Volume 192 Issue 2

Robust evidence, rather than political pressure, should inform decisions about maternity care The status of home birth in Australia has become more contentious than ever with the introduction of legislation which requires that all services provided by registered health professionals be covered by appropriate indemnity insurance. Although never intended to prevent registered midwives from providing care in planned home births, the absence of insurance for home birth has meant that any midwife assisting in a planned home birth appeared to have to forgo midwife registration, or risk penalty. The Maternity Services Review1 recommended that home birth not be supported, but this recommendation was based on the lack of consensus among providers of maternity care that would be required for its safe implementation. The Review remained silent on whether or not home birth should be considered as a safe model of care for the Australian maternity system. Previously published Australian evidence shows that planned home birth in Australia is associated with a higher risk of intrapartum perinatal mortality.2-5 An article by Kennare and colleagues in this issue of the Journal reviews the outcomes of all planned home births in South Australia from 1991 to 2006, and confirms previous findings.6 Although women with recognised risk factors such as nulliparity, Indigenous status, lower occupational status and residence outside metropolitan areas were less likely to plan home birth, planned home birth was associated with a sevenfold increase in risk of intrapartum perinatal mortality compared with planned hospital birth, and a 27-fold higher risk of death due to intrapartum asphyxia.6 These differences were significant despite a sample size of only 1141 home births. Overall perinatal mortality standardised for gestation and birthweight was more than double that of planned hospital births, but because of low numbers these differences were not statistically significant. Of course, not all severe adverse perinatal outcomes in labour can be avoided, but they are better avoided, statistically speaking, when birth is planned to take place in a hospital birth unit. Perinatal mortality is not the only relevant outcome, but it is generally accepted as a most important outcome measure. It is also significant that the incidence of intrapartum perinatal mortality due to asphyxia had halved in South Australian hospital births during 1991–2006 compared with the outcomes recorded for 1976–1987, but hardly improved for planned home birth.2,6 Rates of interventions such as caesarean section and instrumental delivery were lower in the planned home birth group in Kennare et al’s study, but, as there was no adjustment for risk, it is unclear to what extent this is due to the model of care, and to what extent it is due to the fact that hospitals care for higher-risk pregnancies.6 There were no measurable increases in rate of postpartum haemorrhage,6 and it appears that the adoption of oxytocin into home birth practice has resulted in improvement in this outcome compared with data from previous studies in Australia.5 Notwithstanding Australian data, calls for integration of planned home birth into mainstream maternity services continue, based on international evidence of comparative safety.7-9 Advocates argue that the poorer outcomes measured in Australian studies are due to inappropriate inclusion of high-risk pregnancies that will have poorer outcomes in home birth and, if restricted to low-risk pregnancies cared for by accredited practitioners, planned home birth outcomes would be comparable or superior to hospital birth outcomes . Home birth models of care have been adopted by a small number of maternity units within the state hospital systems. The federal Minister for Health and Ageing, Nicola Roxon, has been under much pressure to move beyond the recommendations of the Maternity Services Review and provide indemnity insurance and funding for planned home birth. The decision to exempt registered midwives from the indemnity insurance requirements but not extend further support is a political compromise. It is consistent with evidence that current planned home birth practice in Australia increases the risk of perinatal mortality, but recognises that a small minority of women will continue to choose to give birth at home and that it is safer for these women to be cared for by registered midwives, rather than give birth unassisted. As with most compromises, it angers both home birth advocates, who want indemnity and funding provided, and opponents, who argue that a different professional standard is being applied for the benefit of a noisy minority. The decision essentially maintains the status quo. Uninsured midwives can continue to provide care for women planning to give birth at home without risk of professional sanction (as they have since 2002). But, given the accumulated evidence from Australia spanning 30 years, facilitating and funding home birth in an autonomous setting would be contrary to the principles of evidence-based health administration. The outcome is that midwives can continue to provide care for women who have planned home births, but are required to provide full disclosure to their clients that they are not indemnified, and in return must provide data and participate in a safety and quality framework that will be overseen by the Victorian Department of Health. This should ensure a gradual accumulation of data (including statistics on outcomes such as maternal and perinatal morbidity) that can inform future policy direction, and also encourage adherence to proper clinical risk assessment and management to minimise preventable mortality and morbidity. Those who argue that planned home birth in Australia can be safe will have to show this on the basis of accumulated evidence before any further changes can be considered. With time, the gulf between the politics and science of home birth in Australia should narrow, allowing health policymakers to focus on evidence-based decisions, rather than political ones.

Andrew F Pesce MB BS, FRANZCOG

On health grounds, immigration detention should be used in very limited ways Like all rich nations, Australia has experienced an increase in people crossing its national borders without the documents authorising them to do so. Since 1992, Australia has had a policy of mandatory detention for these people. About a third of the people in immigration detention are asylum seekers who are requesting sanctuary under the 1951 United Nations Convention Relating to the Status of Refugees, to which Australia was an early signatory. Although some form of immigration detention exists in most developed countries, asylum seekers are generally released into the community after a period of time in detention, while their claims are being processed. Australia pioneered the notion that detention for asylum seekers was a kind of endgame, in which people arriving without authority stayed in detention until they obtained a visa or were deported. Among the Convention signatories, no other nation has followed suit. As an island nation, our protection obligations are most frequently engaged by asylum seekers arriving by boat. In the financial year 1999–2000, in response to the Taliban insurgency and escalating crises in Iran and Iraq, 4180 asylum seekers arrived by boat.1 This was more than triple the total number of asylum seekers arriving by boat over the previous 3 years combined. By the following year, Australia’s immigration detention centres, many recently opened in remote Australian settings, admitted a total of 11 439 people.2 In 2000, the mean duration of stay in Australia’s immigration detention centres ranged from 1 month to 9 months.3 The study by Green and Eagar in this issue of the Journal counts the health costs of immigration detention.4 This is the largest Australian study to date of the health of people who have been in detention, and the first to follow up a cohort over an entire year. Studying the health of such people in the past in Australia has been challenging;5 previous studies, although valuable, were necessarily small scale.6-8 In the absence of on-the-ground research, we relied on testimony to a national inquiry by the Australian Human Rights and Equal Opportunity Commission,9 and the People’s Inquiry into Detention.10 For Green and Eagar’s study,4 a new policy of openness by the Department of Immigration and Citizenship (DIAC) gave the researchers access to databases containing the health records of people who had been in detention. Their study highlights the contribution of immigration detention to mental illness. Asylum seekers, and other detainees who experienced prolonged detention, were more likely to develop mental illness as a new diagnosis. However, all people who had been in detention for long periods of time had higher attendance rates for a range of health conditions compared with those detained for a shorter time. Sultan and O’Sullivan, in their characterisation of immigration detention syndrome, describe a three-stage process of escalating mental distress and depression, with people in long-term detention being overwhelmed by hopelessness and a sense of being trapped and alone.6 A follow-up of Mandaean refugees noted that prolonged immigration detention was associated with the most severe mental disturbance, which continued for an average of 3 years after release from detention.7 The location of the immigration detention centre where these refugees were held was not stated. The remote onshore detention centres (now all decommissioned) were operating at the time of Green and Eagar’s study; the geographical isolation of some of these centres may have also affected detainees’ mental health. The number of children included in Green and Eagar’s study was small, as policy changes were made during the study period to limit immigration detention of children. Between 1999 and 2003, over 2000 children arrived without visas, by air or sea, and most spent time in immigration detention (these figures exclude the children in offshore immigration detention centres on Nauru in the Micronesian South Pacific; and Manus Island, Papua New Guinea).9 Immigration detention centres fostered emotional in-stability, and children witnessed violence and security crackdowns. The family unit was often too fragile and damaged to provide stability through the vicissitudes of detention life. At the time of writing (23 October 2009), there were 126 children in immigration detention, housed outside the main immigration detention centres.11 Diligence will be needed to ensure that the residential housing options near immigration detention centres remain supportive of children’s development. As pioneers of the practice of long-term immigration detention for children, Australia has a responsibility to collect data on the health outcomes of this social policy. Internationally, there is now a move to better monitoring of the conditions in immigration detention. In Australia, detention centres in remote locations have been decommissioned, leaving four in large urban settings, as well as one on Christmas Island. In Australia, the Detention Health Advisory Group provides input into the health services of detention centres, and the DIAC provides more transparency and mechanisms to enhance service quality for immigration detention centres and their health services. In the United States, where 400 000 people currently enter immigration detention each year, the Department of Homeland Security recently announced the creation of an Office of Detention Policy and Planning to oversee immigration detention. There will also be greater input from a health advisory group.12 The openness of the Australian Government to improved oversight mechanisms for detention centres is welcome. Such mechanisms are essential. Immigration issues can inflame public imagination and lead to calls for harsher detention measures for “queue-jumpers”. There is a need for the definition of a clinically relevant, immigration detention centre minimum dataset, and for good prospective research to be performed on the health of detainees after their release into the community. The evidence is growing that asylum seekers are likely to be those most psychologically damaged by immigration detention, and that their children are particularly vulnerable. There is a good case to be made on health grounds that immigration detention should be used in very limited ways for asylum seekers, and never for children.

