Volume 196 Issue 3

Physical activity and healthy eating are key components in preventing and managing obesity. Obesity is a major contributor to morbidity and mortality, a considerable economic burden to society, and a non-age-specific condition of increasing global prevalence. It remains an important topic of debate as health professionals and policymakers grapple with how best to manage this condition. The aetiology of obesity is....

Anthea M Magarey BSc, GradDipNut

Price disclosure will only go part of the way to achieving lower prices for generic drugs. The Pharmaceutical Benefits Scheme (PBS) faces both challenges and opportunities. The challenges, which are well known, come when listing new pharmaceuticals. The Pharmaceutical Benefits Advisory Committee (PBAC) determines the cost-effectiveness of new drugs and recommends whether or not they should be listed on the PBS....

Philip M Clarke BEc, MEc, PhD

Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....

Brett McDermott MD, FRANZCP, CertCAPsy

The full content of this article is available by downloading the PDF.

The full content of this article is available by downloading the PDF.

The challenge of removing what’s useless, harmful or cost-ineffective It’s easy to forget that the evidence-based approach to medicine is still relatively new, and that a substantial part of health care is not supported by gold-standard evaluation. New procedures, until very recently, have had no requirement for rigorous testing, unlike new drugs. Of the more than 5000 items on the Medicare Benefits Schedule (MBS) today, most “have never been comprehensively assessed for their safety, effectiveness and/or cost-effectiveness”.1 But now many more interventions will be exposed to the chill winds of evaluation. And those that don’t shape up could become targets for “disinvestment” — withdrawal of funding from existing treatments. Although not explicitly mentioned, disinvestment is part of the thinking behind recent developments in Canberra. Announced in the current Budget, a “comprehensive management framework” for Medicare strengthens assessment of new treatments, and introduces “rolling reviews” of existing interventions, to assess quality, safety and fee levels.2 Systematic methods will be developed to inform “appropriate amendment or removal of existing MBS items”. Judging by the progress of several “demonstration reviews”, clinicians nervous about threats to their livelihoods needn’t worry too much. Sensitive about perceptions of taking something away, the federal government is treading warily — using maximum engagement with affected specialties. For example, despite finding colonoscopy use had jumped an extraordinary 84% in just a decade, the review of this procedure gave it a big thumbs up.3 The most comprehensive review is the ongoing whole-of-specialty review of ophthalmology. A report has been produced by Adelaide Health Technology Assessment, at the University of Adelaide, advised by a clinical working group from the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) — in close collaboration with the health department.4 The report suggests a number of minor changes, including tightening the patient pool for a handful of Medicare items, but little in it is controversial. Importantly, assessing costs was strictly excluded. A key challenge in reviewing the evidence behind all the tests and treatments used by ophthalmologists was actually finding the evidence. Sometimes there was little published literature, so reviewers relied on guidelines built on consensus rather than on solid evidence. And existing procedures tended to be treated more leniently in the review than new procedures seeking funding today. Alex Hunyor, a representative of RANZCO who is intimately involved in the review, says some treatments, particularly medicines, lend themselves to randomised controlled trials, whereas with surgery often “the evidence is not necessarily of the type we’d like it to be”. He adds that, in cases where technology is evolving quickly, “we can’t necessarily say, ‘here’s the hard evidence’”. A high-profile example of a procedure without hard evidence from another specialty area is vertebroplasty. After a long battle between proponents and critics, trials showing no meaningful benefit, and an independent review, the government’s Medical Services Advisory Committee recommended dropping the procedure — a powerful example of disinvestment.5 Three clinical advisers disagreed with the recommendation, but it was accepted. The procedure no longer carries a Medicare rebate. In the United States, the failure to similarly disinvest in vertebroplasty has become a case study in the difficulty of withdrawing support from well established procedures unsupported by good evidence.6 Even in the United Kingdom, where debate is well advanced, decisions to disinvest are often not implemented in practice. Not surprisingly, the term “disinvestment” is little loved, rather than being seen as a positive attempt to bring scientific accountability to health care funding. “We’re trying to work together to get better value for money” is how the process is described by Ian Larmour from the Southern Health network of hospitals in Victoria, which has generated considerable savings using “therapeutic equivalence” to seek lower-cost medicines.7 It’s vitally important that Medicare’s rolling reviews are as rigorous and independent as they can be, to bring much needed scientific scrutiny to medicine’s vast back catalogue. Outcomes would be more credible if the influence of vested interests in the process was diluted, and the effectiveness, safety and cost of existing treatments was assessed with the same rigour applied to new ones. A healthy dose of disinvestment — no matter how unpleasant the term — may be required for those treatments where the balance of benefits, costs and harms is unfavourable. It’s not unhealthy rationing, it’s rational health policy.

