Letters

To the Editor: The Australian Defence Force (ADF) has sustained many cases of malaria following service in East Timor.1 To reliably prevent relapse of malaria caused by the Chesson strain of Plasmodium vivax present in this region, larger doses of primaquine are required2 (up to 6 mg/kg total dose,3 compared with > 3.5 mg/kg to prevent relapse of sub-Saharan vivax malaria4). The ADF uses 1500 mg chloroquine (total base) followed by 315 mg primaquine (total base) for the treatment of vivax malaria, which, in Australia, is commonly treated either without primaquine or with inadequate dosages of either chloroquine or primaquine.5 A fit, 65 kg male soldier who deployed to East Timor from October 1999 to May 2000 experienced one episode of vivax malaria during his deployment and a further four episodes on return to Australia (Box). Having had malaria in East Timor, he complied closely with postexposure prophylaxis with primaquine and tolerated his dose (7.5 mg three times daily with meals) well for the required 14 days (315 mg total). He was seronegative for HIV, hepatitis C, and dengue IgG and IgM, and was not glucose-6-phosphate dehydrogenase deficient. The Table shows that our patient had a parasite that was apparently responsive to chloroquine, although it did not respond as readily in the last episode. In his first episodes of malaria on return from East Timor, he received the recommended dose of primaquine, but developed recurrences in the absence of further exposure to malaria. These relapses presumably indicate an inadequate response to the primaquine. The total dose of primaquine used for postexposure prophylaxis and treatment of the first episodes in Australia was about 4.8 mg/kg. He has subsequently received a treatment of 6 mg/kg total primaquine (see Table, Episode 5). This follows extended suppression with chloroquine before and doxycycline during a three-month deployment to Malaysia. There has been no further relapse six months after treatment. Chesson-strain vivax malaria is known to be difficult to treat and in which to prevent further relapse. Adequate primaquine to treat vivax malaria from other areas is not adequate for that contracted to the immediate north of Australia. Relapsing vivax malaria from East Timor may require a dose of 6 mg/kg of primaquine to prevent further relapse. Parasite density and treatment during the patient's episodes of malaria Episode Date of diagnosis Parasite density Treatment 1 1 April 2000 Positive on immunochromatographic test* Chloroquine 1500 mg, continued doxycycline 100 mg daily, primaquine 315 mg from 2 May 2 17 July 2000 23 000/µL Chloroquine 1500 mg, then primaquine 315 mg 20 July 2000 No parasites seen 3 26 Sep. 2000 8607/µL Chloroquine 1500 mg, then primaquine 315 mg 29 Sep. 2000 No parasites seen 4 11 Dec. 2000 11 400/µL Chloroquine 1500 mg, then weekly for two months† 14 Dec. 2000 No parasites seen 5 3 April 2001 Occasional trophozoites on thick and thin film Chloroquine 1500 mg, then weekly for one month; doxycycline for three months, then primaquine 420 mg 6 April 2001 Occasional trophozoites only on thick film * Immunochromatographic test used in the field. † Patient ceased treatment.

