medical response, and the need to consider complicating causes in the event of cardiac arrest when return of spontaneous circulation does not result in clinical improvement as expected. It is made all the more remarkable by its occurrence in a remote regional centre of north-west WA.

Angus G Thompson · Shakeeb Razak · Rohan Jayasinghe

To the Editor: Sydney’s St Vincent’s Hospital, like many other hospitals, experiences a high occupancy rate which sometimes exceeds 100%, because of continual presentations to the emergency department (ED). NSW Health has recently encouraged new models of community acute/post-acute care (CAPAC) which allow patients to be managed in their homes, thus easing ED overcrowding and avoiding unnecessary presentations.1 However, those presenting most frequently to the ED at St Vincent’s Hospital are homeless. In response, this hospital has sent an outreach team consisting of a medical registrar and a community nurse to the streets of Sydney to deliver a “Backpack” CAPAC service (Figure). The outreach team provides diagnostic support to homeless people in shelters and crisis centres in the inner City of Sydney area. The team has successfully directed appropriate subacute cases to other health services, without the necessity for attendance at the ED. Extended episodes of treatment have also been given, including courses of intravenous antibiotics for a range of infections — even subacute bacterial endocarditis has been treated using portable infusion devices. Inclement weather causes some homeless people to seek refuge in stormwater drains around Sydney. One such patient, with a community-acquired methicillin-resistant Staphylococcus aureus cellulitis, was visited daily in a stormwater drain — his place of residence. Linkages have also been created with mental health services and non-government organisations. The Backpack CAPAC service continues St Vincent’s Hospital’s 150-year tradition of providing acute health care to the vulnerable and needy in our community. As this service was initiated with community donations, it has also reduced the drain on health resources. St Vincent’s Hospital’s outreach team on the streets of Sydney delivering the “Backpack” community acute/post-acute care service to the homeless.

Andrew A Mahony · Stephen F Wilson

Have you ever wondered what makes a good research paper? Since 1995, the best original research paper published each year in the Medical Journal of Australia (MJA), as judged by the Journal’s Content Review Committee, has been awarded the MJA/Wyeth Research Award. To date, 12 papers have won the award ($10 000 and a commemorative trophy), representing a diverse range of research methodologies, practice settings, professional disciplines, and subsequent citation rates (Box 1). We recently interviewed key researchers associated with this distinguished dozen, inviting them to tell us the behind-the-scenes stories of their papers and the impact their work has had since publication. In the course of our discussions, we heard 12 very different but often strikingly similar stories — stories of curiosity, innovation, purpose, determination and teamwork, as well as some significant concerns about the future of medical research in Australia. 1995: Gastric emptying is not needed after acute oral overdose in adultsAs you administered a particularly unpleasant medical intervention, have you ever wondered whether it was really necessary? Susan Pond, an Australian medical graduate, found herself working in the United States as a Fellow in Clinical Pharmacology at San Francisco General Hospital in the 1970s. Following on from the Haight-Ashbury hippie days of the previous decade, drug overdose was a major problem in the city. At that time, the treatment of overdose was quite empirical, and Pond set about collecting evidence for the ways in which charcoal could be used to remove poisons. Adapting the well known tradition of self-experimentation, Pond co-opted a couple of her six children to test out “easy” formulations of activated charcoal (Box 2). “One of them was game enough to swallow this awful black stuff, and he threw up within minutes ... the mess was just terrible”, Pond said. Referring to standard treatment, she added: “Not only were we making overdose patients vomit with ipecac, but we were also giving them activated charcoal, after which they promptly vomited again. It seemed to me to be very pointless”. Pond returned to Australia in the 1980s, where the opportunity arose, at Princess Alexandra Hospital in Brisbane, to challenge the long-established routine care for poisoning through a prospective, randomised controlled trial, comparing activated charcoal with a combination regimen of gastric emptying plus charcoal. In designing the study, Pond spent a long time talking with an American toxicologist, Ken Kulig, who had reported that acutely poisoned patients could be effectively treated without gastric emptying. Pond wanted to build on Kulig’s earlier research but without running into the same pitfalls: insufficient patient numbers and allocation bias.1 The Australian trial involved 876 eligible patients who presented to the emergency department at Princess Alexandra Hospital between January 1988 and June 1990. No significant differences were detected between the two treatment arms, and Pond and colleagues concluded that gastric emptying could be omitted from the treatment regimen for adults after acute oral overdose. Published in the MJA in October 1995, it did not take long for the study results to filter through to clinical practice — in 1997, the American Academy of Clinical Toxicology issued a position statement on ipecac syrup, which concluded that gastric emptying by ipecac should not be administered routinely in the management of poisoned patients.2 “The field was ready for a big study and it [our study] served to crystallise the thinking”, Pond said. “Very rapidly, the issue became whether or not charcoal needed to be administered, and the field moved on quite rapidly to suggest that even that’s not necessary in many cases of poisoning.” In 1997, Pond joined Johnson & Johnson Research Pty Ltd in Sydney to pursue the application of the genomics revolution to therapeutics. Her current research involves discovery and development of RNA and DNA molecules that regulate gene function and expression. The most advanced product, currently in clinical trial, is an anti-HIV RNA molecule inserted into bone marrow stem cells of patients infected with HIV. 1996: A public health investigation detects Japanese encephalitis virus in AustraliaHow would you go about investigating the mysterious deaths of two members of a small island community? When such a tragedy occurred on the outer Torres Strait island of Badu in March–April 1995, the residents welcomed a wide range of investigators from the Australian mainland, led by public health physician Jeffrey Hanna. Scott Ritchie, medical entomologist on the project, told us that Murray Valley encephalitis was initially thought to be the most likely culprit but, before long, virological studies on samples from the encephalitis cases, and serological surveys of other asymptomatic residents revealed evidence of Japanese encephalitis (JE) virus infection. The researchers found themselves investigating an outbreak of a virus that had never been found in Australia before — a classic, emerging, infectious disease. Ritchie said the various teams — medical, public health, entomological, veterinary, and laboratory — worked away for days at a time, applying known “shoe-leather” epidemiological methods to get the information they needed. When not working, they watched late-night test cricket and slept on mattresses at the health centre. The whole investigation took about a month. In addition to infection in the residents, the investigators also identified recent JE virus infection among domestic pigs (one of the viral hosts) on the outer islands of the Torres Strait. Virus isolations and mosquito surveys on Badu Island implicated the mosquito Culex annulirostris as the major vector in the outbreak. The researchers speculated that migratory birds and/or windblown mosquitoes had imported the virus into the Torres Strait, possibly from Papua New Guinea, and that a combination of environmental factors — including large numbers of domestic pigs kept in “wet” pigpens close to human dwellings and mosquito-breeding sites (Box 3) — had facilitated the outbreak. “It fit the pattern of JE virus overseas. In South-East Asia, you have rice paddies and people with pigpens in the backyard. In the Torres Strait, it’s quite low and swampy, and pigs are abundant”, Ritchie said. Ritchie is certain that lives were saved as a result of the public health response to this research. After the Badu Island outbreak, an inactivated JE vaccine was offered to the inhabitants of the outer Torres Strait islands. On Badu Island, pigs were moved from backyards to a piggery out of town, and swamps were drained. “JE virus is now detected nearly every summer in sentinel pigs on Badu Island, but there haven’t been any other human cases since a second outbreak in 1998. If we hadn’t vaccinated, I think we would have definitely seen more human cases”, Ritchie said. Hanna and colleagues have continued to publish papers on disease outbreaks, including the 1998 JE outbreak and the Noah Beach malaria outbreak in Far North Queensland;3,4 the cross-agency collaboration continues to this day. 1997: Photographic surveillance can effectively detect melanoma in patients with multiple dysplastic naeviHow you would respond if you were questioned about your everyday clinical practice because it was different from that of your peers? In the 1980s, when Melbourne dermatologist John Kelly was asked why he was using total body photographic surveillance to follow a group of melanoma-prone patients with multiple dysplastic naevi (MDN), instead of undertaking the then widely used practice of prophylactic excision, he decided to conduct a study to determine the value, including cost-effectiveness, of his approach. Several years earlier, while working in a melanoma clinic in San Francisco, Kelly had been involved in a case–control study that found that MDN were a strong and independent risk factor for the development of melanoma.5 “It seemed logical that if these people were most at risk for melanoma, then they were the people to put into a follow-up program to find the melanoma in the future”, Kelly said. But what if the case–control study had been flawed? He wanted to reassure himself as well as others. Kelly enlisted the assistance of several colleagues and his sister-in-law (a clinical photographer) and followed a high-risk cohort of 278 patients with MDN, using photographic surveillance, for an average of 42 months. All the patients had presented at his private dermatological practice between March 1985 and November 1992. Over the course of the study, 20 new melanomas were detected in 16 patients, corresponding to an age-adjusted incidence of melanoma in these patients that was 46 times that of the general population. “The use of the photographs enabled earlier diagnosis because we were able to detect new and changed lesions that were early melanomas but that were not yet showing typical clinical features. The median tumour thickness was much lower than for tumours reported to the State Cancer Registry at the time”, Kelly said. Further, more than 60% of the melanomas were de-novo, rather than arising from dysplastic naevi, suggesting that prophylactic excision of dysplastic naevi was not a satisfactory alternative to follow-up. This study, along with others, helped to confirm the very high rates of melanoma in patients with dysplastic naevi and to “guide guidelines” for the use of total body photography, said Kelly. With others, Kelly has conducted further research along similar lines with a new cohort of patients, confirming the previous findings and showing that a new or changed pigmented lesion is more likely to be a melanoma in patients older, rather than younger, than 50 years of age.6 Internationally, photographic surveillance is now the standard practice in managing people with MDN. 1998: Outdoor air pollution is linked to night-time cough and chest colds in childrenHow would you go about assessing the effects of the environment on child health in an industrial city? Ongoing community concern about a possible link between childhood asthma and air pollution in the steel cities of New South Wales — Newcastle and Wollongong — helped Peter Lewis and Michael Hensley and their colleagues achieve high participation rates in their 1993 cross-sectional survey of children’s respiratory symptoms and home environment. The existing body of work had been done primarily in the US and Europe, but there were some significant differences in aspects of air quality and air-quality basins in Australia. “We had some lower levels of pollution, in particular, particulate pollution”, said Hensley. The researchers consulted widely and often with the community. They surveyed primary school children living in suburbs close to the steelworks, as well as children from surrounding suburbs further away, who acted as “normals” exposed to “background” levels of pollution. The study found that particulate pollution was associated with respiratory symptoms such as head cold and coughs but not with asthma. They also found that the effects on health were seen at lower levels of particulate pollution than had previously been thought. In 1999, the Newcastle steelworks closed, principally for economic reasons, said Lewis. “However, this paper was one of several studies that contributed to how air quality guidelines should be set in Australia”, he said. “It certainly strengthened the case that the levels of air pollution we were experiencing are not without their potential side effects.” Hensley, with co-researchers, has gone on to publish related papers about indoor air quality, including the effects of environmental tobacco smoke and bronchial reactivity among children,7,8 and is now Dean of Medicine at the University of Newcastle. Lewis has taken his environmental epidemiological research approach to public health work on the Central Coast of NSW and is now involved with measuring the impact on health of such diverse entities as bushfires, fluoridation of the water supply, and retirement village living. 1999: Comprehensive screening and treatment program reduces prevalence of STIs in remote Aboriginal communitiesWho do you think has made a contribution to the control of sexually transmitted infections (STIs) in Aboriginal Australia that is greater than the sum of everyone else’s? For this accolade, Paul Torzillo would not hesitate to pick Penny Miller, a primary care doctor who created a program in the mid 1990s that aimed to improve access to and delivery of STI services in remote Aboriginal communities on the expansive Anangu Pitjantjatjara (AP) Lands in the far north-west of South Australia, with a view to reducing transmission not only of STIs but also HIV. “At the time, it was widely touted that community-wide STI screening would be virtually impossible, let alone unethical, because the Aboriginal communities would not want it; and, if it did occur, it would be ineffective”, Torzillo said. But the Aboriginal communities did want it. Nganampa Health Council is the independent, Aboriginal-controlled health service that provides primary health care to nearly 3000 Aboriginal people living on the AP Lands. The Council’s Aboriginal board of management, which is also the ethics committee, approved Miller’s project. Annual community-wide screening for syphilis was already well established in the AP Lands, and community participation in the new program was voluntary and high. Miller’s community-based program took full advantage of technological advances in screening for gonorrhoea and chlamydial infections, with urine polymerase chain reaction tests replacing diagnosis by urethral swab in men and by vaginal and cervical swabs in women. The urine testing made mass screening both more acceptable and more feasible. The program also involved more than a dozen further interventions, including presumptive treatment (before diagnosis was confirmed by pathology results), single-dose rather than multidose therapy, and reporting back to the community. The program was effective. Coauthored with Torzillo and Wayne Hateley, an Aboriginal health worker who until recently lived and worked in the communities, Miller’s paper reported that, in the short period of 2 years, the prevalence of gonorrhoea in people aged 12–40 years was significantly reduced — in fact, almost halved — from 14.3% in 1996 to 7.7% in 1998. The service also achieved reductions in chlamydia and syphilis. The paper weakened a general resistance at the time to applying public health principles to Aboriginal health. “In retrospect, the resistance was clearly because inadequate screening and treatment isn’t effective, but comprehensive screening and treatment can be”, Torzillo said. Miller now works in the field of international HIV research. Torzillo continues to work for the Nganampa Health Council, as he has done since it was first established in 1983. He also maintains an appointment as a respiratory and intensive care consultant at Sydney’s Royal Prince Alfred Hospital. Today, aggressive public health approaches to STIs are considered the “norm” in Aboriginal communities. On the AP Lands, this program and others, like women’s health and child immunisation programs, continue to operate. New STI program initiatives continue to emerge, like Ushma Scales’ song about condom use, Take your shield to town, with lyrics in Pitjantjatjara.9 2000: Systematic chronic disease treatment program reduces rates of renal failure and death in Aboriginal communitiesWhat would you do if your research revealed a whole community with untreated early disease whose progression could be slowed by a simple intervention? When working in New Mexico in the US, Wendy Hoy, with co-researchers, demonstrated that end-stage renal disease was a significant problem in Native American tribes. On her return to Australia, she investigated a burgeoning epidemic of renal failure in Aboriginal people in the Northern Territory and found probably the world’s highest recorded rates of renal failure in the communities of the Tiwi Islands, north of Darwin. There was also a great reservoir of early disease, including hypertension and albuminuria. Hoy said: “I knew from existing literature that the progression of renal disease could be reduced by treatment with angiotensin-converting enzyme inhibitors. This treatment needed to be widely applied in the Tiwi community, but the health services were very scantily resourced at that time and couldn’t do it”. Another barrier was a prevailing attitude that if you gave Aboriginal people a pill, they wouldn’t take it; and that if they did take it, it wouldn’t have an effect because their biology was different. “You’ve got people with a deadly disease for which treatment guidelines are out there in the international literature, with known very beneficial outcomes. It would have been wrong to allow it to go unattended”, Hoy said. So the research team delivered a service offshoot that was embraced by the community — a systematic chronic disease treatment program to modify renal and cardiovascular disease, involving antihypertensive agents to achieve blood pressure goals and attempts to improve the control of blood glucose and lipid levels. After 2 years of treatment, Hoy and colleagues were able to report a rapid, dramatic improvement in clinical profiles and a fall in death rates. Their paper declared: “These results show that Aboriginal people are interested in health issues and receptive to health messages, and will take medications over the long term to protect against future health risk, with excellent response”. Over the past decade, there has been increasing acceptance and practice of the principles of chronic disease surveillance and rigorous management in Aboriginal communities. “Endorsement, intellectually, of chronic preventable disease strategies is no longer the issue; now, it’s resources and staffing to execute them in remote areas where the people have disastrous disease profiles”, said Hoy. After handover of the treatment program to the local health board in the Tiwi Islands, the intensity of the program declined and compliance with medicines use fell for a time, due to inadequate resources.10 However, Hoy is optimistic about the future of Indigenous health. “The spotlight on Aboriginal health here is becoming brighter, and dialogue encouraging government to be, one, more receptive; and, two, more accountable in terms of delivering good services is only going to intensify.” 2001: Quality improvement project reduces inhospital deaths in patients with acute myocardial infarctionHow would you respond to the suggestion that patients hospitalised with acute myocardial infarction (AMI) at your hospital might have a higher mortality rate than similar patients at peer hospitals? In the mid 1990s, Ian Scott, then Director of Medicine at Queensland’s Ipswich Hospital, responded by initiating a quality improvement project that aimed to achieve, among other things, a reduced time to thrombolysis and an increased number of patients who were taking lipid-lowering agents when they left the hospital. He wrote local guidelines for coronary care practice, started an echocardiography service, and got together with the local Division of General Practice to set up a cardiac rehabilitation program, as well as providing sequential feedback to health care providers. A before–after time-series study suggested that quality of care at the hospital did improve as a result of the project.11 This evidence was soon bolstered when hard outcomes data on inhospital deaths, from the Queensland Hospitals Admitted Patient Data Collection, came to Scott’s attention. Using this state-based data, Scott and colleagues were able to demonstrate a significant reduction in the mortality rate for AMI at Ipswich Hospital, from 12.5% in 1994–1995 (pre-intervention) to 8.8% in 1996–1999 (post-intervention). The rates at a group of control hospitals in Queensland showed no significant change (remaining at about 12.8%) over the same period of time. “The study has given a higher profile to quality improvement science by showing that we can improve and evaluate practice on a reasonable scientific footing, with real data to support what we are saying”, said Scott. The quality improvement interventions have now been rolled out, with beneficial effects, across more Queensland hospitals.12 “I think it’s been a real success story. We’ve gone from a small community hospital to a collaborative of about 21 hospitals across the state, accounting for close to 80% of all AMI admissions.” Now based at Brisbane’s Princess Alexandra Hospital, Scott has continued to pursue further quality improvements in relation to the management of AMI and heart failure. Recently, together with colleagues, he reported on “risk–treatment mismatching”, where much more treatment goes to lower- or moderate-risk patients than high-risk patients.13 2002: Serious doctor–patient and health care worker–patient miscommunication may be compromising Indigenous health outcomesHave you ever struggled to communicate with a patient? What if the patient didn’t speak much English — what would you do? Working in Darwin with Indigenous patients who had kidney disease, Alan Cass and colleagues found themselves operating across what seemed to be a significant cultural and, often, linguistic divide. At the same time, people working as linguists and community researchers in Arnhem Land were also becoming aware that, despite everyone’s best intentions, there were communication problems they didn’t understand. “It was a somewhat fortuitous coming together of people from very different backgrounds, including some of the patients themselves, who wanted to think about how we could work together in undertaking some cross-cultural research to try to understand the issues”, Cass said. The group considered various possible methodologies before settling on the qualitative approach of participatory action research — using video to capture interactions, then analysing them to identify issues. They also conducted post-interaction interviews in the health care workers’ and patients’ first language to clarify what each person had understood to be communicated. In the setting of a satellite dialysis unit, where many of the carers were fairly well known to the patients and vice versa, the researchers videotaped five clinical interactions concerning diagnosis, treatment and management in diverse individual patients from the Yolngu language group of north-east Arnhem Land. In their “Sharing the true stories” study, the researchers found that miscommunication was pervasive, even when both the health care worker and the patient perceived the communication to be effective. Multiple issues were identified — beyond the limited use of interpreters — including “gratuitous concurrence” (when patients tell the health care worker what they think the worker wants to hear); problems with culturally specific understanding and ways of explaining health and illness (eg, health professionals would frequently describe health states using quantification such as percentages of kidney function, which had little meaning for most Yolngu people); and a lack of staff training in cross-cultural communication. Cass said the paper has engendered a powerful response from people working in all kinds of cross-cultural health settings. “So, I think communication — or miscommunication — issues talk very broadly”, he said. The study has been presented and cited not only nationally but internationally, leading to ongoing relationships with doctors and educational videomakers in the US. A “Sharing the true stories” website has been developed, with links to further education resources (Box 4). There is also now greater systematic use of interpreters in Indigenous health settings. Cass is currently involved in several research programs related to Indigenous health. He remains committed to developing and fostering universally available, high-quality education and training in cross-cultural care. 2003: Non-toxic treatment is effective for chronic suppurative otitis mediaWhat would you do if the only treatment your community could access for a particular condition was a product that was potentially toxic in your circumstances? Until recently, Aboriginal health services were faced with treating chronic suppurative otitis media (CSOM) in patients who had a perforated tympanic membrane with aminoglycoside ear drops, which are potentially ototoxic. In 2001–2002, Sophie Couzos, a public health physician with the National Aboriginal Community Controlled Health Organisation (NACCHO), led the NACCHO Ear Trial, which set out to assess the effectiveness of non-toxic fluoroquinolone ear drops compared with the usual treatment. Couzos said Dr Puggy Hunter, then NACCHO Chair, had wanted the organisation to instigate and undertake a research project to benefit the Aboriginal community. “Hearing issues were a big priority, and particularly runny ears due to chronic otitis media. The community needed a non-toxic alternative for treating the condition”, she said. The methodology was to be that of a double-blind randomised controlled trial, so that it would be scientifically meaningful. But the study also had to be community-based, designed in such a way that the Aboriginal organisations had leadership. At the time, Hunter coined the phrase, “We are not just participants, we are in charge”. As well as providing “real-world” results, the trial was designed to build capacity in the communities so that the intervention would be sustainable and transferable. Thus, the researchers opted for a challenging multicentre approach rather than putting all their investment into only one or two sites. Aboriginal health workers, rather than research assistants, were trained to undertake the trial protocol as part of core primary health care. Far from resisting the research project, health services were eager to be part of it. “Some services had to be turned away, because of the limited study budget or because they could not meet explicit criteria, such as having a doctor employed within the service”, Couzos said. Hunter died soon after the NACCHO Ear Trial was underway, but the trial went on to show that non-ototoxic fluoroquinolone drops were more effective than aminoglycoside drops in achieving cure for CSOM. The paper has had an impact in several key areas. Firstly, thanks to NACCHO’s advocacy role, said Couzos, remote area Aboriginal health services can now provide non-ototoxic ear drops to their clients for free, under Section 100 of the National Health Act 1953 (Cwlth). Secondly, the trial was pivotal to the listing of ototopical fluoroquinolone drops on the Pharmaceutical Benefits Schedule, which means that health care providers in non-remote areas can also provide subsidised medicine. Australian prescribing recommendations have also endorsed the use of fluoroquinolone ear drops in the presence of tympanic membrane perforation.14,15 Finally, in terms of research policy, the NACCHO Ear Trial has provided a real-world example of successful, community-based participatory research.16 2004: The Australian Medical Sheepskin halves incidence of pressure ulcers in lower-risk patientsIf you had a product you thought would benefit patients in hospital, how would you get the attention of hospital managers and clinicians? Having developed a sheepskin that they were confident would reduce the incidence of pressure ulcers in low- to moderate-risk patients, staff of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Leather Research Centre approached Don Campbell at the Royal Melbourne Hospital (RMH) about generating some clinical evidence of efficacy. “Here was an Australian industry initiative; here was a large public health problem and an opportunity to collaborate. It was a very attractive proposition”, said Campbell. After gaining some initial data from a small trial conducted in a high-risk group setting in Western Australia,17 the research partnership was granted National Health and Medical Research Council (NHMRC) funding for an open-label randomised controlled trial, conducted at the RMH in 2000. The Australian Medical Sheepskin was designed with a fibre length and density sufficient to perform a pressure distribution function, to minimise shear and friction, and to withstand high-temperature cleansing. In the trial, the sheepskins were used without covering as a partial mattress overlay, in accordance with their design. Sheepskin elbow and heel protectors were also used, as necessary. Of the 441 patients enrolled in the trial, 58 developed pressure ulcers. However, patients randomly assigned to the sheepskin group were less than half as likely to develop pressure ulcers as those in the usual care group. “Our evidence showed that we had a piece of technology that was clearly of demonstrable benefit. But the sheepskin hasn’t been widely taken up into practice. The real tragedy is that it hasn’t been capitalised on from an Australian perspective”, Campbell said. Sales of the sheepskin have mostly been incidental, for use in non-clinical environments and for people who are bed-bound or in wheelchairs. In retrospect, Campbell and the study’s first author, medical statistician Damien Jolley, would have liked the trial to have had sufficient funding to incorporate two further features: a third treatment arm, comparing the sheepskin “head to head” with pressure mattresses; and a proper cost-effectiveness analysis, including effects on hospital length of stay. However, what was missing and is still needed for real translation of their study findings into clinical hospital practice, they said, is an industry partner of sufficient size to manage advertising, sales and distribution requirements. But there is good news too. Recognising that pressure ulcers are a clinical indicator of quality of care, the Victorian Quality Council identified their reduction as a key objective for health care services in Victoria. Since state-wide surveys of the prevalence of pressure ulcers within Victoria’s acute and subacute health services began in 2003, progress has been made in implementing elements of a comprehensive program of pressure ulcer prevention and management. There has been a 33% reduction in the proportion of patients with pressure ulcers, from 26.5% in 2003 to 17.6% in 2006.18 2005: Hand hygiene program reduces nosocomial MRSA ratesHave you ever said you’d like to embark on an ambitious project, not really expecting to be given the opportunity? After an unexpected change in Victorian state government, the infection control team at a Melbourne hospital, Austin Health, suddenly found themselves the recipients of new infection control staff and an opportunity to apply for a state government Quality Improvement Fund grant. Their plan was to try to cut nosocomial methicillin-resistant Staphylococcus aureus infection (MRSA) at Austin Health by 30% over a 3-year period. The only hitch was that they had no real idea how to achieve their grand goal. “It was kind of exciting and scary at the same time”, said Paul Johnson, one of the study authors. Around the same time, while in Geneva at a World Health Organization meeting, Johnson arranged to meet Didier Pittet, who had recently published a landmark Swiss study in the Lancet showing that when staff regularly used a hand hygiene solution before and after every patient, contact rates of hospital infections, including MRSA, could be substantially cut.19 The “secret” of encouraging staff to use the solution was to include, along with the antibacterial alcohol and chlorhexidine, an emollient to protect the skin. “The other insight they had, partly I think because of their French culture, was that you have to engage people at an emotional level as well as cognitive, and one of the ways they set out to do this was by using art — they had these posters that were created as works of art by the staff of each ward to introduce the program ... they called them ‘talking walls’ in Geneva”, said Johnson. Pittet encouraged the Austin Health group to develop a similar program, and so they did — the multifaceted Operation Clean Start (OCS) program — developing their own hand hygiene solution (DeBugTM) and even adapting the concept of the “talking walls” (Box 5). The hospital staff and, in particular, nurses in infection control were incredibly supportive of OCS. “After we’d introduced it [the program] in one area, there was a real demand to introduce it into the next area, and so on. It just took off like wildfire”, said Johnson. Run over 3 years, OCS showed that staff’s compliance with hand hygiene improved. The Australian researchers also added an innovation of their own to the project design: by analysing large datasets in the hospital using interrupted time-series analysis, they were able to show a significant reduction in hospital rates of MRSA infections. After their paper was published, the OCS researchers were approached by the Victorian Quality Council, who were keen to replicate the reduction in MRSA infections state-wide. An alcohol-chlorhexidine hand hygiene program was rolled out initially in six major hospitals and then across the whole of Victoria. At the time of our interview with Johnson, coauthor Lindsay Grayson was in Geneva with Pittet, working with the WHO on aspects of hygiene policy for the world. 2006: Hot water immersion for 20 minutes can relieve the pain of a bluebottle stingHave you ever imagined conducting your research on a beach in summer? More importantly, what if that research were to turn a time-honoured treatment on its head? It might sound ideal, but Geoff Isbister and colleagues in the coastal NSW city of Newcastle weathered several difficulties in conducting their randomised controlled trial comparing hot water immersion with ice packs for relieving the pain of bluebottle stings. For example, in addition to the usual ethics committee approval, there was the not-so-small matter of local council approval, particularly in an era when public liability has become a major issue. Then there was the sporadic nature of bluebottle stings — 35 subjects were recruited in a day; 4 weeks went by with no one stung. And what about beach user behaviour — once a sting had eased with treatment, why sit around for the full 20 minutes required by the study protocol? Although it was organisationally challenging, the actual study was very simple and successfully challenged the existing belief that ice was the best way to relieve pain in this situation. The researchers suggested that the mechanism of reducing pain with heat treatment was the inactivation of venom. It is still early days since publication. Although local practice has changed on the beaches where the study was conducted, national changes in clinical practice as a result of this study are yet to be fully implemented. However, Isbister hopes that the Australian Resuscitation Council’s recent adoption of the new evidence in their treatment recommendations will mean hot water immersion becomes more widely available, and that cost and safety issues related to installing hot-water plumbing at surf lifesaving clubs around Australia can be resolved. And, after all, people can control the way they choose to treat their own jellyfish stings.20 Isbister is actively involved in much more “bites and stings” research. He said, “Within medicine, there are so many myths and, particularly in my area of research, so little research, that for just about anything you do in clinical practice, you can ask the research question and do it [the research]”. Twelve winners, one voiceEach year in the MJA we publish over a hundred research papers. Each one has a story: a reason for being, a unique setting, colourful protagonists, a narrative, a resolution and, in many cases, the possibility of development and continuation. As we spoke to the authors of each of the MJA/Wyeth Research Award-winning papers, however, it often seemed as though they were speaking with one voice — the engaged, thoughtful tones of a focused, committed, intelligent and passionate individual, working in the interests of both science and humanity. None had set out to win an award in doing their work; they had all simply wanted to answer a real question in a real area of need. So what did we learn about what makes a good research paper? Having a question whose answer will have a real impact on public health or clinical practice would seem to be a good start, as would using appropriate, pragmatic methodology. Our MJA/Wyeth winners’ research was also well planned, and each came to embrace the power of collaborative teamwork in conducting their research, not only across medical disciplines but across a diverse range of fields, and often, critically, with study participants. Accessing funding for good clinical research was not easy for many of our winners, several of whom suggested that Australia needs a formal mechanism within the health and medical research environment to specifically fund applied clinical research. Publication was also often a thorny issue — when the time came to submit their papers, many award winners reported pressure from their institutions or funding bodies to publish in “high impact” journals, preferably overseas. In the long run, however, they had considered that the MJA was the right journal with the right readership for communicating messages of relevance to Australian clinicians, particularly when local or national health policy needed to be “influenced”. Several interviewees said, in almost precisely the same definite way, that the intent of their research had been to benefit people and patients rather than to further their careers. Nearly all the award winners were gratified with the impact their work has made since publication. Several were concerned that the long-term sustainability of successful programs was at risk due to funding inadequacies or health service management restructuring beyond their control. Can a single piece of research change the world? There are a few spectacular examples where this may have been the case but, in the end, as many of our winners acknowledged, most research papers contribute only a fragment to the “big picture” of health and health care. As a powerful example, we leave you with Sophie Couzos’ perspective after completing the NACCHO Ear Trial, the first double-blind randomised controlled trial conducted in, and controlled by, Aboriginal communities: While healing the tympanic membrane will improve hearing, if you have recurrent infections because your living circumstances aren’t right, then using ear drops will not totally solve the problem. It will create an environment where healing can occur, but the solution to Aboriginal health problems is not just medicines. Although improved access to medicines is vital, the solutions are holistic. 1 The Medical Journal of Australia/Wyeth Research Award-winning articles, 1995–2006, with ISI citations to date* Year Article and authors Citations 1995 Gastric emptying in acute overdose: a prospective randomised controlled trial. Susan M Pond, David J Lewis-Driver, Gail M Williams, Adèle C Green, Noel W Stevenson. Med J Aust 1995; 163: 345-349. 89 1996 An outbreak of Japanese encephalitis in the Torres Strait, Australia, 1995. Jeffrey N Hanna, Scott A Ritchie, Debra A Phillips, Jack Shield, M Clare Bailey, John S Mackenzie, Michael Poidinger, Bradley J McCall, Phillip J Mills. Med J Aust 1996; 165: 256-260. <eMJA full text> 86 1997 A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. John W Kelly, Josephine M Yeatman, Cheryl Regalia, Grahame Mason, Amanda P Henham. Med J Aust 1997; 167: 191-194. <eMJA full text> 53 1998 Outdoor air pollution and children’s respiratory symptoms in the steel cities of New South Wales. Peter R Lewis, Michael J Hensley, John Wlodarczyk, Ruth C Toneguzzi, Victoria J Westley-Wise, Trevor Dunn, Dennis Calvert. Med J Aust 1998; 169: 459-463. <eMJA full text> 13 1999 Impact of improved diagnosis and treatment on prevalence of gonorrhoea and chlamydial infection in remote Aboriginal communities on Anangu Pitjantjatjara Lands. Penny J Miller, Paul J Torzillo, Wayne Hateley. Med J Aust 1999; 170: 429-432. 19 2000 Reducing premature death and renal failure in Australian Aboriginals: a community-based cardiovascular and renal protective program. Wendy E Hoy, Philip R Baker, Angela M Kelly, Zhiqiang Wang. Med J Aust 2000; 172: 473-478. <eMJA full text> 40 2001 The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction. Ian A Scott, Michael D Coory, Catherine M Harper. Med J Aust 2001; 175: 465-470. 10 2002 Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Alan Cass, Anne Lowell, Michael Christie, Paul L Snelling, Melinda Flack, Betty Marrnganyin, Isaac Brown. Med J Aust 2002; 176: 466-470. <eMJA full text> 17 2003 Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial. Sophie Couzos, Traven Lea, Reinhold Mueller, Richard Murray, Margaret Culbong. Med J Aust 2003; 179: 185-190. <eMJA full text> 13 2004 Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial. Damien J Jolley, Robyn Wright, Sunita McGowan, Mark B Hickey, Don A Campbell, Rodney D Sinclair, Kenneth C Montgomery. Med J Aust 2004; 180: 324-327. <eMJA full text> 2 2005 Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Paul D R Johnson, Rhea Martin, Laurelle J Burrell, Elizabeth A Grabsch, Susan W Kirsa, Jason O’Keeffe, Barrie C Mayall, Deidre Edmonds, Wendy Barr, Christopher Bolger, Humsha Naidoo, M Lindsay Grayson. Med J Aust 2005; 183: 509-514. <eMJA full text> 18 2006 A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. Conrad Loten, Barrie Stokes, David Worsley, Jamie E Seymour, Simon Jiang, Geoffrey K Isbister. Med J Aust 2006; 184: 329-333. <eMJA full text> 3 * As of August 2007. ISI = Institute for Scientific Information (now Thomson Scientific). 2 A little black mouth A “volunteer” tests samples of activated charcoal. 3 Backyard pigpens on the outer Torres Strait islands Pigpens (A) adjacent to swampy conditions or (B) situated over standing water were found to breed Culex annulirostris mosquitoes. 4 Artwork from the “Sharing the true stories” website Courtesy: Phyllis Batumbil, Matamata, Northern Territory. http://www.sharingtruestories.com. 5 Hand hygiene poster DeBugTM — an alcohol/chlorhexidine hand hygiene solution — was featured on a “talking walls” poster as part of Operation Clean Start at Austin Health, Melbourne.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Tanya D Grassi MB BS(Hons), BSc(Vet)(Hons) · Martin B Van Der Weyden MD, FRACP, FRCPA