Ray N Moynihan BA

Despite significant recent public investment in mental health, do we really know what Australia is getting for its money? In response to repeated inquiries revealing a profound crisis in the provision of mental health care services,1 Australia has committed to spending around $8 billion of new money on mental health since 2006. Few would argue that this investment was long overdue, given the significant gap between the funding mental health receives ($5.8 billion2 out of $113 billion of total health expenditure in the 2008–09 financial year3) and the contribution of mental illness to the burden of disease (13%).4 However, proper accountability for this expenditure is crucial. Health care consumers, carers, service providers, funders and taxpayers all have a right to know that funding for mental health is being spent judiciously, is targeted at the areas of greatest need, and is delivering better outcomes for people with mental illness. Establishing this accountability is not easy. The complexity of state and federal Budget announcements (and re-announcements) are the modus operandi of governments and perpetuate an environment characterised by opacity rather than transparency. After decades of underfunding for mental health services, new funding is often simply welcomed without query as to provenance or policy. In this article, we review the recent wave of mental health funding decisions in Australia. While we want to see the level of funding increase, such increases must be evidence-based, effectively delivered and transparently monitored. Recent mental health fundingThe major contribution to recent funding for mental health has been through the Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011.5 This provided $5.5 billion, comprising $2.2 billion from the Australian Government and $3.3 billion from the states and territories. However, analysis of Medicare Benefits Schedule (MBS) item reports shows that the uncapped growth in the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Better Access) initiative alone accounted for $2.1 billion by September 2011. It is concerning that, for such a sizeable investment, there have only been two NAP progress reports published, the most recent being released in September 2009.6 A subsequent COAG agreement in 2010 included $1.6 billion to be spent on subacute care, with an unspecified proportion to be allocated to mental health. Lastly, there is the federal government’s 2011 Budget announcement of a “record” $2.2 billion investment in mental health, partly funded through changes made to curb government payments under the Better Access initiative. A large proportion of this package was to enable continued funding of existing programs like Better Access, but the Budget also continued the government’s extensive investment in largely untested semi- or non-professional coordination of services (the Personal Helpers and Mentors Program) and “flexible” packages of care. There are as yet no data to assess how this new funding is progressing. In total, this new spending represents a significant public investment in mental health and, as such, deserves scrutiny. COAG National Action Plan fundingThe $5.5 billion committed in the 2006–2011 COAG NAP was allocated across four agreed action areas. However, there were no agreed definitions as to what activities could or should occur within each action area, and jurisdictions had complete autonomy over how money would be spent and reported. Consequently, there were significant variations in the funding allocations between jurisdictions (Box).6 Fully two-thirds of all NAP funding was allocated to Action Area 2 — “integrating and improving the care system” — while only 5% was allocated to Action Area 4 — “increasing workforce capacity”.6 The bulk of Action Area 2 funds went to the Better Access initiative. Supported housing options, community participation and employment (Action Area 3) remained secondary elements of the NAP, accounting for 17% of total funding allocations. In New South Wales, more than half the spending in this area ($58 million) was on one program — the Housing and Accommodation Support Initiative. Victoria pledged to spend about $44 million on growing its psychosocial rehabilitation sector, but over a 5-year period (2006–2011) this would barely cover anticipated price pressures and wage increases, let alone service expansion. Increasing access to mental health care was clearly a key goal of the NAP, but the evidence for progress is equivocal. The second NAP progress report certainly shows substantial service growth over the period 1997–2007, largely accounted for by the growth in Medicare-funded (Better Access) services.7 It reported that the proportion of the Australian population receiving clinical care for mental illness under Medicare rose from 3.1% in 2006–07 to 4.8% in 2007–08.6 However, the same progress report also shows that the proportion of the population accessing state-run mental health services dropped from 1.6% to 1.5%. Further, the National Survey of Mental Health and Wellbeing conducted by the Australian Bureau of Statistics in 2007 showed that treatment rates for people with a mental illness were unchanged since 1997.8 If the spending effort in Action Area 2 has not led to a discernible increase in treatment rates, then what substantive impact is this increased investment in traditional services having on mental health care in Australia? One explanation might be that new funds and new services are struggling to reach new clients. The data for state-run mental health services in the second NAP progress report indicate that this is the case for state and territory services. The current debate regarding the effectiveness and reach of the Better Access initiative is significant in this regard.9,10 There is evidence suggesting that groups who were missing out on care before Better Access are still missing out. In 2008, 68% of people using the Better Access program were using it for the first time. In 2009, this figure had dropped to 57%.11 The NAP progress report does not provide reasons for the variation in spending priorities between jurisdictions. There is no context to explain why Western Australia should allocate nearly a quarter of its funding to Action Area 1, while Queensland spent almost nothing (Box). Similarly, WA spent four times as much as South Australia on Action Area 3, and the Australian Capital Territory allocated 20% of its effort to workforce development, to which Victoria committed less than 1%. It is conceivable that these jurisdictional variations may be based on local service deficiencies and are therefore warranted. However, if this is the case, it is not clear how such deficiencies were identified. The NAP progress report shows a patchwork of jurisdictional investments rather than a coordinated national effort to address the agreed priorities. In the absence of nationally consistent definitions and accounting processes, it is impossible to verify whether jurisdictions really did spend what they reported. 2010 COAG agreement funding for subacute careThe 2010 COAG agreement to spend $1.6 billion on creating 1300 subacute beds, some of which are to be allocated to mental health, is also without transparency and agreed guidelines. In making this commitment to subacute care, COAG echoed the 2009 final report of the National Health and Hospitals Reform Commission, which stated: We recommend that every hospital-based mental health service should be linked with a multi-disciplinary community-based sub-acute service that supports “stepped” prevention and recovery care.12 There has been no progress report on the implementation of the mental health aspect of this agreement, but from public announcements it is possible to once again discern major variations in jurisdictional approaches. Queensland is building community care units, while SA is opting for supported accommodation places with crisis respite support. NSW is allocating all its subacute funding to new beds on hospital campuses. This variation between jurisdictions is not surprising, as there is no agreement on what constitutes subacute mental care. The term “subacute” does not appear anywhere in the National Mental Health Policy 2008 and is mentioned only once in passing in the Fourth National Mental Health Plan. Alternatives to hospital admission for mental health care in Australia are few. An unpublished national snapshot survey of acute psychiatric wards across Australia in 2006 indicated that 43% of all acute beds were occupied by people who could be cared for in other settings if suitable services were available. The investment in subacute care offers critical opportunities to build new services nationwide. However, competing priorities and a lack of consistent implementation may mean this opportunity could be lost. ConclusionDespite these increased investments, mental health’s share of overall health spending is shrinking. For the period 2004–05 to 2008–09, total mental health spending in Australia increased by an average of 4.8% per annum,2 while total health spending rose by more than 5%.3 There have been some 44 inquiries into mental health in Australia since the 1890s — about one every 2 and a half years. Despite these inquiries, and dozens of plans and policies, spending between jurisdictions continues to be uncoordinated, lacking both accountability and a focus on patients’ needs. There is little evidence to show that new mental health investments are driving improved health outcomes. For people with mental illness, the spectrum, capacity and quality of services available depends on where they live, and the quality of care goes largely unassessed. For real accountability, the new National Mental Health Commission must begin with a robust plan to identify and close service gaps based on evidence-based models of care. This should be accompanied by a National Report Card that includes nationally validated data of the experience of care, quality of life, and rates of homelessness, education and employment for people with a mental illness. Without this, no one will know if mental health funding is well targeted or just well meant. Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011 funding allocations, by action area and jurisdiction6 Action area* Jurisdiction 1: Promotion, prevention and early intervention 2: Integrating and improving the care system 3: Participation in the community and employment† 4: Increasing workforce capacity Total NAP ($ million) Australian Government 164.2 (8.2%) 1329.8 (66.7%) 369.5 (18.5%) 129.9 (6.5%) 1993.4 New South Wales 121.7 (12.4%) 721.6 (73.6%) 113.8 (11.6%) 23.3 (2.4%) 980.3 Victoria 97.7 (15.2%) 432.1 (67.0%) 110.6 (17.2%) 4.4 (0.7%) 644.8 Queensland 16.3 (1.7%) 717.5 (73.0%) 168.4 (17.1%) 76.9 (7.8%) 983.3 Western Australia 106.8 (22.1%) 216 (44.6%) 139.6 (28.9%) 21.5 (4.4%) 483.9 South Australia 47.1 (16.3%) 215.1 (74.6%) 22.1 (7.7%) 4.2 (1.5%) 288.5 Tasmania 2.2 (3.8%) 36.6 (62.4%) 11.3 (19.3%) 8.6 (14.7%) 58.7 Australian Capital Territory 5.1 (12.3%) 20.1 (48.3%) 8.1 (19.5%) 8.3 (20.0%) 41.6 Northern Territory 1.3 (8.6%) 13 (86.1%) 0.8 (5.3%) 0 15.1 Total 562.3 (10.2%) 3701.8 (67.4%) 944.2 (17.2%) 277 (5.1%) 5490.1 * Figures shown for each action area are $ million (percentage of total COAG commitment). Percentages may not sum to 100% because of rounding. † Including accommodation.

