Volume 191 Issue 11

This year witnessed the roll-out of a suite of reports on the delivery of health care in Australia, ranging from the role of preventive health,1 to the potential directions of primary care,2 the state of Australia’s public hospital system3 and our health care system in general.4 Specific protocols were presumably followed in assembling these reports, employing a convention familiar to doctors: evaluation of systemic symptoms and signs, formulation of diagnoses, and recommendations for appropriate action. However, with the occasional exception,3,5 this cavalcade of reports — despite their long lists of recommendations — failed to provide any substantial blueprints for reform. Absent were any comprehensive and detailed plans outlining remedial action, necessary time frames and attendant costs. It is vital that such essential details be specified in any future reports recommending health care reform. The reasons why we have been inundated by inquiries and reports since the election of the Rudd Labor Government remain obscure, known only to those with access to privileged Cabinet documentation. But in the absence of a comprehensive pre-election health care policy, we may well speculate that this blitzkrieg of inquiries was a means to fill Labor’s bare policy cupboard. Whatever the reasons, it could be stated that there remains an elephant in the room of health care reform: the inexorable and apparently uncontrollable upward trend of the cost of Australian health care. Australians consume about $100 billion of health services each year, amounting to about 9% of gross domestic product.6 Fifty years ago, we only spent about a third of this amount on health care. Moreover, it is projected that in the next 25 years, health and aged care spending will increase to almost $250 billion per year.6 Commenting on this phenomenon, Tom Dusevic, national affairs correspondent for the Australian Financial Review, claimed: Left unchecked, health spending could eat up the entire budget of the states within a generation — leaving nothing for schools, roads, police and other essential services.6 In Australia, we have never had a serious community debate about how much we may actually wish to spend on health care. Nor have we dared to address the even more thorny issue of where our health care dollars should be allocated. Instead we resort to covert rationing, such as blow-outs of elective surgery waiting times and other forms of access rationing. Perhaps the time has come for yet another, even more important, inquiry to openly examine resource allocation in health care — an inquiry that looks at all the multipliers embedded in such a complex and layered system, such as the burgeoning and bloated bureaucracies or our ageing population making decisions of increasing urgency as to how they will spend their last years. It should also advance the means to continuously cost health interventions and tailor these to individual episodes of care and institutions. Without this kind of continuous and current fiscal data, the impact of reform on health care costs will be no more than guesswork. One can only hope that a holistic and all-embracing inquiry will offset the federal Health Minister’s current monstering of the Australian medical profession vis-a-vis Medicare rebates.7-9 Scapegoating, especially in the absence of hard data, is the refuge of those who wish to oversimplify the debate and divert attention from questionable decisions about the allocation of resources. The recent stoush with Australian ophthalmologists over the Medicare rebate for cataract surgery8 is one such altercation, which presumably has its rationale in the desire to contain health costs. However, its barely concealed stridency has become increasingly tainted by ideology and the politics of envy. The same factors are presumably driving Labor’s doctor displacement agenda.10 If we are to pursue reform, the elephant in the room — namely, the inherent multiplier effects of these reforms on the cost of health — should be transparent and debated with all stakeholders.

Martin B Van Der Weyden MD, FRACP, FRCPA

Although it is imperative to keep trying, the fight against obesity is unlikely to be successful until economists, politicians and health scientists agree on similar goals Consider this: the world has just been through one of the worst economic crises since the Great Depression, yet Australia seems to have come through it swimmingly — at least for the moment. How did we do it? The government gave us money to help us consume. Synonyms for “consume” in Roget’s thesaurus include: “eat”, “drink”, “get through”, “devour”, “put away”, “munch through”, “chomp through”, “guzzle”.1 With not a tinge of irony, the Australian Government Senate report, Weighing it up: obesity in Australia2 (and most other obesity reports), advises us to take stock of ourselves, not to be such pigs, to stop overeating, leave the SUV (sport utility vehicle) at home and walk, or ride a bicycle — in other words, to stop consuming! Is this schizophrenic government policy? No, it’s sensible, post-Keynesian economics, currently being applied around the world. But how sensible is a system that puts vast amounts of money into treating a problem that it puts vast amounts of money into creating? Obesity depends on overconsumption — of food, drink and effort-saving technology; hence, the fatter the population, the fatter the economy. A spoof “pitch” on a recent ABC television program on advertising cleverly illustrates this. Asked to develop a campaign to reduce prejudice against obesity, the competing agency came up with an advertisement praising fat people for their overconsumption for being heroes in the battle to reverse the 2008–2009 global financial crisis. The catch phrase of this spoof, “Australia: our success depends on your excess”, sums up the modern conundrum. Reporting in the journal Health Affairs,3 researchers calculated that obese individuals in the United States pay US$1400 per year more for their health (or lack thereof) than their lean counterparts. This adds an extra $47 billion per year to the US budget, or about 10% of all health spending, which, ironically, all goes to the measure of economic health, or gross domestic product (GDP). People with diabetes spend US$4100 more per year on medical care in their first year of detection than people without diabetes, and each incurs an extra $158 of medical expenses each year, which is also added to GDP.4 Currently, these physically sick but economically valuable people make up 7% of all Australians. However, there are another 15% with prediabetes, lining up to contribute to the nation’s coffers.5 Such a vital economic segment of the population could easily be doubled within a generation, with money to consume more fatty foods, use gas-guzzling cars rather than walk or cycle, and watch televised activity rather than actively participating. If the economy remains sluggish, smoking, and alcohol and drug use, which currently add about 9% to GDP directly, and a similar amount from dealing with the consequences, could be increased overnight with a further government bailout. While health experts decry these costs as evidence of health system failure, economists rub their hands together to the tinkle of money that is keeping the GDP in the black. Politicians, of course, are the meat in the sandwich. Without labouring the point (ie, the economic benefits of fast food, obesity surgery, weight-loss programs, etc), it should be obvious that there is now a disconnection between the modern system of economic growth and human health. This is not to suggest that this has always been the case. There is no doubt that economic growth has been the greatest single contributor in history to improving human health.6 But even the early architects of economic growth — Mill, Keynes and others — foresaw a time when growth would pass its use-by date, when the returns on further investment would start to decrease and then become negative. As pointed out by one commentator: “after maturity, continued growth is either obesity or cancer”.7 In his Principles of political economy, written in 1848, John Stuart Mill states: It must always have been seen, more or less distinctly, by political economists, that the increase in wealth is not boundless: that at the end of what they term the progressive state lies the stationary state, that all progress in wealth is but a postponement of this, and that each step in advance is an approach to it.8 In health terms, it seems this time may have arrived. Data from Sweden over the past 200 years show an initial close relationship between health and economic growth, but then in recent years, a reversed relation in which faster growth implies less progress in improving health.9 Diminishing returns in health, as reflected by increases in obesity, disability-adjusted life-years, and health costs (although not yet by decreases in longevity), have also been linked with climate change,10 making an alternative to our current growth fetish even more crucial. For most people, of course (including those in the health professions), this is all too hard, along with its correlates in water shortages, species extinction, freakish weather events, and global warming. So, we tend to ignore it, hoping it will go away. But without considering the macroeconomic system’s dynamic influence on human health, and the fact that economic growth has largely finished its work in developed countries and we now need to pay greater attention to reducing inequity,11 obesity and its related chronic diseases will continue their onward march to becoming the only human epidemic to approach affecting 100% of the population. Let’s hope economists, health scientists and politicians can agree on similar goals before that happens.

Garry J Egger MPH, PhD

Climate change is weakening Earth’s life-support systems The United Nations Climate Change Conference in Copenhagen (7–18 December) will soon be behind us. Climate change, however, continues to progress more rapidly and disruptively than climate scientists foreshadowed only 5 years ago. Recent peer-reviewed reports of climate change processes and impacts show, among other effects, an increased rate of greenhouse gas accumulation in the lower atmosphere, and an accelerating sea level rise. This has prompted a worrying reappraisal of where we might now be heading. Earlier this decade, there were hopes of limiting the global temperature increase to about 2°C. There is now growing scientific recognition that we need to prepare for an even more disrupted world with temperature rises of up to 3–4°C.1-3 Most political institutions have short-term priorities. These impede the urgent, enlightened and unselfish collective action needed to respond to this unprecedented global environmental challenge.3,4 Despite the rapid maturation of climate change science and the wonders of global sensing technology and electronic connectivity, we collectively fail to understand the full extent of the risks we face. Something fundamental is missing. Preoccupation with the technical details of climate change science, and with economic costs, property protection and the politics of shared responsibility, has overshadowed full appreciation of the consequences for human health and survival. Despite the growing recognition of the risks posed by climate change to social and economic wellbeing, the risks to human health are mostly viewed as regrettable, and hopefully tolerable, collateral damage. This view is very naïve. It fails to recognise the profound significance of the risks posed to the biology and health of plant and animal species everywhere, including our species. Christmas joys aside, this situation signals a Red Alert. Climate change is weakening Earth’s life-support systems, and, if not reversed, portends a disastrous outcome. This is no longer a matter of speculation or theoretical modelling. The number of people affected annually by heatwaves and other extreme weather events has risen in several countries over recent decades. For example, the average annual number of excess deaths associated with heatwaves has increased markedly over the past two decades in Hungary, commensurate with a threefold increase in the average annual frequency of heatwaves.5 Food yields have recently decreased in some regions, including parts of Asia, southern Africa and the eastern Sahelian region of Africa, in association with a range of environmental stresses that include warming, drying and severe flooding.6 Some infectious diseases have changed their geographic range and seasonal duration, in association with regional warming. This includes northward extensions in Sweden of tick-borne encephalitis and its tick vector, and in China of the critical winter survival zone for water snails that transmit schistosomiasis. Similarly, malaria has been occurring at higher altitudes in highland regions in parts of eastern Africa.7 Despite current evidence, such as the marked ecosystem changes and accelerated ice losses in the Arctic, human-driven climate change is still at an early stage; excessive greenhouse gas emissions will continue for (at least) decades, and the full realisation of their effect on climate will be drawn out over time.8 The momentum of change in the climate system is huge and protracted, especially for sea level rise. Hence, most current climate “mitigation” actions will have limited immediate effect, and further delay and attenuation of emission reduction targets by governments will invite disaster. Adverse impacts on human health can be expected to rise over coming decades — particularly in vulnerable populations in low-income and poorly resourced countries, such as Bhutan and Nepal, and in geographically exposed locations, such as river delta populations, and small island states, and south-eastern Australia. Meanwhile, the unequivocal detection of climate-related health impacts at this early stage presents a research challenge. The health effects of climate change coincide with various non-climate-related causal factors — so, for example, an upwards trend in excess deaths during heatwaves may also be due to population ageing and a greater prevalence of underlying cardiovascular disease. Further, human vulnerability (unlike that of all other species) is typically cushioned by culture, technology, trade and aid. However, this difference in vulnerability between Homo sapiens and other living organisms is less than we might imagine. The natural environment, the biosphere, furnishes all of Nature’s processes and the products upon which our health and survival depend: food, fresh water and fibre (including timber, firewood and cotton), natural constraints on pathogens, access to natural medicines and a relatively stable climate. These things, rather than hospitals, doctors, genetic testing and dietary advice, are the true foundations of population health. Climate risks to health are both direct and indirect. Direct risks include deaths and physical injury from extreme events, such as increasingly frequent and intense bushfires, cyclones and floods; and deaths and hospitalisations from extreme heat. Indirect risks include changes in the range and seasonality of various infectious diseases, and impaired food system productivity on both land and sea, productivity in the latter being compounded by oceanic acidification due to greater uptake of carbon dioxide. Mental and physical health problems can result from the social disruption and dislocation caused by weather extremes that are bringing drought and long-term regional drying out to parts of rural Australia. A likely increase in the flow of climate refugees, here and elsewhere, will also have consequences for health and health care systems. Climate change will act primarily by amplifying and extending the rates and ranges of existing health problems. Hence, to minimise climate change impacts, it is crucial to reduce the high background rates of poor health in vulnerable populations. Many low-income countries are already struggling to meet the UN’s Millennium Development Goals.9 Their populations face great health threats from climate change, including exacerbations of infectious disease (including water-, food- and vector-borne disease); higher rates of maternal and child mortality (particularly if basic health services are disrupted by environmental stresses); and undernutrition, with impairment of children’s physical and intellectual development. This year has seen a heightened awareness of the significance of the health risks from climate change. In May, the cover of the Lancet announced that “Climate change is the biggest global health threat of the 21st century” — a bold statement, but consistent with the emerging evidence. In that same month, the congress of the Royal Australasian College of Physicians devoted a full plenary session to the topic, as did the 2009 annual conference of the Health Ministers of Commonwealth countries in Geneva. In September, leaders of 18 national bodies of medicine, from low- and high-income countries, published a letter in both the Lancet and the BMJ stressing the potential for a worldwide health disaster from climate change.10 Health professionals, as citizens, will have concerns in relation to climate change as communities increasingly seek an effective policy response. Meanwhile, the specific professional challenges for medical practitioners include: reducing the carbon footprint of clinics, clinical practice and the overall health care system; providing appropriate public education via the clinical setting; setting personal examples (eg, bicycles rather than BMWs); assisting research that elucidates the health risks posed by climate change; and contributing, via professional organisations, to public education and to policy advocacy. We are now all participants in the world’s most important debate on the primary determinants and sustainability of population health.

Anthony J McMichael FAFPHM, MB BS, PhD · Colin D Butler BMed, MSc, PhD

Conference delegates workshopped a realistically staged disaster scenario in which they were completely isolated from outside resources If you have to have a disaster, Broome, on the remote Kimberley coast of Western Australia, seems a good place to be; that is, until you take a closer look at what it would be like at the centre of the action. And this is exactly what delegates did during the inaugural conference on Tropical, Emergency and Disaster Medicine (TED-MED), held in Broome on 22–24 May 2009. The conference was attended by 81 delegates, including 28 general practitioners, eight tropical medicine specialists, six emergency medicine specialists and five disaster medicine specialists, plus representatives of government agencies, rural and remote nurse paramedics, clinical laboratory scientists and environmental health and industry participants. In this conference, we used the scenario of a tropical cyclone to move conference attendees outside their comfort zones and draw them into the reality of health crisis management in regional Australia. As it happened, Broome turned out to be an excellent location for the TED-MED conference because of a series of recent events, including the explosion of a refugee boat off the north-west coast of Australia and a tourist vehicle rollover on the Mitchell Plateau to the north-east. To add further realism to the program, there was severe wind damage caused by storms hitting Perth the day before visiting speakers flew into Broome, and the nation was on the verge of moving from the “Delay” phase to the “Contain” phase of the response to pandemic (H1N1) 2009 influenza. There were two triggers for a broad-based conference such as this. One was a renewed emphasis on regional development, particularly in WA’s north-west, where the expansion of the Ord River Irrigation Scheme, mining and petrochemical industries, and tourism are expected to drive a threefold to fourfold expansion of the regional population over the next decade. The second trigger was the Government of WA’s Royalties for Regions policy, under which some of the revenue generated by the mining and resources industry is returned to regional WA in the form of infrastructure funding, and is expected to add impetus to the population growth in the north of the state. In his opening address, WA Director General of Health Peter Flett emphasised the challenges of providing health care to such a thinly spread population in a tropical environment. He said that there was an urgent need to tackle the declining professional population as the baby boomer generation goes into retirement. David Atkinson, from the Kimberley Aboriginal Medical Service Council, compared his extensive experience in remote Aboriginal communities with indigenous communities in remote Canada. The extremes of hot and cold were explored further by retired remote and rural general surgeon Val Lishman AM, who spoke on his work in northern Australia and as an Australasian Antarctic Expedition doctor. Val’s moving snapshot of wilderness medicine in extreme environments was a profound reminder of the importance of resourcefulness and unquenchable optimism in the face of adversity. At the centre of the conference program was a carefully researched disaster scenario (Cyclone TED). Delegates prepared for an extended problem-solving activity through a series of lectures. Major-General Paul Alexander (Australian Defence Force [ADF] Surgeon General) gave the initial plenary session on ADF health capability, reflecting on the role Defence personnel often play in disaster response. He usefully clarified what the Defence Force can do and under what circumstances they would be tasked to assist. Highlights of subsequent parallel sessions were a vivid description by plastic surgeon Fiona Wood of the management of patients with burns who were injured in the Bali bombing, the challenges to medical evacuation from a combat zone by David Werda (former ADF paramedic during United Nations deployment to Somalia), and tag-team presentations on snakebite and emergency resuscitation by George Jelinek and Steve Dunjey (both from the Emergency Department at Sir Charles Gairdner Hospital). Steve’s recent high-profile resuscitation success in outback WA led him to comment that medicine is full of surprises. “You can see unexpected survival in patients under 50 after over 20 minutes’ resuscitation.” The closing straight was led by a relay team of experts. Juliet Hubbard, speaking for Indigenous communities, advocated much wider training of health professionals in cultural safety, particularly in managing major community crises. Alison McMillan (Department of Human Services, Victoria), speaking on the Victorian bushfire disaster, reminded us how quickly local emergency services can be overwhelmed. She gave delegates a sense of the confusion that arises as responding agencies piece together a picture of a disaster. Finally, Brad Santos, a severe-weather expert from the Bureau of Meteorology, left the storm damage in Perth behind him and showed how cyclones behave, with specific reference to their severity and time course. Having given us a taste of what to expect, he introduced the disaster scenario with a scene-setting severe-weather warning. Unlike in many tabletop exercises that aim to advertise the capabilities of host agencies, the details of the scenario were not disclosed to participating agencies. Michael Watson (Clinical Microbiologist, Perth), who led the team of scenario writers, said that he wanted a realistic challenge. As it happened, the date of the conference coincided with peak high tides, enabling Michael and his team to design a realistic scenario in which cyclonic winds caused a storm surge and significant flooding. They envisaged power, telecommunications, the airport, and road links being out of action for 48 hours. To the frustration of health administrators, there was no phone-a-friend-in-Perth option. Police, fire and emergency services, ambulance services, the Royal Flying Doctor Service, the Water Corporation, the Department of Housing and the Department for Child Protection (which is responsible for resettling displaced people) had to rely on what was available locally. There was a lot of tension in the room in the early stages of the disaster scenario as participants grappled with conflicting priorities. In the wrap-up session, table after table recounted tales of resources they discovered when they started to reach out to other groups. Some discovered leadership skills they didn’t know they had. Others showed a natural talent for critical thinking under pressure. One of the conference highlights was a vivid description by Phil Kuhne (Department for Child Protection) of what it would be like in an overcrowded cyclone shelter, and why there wouldn’t be any cyclone parties on his watch. Adding a little realism to the scenario, television crews from two competing channels arrived to interview organisers and speakers just after the scenario started, diverting critical expertise when it was most needed. Cyclone TED was full-on; a draining experience for all those involved. However, there was little rest for the delegates. While the lessons of the disaster scenario were still fresh in their minds, participants split into three parallel skills-development workshops on practical aspects of disaster response, life support with particular emphasis on failed intubation drills, and deployable molecular diagnostic laboratories. Ronan Murray brought the more esoteric aspects of laboratory diagnostic support down to earth by reminding participants of the potential role of the molecular diagnostics laboratory in assisting with front-line clinical decision making in remote or rural regions. The Australasian College of Tropical Medicine took the opportunity to consult on the practical needs of health practitioners in tropical Australia, convening a small group to write up the lessons learned and condense them into a regional development framework — as one delegate put it, the “where we are, where we need to be and how we’re going to get there” of health care in tropical Australia. This process generated the action statement that was presented at the conclusion of the conference. The document, known as the Broome Declaration (Box), captured the spirit of the meeting and provided a sense of direction. In the final discussion of the conference, converting the Declaration into action was debated. There was uncertainty over where resources could be found for infrastructure development, and some scepticism over anything resembling a centrally driven capital project, but there was considerable enthusiasm for local ownership of the process from local delegates. The TED-MED Conference demonstrated that there are people who work at the hot and dusty end of health care who are willing to provide professional leadership. The Broome Declaration represents a benchmark for health development in tropical and regional Australia. It remains to be seen whether there is a substantive political commitment to support front-line health care professionals in developing health capability for regional Australia. The Broome Declaration 1. On this day, 24th May 2009, in Broome, Western Australia, we, the participants in the first consultative tropical medicine summit convened under the auspices of the Australasian College of Tropical Medicine, hereby recognise that the following 10 themes are essential to the development of tropical health: holistic, one health;* collaborative intersectoral partnership; primacy of prevention, early intervention; cultural safety;† subsidiarity;‡ leadership development; proximity of services; immediate availability; effective communication; and strategic urgency. 2. Recognising the current shortfall in health capability in this region as typical of many parts of the tropics, we commit to: establishing tropical health development priorities based on the above themes; informing health authorities of our conclusions; and working toward practical development outcomes within our immediate areas of professional influence. 3. We therefore propose the following specific priorities for north-west Australia: developing a remote access tropical medicine training program; establishing a regional development centre for all stakeholder groups in the Kimberley and the rest of the north-west; and forming a steering group to identify governance and resource support for these outcomes. * A reference to the concept of health as a state of physical, mental and social wellbeing, rather than an absence of disease, first articulated in the Declaration of Alma-Ata.1 † Achieved in a health care setting when carers and providers are attuned to the cultural context of the individuals and communities, and are sensitive to culture-specific vulnerability. ‡ The principle of devolving responsibility for decision making to as close as possible to the level of community at which action is taken.

Timothy J J Inglis DM, FRCPA, FACTM · Ronan J Murray FRCPA, FRACP, FACTM · Michael Watson FRCPA, FRACP, FACTM

Objective: To examine activity patterns of the Royal Flying Doctor Service of Australia (RFDS) in far western New South Wales and to determine whether frequent use of RFDS services, particularly emergency evacuations, is a useful indicator of patients who may benefit from care planning and review.Design, setting and participants: We conducted a retrospective audit of the RFDS South Eastern Section’s Broken Hill patient database. Patients with a residential address in the study area who had accessed at least one RFDS medical service between 1 July 2000 and 30 June 2005 were included in the study.Main outcome measures: Number of evacuations, clinic consultations and remote consultations; clinic usage by frequent evacuees; number of primary diagnoses recorded for frequent evacuees; number of frequent users who might benefit from multidisciplinary care or specialist shared care.Results: Between July 2000 and June 2005, the number of residents requiring evacuation or remote consultations declined by 26% and 19%, respectively, and the number of residents accessing clinics declined by 6%. (Over the same period, the population of the study area fell by about 24%.) Of the 78 patients who were identified as frequent users of the evacuation service (≥ 3 evacuations/year), 34 had three or more primary diagnoses recorded; 15 were infrequent or non-users of the clinics (≤ 3 attendances/year); 53 may have benefited from multidisciplinary care, and 41 from specialist shared care.Conclusions: Simple, practical clinical review systems can help health care organisations in rural and remote communities to achieve better outcomes by identifying patients who may benefit from planned care.

David L Garne MB ChB, DCH, MIPH(Hons) · David A Perkins BA(Hons), PhD · Frances T Boreland BA(Biol)(Hons), MPH(Hons) · David M Lyle MB BS, PhD, FAFPHM

Objective: To evaluate the acceptance and cost of a ward-based geriatric consultation service delivered via a mobile videoconferencing system.Design and setting: Prospective observational study conducted in the geriatric unit of Toowoomba Base Hospital, Queensland, comparing a specialist consultation service delivered by videoconference (VC) with a “traditional” in-person service. The VC system was established in January 2007 and evaluated over an 18-month period. Patient satisfaction with the service was assessed by questionnaire during a 1-week period in September 2008.Main outcome measures: Hospital acceptance of the service; patient satisfaction with the service; comparative cost of providing in-person and VC-mediated consultations.Results: Uptake of the service increased progressively throughout the study period. Patient acceptance levels were high. The cost of video consultations for a 12-patient ward round and case conference was less than the cost of in-person consultations if the total road distance travelled by the specialist (Brisbane to Toowoomba and back) was 125 km or longer.Conclusion: Consultations via VC are an acceptable alternative to in-person consultations, and are less expensive than in-person consultations for even modest distances travelled by the clinician.