Charles Halliley Kellaway (1889–1952) was one of the first Australians to make a full-time career of medical research. He built his scientific reputation on studies of snake venoms and anaphylaxis. Under Kellaway’s directorship, the Walter and Eliza Hall Institute gained worldwide acclaim, and he played a critical role in its success between the world wars. His administrative and financial strategies in the era before the National Health and Medical Research Council (NHMRC) helped local medical research weather the Depression and gain a strong foothold by World War II.

Peter G Hobbins BA, BSc(Hons) · Kenneth D Winkel MB BS, PhD, FACTM

The Alliance continues to tackle the problem of chronic disease by bringing the right people together With its self-described goal of “confronting the epidemic of chronic diseases”, the Oxford Health Alliance aims to fill the leadership void decried by Beaglehole and Yach,1 the Lancet2 and others. To this end, the Alliance enlists key thinkers and doers, to harness, shape and amplify the energy that is converging worldwide, to address socially and environmentally generated determinants of chronic diseases. It concentrates on high-level approaches, through government and industry, to tobacco control, physical inactivity and unhealthy diets. These, via chronic illness, are responsible for over 50% of the world’s mortality.3 Two years after the launch of the Oxford Health Alliance’s Asia Pacific Regional Centre,4 it is timely to review its progress. Locally, the Alliance is gradually reaching the consciousness of the public health, food and beverage, media and pharmaceutical industries, health departments, non-government organisations (NGOs), and urban designers and planners. Its progress will, no doubt, be accelerated by the global Oxford Health Alliance summit, scheduled for Sydney in February 2008, to debate issues concerning environmental determinants of chronic diseases and make recommendations about “building a healthy future”. Internationally, the Alliance has achieved surprising penetration, participating in World Health Organization, World Economic Forum, Youth Forum and similar high-level meetings and advising governments. It has a formidable network of academic institutions and public health luminaries (see http://www.oxha.org) and is currently conducting an innovative multicountry demonstration program, Community Interventions for Health, to illustrate models for successfully translating the evidence on chronic disease prevention into real life. The Oxford Health Alliance will shortly release the results of an international Delphi survey — spearheaded by the University of Toronto — of 200 international experts to identify “grand challenges” for chronic disease research. It has no qualms about drama, as exemplified by its full-page “global warning” against chronic diseases in The Times (London) last year (Box). Since the launch of its hub in Sydney, the Oxford Health Alliance board, headed by the Regius Professor of Medicine, John Bell from Oxford University, has focused the organisation on six work streams: mounting the economic case for action against chronic diseases; the physical environment (especially urban design) and health; health and wellness protection in the workplace and the role of industry and business in health promotion and prevention; youth — “20% of the present, 100% of the future” (an intention to engage young people, who can contribute to determining the kind of societies they will inherit as adults); the law and health policy; and community interventions for health, and barriers to chronic disease prevention in research. Interaction among these themes promotes rather different thinking about strategies for preventing chronic disease. To develop and promulgate this thinking, the Alliance brings together, through its annual summit meetings and to a lesser extent a series of smaller, local Oxford Dialogue meetings, players who are central to achieving change. Its primary method centres on: Finding the right people: looking outside health systems to other government administrations and the private sector; including people and organisations that influence health but do not often participate in the health debate; engaging those whose business activities are health determinants (eg, food and building design); choosing people who are at the cutting edge of their businesses and can influence colleagues, peers and decisionmakers; and finding and fostering champions of chronic disease prevention. Encouraging debate from a diversity of perspectives: respecting and taking account of differing views; being unafraid to mix youth with experience, left with right, establishment with alternative, and developed with developing world; and bringing to the planning table those who do not normally sit at the same table (eg, grouping food, building and other industries with organisations such as the WHO and the People’s Health Movement). Fostering a collaborative approach: avoiding “good guys versus bad guys” attitudes and approaches; and transforming combatants into collaborators. The Oxford Health Alliance is equally interested in the developed and the developing world and is currently working with Ovations (an arm of the largest private health insurer in the United States, United Healthcare) to establish three to five clusters of excellence to combat chronic diseases in developing countries. Yes, the Oxford Health Alliance works with industry and thereby incurs a risk, but firmly believes that the risk of not doing so is far greater. The Alliance is a United Kingdom-registered charity but, as the progeny of an academic–commercial collaboration between Oxford University and NovoNordisk A/S, Denmark, has sought to work with industry. It is under no illusions about the importance of the bottom line to business, and, like its own law work stream, does not consider that a legislative framework is irrelevant to confronting the problems of chronic disease. For example, the Alliance is a fierce defender of the WHO Framework Convention on Tobacco Control. However, it sees its role not as a legislator or enforcer, but as seeking commitment and involvement from the business sector, through discussion and debate and through recognising and working with companies that are prepared to embrace the necessary changes. The origins of the current chronic disease and environmental crises are located deep in society, suggesting that their resolution will require a complex and inclusive response from society, spanning business, government, academia, and civil society more generally. Hence, the 2008 Sydney summit will bring a diverse group of people together for 2 days to design and issue a formal challenge to government, business, industry, unions, universities, activists and bilateral and multilateral funders to progress the Alliance’s ambition of “healthy people and a healthy environment”. There are risks, but the potential gains are great, and as the Sydney summit will attest, the Oxford Health Alliance is ready to take the gamble.

Ruth Colagiuri BEd, GradCertHlthPolMgnt · Stig Pramming MD · Stephen R Leeder BSc(Med), MD, PhD

Government actions to protect the public’s health are not always consistent What, if anything, will move a government to intervene to improve the health of its population? Government action seems to depend not on how many people will die if it fails to act but rather who they are and how they will die. When almost 3000 people died after aircraft were flown deliberately into buildings in Washington and New York in 2001, the United States government moved rapidly, with no regard for cost. In an unprecedented move, it immediately grounded all aircraft flying over the US, allowing them to fly again only subject to sweeping restrictions on what could be taken on board. Had the government failed to act rapidly, it would undoubtedly have faced widespread condemnation, not least from the representatives of corporate America, which had, in the attack on New York, been the target of mass murder. Yet, of all the Americans who died in 2001 as a result of violence, only a fraction were killed in the attacks on 11 September. More than 10 times as many fell victim to firearms, either at their own hands or the hands of others.1 Successive US governments have steadfastly refused to enact effective gun control, seemingly unmoved even by tragedies such as the mass shootings at Columbine High School in Colorado in 1999 and Virginia Tech (Virginia Polytechnic Institute and State University) in Blacksburg, Virginia, in 2007. In 2004, President George W Bush allowed a law banning sales of semiautomatic assault weapons to lapse at a time when his government was enacting unprecedented security measures in what is termed the “war on terror”. Utilitarian principlesIf it is not the body count that drives politicians to act, what is it? Perhaps, in the rational world that we often aspire to inhabit, it is pragmatism. Knowing what works is purported to be a key principle by some politicians who ask us to vote for them on the basis of their technical ability and experience. Unfortunately, this does not seem to be the answer either. In 1967, the US Federal Government held back funding for highways from states that did not mandate the use of motorcycle helmets. Deaths among riders fell markedly. In 1976, under pressure from bikers’ groups, the US Congress reversed this policy, leading to a marked increase in deaths in those states repealing the laws.2 When should governments act?When, if ever, is a government justified in taking action to improve the health of its population? It is easy to see why this seemingly simple question leaves so many people confused. Maybe we can look to philosophers for guidance. The most frequently quoted, in this respect, is the 19th century British philosopher, John Stuart Mill. In his classic text, On liberty, he argues that “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others”.3 Yet, he also recognised that individuals are not always able to make free choices, a view shared by Karl Marx, who argued that “men make their own history, but not of their own free will; not under circumstances they themselves have chosen but under the given and inherited circumstances with which they are directly confronted”.4 The question of how these arguments apply in any given circumstances is at the heart of the dilemmas that confront public health advocates. In applying philosophy to public health, the first question is whether an action threatening an individual’s health causes harm to others. In some cases, such as drunk driving, the answer is obvious. In others, such as the harm caused by passive smoking, epidemiological research has been required to provide the answer.5 These examples deal only with situations in which there is direct physical risk to others. It has also been argued that, by consuming collectively funded health services, an individual engaging in self-destructive behaviour is harming others by using resources that would otherwise be available to those falling ill through no fault of their own.6 This argument can be taken further. There is now compelling evidence that ill health in a population weakens economic growth, because, with illness, people reduce their labour supply and productivity.7 Is this a justification for governments to act? Certainly, governments intervene in many other ways to promote growth, through fiscal policy and direct investment in research, skills and physical infrastructure. So far, few have accepted explicitly the importance of investing in the health of their population as a strategy to promote growth, even though, in some analyses, this provides a greater return than investment in education.7 The second question is whether individuals really are making free choices. In some cases, it is apparent that they are not. Therefore, almost all governments act decisively against narcotics, although many have yet to recognise the equally addictive nature of nicotine. As a result, some have failed to support effective “quit smoking” programs using nicotine replacement therapy. This may be only a matter of time. Government action against opiates is now widely accepted, but it was only 150 years ago that the United Kingdom went to war with China to protect its right to trade in opium.8 Addiction is only one way in which the choices of individuals are constrained. It is self-evident that behaviour is shaped by the environment. At the extremes, a person living in Mongolia has little option but to eat an unhealthy diet, dominated by animal fat and bereft of fresh vegetables. In contrast, an inhabitant of Crete may find it difficult to eat anything but a healthy diet. Similarly, an inhabitant of rural Nepal has little choice but to walk, while someone in Los Angeles may search in vain for a sidewalk. Governments can do little to change things such as climate and the topography of a country, but they can change many others, by ensuring that health is included in policies for (among others) transport, agriculture, fiscal management, and regional development, so as to remove the constraints that individuals face when making healthy choices.9 Governments have few reservations about using these policies for other goals, including promotion of economic growth, so why not health? Current inconsistencies in policyGovernments are often extremely inconsistent. They are willing to intervene actively in the lives of individuals to protect the health of their populations in some circumstances, but not in others. The war on terror has yet to be matched, in intensity and resources, by a war against tobacco. Governments that promote individual choice see no incongruity in their support for a small number of companies that, through their domination of the retail sector in some countries, constrain our choices about what to eat.10 It seems that no universal theory can explain when a state will act to safeguard the health of its population. Maybe this should not come as a surprise. Policy making is messy. Otto von Bismarck, unifier and first Chancellor of Germany, is reputed to have remarked that two things should never be made in public — laws and sausages. Policies are often a product of events (frequently following tragedies rather than pre-empting them) and interest groups, many of whom see promotion of health as a threat.11 The pursuit of health is as legitimate a goal for governments as national defence or economic growth. All involve balance between individual and collective interests. The challenge for public health is to advocate a greater degree of consistency than currently exists.