Sebastian P Rosenberg MPubAdmin · John Mendoza BEd · Lesley Russell PhD

We have no strategy for measuring rates, mitigating risk and meeting individuals’ needs. Work-related cancer attracts considerable public and media attention, but has received limited attention from researchers and policymakers in Australia, particularly in comparison to other cancers, such as those related to tobacco use and sun exposure. During the 1980s, the National Health and Medical Research Council (NHMRC) issued model regulations for the control of....

Lin Fritschi MB BS, PhD, FAFPHM · Renae C Fernandez BHlthSci, BCom, MPH · Deborah A Vallance MB BS, BMedSci, MPH · Terry J Slevin MPH, FPHAA · Alison Reid PhD · Timothy R Driscoll MB BS, MOHS, PhD · Deborah C Glass PhD

Non-surgical intervention has many benefits. A recent article published in the Journal1 was widely reported in the popular press, with statements such as the following being quoted: public health messages encouraging people to eat healthy food and to exercise are unlikely to have long-term impact on their weight....

Daniel J Green PhD · Andrew J Maiorana PhD

A High Court of Australia ruling has reinstated the need for patients to prove causation of injury. The tort (ie, civil wrong) of medical negligence has recently changed, to the advantage of doctors. By its judgment in the case of Tabet v Gett in 2010....

Neera Bhatia LLB(Hons), LLM · James Tibballs MD, MHlth&MedLaw, FCICM

To the Editor: Since the claims made by Webber in his recent article1 were, in his own words, not based on any substantiated data, it is disappointing that the Medical Journal of Australia did not seek to contact either the Australian Society of Ophthalmologists (ASO) or the Royal Australian New Zealand College of Ophthalmologists (RANZCO) for comment. Certainly, considerable work can be done to improve the operation of Medicare. We are on record as having raised our concerns with successive governments.2 However, Webber’s generalised, sensationalist and unsubstantiated claims add nothing to constructive debate about Medicare. It is disappointing that the Journal would risk damaging its reputation, by choosing to publish a perspective without offering an alternative view to demonstrate balance and evidence, as one would expect in a peer-reviewed journal. Ophthalmology involves more than just removing cataracts, and while technology has made cataract procedures safer and less invasive, they remain complex and the technology very expensive.3 The RANZCO and ASO have worked with government through the Medicare Benefits Schedule Review to address concerns and shortcomings, as well as providing supportive evidence.4 On at least two occasions, we have offered revisions to the funding of treatment of macular degeneration that could save many millions of dollars in the health budget. Additionally, our proposal to reinvigorate the key subspecialty of paediatric ophthalmology has been accepted by government.

Arthur Karagiannis · William J H Glasson

To the Editor: Webber raises some well meaning points in his recent viewpoint article, some of which were taken out of context by the media.1 With respect to his comments on ophthalmologists, I would like to place on record some facts. The Access Economics ophthalmology practice costs survey,2 commissioned by the Australian Society of Ophthalmologists (ASO) in 2011, analysed the costs of delivering ophthalmic services for the financial year 2008–09. The report showed that the average overhead cost per full-time-equivalent ophthalmologist was $506 000, compared with $232 617 in 19993 — an average annual increase of 9%, during which time fees for ophthalmology items on the Medicare Benefits Schedule (MBS) increased by only 2.1% annually.4 Thus, the MBS items become increasingly irrelevant in the context of a small private ophthalmic business model. The cost to the taxpayer of a cataract procedure in New South Wales public hospitals is about $3500 (diagnosis-related group), compared with a Medicare schedule fee of $731 (item 42702). Thus, the procedure can be performed privately for about 20% of the taxpayer cost. Clearly, private surgery is a very efficient use of taxpayer money for an operation with a quality-of-life-adjusted score of about 30 times what is considered cost-beneficial.5 The average eye surgeon performs fewer than half the cataract procedures per week than the 20 which Webber anecdotally claimed (and then multiplied by the entire cost of the procedure, presumably including the theatre fee and prosthesis). Webber is to be congratulated for speaking his mind, but ought to factually balance his writings. The ASO encourages other craft groups to commission their own practice-cost surveys when fiction needs to be separated from fancy.

Peter M Sumich

To the Editor: The “thinking doctor’s” Journal has degenerated to one for doctor’s random thoughts. The commissioned and peer reviewed article by Webber1 was disappointing. For many disenfranchised colleagues, the usual whinge over a cuppa at the local meeting is now plainly inadequate after this Medical Journal of Australia offering. The unsubstantiated claim about billions in Medicare “wastage”1 was reckless. The implication that the current cataract surgery rebate was poor value and had never changed was just plain wrong. Since the introduction of the Schedule of Medical Benefits, cataract surgery now requires entirely different surgical skills, implants a lens, and requires expensive, sophisticated equipment (for examples, see websites2-4). Patients can now expect vastly improved vision without the need for full-time visual aids. The rate of significant sight-threatening complications is now less than 7 in 1000 — one of the lowest complication rates in surgery. The rebate was reduced by about 40% in 1987, 10% in 1996, and 12% in 2009. Even before the last reduction, the total cost provided a significantly better gain (that is, lowest cost) in quality-adjusted life-years than any other surgical procedure,5 something conveniently ignored by the then Health Minister Roxon when cutting costs. With more than 500 ophthalmologists performing over 200 000 operations a year, the statistical distribution will certainly include the few surgeons performing high volumes of procedures or charging high fees, as it does with any other procedure listed on the MBS. Webber’s implied generalisation is totally invalid, as the distribution tail in no way represents the average. I am afraid that Webber has only provided us with sloppy commentary and cheap shots — nice if you can get away with it, but it is poor editorial policy.