Christine B Phillips MB BS, MPH, FRACGP

“We cannot stay silent any longer, waiting and watching as more people are harmed in health care.”1 Error in health care remains a significant problem in Australia, despite more than a decade of efforts to remedy it. Since the landmark 1994 Quality in Australian Health Care Study (QAHCS),2 Australian governments, both state and federal, have introduced various clinical governance, health policy and structural reforms to improve the quality of patient care and reduce preventable harm to patients. However, adverse events have not been measurably reduced. Many acknowledge that barriers to change are embedded in the culture and norms of health care. So, 15 years after the QAHCS and 5 years after a follow-up editorial in the Journal by Wilson and Van Der Weyden3 noting that health care was no safer and calling for a more imaginative strategy to improve patient safety, it is necessary to consider new approaches — not just more of the same. One such approach is to enable patients, carers and families who have experienced poor-quality care and preventable health care harm to develop solutions in partnership with clinicians, health providers and policymakers. In July 2009, 40 people who identified themselves as agents of change met in Perth, Western Australia, to take part in the 3-day inaugural Australian Patients for Patient Safety (PFPS) workshop, convened by the Health Consumers Council of WA, the WA Department of Health, Perth’s Curtin University of Technology and the United States organisation, Partnership for Patient Safety. The workshop was the 12th in a series of global workshops supported by the World Health Organization’s PFPS program,4 which was launched in London in November 2005. The workshop adapted an organisational change strategy known as appreciative inquiry (AI). AI builds on meaningful personal experiences that reflect the most positive core of human systems — values, visions, achievements and best practices.5 Participants in an AI process mine their stories to give voice to their most desired future.5 Half the workshop attendees were patients who had suffered preventable harm in health care or lay carers of people who had been harmed. The other half were health care professionals, health system researchers, government officials and non-governmental organisation leaders interested in hearing from and working with patients to bring about change. Participants came from a variety of backgrounds and cultures (fulfilling a workshop planning goal). In an atmosphere of deep mutual respect, they shared their experiences of health system failure and the profound impact this had had, and continues to have, on their lives. Sharing personal experiences, lessons learned and possible ways to make health care safer, participants developed the Perth Declaration for Patient Safety (Box).1 This passionate call to action seeks to ensure that the impact of health care harm is recognised and that patients’ unique experiences inform change. It calls on all who work in and shape the Australian health system to strive, in partnership with patients and their families, to improve health care safety. Participants emerged from the workshop appreciative of one another’s experience and contributions, and dedicated to working collaboratively to advance patient safety in Australia. Through the WHO, they join an international network of PFPS “champions”, whose mission is to help patients be active partners in health care, not passive recipients.6-8 The Australian PFPS workshop and its recommendations are timely indeed, given the current push for reform of the Australian health care system. Authors of recent reports, including the proposed National Safety and Quality Framework of the Australian Commission on Safety and Quality in Health Care9 and the final report of the National Health and Hospitals Reform Commission (NHHRC),10 encouraged conversation with consumers about future directions. Both reports call for action more than words, a call now underscored by the Perth Declaration. The NHHRC final report specifically argues that, to create a self-improving health system, a necessary first lever is to strengthen the engagement and voice of consumers. The PFPS workshop showed that a partnership is readily achievable when stakeholders reach through the invisible walls that separate them. Cooperation among people who are moved to attain what is possible brings new life and confidence to reform efforts. The vision of a safer future embodied in the Perth Declaration and reflected in the workshop participants’ commitment to openness, appreciation for one another’s experiences and learning from patients’ wisdom, must be supported. The opportunity to co-create that future — to stop harm and save lives — is now here. Perth Declaration for Patient Safety1 We, the participants of the inaugural Australian Patients for Patient Safety workshop, convened in July 2009 to share profound health care experiences in our lives and to take forward our call for action to improve patient safety in Australia. We are patients, family members, carers and health professionals — people from all walks of life. Each one of us is a testament to the personal experience of unintended harm in health care and its continuing impact. Much of that harm was preventable. We declare Policies and protocols alone have not made us safer. This problem is systemic, widespread and deep-rooted. The fact that any person or family could one day experience needless devastating harm within the health care system is unacceptable Action must be taken now across all aspects and all levels of health care to prevent more harm occurring to others Our trusted health care workers and managers must recognise that we, your patients and our families, are an invaluable asset and resource for improving patient safety. We offer our stories and experiences. Seek to learn from our hard-won wisdom and partner with us to make lasting change We are the owners and funders of our health care systems and have collective responsibility for them. We ask everyone in the community, including health care providers, administrators and the Government, to join us in making the right to safe health care a priority for all people, especially those who are currently disadvantaged Care has no borders, neither does harm. The journey through all care settings must be better coordinated as too many lives have been lost or grievously harmed on this journey We need to receive care that conforms to the best evidence and practice. Safe practice must be supported by the reporting of and learning from patient safety incidents, education, innovative solutions and information Many barriers exist for Aboriginal and Torres Strait Islander people which limit access to safe health care. Interpreter services, effective communication, transport and accommodation are all integral elements of patient safety Patients know their own bodies better than anybody else. It makes sense to include patients in decisions about their care and treatment. Patients must always be told the options available, the expected outcome of each option including risks and complications, and the likelihood of each outcome occurring Patient safety is a basic human right. When harmed, people have the right to timely apology, explanation, redress and other remedies meaningful to them In accepting that all humans err, we nevertheless dedicate ourselves to ensuring that effective systems are in place to Track and learn from health care errors, adverse events and near misses Minimise the impact of errors on all involved, including the care provider Make changes to prevent the same errors happening again Current reporting arrangements have failed to deliver safe health care for patients. We accept that everyone, including patients, their families and clinicians, needs to safely report patient safety issues and problems. We therefore demand the application of improved patient safety legislation, including sanctions, which enables good clinical practice and provides real safety We cannot stay silent any longer, waiting and watching as more people are harmed in health care. As Australians, we own this problem and will work together with actions that go beyond words. To progress this call for action to improve patient safety, we expect partnership at all stages and at every level of the Australian health care system This Declaration is our kindling. We, the participants of the inaugural Australian Patients for Patient Safety workshop, will use it to ignite the flame of change to advance patient safety for everyone. This is our promise. Perth, Australia August 5, 2009