Martin McKee CBE, MD, FRCP · Ruth Colagiuri BEd, GradCertHlthPolMgnt

To the Editor: The food environment in Australia and other developed countries is obesogenic. In the United States, personal-injury lawsuits against food and beverage companies are prominent, although proving the addictive nature of a food or its components is challenging. What cannot be questioned is that rates of overweight and obesity among children are increasing, and so are the associated multiple negative health and psychosocial effects.1 Given the serious health consequences of obesity, it is imperative for researchers and community groups to continually challenge the food and beverage industry to produce foods that will not impinge on the health and wellbeing of our children. The consumption of sugar-sweetened soft drinks has been linked to increasing body mass index and risk of obesity in children and adolescents.2 There are many potential reasons for this over-consumption, including aggressive marketing. However, a further contributing factor is the presence of caffeine. Caffeine is mildly addictive at low doses,3 and is an additive in cola soft drinks in Australia (concentration range, 0.55–0.67 mmol/L). Soft drink manufacturers claim caffeine is a flavour enhancer in soft drinks,4 but we have shown that caffeine has no flavour activity in a common cola soft drink (30 trained tasters completed over 1600 individual discrimination tests, and the tasters were unable to detect 0.67 mmol/L caffeine in a soft drink — if we cannot discriminate between a caffeinated and non-caffeinated sample, there is no flavour activity). A caffeine concentration of 0.67 mmol/L is equivalent to about 55 mg of caffeine in a 500 mL bottle of cola, and this dose results in physiological and psychological modifications in adults3 that manifest as behavioural modifications including increased alertness, energy, and ability to concentrate. Such positive postingestive effects are subconsciously associated with consumption of the sugar-sweetened beverage, thereby encouraging repeat consumption. Children are more likely to be affected by caffeine, and it is reasonable to assume that even lower doses of caffeine will result in behavioural modifications in children, and encourage repeat soft drink consumption. On average, 113 L of soft drink are consumed per person per year in Australia, and although not all of these beverages are caffeinated, the top sellers are cola soft drinks.6 As caffeine has been shown not to have any flavour activity in these beverages, we pose the question: given the serious nature of childhood and adolescent overweight and obesity, should caffeine be an additive in soft drinks marketed aggressively and sold to children and adolescents?

Lynn Riddell · Russell S Keast

Further progress may require business and public sector partnerships Chronic diseases in low-to-middle-income countries have continued to increase. At the same time, calls for prevention have grown.1-3 The World Health Organization resolution on diet and physical activity, published in 2004, recommended several specific actions for food companies and the broader private sector.4 Among these were: Limit the levels of saturated fats, trans fatty acids, free sugars and salt in existing products; Continue to develop and provide affordable, healthful and nutritious choices to consumers; Practise responsible marketing that supports the strategy, particularly with regard to promoting and marketing foods high in saturated fats, trans fatty acids, free sugars or salt, especially to children; Issue simple, clear and consistent food labels and evidence-based health claims; and Assist in developing and implementing physical activity programs. PepsiCo’s strategyEven though foods from PepsiCo contribute a modest proportion of calories to a typical diet in most of its markets, we believe we should continually improve nutrition so that each calorie has the optimum fat, sugar and salt content. We do so by reducing certain nutrients and increasing others. We have developed methods of measuring the current use of fats, sugar and salt in all our products in all countries where they are sold. On the basis of these measurements, we have set targets for reducing the levels of food constituents such as fats, sugar and salt by 2010. The example of trans fatty acids and our use of oils illustrates how commitment and actions need careful thought. We continue to reduce trans fatty acids in all markets and have eliminated them from virtually all our oils used for cooking potato chips and snacks. In Europe, introduction of a new oil, Sunseed, which is higher in monounsaturated fats and lower in saturated fats has led to a 50%–70% reduction in the saturated fat levels in our potato chips and snacks compared with the same products in 2005. Further progress on reducing trans fats and saturated fats awaits further research generally on alternatives to trans fats and the optimal mix of fats and oils in food products. Food companies need to ensure the long-term supply of the crops needed to produce high-quality oils. This has become increasingly complex in a world of globalised trade and when the future demand for biofuels is likely to affect the price and availability of oils. It is likely to be an even bigger problem in small and medium enterprises in low-to-middle-income countries. Public demand for reduced sugar in food and beverages has stimulated research efforts to find natural sweeteners with the same taste but fewer calories than current products. Similarly, companies are actively seeking ways to maintain taste and the other qualities that salt brings to foods with healthier alternatives or formulations. In the United Kingdom we have lowered salt levels in all packaged chips by 25% through reformulation. Further progress in the UK and elsewhere requires industry-wide collaboration and agreement on acceptable levels, supported by governments. Public health partnershipsFood industry investments in product reformulation will yield major public health gains, but product reformulation is only part of the solution. Well grounded insights into country-specific consumer preferences drive our decisions about when and how to introduce new products. We now seek ways of working with public health researchers to share our perspectives on how best to truly change the behaviour of consumers for public and private good. Our experience in the United States, for example, suggests that well designed, science-based logos can influence consumer behaviour. Sales of products that carry our Smart Spot logos (Box) are growing far faster then others, leading to more healthful consumption, and profits. To date, most of the public sector research effort in relation to obesity or diet has tended to favour medication solutions over food-based solutions. We believe a shift in focus would stimulate new partnerships between corporations and public health scientists that could lead to healthier food products being developed through innovative science — as we have seen with new pharmaceutical products. A renewed and more forward-thinking nutrition-science agenda should go beyond a focus on reducing “harms” to identifying how the global underconsumption of fruit, vegetables and cereals could be partly addressed through new products; how nutrients might enhance physical and mental performance; and ways of addressing satiety and weight management. Research partnershipsProduct reformulation is only part of the company’s solution. The PepsiCo Foundation, the primary charitable arm of the company, is deeply engaged in developing new models of partnership that will lead to health gains in communities and new research insights.5 There are still no documented successes in reducing obesity in a large community setting anywhere in the world. We are supporting research aimed at meeting this gap.6 For example, in the US, foundation support for Tufts University has helped to develop one of the few examples of a community-based approach that may reduce obesity in children.7 Internationally, we have announced support for Community Interventions for Health, a partnership with the Oxford Health Alliance.8 The partnership will carry out large-scale, community-based research projects in India, China, Mexico and the UK aiming to reduce the effects of the major risk factors for chronic diseases. Further, both the company and the foundation are involved in a range of initiatives aimed at increasing physical activity around the world in settings as diverse as Mexico (through Vive Saludable which addresses healthful eating and physical activity in primary schools) and in the US (through America on the Move). ConclusionNo single company can turn around the current threat of chronic disease. That is why we seek corporate and public sector partners. The role of the medical profession has been decisive in the battles against so many causes of ill health. This is the time, in our view, for them to review their clinical and public health roles in supporting patients and communities to tackle the major public health issue of obesity. PepsiCo is ready to join them in this task. Smart Spot product criteria Smart Spot beverage and food products: contain at least 10% of the daily value of a targeted nutrient (eg, protein, fibre, calcium, iron, vitamin A, or vitamin C); and meet the limits of the Institute of Medicine (the United States independent advisory body on health) or the US Food and Drug Administration for fat, saturated fat, sodium and added sugar; or are formulated to have specific health benefits; or are reduced in calories or nutrients like fat, sodium or sugar. This packet of chips displays the Smart Spot logo.

Derek Yach MB ChB, MPH · Antonio Lucio BA · Carlos Barroso BChemEng

During 2007, the human species became predominantly urban. Australia is highly urbanised, and health varies within Australian cities. Australian urban life is characterised by sedentariness, excess food intake, reliance on cars for transport, a high level of exposure to media and marketing messages, and a consumer culture. These characteristics are linked to obesity, diabetes, heart disease, some cancers, chronic respiratory disease, injury, depression and anxiety. The evolution of cities has been characterised as a four-stage process: poverty, industrial, consumption and eco-city. Each stage but the last has defining health disorders. Transition to healthy and sustainable cities requires infrastructure investment in new urban areas (including mass transit, education and health services), better conditions for walking and cycling, access to healthy food and encouragement of suburban economic development. There is a role for everyone in the transition to healthy and sustainable cities.

Anthony G Capon BMedSc, PhD, FAFPHM

Objective: To investigate morbidity and mortality associated with heatwaves in metropolitan Adelaide using ambulance, hospital admission, and mortality data.Design, participants and setting: Case-series study comparing health risks in the Adelaide metropolitan population during heatwaves and non-heatwave periods.Main outcome measures: Daily observations for ambulance transports (1993–2006), hospital admissions (1993–2006), and mortality (1993–2004), categorised using International classification of diseases (ninth and tenth revisions) codes for the relevant disease groups.Results: During heatwaves, total ambulance transport increased by 4% (95% CI, 1%–7%), including significant assault-related increases for people aged 15–64 years. Reductions were observed in relation to cardiac, sports- and falls-related events. Total hospital admissions increased by 7% (95% CI, − 1% to 16%). Total mental health admissions increased by 7% (95% CI, 1%–13%), and total renal admissions by 13% (95% CI, 3%–25%). Ischaemic heart disease admissions increased by 8% (95% CI, 1%–15%) among people aged 65–74 years. Total mortality, disease- and age-specific mortality did not increase, apart from a small increase in mental health-related mortality in people aged 65–74 years. Significant decreases were observed in cardiovascular-related mortality.Conclusion: In contrast to evidence from extreme heatwaves in the northern hemisphere, we found no excess mortality during heatwaves in metropolitan Adelaide, perhaps because of adaptive behaviour to regular hot weather spells. Projected temperature increases and evidence of modest increases in morbidity during heatwaves indicate the need for a heatwave response plan for Adelaide.

Monika Nitschke PhD, MPH · Graeme R Tucker BSc · Peng Bi MB BS, PhD

The practice of “medical tourism” is gaining popularity. Lower costs and shorter waiting times are compelling motivating factors. There are also increasing commercial interests promoting medical tourism. There are very limited clinical data to support or refute this practice. However, medical tourism breaks important elements in the traditional health care model, including patient selection, continuity of care, and practice auditing. When complications arise, challenges specific to medical tourism patients may be encountered.

Ian K Cheung MB BS · Anthony Wilson MB BS, FRACS

To the Editor: Egger makes novel and valid points in his portrayal of individual human effort as a potential contributor to offsetting greenhouse gas emissions by personal carbon trading.1 Of course, there is an even more potent strategy humans should adopt to modify climate change through their own activities — population control. Anthropogenic greenhouse gases constitute the largest source of pollution, with by far the greatest contribution from humans in the developed world. Every newborn baby in Australia represents a potent source of greenhouse gas emissions for an average of 80 years, not simply by breathing, but by the profligate consumption of resources typical of our society. What then should we do as environmentally responsible medical practitioners? We should point out the consequences to all who fail to see them, including, if necessary, the ministers for health. Far from showering financial booty on new mothers and thereby rewarding greenhouse-unfriendly behaviour, a “Baby Levy” in the form of a carbon tax should apply, in line with the “polluter pays” principle.2 Every family choosing to have more than a defined number of children (Sustainable Population Australia suggests a maximum of two3) should be charged a carbon tax that would fund the planting of enough trees to offset the carbon cost generated by a new human being. The average annual CO2 emission by an Australian individual is about 17 metric tons,4 including energy usage. As the biomass of trees in a mature forest sequesters about 6 metric tons of CO2 per hectare (104 m2) per year,4,5 each child born should be offset by planting 4 hectares of trees, to allow for the time they take to reach maturity, and attrition through crop losses, bushfires, dieback and so on. This infers a levy per child of at least $5000 at birth (to purchase the land needed and plant trees) and an annual tax of $400–$800 thereafter for the life of the child (for maintenance of the afforestation project) (based on 1990 figures,4 and probably much more now). By the same reasoning, contraceptives, intrauterine devices, diaphragms, condoms and sterilisation procedures should attract carbon credits for the user and the prescriber that would offset their income taxes, and lead to rewards for family planning clinics and hospitals that provide such greenhouse-friendly services. As David Attenborough said: . . . instead of controlling the environment for the benefit of the population, we should control the population to ensure the survival of the environment.6 As doctors, I believe we need to think this way. Our responsibility extends further than the patient on the other side of the desk. As Australians, I believe we need to be less arrogant. As citizens of this world, I believe we deserve no more population concessions than those in India and China. In reply: I agree with Walters. One must wonder why population control, which was such a popular topic during the 1970s, is spoken of today only in whispers. Is this because of the discovery of new oil in the 1980s, taking resource scarcity off the public agenda? Is it because of politicians and economists, so keen on the growth trail that “. . . one for mum, one for dad and one for the country”1 seems an easy solution? Or is it the great religions, intent on outnumbering each other? Environmental groups have also gone silent on the issue — perhaps afraid to alienate their growing support on other environmental issues. Population remains crucial to all environmental (and subsequently, health) considerations. The debate needs to be reopened as part of a second ecological revolution (following the failure of the first in the 1960s and 1970s).2 Doctors, as opinion leaders in the community, must be at the forefront of this debate.

Barry N J Walters · Garry Egger

To the Editor: In Australia, the packaging of alcoholic beverages, unlike that of non-alcoholic beverages, is not required to display a list of ingredients or nutritional information, such as the amount of sugar, calories, and any preservatives contained in the drink.1 It is possible that consumers, especially some population groups such as weight-conscious young women, might be less inclined to drink as much alcohol if they knew the calorie content of what they were consuming. There has been no published research on whether Australian consumers want this information. In April 2007, we invited (by letter and email) a random sample of 13 000 students aged 17–25 years at an Australian university to complete a web survey on alcohol consumption, health effects, and attitudes toward nutrition/ingredient labelling. Of the students invited, 7237 responded (56% response rate), and 6497 of these (90%) had consumed alcohol in the preceding 12 months. Results suggest that more than three-quarters of this population group want to see both ingredients and nutritional information displayed on alcoholic beverage packaging (Box). No more than 4% of respondents disagreed with each of these measures. Support for labelling of information among people who exceeded National Health and Medical Research Council (NHMRC) guidelines for avoiding acute harm (no more than four drinks per occasion for women; no more than six for men)2 was somewhat lower than in moderate or non-drinkers (ingredients: 75% v 86%, P < 0.001; nutritional information: 72% v 78%, P < 0.001). Support for the labelling of ingredients was somewhat greater among women than men (85% v 75%, P < 0.001), while support for the provision of nutritional information was considerably greater among women (83% v 65%, P < 0.001). We have been unable to find any studies on the effect of ingredient or nutritional information labelling on drinking behaviour. There would be value in knowing whether such labelling might influence beverage choice or overall alcohol consumption. There has been considerable debate on the effectiveness of warning labels of the type introduced in the United States in 1989, that emphasise the dangers of alcohol impairment while driving.3 A recent review of scientific studies suggested that these warning labels have no measurable effects on drinking behaviour.4 One might therefore expect there to be little or no effect of ingredient or nutrition labels. However, it is possible that the current preoccupation with weight gain in many developed countries, including Australia, might be a more compelling motive for behaviour change than alcohol-related injury risk. Regardless of whether such labels might affect drinking behaviour, it is hard to understand why alcoholic beverages are not subject to the same requirements for disclosing ingredients and nutritional information as non-alcoholic beverages. While the results of our survey cannot be extrapolated to the entire Australian population, the strength of support for (and lack of opposition to) these measures, even among heavy drinkers, suggests that bringing alcohol packaging into line with non-alcoholic beverage packaging would have public support. Responses to survey statements* Statement and response Women Men All It should be a requirement that the ingredients in alcoholic beverages are displayed on the bottle/can/cask Strongly agree 1991 (48%) 1239 (40%) 3230 (45%) Agree 1501 (36%) 1104 (36%) 2605 (36%) Neither agree nor disagree 572 (14%) 651 (21%) 1223 (17%) Disagree 49 (1%) 85 (3%) 134 (2%) Strongly disagree 5 (< 1%) 30 (1%) 35 (< 1%) Total 4118 (100%) 3109 (100%) 7227 (100%) It should be a requirement that nutritional information (eg, the amount of sugar and kilojoules) is displayed on bottles/cans/casks of alcohol Strongly agree 1890 (46%) 1016 (33%) 2906 (40%) Agree 1529 (37%) 1018 (33%) 2547 (35%) Neither agree nor disagree 607 (15%) 864 (28%) 1471 (20%) Disagree 79 (2%) 149 (5%) 228 (3%) Strongly disagree 11 (< 1%) 61 (2%) 72 (1%) Total 4116 (100%) 3108 (100%) 7224 (100%) * Not all respondents answered these questions.

Kypros Kypri · Alexandra McManus · Peter M Howat · Bruce R Maycock · Jonathan D Hallett · Tanya N Chikritzhs

A severe storm that began on Thursday, 7 June 2007 brought heavy rains and gale-force winds to Newcastle, Gosford, Wyong, Sydney, and the Hunter Valley region of New South Wales. The storm caused widespread flooding and damage to houses, businesses, schools and health care facilities, and damaged critical infrastructure. Ten people died as a result of the storm, and approximately 6000 residents were evacuated. A natural disaster was declared in 19 local government areas, with damage expected to reach $1.5 billion. Additional demands were made on clinical health services, and interruption of the electricity supply to over 200 000 homes and businesses, interruption of water and gas supplies, and sewerage system pump failures presented substantial public health threats. A public health emergency operations centre was established by the Hunter New England Area Health Service to coordinate surveillance activities, respond to acute public health issues and prevent disease outbreaks. Public health activities focused on providing advice, cooperating with emergency service agencies, monitoring water quality and availability, preventing illness from sewage-contaminated flood water, assessing environmental health risks, coordinating the local government public health response, and surveillance for storm-related illness and disease outbreaks, including gastroenteritis. The local ABC (Australian Broadcasting Corporation) radio station played a key role in disseminating public health advice. A household survey conducted within a fortnight of the storm established that household preparedness and storm warning systems could be improved.

Michelle A Cretikos MB BS, MPH, PhD · Tony D Merritt MB BS, MPHTM, FAFPHM · Kelly Main BAppSc, MPH · Keith Eastwood MAppEpi · Linda Winn MN · Lucille Moran BComm, CPA, GradCertPubSecMgmt · David N Durrheim DrPH, MPHTM, FAFPHM