Nigel Morlet

To the Editor: Webber is to be congratulated for his concise statement of the ills of Professional Services Review (PSR) audit,1 but his estimate of multiple billions being wasted each year is unsupported by evidence. This remark has already been picked up by several of the nation’s daily newspapers, and well suits those of certain political persuasions. However, it is also essential that the operation of the PSR be subject to scrutiny. The past performance of the PSR must be examined — including the correctness and consistency of the information it uses, its investigative processes, the defence evidence it does and does not accept, and the available avenues of appeal. These issues are all of great concern to doctors who have come to the PSR’s attention. I note that the most recent edition of Medicare’s Forum promises more Medicare audits.2 The fun has only just begun.

A Stuart Reece

To the Editor: After our recently published article1 and subsequent criticism2 that shortages in benzylpenicillin were a “storm in a teacup”, we would like to detail the increasing number of drug shortages at John Hunter Hospital. Not only does this pose increasing costs to pharmacy but there are escalating threats to patient care. As part of our routine formulary management, records are kept on drug shortages, collected to communicate urgent pharmaceutical issues and not designed as a research tool (Box). All shortages recently experienced in this hospital have been in generic medicines, particularly injectables, although any drug is potentially vulnerable. There are shortages that recur; thiopentone has twice been in short supply in recent months, noradrenaline has had recurrent periods of short supply, and intravenous labetalol is currently critically low and has previously been discontinued by a supplier in Australia, requiring a new manufacturer to be found. At the time of writing, midazolam 5 mg/5 mL injection is in short supply despite there being three generic brands in Australia, suggesting that all products come from the same source. The shortages we are experiencing are similar to but less extensive than those described in the United States.3 However, our list is far from complete as we cannot detect suppliers’ shortages that are resolved before our hospital shelves are affected. Hospitals cope in the usual ways — stockpiling (which protects some networks and harms others), switching to alternatives where possible, and finding new suppliers. Not only does this directly compro-mise patient care, it has been shown that subsequent changes in formulary increase medication errors4,5 — not to mention the economic impact, which is not known in Australia but has been estimated to cost $216 million each year in the US.3 Governments in the US and United Kingdom are taking decisive action to rectify this problem. However, the issue remains unrecognised in Australia and the Therapeutic Goods Administration has indicated to the authors that monitoring shortages is not its legislative responsibility. In the interests of national health care security, this issue needs to be resolved immediately by the federal government. Urgent action must be taken to identify medicines that are “essential” and to safeguard their supply through all possible avenues to ensure short-term health care sustainability. Number of different medicines in short supply at John Hunter Hospital, 2006–2011

Robert Pearce · Simon Quilty · Jacqueline Kewley · Lisa M Harris

To the Editor: In 2007, the sale of sugar-sweetened drinks was banned in New South Wales government schools. The ban followed growing evidence linking soft drinks with obesity, and findings from the 2004 NSW Schools Physical Activity and Nutrition Survey (SPANS) that almost 60% of boys and around 40% of girls reported drinking a cup (250 mL) or more of soft drink per day....

Chris E Rissel · Tracie A Reinten-Reynolds · Li M Wen · Louise L Hardy

To the Editor: As an author, researcher and lecturer on the safety of drugs used in the obstetric setting for over 30 years — during which I participated in successive Medicines in Pregnancy Working Parties of the Australian Drug Evaluation Committee and Therapeutic Goods Administration (TGA) — I share Kennedy’s concerns about the alphabetical drug categorisation system currently used in Australia.1 I am also concerned that, since the demise in 2008 of the Prescribing Medicines in Pregnancy TGA Advisory Group (which provided ongoing external clinical expertise to the TGA), there has been a complete lack of action, preparation and consultation with external sources of expertise and experience by the TGA with regard to the safety of drugs used in pregnancy. Expert consultation would be invaluable in preparing for the overseas “game-changing” developments in labelling relating to safety of drugs used during pregnancy, as identified by Kennedy. These changes in labelling are primarily being driven in the United States, with the aim of providing definitive, well substantiated advice to patients and health professionals — advice that reflects the consensus of expert opinion in a way that the alphabetical system, by its inherent structural and functional limitations, is unable to do.

Ronald P Batagol

To the Editor: Kennedy highlights a major source of frustration for mothers and health professionals — the accuracy of information regarding the safety of medications in pregnancy.1 The current categorisation system is inaccurate and outdated. Labetalol, used safely throughout pregnancy to treat hypertension for more than 30 years, has a Category C label because atenolol was associated with intrauterine growth retardation in one study.2,3 Proton pump inhibitors remain in Category C despite large studies demonstrating their safety in pregnancy.4 Hydroxychloroquine is in Category D despite extensive use in pregnancy without any adverse effect.5 The present A to X system could be simplified to three categories — safe, uncertain and definite risk, with a brief description of the information available, together with the references on which the evaluation is made. This could be freely available online and regularly updated as new information is published. In addition, more rapid accumulation of evidence regarding the safety of newer medications in pregnancy and lactation is needed. At present, we rely on the publication of case reports and case series by single institutions. It would be valuable if a national or international database of de-identified information could be kept on mothers and babies who are exposed to drugs for which the safety is uncertain, so that outcomes may be followed, to better guide future parents and their health professionals regarding the safety of these medications in pregnancy and lactation.