Stephanie M Newell Cert IV OHS, DipCouns · Dorothy A Jones BM BS, FAIM, MACMQ · Martin J Hatlie JD

Objective: Design, setting and subjects: An analysis of the health records of 720 of the 7375 people in detention in the financial year 1 July 2005 – 30 June 2006, with oversampling of those detained for > 3 months.Main outcome measures: Health encounters and health condition categories; estimated incidence rates of new health conditions, new mental health conditions, and new injuries for each cohort (defined by time in, and reason for, detention).Results: People in detention had an estimated 1.2 (95% CI, 1.18–1.27) health encounters per person-week. Those detained for > 24 months had particularly poor health, both mental and physical. Asylum seekers had more health problems than other people in detention. The main health problems varied depending on the length of time in detention, but included dental, mental health, and musculoskeletal problems, and lacerations. Both time in, and reason for, detention were significantly related to the rate of new mental health problems (P = 0.018 and P < 0.001, respectively). The relationship between these variables and the incidence rates of physical health problems was more complex.Conclusion: People in immigration detention are frequent users of health services, and there is a clear association between time in detention and rates of mental illness. Government policies internationally should be informed by evidence from studies of the health of this marginalised and often traumatised group.

Janette P Green MStat · Kathy Eagar MA, PhD, FAFRM(Hon)

Objective: To examine the symptoms, level of suffering, and care of Australian children with cancer at the end of life.Design, setting and participants: In a study conducted at the Royal Children’s Hospital, Melbourne, parents of children who had died of cancer over the period 1996–2004 were interviewed between February 2004 and August 2006. Parents also completed and returned self-report questionnaires.Main outcome measures: Proportions of children suffering from and treated for various symptoms; proportion of children receiving cancer-directed therapy at the end of life; proportion of children whose treatment of symptoms was successful; location of death.Results: Of 193 eligible families, 96 (50%) were interviewed. All interviews were conducted in person, and occurred a mean of 4.5 years (SD, 2.1 years) after the child’s death. Eighty-four per cent of parents reported that their child had suffered “a lot” or “a great deal” from at least one symptom in their last month of life — most commonly pain (46%), fatigue (43%) and poor appetite (30%). Children who received cancer-directed therapy during the end-of-life period (47%) suffered from a greater number of symptoms than those who did not receive treatment (P = 0.03), but the severity of symptoms did not differ between these groups. Of the children treated for specific symptoms, treatment was successful in 47% of those with pain, 18% of those with fatigue and 17% of those with poor appetite. Of the 61 families who felt they had time to plan where their child would die, 89% preferred to have their child die at home. The majority of children (61%) died at home. Of those who died in hospital, less than a quarter died in the intensive care unit.Conclusions: Relatively high rates of death at home and low rates of unsuccessful medical interventions suggest a realistic approach at the end of life for Australian children dying of cancer. However, many suffer from unresolved symptoms, and greater attention should be paid to palliative care for these children.

John A Heath PhD, FRACP · Naomi E Clarke BMedSc(Hons) · Susan M Donath BSc(Hons), PhD · Maria McCarthy BAppSc, MAppSc · Vicki A Anderson BA, PhD · Joanne Wolfe MD, MPH

Objective: To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births.Design and setting: Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991–2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios.Main outcome measures: Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage.Results: Planned home births accounted for 0.38% of 300 011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% CI, 1.53–35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% CI, 8.02–88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births.Conclusions: Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

Robyn M Kennare RM, DipApplSc(Nursing), GradDipPH · Marc J N C Keirse MD, DPhil, FRANZCOG · Graeme R Tucker BSc · Annabelle C Chan MB BS, DPH, FAFPHM

From the recognition of the swine flu pandemic in late April 2009, health professionals, politicians and the public needed to know how serious pandemic (H1N1) 2009 influenza (swine flu) was in relation to other seasonal strains of influenza. The Victorian experience suggests that the circulation of pandemic (H1N1) 2009 influenza in the community was at most like influenza circulation in a season of moderate seasonal activity. We have no estimate of the total case count, but we know most infections have been mild. However, while disease in the community appears mild, and the risk of hospitalisation is low, a high proportion of patients hospitalised with swine flu required intensive care. Deaths from swine flu have not been as numerous as the modelled deaths from seasonal influenza, although people dying from swine flu are younger. Because we do not understand the laboratory-confirmed burden of disease due to seasonal influenza (as opposed to the modelled burden of disease), we could not base our response to the pandemic on an informed comparison of seasonal and pandemic influenza. We may not have needed a pandemic response to a disease that, although it has a different footprint, has been predominantly of seasonal intensity. It is critical to accumulate quality evidence about laboratory-confirmed influenza to guide our intervention policies for both seasonal and pandemic influenza.

Heath A Kelly BSc, MB BS, MPH

Objective: To describe the case characteristics and outcomes of patients hospitalised with pandemic (H1N1) 2009 influenza infection during the first 2 months of the epidemic.Design, participants and setting: Prospective case series of 112 patients admitted to seven hospitals in Melbourne with laboratory-confirmed pandemic (H1N1) 2009 influenza between 1 May and 17 July 2009.Main outcome measures: Details of case characteristics, risk factors for severe disease, treatment and clinical course.Results: Of 112 hospitalised patients, most presented with cough (88%) and/or fever (82%), but several (4%) had neither symptom. A quarter of female patients (15) were pregnant or in the post-partum period. Patients presenting with multifocal changes on chest x-ray had significantly longer hospital lengths of stay, and were more likely to require intensive care unit admission. Thirty patients required admission to an intensive care unit, and three died during their acute illness. The median length of intensive care admission was 10.5 days (interquartile range, 5–16 days).Conclusions: This study highlights risk factors for severe disease, particularly pregnancy. Clinical and public health planning for upcoming influenza seasons should take into account the spectrum and severity of clinical infection demonstrated in this report, and the need to concentrate resources effectively in high-risk patient groups.