Large catastrophes have caused the collapse of empires and civilisations.1 Science and knowledge may help prevent some catastrophes, but urbanisation and narrowly concentrated food supplies, climate change and terrorism contribute to considerable risk. Viruses responsible for severe acute respiratory syndrome (SARS) and avian influenza A (H5N1) or “bird flu” are among the most immediately identifiable risks. The World Health Organization has stated that the risk scenario associated with an outbreak of pandemic H5N1 influenza should be considered more serious than was previously assumed.2 Early self-isolation and social distancing measures are known to be highly effective.3 In the event of a lethal pandemic, emergency measures such as closing schools, staying home with family and friends, and avoiding contact with other people (until all have been immunised) will be instrumental in avoiding infection. People employed in essential services or occupations may be required to reside at their workplace for the whole period of the crisis. To achieve this type of isolation, sufficient food of adequate quality and quantity must be available. The Australian Government and the Australian Food and Grocery Council (AFGC) have been planning for such a scenario for several years and have advanced plans in place (Russell Neal, AFGC, Canberra, ACT, personal communication). Nonetheless, the logistics and practicalities of household food stockpiling should be given greater media coverage. Australia has one of the most concentrated food supplies of any country, being dominated by two large supermarket chains. These organisations operate with such efficiency that their logistic chains hold only a few weeks’ supplies (Russell Neal, AFGC, personal communication). If the supply chain shuts down, or if there is no delivery from central stores, supermarkets’ stocks will be depleted within 2–4 weeks (Clare Buchanan, Public Relations Officer, Woolworths Pty Ltd, Sydney, NSW, personal communication). If domestic stockpiling begins at this late stage, then depletion will be accelerated. Food supplies in the home will need to last as long as it takes for vaccine development and production. For ordinary seasonal influenza vaccines, there is a lag of 6 months or more after a new virus strain has first been discovered until a new vaccine is available for distribution. For weather-related catastrophes, food stockpiles might be required for much longer. A destabilised global climate, where small changes in atmospheric and ocean circulations have major consequences for temperature, rainfall, wind and storm patterns, may precipitate food stockpile dependence for several years.4 While long-term food stockpiling could be considered a governmental responsibility, we suggest that home stockpiling of food to last about 3 months might be done by individual households. This would allow a window of time for governments to put emergency action plans and food deliveries in place. Which foods and in what quantities?It is logical that the foods to be stockpiled should be staples and well accepted, easy to store, packed where possible in an inert gas for a longer shelf life, and not dependent on refrigeration. Importantly, they should be nutrient-dense, providing the recommended macronutrients and micronutrients for all members of the family.5 Ideally, they can be eaten without cooking, in case gas and electricity fail. Cost, volume and storage space are further considerations. A food stockpile should provide an average energy intake of about 9 MJ (2150 kcal) per person per day in order to avoid significant weight loss. This is near the average intake — men need a little more than women, while children need less.5 In a home quarantine situation, physical activity is not likely to be high. Box 1 shows a food “lifeboat” for one person for 10 weeks, and in Box 2, we provide an example of a food list that provides one person with 9 MJ per day for 10 weeks and covers all known nutrient needs. This example was generated using the nutrient analysis software, FoodWorks (Professional Edition 2007; Xyris Software, Brisbane, QLD), which is based on the composition of Australian foods, and commonly used by Australian dietitians. The recommended daily intake of specific macronutrients and micronutrients for adults and children is published by the Australian Government Department of Health and Ageing.5 Together, these two sources make it possible to compose diets with the appropriate quantity of nutrients. As most people have no access to detailed nutrient data, we have developed these examples to show what is needed, and typical of what might be acceptable. We acknowledge that such food lists are culturally and ethnic-specific, and that other food combinations are possible. It would be cheaper and require less storage space to rely on multivitamin tablets rather than canned fruit and vegetables to cover the requirements of vitamins such as C and A. For this reason, Box 3 shows a food list that covers basic nutrient requirements when taken together with a multivitamin–mineral supplement. Indeed, some micronutrients do not need to be consumed on a daily basis because of the capacity of the body to store them (eg, vitamin A). Our calculations allow for cooking losses. While the foods can be eaten raw, some foods taste better cooked. In the event that the electricity or gas supply fails, a gas cylinder to fuel a barbeque might make eating more enjoyable. In Australia, most people have adequate money and storage space to build up their own store of foods. For those who do not, federal, state and local governments should consider a plan to construct food stockpiles across the country. Further suggestions, recipes and guidelines are given on our website (http://www.foodlifeboat.com.au). This is a university-linked, not-for-profit initiative, developed by dietitians and public health nutritionists. 1 The food “lifeboat” for one person for 10 weeks All the foods listed in Box 2 in the quantities required are displayed. Food courtesy of Woolworths Pty Ltd. 2 Suggested food list of a daily ration for one person (providing 9 MJ per day) and purchase list for 10 weeks Food g/day kg/person for 10 weeks Milk powder, full-fat, dry* 65 4.6 Weet-Bix,† regular (breakfast cereal) 30 2.1 Pasta, regular, dry 20 1.4 Instant noodles 20 1.4 Rice 25 1.8 Dehydrated potato flakes 15 1.1 Tortilla 10 0.7 Biscuit, savoury 15 1.1 Biscuit, wholemeal 20 1.4 Oil, canola 20 1.4 Powdered soup 20 1.4 Sweet chilli sauce 10 0.7 Tomato concentrate 10 0.7 Tuna, canned 60 4.2 SPAM,‡ regular (luncheon meat) 40 2.8 Lentils, dry 20 1.4 Peas, green, canned 20 1.4 Three beans mix 50 3.5 Baked beans, canned in tomato sauce 20 1.4 Corn, canned 50 3.5 Sun-dried tomatoes 20 1.4 Milo§ (beverage base) 10 0.7 Seaweed, dried 10 0.7 Raisins 30 2.1 Honey 10 0.7 Almonds 20 1.4 Apricots, dried, raw 20 1.4 Juice, carrot 50 3.5 Juice, orange 50 3.5 Vegemite¶ (yeast extract) 2 0.1 Chocolate 30 2.1 * In case of lactose intolerance, the intake of dry milk powder may be replaced by soy protein powder. Alternatively, the milk may be fermented. † Sanitarium Australia, Sydney, NSW. ‡ Hormel Foods Corporation, Austin, Minn, USA. § Nestlé Australia, Sydney, NSW. ¶ Kraft Foods Limited, Melbourne VIC. Total daily ration provides 80 g protein and 80 g fat comprising 24 g saturated fat (31% of fat intake and 10% of energy intake), 20 g polyunsaturated fat (22% of fat intake) and 36 g monounsaturated fat (47% of fat intake). The daily cholesterol intake is 101 mg. Energy intake is 16% from protein, 34% from fat and 50% from carbohydrate. Recommended intakes of all essential nutrients are provided for women and men, except for folate (which is not adequate for women of childbearing age, so a folate supplement might be considered). The cost of this diet for 10 weeks for one person is about $500. The most expensive items are milk powder, Weet-Bix,† SPAM,‡ and chocolate. 3 A list of simple dry foods that will cover basic energy needs (9 MJ per day) and most nutrients for one person, assuming multivitamin tablets are provided, and a purchase list for 10 weeks Food g/day kg/person for 10 weeks Wheat flour, wholemeal, plain 150 10.5 Oats, raw 100 7.0 Oil, canola 25 1.8 Milk powder, dry* 65 4.6 Lentils, dry 30 2.1 Peas, split, green/yellow, dry 40 2.8 Noodles, dry 50 3.5 Vegemite† (yeast extract) 2 0.1 Fruit, mixed, dried 35 2.5 Almonds, raw 40 2.8 Multivitamin–mineral supplement One tablet One box * In case of lactose intolerance, the intake of dry milk powder may be replaced by soy protein powder. Alternatively, the milk may be fermented. † Kraft Foods Limited, Melbourne VIC. Total daily ration provides 80 g protein and 76 g fat comprising 15 g saturated fat (20% of fat intake and 6% of energy intake), 20 g polyunsaturated fat (26% of fat intake) and 41 g monounsaturated fat (54% of fat intake). The daily cholesterol intake is 43 mg. Energy intake is 16% from protein, 32% from fat and 52% from carbohydrate. Vitamins C and A would have to be taken as supplements. Otherwise, recommended intakes of all essential nutrients are provided for women and men, except for folate (which is not adequate for women of childbearing age, so a folate supplement might be considered) and iron (which is provided at a lower level than recommended). In addition, about 2 litres of water per person per day would be required. This diet costs about $250 for one person for 10 weeks. The most expensive items are dry milk powder and noodles. These food items could be packed in airtight packages filled with inert gas of a few kilograms per package, and stored in food stores throughout the country.

Anna Haug PhD · Jennie C Brand-Miller BSc, PhD, FAIFST · Olav A Christophersen · Jennifer McArthur MHPEd, APD · Flavia Fayet BSc, MNutrDiet · Stewart Truswell MD, FFPHM, FRACP

To the Editor: Influenza experts have warned of the possibility of an influenza pandemic, and planning for such an event is underway.1,2 The provision of health care during a pandemic will pose particular challenges. Health care workers will be at risk of exposure, and will become ill at rates similar to those for the general population. Compounding inevitable staff shortages will be health care workers absent from work because of a need to care for dependents or fear of catching influenza. Prompted by discussions on an appropriate response to pandemic influenza, we solicited opinions from employees within our network (including medical, nursing, clinical support, catering and administrative staff) about their attitudes to working during a pandemic. Between 1 February and 30 April 2007, a survey that could be self-administered and completed anonymously was placed on our hospital intranet. Our staff were advised of its presence by email and through advertising on the intranet. The survey could also be completed when attending for influenza vaccination. Participants could complete surveys directly onto an electronic database, or return them to the investigator. We received 1440 completed surveys, including those from 137 medical staff (10%), 628 nursing staff (43%), and 352 clinical support staff (25%). The overall response rate was approximately 14% (1440/10 000). The mean age of respondents was 42 years (range, 18–73 years); 83% were female and 36% had dependent children. Overall, 74% agreed they needed more education on pandemic influenza (medical staff, 66%; nursing staff, 78%; P = 0.025) and 48% believed a pandemic would occur in the next decade (medical staff, 39%; nursing staff, 52%; P = 0.025). Sixty-seven per cent stated they would be available to work during a pandemic; 26% (medical staff, 18%; nursing staff, 27%; P = 0.05) stated they would stay home to care for dependents, while 10% admitted they would stay away because of fear of catching influenza. Most employees expected to be provided with personal protective equipment (92%), antiviral medications (90%) and vaccine (89%). Sixty-four per cent believed the hospital should supply their families with antiviral medications, and 63% thought their families should receive vaccine. Twenty per cent believed they would require a place of residence while working during a pandemic (medical staff, 32%; nursing staff, 24%; P = 0.05), 45% were prepared to be relocated to another site (medical staff, 58%; nursing staff, 40%; P < 0.001) and 36% were prepared to change to another duty (medical staff, 30%; nursing staff, 39%; P, not significant). Our survey has highlighted areas that may need attention in preparing for a pandemic. As a minimum, we believe targeted education is required now for all health care workers who will be expected to work during a pandemic. Our ability to cope will depend on the depth of our preparation.

Rhonda L Stuart · Elizabeth E Gillespie

Working on behalf of deaf children and for the independence of the medical profession As I rose to speak at a seminar of two or three hundred people in 1967, I could feel my heart thumping and a throbbing pain in my lumbosacral region. They had assembled to discuss ways of enabling deaf children to become integrated into the hearing world. I felt my Batson plexus was about to explode. My late wife Annette and I were the parents of two profoundly deaf infants, very new to the game, and on a steep learning curve. We had visited a number of schools for the deaf in the United Kingdom, the United States and Australia. In those days, deafness in a child was seldom recognised before the age of 2 years, frequently later. The usual advice given to grieving parents was to send the child to a dedicated school for the deaf, most often as a boarder. The seminar was attended by educators, bureaucrats, and parents and relatives of deaf children, many of them with years of experience in education. How was I, as a relative newcomer, going to convince them that my belief was correct, that the main obstruction to integration of deaf children and adults into the hearing world was the fact that their education was segregated? In those days, a profoundly deaf child might be sent to a boarding school in a capital city and taught to sign and finger spell, thus becoming a relative stranger, not only to the hearing world, but even to his or her own family. Being a far from gifted speaker, I doubt that I convinced many people on that day. It is hard to change the status quo, especially so in this case, in which many years of planning, building and educating had been directed towards segregated teaching. Fortunately, after establishing a number of centres for the education of preschool deaf children, incorporating the principle of teaching these children in the company of hearing children, we managed to establish the principles of early intervention and integration. These principles seem so obvious today, yet they were extraordinarily difficult to institute, even by example. At that time, hearing aids were relatively rudimentary. Graeme Clark’s miraculous invention — the cochlear implant — was not yet available, so teaching a profoundly deaf child to communicate orally was sheer hard work. My research indicated that deaf adults in that era, no matter how intelligent they were, seldom, if ever, broke out of the mould of being an employee at the level of a printer or a panel beater. This certainly motivated us. With the help of many wonderful people, we managed to achieve our aim of giving the gift of speech, together with the ability to move comfortably with their hearing peers, to our own children. A multitude of cousins of similar ages helped tremendously in the integration process. With our children fully integrated into hearing schools, Annette and I felt that the only way to convince the educators of the deaf was to set up our own education program. That was in the late 1960s. We formed our first centre, at the University of Sydney, which opened in 1970. On 14 February 1972, Annette, my wife, had her first stroke. (This was at a meeting where we were planning to find a candidate to stand for the Australian Senate, with the objective of improving the lot of people with disabilities.) How the Shepherd Centre survived in those years I don’t know. Annette recovered sufficiently to continue her work with the Centre. This was done with great difficulty for her and those around her. In 1981, she suffered a cerebral haemorrhage and suffered the locked-in syndrome until she died in 1986. During her illness, my respect for my colleagues rose to even greater heights and reinforced my conviction that medicine must be for patients and independent of commerce and governments. In the late 1990s, we funded a pilot study and then managed to persuade the New South Wales Government to bring in an early-diagnosis program for congenital deafness: in August 2000 we handed over screening equipment during Hearing Awareness Week. Now, every child born in NSW is tested at birth for deafness (we have achieved a 97% testing rate), and over 93% of our children, no matter how deaf they are, go on to normal-stream education, many to university. It could reasonably be said that NSW is the best place in the world to be born deaf. Other programs have taken up our methods, and recently I received a promise from the Prime Minister that he would make it part of the next Medicare agreement that all children throughout Australia would be tested at birth for deafness. Our cochlear implant program, in association with Sydney Children’s Hospital, is titled “First Sounds”. At our Shepherd centres, we have at any one time 180 deaf children (about a third of whom have cochlear implants) in our care. We regard parents as the main educators, so they are all very involved in our work. Our head centre is at the University of Sydney, with centres in Canberra, Liverpool, Wollongong, Roseville and Bathurst. Children attend from the time of diagnosis, which may be when the infant is just a few weeks old, to the age of 5.

Bruce D Shepherd BDS, FRCS, FRACS

Meningitis and mentors seeded a passion to remedy health inequalities in Africa We have the capacity to feed everybody on our planet. We have the capacity to ensure that everybody has clean water . . . [and] affordable health care. We can prevent many of the diseases to which our children in the poorer parts of the world succumb . . . A person is a person through other persons . . . You can’t be human in isolation; you are human only in relationships. — Archbishop Desmond Tutu I’ll never forget the pounding, throbbing headache that heralded meningococcal meningitis. I remember leaning against the wall in the bathroom of my local doctor’s waiting rooms, steaming with a temperature of 40°C, and thinking “This is it. I must be dying”. The pain was so intense I just couldn’t see how my body could survive. Every skerrick of light seeping through my shut eyelids felt like lasers beaming through to burn my brain. As I was a boarder in a rural school, I was alone — I was afraid — and I was 14. After losing consciousness and a helicopter flight to Sydney, I awoke after a week, in the intensive care unit of the Children’s Hospital at Westmead. One week later, when I could stomach food, I was moved into a ward. I was sharing with a 2-year-old boy who also had meningitis, but whose septicaemia had taken hold of his young body more aggressively than it had of mine. I remember watching him being wheeled out of the room one morning, only to return 6 hours later with no lower legs. The author, surrounded by orphans in Nairobi, Kenya. Days passed, and much to everyone’s shock, I continued to recover, with no residual disability. The months to full health were many, yet the realisation of surviving a fatal disease, completely unscathed, began to sink in. I was left with a sense of “survivor’s guilt” — an intense appreciation of life and how fortunate I was, a realisation of the gift that life is, and a yearning to make the most of every living, breathing moment that remained. My first decision was to study medicine, to fulfil a desire to give something back to the profession that had saved my life. A month in a children’s hospital is the best work experience one could have, and despite coming from a family with generations of strength in the arts, especially music, I decided to take up chemistry at school and begin to focus on the sciences. Unprepared, I sat the undergraduate medicine admission test in my final year of high school, and my marks were nowhere near those required for entrance. Undeterred, I headed off on a gap year abroad, working as a music and drama teacher in the United Kingdom before studying Italian in Florence. I returned in 2001 to the Australian National University (ANU) in Canberra to study for a Bachelor of Science (Psychology)/Bachelor of Arts, following my sister’s footsteps to John XXIII College. A year later, a summer internship on the trading floor at Macquarie Bank in Sydney saw me shift to a Bachelor of Commerce/Bachelor of Science, and I returned to Macquarie Bank for three more challenging summers in finance. Equity markets and medicine are deceptively similar: both are fast-paced, intellectually demanding, unpredictable and exciting work environments. Yet despite the “buzz” of my experience in the financial world, I couldn’t shake my medical aspirations. During lunch hours in Martin Place, I would sit and stare at the homeless people seeking shelter under the buildings in which others were making millions, and I knew that a profession in medicine would be the only way to satisfy my desire to help people while challenging me intellectually. Education session and distribution of subsidised insecticide-treated nets by Hands of Help volunteers and health workers in Uganda. After two more unsuccessful attempts at the undergraduate medical admissions test, I turned to the postgraduate admission procedure. In the penultimate year of my undergraduate course, I sat the Graduate Australian Medical Schools Admissions Test (GAMSAT) as mere practice for the following year, but fortunately, my marks were high enough to result in a placement at the University of Sydney. I was bursting with enthusiasm to begin the postgraduate medical course after 4 inspired years as an undergraduate. To pay the bills during my days in Canberra, I had worked as a therapist for children with autism, conducting applied behavioural analysis for children with profound disability at a special education school in Woden. What began as a job soon turned into a passion as I learned how to communicate with children who had no speech, honing my empathy skills as I tried to learn to read their expressions and mannerisms to understand how they were feeling and what they were trying to say. These children, with beautiful personalities frustratingly stuck in less useful bodies, absolutely grew on me. My appreciation of life continued to grow and, while I hope the hours of therapy I did with those children helped them become a little more capable, ultimately they taught me far more. In my last holidays before beginning medicine, I made a trip to Africa, a continent which had fascinated me since reading Bryce Courtenay’s The Power of One as an impressionable teenager. In my commerce degree, I had majored in development economics and was inspired by a senior lecturer at the university, Dr Alan Martina, who brought to light for me the inequalities existing in our world today. My passion for the subject saw me begin to devour novels on the area, and an inspirational meeting with Nobel Prize nominee Professor Jack Caldwell, who has devoted much of his life to demography in Africa, sealed my interest. Thanking the Bufuula community for their hospitality at the end of the volunteers’ 3-month stay to build a primary school in 2005. I spent a month in East Africa those holidays, and was changed forever by the experience. In Africa, the continent on which we all began as Homo sapiens, it is impossible not to feel alive. There is a magic about the place and its absolute determination to defeat the myriad obstacles that have been placed in its way — geographical disadvantage, slavery, colonialism, and continuing epidemics — and this fiery determination burns through to your heart, making it impossible to walk away unchanged. I remember my plane taking off from Nairobi and promising to myself that I would return, but next time with more money, more time, and more people to make a difference. I graduated from the ANU and started studying medicine 6 months later. I had already emailed all my family and friends to rally interest in working and raising funds for the continent, but as the work began, the interest dissipated. Not knowing a soul in my new medical course, I took the plunge to email my entire year group about my idealistic plan. The response was amazing. The following summer, in December 2005, 17 volunteers, including 12 medical students from the University of Sydney, headed to Uganda to live in a remote community for 3 months, with no water or electricity, as we built a primary school for 650 children. We paid our own way to get there, juggling part-time jobs on top of full-time medical degrees, and left with our backpacks and $100 000 in the Hands of Help bank account — the result of an exhausting year of fundraising and the generosity of those supporting our idea. On the back of such enthusiasm, I set in motion the wheels to register ourselves as a charity, and Hands of Help was born, with a grassroots commitment to ensuring all funds raised reached the areas of the world that needed them most. To date, over 98% of our hundreds of thousands of dollars has been spent “on the ground” in Africa or Indigenous Australia, something we are proud of, and a figure not often achieved in the world of charitable organisations. A young girl in Bufuula, proudly wearing a Hands of Help armband. Living in an African community, experiencing life the way Africans do, is a once-in-a-lifetime opportunity. We grew close to the children, their parents and the local community council, and developed an understanding of health care in the developing world through visits to local clinics and hospitals. I rustled together a survey, which we conducted with local interpreters, of every household in Bufuula — the tiny village we were living in, located 3 hours south-east of Kampala, the capital of Uganda. As we sat in each home, showered with papayas, fresh milk from their cows and raw peanuts or coffee beans, we listened intently to their stories. We swallowed hard past the lumps in our throats as we heard recollections of their many children lost to malaria, while smiling toddlers sat in the corner of the hut eating cardboard to ward off their grumbling tummies. We stood humbly at the grave sites of mothers lost to AIDS while holding the hands of their children left behind, and we listened to their desperate pleas for access to health care and education. The first Hands of Help group of volunteers. Inspired, we headed off to Kampala to meet with Dr Ian Clarke, of the International Hospital Kampala (IHK), who agreed to support us to begin a community health project in Bufuula, training and employing Ugandans selected by their own communities to become grassroots health workers in areas where hospitals are out of reach. The project began in Bufuula and surrounding villages, and this year will reach as far afield as the war-torn areas of northern Uganda. Over 50 Ugandans have been trained as health workers by a public health specialist. Subsidised mosquito nets have been distributed, water sanitation satchels have been added to jerry cans, and HIV testing has been made available, along with education sessions on all relevant diseases, by these health workers who are proud and honoured to be trained as such. They see their new knowledge as such a privilege that they feel a responsibility to spread it to as many towns as possible. That summer was the beginning of years of achievements for Hands of Help. Seventeen volunteers, to whom I — and Africa — are forever indebted for believing in me and my ideas, left that initial project enlightened and inspired to be part of improving the inexcusable health inequalities facing so many in our world today. On the way home, our chance trip to an orphanage with unparalleled atrocious living conditions resulted in a commitment to help 250 orphans in Nairobi, Kenya. These orphans are now being given a chance at life, receiving a secondary school education through our child sponsorship program. Yet, also conscious of the issues in our own backyard, we returned to Australia and established a project to allow medical students to work with local Aboriginal medical services in remote Indigenous communities. And so I approach the final year of medical school, with years of hard work, sleepless nights and exhaustion from overwork behind me — and that’s before internship has even begun! It would be unrealistic, and lying, to say it has been easy, and I often look longingly at those enjoying a weekend off or a holiday. Yet, thanks to the hard work of dedicated committee members, a balanced partnership with medical student and Vice-President Joe Dusseldorp, who believed in Hands of Help from its inception, an extremely supportive family and partner, and the generosity of the Australian public, the charity has achieved more than I could ever have hoped for in that moment my plane took off from Nairobi. Over 100 volunteers have now given up their summers to build three new primary schools in Uganda, 50 Ugandans have been trained as community health workers, 250 Kenyan orphans have been given another chance at life, and a further 25 medical students have spent their holidays experiencing health care for Indigenous Australians. Meanwhile, awareness of African issues, and a chance for Africans to speak with their own voice, is provided by our Sydney African Film Festival1 and photographic exhibitions every year by a professional photographer (my partner, Hamish Gregory, who travels the globe with me). This summer, a further 30 volunteers will travel to the war-ravaged areas of northern Uganda to build a fourth school, while the Community Health Project will expand to service the two million people displaced by years of civil war in Gulu. Conducting hut-to-hut health surveys with local interpreters in Uganda. As I approach the coming years of my junior medical and specialty training with trepidation and curiosity as to where the path of medicine will take me, I find solace and inspiration from the thought that dozens of medical students now have a passion for our world’s health inequalities. I am continuously supported and encouraged by my parents and motivated by the work of doctors such as Catherine Hamlin, whose work with women with obstetric fistulas in Ethiopia has turned around the lives of 32 000 women, and Rowan Gillies, the former President of Médecins Sans Frontières. I am encouraged by supportive lecturers and honours supervisors, and always astounded by the passion of selfless doctors who take the time to pass on the secrets of medicine by teaching and motivating young students every day. But without a doubt, the thoughts that stay closest to my heart are the memories of an African child’s piercing stare delving deep into my soul, and the throbbing pain of that meningitic headache — and I pinch myself and remember how lucky I am to be here, where I am today, and I think of how much there is to squeeze into these short years — and how wonderful it is to be alive.

Phoebe C M Williams BComm, BSc

The Australian School of Advanced Medicine at Macquarie University, Sydney, will provide competency-based university medical specialist training in a private hospital environment. The rationale is the need for additional and innovative programs to meet emerging demands, and alternative training programs to increase the opportunities for doctors to achieve their career goals. The programs will focus on learning (not teaching), on developing a comprehensive set of professional competencies, on teamwork, and on research. Special features of the programs include: the potential for scholars to progress at a variable pace; the use of facilities for simulation and practice; and rigorous evaluation. The school is developing strong linkages with other institutions, nationally and internationally. Challenges include the recruitment of fee-paying trainees; the time commitment required of faculty members; a reliable and bias-free assessment system; and ethical concerns about undertaking training activities on private patients.