Adam P Morton

In reply: As a practising physician, Morton clearly understands the issues faced by prescribers and consumers regarding drug categorisation in pregnancy.1 Currently, the Therapeutic Goods Administration provides no references for the data on which it bases its drug categorisations for pregnancy. It is therefore left to the conscientious prescriber to try to find the data (not always easy or obvious) and then attempt to interpret it in a clinically relevant way. The more narrative approach suggested by Morton is an improvement but would still need clinical context and interpretation for optimal use. The system proposed by the United States Food and Drug Administration (FDA) would provide appropriate referenced data so that clinicians and consumers could see the latest available evidence (and not, as Morton points out, just the limited studies performed up to 30 years ago) about the safety (or otherwise) of medication to enable rational decision making regarding medication use during pregnancy and breastfeeding. The FDA’s proposed new labelling would include contact details of any pregnancy registries, if applicable, for the agent in question.2 At present, there are over 20 pregnancy registries collecting prospective data on the effects of exposures, including antiepileptic drugs and vaccines, as well as registries for pregnant women being treated for chronic medical conditions such as rheumatoid arthritis and HIV/AIDS.3 It is unfortunate that Australian regulators have not properly discussed these issues with interested professionals in the past few years. Even if we cannot remain world leaders in this field, it behoves us to at least embrace innovation occurring in other parts of the world.

Debra S Kennedy

To the Editor: The decline in the number of National Health and Medical Research Council (NHMRC) scholarships awarded to general practitioners over the past 9 years reflects continuing problems in Australia’s capacity to produce a good base of general practice researchers. Since 1998, 20 GPs have received NHMRC doctoral scholarships; nine of these were granted in 2002 and six were granted after 2002....

Gerard F Gill

There are many challenges in developing evidence-based physical activity guidelines for preschoolers that can ensure health benefits for children.Guidelines for the preschool years have recently been developed in several countries, but there are notable inconsistencies in the amount of physical activity regarded as sufficient for this age group.Given the currently high prevalence of childhood obesity, there is an....

Helen Skouteris PhD · Daniela Dell'Aquila BSocSci(Psych), PostGradDip(Psych) · Louise A Baur BSc(Med), PhD, FRACP · Genevieve M Dwyer MAppSc(Phty), PostgradCert (AdultEd · Marita P McCabe PhD · Lina A Ricciardelli PhD · Matthew Fuller-Tyszkiewicz PhD

Abstract: Headache, particularly migraine, is the commonest neurological problem with which patients present to general practitioners and neurologists. Episodic migraine affects up to 18% of women and 6% of men. Acute migraine attacks can be severely disabling and chronic migraine is even more disabling. Of the mental and neurological disorders, migraine ranks eighth worldwide in terms of disability....

Alessandro S Zagami MB BS, MD, FRACP · Sian L Goddard BSc, MB BS

Objectives: To document temporal trends in maternal overweight and obesity in Australian women and to examine associations with pregnancy outcomes....

H David McIntyre MB BS, FRACP, MD · Kristen S Gibbons BMaths(Hons), BInfoTech · Vicki J Flenady MMedSc(ClinEpid) · Leonie K Callaway MB BS, PhD, FRACP

Objectives: To examine the prevalence of overweight and obesity in Australian secondary school students and identify factors associated with excess adiposity....

on behalf of the NaSSDA Study Team*

Plotting the trajectory of some common artery conditions.

on behalf of the REACH Registry Investigators

Putting a team-based intervention approach to the test.

Sandy M Hopper FRACP, FACEM · Franz E Babl MD, FRACP, FACEP · Claire E Stewart PGDipENB, RN · Jia Wei Woo BSc, MB BS