Justin T Denholm BMed, MBioethics · Claire L Gordon MB BS, BMedSci · Paul D Johnson MB BS, PhD, FRACP · Saliya S Hewagama MB BS · Rhonda L Stuart MB BS, FRACP, PhD · Craig Aboltins MB BS, FRACP · Cameron Jeremiah MB BS · James Knox BSc(Med), MB BS, DTM · Garry P Lane MMed(ClinEpi), MQIHC, FRACP · Adrian R Tramontana MB BS · Monica A Slavin MB BS, FRACP · Thomas R Schulz BSc, MB BS · Michael Richards MBBS, FRACP, MD · Chris J Birch PhD · Allen C Cheng FRACP, MPH, PhD

Pandemic (H1N1) 2009 influenza has generated many controversies in Australia around case definitions, laboratory diagnosis, case management, medical logistics and travel restrictions. Our experience as clinical advisers in the Victorian Department of Human Services Emergency Operations Centre suggests the following: Case definitions may change frequently, and will tend to become more clinically specific over time. Early in a pandemic, laboratory diagnosis plays a critical role in case finding and pathogen identification. Later in the pandemic, standardised case management applied to well crafted case definitions should reduce reliance on the diagnostic laboratory in clinical management. The diagnostic laboratory will remain critical to monitoring disease surveillance, pathogen virulence, and drug susceptibility. Medical logistics will continue to challenge pandemic managers as the health sector struggles to do the most good for the greatest number of people. Travel restrictions remain scientifically controversial public health recommendations. Issues of scalability (escalation and de-escalation of the response) relating to virus lethality need to be resolved in current pandemic planning.

David A Bradt MD, FACEM, FAFPHM · Joseph Epstein FRACS, BA(Hons), FACEM

Objective: To compare the patient characteristics, clinical features and outcomes of adult patients hospitalised with pandemic (H1N1) 2009 influenza and seasonal influenza.Design and setting: Retrospective medical record review of all patients admitted to Liverpool Hospital, Sydney, with laboratory-confirmed influenza from the initiation of the “PROTECT” phase of the pandemic response on 17 June until the end of our study period on 31 July 2009.Main outcome measures: Severity of illness; requirement for admission to the intensive care unit (ICU) and/or invasive ventilation; mortality.Results: Sixty-four adults were admitted to Liverpool Hospital with influenza, 48 with pandemic (H1N1) 2009 influenza and 16 with seasonal influenza. Thirteen patients were admitted to the ICU. Seven required invasive ventilation, with 2 patients requiring ongoing extracorporeal membrane oxygenation (ECMO). Five patients died (mortality rate, 8%) with two deaths occurring after the study period. Patients with pandemic (H1N1) 2009 influenza were younger and less likely to be immunocompromised than patients with seasonal influenza. However, the clinical features of pandemic (H1N1) 2009 influenza and seasonal influenza were similar.Conclusions: Our findings show that the clinical course and outcomes of pandemic (H1N1) 2009 influenza virus are comparable to those of the current circulating seasonal influenza in Sydney. The high number of hospital admissions reflects a high incidence of disease in the community rather than an enhanced virulence of the novel pandemic influenza virus.

Ya-Shu Chang MB ChB · Sebastiaan J van Hal MB ChB, FRACP, FRCPA · Peter M Spencer MB BS · Iain B Gosbell MD, FRACP, FRCPA · Peter W Collett MB BS, PhD, FRACP

A graded public health response was implemented to control the pandemic (H1N1) 2009 outbreak in Queensland. Public health measures to contain the outbreak included border control, enhanced surveillance, management of cases and contacts with isolation or quarantine and antivirals, school closures and public education messages. The first confirmed case in Australia was notified on 8 May 2009, in a traveller returning to Queensland from the United States. In Queensland, 593 laboratory-confirmed cases were notified with a date of onset between 26 April and 22 June 2009, when the Protect phase of the Australian Health Management Plan for Pandemic Influenza was implemented; 16 hospitalisations and no deaths were reported during this time. The largest number of confirmed cases was reported in the 10–19-years age group (167, 28% of cases), followed by the 20–29-years age group (153, 26% of cases). With ongoing community transmission, the focus has shifted from public health to the clinical domain, with an emphasis on protecting vulnerable groups. Considerable resources have been invested to prevent and control the spread of disease in Indigenous communities in Far North Queensland. The capacity of clinical services to cope with increased admissions, the potential for widespread antiviral resistance, and rollout of mass vaccination campaigns remain future challenges.

Ranil D Appuhamy BSc, MB ChB, MIPH · Frank H Beard MB ChB, FAFPHM · Hai N Phung MD, MPH, PhD · Christine E Selvey MB BS, MSc · Frances A Birrell MPH, MAppEpid, GCSc(Stats) · Terry H Culleton GradCertMgmt, BHlthServMgmt, RN

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social “vitamins” of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

Mark F Harris FRACGP MD · Elizabeth Harris MPH, BA, DipSocWk · Timothy D Shortus MPH, PhD, FRACGP

Australian federal and state governments were advised several years ago that an influenza pandemic would overwhelm Australian public reference laboratories. It was proposed at the time that currently underused capacity in the private sector be used to enhance pandemic responses. The current outbreak of pandemic influenza has confirmed the predictions of advisors from the private sector. Future official pandemic plans should be adjusted to take into account these observations.

Miles H Beaman FRACP, FRCPA, FACTM · Michael J Leung MB BS, FRCPA

To the Editor: We write to encourage policy debate over newborn screening for congenital adrenal hyperplasia (CAH). Classical CAH is a severe, life-threatening disease affecting about one in 15 000 liveborn infants in Australia.1 An inexpensive screening test for newborns is available, but this test is not included in the current newborn screening program in Australia. Three-quarters of children with CAH have the severe salt-wasting type that typically presents with failure to thrive, and progresses to severe hyponatraemic, hyperkalaemic dehydration and shock due to an adrenal crisis within weeks of birth. CAH is the most common cause of ambiguous genitalia in neonates (due to virilisation from adrenal androgens in utero); girls with CAH may be incorrectly assigned as boys unless the diagnosis is made without delay. CAH can be easily detected in neonates before the onset of illness by an established heel-prick newborn screening test that has good specificity and sensitivity, especially when used together with second-tier testing. Screening for CAH has been available for 30 years internationally, and is used in all American states, New Zealand and many countries in Europe, Asia and Latin America. Newborn screening reduces mortality and incorrect sex assignment.2 Case reports from Australia3 and overseas4 have shown that undiagnosed CAH is a cause of apparent sudden infant death syndrome. These deaths could have been prevented if newborn screening was in place. A pilot study in New South Wales showed that newborn screening for CAH prevented salt-wasting crises and their potential long-term consequences.1 The cost-effectiveness of newborn screening is difficult to measure, and there is little published evidence on this subject. Although a recent study suggested that CAH screening is not cost-effective,5 the only outcome assessed was mortality; other benefits of early diagnosis and intervention — including reduced morbidity and psychological impact — were not assessed. Newborn screening for CAH is not expensive; the cost per test within the laboratory is about $2, and the incremental cost per infant is in line with other newborn screening tests. In a recent survey, the Australasian Paediatric Endocrine Group found that 91% of paediatric endocrinologists considered provision of newborn screening for CAH in Australia to be very important. The Newborn Screening Joint Subcommittee of the Human Genetics Society of Australasia unanimously supports the inclusion of newborn screening for CAH in all Australian states. Two Australian parent and patient advocacy organisations — the CAH Support Group Australia, and Caring and Living as Neighbours — also strongly support the proposal for adding newborn screening for CAH to the current screening program. Despite clear predicted benefits and agreement among key stakeholders and expert advisers, no state in Australia currently screens for CAH. It is the state governments — guided by the Australian Health Ministers’ Advisory Council — who decide on funding for newborn screening tests, and who should be accountable for acting against the weight of expert opinion and systematic evidence.