Rufus Clarke MD, PhD, FAFPHM · Michael K Morgan MD, MMedEd, FRACS

Is it heading in the right direction? The preceding article by Clarke and Morgan discusses a new form of education and training for medical specialists in Australia. The programs at the Australian School of Advanced Medicine at Macquarie University have pre-Fellowship (general specialist training) and post-Fellowship (subspecialist training) components.1 Here, I concentrate on the former. Both the formal university involvement and the new funding model proposed in the article have major implications that warrant widespread discussion. The authors imply that the university environment will enhance the educational experiences of trainees, but they have not provided supporting evidence. If it is true that the new model of training will result in better outcomes than our current system of medical college training in hospitals, should we consider other alternatives? In Canada, most specialist training programs are contracted to university medical schools and affiliated hospitals by the Royal College of Physicians and Surgeons of Canada.2 Would this be a better approach for Australia? Alternatively, should there be competing programs? Traditionally, medical specialist education and training has been seen to be both a public good and a benefit to the individual, with costs shared between the Australian taxpayer and trainee. For almost all trainees employed in public hospitals, the taxpayers’ costs have been met by hospital budgets. It has not been possible to separate out the costs of specialist training because most training is directly associated with patient care.3 There has been considerable debate as to whether the additional costs are significant and whether the benefits to the system outweigh the costs. Undoubtedly, trainees incur costs — unpaid overtime, fees to the specialist colleges, and fees for courses, attending lectures and meetings and the like. The Commonwealth Government, with some understandable ambivalence from state governments wishing to protect the public hospital workforce, is seeking greater private-sector involvement in specialist training. The reason is not only to cater for increased numbers of medical graduates, but because many essential learning experiences in most specialties are now available only in the private sector.4 These include less complex elective surgery, such as stripping of varicose veins, repair of bunions, and plastic surgery procedures, much of dermatology, rheumatology and endocrinology, and management of patients with anxiety and less complex depressive disorders. Funding remains contentious. The sums initially suggested by the Commonwealth Government during the discussion process would have barely covered salaries and on-costs for trainees. Indirect costs to hospitals and supervisors are substantial. The presence of trainees in operating rooms would be likely to lead to a 30% slow-down, reducing the income of both hospitals and supervisors. In the case of ambulatory consulting, the income of supervisors would be affected by about the same percentage. There will be other costs, including office space, access to computers and journals, medical indemnity insurance, consulting rooms, and administrative support staff. These costs may well be equivalent to about 50% of the salary and on-costs per trainee and so not too dissimilar to the fee proposed by Macquarie University. If these costs are not met by government, it is unclear how private hospitals will recover them. Some surgical trainees may be able to claim assistant fees from Medicare, but the issuing of Medicare provider numbers for physician trainees seems unlikely. Would private health insurance funds view funding for specialist training as a legitimate additional hospital cost? Would some not-for-profit hospitals be prepared to cover part of the cost as a community service, even though margins for hospitals able to provide appropriate experience are probably not great? Would for-profit private hospital providers be interested? Private hospitals gain no direct financial benefit. If the proposal outlined is successful, it may well represent the model for funding these additional costs — the trainee pays. This may become a disincentive for trainees to seek essential private-sector experience. However, it has even wider implications. Almost certainly, in the 1990s, one of the drivers for identifying costs of medical specialist training in public hospitals was a desire by some politicians and bureaucrats to recover at least part of those costs from trainees or their colleges, effectively the same source. If the Macquarie venture succeeds, this issue will almost certainly be revisited. Therefore, the proposal described by Clarke and Morgan could lead to a fundamental change in the way specialist training is paid for in Australia — to more user-pays funding — and this may well influence recruitment, training opportunities, and the quality of training, among other things. Just as we need to question increased university involvement, we must ask ourselves if this funding model is a direction in which we want to go. What are the advantages and what are the disadvantages?

Peter D Phelan BSc, MD, FRACP

To the Editor: I read with interest the recent correspondence on “patient privacy and Latin”.1,2 The wheel continues to turn! In 1927, matriculation for the Faculty of Medicine at the University of Sydney demanded passage in the subjects of science at the Intermediate Certificate examination (equivalent to the present Year 9) and Latin at the Leaving Certificate examination (equivalent to Year 11). The 1937 edition of Cunningham’s textbook of anatomy contains no less than a 29-page glossary of “General terms and parts of the human body” listed in four columns headed “British revised”, “Latin form of British revised”, “Basle Nomina Anatomica” and “Nomenklatur Kommission”, respectively (the last three columns representing alternative versions of the Latin terms). A final thought — how much human anatomy is taught in the present-day curriculum?

Keith S Jones

To the Editor: The recent letters1-5 on the “lamentable decline in the use of both Latin and Greek terms in medical practice”4 activated a not-too-distant memory for me. In the 1980s, the Department of Academic General Practice at the University of Western Australia was an orphan, struggling for resources and a toehold in the medical curriculum. Having exhausted all avenues of progress, I managed to obtain an appointment with the Vice-Chancellor. His prior meeting that day had been with leaders of the Greek community, who trooped out of his office looking rather glum. They were unhappy that ongoing financial support would not be provided for the teaching of Modern Greek at the University. That night, I had a dream. In it, the V-C returned home to his wife, who asked, “And how was your day, Bob?” “Oh, just like any other”, he replied. “Kamien from General Practice was in, complaining about the demise of classical Greek from the medical curriculum”. The next day, I rang the V-C to tell him about the dream. He laughed. I have wondered, since, whether such unlikely events may have strengthened his resolve to provide the toehold that our Department so desperately needed.

Max Kamien

Christmas this year will be marked for us by the arrival of our first grandchild, so as a mother and obstetrician I am receiving a steady stream of questions from my daughter on pregnancy-related matters — not the least of which relate to the use of analgesia in labour. At her antenatal classes, the advice has been to draw up a birth plan: warm baths, movement, partner support, and later, possibly, reluctantly, epidural ... But if I do want an epidural, she asks, will it be available even at Christmas? Christmas is also the time for celebrating the birth of Christ — which led me to wonder about the obstetric details of this event. There is little precise information available to us. Luke 2:4-7, though the author was himself a physician, gives but a brief historical account: ... Joseph ... went up ... unto ... Bethlehem ... with Mary his espoused wife, being great with child ... while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes, and laid him in a manger ... (All Bible quotations given here are from the King James Version.) Although there was clearly a birth plan, this was heavenly and long-term, rather than a matter of maternal choices. Presumably the delivery was a spontaneous vaginal one, with a cephalic presentation and rapid labour — possibly initiated by the long donkey ride to Bethlehem. There would have been few facilities for intrapartum care in a stable, and, although angels were in evidence, we are not told of the presence of any human support other than Mary’s husband. The third stage of labour was probably uncomplicated — depictions in religious art always show the mother of Jesus as serene postpartum, with no hint of exhaustion or exsanguination. What can be said with certainty is that for the Madonna there was little in the way of pain relief in labour, and that this situation would continue for women in childbirth for nearly two thousand years. Not only was effective medication lacking, women also had to contend with the curse of Eve — a belief that the pain of labour was women’s lot following Eve’s succumbing to temptation and her subsequent banishment from the Garden of Eden. In Genesis 3:16, God declares sternly, “... in sorrow thou shalt bring forth children”. And so, for hundreds of years, women brought forth children with only the support of other women for relief from pain, and many men, particularly clergy, regarded pain in childbirth as evidence of God’s moving in mysterious ways that should not be questioned. The Nativity, by Petrus Christus, circa 1450. Fortunately, all this finally began to change in the middle of the 19th century, thanks largely to Queen Victoria and a remarkable medical practitioner named John Snow. Victoria, mother of nine, has often been depicted as disliking sex (“lie back and think of England!” is frequently attributed to her), but immediately after her marriage in February 1840 she wrote to her Uncle Leopold, King of the Belgians, that she was the “... happiest Being that ever existed”, and within days she conceived her first child, the Princess Royal, born in November that year.1 She was no wimp — despite “all the ennuies” of pregnancy, she worked until close to each birth — but she was not amused by the experience of labour.1 After her first delivery, she remonstrated with Leopold that “men never think ... what a hard task it is for us women to go through this very often”.1 Later, when her eldest daughter was herself married, Victoria wrote to her of the “heavy trials” and “cruel sufferings” that labour entailed,2,3 and commented that: ... the pride of giving life to an immortal soul is very fine ... but I own I cannot enter into that; I think much more of our being like a cow or a dog at such moments; when our poor nature becomes so very animal and unecstatic.2 Nevertheless, her letters show that she adored her “Angel” — her consort, Prince Albert — and was devoted to all her children.1 In London in 1847, Dr John Snow began to experiment with ether, which dentist William Morton had successfully demonstrated as an anaesthetic to an interested Boston audience the previous year.4 Born in 1813 to a poor Yorkshire family and apprenticed at age 14 to a surgeon, Snow later studied medicine at the Hunterian School of Medicine in London.5 He was a vegetarian, a teetotaller and, by his own admission, celibate all his life, devoting his energies entirely to his profession.6 Snow was one of the first to calculate appropriate dosages of ether; he devised his own apparatus for its administration and soon had “the busiest ether practice in London”.6 He was also interested in chloroform, introduced by James Simpson of Edinburgh in 1847 for obstetric and surgical anaesthesia, and he wrote about both drugs.7,8 Simpson, as well as taking a clinical interest in pain relief for childbirth, also confronted the Church’s objections, quoting from Genesis 2:21-22 the story of Eve’s creation from Adam’s rib: ... the Lord God caused a deep sleep to fall upon Adam ... and He took one of his ribs ... and the rib ... made he a woman. Thus, said Simpson to his opponents, did God condone the use of anaesthesia.9 Victoria and Albert initially expressed interest in chloroform for childbirth in 1848. However, the Royal physicians, Dr Charles Locock and Sir James Clark (a man described as “a walking medical calamity”), had grave concerns about the safety of the drug, so the birth in 1850 of Victoria’s seventh child, Prince Arthur, took place without anaesthesia.6 Over the next 3 years, Snow’s reputation as a safe anaesthetist grew, and, in early April 1853, with the arrival of another child imminent, Albert summoned him to Buckingham Palace for a private conversation. Three days later, the Queen commenced labour, and Snow was again called to the Palace. Subsequently he wrote: April 7, 1853 — Administered ... to the Queen in her confinement ... a little chloroform with each pain ... on a folded handkerchief .... Her Majesty expressed great relief from the application [and] appeared very cheerful and well, expressing herself much gratified with the effect ...6 The Queen indeed found chloroform “delightful beyond measure”, and the child, Prince Leopold, was born healthy. The editors of the Lancet, however, were not amused. “Intense astonishment ... has been excited throughout the profession by the rumour that her Majesty during her last labour was placed under the influence of chloroform, an agent which has unquestionably caused instantaneous death in a considerable number of cases”, they thundered.10 The British Medical Journal hit back at its rival, asserting that “when well controlled and supervised, the use of chloroform is safe”, and by the 1860s, using chloroform in both obstetrics and general surgery was standard practice.11 In 1857, at the birth of her last child, Princess Beatrice, the Queen again used chloroform, once more administered by Dr Snow. “Her Majesty is a model patient”, Snow declared, but very properly declined to comment further on his conduct of either case. The Royal approval much enhanced his professional reputation, and chloroform in childbirth became respectable, being referred to as anaesthesia à la reine. The notion of pain relief in labour was here to stay.12 Snow died in 1858, aged just 45, but left an enduring medical legacy not just confined to his contribution to anaesthesia. In 1854, he had investigated an outbreak of cholera in his London neighbourhood of Soho, becoming convinced — well before the germ theory of disease was accepted — that the source could be traced to water from a public pump in Broad Street. He persuaded a sceptical municipality to remove the pump’s handle — whereupon the epidemic abated. He thus made a significant contribution to epidemiology, as well as to the realisation that plagues and epidemics were not, in fact, the work of a wrathful God.6 Chloroform continued to be used in childbirth until the 1970s, joined by narcotics such as pethidine, nitrous oxide–oxygen mixtures, and other self-administered analgesics. Since the 1960s, increasingly sophisticated techniques of epidural analgesia have been developed.5,12 Currently, 90% of Australian women having their first child have some form of pharmacological pain relief in labour.13-15 However, with the growth since the 1980s of a movement critical of the medicalisation of childbirth, opinions on the acceptability of pain relief in labour have become polarised. Now, instead of the doctrine of the divine necessity of pain in labour, we have the view that experiencing pain is a woman’s right, and that accepting analgesia diminishes the experience of childbirth. “The easy availability of analgesia”, says one advocate of this viewpoint, “can reinforce the medical notion that women’s bodies are intrinsically defective”.16 Not so, respond some obstetric anaesthetists — epidurals are “the gold standard ... you can participate in the experience, you can push the baby out, and it takes the pain away”.17 Had it been possible, Queen Victoria would almost certainly have ordered one. So, what advice should I give my daughter? The same that I would give all women. There is no right or wrong way to have a baby, be it in a stable or a tertiary-level hospital — there is just the best way for you. Epidurals are effective and safe, and available even on Christmas Day. Be well informed, keep an open mind, make the decisions that seem right for you at the time, and do not be tempted to regret them later; the most important thing is a healthy baby and a healthy mother. We will welcome our Christmas arrival with joy.

Caroline M de Costa MPH, FRCOG, FRANZCOG

An obscure Portuguese document from 16th century Indonesia describes an illness that destroyed poultry before devastating the human population of the region. The cause of the illness remains unresolved; it may have been infectious or non-infectious. Isolation of the region because of trading practices probably prevented spread of the illness, reinforcing the value of quarantine or isolation as a public health measure The following extract comes from an unsigned treatise written by António Galvão, captain from 1536 to 1539 of the Portuguese fortress on the island of Ternate in the Maluku archipelago, in what is now Indonesia (Box): At the end of April 1539 there appeared in Ternate and throughout this region a star in the west, with many enormous rays like a natural torch, similar to the one that was seen in Portugal when the earth shook. It lasted throughout May and June. With the south winds came this sickness to Bacan; before long it spread throughout all the islands beginning in the chickens. Because it happened one morning that more than 50 or 60 chickens belonging to António Galvão which had been growing healthy and fat were found dead; and afterward more than 110 of his people, both servants and slaves, fell ill, not one being spared and the more part dying on him, not counting the Portuguese and their children; and this evil was so common throughout all the land that they could not bury them, and the sea was full of the dead, and many places were depopulated, and thus they found themselves in visions at night for the men were amazed, saying that they had never before seen such a thing, nor had they heard of it from their ancestors [translation by Brett Baker].1 Although from ancient times it was traditional for authors to begin the description of any epidemic with the death of birds,2 we believe that Galvão’s description was a true reflection of the events rather than a stylistic convention. Galvão made no mention of bird deaths when describing “an illness like the plague” that occurred 5 years earlier;1 therefore, his description of dying chickens in 1539 is likely to truly reflect what happened. The 1539 epidemicIt appears that a disease rapidly destroyed a group of 60 healthy chickens and was followed soon after by a disease of similar lethality in humans, affecting the indigenous population, slaves and the Portuguese. The striking features of this outbreak are its rapidity, severity, probably its mortality rate (although this cannot be determined) and the fact that, as it spread throughout the archipelago, it always seems to have been preceded on each island by poultry deaths. Galvão states that whole regions were depopulated. However, he may have exaggerated this. Only 7 years later, Europeans commented repeatedly on the high populations they found there, describing Ambon as “densely populated”.3 Still, it seems that the illness killed large numbers of people throughout the islands over a relatively short period. Galvão and the indigenous population did not recognise the illness, although devastating epidemics of unspecified diseases “raged through the islands every 7 or 8 years”.4 The possible causes could be infectious or non-infectious. Possible infectious causesInfections in chickens and humansIt seems unlikely that two separate and lethal infections devastated chickens and humans almost simultaneously; therefore, a single responsible agent is more probable. Newcastle disease can kill chickens rapidly but does not cause disease in humans.5 Psittacosis can infect domestic poultry6 and then humans; however, the rapidity and lethality of the disease in 1539 in both chickens and humans is not typical of psittacosis. Anthrax is a devastating zoonosis most typically associated with herbivores. Infection of birds with anthrax is usually asymptomatic and is detected by spores shed in faeces.7 Chickens, especially, seem resistant to the disease.8 Could avian influenza have caused the 1539 outbreak? In modern times, the H5N1 strain of avian influenza affects birds and humans, with human-to-human transmission considered to be very rare. In the current climate, one would have to consider avian influenza as a differential diagnosis for an infection targeting both domestic poultry and humans. Few zoonoses other than H5N1 influenza kill both. Features of the 1539 outbreak have some similarity to avian influenza of the 21st century. The infection appeared to be an emerging infectious disease, not seen before by the indigenous people or the Portuguese. Also, throughout the islands, the illness seemed to affect poultry before affecting humans, supporting the idea of poultry-to-human transmission. However, there are strong arguments against avian influenza being responsible for the 1539 outbreak. First, the large number of human casualties is in direct contrast to the situation in the 21st century. In today’s H5N1 outbreaks, human death rates are low, despite the exposure of large populations to chickens.9 This may be attributable to the H5N1 virus binding only to galactose receptors in the lower respiratory tract, unlike human influenza viruses, which can bind to galactose receptors in the upper respiratory tract.10 Therefore, if avian influenza was the cause of the 16th century epidemic, the degree of human devastation described is surprising, even if Galvão exaggerated the situation. An avian influenza virus capable of human-to-human transmission might explain so many human deaths, but a mutation rapid enough to allow this is questionable. Also, H5N1 influenza in humans has a distinct clinical syndrome of focal respiratory symptoms often accompanied by diarrhoea,9 yet Galvão did not describe focal features of the 1539 outbreak. One could attribute this to a failure to record the symptoms for one reason or another, but this seems not to have been the case. The treatise elsewhere is filled with details and elaborate descriptions by Galvão, including careful depictions of the clinical features of other epidemics and illnesses.1 Therefore, it is more likely that the 1539 illness truly lacked obvious focal clinical features, possibly because of its rapid and severe course, but this would certainly make avian influenza far less likely as a diagnosis. The role of the monsoonAlthough the specific organism cannot be pinned down, the way in which the illness appeared to spread through this group of islands but not outside it also supports an infectious aetiology if the trading practices of the region are studied. Strong monsoonal patterns strictly regulated the periods of external contact. At the time of year during which the outbreak occurred, there would have been trading only among the islands but not outside them. Generally speaking, sailing vessels from outside the region could arrive in the archipelago only twice each year during rather narrow windows of time. Most ships approached via the Java and Banda Seas, arriving in the southern part of the archipelago about mid February. Those approaching from the north would arrive around the end of October. Regardless of when or by which route they had arrived, all sailing vessels had to depart from the Maluku archipelago via the southern route with the arrival of the south-east monsoon, about the middle of May.11 This monsoon is the “south winds” identified by Galvão as having marked the advent of the illness in Bacan. Consequently, the outbreak would have begun just as external trading vessels were departing from the island of Ambon about 350 km to the south, and it would be more than 5 months before the first outside ship could return to Maluku, presumably after the infection had run its course. At the same time, traffic among the islands in the Maluku region would have continued without interruption. This was possible because korakoras and other native craft could be rowed in shallow, reef-infested seas regardless of the prevailing winds. Constant inter-island trade was necessary because so many of the spice-producing islands depended on imported foodstuffs. Bacan, where this illness was first observed, produced no food of its own and therefore relied entirely on supplies brought in from other islands, and Ternate was in almost the same situation.4 These inter-island food shipments would have included chickens.12 Chickens were imported from a handful of fertile areas within the Maluku region rather than raised locally;13-15 therefore, local inter-island trade in chickens would have been sufficient for an infection carried by fowl to “spread through all the islands”.1 Possible non-infectious causesCauses of the illness other than infection could include environmental agents, especially foodborne or gaseous substances. Claviceps purpurea is a fungus that contaminates rye-based foods primarily, resulting in outbreaks of epidemic ergotism with mortality rates of 10%–20%. Epidemic ergotism has been well documented from medieval times,16 so its distinct clinical syndromes (limb gangrene or recurrent abnormal posturing) would have been recognised and recorded by Galvão. In Lake Nyos, Cameroon, in 1986, 1700 people and 3000 cattle mysteriously and suddenly died. Eventually, the culprit was found to be the massive release of carbon dioxide from crater lakes.17 It is unlikely, though, that any toxin came from the “star in the west” that Galvão described. Astronomical records confirm that a comet was visible in the sky in May 1539, indicating that Galvão’s star was probably a comet in space rather than a meteorite entering the atmosphere bringing a deadly toxin.18,19 Yet, the most compelling argument against a foodborne or gaseous agent is Galvão’s observation that chickens were consistently affected before humans, not just in Bacan, but in all the islands of the Maluku region.1 A zoonosis seems more plausible. Lessons for modern-day quarantineAlthough the 1539 outbreak was probably not avian influenza, it is surprising that, given the current avian H5N1 pandemic, a passage about a devastating illness in poultry and humans from the 16th century has not been discussed recently. Galvão’s treatise has been available in published form with a parallel English translation since 1971. As part of the Jesuit Historical Institute’s Sources and studies for the history of the Jesuits series, it has likely reached a narrow and rather specialised audience, one that, until recently at least, may have skipped over the importance of an illness that appears to have affected both chickens and humans. In conclusion, the devastating illness occurring in north-east Indonesia in the 16th century, affecting first chickens and then humans, is consistent with a zoonosis. The 16th century outbreak probably failed to spread because of the isolation of the islands from the rest of the world through climate-determined trading patterns. This reinforces the value of (even unintentional) quarantine or isolation as a public health measure. Given the ease of global movement of people, animals and cargo in the modern era, its enforcement will now be a far greater challenge. Location of the 1539 epidemic The northern islands of the Maluku archipelago in Indonesia.

Sanjaya N Senanayake BSc(Med), FRACP, MAppEpi · Brett C Baker MA

A 61-year-old woman with known colonic diverticula underwent colonoscopy for abdominal pain. The cause remained obscure until this sinister face appeared in the viewing scope, which the authors instantly recognised as the potential source of evil (Figure).

Anthony F T Brown · Andrew Bryant

A positron emission tomography scan of this patient’s lymphoma revealed a surprisingly “Australian” distribution of disease.