Scott J Kitchener · Isaac Seidl

To the Editor: We were disappointed with the article by Bailie and Runcie on household infrastructure in Aboriginal communities.1 It has major methodological and ethical problems that, in our view, should have precluded its publication. The data were not collected by a process which allows meaningful scientific analysis. In determining the state of health hardware, the authors did not outline the testing methods or how functioning of different items was assessed. No standardised procedure is evident within the process, no formalised training of those conducting the assessment is indicated, and there is no evidence that supervision or auditing of consistency was performed. In fact, these problems are acknowledged by the authors in a publication on the same project, in which they state: "There was no protocol for a number of steps in the data collection process. There was no protocol for what type of information was gathered by interviewing residents, nor for which resident was the most appropriate interviewee. "The way data was collected varied between field officers, and the way an individual officer collected data varied between houses. Firstly, the items might be observed. Secondly, but not always, items may be tested for functionality (eg, by turning a tap on). Whether items were physically tested sometimes depended on how "clean" the house was. If it was clean, then the items were sometimes assumed to be functioning . . .".2 No amount of analysis can correct for such inadequacy in primary data. The authors dismiss this problem by referring to consistent patterns of data across different communities. This in no way addresses the problem of identifying the true level of hardware functioning. It simply suggests that measurement omission or error was widespread. Even if the items tested did not require maintenance, this does not indicate that they were functioning adequately, as no defined and standardised tests were applied (see Appendix B, page 38, in reference 2).2 The article's ethical problems are masked by discussion about community confidentiality. The authors described an audit and assessment of health hardware without any attempt at intervention and improvement. This is in a setting where a method that links assessment and intervention has not only been established, but is now performed by different groups across a wide range of communities. In fact, this process is referenced by the authors.3 The article by Bailie and Runcie reinforces what is widely known — that Aboriginal housing is generally poor. There can be only two reasons for trying to assess the actual state of Aboriginal housing and health hardware. The first is to enable intervention to rectify the problem at the same time. The second is to enable future housing and infrastructure programs conducted by government to be technically targeted and subsequently assessed to determine whether improvement really is occurring. Unless the baseline status is accurately and reproducibly determined, then we will have no way of knowing whether such programs are actually making a difference.

Paul J Torzillo · Paul Pholeros

In reply: A primary objective of our evaluation1 was to identify methodological deficiencies for the purpose of improving data quality in subsequent surveys. These deficiencies, described in detail in our evaluation report and referred to by Torzillo and Pholeros, are also described in our Medical Journal of Australia article.2 Our assessment (reinforced by reference to subsequent survey findings) was that the data were of sufficient quality to be useful for the purpose for which they were collected — to guide and monitor a substantial maintenance and building program. Torzillo and Pholeros appear to have missed this point. Their analogy with a clinical therapeutic trial where the survey is equated with a placebo is absurd, all the more so for the reference to the HealthHabitat work as being "an effective agent [that] is already licensed". This "effective agent" has, to my knowledge, never been subjected to external evaluation or peer review — some licensing process! With regard to ethics, a fundamental aim of the survey was to identify areas of greatest need, and allow the allocation of resources on an equitable basis to improve Aboriginal housing standards across the Northern Territory. In an environment of massive need and limited resources, this is arguably a more ethical approach than that of HealthHabitat, where, in 2001, intensive input was delivered to only four out of hundreds of Aboriginal communities in the NT. Runcie M, Bailie R. Evaluation of environmental health survey data – Indigenous housing. Darwin, Northern Territory: Menzies School of Health Research, July 2000. Bailie RS, Runcie MJ. Household infrastructure in Aboriginal communities and the implications for health improvement. Med J Aust 2001; 175: 363-366. <eMJA Full text> <PubMed> (Received 21 Mar, accepted 25 Mar 2002)

Ross S Bailie

To the Editor: Cunningham has shown that in Australian public hospitals patients identified as Indigenous are significantly less likely than other patients to have a principal procedure recorded.1 This finding is based on data collected by the Australian Institute of Health and Welfare using the coding scheme of the International classification of diseases, 9th revision, clinical modification (ICD-9-CM). No information was available about the clinical indications for conducting a principal procedure. Despite this crucial omission, Cunningham speculates about the reasons for the disparity in the rate of procedures between Indigenous and non-Indigenous patients. These speculations include alarming suggestions such as the possibility of systematic discrimination against Indigenous patients of both an institutional and personal nature. She then concludes that "Work is urgently needed to characterise more fully the nature, level, sources and consequences of institutional and interpersonal discrimination so that we can reduce unfair treatment, ensure equitable care and improve outcomes for the most disadvantaged Australians". These speculations and conclusions are simply unjustified by the data. In addition, such comments may cause more harm than good — Indigenous people have become extremely sensitive about medical and social research and may reject future investigations that are essential to their welfare. There are reasons other than adverse discrimination which may explain the data. These include the common rejection by Indigenous patients of medical advice to have a procedure (they may well be adopting the wisest action), and their more frequent admission to hospital (rather than outpatient care), as they may have travelled from remote communities (ie, there are social criteria for admission without the need for medical procedures). Furthermore, the quality of the data must be questioned, as many Indigenous patients are admitted to hospitals where the data forms are completed by unskilled personnel who do not understand the meaning of a "principal procedure". Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA Full text> <PubMed> (Received 1 Mar 2002, accepted 25 Mar 2002)