Leonard C Gray MB BS, PhD, FRACP · Olivia R Wright PhD · Alison J Cutler MB BS, FRACP · Paul A Scuffham BA, PhD · Richard Wootton DSc, PhD

To the Editor: The Royal Flying Doctor Service (RFDS) has provided aerial emergency services to patients in the remote Kimberley and Pilbara regions of Western Australia since 1935. Until the 1980s, most evacuations were regional, and only small numbers of patients were transferred to Perth. Demand for long-distance transfers from northern WA has increased as a result of economic growth, improved resuscitation of the seriously ill, advances in treatment only available in major cities, and community expectations of more equitable access to tertiary care. In the Kimberley, a handful of specialists service an area twice the size of Victoria, confronting substantial health problems in the predominantly Indigenous population. The Pilbara, an even larger region (two and a half times the size of Victoria) and the epicentre of massive economic development in mining and energy, is also covered by only limited numbers of specialists and a single regional hospital. During the 12 months to 30 June 2009, the RFDS transferred 1018 patients from the Kimberley and Pilbara regions to Perth, up to 2200 kilometres away, and a similar number were evacuated to facilities within the regions, or to Darwin, up to 1500 kilometres away (Box 1). These patients routinely endure some of the longest medical retrievals anywhere in Australia, if not the world. With turboprop aircraft, retrieval times can be up to 12 hours. Pilot flight-time limitations over such distances mean that 93% of Kimberley patients require multiple aircraft and crews to achieve transfer (Box 2). Patient handovers increase transport time and clinical risk, and require considerable coordination. In October 2009, the RFDS in WA launched a fast long-range medical retrieval jet, available to all of the community, irrespective of their capacity to pay. The aircraft, a Hawker 800XP medium-sized jet, has been funded by corporate sponsorship from the mining company Rio Tinto, as well as by public fundraising and cost recoveries. The aircraft has been exclusively outfitted for its aeromedical role. It has the capacity to retrieve two patients in need of critical care with two medical retrieval teams on board, non-stop from the most distant locations in WA, and can carry a third stretcher patient if necessary. Although they are more expensive to purchase and operate, the use of pure jet aircraft can substantially reduce transport times for patients with complex or time-critical conditions, and thus improve clinical outcomes. This is the first jet in the history of the RFDS, and represents a quantum step forward from the “DH50 machine” referred to in the Journal in 1927,1 or the pressurised turboprop aircraft adopted in the 1980s.2 Flying times for patients will be effectively halved. The aircraft, designated “Rio Tinto Life Flight”, will be integrated into the existing RFDS state-wide retrieval service in WA, which coordinates and operates 14 turboprop aircraft from five centres. This is a significant initiative to improve access and equity to tertiary care for Indigenous and non-Indigenous Western Australians in remote areas. To date, aeromedical jet aircraft have not been government-funded. We hope that by demonstrating the viability and benefits of the service, government support will become available in future years. 1 Trends in Royal Flying Doctor Service long-distance medical retrieval from and within the Kimberley and Pilbara regions of Western Australia Years are financial years to 30 June. 2 Patients requiring more than one aircraft to achieve transfer to Perth Years are financial years to 30 June.

Stephen A Langford

My 16-year-old daughter’s heart saved the life of another teenage girl, and her other organs were used to save or improve the lives of six other people. I still believe in organ donation, but there are facts about the donation process that are emotionally confronting and difficult, and we should be given better information so that we are more prepared for the realities of it. These facts should be made clear to anyone considering organ donation, but especially to those who have to make the final decision. The hospital bedside is neither the place nor the time to discover these facts for the first time. In February 2009, my family was eight months into a global circumnavigation aboard our sailing yacht. We had called into a marina in Phuket, Thailand, and our daughter Ali was watching a huge superyacht tie up at a jetty. An error was made during the docking procedure, which caused a cleat to be torn out of the jetty and the heavy mooring rope to whiplash with extreme force. Ali suffered serious head injuries and was rushed to the Bangkok Hospital Phuket, where she was examined by neurosurgeons. That first night we were told there was no brain activity and no brain stem function, but as certain tests had to be carried out before she could be legally pronounced brain dead, we then waited for five days with her in the hospital before life support could be “turned off”. Late on day four, the neurosurgeon told my husband and me that Ali had failed the final tests and would now be declared legally brain dead. He then asked — gently and with no urging — if we wished to consider organ donation. It was not something we had thought about. For four days we had stayed by Ali’s bedside, keeping shifts with the rest of our immediate family who had flown in from Australia, talking, singing, weeping, telling jokes, massaging her hands and feet, unable to lose that flickering of hope for a miracle. Organ donation was part of a step we hadn’t yet reached. The doctor explained that, if we agreed to donation, the transplant team would arrive from Bangkok the next day — or whenever we were ready — and Ali would be taken to the operating theatre and the useful organs removed. She would be returned to us later in the week, and we were assured that she would look perfectly fine. The doctor also pointed out that he had nothing to do with the transplant team, that they were from a different hospital altogether, and that Ali’s organs would not be used in this hospital. We could also change our minds at any time, regardless of signing the document. That sounded acceptable, and we signed. Without actually discussing it, each one of us assumed that we would sit with Ali while life support was disconnected and be with her as she stopped breathing, and that she would then be taken to theatre. Later that evening, the person in charge of organising the organ donation came to see us and explain how it would happen. Awkwardly, the woman explained to us that, no, we couldn’t sit with our precious child as she drew her last breath and her heart stopped its beating. For the organs to be in perfect transplant condition, they had to be removed from a body that was technically still functioning. She would be taken to theatre still attached to life support. Our immediate response was one of horror and disbelief, and we told her that no one would be taking our child while she still had a heartbeat, that they would have to wait until she was dead. The woman, obviously feeling very awkward and uncomfortable, said that was fine, that was our prerogative, but the only organs that might then be able to be used would be the corneas, and not much else. We spent the rest of the night in turmoil. Logically, we knew that our daughter was gone, that an exhaustive testing regime proving brain death meant she was dead. We understood the reasons why the procedure had to happen that way — that as soon as the heart stopped beating and oxygen stopped being delivered to the cells in the body, the organs would immediately begin to deteriorate. We also knew Ali would want her organs donated. She was the kind of kid who couldn’t walk past someone with his hand out or someone who looked upset. But the sudden reality of what her donation asked of us was unbearable. Early the next morning, I phoned a doctor we knew in Australia. He confirmed that it was the correct procedure; that for the best possible transplant potential, the organs had to be removed from a body still attached to life support, with a beating heart supplying oxygen to the tissues. This was why organ donation was such a controversial issue. We wanted to honour what we knew Ali’s wishes would have been, and we wanted the donation to be as useful and as beneficial as possible, to make the best possible gift on her behalf. But doing so meant that we had to absorb these confronting facts about organ donation at a time when we were overcome with grief. I knew that none of us could walk away from her while she still seemed to be alive — her skin warm, her chest rising and falling, the machine beeping her pulse rate, all those signs you hang on to as proof of life even though you know it’s hopeless. I talked to the rest of the family and explained the procedural requirements. We had to accept — emotionally as well as rationally — that the only things keeping Ali’s heart beating and her chest rising were machines. We had to acknowledge that she was already gone. When the team was assembled, we would say our goodbyes and then call them in when we were ready to let Ali be taken from us. It was the hardest thing I’ve ever had to do in my life, and it should not have happened that way. No family should have to face the shock of discovering these details for the first time at that point. I am an educated, widely read, well informed Australian woman and, then and still, a registered donor, but I knew nothing about the procedural requirements for organ donation. No one I have spoken to since, apart from doctors, has had any idea either. None of us had ever been in the situation where we needed to know. Since returning to Australia, I have studied the Medicare leaflet about organ donation — the one that comes with your drivers licence renewal — and the new organ donation website (http://www.donatelife.gov.au). There was no mention anywhere of the emotional impact you might need to be prepared for, nothing that said: You need to know certain facts about organ donation that may be emotionally confronting and difficult. It’s a good idea to talk about these facts with your family before they might be called upon to face them in a hospital ... The deceased will be taken to the operating theatre still attached to life support. This may be upsetting for the donor’s family because the person has the appearance of being alive. You will need to remind yourself that a diagnosis of brain death means that the person is already dead. Breathing and heartbeat are being maintained by machines in order to ensure the organs stay healthy and usable ... If clear information was provided in advance about brain death, life support procedures and the requirements for organ removal, then at least we might have been a little more prepared. At some point in the past most of us would have talked about it, academically and dispassionately, but with further information we could have already considered the notion of “beating heart donation” and had the chance to consider the sacrifice the family of an organ donor is called upon to make. It might be argued that in Australia we would have had these facts carefully and sensitively explained to us at the hospital. I am sure it also happens in Thailand, and certainly an effort was made to explain it to us, in spite of language barriers. However, the real point here is that the hospital bedside is not the place or the time to find out these facts for the first time. If such information was available, then perhaps there might be more consent to organ donation at the hospital bedside. I never previously understood why a family would go against a potential donor’s signed consent. Now I can completely understand a family countermanding their child’s wishes when they discover at the last moment what it means — that they have to hand over their apparently still living child, and that they must give up the final solace of the survivor, of holding their loved one in their arms as they take their last breath. We are parents, sisters, brothers and children of the dead person. We are not all going to be rational and sensible at such a time. Ali was a very healthy 16-year-old who had never had a serious illness. Her heart saved the life of a teenage girl in Bangkok a day later, and her other organs were used to save or improve the lives of six other people. I still believe in organ donation. But human beings often make decisions based on emotional responses. We are already facing the most unutterable grief when our children, our husbands or wives, our parents or siblings, are declared brain dead. Please, make people aware of everything involved in organ donation through the leaflets and websites, so that the ordinary person is better prepared, at least in some way, to deal with it if they’re unlucky enough to have to face it one day.

Joanne M van Os

Comment: Death is a reality that confronts us all at different times and in different ways. Death of a child, especially your own child, is an ever-present fear. Sadly, every day, somewhere in the world, parents will be confronted by the death of their child in an intensive care unit (ICU). Surrounded by the paraphernalia of high-tech medicine, those who work in the ICU must bring understanding to the family with both sympathy and empathy. Brain death does not seem like death in the same way as cardiac death, and that disconnection between what we know and what we feel is described here with exquisite pain by Ali’s mother.1 van Os first calls for sensitivity from the medical, nursing and other staff in emergency and intensive care departments — clearly spoken here, and indeed spoken before by others. This call has been well heard in Australia and New Zealand, where specific training has been provided to ICU teams for the past 15 years by a program called ADAPT (Australasian Donor Awareness Programme).2 It is not possible to qualify as an intensive care specialist without first completing this training program. The process of gaining permission to proceed to organ donation in Australia should leave none of the uncertainties that crept up unannounced on van Os and her family.1 Our transplant coordinators are trained, and our organ donation agencies have specific bereavement counselling programs to provide care for the donor’s family after organ donation. Emotional doubt over brain death is inescapable, but we try harder here to resolve these concerns than in many places in the world, which may be one reason why our organ donation rates fall behind those in many other countries. The second call from van Os is to ensure that the community is better informed about the realities of organ donation. Providing appropriate information to the community has been a continual struggle. The expenditure of sufficient advertising money to get these complex messages across has been deemed an unacceptable use of the health dollar. However, there are other ways, and we can always improve our act. The recently created Australian Organ and Tissue Authority is doing just that.3 Ms van Os, your calls have been heard. Somewhere, every minute of every hour of every day, someone dies for lack of the decision that you and your family took — but it was not that day for a teenage girl with heart failure in Thailand.

Jeremy R Chapman

Comment: The families of organ donors are usually deprived of the opportunity to be present when the donor’s heart stops beating. As this personal account by van Os eloquently demonstrates,1 forsaking this opportunity can be experienced as an additional loss — one that exacerbates a family’s trauma during the donation process and that possibly imperils the donation itself. We should not underestimate the cultural significance of heartbeat and breath, and the symbolic importance of the moment in which they cease. Neither is diminished by medical redefinitions of death. Should we do more to educate Australians about the fact that a donor must enter the operating theatre attached to a respirator with a heart still beating? There may be some reluctance to do so on the grounds that drawing attention to this might drive Australia’s low donation rates even lower. There is also no strong precedent to do so; countries with high donation rates such as Spain, France and the United States do not generally make this information publicly available. On the other hand, information provided to Australians about organ donation does now routinely include discussion of other sensitive issues, such as the diagnosis of brain death, the organ retrieval process and the physical appearance of the donor’s body after surgery.2 Although no amount of disclosure can fully prepare a donor’s family for the experiences they are about to face,3 a more detailed and carefully worded explanation of why brain death necessitates the mechanical ventilation of a donor immediately before surgery may help address the key issue identified by van Os: that the hospital bedside is not the place to find out about this for the first time. Overseas experience suggests that organ donation after brain death depends heavily on trust.4,5 Trust surely rests on frank and open disclosure. If the latter also helps to prevent one nasty shock to a family being exacerbated by another, then there are two sound reasons to pursue this policy.

Aric Bendorf

I have always dreaded that moment at funerals when you see the coffin for the first time. Perhaps it’s the finality of death or the sadness of the loss, but that moment seemed an inevitable consequence of the dying process, until I was faced with the impending death of my father. My father was 75 years old when he died of cholangiocarcinoma. He was a man with many friends. He was curious and loved to chat, he loved a beer, he made people laugh, he worked hard and was well loved. He was cared for at home, mostly by my mother. Friends and family came to pay their respects, and some came again for another “last time”. We sat with him, tended to his needs and contemplated life without him. The palliative care team visited often and waited for the cue to arrange hospice care because we could no longer cope; to us, this meant dad leaving and being cared for by someone else. The cue never came. The family rallied and dad stayed at home. This raised another issue I had with dying — the moment of separation when the body is taken away from the family. I had witnessed it often in my working life and wondered how families determined the right time to go and how they felt about leaving their loved one behind. Would they want to take the body with them? A few days before dad died, the funeral director came to the house. We leafed through folders of coffins and flowers, and discussed the service. She said to call them at any time when he died and they would come to the house (to take him away). I took a breath. “Can’t we keep him here?” My mother looked at me. “Are you sure you’re allowed to?” We hadn’t discussed this option so I had no idea what she thought about it. In fact, I didn’t think I would raise it. I hadn’t thought it through completely but felt intuitively it was the right thing to do, for me and possibly for her. Between us we had attended many funerals but had no knowledge of anyone who had kept the body at home. Ultimately, the decision would be hers; he was her husband, and she would continue to live in the house. Maybe it would be too much for her to bear, but she didn’t seem opposed to the idea, and it was possible. In the warmer months a cold table can be provided, but we were in the middle of winter and the garage under the house was particularly cold, so a body could rest down there. After some discussion, we decided that dad would go to the garage and not leave us until the last. That decision would have a profound effect on my view of death and grieving. Dad died early one Sunday morning at home, with my mother by his side. The rest of the family slowly arrived. Dad stayed in his bed, where we washed him and dressed him as if ready for golf. The children came in and out of the bedroom. They tied up his shoes and added things to his pockets. We ate lunch. The civil celebrant conducting the funeral came over and we talked about dad. Someone would disappear into the bedroom for a while and come out with red eyes. In the afternoon, the funeral directors arrived. We carried dad downstairs and placed him in the coffin, next to the caravan my parents used as their second home on travels. His golf clubs were beside him and his work bench just behind. Mum moved into the caravan for two nights. Dad was now in the garage. Mum’s sister arrived after a long journey. After cups of tea, they went downstairs to see dad. The garage became a sanctuary where people came and went and the children ran and danced around the coffin. Being close by allowed many quiet moments to sit next to the coffin, talking, weeping and taking time. Mum sat beside him in the early hours of the morning. On the day of the funeral, the family gathered for more food, more cups of tea and last-minute writing of speeches. We went down to the garage and lifted the lid of the coffin. Dad was still the same, looking pale and peaceful. We cried, laughed and added extra things that we thought he might want, or that we wanted him to have. The hearse arrived and we carried dad out and drove slowly to the church in this small country town. The family carried the coffin into the church that was filled with dad’s family and friends, and the friends of his children and friends of friends. Many burst into tears at the sight of us and the coffin. It was a good ceremony, and then we carried him out again. We arrived at the cemetery and carried the coffin to the graveside. The children wondered whether we would also have to dig the hole. The coffin was lowered and we all went for more cups of tea, and sherry and cake. The death of my father was an experience I had not expected. I imagined being inconsolable with grief and unable to make decisions. However, it was a gentle time that brought the family together and created a wonderful memory. He had a good death at home and a good after-death. Keeping his body at home was an unusual decision in the eyes of many. For the family, it represented an opportunity to do something special for someone we loved, but it also facilitated the grieving process. It seemed to slow down the period from the death to the funeral. There was no pressure to have the body removed or to pay visits to the funeral home for a “viewing”. He was in the garage and we could see him whenever we wanted; we grew accustomed to looking at the coffin and began to come to terms with his death. There was also comfort in continuing to offer care until the end, rather than his body being in the care of someone else. There are cultures where it is the norm to keep the body at home. I had witnessed it in Tonga on my student elective, where I equally appreciated the symbolism of coming together and sharing a meal (or cups of tea!) at these times. In contrast, the ritual of keeping the body at home is uncommon in Australian culture. It certainly seemed uncommon to the funeral director and others I have spoken to. Maybe people think about it but don’t ask. Perhaps we should ask for them.

Karen L Dunn MB BS, FRACP, PhD

In complex and challenging cases, care should be individualised to reflect a patient’s unique situation, values and goals In all areas of medicine, we encounter complex and tragic cases that challenge our medical expertise, our emotional resources, our clinical judgement and our capacity to make ethical decisions. In challenging cases where there is a diagnosis of a progressive life-limiting illness, a palliative care team may have much to offer. The patient we describe here, a young pregnant woman diagnosed with incurable malignancy, represents one such case. Only by working with the patient at the centre, surrounded by collaborating specialist staff, can we negotiate the path to the “right” care. A 35-year-old, previously healthy, 16-week pregnant woman presented with a 7-hour history of right leg paresis on a background of vague back pain. Examination revealed normal sensation but power of 0/5 throughout the affected limb. Magnetic resonance imaging showed multiple metastatic intracerebral deposits, most likely in keeping with melanoma. Neurosurgical, medical oncology and radiation oncology reviews followed. A left supraclavicular lymph node biopsy confirmed melanoma, consistent with a distant past history of left shoulder melanoma. The optimal treatment regime was considered by the specialists involved to be dexamethasone and whole brain irradiation. The obstetric medicine consultant identified a potential but necessarily unavoidable risk of intrauterine growth retardation from use of corticosteroids, but the risk from whole brain radiotherapy was considered to be negligible. Importantly, the obstetrician clearly identified that the patient did not want to terminate her pregnancy, citing strong Christian beliefs and a primary intent of delivering a healthy baby. The patient had one other child, an 8-year-old son from a previous marriage. The potential for crises and the likely need for urgent decision making, including life support issues, were raised by the obstetrician. With encouragement, the patient completed an advance health directive and appointed her husband, who shared her Christian values, as enduring power of attorney. By terrible coincidence, her newlywed husband’s first wife had died of a brain tumour diagnosed during pregnancy. In the space of 6 days, this previously healthy woman learned that she could not move her leg because she had multiple brain tumours, that she could not be cured, and that she was going to die. She also learned that she might die before her baby was born or that she might have to be kept alive artificially, and unconscious, to support her baby until birth. During the ensuing 10 days, the patient was treated with whole brain radiotherapy, corticosteroids and physiotherapy, and gained significant recovery of right lower limb function. At 18 weeks’ gestation, she developed acute-onset dyspnoea, haemoptysis and oxygen desaturation to 92%. A focal wheeze in the left upper zone was evident on examination. Bronchoscopy revealed a pulsatile vascular endobronchial tumour in the left upper lobe that was not amenable to cautery. With the risk of major bleeding and potential for sudden deterioration, an urgent referral was made to the palliative care service. The role of the palliative care team was to provide emotional support and to act as an advocate for the patient, who needed relevant medical information presented in such a way that she could make decisions based on realistic options, understanding both the risks and benefits. In a short space of time, this patient had lost many aspects of her life — her roles as teacher, active churchgoer, mother and wife were disappearing. A young expectant mother’s unquestioning hopes for the future were being eroded. The aspects of her life that remained intact were her values and choices regarding her own and her unborn child’s care, allowing her to maintain some control over her future. The palliative care team recognised the need for a case conference involving staff from intensive care medicine, radiation oncology, respiratory medicine and palliative care, as well as the social worker and the ward nurse manager, to produce a consensus opinion for guiding decision making. Obstetrics staff, who were unable to attend, had already explained to the patient that a baby born at 28 weeks’ gestation could have a reasonable chance of healthy survival, but that 32 weeks would be an ideal minimum gestation. Issues addressed at the case conference included: What were the patient’s wishes for herself and her baby? How long would it realistically be possible to ventilate and support her artificially, to allow the fetus to mature? What could be done in the event of massive haemoptysis? Would ventilation be possible? What were the other possible clinical outcomes and how could they be managed? The case conference resulted in a realistic palliative care plan to anticipate and manage potential difficult scenarios, which was relayed to the patient and her husband by the palliative care consultant. She agreed to the plan to use radiotherapy to treat lung metastases and understood that admission to the intensive care unit (ICU) would not be an option in the event of massive haemoptysis, because adequate ventilation was technically impossible. Massive haemoptysis, dyspnoea and anxiety would instead be managed with opioids and benzodiazepines kept in her room. Should her condition decline with other complications and require ICU admission for life support to facilitate the birth of her child, this could not occur until 26 weeks’ gestation. By 27 weeks’ gestation, she had remained an inpatient, with occasional day passes home. Gestational diabetes secondary to steroid treatment had further burdened her clinical course. She developed severe abdominal pain, with increased abdominal girth. Investigation revealed a large pelvic mass and ascites, and paracentesis produced haemorrhagic fluid. A further case conference concluded that, due to her clinical decline and concern that intra-abdominal disease would place the baby at increased risk of congenital melanoma, the patient should undergo a caesarean section at 28 weeks’ gestation. Three days before this was due to take place, she had a generalised tonic–clonic seizure and was admitted to the ICU. Fortunately, her son was successfully delivered by caesarean section as planned. Though profoundly fatigued and with her condition deteriorating rapidly, she was able to visit her son in the neonatal ICU. She died 24 hours later of a suspected pulmonary embolism, for which she received symptomatic relief of dyspnoea and distress, in the company of the nursing staff. Evidence to guide management of pregnant women with cancer is limited, particularly when the prognosis is short. This case challenged all the teams involved in her care, both emotionally and clinically. What was the right thing to do in the absence of evidence specifically relevant to her case? At each stage of the patient’s illness, knowledge of her goals and wishes was crucial to good clinical decision making. Each decision needed to be carefully made, bearing in mind the patient’s wishes for herself and her baby while remaining within the limits of her illness and the capabilities of modern medicine. Although some literature exists on melanoma in pregnancy, most pertains to placental metastases and transmission.1-3 There has been little written to guide decision making for pregnant patients with incurable cancer. Four articles discuss the balance and potential conflict between optimal treatment for the patient and the risk of damage to the fetus.4-7 Care needs to be individualised to reflect a patient’s unique situation, values and goals. Interdisciplinary collaboration to advocate for the patient’s individual wishes is one of the central tenets of the palliative care physician’s approach to patient care. Advocacy, collaboration and making difficult decisions in the face of a terminal illness are central to good palliative care. Palliative care physicians are particularly skilled when outcomes are uncertain, and when meaning and individuality are key to good decision making. We recommend an early referral to the specialist palliative care service for patients with similarly challenging cases.