Colin K F Tan · Tim Y Demetriades

A brief taxonomy of reviewers, and how to deal with them Progress, we are told, can be helped by differences in opinion. If we always agreed on every issue, advance would be slower or perhaps even non-existent. This applies to all walks of life, and medical publishing is no exception. But differences in opinion can involve criticism, and criticism can be difficult to take. Today most journals rightly insist on peer review, which essentially means you receive written criticism on your submission. Having had my fair share of it, I would like to assist the novice by describing the archetypical critics and by suggesting strategies for dealing with them. The nitpickerThe nitpicker is obsessed with detail. Acting as peer reviewers is where nitpickers have their heyday! They might dislike anything — from your approach to statistics to the way you use semicolons. The best way of dealing with nitpickers is, I am ashamed to admit, to give in. It is, of course, tempting to justify this or that semicolon, but my advice is, don’t. Life is too short! Unless you are a nitpicker yourself, try to rise above nitpicking criticism. The aggressorFor those of us who are not born masochists, criticism is rarely an enjoyable experience. The aggressor makes sure it is thoroughly unpleasant. Whatever the arguments, they articulate them so forcefully that the opponent is likely to get hurt — regardless of the validity of the argument itself. I once received a review of a paper I had submitted for publication which started with the statement “This article is staggering in its incompetence”. What followed was hardly a qualification of this opinion, more a mindless enforcement of it. Aggressors do not normally assist you in your efforts to enhance anything; constructive criticism is not their cup of tea — they only aggress. There are several ways of dealing with the aggressor. Avoid an escalation of aggression, but insist on discussing the real issues openly. You might just win the day because the quality of the aggressor’s arguments is often inversely correlated to the force with which they are produced. The evangelistEvangelists are so utterly convinced of being correct that they view any deviation from their truth as heresy. If your data fail to support their beliefs, your data must be wrong. Evangelists read medical publications upside down — they first study the conclusions. If these are in accordance with the evangelists’ convictions, you have little to worry about. Even if your method is fatally flawed, they will praise you and your work. But if your conclusions contradict their beliefs, they will find plenty of fatal flaws in your work and condemn you forever — even if the research is flawless. After having been confronted by evangelists all too often, my advice is to ignore them. There’s no other choice. Only another evangelist can change an evangelist. The wind-bagIf a written criticism extends to more than five pages, or if a verbal comment goes on until you feel hypoglycaemic, it is, in my experience, likely to be worthless. Wind-bags love to hide the presumptuousness of their arguments behind large quantities of pseudoscientific waffle. They use tedious pseudoscientific jargon to indulge in apparently complex thoughts or theories. Unfortunately, this tends to impress a surprising number of people. But, once one manages to look behind the smokescreen, one is usually struck by the hollowness of the arguments. Subsequently, it is easy to deal with wind-bags; simply expose their elaborations for what they are: hot air. The inventorIf your opponent cannot find anything wrong with your work or arguments (or cannot even be bothered to study them), he or she may decide to become inventive. This strategy works best in published debates. Once the invention is out there in black and white, it is difficult, perhaps even impossible, to re-establish the truth. Whenever I publish research suggesting that a given “alternative” therapy does not work, you can be sure that someone counters by claiming I was bribed by “big pharma” to do so. There is nothing more efficient for tarnishing somebody’s work than a good old-fashioned lie. If the lie is important enough, you obviously have to deal with it. You then need to expose it and clarify who is inventing things and why. This process can be nerve-racking. Therefore, it might be wise to just ignore inventors, particularly if their lies are inconsequential. Criticism is meant to be helpful. It can and should be a good and constructive contribution to progress. Every now and then we do receive thoughtful criticism that is highly profitable. It enables us to reconsider certain issues and perhaps correct or prevent mistakes. This is the sort of criticism that does indeed further progress. I only wish we had more of it!

Edzard Ernst MD, PhD, FRCP, FRCPEd

Riding on the tail of the coauthorship explosion Once upon a time, well-bred scientists sucked on the end of a quill and produced magnum opuses with single-author bylines, such as Charles Darwin’s The origin of species. Following the model of other creative domains (eg, Rodgers and Hammerstein for musicals, Gilbert and Sullivan for operettas, and Galton and Simpson for television series), scientists moved to byline couplings (eg, the double-helix twist of Crick and Watson). But now, the contemporary “explosion” in scientific publications has been outstripped by an explosion in coauthors, presumably reflecting publication counts that allow an academic career to slouch towards Bethlehem. This report provides some quantification of the proliferation in prolix and profuse bylines, notes their climate-change impact and argues for a climacteric solution. MethodsWe (et al, et moi) sought to examine the average number of authors of research reports (ie, excluding editorials, reviews, correspondence, book reviews and corrigenda) appearing in the July issues of two leading general medical journals (BMJ and JAMA) and, as a reflection of this author’s discipline, two psychiatry journals (the American Journal of Psychiatry and the British Journal of Psychiatry), at 5-yearly intervals (2007, 2002, 1997, 1992 and 1987) over a 20-year period. ResultsByline creep was established. In the BMJ there was a modest increase (of 36%) from 1987 to 2007, with the 2007 issue averaging 6.3 authors per paper. In JAMA, a differentiation of the article types from “articles” to multiple classifications in more recent years allowed comparison only of “original contributions” across relevant 2002 and 2007 issues. The average number of authors per paper increased by 73% (from 6.8 to 11.8) over that brief period. The number increased by 58% in the American Journal of Psychiatry (rising from 3.9 authors per paper in 1987 to 6.2 in 2007), and 130% in the British Journal of Psychiatry (from 3.2 in 1987 to 7.3 authors per paper in 2007). During the quantification process, this author became distracted by the byline gallop in published letters. A “letter” is surely a brief personal communication from one person to another. Letters (other than belles-lettres) should not be expected to have great status or (other than petitions to the Queen) require multiple authors. But again, authorship of letters is breeding to such a profligate extent that the list of authors can take up more space than the letter itself. And letters breed letters. A representative example is a letter published in Nature, in which Nusbaum, the principal author, was joined by 53 coauthors.1 However, as one author’s name “was accidentally omitted”, a new letter pointing out this grave anomaly was subsequently authored by 55 authors,2 with the byline requiring eight lines of text, as against the one line occupied by the actual 23-word correction “letter”. DiscussionThe current study — like much of science — merely quantifies what is widely known. It is perhaps more important to recognise the causes and the consequences. Unless otherwise explained, we must assume that the coauthorship explosion is a virus designed to advance the academic and research careers of individuals and their institutions. As competitive grant funding is like rain on a salt flat, coauthors will breed like Sea Monkeys in such a climate. While medicine is viewed as a particularly “collaborative” discipline,3 and doctors are expected to be caring and generative, gift authorship — defined in the Lancet as “polyauthoritis giftosa”4 — comes with a price. The question must be asked: is byline creep good breeding, or overpopulation? While acknowledging all those who have contributed to the research endeavour seems a model of responsibility, responsibility so diffused risks irresponsibility writ large. The equivalent of verbal filibustering, such unsightly frilly cluttering of articles signals more style than substance. The recent corrective strategy, whereby many journals now require authors’ individual responsibilities to be stated, is merely a challenge inviting creative writing. The Biblical story of “Ruth amid the alien corn” has contemporary relevance, and journals need to review their current chaff-to-wheat ratio. In some arenas, such as medicine (eg, genomics, clinical trials) and other scientific disciplines (eg, physics), we also see a blitzkrieg phenomenon, in which it appears that overwhelming numbers of authors and affiliated institutes (rather than the science itself) are being deployed to allow a particular field to be captured or dominated, as described in Nature.5 Hypercollaborative sciences, such as high-energy physics, have led to so-called “mega-authored” publications arising out of international collaborations, like CERN (European Organization for Nuclear Research) in Geneva, where the OPAL and ALEPH collaborations had 209 and 277 coauthors, respectively, appearing on two articles.6,7 Particularly high-mega-authorship collaborations have arisen out of the DESY (German Electron Synchrotron) research group, with the ZEUS and H1 efforts publishing reports with close to, or more than, 300 authors.8,9 A species of gravitational interaction has emerged. The impact? Could I suggest reference to an H1 collaboration article.9 This nine-page article has two-and-a-quarter pages taken up with the 296 authors, their 40 affiliative institutions and their 11 funding bodies. Next, as in cinematography, the assorted associates are likely also to be listed at the article’s end as “data wranglers”. The future? Well the future is already here, as just noted and illustrated earlier by the Nature letter–corrigendum scenario. All of us who aspire to having a letter published by Nature will be teamed up by “Google Coauthor” and coalesced into a consortium. The multiplicity of authors should ensure sufficient errors for the average letter published in Nature to generate at least one correction “letter”. This might draw attention to authors who were initially missed, perhaps because they were late in bedding down with the original letter writers (spontaneous co-respondents become formal correspondents). A few more “letters” to Nature might draw attention to a missing umlaut or some other critical byline error. Everyone will be able to fight for his or her contribution to a letter to Nature (risking Nature being read in tooth and claw?) and soon — as Nature abhors a vacuum — it will be unnatural for a scientist not to be published in Nature. The ceiling will have become the floor. Solutions? Perhaps the once-condemnatory journalistic term “hack” needs to be redefined and a hacksaw brought into play. I propose that scientific journals publish only single-author papers or, if multiple authors are involved, the non-principal authors be grouped as “et al” in the byline and in the reference section. By rough calculations, this would reduce the contents of the average scientific journal by 12.6745%, which, multiplied by the current number of scientific journals, would save 250 000 hectares of South American rainforests and numerous butterflies from putting chaos theory into practice. We need ecoauthorship rather than having coauthorship put our climate at further risk. Clearly, we need to ensure that “et al” receives its rightful place in the sun, replacing all coauthors in any article byline. At first pass, some might reject the possibility, perhaps judging that “et al” sounds like “also ran”. But the term “et al” has majesty and status. In traditional Hawaiian society, the hereditary “ali’i” or “alii” occupied the highest societal class, even ranking above priests (and editors). Possessed of divine powers, they were able to place curses on others, including, presumably, first authors who traduced their byline status and any editor who did not view their manuscript as Nobel Prize-winning material. A more contemporary argument can be offered. Presuming that the name “Alfonso Joseph D’Abruzzo” means nothing to you, I can reveal that this man’s acting career was launched by his changing his name to “Alan Alda”, merely one step before the even more alliterative “Al Al”. The logical next step, a paper published by “Al et al”, has already occurred in a British journal,10 demonstrating respect for, and gravitas surrounding, “Al”. “Al” clearly implies “A 1” status. Instead of the disquiet experienced by authors who quibble with the order of authorship, the proposed system would give comparable status to both the first author and those high-class members of the et al set; thus, it is a non-hierarchical parity model. We could go further and delete the titles of many research papers, and merely add a subject to the et al predicate. For example, a paper by “Bloggs et alalia” would be immediately recognised as discussing speech impediments; “Bloggs et al-Qaeda” would be considering the impact of terrorism; “Bloggs et alimentary” would be a gastrointestinal review; “Bloggs et algolagnia” would cover painful sexual experiences; and “Bloggs et al-anon” would report on alcoholism support systems; while a paper on climate change would be sufficiently explained by the byline of “Bloggs et al Gore”. The last suggestion even encourages the convenient truth that et al could run for President.

Gordon B Parker DSc, MD, FRANZCP

The cadavers and we began the year together. We tentative, curious, wanting experience, They pickled and shrouded, occult mysteries. Months on, familiars, they dwindled, yielding their secrets. Hands probing, teased, peeled and picked down to bones. Regard grew with understanding, confidence and skill. Though too there was levity, subdued; we were young, hard learning, How try and temper exuberance with respect, For dignity of life and mortal frailty, and of death. Years on, while watching much of human striving failing, Some images, unwilled, out of those times, still come. Especially of flayed and party coloured specimens in jars. Sinews laid bare, the bottled hands, those truly human elements, displayed, Still cause to muse again, what violence, arts or music they had made.

Donald D’Arcy Webling MB BS, PhD

A 39-year-old man with a lifelong history of asthma reported recurrent productive cough and wheeze over the previous 2 years. Antibiotics and specific asthma treatment produced only temporary decreases in symptoms. Chest examination revealed monophonic wheeze in the right mid and lower zones. The appearance on computed tomography was unremarkable. On flexible bronchoscopy, the blue end-cap of a ballpoint pen was seen within the apical right lower-lobe bronchus (Figure, A and B). It was removed by rigid bronchoscopy (Figure, C). Subsequent questioning of the patient revealed no history of aspiration, although he habitually chewed his pen while working. Airway foreign bodies are more common in childhood1 and are often not considered in adults. This case underscores the clinical significance of a monophonic wheeze,2 which may arise from abnormalities not detectable by imaging.

Celia M Zubrinich · Christine F McDonald · Simon R Knight · Fergal J O’Donoghue

“Kelly Laerdal”, age unknown, but repeatedly resuscitated, was scheduled for a chest x-ray to investigate the metallic contents of the thorax, with the aim of understanding why resuscitation manikins might differ in their susceptibility to electromagnetic interference in electrocardiogram recording.1 Besides some minor electronic components, the image shows a prominent cardiac massage pressure point, gives a hint of shoulder joint junctions, and shows exactly where the auscultation regions (covered by loudspeakers) are located — a “must know” for every advanced cardiac life support student.

Wolfgang Lederer · Martin Breiteneder · Michael Rieger · Christoph J Schlimp

Satirical prints and drawings have been popular for centuries, and politicians and prominent people have been fair game for the barbed pen of the artist. The medical profession has come in for its share of satire, usually in relation to the treatment available and the fees charged In newspapers and periodicals, artistic expressions of political and social events are presented to us daily in various forms, from caricatures of prominent people to line drawings and thumbnail sketches that depict a particular situation. In 18th and 19th century London, such satirical prints were very much in vogue. Satire was the language of the day, and no level of society was spared. Prints were the only pictorial records of life at that time, and the print shops were extremely popular. They provided amusement, but also powerful social and political criticism. In those times, society, politics, and economics were changing rapidly, and scientific knowledge was emerging. Managerial and professional classes were rising in power and status. Tall poppies were there to be cut down, and the caricaturists were always willing to do this with their pens. The first publication in the United Kingdom of Punch, in 1841, and the British version of Vanity Fair, in 1868, saw the emergence of illustrated journalism. Medical treatment in the 18th and 19th centuriesIn the 18th and 19th centuries, medical treatment was harsh and violent, and the cartoonists treated it and its practitioners in the same way.1-5 The aetiology of diseases was unknown, and conditions such as fever, ague (malaria-like acute fever) and gout were personified as monsters or devils. The doctors were depicted as pompous pretenders to fashion, with their wigs, cocked hats and gold-headed canes (Box 1). Physicians prescribed medicines — many ineffective and unpalatable — including emetics, cathartics and clysters (enemas). Being ill was bad enough, but being “physicked” could be even worse. Surgeons lanced, cut, bled and amputated, their skill being judged by their speed. Anaesthetic agents were non-existent until the mid 1800s, and the only relief would have been from opium or alcohol. Therefore, disease and doctors were to be feared. The standing of those practising medicine, in the eyes of the artists and the public, was not high, and disease and death were considered to be the doctor’s constant companions. The humour of the time was “black”. The misfortune of the patients and the attitude of the doctors were material for satire by the artists. William Hogarth (1697–1764) is regarded as the founder of the English form of satirical art. He was not a caricaturist, but is better described as a graphic satirist and moralist. His works are a perfect representation of life in London in the first half of the 18th century, and examples would be such works as The March to Finchley, Southwark Fair and Gin Lane (Box 2). After Hogarth, other British satirists who applied themselves to recording life and events were Thomas Rowlandson (1756–1827), James Gillray (1757–1815) and George Cruikshank (1792–1878), and the period in which they worked has been referred to as the “Golden Age of English caricature”. The social stratification at the time was reflected in the medical profession. The pecking order of those practising medicine would have been: The physicians with degrees from Oxford or Cambridge, who considered themselves to be learned men and above all others. The licentiates who had a qualification from some other university in England or abroad. The surgeons. The apothecaries. The quacks. However, success in the practice of medicine did not always depend on qualifications, but often on patronage and, in the case of the quacks, advertising. Hogarth’s work, A consultation of physicians or The company of undertakers (which he presents as a coat of arms), satirises the standing of the physicians (Box 3). It shows 12 members of the College of Physicians examining a flask of urine. In the escutcheon, he presents three famous quacks of the time, (“Chevalier”) John Taylor the oculist, Sally Mapp the bone setter and Joshua (“Spot”) Ward of “drop and pill” fame. In Hogarth’s opinion, there was little difference, if any, between them. Another Hogarth print, published in 1726, Cunicularii, or the wise men of Godliman in consultation, depicted the story of Mary Tofts. In 1725, Mary Tofts of Godalming had been reported in a Guildford newspaper as having given birth to rabbits, and the doctors believed it! The event even came to the attention of the king, who sent his anatomist–surgeon to investigate and report. Eventually, the situation was found to be a complete fraud, and Mary Tofts confessed. In the drawing, three “surgeons” are pilloried for their gullibility — Mr Howard, the midwife, who first reported the event; Nathaniel St Andre, the royal anatomist–surgeon; and Cyriacus Ahlers, a royal surgeon. It has been suggested that the accoucheur, labelled as the philosopher searching into the depths of things, was Sir Richard Manningham (Box 4). Jealousies and enmity existed among the strata of the medical profession — physicians, surgeons, apothecaries and quacks. These reached the press, and even the law courts, providing more material for the print shops, who would represent them as battles. The cartoon, Siege of Warwick Castle (1767), illustrates a fight between the licentiates and the Fellows of the College of Surgeons (Box 5). The licentiates had invaded the College after having been denied access to a College meeting and dinner at an establishment in Warwick Lane. The president is depicted as a skeleton and the weapons are urinals, clyster pipes and syringes, as well as canes and fists. The licentiates were finally dismissed with the aid of the College fire engine. The physicians also battled with the apothecaries over whether the latter could treat patients. Eventually, this was settled by the court, which found in favour of the apothecaries. All levels despised the quacks. Cruikshank satirised the board of examiners at Surgeons’ Hall in his drawing, The examination of a young surgeon (1811). A fierce-looking examiner asks the candidate to describe the organs of hearing. Of the motley collection of examiners around the table, two are deaf, others are bored or uninterested, another takes snuff, and a skinflint counts his money (Box 6). Patients then, as today, sought cures to their ailments and improvements to their wellbeing in clinics and health centres. Bath was a popular place for the gentry and wealthy to visit to bathe in the hot springs, and to take the air and the waters. There was also a very important social side to the Bath visit, which involved afternoon teas, dinners and balls. Doctors were in abundance and available for consultation. Rowlandson satirised the situation in his series, The comforts of Bath, published in 1798.6 One of the main figures in the series is an elderly obese gentleman with a gouty leg. Cartoons show him being examined by a group of doctors; attending the pump room in his Bath chair; and visiting the marketplace where he appears to critically examine a large fish as well as the lady assistant’s attributes. In another scene titled The gourmets, two gentlemen indulge themselves in the good food and drink that would suggest a contributory factor in the aetiology of their gouty legs and other medical conditions. Another satirical view of the Bath visit was the Bath races. Here, the decrepit visitors race down the slope below the Royal Crescent. Death was also in attendance, and in a couple of cartoons was shown driving a coach drawn by some of the visitors. Lecherous doctors did not escape the artist’s pen. A Rowlandson drawing, Medical dispatch or Doctor Doubledose killing two birds with one stone, shows a portly doctor taking the pulse of a dying crone and at the same time putting an arm around the shoulders of a nubile maid (Box 7). Innovations in medical treatment also provided material for the satirists. One of Gillray’s prints shows Jenner inoculating patients with cowpox exudate. As a consequence of the procedure, the patients have begun to sprout miniature animals from their arms and faces, etc. A drawing by Gillray titled Scientific researches! New discoveries in pneumatics! satirises the effects of air or nitrous oxide treatment in a lecture–demonstration. The subject’s trousers are blown off, while members of the audience show shock and disgust. Death was considered to be the doctor’s constant companion, and the skeleton was used as a symbol. One cartoon (artist unknown) illustrates a doctor carrying a bag of gold, with a skeleton riding on his back (Box 8). The doctor has pointed ears, which might suggest an association with the devil, and in the background, a funeral procession can be seen. Metallic tractors were invented by Elisha Perkins in 1795. These instruments were supposed to produce galvanic electricity and were available (at 5 guineas a set) to cure all conditions. A Gillray cartoon of 1801 shows them being used to treat a brandy-loving patient’s large inflamed nose, with resulting discomfort (Box 9). Boards of public health were established during the 1831–1832 outbreak of cholera in England; the Central Board was in London, and its members were employed on high salaries. (The present-day analogy would be “jobs for the boys”.) Although the board issued statistics, it had no effective measures to deal with the problem, and The Times stated that “Choleraphobia was profitable to the medical profession”. The members of the Central Board of Health were lampooned by the cartoonists, and in one drawing by Cruikshank, four distinguished members, indulging themselves with a sumptuous dinner, drink a toast: “May we preserve our health by bleeding the country” (Box 10). The relationship between contaminated drinking water and cholera had not been appreciated at that time. In London, 130 sewers emptied into the Thames near the site where the Southwark Water Company drew its drinking water. A cartoon by Cruikshank depicted John Edwards, the owner of the company, sitting on a buoy in the filthy Thames while people on the bank called for pure water. It was not until 1854 that John Snow confirmed that the cholera infection was related to the quality of the water. Later 19th centuryIn the latter half of the 19th century, the satire became more sedate and the humour more subtle, a change from the black humour of the earlier years. Because of the advances in medicine, violent treatment such as amputation and other painful procedures were no longer a target. Doctors and patients became the main subjects, the former because of their pretensions to upper-class status and the latter, their gullibility. The doctors’ attire changed to the top hat, morning coat and striped trousers. A cartoon in Punch shows the fashionable patient protesting at the medication prescribed (cod-liver oil) and the fashionable doctor’s solution to the problem (cream and curaçao). In another drawing, the specialist writes a prescription, which the patient can have filled or not — for it would make no difference.7 Diagnostic problems were illustrated, as shown by a few examples from Punch: The specialist physician searching for a diagnosis asks the patient, “What do you drink?” The reply, “Oh, Sir! — thank you Sir . . . I’ll leave it to you, Sir!” The beneficial effect of taking the patient’s temperature and the patient’s comment, “That done me a lot o’ good, Sir!” The doctor makes a diagnosis on the patient’s symptoms of “feeling wretched . . . no interest in anything, have no appetite, can’t sleep”, and his advice is “Why don’t you marry the girl?” Another cartoon (1882) shows an American physician and an English physician in discussion (Box 11). Modern timesBetween the 1940s and the 1990s, Giles in the British Daily Express used members of the “Giles family” to put a humorous aspect on events of the day, medical and otherwise. The foils were usually Grandma and sickly, snivelling Aunty Vera, who always had her handkerchief to her nose and carried her bottle of pills. In Australia in the 1970s, Larry Pickering drew a series of sketches on the activities of the medical profession,8 which included a doctor operating on his hobby antique car assisted by his son in the role of theatre sister, and another rather cynical set published in The Weekend Australian newspaper in 1979 lampooning doctors and their fees (Box 12). Handwriting and fees are perennial subjectsThe handwriting of doctors has always been criticised. A cartoon in Punch shows the annual pharmacists’ competition, in which they are adopting many bizarre positions in their attempts to interpret the writings of members of the British Medical Association. In the 1970s, the Australian cartoonist Larry Pickering produced a drawing on this subject in which a lady, leaving the pharmacy carrying a large purchased teddy-bear, complains to her companion that her doctor’s writing is not getting any better. Fees have been a subject for satire throughout the years. An 18th century drawing shows Dr Gallipot weighing the guinea (at the time a precaution against “light guineas”). Punch had its own examples, such as the specialist surgeon being asked by his colleague, “What did you operate on old Jones for?” “100 pounds.” “But what had he got?” “100 pounds”. Another cartoon, in the 1920s, shows the patient expressing surprise on receiving the bill: “Good Lord, doctor, have I been as near death as that?” Disease and doctors both fair targets for humourHumour and jokes have often been used as a way to deal with adversity, and satirical humour could be described as a form of benign aggression. Disease and death have been mankind’s greatest enemies. Anything that interferes with life and makes it uncomfortable (which could include the doctors and their medicines) falls into a similar category. Being physicked, 250 years ago, was unpleasant, and going to the surgeon a painful and horrible experience. Those unpleasantries have passed but are now replaced by other inconveniences and irritations, such as waiting times for appointments and operations, and complicated and invasive tests and the fees they generate, all of which can act as grist to the mill for the satirist. 1 A Going! A Going! Reproduced with permission of the Museum of the Royal Pharmaceutical Society of Great Britain. 2 Gin Lane Hogarth, 1751 (engraving). 3 A consultation of physicians or The company of undertakers Hogarth, 1736 (engraving). 4 Cunicularii, or the wise men of Godliman in consultation Hogarth, 1726 (engraving). 5 Siege of Warwick Castle Source: George MD. Hogarth to Cruikshank.1 6 The examination of a young surgeon From a print in the library of the Royal College of Surgeons of England. 7 Medical dispatch or Doctor Doubledose killing two birds with one stone Rowlandson, circa 1800. 8 The doctor’s constant companion Anon. From the Stephen Don Print Collection, Royal College of Obstetricians and Gynaecologists 9 Treatment by metallic tractors Gillray, 1801. From the Boston Medical Library. 10 “May we preserve our health” Cruikshank, 1832. From the Manfred Kraemer Collection, Harvard Medical School. 11 An American physician and an English physician in discussion “Now, in Vienna, they’re first-rate at diagnosis; but then, you see, they always make a point of confirming it by a post-mortem!” From Mr. Punch among the doctors.7 12 The Australian medical profession, by Larry Pickering From The Weekend Australian.8