Clinical record In 2011, a previously well 26-year-old office worker presented to a large Australian metropolitan hospital with a severe headache. Her illness had begun 3 days earlier with fever and a sore throat, after which she developed a severe, unrelenting occipital headache that was associated with nausea, vomiting, photophobia and neck stiffness. She had no respiratory symptoms such as cough or dyspnoea. The patient had a temperature of 38.5°C, pulse rate of 132 beats/min, respiratory rate of 20 breaths/min and blood pressure of 102/65 mmHg. Clinical examination revealed meningism and tender lymphadenopathy in the anterior cervical chain. Blood tests showed an elevated creatinine level (104 μmol/L; reference interval [RI], 50–100 μmol/L) and leukocytosis with neutrophilia (neutrophil count, 15.56 × 109/L; RI, 1.8–7.5 × 109/L). Lumbar puncture revealed a raised cerebrospinal fluid (CSF) opening pressure of 37 cmH2O (RI, < 18 cmH2O). CSF microscopy showed no cells and no bacteria. No antibiotic therapy was given. Results of a plain computed tomography scan of the patient’s brain and a subsequent computed tomography venogram with contrast were normal. On Day 2, the patient continued to be febrile and two sets of blood cultures were performed. Further tests showed a raised C-reactive protein level (380 mg/L; RI, < 8.0 mg/L) and a mild coagulopathy (international normalised ratio, 1.4; RI, 0.8–1.2) with thrombocytopenia (platelet count, 123 × 109/L; RI, 150–400 × 109/L) suggesting early disseminated intravascular coagulation. That evening, the patient developed respiratory distress and hypoxaemia, with an arterial partial pressure of oxygen of 66 mmHg despite receiving a fraction of inspired oxygen (Fio2) of 80%. She was transferred to the intensive care unit, where she received non-invasive ventilation. A chest x-ray revealed bilateral patchy infiltrates consistent with a pneumonic process (Box 1). Antibiotic treatment with ceftriaxone and azithromycin was initiated. On Day 3, growth was detected in the aerobic bottle from one set of blood cultures after 20 hours of incubation (BACTEC Plus, BD Diagnostics, Sparks, Md, USA), and antibiotic treatment was changed to piperacillin–tazobactam and ciprofloxacin. An initial Gram stain showed a thin gram-negative rod with no distinguishing features. After 24 hours of incubation, light growth of an organism was noted on blood and chocolate agars (Oxoid Australia, Thebarton, SA) which had been incubated anaerobically and in supplemental carbon dioxide. Gram stain of these colonies showed irregular, bulbous gram-negative organisms typical of Streptobacillus moniliformis (Box 2). Antibiotic susceptibility was performed by Etest (bioMérieux, Marcy l’Etoile, France). The organism’s minimum inhibitory concentration to penicillin was 0.016 mg/L and to ceftriaxone was 0.008 mg/L. The organism was definitively identified by 16S rRNA sequencing. This showed a 100% base-pair match with S. moniliformis. The next closest match was a Leptotrichia species with a 94% base-pair match. On Day 5, a blanching macular rash involving all limbs, including palms and soles, became apparent (Box 3). Histological examination of a biopsy sample of a macule from the patient’s hand showed a neutrophilic inflammation of the small dermal vessels consistent with leukocytoclastic vasculitis. By this time, the patient’s respiratory function had improved markedly and she was transferred to a medical ward. Further history-taking revealed that the patient owned two pet rats. Although the animals had never bitten her, she had had close contact with her pets, including cuddling and kissing them. On Day 9, lumbar puncture was repeated to ensure normalisation of pressures; the CSF opening pressure was normal (14 cmH2O), but the CSF showed a pleocytosis with two polymorpho- nucleocytes, 59 monocytes and 75 red cells. There was no growth of bacteria on standard cultures of CSF. Antibiotic therapy was changed to intravenous ceftriaxone (2 g twice daily) for a further 7 days to ensure treatment of possible meningitis. Results of further investigations, including transthoracic echocardiogram, whole-body bone scan and CT pulmonary angiogram, were negative. The patient was discharged home after 17 days in hospital and made a full recovery with no relapse. This case highlights the importance of history-taking and the need to perform blood cultures in patients presenting with fever. The differential diagnoses considered were wide and included bacterial sepsis, viral infection and autoimmune disease. Bacterial sepsis from streptococcal, meningococcal or staphylococcal infection was considered most likely in this patient. Definitive diagnosis was helped by the isolation of S. moniliformis from blood culture, which allowed targeted therapy and improved prognosis. It is possible that our patient was co-infected with an arenavirus such as lymphocytic choriomeningitis virus (LCMV). Although LCMV is rare, it can be acquired by handling pet rodents or their excreta and can cause a flu-like illness with aseptic meningitis.1 Diagnosis of LCMV infection would require molecular testing of blood or CSF in a reference laboratory. S. moniliformis, a causative agent of rat bite fever, is part of the commensal flora of the rat’s oropharynx.2 Another form of rat bite fever — known as “sodoku” — is caused by Spirillum minus, a spirochaete-like organism.2 Sodoku generally differs from S. moniliformis infection by causing induration at the site of the rodent bite and having an incubation period of more than 10 days. The incubation period for S. moniliformis infection is typically fewer than 7 days.2 Rat bite fever, as the name suggests, is usually acquired through a rat bite. However, the disease can result from handling and exposure to excreta or saliva of rodents such as rats or guinea pigs.2,3 S. moniliformis infection can also be caused by ingestion of contaminated milk; in such cases it is known as Haverhill fever, as the first known outbreak (in 1926) occurred in Haverhill, Massachusetts.2 Clinical manifestations of S. moniliformis infection include fever, headache, rash and polyarthritis. The rash typically involves the extremities, including the palms and soles, with a leukocytoclastic vasculitis seen on histology.4 The disease is often mild or self-limiting. However, infection is potentially lethal and can cause rapid death in previously healthy adults.2,5 The overall mortality rate is estimated to be 13%.2 Although less frequently reported than fever, headache, rash and polyarthritis, pneumonitis and endocarditis are common autopsy findings in those who succumb to the disease.5-7 Meningitis due to S. moniliformis is rare, but it has been described in Dutch and Portuguese literature.8,9 Classically, this organism has been described as slow and difficult to grow in the laboratory. This was not the experience in our laboratory as growth occurred within 24 hours, although enriched media and incubation with supplemental carbon dioxide was required. The initial Gram stain was not distinctive, but with subculture the bacteria became irregular and formed bulbar swellings, a feature highly suggestive of S. moniliformis. The standard recommended therapy is penicillin, but S. moniliformis is susceptible to a number of other antibiotics including cephalosporins and macrolides. In cases where the organism has been isolated, in-vitro antibiotic susceptibility testing should be done for any antibiotic being considered for clinical use.2 Systemic illness following rat bite has been recognised for thousands of years. Historically, the disease was associated with squalor and slum-dwelling. However, victims in recent years have included laboratory workers, pet shop employees and, increasingly, owners of pet rats.2,4,5,10 As this case demonstrates, a bite is not necessary for infection — close contact with rodents may be sufficient. As rodents become more popular as household pets, more cases of S. moniliformis infection due to affectionate contact are likely to occur. 1 Chest radiograph (mobile, erect) taken on Day 2, showing diffuse bilateral infiltrates consistent with a pneumonic process 2 Gram stain of Streptobacillus moniliformis cultured from the patient’s blood (100 × magnification) 3 Characteristic rash on the patient’s palms Lessons from practice Rat bite fever caused by Streptobacillus moniliformis is an uncommon but potentially lethal systemic infection. The organism has a distinctive Gram stain appearance which allows for early presumptive identification. A thorough history, including history of animal exposure and pet ownership, should be taken for all febrile patients. Transmission of S. moniliformis can occur by affectionate contact; a bite is not required.