Faith D Cranfield MB BAO BCh, MRPCI · Carol M Douglas FAChPM, MB ChB

New forms of journalism offer opportunities and pitfalls for health Newspapers and other forms of “old” media face an uncertain future because of withering traditional revenue streams, rising new media technologies, and changing audience expectations. Comparisons have been drawn between the demise of the Roman Empire and that of modern media empires.1 To date, the collapse has been most evident in the United States, where, between 1 January 2008 and 15 September 2009, 46 599 jobs in the journalism industry were lost and 201 media outlets closed.2 The journalism industry lost jobs at almost three times the rate of other industries.2 The number of full-time journalism positions in Australia fell from 8500 to 7500 between 2001 and 2007,3 and more losses are expected (Jonathan Este, Director, Communications, Media Entertainment and Arts Alliance, 20 October 2009, personal communication). The changing nature of the media landscape brings dangers and opportunities for those concerned with the health of societies and populations. The mass media, for all their flaws, have been a powerful force that have influenced and informed policy, practice and attitudes in the health sector and other spheres. The “fourth estate” has also had an important role in scrutinising society’s powerful institutions, and holding them accountable. Media coverage has contributed to significant advances in public health policy. Notably, according to the Advocacy Institute in the US: “News coverage has been the lifeblood of the tobacco control movement”.4 The demise of the traditional media, therefore, has serious implications if it means fewer resources for investigating important health and medical issues or related matters, such as social determinants of health. The traditional media are losing their monopoly on news gathering and dissemination as the Internet and related technologies enable a proliferation of new media outlets and applications. These include blogs, wikis and online social media tools such as Facebook and Twitter. The definition of a blog is a fluid one. Originally coined to mean an online journal in which the entries appeared in reverse chronological order, the term is now used to encompass a wide range of Internet publishing, including journalism.5 A wiki is a website that can be freely edited by participants, who can be either the public at large or a defined group working on a project or from within an organisation. The best-known wiki is the online encyclopaedia Wikipedia. Online social networking tools are evolving fast. One of the first was MySpace, where individuals could post information and send other members messages. Facebook has largely overtaken it as the most popular social networking site, whereas Twitter is a newer social networking tool that is possibly the most relevant for journalism, relying as it does on short, real-time 140-character “headline messages”. The transition from mass media to “masses of media” creates new opportunities. Never before has there been so much media choice or so many adept media users. Anyone with access to the Internet can publish news and views for the world to see. This is a first in human history, and has contributed to the rise of “citizen journalism”. The technology also enables news to reach larger audiences in more ways, and creates new ways of telling stories and engaging audiences. As Mark Scott, managing director of the ABC, stated: “The opportunities to connect and engage have never been more exciting”.1 At the same time, new media have undermined the business models of media institutions. Commercial free-to-air broadcasting remains the main way Australians get their news and information.6 It makes money by aggregating audiences and selling their attention to advertisers, but the audience is fragmenting as more choices become available. Once Australia’s National Broadband Network is complete, and more audiovisual material is delivered via the Internet, the audience will be everywhere at once. Meanwhile, newspapers, which have been the largest employers of journalists, have seen classified advertising decline as advertisers find the Internet is a cheaper and more efficient way of reaching buyers. Although all newspapers have an Internet presence, so far none of their websites make money in their own right once the costs of providing editorial content are factored in. Companies cannot charge as much for an online advertisement as they have been able to charge for a printed advertisement because there are so many online options. If the price is too high, there is always the possibility that industry groups — for example, real estate agents — might start their own online publication. Indeed, this has happened in the case of car dealers. Hence, over the past few years, Australian newspapers have radically decreased their editorial staff. Industry analysts anticipate that, within the next decade, major Australian mastheads will cease to exist, at least as print products and as major employers of journalists.7 However, there is no evidence to suggest that there is a crisis in terms of the public’s appetite for news and information. The health sector is exploiting the opportunities offered by new media. Organisations such as the Cancer Council Australia use social media tools to communicate health information and build communities of engaged supporters. Members of the public also use these tools for patient advocacy, to raise funds for medical research and to mount public health campaigns.8 Social media have also helped disseminate critical information during bushfires and other disasters. US academics who analysed the role of new media in President Barack Obama’s election campaign concluded that there were many lessons relevant to public health advocates, including the potential for increasing audience engagement.9 These lessons appear to have been absorbed by those responsible for the Australian Government’s health reform website (http://www.yourhealth.gov.au/), which encourages interaction from members of the public and health professionals. Health-related blogs compiled by media outlets, organisations, governments, commercial interests and individuals are also proliferating. They open up new avenues to communicate information and disseminate research, and they enable “bottom up” as well as “top down” exchanges. A survey of medical bloggers found that they wanted to share practical knowledge and skills, and their blog ideas were often reported by mainstream media.10 The authors of the survey concluded that blogs are an important vehicle for influencing medical and health policy. At the BlogWorld & New Media Expo held in the US in October 2009, the implications of new media for the health sector were widely discussed. The quality of bloggers’ information is enormously variable, but some, such as Effect Measure (http://scienceblogs.com/effectmeasure/), authored anonymously by senior public health experts in the US, enable more open and incisive discussion about health issues. The Pump Handle (http://thepumphandle.wordpress.com/) is another public health blog with an interest in issues that are “not getting the treatment we think they deserve in the mainstream media”. In Australia, staff at Katoomba Hospital have also harnessed the anonymity available to bloggers to raise matters of interest to their local community (http://whowillspeakforus.blogspot.com/). On the other hand, anti-health interests such as tobacco companies have been quick to seize online opportunities for marketing campaigns, often covertly.11 Meanwhile, media practitioners concerned with the public interest are attempting to develop new journalism models. In the US, several not-for-profit organisations, often funded by philanthropists or universities, commission investigative journalism projects, and some have covered important health issues. The Center for Public Integrity (http://www.publicintegrity.org/) has published investigations into illicit tobacco trafficking and the political influence of the pharmaceutical industry in US politics, for example. Another not-for-profit organisation, ProPublica (http://www.propublica.org/), commissioned an investigation into how hospital staff responded in the aftermath of Hurricane Katrina. A number of health stories are commissioned through an innovative project called Spot. Us (http://www.spot.us/) that experiments with different journalism methods, including the use of community funding and community-sourced news. Australia has been relatively slow to develop new journalism models, perhaps because the traditional media here have not been as hard hit as elsewhere. However, there are some notable examples, including online publications newmatilda.com, funded by a single philanthropist, and Inside Story, based at the Institute for Social Research at Swinburne University of Technology, which has run lengthy pieces on health issues.12 Both of us helped found and are on the board of the recently established Foundation for Public Interest Journalism (also based at the Institute for Social Research), which will develop and test new journalism models. The Foundation will give priority to issues that are under-reported by the traditional media, providing an opportunity to improve coverage of currently neglected health issues. New media ventures are not only expanding the range and type of outlets, but are also changing the nature of the relationship between media and their audiences. According to a US journalism academic, the audience has become “the people formerly known as the audience”.13 They are now also collaborators, antagonists and participants. This changes the relationships between professional news gatherers and their audiences in ways that can make them more interactive, open and transparent than they have been in the past. We believe this can lead to healthier public debate than existed in the era when only a few people had privileged access to the means of publication. However, the new media era involves many challenges and uncertainties, including the need to develop viable and sustainable business models to support journalism that is in the public interest. The proliferation of new media outlets may have some advantages, but it also risks fragmenting public debate — with all the attendant risks that this brings for policy processes and society more broadly. It also raises legitimate anxieties about the quality and reliability of information. Editors have a critical role in new media; in fact, curating masses of material and sifting for quality and importance may be one of the main roles of journalists in the future. There are also concerns about the impact of proliferating digital media on the development of children and young people; there is a need for research to help guide policy in this area.14,15 The new media revolution is underway, but it will be some time until its impact upon the health of our societies and populations is fully understood.

Melissa A Sweet BA, MA(SciTechStud) · Margaret J Simons BA, DCA

Objective: To describe the content and structure of health and medical news and current affairs reportage on free-to-air television in Sydney, New South Wales.Design and setting: Review of content of all health-related evening news and current affairs items recorded over 47 months (May 2005 – March 2009).Main outcome measures: Number and length of health-related items on news and current affairs programs, and topics covered in these (21 broad content areas and the leading 50/237 specific content areas); use of news actors, soundbite duration and apparent news triggers.Results: 11 393 news items and 2309 current affairs items were analysed. Health news items lasted a median of 97 seconds. In a randomly selected sample of 251 items, items featured a mean of 2.2 news actors (3.9 in longer current affairs items). Median soundbite duration was 7.2 seconds for news items and 8.9 seconds for current affairs items. People affected by disease or injury were the most commonly featured news actors (84% of items), followed by experts and health professionals (56%). Many items (42%) appeared to be trigged by incidents, but a further 42% could have been triggered by press releases and other forms of publicity.Conclusions: Health workers wishing to participate in news coverage should be aware that complex issues are reduced to fit the time constraints and presentational formulae of the news media. Advocates should plan their communication strategies to accommodate these constraints.

Simon Chapman PhD, FASSA · Simon J Holding BA · Jessica Ellerm BSc · Rachel C Heenan · Andrea S Fogarty MIPH · Michelle Imison MIPH · Ross Mackenzie MA · Kevin McGeechan BSc

Objective: To examine the nature of disease awareness advertising (DAA).Design: Therapeutic advertisements in six popular Australian women’s magazines were monitored between April 2006 and March 2007. A subset of advertisements was included in the study based on criteria derived from a definition of DAA. Unique advertisements were analysed by four independent coders.Main outcome measures: Types of advertisements and their sponsors, the types of disease information present, and the persuasive techniques utilised.Results: Of 711 advertisements identified, 60 met the inclusion criteria for DAA, and 30 of these were unique. Over one-third of the advertisements were classified as “unbranded product advertisements”, which promote a product without referring directly to a brand. DAA sponsored by pharmaceutical companies most often provided treatment and prevalence information. Most (22/30) advertisements used emotional appeals; 15 of these used “happiness/healthiness/wellbeing”.Conclusions: The educational value of industry-sponsored DAA could be improved if regulations and guidelines stipulated disease information requirements, such as inclusion of risk-factor and symptom information. Regulators should provide guidelines for “unbranded product advertisements” and the acceptability of other persuasive techniques. Further research into DAA is required and should consider advertisements in a range of media, and behavioural responses.

Danika V Hall MEd, BA · Sandra C Jones MBA(Marketing), MPH, PhD · Donald C Iverson BSc, MSc, PhD

When I took a call from MJA Editor Martin Van Der Weyden asking me to write a “Power of One” article for the Christmas issue of the Journal, I was excited and honoured. Here was an opportunity to reflect on the drivers and influences that led me first into medicine, then diabetes and public health advocacy. Baker IDI Heart and Diabetes Institute, Melbourne, VIC. Paul Z Zimmet AO, MD, PhD, FRACP, FRCP, FAFPHM, FTSE, Director Emeritus and Director of International Research paul.zimmetATbakeridi.edu.au In the beginningThe story starts in the small town of Tarnopol in Poland. My father, Jacob Zimmet, studied medicine in Vienna and graduated in 1935. He returned to an unpaid position in the Tarnopol Hospital — unpaid because Jewish doctors could not be “officially” employed in Poland. Realising there was no future for him there, and having experienced the mounting threat of Nazism in Austria, he applied for visas to Australia and the United States in 1937. The Australian visas arrived first, but my mother, Anna, wanted to burn them. She dreaded leaving their families; but my father was certain war was imminent. So, in December 1938, my parents and Rena, their first child, left for Sydney, arriving in January 1939. World War II broke out in September. The remaining family were taken to concentration camps; there were no survivors except my mother’s younger brother.1 My father found that his medical degree from Vienna, one of the world’s finest universities, was not recognised in Australia because Austria was under German occupation. So, after living virtually penniless in Sydney for 6 months, he moved the family to Adelaide where it would take him only 3 years to requalify, rather than 5 years in Sydney. My parents had to find supporting income and, as my mother had brought a treadle sewing machine from Poland, they established a leather business. Mother sewed, and father skipped lectures at the medical school and bicycled around Adelaide to obtain orders. Arriving on the scene — my start in lifeI was born in 1941, and my father graduated from the University of Adelaide in 1942. He obtained a position as a doctor with BHP, and we moved to Whyalla. It was here that the seeds of my future medical career were planted. My father had a wonderful bedside manner and was adored by his patients. I would accompany him on his rounds in Whyalla and to outlying cattle stations and mining communities like Iron Knob, sitting in the back seat of our old Chevrolet. This was my first taste of medicine. In 1950, we moved back to Adelaide. My father commenced general practice, working from our home so we always had patients around us. It was clearly a powerful influence. In later years, he was very proud that three of his children, Rena, Leon and myself, studied medicine and became Fellows of the Royal Australasian College of Physicians because, with the war interrupting his studies and changes in specialist recognition in Australia, he had been unable to practise as a consultant physician. My youngest sister, Miriam, was smarter and elected instead to join the teaching profession, and she has made a significant contribution to community activities. Today, my father would have been even prouder of my sons, Hendrik (cardiology) and Marcel (paediatrics), who have followed the same path, and another grandson, Adam Zimmet, a cardiac surgeon. Although I always wanted to study medicine, I had a less than impressive school record. Only when I reached the University of Adelaide did I come into my own, obtaining a Commonwealth Scholarship based on my first-year results. However, it was then that my medical career nearly ended. On the first day of second-year medicine, we were introduced to the anatomy dissection room. I lasted for 15 minutes before heading up North Terrace to my father’s consulting rooms to tell him I was ditching medicine! I was marched back to the medical school, and that was that. A fond memory of my student days was the clinic dinner at the end of each rotation when we wined and dined our consultants, but this was not for one of them, Basil Hetzel, who had a remarkable career in medicine.2 For Basil, it was a cup of tea and a sandwich in the ward clinic room! At this stage, I had no career aspirations apart from joining my father’s practice. However, because of the small Jewish community in the area, I moved to Melbourne in 1966 in the hope of finding a wife to bring back to Adelaide. I was offered a second-year residency at the Alfred Hospital but, as I had not consolidated my relationship with my wife-to-be, Vivien, by the end of that year, I needed to stay another year in Melbourne. Luck was on my side, as Don Cameron, who was Registrar of the Diabetes and Metabolic Unit at the time, told me that his boss, Pincus Taft, wanted to know if I was interested in the diabetes job. Thus, serendipity stepped in as a partner to Cupid — it seemed a good opportunity and gave me another year to court my future bride. So began a career in diabetes. The first taste of researchDuring that year (1967), I had my first real taste of the excitement of research. We had a case of intestinal lymphangiectasia with marked hypocalcaemia and tetany that was unresponsive to calcium replacement.3 Hal Breidahl, my consultant, and I were puzzled by this. While on a skiing holiday at Falls Creek, I was listening to the “Farmers Hour” on radio, and the penny dropped! They were discussing how magnesium relieved grass tetany in the local cows. Racing back to Melbourne, I arranged a test of the serum magnesium level, which demonstrated hypomagnesaemia. Following magnesium replacement, the tetany ceased and the serum calcium level rose. Thus arose my first publication, in the British Medical Journal.4 I carried the acceptance letter around in my pocket for months. Fortune smiled on me again and, as luck would have it, my next step profoundly influenced my career direction. Monash University was opening a Department of Medicine at the Alfred — I was determined to be their first registrar, and was subsequently appointed. Even though applications for all the other hospital jobs had closed by this time, Pincus Taft called me to say that Bryan Hudson, Head of the Monash Department of Medicine at Prince Henry’s Hospital, had called to ask why Zimmet had not applied to be his registrar. Pincus ordered me to see the charismatic Bryan immediately, and he told me I was to work for him! Hudson’s department had a powerful team including Henry Burger, Kevin Catt, Ken McLean, and Jack Hansky; Mel Korman was the other registrar. It was a wonderful training experience, not only in endocrinology but across internal medicine. Bryan was a fabulous and caring mentor, but a research career was still far from my mind. However, Bryan insisted that I must do a PhD and dispatched me off to the Monash Department of Biochemistry under the legendary Joe “Ginger” Bornstein (Box 1). My PhD was based around Bornstein’s belief that growth hormone fragments were involved in the regulation of glucose metabolism and insulin sensitivity. I slaved at the bench for 2 years, processing hundreds of litres of urine, and isolated a peptide with hypoglycaemic action5 which, some 35 years later, has commenced clinical trials as a drug for type 2 diabetes.6 Joe was convinced that my research was “cutting edge” and that his hypothesis needed better recognition, so he sent my thesis off to be examined by Professor Rolf Luft, the chairman of the Nobel Committee! My introduction to epidemiologyThe time had come for an “overseas” stint. I chose to work with Harry Keen at Guy’s Hospital in London, as I perceived he was a rising star in the field of diabetes and already a leader in diabetes epidemiology. Intuitively, I believed my PhD work needed a population perspective and that the only way to show its real significance in human diabetes would be to test it in an epidemiological framework. Harry stood out as the person to work with, so, with a Royal Australasian College of Physicians Travelling Scholarship, I headed off to spend a year and a half with him and John Jarrett, another outstanding figure in diabetes epidemiology. That well known pub the Bunch of Grapes was adjacent to the grounds of Guy’s and, between their office, the pub and the laboratory, we threw around many ideas. It was an intensely stimulating environment. Then came my next break, and again chance came into play. It was Christmas 1973 in London, and I was flipping through a pile of old Lancet issues when I came across a 1966 article by the famous New Zealand epidemiologist Ian Prior and his colleagues. They had reported a high prevalence of diabetes in Pacific islanders.7 Pincus Taft had a private practice that included the President of the Pacific island of Nauru, Hammer DeRoburt, and, struck by Prior’s findings, I convinced Pincus that we should undertake a diabetes survey in the Micronesian community of Nauru. This plan became the focus of my attention when I returned to Melbourne. By 1975, we were all set to go. I now had my first experience of the difficulties and logistics of undertaking a survey thousands of miles from home on a remote Pacific island. Nauru was a 7-hour flight from Melbourne and there was only one Air Nauru flight a week (but at least they served Château Mouton Rothschild with the meals!). Imagine our dismay on arriving to find that Air Nauru had left most of our equipment, including the oral glucose loads, at Melbourne Airport! Well, we had to thank the British, as a search through old stocks in the pharmacy left over from the colonial days revealed hundreds of bottles of British Pharmacopoeia 50% glucose, which we diluted and made palatable for the oral glucose loads. We tested 100 people on the first day, and I was stunned by the results — 33% of them had diabetes. Pincus, who I had convinced to join me, was certain it was something to do with incorrect dilution of the glucose, or that the blood glucose methodology was flawed. So sure of this was he that he decided to return to Melbourne, leaving me on Nauru. On the second day, another 33% had diabetes; and so on it went. We finished the survey with a prevalence of over 30%, the highest national figure ever reported anywhere in the world.8 The time was ripe to start warning the world about the potential epidemic of diabetes, a disease that still had “Cinderella” status. In 1976, I presented the Nauru results, reporting the highest diabetes prevalence ever recorded for the first time internationally, at the European Association for the Study of Diabetes (EASD) meeting in Helsinki. I spoke at the opening plenary session to a packed hall, wearing a bright red safari suit (Box 2) that made quite an impression on the audience. Its use was intentional, as I wanted my message to be remembered. I had seen the suit in Aquascutum’s window when I passed through London on my way to Helsinki. I thought that even if the participants forgot my message, they might at least remember the suit! Due to a chance meeting, Nauru provided me with further opportunities in epidemiology. In 1976, the Nauru Government asked me to act as physician to the heads of state attending the South Pacific Forum. While relaxing with my family on the beach at Anibare Bay, I started up a conversation with the only other person there. It was John Hirshman, the World Health Organization Representative for the South Pacific. Incredibly, it emerged that he had been a school classmate of my mother-in-law in pre-war Vienna! John was amazed by my Nauru findings and asked me to become a consultant to the WHO. As a result, I was then asked to undertake surveys in other Pacific Islands over the next few years, including Western Samoa, Fiji, Tuvalu, Kiribati, New Caledonia, Wallis and Futuna, the Cook Islands and Papua New Guinea. In each case, the same pattern emerged of high diabetes rates with modernisation of the islanders’ way of life. I “borrowed” the term “coca-colonisation” from Arthur Koestler9 to explain the impact of Westernisation in causing the high prevalence of diabetes in these Pacific communities. Even so, my predictions of an impending global diabetes epidemic and the potential time bomb in terms of morbidity and mortality were not taken seriously. Of course, sometimes my passionate message was misconstrued, as happened with a leading article in Melbourne’s The Age in 1992, titled “A Western killer let loose in paradise” (Box 3). Unfortunately, the message of the article was largely missed, as a photo of me was printed directly under the headline! But at least I now knew where my career was taking me — headlong into diabetes epidemiology and public health. Uncle Sam and the NIH to the rescueIn 1978, I applied to the National Health and Medical Research Council (NHMRC) to pursue the Nauru studies in greater detail, as it promised to be a goldmine of epidemiology. Requesting a modest $25 000 grant, I was rejected because they were not funding projects offshore. Around that time, the US National Institutes of Health (NIH) became a very strong supporter of diabetes epidemiology. This thrust was led by the enthusiasm and vision of Maureen Harris, from the NIH’s diabetes section, and Peter Bennett, internationally renowned for his research into diabetes in the US Pima Indian population. They suggested I apply to the NIH, as the agency was prepared to support overseas groups if they were undertaking work that would benefit the US. I added an extra zero to my NHMRC application and, in 1979, was fortunate to receive NIH funding. The rest is history, and over the next 20 years I received grants totalling in excess of $10 million for epidemiological studies in Pacific and Indian Ocean nations. From 1979 to 2000, my research was continuously funded by the NIH. It focused on the role of genetic susceptibility, obesity, physical activity, nutrition and sociocultural change in the aetiology of type 2 diabetes. My group also made contributions in the area of type 1 diabetes causation and detection with studies on glutamic acid decarboxylase (GAD), and we developed the first anti-GAD immunoassay for predicting type 1 diabetes.10 With Ian Mackay, and Leif Groop and Tiina Tuomi from Finland, we defined the condition of latent autoimmune diabetes in adults (LADA).10 With Mark Myers and Kalindi Hettiarachchi, I reported that bafilomycin, a food toxin produced in potatoes infected by potato scab, might cause β cell damage11 and type 1 diabetes. The founding of Australia’s first diabetes instituteMy clinical and other research strands came together in 1985 when I founded the International Diabetes Institute (IDI). On the way back to Australia from my stint in the United Kingdom, I had spent time in Denmark with Jørn Nerup at the Steno Memorial Hospital in Copenhagen. I was inspired by this unique facility, which brought together all aspects of diabetes research and care. I came home determined to try to replicate it. From a small base at the Royal Southern Memorial Hospital in Caulfield, my associate physician Matthew Cohen and I gradually built up a team covering diabetes education, care and epidemiology research. The IDI was the result, and it was officially opened by the Governor-General, Sir Ninian Stephen, in 1985 (Box 4). Over the next two decades, the IDI became a major force in diabetes both nationally and internationally and was designated as the first WHO Collaborating Centre for Diabetes. My epidemiology interests next took me to Mauritius in the Indian Ocean. Again we found a very high prevalence of diabetes.12 As the population of Mauritius is tri-ethnic — Asian Indian, Chinese and Creole — it represents almost 70% of the global population, making findings there of global relevance in predicting the chronic disease epidemic.13 A very exciting collaboration with Greg Collier at Deakin University commenced in the mid 1990s. I became aware of Psammomys obesus, a unique animal model of obesity and type 2 diabetes, and imported breeding pairs from Israel. Although better known as the Israeli sand rat, it’s actually a gerbil, having 85%–90% homology with the human genome. In its natural desert habitat, P. obesus remains lean and healthy on a low-energy diet of saltbush.14 However, when given access to standard laboratory chow, the animals develop insulin resistance, obesity, type 2 diabetes and the metabolic syndrome. Greg and I established a wonderful and productive collaboration to explore the genetic aspects of “diabesity”, resulting in numerous publications, patents and an exciting decade of research. Calling the diabetes epidemicBy the mid 1990s, it was even clearer to me that obesity and diabetes were destined to be the most important public health challenges of the 21st century, and that the combined diabesity pandemic was now set to affect most nations. Yet, I was very frustrated and saddened that I still could not get diabetes on the international agenda as a major public health issue. Fortunately, the message hit home in Australia in 1996 with the appointment of a new federal Health Minister. As Shadow Health Minister, Michael Wooldridge had seen a publication, The rise and rise of diabetes in Australia,15 that my Institute had prepared for Diabetes Australia. Struck by this, and after lobbying led by John Carter, a leading Sydney diabetologist, Michael committed the Liberal Party to a pre-election promise of $8 million for tackling diabetes. With the election won, he committed himself to projects that got the ball rolling, including a National Diabetes Strategy and eventually AusDiab, the first ever national diabetes and obesity study in Australia. I was fortunate to serve on a small ministerial advisory committee with John Carter and Stephen Colagiuri. Tim Welborn and I had long been advocates for AusDiab. We put together a national consortium and, with government funding facilitated by Michael, and support from the states, the pharmaceutical industry and some trusts, we were off and running in 2000 (Box 5). AusDiab became the largest national diabetes study in the world. We found that 1 million Australian adults had diabetes, another 2 million had prediabetes, and 60% were overweight or obese.16 The study, and its 5-year follow-up, have produced more than 80 peer-reviewed publications, and the data have been used extensively for health care planning both in Australia and internationally.17 National and international recognitionOur research has received global recognition and I have been fortunate to receive numerous national and international awards, including those from the American Diabetes Association, the EASD, Diabetes UK, the Australian Diabetes Society and the Canadian Diabetes Association, and an Honoris Causa Doctoris from the Complutense University of Madrid in Spain (Box 6). In 2007, I received the global Novartis Award for longstanding contributions in the field of diabetes. In fact, the IDI pulled off a trifecta, as it was a great thrill to see Jonathan Shaw, my Deputy Director, and our collaborating ophthalmologist, Tien Wong, receive the two Novartis Awards for younger investigators the previous year. But one award beat them all. In 2007, I was advised that I was to receive the Honorary Silver Breastplate of the All-Russian Diabetes Association. Further enquiries on my part revealed that this was usually a posthumous award that had gone to distinguished researchers such as Aretaeus (147 bc), Paul Langerhans, Elliott Joslin, and Banting and Best. After I informed the Russians that I was still alive, the award was elevated to a Gold Breastplate. As I was to be in St Petersburg soon after, they dispatched an official delegation from Moscow to make the presentation (Box 7). Vivien and I were rather concerned about how we would ship a large and heavy gold breastplate out of Russia, but we need not have worried — it turned out to be a gold lapel pin! The global epidemic and public health advocacyThe forthcoming and first ever national Health Risk Study proposed for 2010 has had its genesis in AusDiab and our advocacy. We can also take some credit for many of the new initiatives in diabetes, including those directed at preventing type 2 diabetes. The current scale of diabetes and obesity in Australia has serious ramifications. Through all of this diabetes “tsunami”, funding for health professionals to handle the epidemic has fallen very short. In parts of Australia, particularly in our Indigenous community, the prevalence of diabetes and its complications, especially renal failure and amputations, exceed those seen in developing nations and rate among the highest in the world. Prime Minister Rudd recognised this burden in an address to the Sydney Institute last year, stating that diabetes will be the number one disease in Australian men, and number two in women, by 2020.18 The studies in Nauru and Mauritius enabled me to confidently predict the diabetes epidemic that has now evolved,12 and we have estimated that the global number of people with diabetes will rise from 246 million in 2007 to 389 million by 2025.19 It was against this background that, in December 2006, the United Nations (UN) General Assembly unanimously passed Resolution 61/225 declaring diabetes an international public health issue — only the second disease after HIV/AIDS to attain that status. For the first time, governments have acknowledged that a non-infectious disease poses as serious a threat to world health as infectious diseases such as HIV/AIDS, tuberculosis and malaria. The UN resolution recognises that tackling diabetes is likely to be one of the most important challenges for the global public health community in the 21st century. Because of the close link between diabetes and heart disease, about 5 years ago I approached Garry Jennings, then Director of the Baker Heart Research Institute, with the idea of merging our two institutes. The marriage is now happily consummated. Together, as the Baker IDI Heart and Diabetes Institute, we have critical mass and will be a powerful force to face the mounting burden of diabetes and heart disease — two partners in crime. We will continue our strong public advocacy for fundamental alterations to how our lives are organised. Unless we learn the lessons from Nauru and Mauritius, and indeed our own Indigenous community, the epidemics of obesity, diabetes and heart disease will only worsen. ConclusionKey features of my career have been chance and the good fortune to have wonderful and inspirational mentors, a very supportive and loving wife, and two sons, Hendrik and Marcel, who continually challenge my social values and continue the family tradition in medicine, music and debate. I have had a great partnership with that towering figure in diabetes, Sir George Alberti, with whom I have chaired numerous WHO and International Diabetes Federation expert consultations on diabetes and the metabolic syndrome, and with whom I have collaborated, along with Jaakko Tuomilehto, in epidemiological studies. I have had other very supportive colleagues and a strong and dedicated team. In particular, Matthew Cohen and Jonathan Shaw have been devoted partners, as we built the IDI into an influential and innovative force on the world diabetes scene. The merged Baker IDI Heart and Diabetes Institute is now one of the largest forces in heart disease and diabetes research in the world. It has been a long road to travel, assisted by many episodes of chance, to achieve my ambition to see diabetes recognised as a major and serious international health problem and to catalyse action for better treatment and prevention. It has been a particular privilege to be a member of the National Preventative Health Taskforce selected by Nicola Roxon, federal Minister for Health and Ageing. The National Preventative Health Strategy, released in September 2009, embraces much of my own philosophy on preventing the escalation of the obesity-driven diabetes and cardiovascular disease epidemic.20 1 The 50th Anniversary of the Discovery of Insulin Congress, Jerusalem, 1971 L–R: Paul Zimmet, Pincus Taft, Joe “Ginger” Bornstein. 2 The red safari suit, Agra, India, 1976 L–R: Paul Zimmet, Professor Tom Johnson, Professor John Jarrett. 3 Report of a killer in paradise 4 With Governor-General Sir Ninian Stephen, opening the International Diabetes Institute in 1985 5 The AusDiab consortium at the 2003 annual meeting in Melbourne 6 Receiving the Honoris Causa Doctoris from the Complutense University of Madrid, Spain, 2002 7 Receiving the Honorary Gold Breastplate of the All-Russian Diabetes Association, St Petersburg, 2007