H Reginald Magee FRCS, FRACS, FACS

We seldom identify the holiday season with medical matters, but perhaps we have been remiss in not doing so. Many holiday customs have medical significance — some positive, some negative. Christmas and the following 2 weeks host the highest cardiac and non-cardiac mortality of the major holidays,1 but few people seem to dread the approach of December as a threat to their physical health. On the positive side, some ancient kinds of Christmas gifts turn out to have modern medical applications, while, not so positively, some modern decorations cause a fair degree of morbidity. Here, solely to amuse and pique curiosity, not to provide an exhaustive review, we explore the pharmacology of the first Christmas gifts, as well as the potential benefits and hazards of some modern Christmas decorations. Ancient gifts that keep on giving today The first holiday custom we thought might have a medical application is the giving of Christmas gifts. This apparently originated with the arrival of the Magi, the three wise men, some time around the year 1 CE. Given the apostle Luke’s vocation as a physician, we felt it only fitting to use his biblical account of the three wise men bearing gifts to the baby Jesus. But, alas, his gospel includes no account of this exchange, so we were forced to quote Matthew, a tax collector: “Then they opened their treasure chests and gave him gifts of gold, frankincense and myrrh”.2 Interestingly, all three of these items have modern medical applications. Gold is the most obvious. As sulfhydryl-containing organic gold compounds, it has been used for rheumatoid arthritis and tuberculosis since the early 1920s, although elemental (metallic) gold was used for many centuries before. Elemental gold is largely inert, not reacting to any chemicals it encounters inside the body; however, it can be deposited in the soft tissue of the skin and eye, leading to a condition known as chrysiasis. Unfortunately, the gold deposits are actually an unappealing grey–blue, rather than the metallic gold glow that might be considered festive. Although the use of gold is not as common today as it was in previous years, exposure to modern therapeutic technology, such as the Q-switch laser, or even ultraviolet light, has resulted in chrysiasis many years after gold therapy was discontinued.3 Gold also causes its share of problems when combined with another holiday tradition: ethanol. Case reports indicate that Goldschlager, a liquor that contains gold flakes, has been associated with lichen planus.4 Although frequently having a lacy white pattern, known as Wickham’s striae, lichen planus too is unappealing, rather than festive. The next gift of the Magi, frankincense, has several medical uses. This substance is obtained from trees of the genus Boswellia, by slashing the tree trunk longitudinally and harvesting the liquid released after it has dried to “tears”.5 It has been valued greatly since ancient times, although its mechanism of action has only recently been discovered. Frankincense inhibits leukotriene synthesis via the inhibition of 5-lipoxygenase, but, interestingly, it does not block cyclo-oxygenase or 12-lipoxygenase.6 This mechanism is similar to that of the leukotriene-receptor antagonist, monteleukast, and indeed frankincense has been shown to prevent exacerbations of asthma much more efficiently than placebo in a small study.7 Frankincense also appears to be bacteriostatic and larvicidal, and may yet prove beneficial as an antimicrobial.8 Further, it seems to have activity against skin cancer as an escharotic agent and stimulates apoptosis in colon cancer cells.5 It has also shown some cytotoxic activity against meningioma.5 Finally, myrrh, a secretion of plants of the genus Commiphora,9 is proving to have its own set of medical benefits. It appears to have an analgesic effect through action on opioid receptors.9 It also seems to have antimicrobial activity, and has recently been touted as a highly effective treatment for schistosomiasis in Egypt.10 Myrrh extracts have shown antibacterial activity against common pathogens such as Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus.11 On a more practical level, myrrh combined with bee propolis (a hive sealant used as an alternative to beeswax) and, paradoxically, honey has been used to treat wounds in patients with diabetes mellitus, with great success in limited trials.12 Another product of plants of the genus Commiphora, guggulipid, is purported to have a favourable effect on lipids — causing a modest decrease in low-density lipoprotein (LDL) cholesterol concentration, but a profound increase in high-density lipoprotein (HDL) cholesterol.13 However, randomised trials have failed to show this effect.14 Traditional decorationsMistletoe, a plant popular as a decoration around the Christmas holidays, is also finding a myriad of medicinal uses. This tree parasite, thought to have been sacred to the Druids, and blamed for the death of the Norse god Balder, is commonly used as an excuse for stealing a kiss during the Christmas season. But mistletoe does not, to our knowledge, have any aphrodisiac qualities. However, it has been found to inhibit peristalsis, and has been suggested as a treatment for colic.15 A mistletoe extract has shown antihypertensive effects in rats, although safety in humans has not been established.16 Mistletoe extracts also apparently have activity against bladder carcinoma in both mice and rats.17 In humans, mistletoe has been used to treat prostate cancer.18 Modern decorations or dealers of disease?The humble Christmas tree can be a source of disease, as well as providing pleasure. A young man in Molokai, Hawaii, contracted ophthalmomyiasis while unloading a Christmas tree.19 Perhaps the larvicidal effect of frankincense would have been of benefit to him in this situation (as it might be to a herd of reindeer — flying or otherwise — infested by botfly larva). As might be expected, children are not immune from the dangers of Christmas trees. A 2-year-old Canadian child with recurrent pneumonia eventually underwent a thoracotomy and right lower lobectomy for the disorder. The pathology examination revealed a 3 cm by 0.5 cm foreign body resembling the distal branch of an evergreen tree.20 Similarly, a 2-year-old Australian child apparently inhaled an ornament shaped like a Christmas tree, which caused asthma-like symptoms until it was removed laryngoscopically.21 Even artificial trees have been the source of disease. A 44-year-old English woman had a relapse of bird fancier’s lung a long time after she got rid of her fine, feathered friend.22 Apparently, her symptoms were triggered by an artificial Christmas tree that had been her bird’s favourite perch — protein deposits left on the branches were enough to cause the recurrence. Christmas trees have also been — unfairly — blamed for sporotrichosis. It seems that, although Christmas-tree farming has been associated with this disorder, it is actually the sphagnum moss used to wrap the roots of the trees, rather than the trees themselves, that are the culprit.23 Christmas trees are not the only unfairly maligned plant of the Christmas season. Perhaps the most notable medical feature of a common Christmas decorative plant — the poinsettia (Euphorbia pulcherrima) — is actually the lack of any adverse events associated with it. This festive red and green plant is used throughout the United States as both a Christmas gift and a holiday decoration, despite the widespread public notion that it is highly toxic. Recent investigations failed to show any fatalities — and indeed very few adverse events at all — associated with poinsettia ingestion.24 Likewise, that common Christmas plant, holly (Ilex aquifolium), is traditionally thought of as poisonous, but a PubMed search of this genus and species revealed no reports of ill effects associated with traditional European holly. That said, there were also no reports on the safety of European holly ingestion either, so it is probably a dish best avoided. Other members of this species have been shown to have toxic effects when ingested in tea form.25 So, as families and friends gather this Christmas holiday season, they can delight in the fact that most of the decorations in their homes are medically relevant. The traditional biblical gifts of gold, frankincense and myrrh are all doing their part to stamp out disease. The humble tree parasite, mistletoe, despite its toxic nature, has its place in the medical pharmacopoeia. Parents need not fear their toddlers drifting too close to the poinsettia, because the plants are pretty much harmless. On the other hand, they should keep an eye on that Christmas tree . . .

Stuart M Smith MD · B James McCallum MD, FACP

For over two decades, there has been savage conflict in Sri Lanka between a minority group of Tamils who claim traditional rights for land in the north-east and the majority, Sinhalese, government in Colombo. The conflict has consumed tens of thousands of lives, displaced hundreds of thousands, sown agricultural land with mines, laid waste plantations, and stunted a generation of children. It could be argued that the only rule of warfare is the respect each side has for the capacity of the other to terrorise: the desire for self-preservation has tended to restrict the number of civilians being bombed. Nevertheless, human rights organisations have reported over 4000 Tamil deaths in recent months. The conduct and cost of the conflict is obscured by suppression of the press on the government side and lack of access of the press to the other. The Ceasefire Agreement in 2002 between the leaders for Tamil autonomy, the Liberation Tigers of Tamil Eelam, and the government in Colombo, and the effects of the Asian tsunami in 2004 have combined to reduce hostilities and permit greater access to the north-east by foreigners. In this time of relative peace, I visited the region in January and again in May 2005, delivering antibiotics and then ventilators and surgical equipment to hospitals throughout the island, supplied through the generous response of North Queensland to the tsunami. Sri Lanka and southern India Driving north from Colombo to Jaffna, I was struck by the poverty on the Tamil side of the armed border, the lack of facilities in the hospital in Kilinochchi (the administrative centre of the “Tamil” land) and the dilapidation of the tertiary hospital in Jaffna. Only the crowds in the corridors and the patients on the floors obscured the filth on the walls and passageways. Nothing obscured the suffering of apparently half-dead people being carried on bare metal stretchers at perilous angles up and down the stairs, buffeted in the surge. I was struck by the whites of their fingers as they clung to the metal. Nothing prevented the recycling of dengue through unscreened windows from sullage that pooled from broken pipes alongside the wards. One piddling tap leaned vainly against cross-infection in the crowded children’s barn. Why was this hospital so different to the many I had visited in the Sinhalese areas? I later learned of economic sanctions and underfunding by Colombo. I volunteered to return to Sri Lanka in September 2005, originally to work as a paediatrician on the east coast, but diverted by my hosting organisation to work in Kilinochchi for a couple of weeks and teach “some students who had missed out because of the war”. I remembered the needs of Kilinochchi and was willing to comply. About three weeks later, I discovered that my students comprised the medical wing of the “terrorist” Tigers! I met them in a shed whose walls reached halfway to a roof of corrugated iron that creaked in the heat of the sun, then roared with the monsoon rains as the weeks extended to three months, and I swapped tales of sick children for tales of my students’ lives. We began awkwardly. As I entered, there was a sudden scraping of chairs on the concrete floor and then a silent standing to attention. I was further surprised by how many there were — 32 — and their being perhaps a decade older than I had expected. I introduced myself and asked them to sit. There was more scraping of chairs. Now they were sitting stiffly and silently. “Does anyone speak English?” I asked, and began to try to work out what they knew and what they needed. I had no idea I would grow to love them. A home visit by one of the medical students I realised they needed grounding in the old-fashioned approach of taking a history, examining methodically, and making provisional diagnoses and plans of management, though I soon sensed they had had profound experiences in triage and trauma. They had seen a lot of sick children but were thin on theory, so I decided to prolong my stay and start at the beginning. After about two weeks, we had worked our way to the examination of the respiratory system and it was then that I discovered how close my students had been to the acute end of medicine. I invited a man to remove his shirt and a woman to demonstrate her method of examination and was surprised by the divot out of the man’s shoulder. Asking him what had happened, I noticed a similar deformity in the woman’s forearm. Shrapnel and a bullet, they explained, and everyone began to laugh. “Well, who hasn’t been shot?” I asked, and, to my astonishment, only about a third raised their hands. “Didn’t you notice our wooden legs?” someone asked and, adding to my foolishness, three were waggled for my inspection, with the class now in uproar. Who are these people? I wondered, and began the journey of discovery. They comprised the medical wing of the Liberation Tigers of Tamil Eelam and were the remainder of an original group of over 70 who had been chosen from the ranks of the infantry because their commanders had concluded they had the potential to become doctors. The struggle for a Tamil homeland, Tamil Eelam, had entered a violent phase in the late 1980s, and the problem of casualties had originally been solved by taking them in small boats to sympathisers in nearby Tamil Nadu, in India. As the numbers increased and the political situation altered, they were taken to the hospital in Jaffna. But lives and limbs were lost in transportation through jungles or around the coast from distant front lines, and the need for the movement’s own medical wing became obvious. In time, I asked them all why they had joined the Tigers and learned of the deaths and torturing of family members, of schools bombed, of the bodies of neighbours washing ashore, of mobs rampaging against Tamils and of discrimination in education and language. Each one had a saga and each had joined the Tigers because “they spoke less and did more” to protect their race against what they were all convinced was genocide. They had all been trained as infantry, but none had forgotten the speech by their leader, who had asked them to forego fighting for the greater goal of healing their people. Paraphrasing a student’s stories of his experiences The course had started in 1992, with some students needing preparation in maths, chemistry and English because they had not finished high school. Others had graduated in biology from university. The course paralleled the curriculum at Jaffna University but had been interrupted by long periods of service in field hospitals, in public health campaigns against cholera and malaria, in the manning of general hospitals, and by the needs of the tsunami, which had wrecked the north-east coast. The Ceasefire Agreement of 2002 had allowed them to catch up on formal education, but they were lacking a module on paediatrics, when I turned up out of the blue. My 32 students were those who had stayed the course. Others had been unable to resist the call of the armed struggle, some had failed academically, and five had been killed on active duty. It was obvious they needed tuition that emphasised infectious diseases and malnutrition and it was easy to gather cases for presentation from my rounds in the ward and from outpatients. The days began with a lecture or two, then moved to cases, and included examination of the newborn and resuscitation. The poverty in the nursery was painful — mothers used old handkerchiefs for nappies. They had never performed any formal research and were keen to be divided into groups to review perinatal outcomes, nutrition, causes for acute admission, snake bites and emotional effects of the tsunami. We found mothers and children to be wasted and stunted, road accidents to reflect the dangerous driving through the town, snake bites to be handled well, and counselling to be effective for grief. The findings were presented on a special research day, which evolved into an emotional ceremony of graduation. Student treating civilian wounded by artillery fire As the weeks progressed, I learned more of their lives and could not rest until one began to translate short stories he had written about their experiences. We began to meet every night in a small gazebo, sometimes curtained with rain, and went over his stories, line by line, paraphrasing from Tamil and amplifying for a wider audience in English. My mind was fascinated by the stories of medicine, my emotions drawn by their humanity. I learned of the development of the medical wing from first aid to reconstructive surgery, encompassing the triage of mass casualties, blood transfusions on the front lines, and end-to-end anastomoses of arterial wounds with ketamine anaesthesia by torch light under artillery fire that thudded shrapnel into the coconut-trunk walls of their bunker. I learned of organisation and secrecy that could construct a hospital overnight in preparation for a battle in the morning . . . and of my students who had worked and worked until the casualties stopped coming — in their uniforms stiff with blood, on legs that could barely stand and under the sustained threat of sudden death. I could scarcely believe accounts reminiscent of the First World War, and insisted on interviewing all the students mentioned by name, others not mentioned, and particular patients, cross-checking the details. I went to battlefields to see if the layout was as described. It was. Though overgrown by jungle, the bunkers that had contained the operating theatres were still visible, confirmed by half-buried vials of empty medical containers. Mounds of dirt confirmed former protective walls, and abandoned paraphernalia confirmed the fighting. Bones and shredded uniforms confirmed casualties. Why they continued to fight still puzzled me, especially as I visited war cemeteries and pondered the carnage in which over 17 000 Tamil young people have died in the past two decades. Understanding began on the afternoon of 27 November, their equivalent of Anzac Day. My students collected me and, for the first time, I observed them in uniform, making their way through the cemetery, squatting here and there with parents of the dead who had begun to arrive in droves to festoon the graves with garlands and food for their young men and women who “were living on in the spirit of Tamil Eelam”. There were about 3000 graves and soon the cemetery was pulsating with grief. The burning sun sank beneath a row of palms and I anticipated some kind of communal eruption of emotion as candles were lit on the graves and flickered on distorted faces. But there was nothing. No hymns, no chants, no catharsis. Just a speech on the necessity for more sacrifice. Silently, the crowd shuffled away, leaving the garlands and the candles to the moonless night. I began to realise what some people are prepared to endure for freedom. I had a farewell meal with my students before I left and before they were dispersed to look after the population of their Tamil Eelam and the casualties of a war that has escalated. We made speeches, and they presented me with what was clearly a special gift: a Tiger flag (which caused anxiety clearing Customs on the way out). Students operating and giving anaesthesia Private possession of a Tiger flag, I am informed, is not “recklessly supporting a terrorist organisation”, but detectives from the counter-terrorism team of the Australian Federal Police were keen to explore why I stayed in Kilinochchi when I learned the identity of the students. I figured teaching doctors how to resuscitate children was in the interests of the people, whoever controlled them, but wondered if my career had reached a crossroads! Subsequently, I did not mind going over all our overseas phone calls with the police or explaining why my bank had sent money to England (for a course on radiation biology), but I was a bit unnerved by the attention I received from immigration officials when I recently left for New Guinea. Being profoundly Australian, I found it unsettling to be perceived as being on the “other side”! I hear, however, that the Department of Public Prosecutions is not proceeding with my case, which is good news. The bad news is that it is unlikely I will ever be able to return to Sri Lanka, and the needs of the north-east weigh heavily. Tamil friends assure me that publicity for the situation is the greatest help I could offer Sri Lanka. With that in mind, the collection of short stories I paraphrased will be published in the near future.