Lito E Papanicolas BM BS · Judith M Holds BLabMed · Narin Bak MB BS, FRACP, MPH

Dr Hilton Immerman and Dr Josef McDonald (“Macca”) speak of their association as mentor and Indigenous medical student HiltonIn late 2004, Macca successfully completed the bridging course for Indigenous students to gain entry to the University of New South Wales (UNSW). He started the 6-year Medicine degree in March 2005. Since he is from the Newcastle area, he had to find accommodation near campus for his first year-and-a-half. However, he and his family were no longer able to cover the high cost of his accommodation. He had also felt alienated living where he was and was uncomfortable about revealing his Indigenous identity. In 2005, we had just established the Shalom Gamarada Indigenous Scholarship Program, which provides board and lodging, tutoring and other forms of support at Shalom College — the college I have been running since 1989. Macca succeeded in gaining a scholarship in July 2006. He received the Sabina Ross Slater Memorial Medical Scholar-ship, which was provided by Edna Ross in memory of her mother, who had died the year before. I remember interviewing him. He had a sense of humour and a mischievous sparkle in his eyes. I sensed that he might prove a handful as a resident of a UNSW college with an academic culture, accommodating 129 other students. My intuition was proven right. Macca for me exemplified the wonderful Aussie term “larrikin”. In the early years of his studies, he was a bit of a rascal and scallywag — but one with endearing qualities. If ever there were pranks or mischief in college, chances were that Macca was involved! On quite a few occasions, I had to summon him to my office to discuss his youthful indiscretions. As stern as I tried to be, I suspect that I never really succeeded in concealing the fact that I was genuinely fond of and believed in him. In 2007, I was invited to speak about Shalom College’s Indigenous scholarship program to a chapter of Rotary. I proposed that one of our scholarship students would join me and talk about it from his perspective. To be honest, my first choice was a more senior female scholarship holder, but she was not available at the time. So, I decided to take the plunge and ask Macca if he would accompany me. During his talk, to a crowded room, he commented on his former experiences of racism and self-doubt and explained how, ironically, a Jewish college had given him the opportunity to explore and take pride in his Indigenous identity for the first time. At this point, he was so filled with emotions about which he had not previously spoken publicly, that he burst into tears. There were not many dry eyes in the room — mine included! Each year since the scholarship has been running, we have held a Shalom Gamarada Aboriginal Art Exhibition to publicise and raise funds for it. This is an excerpt of what Macca wrote for a display board: “Receiving the Shalom Gamarada Scholarship has been a life-changing experience for me. Apart from the advantages it offers my studies, another great benefit of the program is that it offers a racism-free environment in which Indigenous students can live and discuss Indigenous issues and what it means to be Indigenous. “Without it, [the scholarship] it would be impossible for me to study medicine as there is no way my family could afford for me to live in Sydney.” At the end of 2008, after Macca had successfully completed his 4th Year, he decided to defer his studies in 2009 to support his family over a difficult period. Some had doubts about whether he would return and I confess to sharing their concerns. I endeavoured to keep in touch with him over the course of the year and to involve him in various scholarship-related activities, including the annual art fair. He has always been generous with his time and this was no exception. Macca came back to Shalom College and his studies in 2010. In semester 2 of 2010, he successfully applied to become a college tutor — a role he has ably filled since. He’s been a great mentor and role model to other students, both Indigenous and non-Indigenous. At the recent formal dinner for the new bridging course run by the Nura Gili Indigenous centre at UNSW, Macca was one of four UNSW students interviewed. At the end, he was asked if he had any words of advice for the new students. After deliberating briefly, he said: “If you succeed in getting into medicine and law next year, you’re likely to feel like an imposter. I did. Your peers in the program will be the brightest and most privileged students from around Australia and the world. Many will have come from exclusive, private schools. Most of you come from underprivileged and disadvantaged backgrounds. But, you must never forget that you will have earned your place in your course. You deserve to be there and you owe it to yourselves, your families and your communities to succeed. You can and must!” I feel so much emotion and pride in him when I reflect on how he has grown from being a mischievous adolescent, who was frequently in trouble in college, to a mature and wise adult. On 16 December 2011, I was a member of the academic procession at the UNSW graduation ceremony at which he formally became a doctor.

Hilton Immerman

MaccaMedicine was one of many options that I considered at the end of high school, along with engineering and even astronomy. But my interests in science and social justice drew me to medicine and, in the summer before commencing my studies, I was naively confident and felt as though the world was my oyster. These feelings were short-lived when I moved to Randwick in February 2005 to begin my medical studies at the University of New South Wales. I found the content challenging, and studying occupied most of my time. I also found socialising to be very challenging, as my peers were quite different from those I had spent my time with at home. This caused a feeling of alienation and I succumbed to the “imposter syndrome”, where I felt as though I did not deserve to be in medicine. Everyone appeared to be smarter, better educated, better supported, better travelled and more articulate than me. As a result, I mainly focused on my work and avoided engaging in medicine-related extracurricular activities. I travelled back home to Newcastle every weekend because I was homesick, and this affected my academic performance. Travelling home often reinforced a very poor habit of only studying towards the exam period, which caused lots of anxiety and little sleep, eroding my enthusiasm. My friends and I used humour to maintain a positive mental attitude, often to the delight of spectators. However, despite my best efforts, I was losing stamina quickly and didn’t think I could continue my studies at this rate. I had lost all my pleasurable pastimes — I found little opportunity to go fishing in Sydney. The only thing I seemed to gain during the early years of my medical studies was 15 kg. At 11 o’clock one morning I received a phone call from Professor Lisa Jackson Pulver (Director of the Muru Marri Indigenous Health Unit at the university). She encouraged me to apply for the Shalom Gamarada Indigenous Scholarship Program and, in mid-2006, I was accepted into the program by the Master of Shalom College, Dr Hilton Immerman. Receiving a Shalom Gamarada scholarship was crucial to my personal development and my transformation into a doctor. If it wasn’t for the support of the people on the scholarship program, I doubt that I would have successfully completed medicine. I started to become less homesick, as Shalom College offered a very welcoming, racism-free environment, with fellow students from an Indigenous background. Hilton and the other staff at Shalom should be congratulated for this, as it is only due to ongoing vigilance that a racism-free college can be achieved. I became less homesick and more confident to spend time in Sydney and with my peers, knowing that if I had a bad day, I always had a safe place to return to. My results instantly improved. I started engaging with the material and taking responsibility for my medical career — although not without some bumps along the way. Seeing people like Hilton and Lisa model professional behaviour was another crucial element in my success in the medicine program. I usually saw Hilton in his office, often by his request, to discuss something that happened over the weekend. My friends and I came to dread the 9 am phone call on the Monday after an eventful weekend. Hilton was always fair and this appealed to our sense of justice. I felt comfortable to “pop in” to Hilton’s office to ask him questions about my studies, relationships or personal conduct, and his opinions were always valued. I no longer felt like a rudderless ship. My self-esteem was greatly improved, knowing that I had support and finally had a place in Sydney that I knew I could call home. It was the first time in my life that I felt empowered to achieve anything I set my mind to. It was an indescribable feeling seeing Shalom College and Muru Marri staff at my graduation. What I have achieved still hasn’t sunk in, and I cannot be thankful enough to those who gave me this opportunity. What I do understand very well is that if it had not been for a phone call, the great work of Shalom College, and my very generous benefactor, I could have been in a very different place. Hilton (left) and Macca at Macca's graduation in December 2011. Photograph: Shirli Kirschner

Josef McDonald

Reproductive and sexual health: an Australian clinical practice handbook, 2nd ed. Sydney: Family Planning NSW, 2011 (197 pp, $65.00). ISBN 9781877026218. THIS HANDBOOK is an excellent resource for all primary care providers and medical students. The first edition was published in 2006. Since then, there have been a number of developments within the practice of reproductive and sexual health. The book is divided into 13 easily digestible chapters. There are organ-specific chapters as well as chapters on individual topics, covering pregnancy, menopause, fertility, sexually transmitted infections, pelvic inflammatory disease and sexual assault. Male sexual health issues are discussed as well. History-taking, examination, investigation and management of each area are covered in a comprehensive manner. Key points are boxed and highlighted. As many practitioners feel uncomfortable taking a sexual history and have limited experience in this area, the first chapter deals with consultation skills. The challenges involved when working with people from culturally and linguistically diverse backgrounds are discussed. The book also provides a detailed and clear guide to the management of sexual assault. This is particularly useful for providers (most, I suspect) who deal with this difficult problem very infrequently. Particularly useful, given our ageing population, is an expanded chapter covering urogynaecological issues, including urinary incontinence and pelvic organ prolapse. This book is more manual than textbook. For those requiring further information, a reference section at the end of each chapter includes useful books, articles and websites. Perhaps the book could benefit from photographs, but it does have useful diagrams, lists and flow charts. This book is up to date, succinct, well written and easily accessible. It is bound to be of everyday practical use to primary care providers working in the area.