Garry L Warne · Katrina L Armstrong · Thomas A Faunce · Bridget M Wilcken · Avihu Boneh · Elizabeth Geelhoed · Maria E Craig

To the Editor: Our positive experience with insulin pump therapy (IPT) in children without private health insurance contrasts with that of Thong and colleagues,1 who found that IPT did not significantly reduce glycated haemoglobin (HbA1c) levels in uninsured adults. IPT improves metabolic control, reduces the risk of microvascular complications and improves quality of life in children with type 1 diabetes mellitus.2,3 Private health insurance fully rebates the cost of an insulin pump, but many uninsured Australian children with type 1 diabetes are denied access to IPT because their family cannot afford the $8000 purchase price of an insulin pump. The other major impediment to using IPT is the paucity of access to skilled local IPT teams. In November 2008, to improve access to IPT, the federal government introduced a means-tested subsidy (to a maximum of $2500 per child) to be administered through the $5.5 million Type 1 Diabetes Insulin Pump Program.4 By 30 June 2009, the program had subsidised only 31 children for insulin pump purchase (unpublished correspondence from the Hon Mark Butler MP, Parliamentary Secretary for Health, to Mr Darren Chester MP, Member for Gippsland, July 2009). The largest user of this scheme, Gippsland Paediatrics (a private practice in rural Victoria), commenced IPT in 11 of the 31 children. Through local service clubs and other charitable institutions, we raised the funds required to pay the $5500 balance for all 11 children.5 Six other financially disadvantaged Gippsland Paediatrics patients had obtained insulin pumps through grants or community fundraising before the government subsidy program was introduced. Thus we have experience of 17 children, aged between 4 and 18 years (mean, 10.8 years) who were recipients of “donor” pumps. This sample represents about a quarter of the local children with type 1 diabetes and almost two-fifths of the 46 patients we have commenced on IPT. To evaluate the metabolic outcome of IPT for these 17 children, we conducted a retrospective analysis of glycaemic control by comparing the average level of HBA1c during the 12 months before commencing IPT with the most recent HbA1c level. The pre-IPT mean HbA1c level of children using the donor pumps was 9.2% (SD, 1.45%), which fell to 7.6% (SD, 0.83%) (P < 0.001) after a mean IPT duration of 10.2 months (SD, 6.1 months). In children aged 12 years or under (10 patients), the mean HbA1c level fell from 9.0% (SD, 0.94%) to 7.6% (SD, 0.43%) (P < 0.001) after a mean IPT duration of 11.9 months (SD, 7.6 months). In the remaining seven patients, aged 13–18 years, the mean HbA1c level fell from 9.4% (SD, 2.0%) to 7.8% (SD, 1.43%) (P = 0.03) after a mean IPT duration of 7.6 months (SD, 1.4 months). Gippsland Paediatrics uses the RADICAL (Rural Australian Diabetes — Inspiring Control Activity & Lifestyle) model of care.6 The model consists of a collocated multidisciplinary team, including a general paediatrician, diabetes educator and counsellor, with the patient and family receiving proactive emotional support, consistency of personnel, and point-of-contact HbA1c testing. We individualise our approach through regular case conferences and try to match therapy with desired lifestyle. Our study demonstrated that, using this model, IPT improves glycaemic control in uninsured children targeted by government policy — at least in the short term. To improve short-term health and reduce long-term diabetic complications in families who cannot afford insulin pumps, government programs need to make IPT more accessible to those families and support local multidisciplinary IPT teams.2

Peter W Goss

To the Editor: Norovirus, previously known as the Norwalk agent, is a recognised cause of acute diarrhoeal illness in all age groups, but its significance in hospitalised children is poorly described. Noroviruses cause infection worldwide and year-round, with a distinct increase in disease occurrence in colder months.1 Rotavirus has long been recognised as the most important viral cause of gastroenteritis in young children, causing significant morbidity, as well as cost to the community of hospital admission and lost parental productivity.2 In July 2007, two new rotavirus vaccines were licensed for use in Australian infants; their use has reduced severe rotavirus disease requiring hospital admission.3 One difficulty in accurately documenting the role of norovirus in childhood acute diarrhoeal illness has been the limited availability of routine diagnostic testing. Enzyme-linked immunosorbent assay (ELISA) for noroviruses is now available commercially; it has limited sensitivity of 55%–93% but good specificity of 73%–97%. We retrospectively reviewed the frequency of detection of norovirus in the faecal samples taken from inpatients and outpatients with acute gastroenteritis at a tertiary paediatric hospital. We tested stool samples of 3962 children with episodes of acute diarrhoeal illness in a 12-month period (2007) and detected norovirus in 122 (3.1%). Ninety-one of the children infected with norovirus were admitted to hospital; 63 patients had a stay of less than 7 days with a median of 1 day, while 28 patients where in hospital for more than 7 days. The norovirus infection in 30 of the inpatients (33%) was hospital-acquired. Most hospital-acquired infections occurred in patients hospitalised for more than 7 days (19 of 28; 68%), and most of these patients had predisposing medical conditions, predominantly immunosuppression due to treatment for malignancy or other causes. Norovirus is a significant cause of viral gastroenteritis in infants and children. Our findings are comparable with those of other studies, which indicate that norovirus infection causes 20%–88% of viral gastroenteritis in children and is responsible for a significant proportion of hospital admissions of children with gastroenteritis.4,5 With the introduction of universal rotavirus vaccination for Australian infants, the importance of norovirus as a cause of gastroenteritis in infants and children is likely to increase. We recommend that hospitals which admit children consider using norovirus testing to establish the incidence and prevalence of disease, and to inform public health authorities responsible for infection control policy and practices.