John S Whitehall FRACP

A diagnosis of meningioma presents challenges but more so when you discover that mifepristone, which could halt the growth of the tumour, is unapproved in Australia Medical practitioners often face the difficult challenge of delivering unpleasant news to patients. When my doctor used the words “brain tumour”, like most people who have to deal with that diagnosis, I found it difficult to comprehend anything else for a few moments. However, the word “benign” did bring me some comfort. I had had no pain and just a little hearing loss in my right ear so was stunned by the finding. Over the next few months, I saw specialists for opinions on treatment options for meningioma. It was important for me to gain a better understanding of what I had to deal with and my treatment options and their associated risks. I didn’t let family or friends know for some time and needed more information to be equipped to deal with those who might react emotionally, particularly my elderly mother who was convinced my hearing loss was probably caused by ear wax. It soon became apparent to me that, owing to the tumour’s location at the skull base, adjacent to the brainstem (Box), and its involvement with three facial nerves and the carotid artery, removal or treatment was not going to be without considerable risk. While doing some research on the subject, I came across references indicating that a high percentage of meningiomas contained progesterone receptors, and there was mention of a drug that could halt the growth of the tumour. The drug was RU486 (mifepristone), the most effective progesterone antagonist available. In overseas clinical studies, it had been successful in some meningioma patients.1-3 In my view, a trial of the drug was a better option than the 50% risk of irreparable damage to my vision through surgery. The uncertainty of the long-term prognosis after stereotactic radiotherapy was also unappealing. After doing more research on the drug itself, I found that it had extensive medical uses, such as treatment of meningioma, some breast and ovarian cancers, endometriosis and fibroid tumours and, in higher doses, its action as a glucocorticoid antagonist in Cushing’s syndrome.4 Research on the drug’s myriad medical uses had been plagued by controversy. Why? Well, apparently because progesterone is the hormone necessary to sustain a pregnancy, and not interfering with it is considered to be sacrosanct by the powerful antiabortion lobby groups. As a result, research into and clinical trials on the drug’s other uses have been hampered and delayed. I contacted the Feminist Majority Foundation and the Association of Reproductive Health Professionals in the United States and had several email conversations with their representative. The insights provided were invaluable, and we maintained regular contact for some time. I will always be grateful for the information and support she provided at that time. When I looked into the drug’s availability in Australia, I came across a story on the website of the Australian Broadcasting Corporation titled “No room at the inn for RU486”, posted only a few months earlier in November 2004. It included dialogue with representatives of the Minister for Health and Ageing. In closing, the message to those who were interested in the drug being made available in Australia was “don’t hold your breath”.5 I had a tumour growing in a confined space that threatened to compromise the functioning of vital nerves and life itself. I understand there is about a 1 : 50 000 chance of a diagnosis of meningioma and 20% of these are at the skull base, therefore a 1 : 250 000 chance of diagnosis of a skull-base meningioma. What are the chances of having a diagnosis of meningioma while working in the Department of Health and Ageing, as I was at the time? There was no point in raising the issue internally. I was acutely aware of the precarious position I was in, but, nonetheless, I had to do something about this issue. After giving the matter some thought, I contacted Senator Lyn Allison, the leader of the Australian Democrats, who made some enquiries in Parliament via Questions on Notice to the Minister for Health. I was later provided with a copy of the response. The government knew the drug could be used for a range of serious medical conditions and advised it could be obtained through the Special Access Scheme of the Therapeutic Goods Administration (TGA). I thought it peculiar that the government knew this, but did not make that information public to ensure patients and doctors were also informed. I contacted my general practitioner with the details, and she lodged an application with the TGA. On 7 September 2005, Senator Allison gave a speech in Parliament titled “Matters of public importance — mifepristone”.6 The campaign to amend the legal status of the drug was subsequently launched. Thankfully, Senator Allison had the courage to take on this enormous challenge and the breadth of vision to do so in the interests of public health. The day after Senator Allison’s speech in Parliament, the TGA issued a permit to my GP to import the drug to treat my tumour. I was elated and spent the next month and a half trying to track down overseas suppliers, with the help of a local pharmacist. When I obtained those contact details, I then saw my GP again so we could get the importation under way. At that point she advised me that she had decided not to proceed, because of medical indemnity insurance issues. I offered to get a lawyer to draw up a personal indemnity. She refused the offer. My GP gave me a copy of the letter which accompanied the permit. It was signed by a “delegate of the Secretary” and dated 8 September 2005. It stated “All parties involved need to recognise the practice may carry medico-legal risk, and there may be implications regarding indemnity”. Why did the TGA wait until they issued a permit before providing that advice? Clearly, no consideration was given to the impact on the patient who had the rug pulled out from under her feet in an instant. I contacted Senator Allison to inform her of this problem and she raised it at the public hearings in the Senate in December. Senator Allison asked the following question of the Secretary of the Department of Health and Ageing and the head of the TGA: “Could you outline the issues to do with medical indemnity, which I gather are a problem in some of these cases?”. They both replied, “not that we are aware of”. When asked whether the Department had done any studies of the drug, the Secretary advised that they had not. She also advised that the Department was responsible for administering the legislation and believed it did so with “due diligence”.7 She claimed there were no barriers for anyone wanting to do research here into the drug’s non-abortifacient uses, but the experiences of some have been to the contrary.8 Unknown to most people is the fact that the supplier succumbed to pressures via threats of boycotts by the powerful antiabortion lobby groups some years ago and decided that “. . . the company would not sanction exports unless ranking government officials in the country urged them to do so . . . there must be an actual wish for the licensing of mifepristone in a particular country . . . the letter indicated such a wish could come in the form of a written request from a representative, competent body such as the government or health authorities”.9 Lobbying during the campaign to change the legislation to allow the TGA to regulate RU486 was intense, and to help raise awareness of the drug’s use as a treatment for meningioma, I participated in some broadcasts, with the help of the Australian Broadcasting Corporation.10 My contact in the US kindly did a submission for the Senate Inquiry,11 and I later found one from Professor Healy,12 who wrote the first clinical review of the drug in 1985.13 Because of the hard work of many, the parliamentary conscience vote to repeal ministerial responsibility for approval of RU486 in early 2006 was won by a resounding majority. The vote was an important milestone, but there is still a long way to go before the drug will be readily available. The amendment changed the legal status of the drug and allowed a drug company to lodge an application with the TGA for approval of mifepristone for use as an abortifacient. Easier access to the drug will facilitate research and clinical trials into the drug’s uses in Australia, depending on the necessary funding approvals by government. Access to the drug for individual patients and for non-abortifacient uses is, at this stage, only available via the TGA’s Special Access Scheme. It was over a year after I found out about mifepristone, and nine months after the TGA issued its first permit, before I was finally able to start my treatment, with the assistance of an oncologist who heard of my predicament. He was willing to import the drug and required only my written agreement to be treated with an unapproved drug. I have now been taking mifepristone for just over a year at 200 mg per day and can say from personal experience that it has very little in the way of side effects, and I am happy to continue with my treatment. It will be another year or so before any meaningful responses can be measured via magnetic resonance imaging. A few months ago, I was contacted by another patient with meningioma (diagnosed several years earlier and treated by monitoring of the progress of the tumour). She would have liked to have had a trial of mifepristone, but like most people, thought it was unavailable here. Unfortunately, her vision had deteriorated since her initial diagnosis. I provided her with information, and as a result, she has recently commenced treatment on the drug as well. Why don’t GPs refer patients to oncologists when they refer them to specialists for opinions, especially when standard treatment options carry such substantial risks? If the Australian Government is serious about “better health outcomes for all Australians”, including those who would benefit from the drug’s non-abortifacient uses, some thought should be given to the people who could be helped by this drug. Interestingly, in addition to the medical uses mentioned earlier, recent developments in overseas research indicate that mifepristone has potential use in some gastric cancers as well,14,15 and it also has viability for use as a helper-dependent adenovirus vector in gene therapy for cancer treatments.16 The more research I did, the more fascinated by this drug I became. The anti-glucocorticoid effects are dose-dependent, but on the basis of animal trials it has been shown to be neuroprotective17 and can minimise the adverse effects of ischaemic stroke.18 Mifepristone can prevent retrograde amnesia induced by electroconvulsive therapy19 and is currently being trialled for that purpose (ClinicalTrials.gov identifier NCT00285818). In animal studies the drug has been shown to help ameliorate the symptoms of diabetes.20 The drug’s potential use in overcoming the adverse effects of elevated cortisol due to a dysfunctional hypothalamic–pituitary–adrenal axis means it is a potential treatment for Alzheimer’s disease, in which higher cortisol levels are associated with a higher level of impairment.21 The US Food and Drug Administration has just approved mifepristone for the purposes of reversing the side effects of corticosteroids and for use in patients with Cushing’s disease.22,23 If only a drug sponsor in Australia would consider sponsoring the drug for the TGA’s Orphan Drug Program. This would see it subsidised via a special appropriation until such time as it is made available on the Pharmaceutical Benefits Scheme, which may take up to 10 years for some non-abortifacient uses pending further clinical trials. It saddens me to think that those on low incomes or age or disability pensions would not be able to afford the drug via the TGA’s Special Access Scheme, even if other treatment options are not suitable. Although the Senate amendment was an important campaign to be part of, and I feel honoured to have contributed, given my personal circumstances, it was a challenge I really could have done without. The next is to be able to continue to pay the cost of this currently unsubsidised drug. Coronal magnetic resonance images showing a meningioma (arrows) compressing and displacing the brainstem.

Mary Lander

Before work — getting thereToday I realised that the aim of travelling to work is survival. I need to arrive at work fighting fit and raring to save lives. Most doctors drive to work — on their own, in a four-wheel drive, SUV or large European sedan of sufficient grandeur and engine capacity to illustrate their importance to the rest of humanity, while protecting themselves against the eventuality that they might accidentally run into any of the rest of humanity. Conservation issues like air pollution, noise pollution, consumption of fossil fuel resources, and pedestrian safety are matters of global concern, but apparently do not apply to small, important self-interest groups such as doctors. Once the children have left home, doctors may exchange the four-wheel drive for a two-seater convertible; it is never too late to have a happy adolescence. An advanced sense of political correctness had persuaded me to travel to work by public transport instead. Public transport is nature’s way of introducing you to your fellow human beings with a degree of intimacy normally reserved for other species — say, locusts, termites and wildebeests. Of course, the money I save by not running a car is picked from my pocket on a regular basis. Each journey is an olfactory kaleidoscope of cheap deodorant, pheromones, body odour, and garlic. After each rush-hour journey, I envy lemmings, who can at least look forward to an end to their travels. Today, my bank balance and waistline encouraged me to cycle to work. The purpose of cycling is to make you feel good about yourself and your lifestyle — you are an environmentally friendly urban crusader against pollution. The bonus is that the gridlock of modern city traffic means cycling to work actually saves time. I spent this time donning the protective headwear, luminous protective clothing and protective breathing apparatus that I need to survive cycling to work. The money I save by cycling to work will no doubt be spent on replacing stolen bicycle parts, and chiropractor’s bills. I have discovered that I should aim to arrive at work earlier than my colleagues, so I can glance pointedly at my watch as they arrive. If any of my colleagues consistently arrives before me, I will send them an anonymous note suggesting they get a life. Travelling to work is just part of the rich tapestry that comprises a working physician’s day. At work — the committee meetingI am learning through experience that the aim of a committee meeting is not to commit to anything. The aim of a board meeting is boredom. The seating arrangement at committee meetings appears to be a ritual rooted in deep tradition. You sit flanked by your friends and show them the defamatory cartoons you have drawn, and giggle conspiratorially. You sit opposite your sworn enemies, the subjects of your cartoons, and try to out-stare them. Any attempt to alter the seating arrangement is a Declaration of War. For committee meetings, an interest in conflict is much more important than a conflict of interest. I now know the two operating rules applicable to all committees on which I sit. Rule One is: “Never volunteer for anything”. Rule Two is: “Never become the Secretary”. The Secretary is the only member of a committee who ever does any work. It has become clear that I will never have time to read the meeting agenda in advance. However, I have decided to always bring an impressive manila folder, containing the agenda papers for the meeting later that afternoon, which I can try to read surreptitiously. If the meeting is long enough and I am not too tired, I can also deal with the other papers in my manila folder, including the curriculum vitae of the applicants for the registrar position, the journal articles I should have read for that evening’s journal club, and a sheaf of love letters, which, sadly, I had to write to myself. For meetings of sufficient length, the technique of microsleeps can improve my cerebral function for the remains of the day. For the appropriately named board meetings, a siesta may even be an option. I have found that if I am startled awake by hearing my name mentioned, I should say confidently, “I agree completely”. If I have just inadvertently agreed to chair a sub-committee or, horror of horrors, to be the new Secretary, the solution is to subsequently remember an unfortunate conflict of interest. If a more detailed reply to the question was expected, a long sentence liberally interspersed with terms like “clinical governance”, “mandatory criteria for accreditation”, “quality improvement”, “transparency” and “public accountability” is guaranteed to glaze eyes and end interrogation ... er ... discussion. The third, unwritten, rule of committee meetings is that when the Chair says “Any other business”, this is not a question, but in fact a signal for us to pack up our papers and head for the exit. After work — journal clubI have long known that the aim of a journal club is calories. In order to nourish your brain, you first need to nourish the larger proportion of your body that is not brain. Pharmaceutical company sponsorship improves the nutritional status of the journal club substantially, while also improving the interest of junior staff. Apparently, lavish journal club suppers (or breakfasts or lunches) do not constitute a confiture of interest. I know that the probability of my having to present at journal club is inversely proportional to the number of attendees. However, although a large journal club reduces the frequency of my presentations, it increases my exposure to my colleagues’ presentation foibles. I spent this evening’s journal club noting down the seven recognised stereotypes of journal club presentation: The abstract artist is an advocate of abstract thinking, who never progresses beyond the abstract of a paper. After hearing 12 consecutive abstracts in an hour, I usually feel like using a lump of cement to demonstrate the power of concrete thinking. The anecdotist presents interesting case reports. The evangelist reads long sections of the paper verbatim, in an ecclesiastical monotone or drone usually reserved for sermons and bible readings. The EBV-ologist is not an evangelist, but has nevertheless undergone a religious conversion, as well as a seroconversion, after being infected with EBV (evidence-based virus). The symptoms of EBV infection are both local and systematic: echolalic repetition of the terms “randomised controlled trial”, “meta-analysis” and “What is the level of evidence?”; a mania for searching the literature; and irrational worship of an obscure deity named Archie Cochrane. The reflexologist presents papers on alternative medicine, using a holistic approach that excludes statistics and data. The psychoanalyst interprets the paper from a Freudian perspective, while reclining on a couch. The results may not be statistically significant, but the true significance of the paper depends on the author’s unconscious motives for performing the study, and the author’s relationship with his or her mother. To the psychoanalyst, EBM means expressed breast milk more often than evidence-based medicine. The apologist has forgotten to read the papers and forgotten to organise the supper. My conclusion from this evening is that while the journal club is of anthropological interest, it does not otherwise qualify as further education.

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

Quotes from MJA contributors in 2007 Peer review is a critical component of quality control in scientific medical journals. However, given the competitive nature of publishing, it is not surprising that the process of peer review has been described as a turf battle — the writers and originators of ideas aligned against the editors and critics — with the ultimate prize of the knowledge or doctrine being published.1 Peer review of medical care was first documented in a book called Ethics of the physician by Ishap bin Ali Al Rahawi (854–931 ce) of Al Raha, in northern Syria.2 However, its presence in scientific medical publishing is more a part of modern than ancient history. Beginning in the mid 18th century and flourishing after World War II, particularly with the development of the photocopier in the 1950s,1 journal peer review is now often Internet-based, as at the MJA. The “Cyperspace Wars” are here. Participants on the “critics” side of the battle may receive briefings from recent articles like Ten simple rules for reviewers,3 freely available on the Internet. But, war is war in any time and place. This year, we share with you quotes from MJA reviewers who may well have studied a definitive work on military strategies and tactics: The art of war, a Chinese military treatise written during the sixth century bce by Sun Tzu.4 Consider, in particular, this from the chapter on “laying plans”: Attack him where he is unprepared, appear where you are not expected. And this, from the chapter on “energy”: The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim. Therefore the good fighter will be terrible in his onset, and prompt in his decision. No part of the main IMRAD (Introduction, Methods, Results, and Discussion) structure is impenetrable to such an attack. Introduction: why did they do it? On analysing “aged” data: It is a romantic notion to think that we’d uncover stunning new insight into the past, by rummaging through attics and basements filled with relics of a bygone age. We’re more likely to find dust bunnies and Nan’s collection of vaudeville programmes than to uncover Macfarlane Burnet’s long-lost personal diaries. Methods: what did they do? On study design: The authors continually refer to their sample as a cohort. It is not. A cohort is a sample of people followed over time. The Romans established and maintained their empire by building roads, straight roads, enabling them to deploy their army in any corner of the empire. The basic unit of the Roman legion was the cohort and these cohorts marched forward along these roads. In epidemiology, a cohort marches forward in time. Results: what did they find? On outcome measures: “Mild toxicity” could be considered to be an etymological oxymoron. The word toxic comes from the Greek word meaning a bow (as in bow and arrow) and is inextricably linked with the word poison. This is, of course, because of the early use of poisoned arrows by the Greeks. This idea endures in the phrase “a poisoned arrow”. Discussion: what does it mean? On possible researcher bias: It looks as if there is a political agenda at work here and the complexity of the truth is hidden behind broad generalisations made through the obscuring power of the P value. Implications: what happens next? On style of writing: The authors write as if they have discovered Third World poverty and a partial mechanism for its solution ... I recommend that the article be reworked so that it is more realistic, humble, and less enthusiastically gushing. The authors’ prediction is for future medical leaders, not spin doctors. Of course, at the MJA, we prefer to see things as though innovators, authors, editors and reviewers are all on the same side — working together to advance science against disparate, unproven hypotheses. As Sun Tzu put it: We can form a single united body, while the enemy must split up into fractions. Hence there will be a whole pitted against separate parts of a whole, which means that we shall be many to the enemy’s few.

Ann T Gregory MB BS, GradDipPopHealth

The MJA editors are often asked the thorny question — how do I get published? By way of a Christmas gift this year, we have prepared some simple tips. Happily, many of these are mirrored by the offerings we received for our 2007 MJA Christmas Competition. So, using these clever contributions as examples along the way, here is an unofficial (although certainly not complete) guide. Do submit a decent covering letter with your manuscript — remember that there are real people at the other end (note that the Editor of the MJA is not the same as the Editor of the BMJ, so at least change the addressee when you send it on to us). We also like to think that all your coauthors have played an important part in your work, so remember to make sure all the listed authors actually exist, and try to keep them informed of your paper’s progress. Alternatively, if that all seems too hard, you could just change your name to Et Al, as astutely suggested by Gordon Parker in his useful guide to coauthorship (→ On the breeding of coauthors: just call me Al). You could then at least be certain of citations for ever more! As editors, we read a lot of papers. And I mean a lot. When an author sends us something new, interesting and well researched (even if it has been to the BMJ first), we recognise it as such. We enjoy helping inexperienced authors, and we like to think it is our job to assist them in the journey to publication. As so eloquently put by Donald D’Arcy Webling in his poem, “Memoria manuum — handprints”: “Regard grew with understanding, confidence and skill”. I once commented to an author that, as editor, I was only the midwife, and that he was the one giving birth to his paper as it went through the publication process. He dryly assured me that he felt it had been a difficult birth, but worth the pain in the long run. At least we at the Journal can offer you pain relief in the birth of your manuscript, in the form of editorial assistance and encouragement; just as in real-life childbirth, an evolution detailed by Caroline de Costa in her article “Snow — at Christmas”, describing Dr John Snow’s contribution to obstetric anaesthesia in the 19th century. It is always clear when authors are passionate about their cause. The editors are constantly inspired by the work that Australian doctors and researchers do to improve health and encourage learning. We are so fortunate to have shining examples in our midst, like John Whitehall, who gives a moving account of his experience of teaching Tamil Tigers in Sri Lanka (→ Teaching Tamil Tigers), and Mary Lander, who describes her own courageous fight for treatment in the face of numerous obstacles (→ The fight for a life-saving drug: a personal perspective). It pays to remember that editors don’t eat salami or pizza. No, we are not all on a diet, we just happen to have a nose for research that has been divided, sliced up, reconstituted, or otherwise processed to make it about as palatable as fast food. When faced with such a meal, the editorial committee may adopt the stance described by David Isaacs and colleagues in their extract “From the diary of a novice physician” “the aim of a committee meeting is not to commit to anything”. Be aware that, as an aspiring author, you need to learn to love criticism — or at least pretend to. Although commonly believed to be a modern-day form of academic water torture, peer review is a mainstay of scientific publishing, and a little education in the taxonomy of that dreaded creature, Reviewer horribilis, will not go astray. We suggest you peruse Edzard Ernst’s learned review on the subject — but not under the Christmas tree if you value your health (→ A beginner’s guide to criticism). See Stuart Smith and James McCallum’s treatise on the dangers of festive season decorations in "We three kings and Christmas trees: pharmacotherapy from presents and diseases from decorations" for more information on this topic. It is the editors’ unenviable task to make a final decision on the fate of each submitted manuscript and, as much as we enjoy the Christmas Competition, every year we find ourselves in the equally unenviable position of having to choose the winners. In order to share the burden, the entire AMPCo staff is invited to participate in a secret ballot. In the category of “Story”, this year the prize goes to David Isaacs, Stephen Isaacs and Dominic Fitzgerald for their “From the diary of a novice physician”. In the “Snapshot” category, the winners are Anthony Brown and Andrew Bryant for their eerie portrait of a well known cinematic villain emerging from the diverticulum in “The colonoscope strikes back: a diverticular Darth Vader”. Suitable hampers of Christmas cheer are on their way to these worthy winners. So that’s the MJA Christmas Competition over for another year. We would like to thank all our contributors, congratulate all the finalists, and welcome submissions from enthusiasts both new and old next year. And the secrets of publication? As our Christmas Competition entrants have demonstrated — if you are prepared to weather the weary cynicism engendered by working in the medical field; if you send us the best evidence and your honest interpretation of it; if you love your work and are primed to learn from the experience of your peers; if you can have a laugh at your own expense; and know we at the Journal are here to help in the birth of your genius . . . then you just might survive the publication process, and almost painlessly at that!

Tanya Grassi

A 35-year-old man presented after a generalised tonic–clonic seizure. He had a 6-month history of intermittent headache and vertigo but no previous seizures. An electroencephalogram showed diffuse slowing, indicating the postictal period. Axial contrast-enhanced computed tomography (CT) showed multiple cystic lesions scattered throughout the brain parenchyma, many containing dense white inclusions with a typical appearance of scoleces (tapeworm attachment organs), consistent with a diagnosis of neurocysticercosis (Figure). Serum was positive for cysticercus IgG antibodies by ELISA (enzyme-linked immunosorbent assay) (1.68 optical density [OD] units; reference range, < 0.9 OD units). Stool examination failed to show eggs of Taenia solium. There was no evidence of cysticerci in thighs, subcutaneous tissues or in the posterior segment of the eye on fundus examination. The patient was treated with antiepileptic drugs, glucocorticoids and albendazole (15 mg/kg/day for 21 days). He remained seizure-free and was advised to have a repeat CT scan after 12 weeks.

Vinay Kapur · Jeet Ram Kashyap · Ravinder Kaur · Atul Sachdev

Doctors and paintings. Insights and replenishment for health professionals. John Middleton, Erica Middleton. Oxford: Radcliffe Publishing, 2006 (x + 102 pp). ISBN 978 1 84619 052 0. I wanted to like this book. The idea of a husband British GP educator and wife artist/art historian coauthoring a book about the interface of painting and medicine intrigued me. The structure is also quite novel. It follows four fictional general practitioners starting up a group learning course about painting and medicine, listening in on their discussions in a play-like format. Superimposed on this are two more layers, the first being two other characters walking through an art museum, listening in on and commenting on the group of doctors. Secondly, there is a non-fictional analysis of various famous artists and their works, as well as the art-in-medicine movement. Strangely, the artist co-author includes her own works in the book for analysis, putting herself up against some of the most famous artists in history. All of this in a book under 100 pages long! It did come across as confusing to me; on many occasions, I found myself unaware of who was talking (author or character) or whether I was reading fiction or non-fiction. That said, both authors seem knowledgeable in their respective fields. Analysis of communication techniques, of empathy and listening, and of “patient-centredness” are well discussed and referenced. Philosophical points on the role of the doctor, of death and dying, and even faith suffuse both the fictional and non-fictional sections. Artists as diverse as traditionalists like Rembrandt and Rubens through to modern artists such as Francis Bacon and Mark Rothko are analysed both in terms of how their lives and personalities helped shape their works and in how their philosophy and its expression can influence us as doctors viewing their works. Rather than being printed in the book, the works discussed have web addresses for viewing (except for the coauthor’s work!), I suspect to reduce cost. While interesting in parts, Doctors and paintings may be trying to be too many things. Nevertheless, those with a passion for painting and/or medical philosophy might find it worth a read.

James A Best