Paul Z Zimmet

Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe The most rewarding aspect of a career in mental health is that you get to spend time with truly inspiring people. My clinical work has focused on people whose lives have been affected by depression, bipolar disorder or schizophrenia. For any doctor who wants to connect with the most fundamental aspects of what it is to be human, nothing beats a career in mental health. However, the big frustration that I face on a daily basis is the impoverished mental health system in which we provide services. Too often have I run up against the comment, “That’s all true, Ian, but we won’t see any real change in our lifetime”. Brain & Mind Research Institute, University of Sydney, Sydney, NSW. Ian B Hickie AM, MD, FRANZCP, FASSA, Professor of Psychiatry and Executive Director ianhATmed.usyd.edu.au Getting into medicineI was fortunate to grow up in a large, academically oriented family. A rather strong Irish cultural legacy on one side and a printers’ union background on the other left me (and each of my siblings) at odds with the status quo. My early exposure to multiple perspectives, endless rounds of negotiation, and the need to come up with a collective rather than personal solution proved more valuable later in life than much of my professional training. Given my father’s distinguished career in academic medicine, my own journey down that same path may seem to have been rather predictable. Indeed, it now appears that there are strong transgenerational elements at work (Box 1).1,2 Unfortunately, like other rather glib narratives that are common in psychiatry, it’s an interpretation that doesn’t really fit the data. Having a father in academic medicine actually seemed to result in a household with an oversupply of lawyers! Perhaps we all do share a common sense of social justice. However, from my parents’ perspective, having only one of their seven university-educated children pursue a medical career always seemed a rather poor return on investment. While I enjoyed my early medical training at St Vincent’s Hospital in Sydney, the time I spent working for a bookmaker gave me a much better introduction to the more colourful aspects of everyday life. The real highlight of my undergraduate years was the time I spent in the Philippines during the later years of the Marcos regime. Not often can one so clearly experience the direct relationship between the impoverished state of a nation and the grossly inadequate health care that its citizens receive. The time spent with health professionals who took direct social actions to improve the lives of others also left a lasting impression on me. Pursuing psychiatryOn graduating, I jumped at the opportunity to be a resident medical officer at the still rather new and often chaotic Westmead Hospital. Here was a medical centre that was critical to the future of the community in which it was based. While working there, it became very clear to me that, although the rewards of procedural medicine were great and the challenges of internal medicine considerable, only psychiatry was really challenging from a personal and intellectual perspective. At that time, one training program stood out in terms of its academic rigour and breadth of teachers. Consequently, I moved to Prince of Wales and Prince Henry Hospitals to pursue my specialist training. Promoting medical paradigms in psychiatry researchOne of the difficulties that young psychiatrists face is the apparent drift away from conventional measures of pathophysiology. In the absence of clear laboratory markers, there is a recurring tendency to invoke more narrative accounts or other pseudo-sophisticated illness models. Fortunately, I was spared these distractions through my early research collaboration with two great physicians; namely, Andrew Lloyd and Denis Wakefield. Although our shared interest in post-infective fatigue syndromes has always aroused great controversy, it allowed us to work with a robust model for the onset of neurocognitive disturbance following a discrete medical event.3 Twenty years later, this work is now firmly based in more respectable models of cytokine-induced cognitive and mood disturbance.4 More importantly, very few psychiatrists ever receive the collegiate support that I have had from Andrew and Denis over the past two decades, and this collaboration put me in contact with a collection of international experts in medicine and psychiatry who share a much broader world view. Mood Disorders Unit at Prince Henry HospitalTowards the end of my registrar training, I was fortunate to work with the newly established Mood Disorders Unit at Prince Henry Hospital. The concentration of clinical researchers assembled under the leadership of Gordon Parker and Henry Brodaty was crucial to its success. While the work borrowed heavily from Leslie Kiloh’s earlier focus on the subclassification of depression, it used a range of neuroendocrine, neuropsychological and brain imaging technologies to develop a more specific fronto-subcortical model of severe mood disorders.5 During this period, I was lucky enough to lead projects that used magnetic resonance imaging. Although our neurological colleagues were aghast at our “waste” of such expensive tools, conveniently, the Professor of Radiology did not share their narrow view. Consequently, in partnership with Dr Liz Scott at Prince Henry Hospital, we were among the first groups internationally to demonstrate the clinical utility of these new techniques in people with severe depression.6,7 It kick-started a line of work that moved rapidly from detection of an underlying vascular abnormality in late-life depression to the development of large-scale preventive and early intervention programs.8,9 Growing more politicalWe should be active and loud advocates of the mentally ill and be in the forefront of their battle to realise their rights. This might require that we relinquish some of our professional role and add some political activism to our daily chores. Norman Sartorius, 199810 By its nature, the discipline of psychiatry is both philosophical and political. While many prefer the former path, I’ve always thought that Norman Sartorius was on the right track. In the early 1990s, I was very fortunate to win a Harkness Fellowship to pursue both my sociological and brain imaging interests at Duke University in North Carolina. Packing up a family with four young children and shifting continents proved to be quite an adventure. The Fellowship provided me with fundamental insights into the way in which communities could act collectively across a whole range of health and social issues. The emphasis on community action rather than government-based initiatives is central to social progress in the United States. Throughout this period, I had the good fortune of being assisted by an eminent clinician and Dean of Medical Education at Duke University School of Medicine, Dan Blazer. Dan is not only an international leader in depression research but, more importantly, he is gentle, educated, spiritual and community-oriented. His ongoing contributions are thoughtful and particularly relevant to those of us who work at the interface of society and biological medicine.11 Too few medical schools promote role models of this calibre. Joining forces with health administrationSoon after returning to Australia in 1995, I joined Dr Margaret Tobin at Sydney’s St George Hospital. She was determined to drag mental health services into the late 20th century. Margaret and I shared an ongoing joke over who would sustain this charm-free campaign after we had both moved on. Although the facilities were limited, the services were stretched, and the whole process appeared unnecessarily disruptive, it was a great learning experience. Margaret’s tragic death some years later robbed Australia of a person who was truly committed to changing the system. During my 5-year stay in southern Sydney, I learnt what it was possible to achieve with a small group of people who shared a common view of a better future. The deeply personal and broader collegiate relationships that I formed during this period continue to sustain me through tough times. Around this time, my own interests moved rapidly to the substantive issue of the lack of adequate management of depression in primary care settings.12 Working with Liz Scott, Tracey Davenport and a team of young psychologists, we were able to roll out SPHERE: a major national educational and service evaluation program.13 We conducted an audit of over 46 000 consultations in primary care settings. The study emphasised the low rate of detection and active treatment of common mental disorders, highlighted the lack of access to skilled non-pharmacological therapies, and set in place an enduring national general practitioner training program. Over a decade later, that program alone has provided various forms of general practice-based mental health training to more than 10 000 primary care practitioners. This work, in combination with my later advocacy work with beyondblue,14 provided the impetus to correct one of the major flaws in our Medicare funding system; namely, the lack of financial support for psychological services. By 2001, we had convinced the Australian Government of the need to provide specific payments for well trained GPs and clinical psychologists who provided psychological services.15 From my perspective, this was the first in a series of “not in our lifetime” predictions to be defeated. beyondblue and the Kennett eraIn the late 1990s, the Kennett Government in Victoria had moved to confront major health and social problems such as mental illness and drug misuse. In 1999, Kennett’s proposal to establish a national depression research institute appeared to have died with his election loss. However, immediately after that election, the federal Health Minister, Michael Wooldridge, set about resurrecting the plan. In 2000, beyondblue: the national depression initiative was born and Jeff Kennett was appointed as the chairman. It was a credit to the Victorians involved that they were able to put together this very smart deal. I jumped at the opportunity to become the inaugural chief executive officer of beyondblue (Box 2). Sadly, through a bizarre combination of state-based and professional rivalries, my home state of New South Wales refused to join. Despite the resistance, we set an ambitious agenda not only for improved community awareness of depression, but also for significant reform of primary care services, establishment of large-scale postnatal depression and secondary school-based preventive research, and investments in smaller-scale community-based and translational research programs. Importantly, we achieved major changes in other key industries such as life insurance and income protection.16 In the longer term, beyondblue has proven to be the major national driver of increased community awareness of depression and other common mental health problems.17 The wider significance of this to the field of mental health, and specifically the lives of those who live with depression, cannot be underestimated — we have seen major changes in community attitudes in our lifetime. Some have described my relationship with Mr Kennett as a rather odd example of a very odd couple. I always preferred the description provided by a Victorian taxi driver — he thought we could easily double for the comedians Roy and HG! In truth, Mr Kennett has many skills that are invaluable to our field. He also respected the fact that those with technical or clinical skills needed to take the lead on illness-related issues. If not for the offer of a lifetime from Max Bennett and the University of Sydney, I would have been happy to have spent a much longer period in Melbourne. Establishing the Brain & Mind Research InstituteThere is no doubt that the lack of a solid evidence base, and the long periods between genuine breakthroughs in clinical therapeutics, discourages some young doctors from pursuing a career in mental health. By the end of the 20th century, it had become clear that a fundamental change in direction for psychiatry was possible. The opportunity to forge real links with other clinical and basic neurosciences was emerging. Thanks to the foresight of Gavin Brown, then Vice-Chancellor of the University of Sydney, and the unrelenting drive of Professor Max Bennett, the Brain & Mind Research Institute (BMRI) was created (Box 3).18 In 2003, I left Melbourne rather prematurely to become its inaugural executive director. The BMRI is a unique campus, now combining over 20 major research teams that span key disciplines and technologies. I am proud that at least one major Australian educational institution has chosen to value mental health research so highly. The federal and state governments have responded positively to this movement, and we can now boast that the facilities provided for both patients and researchers are as good as any that one would expect for the management of cancer, infection or heart disease. This has been the third major “not in our lifetime” moment that I have experienced. Our ongoing focus on discovering how dysfunctional glial cell–neuronal networks give rise to the major mental disorders will keep us busy for some time to come. The BMRI is now the home of my own interdisciplinary and clinical research program. From 2007, this has been supported by a National Health and Medical Research Council (NHMRC) Australia Fellowship for health and medical research. Some of those close to me suggested that the NHMRC would be unlikely to back a clinical and health services-oriented psychiatrist under this scheme — just another “not in our lifetime” prediction that proved erroneous. It has enabled my talented team of clinicians and scientists to pursue large-scale national and international collaborative research. In partnership with Pat McGorry and his team in Melbourne, and led by Liz Scott and Sharon Naismith at the BMRI, we are rapidly developing a world-leading program of youth services19 and clinical research.20,21 This is complemented by our academic (with Helen Christensen at the Australian National University) and community (with the Inspire Foundation) partnerships in developing relevant e-health services. Achieving real political and social changeTwice in the space of a recent month I had senior political people say to me, “I know that needed to be said, but did you have to be the person who said it?!” One of the more obvious responsibilities associated with working in mental health is to speak out on behalf of those who are marginalised, neglected or abused. Fortunately, my peer relationships have grown to include a wider group of community and political leaders. Collectively, we have tried to push the political and social agenda. While the world of mental illness is no longer characterised by the more obvious abuses of human rights, it is still plagued by systematic failures in access to basic health care (only 35% of those with a common disorder receive treatment, and this has not improved in the past decade22), a lack of focus on early intervention for young people,23 too much reliance on the old restrictive ways,24 and disconnection from essential social, economic, employment, education and housing supports.25 As recently emphasised by the National Health and Hospitals Reform Commission,26 mental health continues to be an area of great inequity. Traditionally, politicians, health and educational institutions or philanthropists do not rush to identify with this form of suffering. At times, however, there have been notable exceptions. In 1993, the Keating Government responded positively to the findings of the Burdekin Royal Commission into mental health services and backed the first National Mental Health Strategy (1993–1998). This was continued as a second 5-year strategy (1998–2003) by the Howard Government. Sadly, leadership of that reform process was left under the control of a state-based committee that had little stomach for real change. By 2002, the community’s frustration with the lack of progress was palpable, and my colleagues and I decided it was time to revisit the community’s experiences. Working through the Mental Health Council of Australia, and with the assistance of the Human Rights Commissioner, Sev Ozdowski, we were able to complete a national evaluation that once again highlighted the disastrous consequences of our fundamental lack of investment in key mental health services and related social supports.27 The launch of the resulting report, Not for service: experiences of injustice and despair in mental health care in Australia,28 at the BMRI in 2005 indicated that our new academic home was not only committed to fundamental scientific advances but would also continue to engage in the issues that affected the daily lives of those with severe mental disorders. Although the Health Minister of the day sought to lay the blame at the feet of the states, a few days later, Prime Minister John Howard made it clear that mental heath reform was indeed a major social and economic issue that demanded a serious response. This rhetoric was matched by real action in mid 2006 when Prime Minister Howard and NSW Premier Morris Iemma enacted the Council of Australian Governments’ new National Action Plan on Mental Health 2006–2011.29 This national political action was a direct result of our 4 years of sustained campaigning. It was accompanied by over $4 billion in new investments and led directly to key structural changes. The most important of these was the introduction of new Medicare rebates for psychological treatments. Once again, this was a genuine “not in our lifetime” breakthrough. Prime Minister Howard went on to support the development of a new stream of youth services under the headspace initiative,23 while Premier Iemma backed substantial new infrastructure investments in youth mental health (Box 4) and research into the biological basis of psychotic disorders. Since its election in 2007, the Rudd Government has promoted much discussion about the future of our health system and, importantly for mental health, the development of the concept of social inclusion. At this stage, we are still waiting to see whether the rhetoric will be backed by decisive action.30 Although I have been appointed to the Health Minister’s new National Advisory Council on Mental Health, it is clear we need a government that genuinely prioritises improved access to mental health care, as well as linking health with other key areas of social services and disability support. The struggle to achieve another “not in our lifetime” moment is ongoing. Trying to find new ways to achieve real changeMost of my own community and advocacy work has sought to develop new styles of social and political partnerships. The key roles that the media, the business world, industries, community organisations and other professionals can play in improving the lives of those with mental illness have been obvious. I’m now deeply suspicious of those who seek either a largely government-delivered solution or, on the other hand, promote a simplistic, laissez faire approach. As in other areas of health care, developing services that respond personally to the particular needs of those we serve remains the biggest challenge. Staying in the businessA sustaining influence for much of my academic and social advocacy work has been the intellectual prowess of my professional colleagues. When asked why I chose to pursue psychiatry, I remark that the most interesting people I met throughout my medical training were psychiatrists. Real characters and genuine thinkers like Neil McConaghy, Gavin Andrews, Issy Pilowsky and Scott Henderson stand out. While leaders in other areas of medicine are identified by their technical skill or their lifetime dedication to patient care, psychiatry thrives on the daily contest of ideas. Although too few senior psychiatrists have engaged in the broader struggle to overcome the fundamental inequities that people with mental illness face, I have immensely enjoyed my work with the leadership of the Mental Health Council of Australia (and, specifically, the late Dr Grace Groom and then Mr John Mendoza). These days, I have the pleasure of the company of a new generation of Australian-based but international leaders in mental health such as Pat McGorry, Chris Pantelis, Helen Christensen and Nick Martin. Looking to the futureFor my colleagues and me, the past two decades have really been about working with the wider community to set a clear reform agenda in mental health. While our collective minds remain firmly focused on key issues of health equity, promotion of early intervention and youth-specific services, protection of human rights, access to evidence-based health services, and provision of appropriate social, employment and housing supports, real progress will remain dependent on our capacity to engage genuine community and political support. From a personal perspective, there are many more challenges ahead. 1 Three generations of medical research Ian Hickie (standing), with daughter Megan Hickie (left), partner Elizabeth Scott (right), and father Professor John Hickie AO (seated). 2 Launch of the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, July 2002 L–R: The Hon Bronwyn Pike (Victorian Minister for Community Services), The Hon Jeff Kennett (Chairman, beyondblue), Ian Hickie (Chief Executive Officer, beyondblue), Professor Bruce Singh (University of Melbourne). 3 Opening of the Brain & Mind Research Institute research laboratories, 2006 Ian Hickie and Prime Minister John Howard. 4 Opening of the clinical and translational research facilities at the Brain & Mind Research Institute, 2007 L–R: Premier Morris Iemma, Professor Max Bennett AO, Ian Hickie.