Alison M Kesson · Nicola Benwell · Elizabeth J Elliott

To the Editor: Rudkin and colleagues1 remind readers of the importance of detecting congenital glaucoma early to reduce the risks of permanent eye damage, including blindness. The first clinical signs of congenital glaucoma are reported to be blepharospasm, photophobia and excessive tears, all difficult to discriminate in an infant. If the condition is untreated, the cornea progressively loses clarity, and diagnosis becomes more obvious. In giving this account of my personal experience, I remind general practitioners, paediatricians and ophthalmologists that early oedema of the cornea may be detectable before other signs. Our daughter was born uneventfully and without medical problems. Four weeks after the birth, my wife, while gazing into her newborn’s eyes, commented, “Do you think her right eye is . . . more “shiny” than the left?” Looking at all angles, the anxious medical parents were convinced it was. Various medical friends were consulted. “Maybe, possibly”, they indulged us. A call to the senior paediatric ophthalmology registrar at our local children’s hospital was made along the lines of, “Is there such a thing as loss or increase in shine to the eye of a newborn?” In the absence of any other signs, such as inflammation, misery or excessive tears, we were told not to worry. Not reassured, we prevailed upon another ophthalmology registrar who, in a fit-in appointment, confirmed subtle corneal oedema caused by bilateral glaucoma, worse in the left eye. In retrospect, the diagnosis was obvious. “Couldn’t have been anything else”, except the presenting sign was not a cloudy cornea, blepharospasm or misery — it was simply light reflecting off one eye less brilliantly than the other. “It ain’t fine, if it don’t shine.”

Peter J Lewindon

To the Editor: I would like to report the results of a recent survey showing that junior doctors who undertook undergraduate training in a rural clinical school (RCS) felt better prepared for their new role as a doctor than those who did not. In Australia, the potential threat to the quality of clinical training because of increasing numbers of medical graduates justifies an interest in junior doctors’ perceptions of their learning environment and their level of preparedness for hospital work. Factors affecting this potential threat were investigated. In 2008, 428 junior doctors employed in Queensland training hospitals were asked to complete an online survey. Ethics approval was obtained from the Behavioural and Social Science Ethical Review Committee of the University of Queensland. During their undergraduate training, the majority of respondents had not studied at an RCS. The remaining respondents had attended a large university RCS (of about 1600 enrolled students) or a small university RCS (of about 650 enrolled students) in Queensland, or had attended an RCS of unknown size in another state (n = 9). A mixed methods cross-sectional design, based on two validated scales, was used: The Preparation for Hospital Practice Questionnaire (PHPQ) assessed respondents’ perceptions of the adequacy of undergraduate medical training to prepare them for hospital work;1 and The Postgraduate Hospital Educational Environment Measure (PHEEM) measured respondents’ hospital clinical teaching and learning environment.2 Of 167 responses received (a 39% response rate), 33 were incomplete, leaving 134 usable responses. The majority of respondents were women (60%), aged 26–29 years (53%) and graduates of the large university (79%). Forty-eight per cent had chosen to spend a portion of their undergraduate training at an RCS. A univariate analysis (using analysis of variance and analysis of covariance) made comparisons by age, sex, undergraduate university medical program (large or small Queensland university, university in another state) and attendance at an RCS. Overall responses to the PHEEM indicated that there was “room for improvement” in the autonomy, teaching and social support of the hospital learning environment. No significant differences were detected in either the PHEEM or PHPQ subscale scores by age, sex, postgraduate year or undergraduate university. Junior doctors who attended any RCS as part of their undergraduate education scored significantly higher on three out of eight scales of preparedness for hospital work (based on the PHPQ) (Box). A caveat is that confidence and feelings of preparedness do not equate to “competence”, but the study was not designed to assess competence. Confidence is also strongly related to temperament, which could influence self-selection choices such as factors associated with the size of medical school. These findings are congruent with other studies showing that students perceive undergraduate training outside a traditional metropolitan-based program to be of higher quality3 and that the performance of students trained in RCSs is comparable to that of their urban-based peers.4,5 Dispersing smaller cohorts of students to individual clinical schools (similar to the RCS model) may prove a successful strategy to cope with escalating numbers of undergraduate students. In theory, better prepared junior doctors should require less intensive supervision, contribute more to the hospital workload and alleviate the strain on already stretched educational resources in hospitals. In summary, given the imminent increase in medical graduates entering training hospitals, considerable work needs to be done to improve the quality of education provided for junior doctors in order to maintain a high-quality, supportive educational atmosphere. Comparison of Preparation for Hospital Practice Questionnaire (PHPQ) mean subscale scores between Queensland junior doctors who attended a rural clinical school (RCS) as part of their medical training and those who did not* Medical school attended Interpersonal skills Confidence Collaboration Management Science Prevention Holistic care Self-directed learning Any RCS (n = 65)† 3.97 (0.920) 4.00‡ (0.883) 4.28§ (0.735) 4.04§ (0.889) 4.08 (0.838) 4.56 (0.717) 4.56 (0.809) 4.44 (0.643) Large university RCS (n = 42) 3.84 (0.925) 3.82 (0.877) 4.15 (0.772) 3.74 (0.875) 3.95 (0.882) 4.46 (0.737) 4.43 (0.817) 4.36 (0.666) Small university RCS (n = 14) 4.28 (0.897) 4.68‡ (0.770) 4.68§ (0.583) 4.73‡ (0.691) 4.46 (0.692) 5.00§ (0.418) 5.01§ (0.558) 4.71 (0.641) No RCS (n = 69)¶ 3.87 (0.905) 3.58 (0.784) 3.98 (0.853) 3.69 (0.858) 3.88 (0.918) 4.55 (0.726) 4.47 (0.767) 4.43 (0.694) * Figures are mean score (SD). Rating scale of respondents’ perceptions of their preparedness for hospital work: 1 (very inadequately prepared) to 6 (very adequately prepared). † All junior doctors who attended an RCS during their undergraduate degree, including nine non-Queensland RCSs. ‡ Significant at P < 0.001 level. § Significant at P < 0.05 level. ¶ All junior doctors who did not attend an RCS during their undergraduate degree.

Diann S Eley

To the Editor: The general practitioners’ dilemma is acute. Women asking for mammography and/or testing for ovarian cancer; men asking for prostate-specific antigen (PSA) testing for prostate cancer. The debate, fuelled by uncertain knowledge, rages in the general medical journals,1,2 including contributions in the 17 August 2009 issue of the MJA.3,4 The PSA test is, of course, intimately associated with the name of its inventor, Thomas A Stamey. I am, therefore, somewhat surprised that neither of these recent MJA articles mentioned Stamey’s 2004 “recanting” of his proposed value of the test back in 1987: “current evidence from the last 10 years is convincing that the relationship between prostate cancer and serum PSA is tenuous at best, especially with serum PSA less than 10 ng/mL and perhaps even less than 22 ng/mL. This time is not the first we have had second thoughts regarding the usefulness of serum PSA in preoperatively reflecting prostate cancer”. He concludes: “any excuse to biopsy the prostate has an excellent, age dependent chance of being positive”.5 Perhaps the authors could tell your readers why they did not think that Stamey’s 20-year experience of PSA testing and his 2004 conclusions warranted a mention?