James S Lawson

In reply: Lawson suggests that my conclusions1 are not justified, and that they may "cause more harm than good". I strongly disagree. He suggests a number of alternative explanations, including "social" admissions for remote patients, and poor coding, but these do not account for the differences observed. Over half of the separations identified as Indigenous were of urban (19%) or rural (33%), rather than remote, area residents. Disparities in procedures for Indigenous and other patients were evident for each area. Almost half (46%) the separations identified as Indigenous were in principal referral or major hospitals, where coding should be of a high standard. Indigenous–non-Indigenous disparities existed within each hospital category. The results presented in my report1 were adjusted for area of residence, hospital category, as well as several other factors, and large differences in procedures remained. Lawson also suggests that rejection of medical advice by Indigenous patients may play an important role. Rejection of advice certainly occurs on occasion, by both Indigenous and non-Indigenous patients. I question whether it is "common", as Lawson suggests, but that is not really the point. It would be far more productive to ask why and how this occurs, and how interactions between healthcare providers and Indigenous patients can be improved. Lawson takes exception to my raising the possibility of systematic discrimination in the Australian healthcare system, referring to it as "alarming". In that we are in complete agreement. I, too, find it alarming. However, unlike Lawson, I choose not to deny it, but to accept it as an important challenge. My aim is not to make medical practitioners defensive, but to invite them to participate in finding ways to reduce disparities. Systematic discrimination can occur even when well-meaning people are trying to do the right thing. The systems in which we work can defeat our best intentions, even when we don't realise it. The reasons why a procedure was not performed on a particular patient may be perfectly sound given the circumstances. What we must ask ourselves is how those circumstances came to be, and what we can do to change them. I agree with Lawson that some Indigenous people are sensitive about research, but I do not accept that they will "reject future investigations that are essential to their welfare". On the contrary, I expect that many Indigenous people would be happy to participate with healthcare providers in the development and implementation of creative solutions to improve the healthcare system. Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA full text> <PubMed> (Received 21 Mar 2002, accepted 25 Mar 2002)

Joan Cunningham

To the Editor: It is possible to diminish bias, especially in litigation concerning general practitioners.1 First, request all the defendant's clinical notes about the patient, not merely the records of the incident. Then, before reading the allegations or the history following the incident, read the entire history of the patient's contacts with the doctor or the practice: frequency of attendances, nature of complaints, details of history and examination, referrals for tests or second opinions — all give insight into the nature of that patient–doctor relationship. Reading the notes from the beginning allows the expert to approach, anterospectively, the consultation(s) at which things went awry. If the relevant consultation cannot be identified, the expert has to correlate the patient's story, as presented by the solicitor, with the doctor's records. As he or she progresses through the records, the expert can assess whether or not the doctor's recorded acts accorded with responsible practice. Unrecorded omissions can also be identified, based on what is written in the records: why didn't the doctor ask about X, examine for Y, request a test for Z or refer to a specialist? Of course, these things might have been done, but not recorded. One would hope that barristers for both parties would frame their questions based on a similarly anterospective approach, and that judges would focus their attention and that of a jury (if there is one) on the appropriateness of process rather than on the unfortunate outcome. I cannot conclude without mentioning one solicitor's claim that the doctor had failed to use a retrospectoscope. Competing interests: P C A, at the request of both plaintiffs and defendants, provides expert opinions for the courts. Hugh TB, Tracy GD. Hindsight bias in medicolegal expert reports. Med J Aust 2002; 176: 277-278. <eMJA Full text> <PubMed> (Received 19 Mar 2002, accepted 11 Apr 2002)