Ian B Hickie

Health services research is now a top priority for the National Health and Medical Research Council Health research has many objectives. It can develop fundamental knowledge about human health and what causes ill health, improve means of diagnosing diseases and treating patients, provide evidence for preventive health strategies and interventions, invent new devices and agents to treat and cure disease, and provide the community with better knowledge on how to safeguard their health and wellbeing. It is therefore surprising that the health system has historically been the focus of much less research than has been concentrated on the health of individuals. During the past decade, Australia has increased its research effort into public health and preventive health through National Health and Medical Research Council (NHMRC) funding, from a budget of $10.6 million in 1997 — the last year of the Public Health Research and Development Committee (PHRDC) — to $91.5 million in 2009. (The PHRDC was established by the NHMRC in 1987 in response to the Kerr White Report,1 published in the mid 1980s; in 1997, its role was absorbed, along with that of the then Medical Research Committee, into the newly created NHMRC Research Committee.) But health services research has lagged and in 2009 attracted only $32.4 million (out of a total NHMRC research budget of $706.9 million). Of 3111 applications received by the NHMRC for project grants in 2009, only 134 (0.4%) were categorised by applicants as being for health services research. There is further support for health services and systems research from the health system itself, but little by way of a coordinated approach that recruits the most able researchers. In 2006, the NHMRC made a commitment to increase its support of health services research — in line with the recommendations of the Investment Review of Health and Medical Research review committee chaired by John Grant, which reported in 2004 to the then Minister for Health and Ageing.2 A special advisory group was established by the NHMRC, chaired by Professor Sally Redman of the Sax Institute and the University of Sydney, to set up a framework to influence and support the infusion of evidence from research into improving the health care system and the actions of health professionals, and into public health policy. This committee completed its work in early 2007, and its report was considered by the NHMRC’s Research Committee and Council.3 Both agreed that the NHMRC Partnerships for Better Health initiative be established. In 2008, the NHMRC committed $250 million over 5 years — commencing in 2009 — to support the Partnerships for Better Health initiative, which comprises two key initiatives. The first key initiative is the Partnership Projects scheme, which aims to: provide support for research that addresses the delivery, organisation and funding of programs and services that affect health; and encourage researchers and partner organisations to form alliances to identify research projects, conduct research, interpret their findings, and promote the use of their findings to influence design and evaluation of health and health care policy and practice. As with all NHMRC funding schemes, a rigorous peer-review process was established for this scheme to ensure that only the best research and researchers would be funded. Applications for Partnership Projects were called for on 25 July 2008 and closed on 19 December 2008. This longer than normal application period was considered essential, given that a requirement of applications was that a partnership be established between applicants and organisations involved in health care. One hundred and thirteen applications were received, with a wide range of health bodies partnering health researchers. The applications were reviewed by a panel that consisted of experienced health services researchers (including two from New Zealand), as well as experienced, research-trained state and federal health officers. The 27 successful applications, valued at a total of $21 million, were announced by the Prime Minister on 16 October 2009. They cover a wide range of health services research, including: improving services for people with dual sensory impairment (vision and hearing); improving maternity care services; studies in general practice (including guideline implementation for chronic disease, Indigenous primary care services and diabetic retinopathy monitoring); acute stroke care; sports safety; hepatitis C assessment and treatment in drug users; allied health services in rehabilitation; childhood mental health; system design for the care of pregnant women with diabetes; public health interventions to reduce metabolic syndrome; patient-centred chronic care in Indigenous communities; rural cancer care; and improving hand hygiene in health care settings. A full list of these grants is available at http://www.nhmrc.gov.au/grants/partnerships.htm. The partner organisations, which have committed to work with the researchers with a view to improving health policy and practice, include state health authorities and non-government organisations, as well as community groups, Indigenous community groups and commercial associations. Other partner organisations include: Australian Commission on Safety and Quality in Health Care Sydney South West Area Health Service Australian Football League Hepatitis C Council of NSW Cancer Council Australia Water Quality Research Australia Australian Food and Grocery Council Diabetes Australia Australian Red Cross Blood Service Epilepsy Australia National Stroke Foundation. The second key initiative in the Partnerships for Better Health initiative will be the Partnership Centres for Research Excellence program. This will promote collaboration between researchers and those working in health and the health care system, and will be announced in 2010. A discussion document developed by an international team — Jonathan Lomas (former Director, Canadian Health Services Research Foundation), Sally Davies (Director General, Research and Development, Department of Health, United Kingdom) and Chris Baggoley (Chief Executive Officer, Australian Commission on Safety and Quality in Health Care) — was released for discussion as part of a final consultation process in July 2009.4 The NHMRC Research Committee will consider this feedback in late 2009. To further promote health services research, the NHMRC introduced the Capacity Building Grants in Population Health and Health Services Research program in 2008, which in 2009 was transformed into the Centres of Research Excellence Scheme. This scheme does not require contributions from partner organisations, and aims to support teams of researchers to pursue collaborative research and develop research capacity in health services. The cost to Australia of its health system is more than 9% of its gross domestic product, and exceeded $100 billion per year for the first time last year.5 Although many health professionals do not like to regard health care as an industry, it is the second largest employer of Australians and most of us use its services each year. High-quality research and development is therefore essential for developing a health system that operates on the basis of evidence and ensuring that the health system can be, in the words of the National Health and Hospitals Reform Commission, an “agile, self-improving” system into the future.6

Warwick P Anderson BSc(Hons), PhD · Elim M Papadakis BA(Hons), PhD

Objectives: To explore National Health and Medical Research Council (NHMRC) funding for each National Health Priority Area (NHPA) over time and by grant type, and to quantify the relationship between grants awarded and a range of measures of societal burden of disease (BoD).Design and setting: We conducted a retrospective analysis of NHMRC funding for each NHPA from 2000 to 2008 to assess the strength of correlation between level of NHMRC funding and contribution of each health condition to BoD. Information on mortality, incidence, prevalence, “healthy” years of life lost due to disability (YLD), years of life lost due to premature mortality (YLL) and disability-adjusted life-years (DALYs) was obtained from the 2003 Australian BoD study. Information on health system expenditure for each NHPA was obtained from an Australian Institute of Health and Welfare report.Main outcome measures: Observed versus expected number of grants; amount of funding allocated to each NHPA; relative contribution of each NHPA health condition to BoD.Results: 6099 new and continuing NHMRC grants were linked to NHPAs. Total NHMRC funding by NHPA was strongly correlated with YLL and DALYs, but there was no clear association between the amount of funding per NHPA and YLD or health system expenditure. Based on the proportional contribution of each NHPA health condition to total NHPA-related DALYs, a higher than expected number of grants was allocated to diabetes and cancer research, and a lower than expected number to injury and mental health research.Conclusions: Some of Australia’s NHPAs are better funded than others. The NHMRC could begin to redress this imbalance by allocating research and workforce development funding to less well developed research areas to ensure appropriate resourcing that is commensurate with their contribution to BoD.

Rebecca J Mitchell MA(Psych), MOHS, PhD · Rod J McClure PhD, FAFPHM · Jake Olivier PhD · Wendy L Watson BSc(Hons), MA, PhD

In October 1918, an Allied army (Egyptian Expeditionary Force) in Palestine experienced simultaneous epidemics of falciparum malaria and influenza during the cavalry campaign that defeated the Turkish Army. Malaria infection occurred 2 weeks after the advance of cavalry units into areas without environmental mosquito control. Pandemic influenza, now thought to be an A/H1N1 strain, struck at the same time. In the Egyptian Expeditionary Force of 315 000 soldiers, 773 died from malaria and 934 from influenza–pneumonia. Disease casualties outnumbered those due to combat by more than 37 to 1. Simultaneous infectious disease epidemics can cause mass casualties, capable of overwhelming any health service.

G Dennis Shanks MD, MPH

Charles Darwin visited New Zealand in December 1835, and Australia from January until March 1836, on the return portion of his voyage around the world in HMS Beagle. Despite the shortness of these visits, he retained an interest in these countries throughout his life, maintaining correspondence and receiving many biological specimens. His experiences in these places influenced his thinking on evolution, particularly on the evolution of man. Aspects of his health recorded during this part of the voyage support a new hypothesis for the diagnosis of the illness that Darwin endured for most of his life.

John A Hayman MB BS, MD, FRCPA

Body and mind. Historical essays in honour of F B Smith. Graeme Davison, Pat Jalland, Wilfred Prest, editors. Melbourne: Melbourne University Press, 2009 (ix + 243 pp). ISBN 978 0 522 85717 7. Francis Barrymore “Barry” Smith, Emeritus Professor at the Australian National University (ANU), is one of Australia’s most outstanding and influential historians. This festschrift is a fine collection of essays by a very well respected group of historians, all of whose work has in some way been influenced by Smith. Retiring in 1997 (to continue his work as a Visiting Fellow), Smith spent most of his career at the ANU. Much of his work was concerned with British, rather than Australian, social and medical history and, reflecting this, six of the 10 chapters focus on aspects of British history. These include Alex Tyrrell’s delightful study of the mid 19th century British water cure, Pat Jalland’s thought-provoking piece on the treatment of tens of thousands of civilians killed during the Blitz, and Joanna Bourke’s insightful discussion of “malingering” and the complex relationships between members of the medical profession, especially psychologists, and those who seek to be certified as officially sick. Among the essays dealing with Australian topics is one on a major study in historical demography and epidemiology currently still being conducted by Janet McCalman, Ruth Morley and Gita Mishra. It draws on a range of sources of historical statistics, particularly the records of the Lying-in Hospital for Melbourne, and follows large numbers of individual lives from birth to death, by linking to other sources such as birth, marriage and death records, criminal records, school records and war service records. The essay “To die without friends: solitaries, drifters and failures in a new world society” examines the relationship between poverty, marginalisation and the absence of family and friends. Australian chapters also include Peter Edward’s study of Agent Orange and Australia’s Vietnam veterans, Philippa Mein Smith’s history of the concept of “Australasia” and Susan Margarey’s biographical sketch of Catherine Helen Spence (writer, preacher, reformer, feminist and leading woman in public affairs in Australia at the end of the 19th century).

Sally Wilde

With healing hands. The untold story of the Australian civilian surgical teams in Vietnam. Gary McKay, Elizabeth Stewart. Sydney: Allen and Unwin, 2009 (xvii + 286 pp). ISBN 9781741750744. Even after the passage of more than 30 years, Australians retain a collective memory of the war in Vietnam. But the volunteer surgical teams, sent by the government to work in local hospitals and treat the civilian population, have largely been forgotten. From 1964 to 1972, about 450 doctors and nurses served for periods of 3 to 12 months in one of four locations — Long Xuyen, Bien Hoa, Vung Tau and Ba Ria. Some returned for a second or third term. They were exposed to considerable personal danger and, on occasion, were under attack by the Viet Cong. Using diaries, letters and reminiscences of many team members, the authors (McKay, a Vietnam veteran, and Stewart, a historian at the Australian War Memorial) paint a vivid picture of the difficulties and frustrations of medical and surgical practice in primitive conditions with inadequate equipment, in the face of cultural indifference and lukewarm government support. This situation will be familiar to every doctor and nurse who has worked in developing countries in more recent times. More than half the patients treated were the victims of war; many others had been involved in road accidents. The stress under which the team members worked was unrelenting. Many have since suffered physical impairments to their health, with some developing post-traumatic stress disorder. Unlike Vietnam veterans, members of the surgical teams have no entitlement to repatriation benefits. The government has acknowledged their service to Australia by awarding them the same campaign medals given to soldiers, but has withheld the same entitlements. It is not too late, the authors believe, to redress this injustice. They conclude by posing the question, “Was it worth it?” Most of those interviewed seemed to think so, even if little of a permanent nature was achieved. After all, is not the relief of suffering the foremost of a doctor’s duties?

Robert K Likeman

The yipping tiger and other tales from the neuropsychiatric clinic. Perminder Sachdev. Sydney: UNSW Press, 2009 (x + 289 pp). ISBN 978 1742 230849. With the opening phrase “The golf swing is an act of grace and supreme poise,” I felt I was about to read another Harvey Pennick (teaching golf pro) publication. Rather, this is a compilation of case studies the author gathered over 20 years. Perminder Sachdev, Professor of Neuropsychiatry at the University of New South Wales and Director of the Neuropsychiatric Institute at Sydney’s Prince of Wales Hospital, considers 10 disorders and their underlying brain mechanisms. “The yipping tiger” examines golfer’s cramps, “Shaking hands with Dr Strangelove”, the alien hand syndrome, and “Swearing like a Spanish sailor”, coprolalia in Tourette syndrome. Other chapters cover brain enhancement, anorexia nervosa, frontal lobe dysfunction, major depression, obsessive compulsive disorder, phantom limb and mild cognitive impairment. The inclusion of depression and obsessive compulsive disorder as topics was a little surprising — knowing the immense range of material referred to neuropsychiatrists I was expecting to find other topics (such as Lewy body dementia, Huntington disease, stroke and depression, epilepsy and psychosis and demyelinating disease) selected for discussion of the overlapping neurological and psychological/psychiatric aspects of brain disease. While well referenced with good notes accompanying each chapter, Sachdev might have shortened each chapter by a few pages in order to include other examples of neuropsychiatric disorders. Books of this format demand the difficult balancing of clinical vignettes with more detailed discussion of underlying systems and constructs (as demonstrated by Oliver Sacks and Harold Klawans). Some of Sachdev’s detours and digressions are distracting to the reader, particularly if this book is intended for the lay audience rather than the medical fraternity. Yet this book is interesting and informative, with the audience lying midway between the interested layperson and the professional. It is very reasonably priced.

John H Lloyd

Waiting room. A memoir. Gabrielle Carey. Melbourne: Scribe, 2009 (217 pp). ISBN 9781921372629. I’ve got mixed feelings about memoirs. Having cringed my way through the insipid or vitriolic ramblings of a number of previously admired politicians, actors and journalists, I’ve come to the conclusion that some people’s inner worlds are best kept that way. Nonetheless, I had high hopes as I read the blurb for well known Australian writer Gabrielle Carey’s Waiting room, and plucked it from the review pile to read over a long weekend. All doctors should read patient stories and Carey is an accomplished Australian writer of my generation — surely there would be much in the book to learn from and relate to. I was not disappointed. Waiting room details the diagnosis and management of Carey’s elderly mother’s meningioma. As a medical story, it appears accurate and straightforward and its portrayal of the clinical encounters, surgery and hospital stay is surprisingly undramatic. Without labouring the point, and with a very Australian sense of acceptance and ultimate trust in the medical system’s competence, Carey documents long hours spent waiting for life-changing medical appointments and the all-too-common experience of having planned surgery delayed by a lack of hospital beds. The medical characters are in the book for their functionality rather than their personalities. In fact, the medical story is really a backdrop to the main business of the book; Carey’s relationship with her enigmatic mother. When you reach a certain age, you realise that life is filled with unanswered questions, incomplete understandings, ambiguous meanings and relational loose ends. The beauty of a memoir is that it can unapologetically reflect this chaos without the need for momentous conversations, dramatic revelations and eventual resolution. As a doctor, writer, daughter, wife and mother, I found much to learn from and relate to in Carey’s Waiting room. Sometimes the truth may be stranger than fiction, but generally it is just much more real.

Ruth M Armstrong

Contagious: cultures, carriers and the outbreak narrative. Priscilla Wald. Durham: Duke University Press, 2008 (xi + 373 pp). ISBN 978 0 8223 4153 6. Although the medical aspects of communicable diseases are no doubt fascinating, the impact of infections on our local and global community is no less enthralling. Richard Preston’s The hot zone and Ken Alibek’s autobiography, Biohazard, are two examples of such intriguing narratives, the former a spine-tingling tale of the discovery of Marburg and Ebola infections and the latter exploring the Soviet bioweapons program and Alibek’s defection to the United States. Priscilla Wald’s book, Contagious, is not just another narrative about various outbreaks. It is primarily about the historical and social views in times past and present and how they paralleled, influenced and were themselves influenced by the emergence of infectious diseases. Contagion literally means to “touch together”, and originally referred to the circulation of seditious or dangerous ideas. It eventually came to be adopted as a term for communicability of infections, retaining the negative connotations of its origins. Highlights included the stigmatisation of “superspreaders”, those people who deliberately or unwittingly infect large numbers of people. Wald gives examples: a flight attendant during the SARS outbreak in 2003; Patient Zero during the early AIDS epidemic; and probably the most famous superspreader of them all — Mary Mallon, also known as Typhoid Mary, who was a healthy carrier of typhoid fever in New York in the early 1900s. Wald describes how at least one contemporary author cast Typhoid Mary as a “fallen woman” sexually. It was as if her supposed sexual transgressions, her mobility and independence — so different from that of the stereotypical virtuous woman of the time — allowed her to take on the role of a superspreader. Similarly, the ghettos in Manhattan of the early 20th century were not just seen as a home to new arrivals to the United States. They were simultaneously regarded as concentrated areas of foul infections and unfamiliar cultural beliefs emanating from immigrants waiting to be “Americanised”. Wald describes this as “medical nativism”, where one justifies the stigmatisation of immigrants through their association with communicable diseases. Wald also draws an interesting parallel between communicable diseases, the communist threat of the Cold War and popular fiction of that time (such as The body snatchers), where normal people have been infiltrated or “infected” by malicious influences, transforming them into “human-looking monsters”. The author herself is not a medical doctor but a Professor of English at Duke University in the US. The book is extremely well written, although it isn’t a light read by any means. It is a good book that has given me a new perspective on the outbreak narrative.

Sanjaya N Senanayake

Each year, medical editors at the MJA read thousands of peer-review reports recommending the acceptance, revision or rejection of hundreds of manuscripts. This advice is generally sound and based on data, information and knowledge. It is always gratefully received and highly valued. Most rarely received, but most prized of all, are comments steeped in wisdom. What is wisdom? It seems that data progress to information and then on to knowledge. British physicist, experimental psychologist and revolutionary futurist Peter Russell suggests that knowledge then progresses to a new level of thinking — what we call wisdom.1 The essence of wisdom is discernment — of right from wrong, of helpful from harmful, and of truth from delusion. Here, we string together some of our reviewers’ pearls of wisdom that appeared on MJA medical editors’ screens this year. When one is not enough“On its own, monitoring cannot combat rising obesity levels. If this argument were to hold for Indigenous health, we would have closed the gap between Indigenous and non-Indigenous morbidity and mortality well before now.” Timing matters“This is a ‘work-in-progress’ report on an important initiative, although the fruits have yet to ripen, let alone be gathered.” Apples and oranges“Petrol sniffing and filling up your car with petrol are comparable — yes, the end result is acquiring petrol, but they should not be mentioned together.” Nothing will happen“The trouble with the term ‘judicious use’ is that it results in no meaningful change in behaviour.” Anyone for a purge?“The only way to tell the difference between the sheep and the true believers is by the occasional bloody purge (no, not the swear word, the literal meaning). Thomas Jefferson said: ‘A little revolution [sic] now and then is a good thing... The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants’.2 So publish I say, and let the blood run free.” Woof! Peer review can be a tricky business. Although it is not uncommon for a content expert to suggest a revision that is at odds with the statistical advice received, it is indeed uncommon for the content reviewer to be proven right. After seeking further advice to resolve one such contentious point, our arbitrator delightfully quipped: “You should give this content expert a gold star! A big one. About the size of a small dog. He is absolutely correct in his points and I support his concern about the suggestions of the statistical reviewer.” The reviewer who received the compliment was just as quick-witted: “Let’s hope the ‘small dog’ does not bite me!” Food for thoughtBlissfully, MJA authors display an equal share of wisdom, not only in the Journal pages but also in their correspondence. Author: “There is not much one can put in 850 words and 10 references, but an editorial should probably be an invitation to think rather than a recipe to follow.” TouchéReviewer: “The editorial needs to be much more critical, eg, pointing out the preliminary nature of the studies and that they are at best hypothesis-generating. It might even stipulate the definitive studies that are needed and the confounders that need to be overcome...” Authors’ reply: “We would like to quote Sir Austin Bradford Hill: ‘All scientific work is incomplete — whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand ...’”3 Whereas online publishing is a relatively recent innovation, wisdom is ancient and enduring. In the 17th century, Thomas Bartholin, the Danish physician, physiologist and anatomist, penned what has become one of my favourite quotations: Unfortunately, there are enough people who are so infatuated with their specialized studies that they are ignorant and unaware of other disciplines. If fate happens to lead them to fields other than their own, they are helpless and lost. May God protect you from an infection with the germs of haughty contempt for the efforts of scientists in other branches of science. Your country demands more than one-sided proficiency. Only the correlation of extensive knowledge will bring us closer to actual wisdom.4 Perhaps depth comes with a breadth of experience?

Ann T Gregory MB BS, GradCertPopHealth

Stimulate: To animate, excite, arouse. — Concise Oxford dictionary, 8th ed It’s been a tough year. To survive the economic downturn (not technically a recession, but it feels like one), we have been forced to tighten our belts, hire DVDs and stay home for cheese on toast. Here at the MJA, we have decided this is a time to keep smiling, even as property prices plummet (or skyrocket, depending on which paper you read), the mercury rises, and the promise of health reform languishes. As the prospect of the annual beachside holiday recedes and you attempt to convince morose and monosyllabic teens that playing under the sprinkler in the garden really is as much fun as the Gold Coast, we are delighted to entertain you. Thus, we offer you an alternative to turkey sandwiches and reruns of Bush Christmas by announcing our own stimulus package — the MJA Christmas Competition. As usual, the calibre of the entries this year was very high and, once again, the number of submissions record-breaking — supporting the premise that the health care industry really may be recession-proof. In keeping with our theme, and proving finally that men are wimps, Furyk and colleagues show that when it comes to stimulating pain, it is preferable to pull a bandaid off fast rather than slow, especially if your patient happens to be hirsute. So when you find yourself in the position of removing a sticky dressing after one of the aforementioned teens has done a skid on the concrete under the sprinkler, you can reassure him that you are a health professional and you have the evidence. Then just rip it off (→ Fast versus slow bandaid removal: a randomised trial). Another humour-stimulating offering comes from Mullins, who, while working in East Timor, found that dancing about an operating suite clutching a newborn baby and repeatedly whacking oneself over the head does not translate into any language. But he certainly learned one way to communicate — by stimulating a smile, both from his bemused colleagues and MJA staff members (→ Out of my depth in East Timor). If exciting your guests’ jaded appetites causes you to consider a seafood alternative to turkey this year, perhaps you should take note of Davies and Bate, who suggest that the bones of Dory are the least visible on x-ray of the common fish species they examined (→ Relative radio-opacity of commonly consumed fish species in South East Queensland on lateral neck x-ray: an ovine model). To avoid a trip to the emergency department, maybe have prawns instead — if you can afford them, of course. In a more poignant vein, offerings from Livermore (→ Christmas celebrates birth: new life, new love, new hope), Hodgkinson (→ The pressure of time) and O’Callaghan and colleagues (→ ”The moment is all we have“: patients and visitors reflect on a staff Christmas choir) remind us of the spirit of the season, and Johnson remembers with a smile how a slip of a patient’s tongue can make even the most exhausted medical team fall about the ward in fits of restorative laughter (→ A prescription for a smile). While digesting our erudite Christmas offerings this year along with the turkey, Dory, or prawns, you might like to peruse Parry’s take on the DSM-IV — while concurring with an “‘ah, yes’ and ‘hmmm’ (shorter, higher pitched subtype, usually indicative of agreement)” Parry (→ Cough disorder: an allegory on DSM-IV). But there must be a winner, even among a selection as strong as this. Our ballot, conducted with the utmost secrecy, akin to inviting a peer review, showed that the True Story with the most votes was Geoffrey Mullins’ account of obstetrics in a developing country. In the Christmas Offerings category, the winner was Francis Bowden’s thought-provoking musings on the great divide between physicians and surgeons, “When two tribes go to war”. Both winners will receive a fantastic hamper courtesy of the MJA as an extra stimulus to further creativity. Finally, remember that we appreciate and enjoy your every contribution throughout the year, and wish you all the peace and goodwill of the season. It may be that you are not yourself luminous, but you are a conductor of light. Some people without possessing genius have a remarkable power of stimulating it. — Arthur Conan Doyle

Tanya Grassi

For Susan * Richard Bronson’s collection of poetry Silent music is published byPadishah Press (New York, 2009). This poem is reproduced with permission. You lit a candle at Chartres, a prayer from one mother to another and placed it with the hundred others, white wax in red glass, a light burning in the deeps of this Earthly palace which men of all stations had labored to build for the Queen of Heaven. Neither of us believers in the faith that told of God incarnate born of a woman to rescue all men from Death — yet in this ancient place, in the quiet shadows of its holiness, you felt the need to say your fervent prayer for the world.