Peter C Arnold

In reply: The letter by Arnold highlights the practical dilemma facing busy doctors when communicating with patients about whether to screen for various cancers, prostate cancer in particular. There are no easy answers at present, although presentation of both sides of the argument regarding prostate cancer testing helps doctors and patients make a shared decision.1 We believe the following decision-aid show card, written in plain English, is an excellent resource to assist with this: <http://www.cancer.org.au/File/HealthProfessionals/GPprostateshowcard.pdf >.

David P Smith · Emily Banks · Mark S Clements · Robert A Gardiner · Bruce K Armstrong

To the Editor: In a recent letter by Kowal,1 reference was made to my previous letter2 commenting on an article by Andreasyan and Hoy.3 Kowal questions my suggestion that Andreasyan and Hoy’s work adds evidence to the body of work indicating the health benefits for Indigenous Australians of living in small remote communities. She then suggests that “rather than jumping the gun, we need more research into the effects of outstation life on health and wellbeing”. I think Kowal misses the point. I did not refer to “outstations”. I wrote of the many remote Indigenous communities, most of which have been established in the past 40 or so years, not all of which are called “outstations”. These communities now have their survival threatened by current government policies that support a few selected larger communities at the expense of many smaller communities. The evidence provided by Andreasyan and Hoy, building on other work, does not support policies that are likely to lead to a drift of people away from their homelands to large centralised settlements and the fringes of towns and cities. While the research evidence is not overwhelming, on balance there appears to be more evidence suggesting health benefits from helping people remain on their traditional lands than evidence to support policies that encourage them to migrate to larger settlements and towns. Kowal accuses those who cite this evidence, such as Tom Calma and myself, as jumping the gun. I suggest it is governments that are jumping the gun in imposing policies that are not evidence-based. While there is a need for more research and for careful scrutiny of the research, as undertaken appropriately by Zhao and colleagues,4 the evidence definitely points to concerns that current government policies may have a significant detrimental effect on Indigenous people.

David J Scrimgeour

To the Editor: A timely article by Yelland and colleagues in the 7 September 2009 issue of the Journal1 correctly identifies postnatal depression as a significant public health issue. However, as members of the consortium that developed the 2008 beyondblue National Action Plan for Perinatal Mental Health (NAP),2 we are concerned that the National Perinatal Depression Initiative is being considered by Yelland and colleagues without reference to the NAP, the document on which the federal government based its funding allocation. The NAP recommended not only identifying current depressive symptoms, but also — equally importantly — using a structured method to assess the broader psychosocial risk factors known to affect maternal and infant mental health.2 The NAP also clearly recommended that any psychosocial assessment be accompanied by adequate workforce training and supervision and integrated pathways to care, complemented by community awareness programs. Although Yelland and colleagues1 raise concerns about the potential harm of routine screening for depression in women during pregnancy, none of the participants in a recent Australian study of antenatal screening for depression reported feeling stigmatised, labelled or distressed after using the Edinburgh Postnatal Depression Scale (EPDS).3 Indeed, many reported feeling relieved and supported that additional care was offered. This reinforces the assertion made in the NAP that a well trained workforce is essential for conveying the purpose of routine assessment — that such assessment is not an endpoint nor a substitute for full diagnosis, but the beginning of an ongoing process that helps professionals to be aware of women who may need support and treatment. Multiple studies evaluating the EPDS against structured diagnostic interviews for detecting major depression have shown that the EPDS has very good psychometric properties for scores of 13 or more (indicative of possible depression) in English-speaking populations.4 Yelland and colleagues also express concern that a limited number of interventions will be recommended to help depressed women. In fact, the NAP recommended that the full range of treatment options be offered within an integrated framework of community, primary care and specialist services.2 A first step in a national approach to perinatal mental health is to develop evidence-based clinical practice guidelines for perinatal depression and related disorders. This task is now underway, a clear indication that we are well placed to begin translating knowledge into practice. Research across Australia continues to examine the efficacy of a range of psychosocial risk assessment models,5 barriers to the uptake of referral and treatment options, and the impact of psychosocial assessment on maternal outcomes. This work will help ensure that a national approach to perinatal mental health is embedded in an evidence-based and evaluative framework.

Marie-Paule Austin · Nicole Reilly · Jeannette Milgrom · Bryanne Barnett

To the Editor: The research article by Keogh and colleagues1 on uptake of genetic testing and insurance implications highlights the need to ensure that Australian insurance industry policy in relation to genetic testing does not increase the risk of adverse health outcomes. The authors called upon the insurance industry and the Human Genetics Advisory Committee (HGAC) of the National Health and Medical Research Council (NHMRC) to reconsider the use of genetic information in relation to insurance.1 Another recently published study has also raised concerns about the way genetic information is used in the insurance industry.2 The HGAC has had initial discussions with the insurance industry about: avoiding genetic discrimination in the insurance setting; developing policies and guidelines to ensure appropriate use of genetic test results in insurance underwriting; promoting genetic education and training in the financial industry; and providing support for consumers and health professionals wanting to challenge adverse decisions. Through the HGAC, the NHMRC will encourage the development of an evidence-based process for assessment of genetic tests for use by the insurance industry, to ensure that it meets the required standard for underwriting. This will, in turn, support appropriate, equitable consumer access to optimal health care.

Warwick P Anderson

To the Editor: Congratulations on the 21 September 2009 issue of the Journal, highlighting preventive cardiology in Australia. I believe that the “working class man” of the well known Jimmy Barnes song has trouble affording preventive cardiology care in Australia. Assuming that he is currently employed, he will not be entitled to a Health Care Card and will be paying full price for care in general practice. There will be a gap of $20 to $60 between what he pays and the Medicare rebate per visit. He will have to pay about $30 per prescription. Assuming that he is taking antiplatelet agents, statins, and a blood pressure agent such as an angiotensin-converting enzyme inhibitor, he would be paying about $90 per month for medication. On an average income of $1200 per week1 ($800 after tax), and assuming that he visits his general practitioner monthly, preventive cardiology care might cost him about 4% of his disposable income. If our working class man is earning $900 weekly ($600 after tax), then preventive cardiology care would cost him 5% of his disposable income. Of course, the costs are similar for a wealthy man. However, the costs represent a far smaller percentage of his income than for the working class man. In this regard, the costs of preventive medicine are similar to the poll tax imposed in England in the 14th century. This regressive capitation tax was raised to pay for the imperial wars in France. However, the disproportionate burden it imposed on the serfs resulted in such anger that it led to the Peasants’ Revolt in 1381. Until medicine is funded more equitably, there will be a major disincentive to pursue preventive cardiology care for poorer people, who experience cardiovascular disease at an earlier age than their wealthier counterparts.2 The problem is not which model to use for absolute risk assessment,3 but the money to apply it.