Janice G Newton

Starlight: An Australian Army doctor in Vietnam. Tony White. Brisbane: Copyright Publishing, 2001 (xii + 183 pp: $25.00). ISBN 9871876344689. RETIRED COLONEL Tony White of the Royal Australian Army Medical Corps served in South Vietnam in 1967, and this narrative is largely based on his detailed correspondence with his family at the time. The title, Starlight, refers to the radio call sign for army doctors and medics. Following a move, midway in his medical studies, from the University of Cambridge in the United Kingdom to the University of Sydney in Australia, White accepted an undergraduate scholarship from the Australian Army to complete his studies. After finishing his hospital residency, he was posted as Regimental Medical Officer (RMO) to the newly formed 5th Battalion, Royal Australian Regiment (5RAR). Flying into Saigon’s Tan Son Nhut Airport brought the young 25-year-old RMO to the so-called “Sufferer’s Paradise”. The Vietnam War, in essence a civil war, became the longest and most controversial of Australia’s military conflicts to date. Twelve of the book’s 17 chapters are devoted to White’s wartime experiences with the 5RAR at the Australian base at Nui Dat in Phuoc Tuy Province. The battalion took many casualties during its deployment. February 1967 was the battalion’s critical period, when two tragic episodes beset the unit — White describes them with sensitivity and compassion, but also with a sense of despair. The final segments of the book are devoted to White’s subsequent civilian medical career in dermatology in Sydney. This compact, hardcover book is well illustrated, with several photographs and a map. It contains a handy list of abbreviations and terminologies, as well as a comprehensive index. The text is also supported by appropriate end notes. This moving work is a welcome addition to the few publications of military medical officers’ accounts of their experiences in the Vietnam War. It is recommended to those who partook of that war, to the wider non-military readership who remember the era, as well as to today’s younger generation.

Bruce H Short

Despite having spent many a rapturous hour staring at the back of cereal packets, I tried not to take it personally when I heard Professor Bruce Neal from the George Institute saying, on ABC Radio, that anyone who reads and understands an Australian nutritional panel is a weirdo....

Ruth M Armstrong

Clement J Walter was a talented, innovative and understated ophthalmologist. He was born in Pambula, New South Wales, on 29 August 1915 and grew up near Bega. He lost his parents and sister when young and was brought up by family friends. Clem was dux of Bega High School and graduated in optometry from Sydney Technical College with a special medal in 1939. Having no close family support, Clem’s sole income was derived from hard work and lecturing in optometry. He began his medical studies at the University of Sydney in 1941, graduating in 1947 with a distinguished undergraduate record. During this time, he married Sue in 1942 and, in 1946, their daughter Michele was born. After residency at Sydney Hospital, Clem undertook ophthalmic training at Sydney Eye Hospital and gained his Diploma in Ophthalmology in 1951. He then became a Staff Ophthalmologist at Royal Newcastle Hospital, where he worked until 1974. Clem provided the best possible expertise to patients irrespective of their income and he excelled in his public and private work. In 1972, Clem received Fellowship of the Royal Australian and New Zealand College of Ophthalmologists. Clem was always interested in medical retinal work and, when he moved to Sydney in 1975, he developed a large city laser and medical retina practice consisting solely of tertiary referrals. He imported the first Nd:YAG laser to Australia when there were only three such lasers functioning in the world. Ill health forced Clem to retire officially in the late 1980s. However, Fred and Ian Wechsler persuaded him to assist in their comprehensive ophthalmic practice in Burwood for many years. They admired his intellect, ingenuity and talent. He set the gold standard for a medical ophthalmic consultation and refraction. He designed his own indirect ophthalmoscope. He bred a camellia (which bears his name), and carried out all his own boat and car repairs. His humility was like a breath of fresh air in an era of advertising and aggressive self-promotion. After a stroke, he retired in 2001 and joined his daughter Michele, her husband Malcolm and their two boys in Berwick, Victoria. We all mourn the passing on 27 June 2011 of a truly remarkable pioneer who contributed so much to ophthalmology.

Alfred W Wechsler · Donald B Dunlop · Ian B Wechsler

Dr Timothy Mathew - Awarded an AM (Member in the general division of the Order of Australia). Professor Kathryn North - Awarded an AM (Member in the general division of the Order of Australia). Dr Kerry Moroney - Awarded an OAM (Medal of the Order of Australia in the general division).

Amanda Bryan

With a focus on nutrition, Dr Ian Darnton-Hill has held senior advisory roles with the World Health Organization, UNICEF and Helen Keller International, among many other organisations. Last month, his efforts were recognised when he was awarded an AO (Officer in the general division of the Order of Australia) for his distinguished service to the international community, particularly in the areas of public health and nutrition, disease prevention and health promotion, and as a physician, academic and educator.

Sophie McNamara

Marketing your practice can cost tens of thousands of dollars. Is it money well spent? Marketing and advertising in the medical profession have been undergoing a transformation in the past 15 years. Until the late 1990s, medical practitioners were subject to tight restrictions, which meant they could do little more than advertise their address and opening hours. Any attempt to advertise special skills or services could result in a breach of the medical practice act in most states.

Kath Ryan

Dr Jennie Connaughton says she was a disillusioned medical student when she took a year off to travel. Armed with a backpack, a passport, and good intentions to do “something useful somewhere”, she wound up in Kolkata (Calcutta), India, where she lent an extra pair of hands to help malnourished children.

Amanda Bryan