Richard Bronson,* MD

Incorrect order of authors: In “ASID (HICSIG) position statement: infection control guidelines for patients with influenza-like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities” published online on 21 September 2009 and in the 19 October 2009 issue of the Journal (Med J Aust 2009; 191: 454-458), John K Ferguson was incorrectly listed as the first author of the article. The correct order of authors is: Rhonda L Stuart, Allen C Cheng, Caroline L Marshall and John K Ferguson.

Rhonda L Stuart FRACP, PhD · Allen C Cheng FRACP, MPH, PhD · Caroline L Marshall FRACP, PhD, GradDipClinEpi · John K Ferguson FRACP, FRCPA, DTMH

Two sisters aged 6 and 11 years presented with pruritic inflammatory lesions, one on the arm and one on the shoulder (Figure). The lesions appeared 72 hours after the girls had black henna tattoos applied while they were on holiday in Egypt. On examination, each girl had eczematous eruptions that perfectly outlined the tattoo. Patch tests were positive for paraphenylenediamine, a known potent contact allergen. Black henna tattoos are a frequent source of sensitisation to paraphenylenediamine among Australian tourists to South-East Asia.1 Potential significant consequences include allergic reactions to hair dyes, textile dyes, anaesthetics, sulfonamides and sunscreens containing p-aminobenzoic acid.

Pablo J Almeida · Leopoldo Borrego

“I vont to do an emergency caesar, quick!” Andre’s voice crackled into my heavy, hand-held emergency telephone, which I had not yet mastered. Andre was a tall, good-natured Dutch general practitioner who had been working at Dili National Hospital for over a year and did much of the obstetrics when the hospital lacked a specialist obstetrician (a frequent occurrence). I had warmed to him immediately; he was one of the very few people employed in the hospital who spoke English, and he had an air of confidence that was reassuring. He told me that the operating room was already preparing for the procedure, he would be there in 30 minutes, and he hoped I could have the patient anaesthetised and ready by that time. It was my second day as the only anaesthetist at the only tertiary referral hospital in East Timor, and I had just discovered that, at that time (August 2001), I was the only specialty trained anaesthetist in the country. I was already finding my job challenging. Dili National Hospital (formerly, the Indonesian State Hospital) had had an eventful recent history. After the referendum supervised by the United Nations in August 1999, when the people of East Timor voted overwhelmingly for independence from Indonesia, the Indonesian army and its local militia withdrew — burning, looting and killing as they went. When the International Committee of the Red Cross took over temporary management of the hospital in September 1999, they found that the buildings were intact but much of the equipment had been looted or damaged, and only 10 nurses remained caring for 37 patients. With the support of the Red Cross and the local population, the hospital was re-established and handed over to the new Government of East Timor on 30 June 2001. The hospital’s bed capacity was 226, and it was greatly in need of external support, especially specialty medical staff, technical assistance, equipment and drugs. The challenges for an anaesthetist at this time in East Timor have been well described.1 The limited facilities for anaesthesia, the minimal laboratory and radiological investigations available, the lack of drugs, and the scarcity of blood for transfusion were major daily concerns. However, by far the greatest difficulty I faced was the language barrier. The languages spoken in East Timor are Indonesian, Tetum and Portuguese. Apart from a few expatriate medical practitioners, very few of the more than 300 East Timorese hospital staff spoke any English, and it was rare to find a patient with any understanding of English. In particular, none of the staff working in the operating room spoke or appeared to understand English. My initial approach was that commonly used by English speakers when faced with people who don’t speak English. I would speak very slowly, opening my mouth wide and carefully enunciating my words, which of course they didn’t understand. Next, I would raise my voice in the hope that loud English words would penetrate further into the brain of the listener, perhaps to a part of the brain that somehow understood English. Failing this, I would add some crude improvised hand and arm movements in an attempt at sign language. Finally, if my listener still had that gentle, bemused look that I was becoming very familiar with, I would reach into my pocket for my Indonesian–English dictionary. I would find the appropriate word and point at it repeatedly, while staring at my listener hoping for some indication that all was now clear and that he or she understood what in the hell I was talking about. This was a slow process to be sure and, as I was to discover, fraught with risks. Part of my responsibility was to instruct the East Timorese male nurse anaesthetists when they were in the operating room. So, on my first day, when confronted with a patient who developed tachycardia during anaesthesia, I decided this was an excellent opportunity to begin my teaching sessions. Applying the communication techniques described above, I soon had the attention of the entire operating room staff. With a raised voice, I slowly and loudly enunciated the words “too fast”. I then repeatedly pointed at the rapid electrocardiogram trace on the patient monitor, saying “too fast”. Unconvinced that I was being fully understood, I took out my dictionary, found the word “fast” and pointed at the word and then at the monitor. Suddenly, to my delight, the two nurse anaesthetists both smiled knowingly, but then strangely began to make blowing noises through their pursed lips, much to the amusement of the rest of the operating room staff. Somewhat bemused, I finally looked down at the dictionary and found that my finger had inadvertently been pointing at the word “fart”, not the word “fast”. This early incident, although highlighting the difficulties I would face in communicating easily and effectively, also paradoxically helped me rapidly establish a casual rapport with the staff that lasted for my stay at the hospital! Responding to Andre’s request for my anaesthesia services, I hurried to the maternity ward to see my first obstetrical patient in Dili. Neither the patient nor the staff spoke or understood English but, by observing the patient and looking up her records, I did glean some important clinical details. She was a distressed 32-year-old multigravida with severe pre-eclampsia. She was in strong labour with ruptured membranes and meconium-stained liquor. Her eyes were puffy, she was photophobic, her blood pressure was between 180/140 and 240/170 mmHg, and there was protein in her urine. There were no antihypertensive drugs on the ward; in fact, there were none in the entire hospital. This was indeed an emergency situation. There was no time for me to practise my communicating skills, so I hurried to the operating room, trusting that Andre and the nursing staff had explained the need for a caesarean section to the patient. I arrived in the operating room closely followed by the patient on a trolley. Two male nurses were present. They were scrubbed and gowned and busily preparing instruments as I moved the patient onto the operating table and positioned her on her side in preparation for a spinal anaesthetic. I was about to place monitors and insert an intravenous line when she suddenly had a strong, painful contraction. I stopped my preparation and began massaging her lumbar region, while murmuring quiet, reassuring English words (gibberish to her ears) and waited for the end of the contraction. Without warning, there was a sudden thud and a loud cry. Looking down at my feet, I saw a wailing, meconium-stained baby on the floor. I looked at the mother and saw, emerging from between her legs, an umbilical cord that had obviously broken off as the baby fell to the floor. The two nurses standing behind their instrument trays were wide-eyed and aghast and appeared unable to move. I picked up the now screaming, slippery baby boy and was holding him in my arms when a midwife entered the theatre. I immediately tried to communicate to her that the baby had fallen on the floor, and probably on his head. This I did by repeatedly hitting my head with my free hand, as I held the baby in my other arm. At the same time I was imploring the scrub nurses, who still seemed unable to move, to “Get Andre! Get Andre!” Meanwhile, the mother had now rolled onto her back and was staring in disbelief at the long umbilical cord between her legs and then at my antics with the baby. I felt completely out of my depth and very far from home. Here I was in a foreign country, in an operating room full of people who didn’t understand a word I was saying, holding a baby in one arm and repeatedly banging my head with my other hand, while talking excitedly to a midwife who was looking at me as though I was crazy. Flashing through my mind were visions of my O and G professor from medical school days. I kept thinking of the delight he would have taken in reprimanding me in his usual aggressive, sarcastic manner for this utterly inept performance. I eventually recovered some degree of composure and handed the screaming baby over to the bemused midwife, so I could turn my attention to the mother who seemed completely overwhelmed by these events. I placed monitors, gave her some intravenous syntocinon, and then massaged her lower abdomen while gently pulling on the umbilical cord. To my astonishment and relief the placenta delivered with ease. Five minutes later Andre arrived to smiles all around. The mother was now holding her new baby boy, and was obviously relieved at not having to have an operation. The baby appeared well and unaffected by his precipitous birth. The staff were talking excitedly, presumably about the events they had just witnessed, but I had no idea what they were saying about the strange behaviour of the doctor from Australia. I had settled somewhat, although I still had visions of the out-of-control events and was eager to change out of my operating theatre garb. During my 3 weeks in East Timor, I continued to have many communication difficulties and frustrations, but my saving grace was the East Timorese people. They are a gentle, kind, fun-loving people and their response to my pathetic attempts at communication was always tolerant and often accompanied by a bemused smile, if not gentle laughter. The East Timorese have suffered much in their long history of invasions, civil war and interactions with foreigners. Perhaps, out of necessity, they have developed a resilient and tolerant attitude to the presence of foreigners. They have been invaded in the distant past by the Portuguese and, in World War II, by the Japanese. In more recent times, there have been invasions by the Indonesians, followed by United Nations peacekeepers, and now most recently by the most subtle of invaders — the aid worker. I learnt to greatly respect and admire the courage of the East Timorese people, especially the way they coped with their tragic past, the uncertainty of their everyday life, and the sad events that we faced at times in Dili National Hospital. As with my other sojourns in developing countries on “aid missions”, I have learnt much more from the people I met than they have from me. The gentle, tolerant and bemused smiles of the East Timorese remain with me still.

Geoffrey C Mullins MB BS, FANZCA

Some years ago, a woman in her late 30s was referred to me for consideration for an amniocentesis on the basis of advanced maternal age. She had had three previous pregnancies, all resulting in healthy babies. An ultrasound confirmed a single, viable intrauterine pregnancy, and a fetal size consistent with dates. The amniocentesis was performed without complications. However, the results of the chromosome culture showed there was a balanced 2 on 17 translocation (Box). This was of concern to me — if this was a new mutation, there would be a significant risk that the fetus could have a neurological disorder, ranging from mild cerebral dysfunction, through to severe intellectual disability. However, most cases that I see with a translocation are not new mutations; they are a reflection of the chromosome makeup of one of the parents. I contacted the patient, and told her of the result, and requested that her blood and her husband’s blood be analysed for evidence of a translocation. After 72 hours, the laboratory issued the report showing that neither the patient nor her husband had the translocation. This did alarm me, but when I told the patient about the results, she asked whether it would be reasonable for her boyfriend to have chromosome analysis done as well. I assured her that this would be very useful, and contacted her boyfriend. He supplied blood and, sure enough, it showed that he had a balanced 2 on 17 translocation. I explained to the patient that, under these circumstances, the fetus was very unlikely to have an intellectual disability, and she seemed quite relaxed about this information. I discussed the result further with the patient’s boyfriend, pointing out to him that it may be possible that his siblings could also have a balanced translocation. If he or his siblings had any further children, these children could be affected. The patient’s boyfriend told me categorically that he was not going to be having any more children. He had a sister who had three children, and she was not going to have any further pregnancies. Nevertheless, his sister agreed to have a chromosome analysis done, which confirmed that she had a normal chromosome complement. The boyfriend also told me that he had a brother who lived on a farm. When I asked if it was likely that he would have children, he said that his brother was 28 years old and had been damaged by obstetric forceps during a difficult delivery, leaving him with an intellectual disability. This brother agreed to have chromosome analysis, and surprise, surprise, it showed that he had an unbalanced translocation. This then would explain his intellectual disability. I doubt very much whether the obstetric forceps played any role in his condition. When my patient’s baby was born, a physical examination showed that the baby was normal. I recount this history to reinforce that sometimes the obvious is not as clear cut as one may first think. The country general practitioner who delivered the boyfriend’s brother 28 years ago has probably laboured under the weight of blame being ascribed to him for the poor outcome in this young man. Chromosome translocations If two chromosomes break, genetic material can be exchanged between the chromosomes. This is called a translocation. If the person with the translocation has lost or gained no genetic material, and is phenotypically normal, the rearrangement of the genetic material is said to be balanced — a balanced translocation. If the person has an excessive or decreased amount of genetic material after the breakage, the rearrangement of the genetic material is said to be unbalanced — an unbalanced translocation.

Francis V Carmody FRCOG, FRANZCOG, DDU

A child is born to be cared for, loved and nurtured. However, the hope that birth brings is not to be taken for granted. Where, and in what circumstances, the new life takes hold is a lottery that some win and others lose. I have worked for some years in both East Timor and Central Australia. I find the burden of despondency and disease heavier in my own country than in East Timor. Non-Aboriginal Australia is tired of hearing of the problems of Aboriginal Australia. A culture, they say, of handouts and victimisation — why can’t they just get over it like every other ravaged and decimated people? The domino effect is in play — one generation is knocked out and the effects are felt in subsequent generations. Try to imagine losing your land, your language, your way of life, your mother and father. I reflected on all of this when I went out to a mission settlement, Kumanjai Creek (near Tennant Creek, in the Barkly region of the Northern Territory), with three sisters, Connie, Joyce and Theresa. We stood on slabs of cement as the women explained: This was the “half-caste” dormitory; this was the kitchen; this is where we were locked in; this is where the boys slept. We had to carry out toilet buckets past the boys in the mornings and they mocked us. The old women swept away the dirt to reveal a date — 1945 — that they knew was scrawled in the cement. We sat around a camp fire under an ancient gum tree, which stood as a silent witness to past events, and ate kangaroo tails, witchetty grubs and seeds the women had collected. They told stories of the day Joyce was taken away. I tried to imagine: being a child who had to run away with my family for hundreds of kilometres because a white man was killed and I might be killed in retaliation; landing at a mission, being locked in at night, being beaten, eating only flour, rice and goats milk, eating no fruits or bush tucker, and little meat or vegetables; being that “half-caste” child separated from those I loved and locked up with others of lighter skin in a separate dormitory; being sent away because of my colour, while those who remained banged their heads with rocks as if in mourning for the dead. In the last century, a large percentage of the women’s kinsmen were killed or displaced. The old people had mastery of the language of the land, but it was hard to regroup in a new and alien world. They were powerless, landless and their ancient skills were not valued. The keepers and owners of country became outcasts and margin dwellers. They knew each plant, animal and water soakage. They knew medicinal bark, the goanna holes, bush raisins and tomatoes, and the roots that harbour witchetty grubs. They survived in one of the harshest environments in the world. They are resilient people whose roots tap deep into the red soil. The old people of Central Australia still remember how to survive. They also remember what happened to their people. The wheel keeps turning. Now the old people can’t sleep at night because younger people are drinking too much alcohol. What can be done? They don’t know; no one knows. They care for others’ children because part of a generation is lost. What will happen when they are gone? A 3-week-old baby, his mother, father and sister, his grandmother and 89-year-old great-grandmother live in a tin shed without power, water or sanitation. That newborn doesn’t have a fair chance. Too many children in Central Australia struggle as no child should have to. A child has a right not to be blighted with fetal alcohol syndrome, not to have rheumatic fever, not to have kidneys destroyed by glomerulonephritis, not to suffer intractable otitis media, not to have scabies so badly that to walk or make a fist is nearly impossible. Children deserve to hear, to be sent to school and to live in safe and clean environments. A young woman is angry because she needs to nurture her child, and yet her future is uncertain — like many others, she has end-stage renal failure. In her early twenties, she is facing a long period of exile in Alice Springs (the nearest major town to Tennant Creek about 500 km away) because of a shortage of dialysis beds where she lives. In our town, you often see wheelchairs used by people missing limbs because of diabetes, or by children with congenital abnormalities. There is a high rate of substance misuse, with all its consequences for the individual and their family. We hope there will be funding for ear, nose and throat surgeons to visit regularly so that the hundreds of children of the Barkly needing surgery will be spared the long waiting lists and midnight bus trips to Alice Springs. We hope for more dialysis beds so that the incoming wave of patients with renal failure will not be faced with the choice between exile in Alice Springs or death. We hope for more public health staff to tackle scabies, strongyloidiasis, alcoholism, diabetes and the other medical curses of the inland. We hope for more social workers and child protection officers to help and follow up children at risk. I have worked in East Timor,1 where, despite enormous poverty, the people are rebuilding their communities after a long period of destruction (related to the Indonesian occupation and resulting civil conflict). They have regained their sovereignty, and preserved their language and beliefs. They retain their hope while many of our own people do not. In East Timor, the thread of culture is not broken. The spirit and structure of society survives. The indigenous people still plant their corn, tend their caribou and thatch their houses as before. There are changes at the margin but the fabric of their society is not torn asunder. Many towns in East Timor now have “sister cities” in Australia. There is contact and connection between East Timorese and Australian communities. What stops similar connections being forged within Australia itself, between coastal communities and the outback? Should we not face our history a little more squarely and admit that the atrocities were real, and not a delusion perpetuated by the “black-armband set”? Could a new understanding be reached between Aboriginal and non-Aboriginal Australians, who for too long have sat in opposing camps? The welfare of the people of Central Australia has been thought of as a “government issue” that the ordinary citizen, business sectors and non-government organisations have stayed out of, but this is changing. No one knows the way forward. It is a way we need to forge together. There is anger and suspicion to overcome; people have been hurt and damaged. Nothing will be easy. The problems of the outback are social, but the consequences are medical. People need suitable housing, but ideally they should be involved in their design and construction and so have pride and personal investment in the buildings. They need support to maintain their buildings. Education is offered as a way out of the poverty trap of “sit-down money”, but still many children attend school irregularly and leave as soon as they can. Traineeships and apprenticeships are few, and work in general is scarce. Poor physical health is a symptom of a deeper illness at the heart of Australia. Change will take a long time, but a groundswell of support and small projects may do more than top-down intervention. To paraphrase Marcus Aurelius: to work for change and stay on our feet, we don’t need the fancy footwork of the dancer, but the determination of the wrestler. If enough people, both Aboriginal and non-Aboriginal, stay engaged, we can work together towards healing. Then, perhaps, love will be reborn in the heart of our country. “They told stories of the day Joyce was taken away.” “Children deserve to hear, to be sent to school and to live in safe and clean environments.” “They are resillent people whose roots tap deep into the red soil.” Indigenous women, Kumanjai Creek, NT Tilling the field, East Timor School children, East Timor