V Michael Jelinek

A history of the ‘unfortunate experiment’ at National Women’s Hospital. Linda Bryder. Auckland: Auckland University Press, 2009 (vi + 250 pp). ISBN 978 1 86940 435 2. The so-called “unfortunate experiment” of this book triggered the 1987 New Zealand Cartwright Inquiry into cervical cancer treatment. Consultant gynaecologist Herbert Green of the Auckland National Women’s Hospital was the main target of a long and complex legal process hinging on allegations that he had prospectively studied two groups of women referred to the hospital with positive cervical cytology. One large group received treatment, following which most had no further problems (although some later developed invasive cancer). The second group, it was said, had no treatment but, despite positive cytology, were followed for years so that the natural history of what are now called high-grade epithelial abnormalities (formerly carcinoma-in-situ) could be studied; these women were 25 times more likely than the first group to develop invasive cancer, from which some of them died. Green was accused of callously disregarding the health of these women to satisfy his own scientific curiosity, and condemnation of his actions was central to the findings of the inquiry. However, as Linda Bryder painstakingly demonstrates, there was no such “experiment”. The two groups were a statistical construction in a 1984 paper by four of Green’s colleagues.1 Both groups had been treated but when positive cytology persisted, women were (unsurprisingly) more likely to develop invasive cancer. Green himself certainly advocated a less interventionist approach to the management of cervical pre-malignancy, which in the 1960s tended toward hysterectomy and in the 1970s to cone biopsy. A more low-key approach, now that we understand the role of human papillomavirus and have LLETZ (large loop excision of the transformation zone) procedures available, is universally practised — but, as I’ve observed over my own 30 years of gynaecological practice, it has required a great deal of clinical and scientific effort, much of it by people like Green, to reach this point. Bryder’s book is meticulously referenced and even-handed — although she does not conceal criticism of the feminist health activists who instigated the inquiry. Undoubtedly, the book will arouse much comment from those still able to recall these events, but as a work of medical history it will be a valuable and lasting resource.

Caroline M de Costa

Practical cardiology (+ CD ROM). 2nd ed. Tracey Baker, George Nikolic, Simon O’Connor. Sydney: Churchill Livingstone, 2008 (xxiii + 391 pp). ISBN 9780729538411. The first edition of Practical cardiology: an approach to the management of problems in cardiology, by Baker and O’Connor, appeared in 1999. This second edition includes a third author, George Nikolic. Baker is a Canberra general practitioner, while Nikolic and O’Connor are cardiologists at the Canberra Hospital. Larger than the first edition (391 pages versus 192), and including a supplementary CD of angiographic and echocardiographic video images, it is excellent value at $89.95. It is likely to be useful for GPs and their trainees, medical students and cardiac nurses, and could be read with profit by those training in general medicine or beginning advanced training in cardiology. The sections on case- or problem-based learning are practical, well done and worthwhile exercises for senior medical students and trainee physicians. There is a helpful chapter on clinical trials, although there is no mention of some of the important earlier studies (GISSI, ISIS, GUSTO, LATE, etc). There are useful sections on electrocardiography, arrhythmias, heart disease and non-cardiac surgery, coronary revascularisation, antiplatelet therapy, anticoagulants, heart disease in pregnancy and congenital heart disease. My primary concerns relate to the illustrations. Some of these have been reproduced poorly, so that, for example, the demonstration of rib notching in a chest radiograph of a patient with coarctation of the aorta is unconvincing, as are the illustrations of Kerley B lines and valve calcification. Some images of echocardiograms need more comprehensive labelling. The CD images are a worthwhile addition, but their value would also be enhanced by explanatory labels, diagrams or cartoons: intravascular or transoesophageal studies are unlikely to mean much to the uninitiated without such help. This book retains the attractive features of the first edition, in that it is concise, simple, authoritative and as up to date as we might expect of any publication when it deals with so rapidly changing a field as cardiology.

J H Nicholas Bett

What a world: 2009 in review Did you know that the Maldives Government learned how to scuba dive and held a cabinet meeting underwater to draw attention to the planet’s rising sea levels? So says The Lancet, in an editorial that nominates climate change as the main subject in medicine at the close of the year 2009. The beginning of the year was marked by the election of a new US president set on health care reform in that country. Several honourable mentions were made of several advances in medicine, including a cure for a form of severe combined immunodeficiency, courtesy of gene therapy. However, the year’s biggest health story was the emergence of the pandemic (H1N1) 2009 influenza in April. What will 2010 bring to the world of medicine? Lancet 2009; 374: 2027 Legend of Antarctica “It seems that I have appendicitis. I am keeping quiet about it, even smiling. Why frighten my friends? Who could be of help? A polar explorer’s only encounter with medicine is likely to have been in a dentist’s chair”, wrote Russian surgeon Leonid Ivanovich Rogozov in his diary. It was April 1961 and Rogozov was in the Antarctic, with 11 others. He was the only doctor, and contact with the outside world was not possible at that time. Rogozov’s condition deteriorated (as did the weather), and his colleagues became aware of his predicament. Under his instructions, they turned Rogozov’s room into an improvised operating theatre and then assisted him in conducting his own appendectomy. He chose a semi-reclining position and was aided somewhat by a mirror: “The mirror helps, but it also hinders — after all, it shows things backwards. I work mainly by touch”, he later wrote. Rogozov recovered and returned to Russia in 1962 but never to Antarctica, according to a recent report of the event co-authored by Rogozov’s son, an anaesthetist. BMJ 2009; 339: b4965 Pandemic ’flu at sea The recent influenza pandemic has prompted much review of the 1918–1919 Spanish influenza pandemic. New Zealand researchers report that the case of a soldier stated in at least one official record as “missing at sea” on 4 September 1918 could, in fact, be considered as an influenza-related fatality. A different archival report was identified which noted that, during an outbreak of pandemic influenza on the troop ship Tahiti, a soldier with influenza became delirious, “jumped overboard”, and was lost at sea (presumed drowned) — and on the same date. At the time, the Tahiti was off the coast of West Africa en route from Wellington to Plymouth, England. The researchers said the ship had stopped in Freetown, Sierra Leone, to take on coal and meet other ships to form a convoy. Officials from the various ships in the convoy met on another ship, including some from the Mantua — the ship which probably brought the pandemic influenza to Freetown from England. In all, 77 deaths resulted from the outbreak of pandemic influenza on the Tahiti. Freetown was one of three major distribution points for the more virulent second wave of the 1918 influenza pandemic. NZMJ Digest 2009; 122: 9-20 Flower arrangements We wrap up your holiday reading with some flowers for thought. UK authors say some hospitals have prohibited flowers on their wards, citing various reasons — many of which don’t necessarily hold water; for example, that the flowers themselves carry a risk of infection.1,2 Day and Carter’s good flower guide to increasing the chances that flowers will be accepted at hospitals suggests giving bouquets that aren’t too big and unwieldy, aren’t too heavily scented and are composed of flowers that do not shed pollen.1 In a linked editorial, Cohn said that the flower ban reflects a more general shift in current definitions of care, where technical efficiency coupled with greater bureaucracy and accountability have “elbowed” flowers out of the way.2 He said gift giving is important to patients and their visitors and called for a broader version of care within the everyday practices of hospitals that preserves such rituals. 1 BMJ 2009; 339: b5257 2 BMJ 2009; 339: b5406 Dr Ann Gregory, MJA

Ann Gregory