Colette L Livermore MB BS(Hons), FRACGP, MPH

The first rat I met in South Vietnam in 1967 was a hairless pup, jiggled by the tail in front of a bawling infant in a clinic we were holding in a refugee camp in sand dunes on the central coast, south of the city of Tuy Hoa. His mother had produced it from inside her shirt for tranquilising purposes, and it did the trick. As his eyes focused, the infant’s larynx relaxed, and everyone began to feel better until stubby hands groped for the rodent. With a twist of the wrist, however, the mother avoided a spectacle that might have lingered in our minds. I met my second rat later that day. He was a hairy thing, bolting across the sandy road between the barracks, and I wondered what he was doing out in the sun. I was surprised when he came to a sudden stop, and incredulous when he began to move backwards in a limb-whirling shower of sand. I blinked to clear my eyes of perspiration and found the reason for the rat’s reverse: fishing line connecting a rear leg to the hand of a small boy squatting with friends in the shade beside one of the huts. The rat was being reeled in to be released again, and yet again, by serious captors. I met more rats when I went into one of the barracks on a “home visit”. The huts were all the same, erected on the sand from corrugated iron and jammed with 30–40 people and their belongings. The inmates had been relocated from war zones for their own “good” and passed their days in idle misery, eating grain delivered by the government and throwing their refuse into open pits. It was very hot in the barracks — literally like being in an oven because each family cooked its meals over open fires, inside the tin sheds, in the sand dunes, under the blazing sun. The huts were stifling with smoke and humanity. I made my way to one fire to see what was on for lunch and found a frying pan filled with rats. Denuded, disembowelled and beheaded, they sizzled flank by flank under the care of an older woman in black pyjamas. Nearby lay the first of my patients: a man who was sick, febrile and immobilised by a large, painful lump in his groin, which was covered by oedematous, bluish skin. An abscess, I thought, and injected the only antibiotic I had, streptomycin, before moving to the next patient, who also had an abscess. And then, another. This seemed odd, but I remembered the holiday I had once endured as a small boy on a waterless farm in Queensland and the crops of boils that had erupted in the nether regions of several of us children after sharing an inch or two of black bath water. I suspected poor hygiene. It never crossed my mind the abscesses might have had something to do with the rats. But these “boils” were so large, and the people so sick, I aspirated one and sent pus to a nearby United States Air Force laboratory. Returning in a few days for the results, I had barely begun to savour the delicious air conditioning when a door was flung open and the technician announced with great excitement: “It is P. pestis! P. pestis! [Pasteurella pestis; now known as Yersinia pestis]” So what? I wondered, trying to recall any mention of that organism in my recent undergraduate experience at the University of Sydney. The technician informed me that we had discovered an outbreak of plague. Plague in Vietnam did not begin or end in our refugee camp. It was first recorded in 1898 in Nha Trang, south of Tuy Hoa, and the absence of any local name seemed to confirm its novelty.1 It was assumed it had been transported by ship from Hong Kong, where the Chinese epidemic had reached in 1894.1 In 1906, it was reported in Saigon (now Ho Chi Minh City), where it became endemic and caused about 1000 cases a year until the strict French administration managed to restrict it to about 25 cases a year in the 1930s. It increased again in the 1940s, during World War II. From 1962, however, the incidence in South Vietnam soared —5000–10 000 cases were reported annually until 1973,1,2 after which it fell. What caused this apparent outbreak? Where did it come from? Why did it stop? Marshall and colleagues denied an outbreak, stating it had been endemic since importation, and this notable increase merely reflected better identification by the increased numbers of doctors and laboratories associated with the Vietnam War.3 As confirmation of endemicity, they cited outbreaks in refugees and Viet Cong prisoners from regions beyond the reach of allied hospitals.3 Most rejected these denials but, if endemic, where was the fertile reservoir? Rural or town rats? It was argued “if there is no evidence that plague has come from outside sources” it must be based in “local wild rodents”,4 who transmit it either directly to humans, or indirectly, via urban rodents they have infected. Historically, plague has occasionally been associated with rural disruption. In India in 19945,6 and Algeria in 2003,7 outbreaks were preceded by rural earthquakes. Did burrows of rodents in rural areas collapse, forcing their residents to join — and infect — human refugees? Did broken buildings provide access to more food and permit proliferation? In South Vietnam, during the Vietnam War there were two massive disruptions in rural ecology: the bombing campaign and defoliation. Coincident with the outbreak of plague, 7.5 million tons of bombs (plus other ordnance) were dropped on rural South Vietnam: three times the weight dropped in World War II and with 100 times the combined impact of the atomic bombs dropped on Japan.8 Did these artificially made earthquakes drive rural rodents to the towns? Did they rupture grain stores, allowing access to food sources? Was there a limit to how much even a rat could take? Did defoliation alter their eating habits, with the same result? In 1962, Operation Ranch Hand was launched to deprive the Viet Cong of food and cover. It peaked in 1968–1969 and ended in 1971, after the spraying of over 6 million acres of rural land.9 Deforestation increases contact between humans and sylvatic sources,5 and Akiev noted that 86% of cases of plague in South Vietnam between 1966 and 1970 occurred in the most defoliated provinces.10 In many of these provinces, plague appeared for the first time. Although plausible, the theory that rural mammals were the source of plague was contradicted by field studies that found the disease to be surprisingly restricted to town mammals. Although trapping in the countryside was a dangerous pastime in those days, restricting research, Marshall and colleagues found that 99% of infected animals were the town rats, Rattus norvegicus, R. rattus, R. exulans, and the house shrew, Suncus murinus.11 After the war, researchers found that zoonotic foci were restricted to human settlement. Moreover, the flea vector, Xenopsylla cheopis, “exist[ed] only on indoor, commensal rodents”.12 Later, Suntsov and colleagues found only one rare flea to be common to rural and urban rodents, making it unlikely plague would be transferred from one to the other.13 If the rural mammals were not abandoning their homes, humans were. Around 3 million people (10% of the population) were relocated to camps such as ours in Tuy Hoa, and plague has long been recognised as a disease of the poor, crowded in slums where rats proliferate on rubbish.14 Certainly, there was inadequate disposal of rubbish in our camp, but proliferation of the urban rodents may have been even more encouraged by the practice of feeding refugees with grain shipped from central deposits and stored imperfectly in the camps in the provinces.3 This promoted transportation of rats from sites of endemicity and ensured they were well fed for reproduction. Perhaps eating habits further contributed to disease. Human skinners of infected camels15 and marmots have contracted plague through breaks in the skin, and consumers of undercooked meat have become infected.16 The former are likely to present with axillary buboes and the latter cervical, but our cases were predominantly inguinal, suggesting flea bites on the legs. Also, the rats I saw being cooked were more in danger of being over- than underdone. Fleas quickly abandon the cooling bodies of their dead hosts. I suspect the refugees in our camp were infected as they prepared the corpses for dinner. The weather affects the incidence of plague and our outbreak occurred in the drier months, as observed elsewhere. It is argued that eggs and larvae of fleas perish in the wet season.17 However, the onset of the wet can hardly explain the pattern of illness, restricted infectivity and low mortality in the outbreaks in Vietnam compared with historical accounts of other epidemics. In South Vietnam generally, the classic signs of the disease were observed: the bubonic form (after the Greek bubo, for groin), in which lymph nodes draining the infecting bite of the flea are severely affected in association with the usual systemic poisoning by gram-negative bacteria; the septicaemic form, in which the lymph nodes are not prominent; and the pneumonic form, in which bacteria invade the lungs and can be very infectious.3,18 In our outbreak, however, we only recognised the bubonic form, which also seems to have predominated in other regions. Despite the crowding in the barracks, we recognised no pneumonic forms or transference. Less common features of plague were also observed in Vietnam: asymptomatic pharyngeal carriage;19 pharyngitis and cervical adenopathy;20 and meningitis, particularly if undertreated21 — but we recognised none of these forms. Vietnam, however, did not conform to the historical concepts of expanding disaster. Many outbreaks were described, but they remained contained in numbers and sites. For example, we only recognised 15–20 patients with plague, and the disease did not spread to nearby camps or the city of Tuy Hoa; nor, mercifully, did any of our team become infected, despite the lack of any preventive measures. Early diagnosis and treatment was considered “the single most outstanding facet of plague control” in Vietnam, reducing the overall mortality to 1%–5%.3 Our practice of widespread injections of streptomycin, therefore, must have been blindly successful. We did not observe any deaths. Mass vaccination with live attenuated strains of some 10 million South Vietnamese would have contributed to control, but we did not even know this existed. Our public health management bore no responsibility for the containment of plague in our camp. There was none. Did the high ambient temperature inhibit spread? Infectivity in the flea is promoted by a “blockage” in the gut, which allows the bacteria to multiply before being regurgitated into the next host, but Cavanaugh and colleagues showed that blockage was reduced when the temperature of the flea exceeds 27.5°C, and I doubt our camp ever got below that temperature.1 Hinnebusch and colleagues found all fleas fail to block at temperatures greater than 30°C and, moreover, that their lifespan at that temperature is severely reduced, arguably due to dehydration.22 Perhaps the hot, dry environment in the camp, especially in the huts where rats were killed and prepared for food, restricted the passage of the disease by its effect on fleas. The outbreak from 1962 to 1973 was probably due to proliferation of rats and refugees and catalysed by recipes (that involved cooking rodents to prevent starvation), with the bombing and defoliation more a cause of human than rodent displacement. After the war, the reported incidence fell to several hundred cases annually until 1997, and to 22 in 2000.23 No cases have been reported since 2002.24 This progress may reflect better living conditions and patient care in Vietnam, but the natural history of plague has always been episodic, with the disease emerging and disappearing for reasons not understood.7 Pham and colleagues report a reduction in the number of rodents and fleas trapped in central Vietnam from 2000 to 2007, and absence of Y. pestis in both rats and fleas in recent years, and suggest that Vietnam may have entered one of the “silent period[s]” that have historically preceded “sudden explosions of rodent or human plague”.24 Although we did not observe any plague-related deaths in the epidemic in our camp, it might have been close. One night, feeling the need to give a sick child an extra injection (and, it must be confessed, to pursue adventure), three of us set out to visit the camp, which lay on the other side of a wide river, the Song Ba, beyond the security of the town. The road bridge had been destroyed and cars had to traverse the kilometre-long railway bridge on planks of wood that covered the sleepers, about 60 feet above the fast-flowing water. To add to the challenge, no one dared use headlights. We travelled in our old Land Rover whose gears were as disinclined to engage as the brakes, and whose muffler was as loud and steering as loose as the ladies in the “entertainment” area between the camp and the Air Force base. But when we arrived at the camp, and shut down the roaring engine, we were astonished by the silence and emptiness of the streets. It was a moonless night and we had difficulty in finding the right barrack, searching along the road with increasing dismay. The people were slow to open the door, and stood silently while we gave our needle. Firelight flickered on unsmiling faces. Just how “pacified” were these people? Let’s go! We held our breath until the car started and hurried back to the bridge to begin the slow, lurching crossing to safety. Then, about a quarter of the way across, a shape loomed from the darkness in front of us and a huge truck ground to a halt, followed by some others. We had run into an American convoy on its way to war. I was driving and, looking up, against the stars I could see the shape of a machine gunner hunched down upon us. There was a pause, with engines growling like dogs gearing for savagery; then Bruce Hansen, my team leader and good friend, swung open his door, bounded across the sleepers and pounded on the door of the truck, demanding they “back up” because “we were on the bridge first” and we were “Australians”. The driver of the truck did not take long to respond. A head appeared from above me with a simple message delivered with a southern drawl. Stripped of embellishments it was, “You back up right now, or I will push you off”, and it was confirmed by a roar of his engine and a lurch of his mighty truck. There were two practical problems with our gears: finding the right one and holding it in place. Crashing through several, I found reverse and, holding it in place, began the long, backward retreat. My leader maintained criticism of my cowardice — but from the safety of the sleepers. The machine gunner maintained his downward menace. I could have drowned like a rat. Would they have counted me a victim of plague? At least I would have been spared the injections. Boys in South Vietnam play with a lizard and rats, 1967. Reproduced from the Bruce Hansen Collection with permission of his widow, Miranda Hansen. The interior of one of the barracks in the refugee camp near Tuy Hoa, South Vietnam, 1967. Reproduced from the Bruce Hansen Collection with permission of his widow, Miranda Hansen.

John S Whitehall FRACP, MRCP(UK), DCH

Patients often have difficulty remembering drug names accurately. Two instances, from my time as a junior doctor in the United Kingdom in the 1990s, have stayed in my memory. The first occurred during a long and busy night on call. I was admitting an elderly woman and I was tired and fed up. I asked her about her medication and she gave me a handwritten list. Halfway down, in quavery capitals, was FROLIC ACID. It made my night. It also triggered a memory, from several years earlier, of another patient, encountered on a consultant’s ward round. She had been prescribed omeprazole, which was still under patent at the time and marketed under the trade name “Losec”. The consultant asked her if her indigestion had improved. “Oh yes, doctor”, she replied, “it’s been ever so much better since you gave me that Slosex tablet”. We had to stop the ward round for several minutes to compose ourselves. Even though more than 10 years have elapsed, the memory still makes me smile.

Paula H Johnson

To the Editor: A 40-year-old, first-time traveller from the northern hemisphere, on an expedition cruise to the Antarctic Peninsula, experienced thirst, polyuria, fatigue and worsening headaches for several days before embarking on a rough Drake Passage crossing in January 2009. Being well-to-do, fit, and taking no regular medication, he had decided on an adventurous holiday rather than his usual high-end European resort vacation. En route to the expedition vessel in Ushuaia, Argentina, the passenger hurriedly obtained a non-prescribed supply of “adventure travel” medication from a pharmacist acquaintance in the Middle East. To ensure its effectiveness, the passenger had complied with the pharmacist’s recommendation to begin taking the medication prophylactically several days before sailing. On the outbound crossing, the passenger consulted me, the ship’s physician, about the aforementioned unusual constellation of symptoms that he had been experiencing for several days, which were now compounded by severe motion sickness. On examination, he was not confused, had no meningeal irritation, loin percussion tenderness or fever, and was mildly dehydrated. It was soon revealed that he had been using acetazolamide for several days, as recommended. On reflection, I thought the container for acetazolamide that he showed me bore some resemblance to the containers used to store promethazine in the ship’s clinic (similarly sized bottles with similarly coloured lids and labels), with promethazine being well recognised as an effective treatment for motion and sea sickness.1 The symptoms that he had had for several days while taking the “adventure travel” medication before embarking on the expedition vessel are ascribable to acetazolamide.2 The passenger had been given medication on the now apparent misunderstanding that it was for ameliorating symptoms associated with a “high altitude” rather than “high latitude” destination (the bottle had been dispensed after a brief conversation in English — neither party’s first language). The pharmacist had misunderstood, believing that the passenger was travelling to a destination at a high altitude, for which acetazolamide chemoprophylaxis would have been appropriate to reduce risk of high-altitude sickness.3 Polar expedition cruising remains a relatively exclusive though environmentally sensitive pursuit. In the 2008 southern summer season, 34 000 passengers departed for an Antarctic destination by ship;4 most experienced some degree of motion sickness exacted by rough passages across the Drake Passage (the “Drake Shake” rather than the much prayed for and preferred smooth crossing across the “Drake Lake”) to the Antarctic Peninsula. Misunderstanding can occur when high latitude (the Antarctic and Arctic) is confused with high altitude, with the adventurer passenger at risk of being prescribed the wrong chemoprophylaxis. This risk may be accentuated in countries where travel medicine and pharmaceutical dispensing are not well regulated. On another note, in my opinion, it may be helpful to give medication containers and tablets a colour related to their purpose; perhaps bilious green for sea sickness and clear blue for altitude illness.

Joseph Y S Ting

Here are some tips to keep in mind And others you may simply find Essential to your research design Whether it’s RCT or double blind The ethical considerations you must ponder Ethical considerations Are not mere exaggerations Or NHMRC machinations Designed to prompt procrastination Or slow your application Because we know there is little time at your disposal — for work on your proposal Above all: Be sure your patients are content To give to you informed consent There is no need to reinvent Reasons to cause malcontent You’re just required to present Any unclear danger or event That may be considered torment Or cause harm and discomfort to your participants And: Speaking of those who comprise your experimental troupe Always consider those of a vulnerable group This is of prime importance and not just another hoop For you to jump through Now: Is it possible I ask? Multi-institution review will be a thing of the past? Best not to speculate — or move too fast Remember the adage that good things don’t last Indeed the number of review boards is beyond belief So if multi-site approval is giving you grief Be joyous and thankful — there is a portent of relief Just get on the website and fill out the NEAF Also keep in mind: It’s sad but true That expedited review is for only a few Of those of us who knew Exactly what to do To construe the application With minimal frustration And get it through administration Without submitting 15 hard copies . . . And remember: Maintaining confidentiality Is not merely a formality But involves matters of morality Not to mention of legality So choose your methods carefully So all your risks are plain to see The bottom line is: To obtain ethical clearance Takes skill and perseverance And it’s not just for appearance But proof of your adherence To all ethical considerations in your research NHMRC = National Health and Medical Research Council. NEAF = National Ethics Application Form.

Diann S Eley MSc, PhD

Vaccinia vaccine is used to immunise against smallpox, which is caused by the orthopoxvirus, variola. A 26-year-old laboratory worker was inoculating mice with vaccinia vaccine as part of research into cross-reactivity among poxviruses. This particular vaccine contained a live attenuated strain of vaccinia (Western Reserve). The laboratory worker had himself received vaccinia vaccine in 2004 because of the nature of his work. On this occasion, after inoculating two mice, he suffered a needlestick injury to the left index finger. Two days later, a cloudy vesicle, typical of vaccinia virus,1 appeared at the inoculation site (Figure, arrow). After 3 more days, the finger became acutely inflamed, with secondary lymphangitis and axillary lymphadenitis. After antibacterial therapy, the lymphangitis and lymphadenitis rapidly resolved and the vesicle disappeared within 10 days. The man remains well. Infection with vaccinia usually follows vaccination or needlestick injuries. Although this is usually mild and self-limiting, certain conditions (eg, immunocompromise, pregnancy, eczema) predispose to more severe and even fatal illness. Prior immunisation with the vaccinia vaccine is thought to prevent or reduce the severity of such infections, and it is recommended that people working with vaccinia or related orthopoxviruses be vaccinated every 10 years.1 Vaccinia immunoglobulin and certain antiviral agents have been used to treat severe infections.2 Given the potential dangers from accidental exposure and the fact that the last documented case of smallpox (in 1978) was related to a laboratory incident,3 strict infection control measures are paramount, including disinfection after injury, prompt reporting, urgent medical review, and measures to minimise secondary spread to contacts.1

Sanjaya N Senanayake

All established researchers are well aware of the challenges involved in getting their unique and vital contributions published. The frustration of multiple journal rejections and resubmissions, and the ensuing revisions, would be known to almost all published researchers. This contrasts with the joy and satisfaction that authors derive from having their publications appear in print. The manner in which authors celebrate their successes will vary from person to person. I propose a formula to guide authors on the extent of celebration that their success warrants: C = J × R where C = number of celebratory drinks, J = number of different journals submitted to, and R = number of revisions. Of course, responsible, moderate and safe alcohol consumption must be encouraged. Therefore, the total number of drinks does not need to be taken in one session and the drinks need not be alcoholic. Alternatively, “C” can be substituted for any other form of celebratory activity or treat, such as massages or dinners at nice restaurants.

Peter W New

The DSM-IV is more a reliable descriptive nomenclature than a valid classification of diseases The Diagnostic and statistical manual of mental disorders, third edition (DSM-III), published by the American Psychiatric Association in 1980, sought to define psychiatric syndromes in a way that increased the reliability of psychiatric terminology and diagnoses between practitioners and nations. The DSM-III’s introduction cautioned that, with regard to aetiology, it was a “generally atheoretical” document. The subsequent edition, the DSM-IV, published in 1994, went further, and cautioned specifically against diagnoses being applied in a “cookbook” fashion. Despite these warnings, conversion of the description of psychiatric disorders to discrete disease entities has not only occurred but, I believe, has also become problematic. Here, I present an allegory of a boy with “cough disorder” to illustrate. It was time for the annual post-prandial Christmas dinner nap. A niece was coughing on inhaled lemonade. Dreams are often allegorical; it had been a busy year, and I started to dream. “Cough disorder” — a dreamA mother came into my consulting room with her son. “He’s got cough disorder”, she declared. She’d read the symptoms on the internet: “a short, repetitive noise coming from the throat associated with the expulsion of air from the lungs”. This was, indeed, true. The website had quoted the DSM-IV. That is, the fourth edition of the Diagnostic and statistical manual of human noises published by the American Phoniatric Association. “He’s clearly got cough disorder, and he needs Suppressalin cough suppressant”, the lad’s mother said. Suppressalin had been advertised via a link on the “Help for Parents of Kids with Cough Disorder” website. The young chap himself broke into a succession of hacking coughs as if to emphasise the problem, at which point his mother widened her eyes and slowly and firmly nodded, to emphasise the obviousness of the diagnosis. One that, presumably, was now even more clearly in need of the advertised pharmacotherapy. I sighed. That is, I “exhaled in concert with slight laryngeal constriction, following a deep diaphragmatic inhalation”, making a “soft, rather low-pitched noise”, and this occurred “in a situation of frustration, tension, tiredness or boredom”. (I noticed my noise, recognised I was in a situation of frustration, and recalled research showing I’d just stimulated my vagus nerve to maintain autonomic nervous system equilibrium.) I coughed, but it was the “ah hem” subtype; the “short, sharp, double noise emanating mainly from the larynx without significant pulmonary air expulsion”. This is not normally considered a pathological cough, although I noted the lad’s mother raised an eyebrow. I knew my “ah hem” cough was the prelude to my well worn (and weary) noise-educative spiel to parents of coughing kids. “Well yes, he does cough; I totally agree with you there”, I said, to get mum on side, and noticed a slight easing of her wary defensiveness. “But you see ‘cough disorder’ doesn’t tell us very much. It is not really a diagnosis but a description of behaviour.” She was starting to resume the wary defensive posture; the boy uttered a quick succession of coughs. I decided to look grave and said how concerning his coughing was, and that it was very important we thoroughly investigated it. She said the parents’ help website had indicated that Suppressalin was exactly what was needed, but I noticed she was now less certain, and I made a “hmmm” sound in a particular way, to indicate understanding and empathy, but also that I knew more. I was, after all, the doctor. I sensed she seemed willing to listen to the spiel. “Cough disorder is simply a description, a starting point”, I said. “We have to find out why your young man here is coughing. Cough disorder can have many causes, and, for some children, several causes can combine.” I went on to describe inhaled objects, drinks down the wrong way, asthma, croup, bronchitis, pneumonia, pharyngitis (the tickly throat cough), postnasal discharge, and rarer, more serious causes, such as throat and lung cancer, pneumothorax, bronchiectasis, silicosis and congestive cardiac failure. It could be a reaction to dust or cold dry air; there is always an environmental context. And, it could even be something as mild as a frequent habitual “ah hem” cough to try to gain attention. I had the lad’s mother’s attention now, and the lad himself had also stopped coughing and was listening. I said that his cough may not need Suppressalin (although I acknowledged that, for some kids, Suppressalin is very beneficial, and they may need it for many years). We went on to look collaboratively for what was causing the cough. Even dad came to the next consultation. I also had an informative telephone discussion with the child’s teacher, who told me how the boy generally stopped coughing by morning recess. The problem with the DSMThe astute reader may by now have guessed that my “dream” is an allegory about attention deficit hyperactivity disorder (ADHD), and that, by corollary, the “DSM of human noises” is the Diagnostic and statistical manual of mental disorders published by the American Psychiatric Association, currently in its fourth edition.1 The DSM is sometimes referred to as psychiatry’s bible. However, like the Bible, it should be mainly read as descriptive, not literal, truth. The problem dates primarily from 1980 and the publication of the DSM-III. At the time, psychiatric terminology suffered from a different problem — psychiatrists using the same labels for different conditions; in particular, schizophrenia, which was overdiagnosed in the United States compared with Europe (and Australasia).2 The DSM-III devised “operationalised criteria” — lists of symptoms to define descriptive “disorders”, so that everyone would at least know what behaviour was being described when a term like “schizophrenia” was used. Reliability is a necessary step on the road to validity. The DSM-III brought about a more reliable nomenclature and a more robust definition of syndromes, a vital prerequisite for psychiatric nosology (the branch of medical science dealing with the classification of diseases) to advance. However, the DSM-III was not meant to be read as a valid classification of diseases, even though it aspired towards that goal. Diagnoses in other areas of medicine also vary in levels of understanding of aetiology (eg, migraine is still a syndromal diagnosis, and hypertension is a diagnosis based on deviance from normative dimensions); however, the level of scientific knowledge is more advanced in many other areas, and many disease states are well understood. Psychiatry is not so far advanced. A further complicating factor in psychiatry is the, as yet, unresolved mind–brain problem,3 and that for such a social species as Homo sapiens, the psychosocial and intersubjective domains, including narrative and meaning, are not easily accessed by symptom checklists. The DSM-III and DSM-IV attempt to address this with their multi-axial approach to a range of factors, such as personality, concomitant medical disorders, psychosocial stressors and level of functional impairment, as well as the “V-code” diagnoses — codes used to indicate problems that aren’t clinical disorders — such as “parent–child relational problem”. Further complicating nosology is the issue of multicausality and equifinality — syndromal end states may comprise a clustering of individuals with quite different aetiologies for similar presenting symptoms. This is implied in the DSM introductions, with the DSM-III purporting to take a “generally atheoretical stance” with respect to aetiology, and the advice in the DSM-IV that it is “not to be used in a cookbook fashion”. Despite these warnings, all too often, collections of symptoms classified as disorders tend, in practice, to be thought of as disease entities in their own right. This is less problematic for severe psychotic disorders such as schizophrenia and manic-depressive psychosis (now called bipolar-I disorder in the DSM-IV), which likely represent underlying brain disease. However, I do think that it is problematic with what used to be called “neuroses”, and symptoms that overlap with temperament, personality and responses to stress and trauma, where the interactions of brain, mind, body, relationships and environment are multidirectional. So the problem is not so much with the DSM itself, but with the way it is often used pre-emptively. My allegory on ADHD could apply to “conduct disorder”, “oppositional defiant disorder”, “school refusal”, “autism spectrum disorder” or, particularly in the US, the controversial “paediatric bipolar disorder”4 which, although it is not defined in DSM-IV, can be argued reflects an overly reductionist “neo-Kraepelinian” approach5 that common use of the DSM tends to foster. A similar problem occurs with anxiety, depression and adult “bipolar spectrum disorders”. The problem of seeing all depressive states as homogeneous, differing only in severity, has been raised previously.6 In his 2005 presidential address to the Royal Australian and New Zealand College of Psychiatrists (RANZCP), Boyce referred to a “dumbing down” of psychiatry by using the DSM for simplistic “cookbook” diagnoses. He also referred to the pharmaceutical industry’s pervasive influence in medical research and medical education.7,8 In psychiatry, this influence often supports a reductionist biomedical model of human emotional and behavioural problems, rather than the systemic biopsychosocial model upheld by the RANZCP. A simplistic cookbook approach to the DSM would, indeed, seem to be in industry’s interests, as behavioural symptom clusters get reified to disease states, and marketing to both the medical profession and the public can support a “pill for every ill” approach.9 Such marketing finds fertile ground — in a busy world, the siren call of such simplicity in diagnosis and treatment is appealing to both the public and the medical profession. Such misapplication of psychiatric nosology was predicted two decades ago as the rise of “biologism”,10 and eloquently expressed by Lipowski in his 1988 presidential address to the Canadian Psychiatric Association as the rise of “mindless psychiatry”.11 (Lipowski also noted the perils of the other extreme — “brainless psychiatry” — in which all psychopathology is seen in only psychosocial terms, something this essay is not advocating.) DSM-associated biomedical reductionism has been noted by many American psychiatrists.12 In contrast, an alternative approach to psychiatric nosology proposes the “four perspectives of psychiatry” (“disease, dimension, behaviour, life story”),3 which is a more radical multi-axial approach than the DSM axes and seeks to balance the neo-Kraepelinian disease approach with the “neo-Meyerian” focus on biopsychosocial case formulation.13 It was described in a course at the recent American Psychiatric Association annual meeting titled “Going from the bio-bio-bio model forward to bio-psycho-social reasoning”.14 Where disorders most likely fit the disease model, as with the psychoses, there are promising proposals to refashion the upcoming fifth incarnation of the DSM — the DSM-V — to move beyond the descriptive approach and attempt to base psychiatric classification on underlying causes.15 Further changes proposed include greater emphasis on dimensional measures (eg, to look at subsyndromal risk factors for depression and possible prodromal psychotic symptoms, like suspiciousness, that may aid early detection), rather than categorical measures (such as currently, when meeting sufficient criteria indicates disorder, and below that implies no disorder) to better reflect clinical reality. On the other hand, the head of the former DSM-IV taskforce has expressed strong concern that such moves are premature, would “flood the world with . . . false-positive patients” who “would pay a high price” in stigma and by being overmedicated and, with respect to problems like excessive Internet use, that expansion of criteria in the DSM-V would further “inappropriately medicalise behavioural problems”.16 Despite, or even because of, this problematic nosology, psychiatry remains a complex but compelling and rewarding profession that requires time, and experience, patience and wisdom acquired through clinical and life experience in helping those who come for help. There are no short cuts, DSM or no DSM. Return to our allegorical dream of cough disorderThe dream ended happily. The lad and his parents came to understand that cough disorder was not a diagnosis but a description, and that his real problem — mild asthma — required a different medication, and then no medication at all when his parents stopped smoking in his presence. We had tried Suppressalin at one point, but it gave only short-term relief. The parents and I even had a more philosophical discussion about how the third edition of the DSM of human noises focused on defining human noises descriptively, at a time when some doctors talked about “cough” when they really meant “sneeze”, “burp” or “hiccup”, and how that was a good development back in 1980. But we also discussed how, as an atheoretical descriptive system, it generally gives no information about underlying causes, and how important the search for real causes is; this is something the family now appreciates. During my last session with this family, there were several repetitions of “ah yes” and “hmmm” (shorter, higher pitched subtype, usually indicative of agreement) — all, in my opinion, completely non-pathological noises, although I understand some do think them overused and claim to have medications for them. . . . I awoke. My niece was playing happily with her Christmas presents. The cause of her coughing — inhaled lemonade — had cleared.

Peter I Parry MB BS, FRANZCP, CertChild

Objective: To determine the relative radio-opacity on plain x-ray of bones of fish species commonly consumed in South East Queensland.Design: A cadaveric sheep model was used to mimic the soft tissues of a human neck. Bones of 10 fish species were placed in the paratracheal tissues and adjacent to the larynx. X-rays were taken and the images (including four control images with no bones) were incorporated into a Microsoft PowerPoint presentation to be interpreted by emergency specialists and registrars. Observers were blinded to which specimens contained fishbones and which did not.Main outcome measures: Sensitivity and specificity of plain x-rays for detecting impacted fishbones.Results: Significant interobserver variability was identified. Despite this, the overall specificity of plain x-rays was 90%. The sensitivity of the technique was 79% overall, but varied significantly between fish species.Conclusion: Lateral soft tissue neck x-ray is an appropriate screening tool in cases of a suspected impacted fishbone. If a fishbone is identified on x-ray, the patient should be referred for endoscopy without further imaging. X-ray may be of limited value in cases of Dory or Spanish mackerel bone ingestion. In such cases, a computed tomography scan should be the first-line investigation.

William R A Davies MB BS · Patricia J Bate PhD, MAppSci, BAppSc(Phty)

Objective: To determine whether slow or fast bandaid removal is less painful.Design, setting and participants: A prospective, randomised, crossover trial was carried out at James Cook University, Townsville. Participants were healthy volunteers from Years 2 and 3 of the James Cook University medical school program.Interventions: Medium-sized bandaids were applied bilaterally in three standard body locations and removed using slow and fast techniques.Main outcome measures: Pain scores were assessed using an 11-point verbal numeric pain scale.Results: 65 participants were included in the study. The overall mean pain score for fast bandaid removal was 0.92 and for slow bandaid removal was 1.58. This represents a highly significant difference of 0.66 (P < 0.001).Conclusion: In young healthy volunteers, fast bandaid removal caused less pain than slow bandaid removal.

Jeremy S Furyk MB BS, FACEM, MPHTM · Carl J O’Kane FACEM · Peter J Aitken MB BS, FACEM, EMDM · Colin J Banks MB BS, FACEM · David A Kault MB BS, BSc, PhD

Objective: To examine how performances by the Staff Christmas Choir of the Peter MacCallum Cancer Centre (“Peter Mac”) affected inpatients, outpatients and visitors in 2008.Design, setting and participants: During the Christmas season 2008, the Peter Mac Staff Christmas Choir gave seven performances at the Centre. Locations included inpatient wards, outpatient waiting areas and a cafeteria. To assess their response to the choir, oncology inpatients, outpatients and visitors (including early-departing bystanders) were given anonymous, semi-structured questionnaires during and after performances. To analyse the responses, we used a constructivist research approach informed by grounded theory.Main outcome measures: Participants’ descriptions of the choir’s effects on them.Results: Questionnaires were returned by 111 people. The performances were received favourably by 93.7% of respondents, including nine from Jewish, Hindu or atheist backgrounds. Many said the music aroused positive emotions and memories. Several described transformative thoughts and physical reactions, felt affirmed by the Christmas spirit or message, and/or appreciated the peaceful or enlivened and social atmosphere. The choir also elicited personal perspectives about Christmas and Judaism, and the importance of “enjoying the moment”. Only three respondents (2.7%) reported adverse effects, relating to emotional and audible intrusiveness.Conclusions: The Staff Christmas Choir created a supportive and uplifting atmosphere for many oncology patients and their visitors. However, responses from people from non-Christian backgrounds were limited, and further investigation is warranted to extend our understanding of the effect of Christmas music in Australian public health settings.

Clare C O’Callaghan PhD · Colin J Hornby FIR, MAppSc, GradDipEd · Elizabeth J Pearson BAppSc(OT) · David L Ball MB BS, MD, FRANZCR

We were cruising at 5000 feet, enjoying beautifully clear winter weather, just south of Tennant Creek in the Northern Territory. My friend Don and I were flying in his Cessna 182 and about to turn east and follow the Barkly Highway to a large cattle property known as “Avon Downs”. We were planning to visit an old patient — let’s call her Claire. Originally from England, she was working for the South Australian Government in the NT looking after Aboriginal children in a kindergarten. The story began when a letter arrived from Claire asking if I would make a flying visit to her “back country” village. She heard that I had taken up private flying and had an interest in visiting the bush. My friend Don was a novice private pilot like myself, and we were both very keen to take the opportunity to test our wings on a long flight to the country. Claire lived alone in a large caravan that could accommodate four adults. It was grouped in a large, protected area with three other similar caravans: one served as the ablution block for the children, another was for their changing and rest rooms, and the third was a large classroom where lessons were conducted. Claire was endeavouring to help with training in health and education for young Indigenous children from deprived areas. The excitement was immense as we landed in a cloud of dust on the bush airstrip. We taxied up to Claire, who was surrounded by dancing and shouting children. It was not long before we were chatting about bygone years and about how Claire was coping with the various demands while attempting to introduce Western culture into the Aboriginal community. Claire described her disappointment with the lives of some of her former pupils — for example, girls aged 10 or 12 who, on returning to their Aboriginal communities, were allocated as wives to elders of the tribe. She was anxious to visit some of these older children, who now lived on the coast at Borroloola, about 500 km north of Avon Downs. Why not make a flying visit to Borroloola? It was soon decided that we should. We quickly cleared the aircraft of unwanted gear so that Claire would be able to join us on the flight. We took off early the next morning and arrived at Borroloola after about two and a half hours. Claire was very excited to see her former pupils and learn about their lifestyle and activities in the years since leaving school at Avon Downs. We spent a happy day meeting all the young mothers and their children, and the time passed very quickly. Then we suddenly remembered that the airstrip at Avon Downs did not have landing lights! We realised we had to leave quickly because the calculated flying time would only just allow us to arrive home before last light. When I turned to walk to our aircraft, I met the anxious gaze of the hospital matron: “Could you possibly help with a desperately ill little Aboriginal baby? The Flying Doctor can’t come till tomorrow and this wee child is seriously distressed and unfortunately the hospital sisters can’t help.” I looked across to Don and Claire as I followed the matron running to the sick child’s bedside. He was seriously ill from dehydration after protracted vomiting and diarrhoea and needed an intravenous saline drip. So a small baby with collapsed veins set the challenge for time and urgency. Naturally, my flying companions were a bit anxious about the prospect of delaying our departure. However, the nursing staff were all very grateful for my help. After some effort, the needle entered the vein of this brave little boy, who began to improve with the added fluid. I stood back with relief, which was shared by us all. After a quick farewell we went out to the aircraft. We checked the seatbelts, oil and fuel, then warmed up the engine and leapt into the air on track for Avon Downs. We checked our calculation on the time for last light for Avon Downs with a radio call to Mt Isa traffic control. Our calculations were correct — we would be 25 minutes late for last light on arrival! There were no options at this stage, so we pressed on, hoping the last light of the sunset on the flat landscape would give us sufficient vision. But look! What was that unusual glow ahead on the track near the horizon? That must be close to the Avon Downs airstrip! As we flew nearer to this bright area, while the natural light was failing rapidly, we saw we were being welcomed by numerous cars that had their headlights lighting up the airstrip to guide our return. It seemed the hospital staff from Borroloola had called the folk at Avon Downs and told them about our problem and why we had a delayed departure. Claire was sad to say goodbye to us but, happily, she wrote to say what fun our visit had been and that the little boy had recovered and was doing well. North-eastern region of the Northern Territory

Anthony H T Hodgkinson FRCS, FRACS, FAOrthA

Surgeons v physicians: when push comes to shove, there’s “us” and there’s “them” Physicians and surgeons are natural enemies. It is nothing personal: just as the lion circling for the kill affords its wildebeest prey no malice, the mutual antagonism between surgeon and physician is simply a law of the medical jungle. The antipathy that each group holds for the other is submerged in the shallow waters of professional courtesy, but when, on occasion, the true feelings of either tribe breaches the surface, the medical student initiate may be in for quite a shock. On the outside, relations might appear quite amicable — matey even — but try this experiment: ask your student whose next rotation is with a surgeon to casually drop the term “evidence-based medicine” into the conversation in the operating theatre. Look, I’ll admit this up front — some of my best friends are surgeons. I have shared their table, been on holiday with them, coveted their new convertibles and drunk too much of their 18-year-old single malt whisky. But the fact remains that when diagnostic push comes to therapeutic shove, I am one of “us” and they are one of “them”. In the second year after entering the workforce, young medical graduates are faced with a crucial decision: will they become surgeons or physicians? In theory, there are dozens of other vocational choices (general practice, psychiatry, pathology, radiology and emergency medicine, to name a few), but for the surgeon and physician, these other paths are hardly worth considering — the “real” doctors, they believe, have only a dichotomous choice. Sometimes, the novices are unable to make up their minds and are submitted to a number of vocational aptitude tests, including being asked to comment on the following scenario: A surgeon, a physician and a pathologist go away for a weekend of duck shooting. They row their punt to the middle of a lake and decide to take turns to shoot. First-up is the physician. Suddenly, a flock of ducks flies overhead. The physician takes aim, tracks the path of the ducks with his gun but doesn’t fire. “Why didn’t you shoot, you idiot?” shouts the surgeon. “Well, I was just about to when I glimpsed out of the corner of my eye a tail feather on one of the birds that made me doubt whether these were really ducks at all. I felt that the likelihood of these actually being Anserini geese was high enough for me to hold fire and do a little more research on the local migratory patterns of the two species.” It is the surgeon’s turn next. The sky fills with birds and, without a moment’s hesitation, he lets off 12 rounds from his pump-action shotgun. Birds, feathers and entrails fall into the lake around them. When the air clears, the surgeon pushes the pathologist overboard and says, “See if they’re ducks, will you old chap?” It is, of course, a trick test. If the students haven’t made up their minds before they take the test, then they’re not meant to be surgeons. If they laugh, they can’t become pathologists. If they look up the meaning of “Anserini” then their die is cast as physicians. Do you become a physician because you can’t make quick decisions, or do you choose surgery because, when young, you liked working with the family’s sewing machine and power tools? Was Ben Casey your role model or that lovely Dr Welby? Do you pine for McDreamy or fantasise over Greg House? In other words, are surgeons and physicians made or are they born? Let’s examine this question. It would be reasonable to believe that surgeons require a degree of manual dexterity, yet some are among the clumsiest people I have ever met. One surgeon I knew often arrived at work on Monday with his hands bandaged, having injured himself with his woodworking tools. Another was notorious for losing things — keys, phones, computers, medical documents, two wives and, on one famous occasion, his children. In fact, I have never detected a strong association between talent in the theatre and hand–eye coordination out of it. Most skills of surgery are specific to the operating theatre, and a clumsy-ish person can probably make a decent surgeon. Having said that, I have no doubt that the “gun” surgeons, the ones who other surgeons would allow to operate on them, do have special physical abilities. And there are some subspecialties for which fine motor coordination is a prerequisite. The neurosurgeon and the plastic surgeon must bring a naturally steady hand to the operating theatre; a fine tremor is manageable in the abdominal cavity, but will not do in the unforgiving space of the brain. There’s no prescribed height or weight for surgeons. They come in all shapes and sizes, with one exception — the orthopaedic surgeon. Here is an example of genetic inevitability: what’s bred in the bone really does come out in the medical flesh. The orthopod is an archetype best summed up in the song by the legendary Captain Matchbox Whoopee Band, surely familiar to the discerning reader of a certain age — “Six foot six, broad shoulders, what a whacker!” Outliers in this specialty exist only to prove the rule. If physicians are the thinkers of the profession, then it follows that their ilk should all be gifted scholars. But the young doctors I shepherd through postgraduate training are mainly of solid intellect — more Watson than Holmes. Some are brilliant, but only a very few possess Mensa-level IQs, and this genius often displaces other personality traits such as empathy and humour (the latter being defined as the ability to find my jokes constantly amusing). Physicians pursue a difficult diagnosis by taking a meticulous history and thoroughly examining the patient. They pride themselves on their understanding of pathophysiology and the social determinants of disease. The traditional hallmark of physicians is their ability (and desire) to consider the patient as a whole. These attributes may now be in decline; the interventional specialties, such as cardiology and gastroenterology, have attracted a whole generation of, well, surgeonly physicians who, in some cases, seem more inclined to consider the patient as a hole. Another crucial difference between our two species was summed up by the artist formerly known as Cat Stevens: “The first cut is the deepest”. The surgeon must have the guts to go boldly with a scalpel where no one has (usually) gone before. There is no turning back once you are inside the peritoneal cavity — too late to say, “On second thoughts . . . ” The surgeon must be naturally decisive, prepared to make a call and stick with it. (And here is an important lesson for the young physician dealing with surgeons — remember that your conversation will not work if you try to engage in dialogue. Your physician’s desire for intellectual honesty and explicit depiction of the uncertainty of a course of action will be seen only as weakness.) Surgeons don’t take long histories from their patients or do long ward rounds. In fact, many don’t seem to enjoy consulting much — surgeons like to operate. And if the answer to a problem is not immediately obvious, then it is time to call in the “clever doctors”. This is, of course, an ironic use of the term “clever”, for surgeons don’t really think that physicians possess any more skill or intelligence than they do. In their minds, the only thing that the physician has that the surgeon doesn’t is time. Surgeons are always busy, always somewhere else, or on their way to somewhere else. While the surgeon is doing the doing part, the physician is most likely reading a journal in a library somewhere or talking (yes, talking) to a patient. Physicians usually sleep in their beds at night; surgeons often sleep in their clothes. Although they inhabit the same geographic space, physicians and surgeons live in different worlds. It is not unusual for a physician to pass a week without talking to a surgeon, and vice versa. One thing that can sometimes bring the tribes together is laughter. Walk into any hospital common room and you will find physicians telling jokes about surgeons and, across the corridor, surgeons telling jokes about physicians. And, on the rare occasions that they get together in the same room, surgeons tell the physicians jokes about orthopaedic surgeons. “What is the difference between an orthopaedic surgeon and a carpenter? The carpenter knows the name of more than one antibiotic.” “How do you hide something from an orthopaedic surgeon? Put it in a book.” Or my favourite: “Did you hear that we have employed a holistic orthopaedic surgeon? He cares about the whole bone and not just the fracture.” Physicians, especially those who don’t perform procedures, are ever so slightly jealous of surgeons. They remember the fun they had when they were training, when they could get their hands dirty and do things that had an immediate effect on the wellbeing of their patients: the emergency tracheostomy for the man with an obstructed airway; the immediate relief for the woman following the drainage of her perianal abscess; the appendicectomy for the patient with the, er, normal appendix (OK, forget the last one). They pine for the uninterrupted hours that the surgeon can find in the operating theatre, where the existential thrill of operating insulates them, for a while at least, from the stress of the chaotic and uncontrollable world of the hospital. The physician can be envious of the elegant simplicity of surgery. “You need an operation”, says the surgeon to the patient, “I will do an operation”. The operation is done. “You are better now. Goodbye.” The physician must live with a series of much less conclusive interactions. “You have diabetes”, says the physician, “I will start you on insulin”. The insulin is injected. “You still have diabetes. See you next week (repeat).” Every young person in the course of training to be a doctor dreams, at least for a while, of becoming a surgeon. Hardly any do. Surgeons don’t choose their career, surgery chooses them. Physicians? I’m not sure that the same vocational predetermination applies. Indeed (and it hurts me to say this), happy though your professional life may be, I suspect that sometimes a physician is what you became while you were making other plans . . .

Francis J Bowden FRACP, FAChSHM, MD

A 70-year-old man developed melaena after taking aspirin and clopidogrel for 2 months to treat ischaemic heart disease. Other medications the patient was taking included metformin and metoprolol. A lipoma, the endoscopic appearance of which resembled a finger (Figure), was the only endoscopic abnormality. It was resected endoscopically, with the aid of an endoloop to cut off its blood supply before removal with a snare. The diagnosis was histologically confirmed but ulceration was not found, possibly because one section of the lesion was not retrieved. Lipomas are soft and typically appear as an isolated bulge of smooth mucosa, often with a yellow hue. Such lesions bleed rarely.

Hayley Clifford · Millie Lui · Roger Lee · Andrew Thomson

Objective: The belief that the full moon and disturbed behaviour are closely linked is alive and well, despite studies to the contrary. We investigated the possibility that there is an association between only extreme behavioural disturbance and the full moon.Design, setting and participants: We undertook an observational study of patients with violent and acute behavioural disturbance who presented to the emergency department of Calvary Mater Newcastle and patients with less severe behaviour for whom hospital security calls were made.Main outcome measure: Proportion of patients for whom presentation or security call occurred in each lunar phase, modelled as a Poisson process.Results: Of 91 patients with violent and acute behavioural disturbance, 21 (23%) presented during the full moon — double the number for other lunar phases (P = 0.002). Sixty (66%) had either alcohol intoxication or psychostimulant toxicity, and five attacked staff (biting [2], spitting [1], kicking [1] and scratching [1]). In contrast, 512 hospital security calls for patients with less severe behaviour were evenly distributed throughout the lunar cycle.Conclusion: Violent and acute behavioural disturbance manifested more commonly during the full moon.

Leonie A Calver · Barrie J Stokes BSc, MSc · Geoffrey K Isbister BSc, FACEM, MD

To the Editor: Two 35 cm long blue-tongue lizards live in the rockery above my home swimming pool (water temperature, 19ºC). While cleaning the pool, I was shocked to see one of them floating motionless on the surface, but with its head held out of the water. Rescue with a net revealed a sluggish but healthy lizard, that slowly crept into the ground cover. Returning to my task, I was devastated to see the other lizard motionless on the bottom of the pool. After rescuing it, I thought it was dead, but a trace of slow muscular movement led me to action. With its head down, I rhythmically squeezed the upper body circumferentially with one hand, expelling an amazing amount of water and then saliva-like fluid. The abdomen, which had been distended to about 7 cm in diameter, reduced in size at least 1 cm. Gradually, there was more sluggish body and limb movement, but no discernible respiration and no opening of the mouth. After about 10 minutes, the eyes opened and I reduced my gentle efforts, but still fluid drained if the head was held down. Eventually, the lizard was placed on the rockery and observed. After a few minutes, it opened its mouth widely, revealing the oral cavity completely full of froth. More head-down draining and rest gradually improved the situation and, some time later, normal respiration seemed to have returned. Later in the day, it had moved about 30 cm and, before nightfall, it had gone. Next morning, both lizards were seen, appearing perfectly healthy and normal. I have no idea how long they were in the pool, or why, but presumably they had had a tussle, a game of chasey or a fight and lost their bearings. After 3 years of retirement from general practice, I felt considerable personal and professional delight! Comment: Lizards generally have simple lung structures compared with those of mammals. Their lungs are basically two membranous sacs, with no bronchial tree that leads to the alveolar sacs in mammals. This means their capacity for oxygen exchange is less than that of mammals. They have, however, many physiological adaptations to compensate for this limitation, including a capability for prolonged anaerobic metabolism and the ability to perform right-to-left cardiac shunting. Consequently, reptiles are much better able to cope with hypoxia than mammals. If hypoxia continues for more than an hour, heart rate may fall 50%, and a right-to-left shunting of up to 80% of cardiac output occurs. Several species of lizards use their capacity to cope with hypoxia to advantage and will submerge themselves for several hours to escape predators. Blue-tongue lizards are a terrestrial species and generally avoid contact with water. If necessary, however, they are very good swimmers. They tend to inflate their lungs, and use their tails to propel themselves across the surface of the water. The lizard described by Darvall probably drowned because of exhaustion and hypothermia. In reptile drowning, it is important to help remove water and respiratory secretions from the lungs using gravity and coupage, particularly as reptiles appear to lack a good mucociliary clearance system. The pool water, being chlorinated, would have had reduced microbial levels, making bacterial pneumonia, seen in accidental drowning in reptiles, less likely. Keeping the reptile warm is also important, to stimulate muscle activity and respiration. Had this lizard failed to respond to drainage and coupage, it may have needed supplementary oxygen, a measure that warrants caution. The respiratory centre of reptiles responds mostly to low partial pressure of oxygen, unlike the respiratory centre of mammals, which normally responds to increased partial pressure of carbon dioxide. Thus, supplying 100% oxygen to reptile patients requiring resuscitation inhibits return to normal respiration. Reptile resuscitation is best provided with normal air, at a rate of six breaths per minute.

William L Darvall · Shelton Smith

If you want a challenge, and need a laugh, try a day as a hospital switchboard operator! The telephone switchboard is the nerve centre of the hospital, and the people working there are our unsung heroes. In my hospital, they handle at least 6000 calls a day, which is around 250 calls an hour. They work under extreme pressure, fielding questions and demands that range from the routine to the rude or the ridiculous. A sense of humour is an essential requirement to work there. One caller, a doctor, asked to have me paged. When the operator said, “Yes, we will page him”, the caller replied, “Yes, thanks, on his pager please”. Apparently, when a particularly weird call came through, one operator was heard asking the other, “Is it a real person or a doctor?” Another caller asked to talk to a “doctor with some medical background”. The major challenge is how to deal with distressed callers. For example, one woman rang to see whether she could talk to a doctor because she was getting palpitations and wanted to know whether it was menopause. A younger woman rang to ask what time the maternity delivery hours were! What about the young man who asked to be connected to a ward and, when told that the line was busy, said, “I want an answer from my grandmother whether she is alive or dead”. Another caller enquired about his son who was brought in with a “Caesar”, while a young man rang to find out about his pregnant wife who was full term and had come to hospital to have a “seizure”. The operator did not know where to forward the call from the young woman who was worried about dyeing her hair: “Could the dye seep over to the baby, since I’m 14 weeks pregnant?” What about the caller who wanted to know where to get spare parts for the baby? He was actually after a car “capsule” (baby seat) for his newborn. Was the young couple who rang to be connected to the “infidelity” clinic trying to patch up their relationship? And where do you find the neon-natal ward? Maybe it is dark and not well signposted? It must be hard sometimes to pick the comedians from those who are just too clever — many people ask for the “imagining department” (as I do when I look at MRI scans). Others want the “extensive care unit” (what a compliment to my ICU colleagues!), the “numerology department” (acalculia can be a consequence of stroke) or the “incompetence clinic” (incontinence is often an “incompetency” of dementia). How did the woman who rang to speak to the “neo-native intensive care unit” know that we have lots of foreign doctors? When a caller asked to be put through to Ward D, the operator wanted to know whether it was “d” for dog or “b” for baby; the answer was, “They never told me”. When someone asked for Bob Reynolds and the operator wanted to know which ward he was in, the answer was, “I don’t know, but he will know” (even if Bob was demented?). Then there was the woman who rang to speak to the crisis team in mental health. When the operator said the on-call person would be paged, the caller said she had paged someone 2 weeks ago and had not heard back! Another time, somebody wanted the registrar of the psychiatric crisis team and was given the number 53732. The response was, “Is this his name or pager?” My favourite was the call from an anxious young man about his wife who was having labour pains. To try to calm him down, the concerned operator asked, “Is this her first baby?” His answer was, “This is her husband, you stupid?” The switchboard operators have a tough job, but it has its moments!

Balakrishnan R Nair FRACP, FRCP