Peter C Arnold

To the Editor: I read with interest the recent article by Hugh and Tracy on hindsight bias in medicolegal expert reports.1 As they themselves admit, "the very seeking of an expert opinion usually indicates that there has been an adverse outcome". In my experience, the unfortunate outcome can usually be predicted within reading the first few paragraphs of the brief. I do not think withholding information on outcome would prevent the occasional use of the "retrospectoscope". I wondered whether the views of the authors might have been slightly biased on the basis of the particular cases they had reviewed as Chairmen of the Australian Cases Committee of the Medical Defence Union. Did these cases range across all specialties and subspecialties? The problem of hindsight bias is, in my view, greater when there are no clearly accepted guidelines for diagnosis and management, or where the case is unusual and falls outside the exposure of experienced clinicians. They mention clinical practice guidelines as a way to improve the objectivity of experts, but then seem to exclude them on the basis of the expense and time involved in their development. In cardiology, there are now internationally accepted guidelines developed by the American College of Cardiology and the American Heart Association for the diagnosis and management of all common clinical situations.2 These are regularly updated and have been sometimes modified for Australian use by the Quality of Health Care Committee of the National Health and Medical Research Council (NHMRC) or the Cardiac Society of Australia and New Zealand.3 These guidelines provide an important baseline for any expert opinion in this specialty. More universal clinical guidelines will educate reviewers. It will reduce the problems of hindsight and the overzealous expert. It will also allow the expert to be tested by the well-prepared barrister. Human nature being fallible, it will not eliminate personal bias. Hugh TB, Tracy GD. Hindsight bias in medicolegal expert reports. Med J Aust 2002; 176: 277-278. <eMJA full text> <PubMed> American College of Cardiology/American Heart Association guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. Circulation 2001; 104: 2996-3007. <PubMed> Clinical exercise stress testing. Safety and performance guidelines. The Cardiac Society of Australia and New Zealand. Med J Aust 1996; 164: 282-284. <PubMed> (Received 19 Mar 2002, accepted 11 Apr 2002)

John B Hickie

In reply: We agree with Arnold that, ideally, expert witnesses should attempt to assess management decisions before acquainting themselves with the outcome and allegations in negligence cases. In practice, we suspect this is rarely done. In any case, the mere seeking of an expert opinion conveys the information that there has been an adverse outcome and, as we noted, there is evidence that, even if experts attempt to guard against it, hindsight bias is unavoidable in such circumstances. The central problem is that the expert is, as it were, looking back down one fork in the pathway of events, whereas the treating doctor was looking forwards at many possible and often uncertain forks.1 Hickie's statement "in my experience the unfortunate outcome can usually be predicted within reading the first few paragraphs of the brief" epitomises the very problem we address. Such retrospective snap judgements are characteristic of hindsight bias and are often accompanied by the telltale phrase, known to be a marker for hindsight bias,1 "it should have been obvious". We are unable to understand Hickie's statement that our "views . . . might have been slightly biased on the basis of . . . cases . . . reviewed as Chairmen of the Australian Cases Committee of the Medical Defence Union". The Committee contained representatives from the major specialties, including two consultant physicians, and the cases ranged over all specialties and subspecialties. Experts from subspecialties, including cardiology, were co-opted when appropriate. We agree with Hickie that clinical practice guidelines are useful. We did not recommend that they be excluded, but we did draw attention to their difficulties and limitations. We acknowledge the admirable work done by the American College of Cardiology in developing an impressive range of guidelines, but our view remains unaltered that they are costly in terms of time and effort to produce, cannot cover all clinical contingencies, and have limitations when applied to negligence cases. The guidelines for heart failure referred to by Hickie took more than three years to prepare, involved numerous committee members and no fewer than 26 reviewers, and were not subsequently updated for six years. Relatively few guidelines have been modified for Australian use and some are obviously deficient. For example, the current National Health and Medical Research Council (NHMRC) guidelines relating to the common problem of chest pain2 are six years old, and have been criticised on the grounds that they have not been rigorously tested to ensure clinical usefulness and do not include appropriate management strategies for patients with non-cardiac chest pain.3 We adhere to our view that these problems make it likely that clinical practice guidelines will have a limited role in negligence cases. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner MS, editor. Human error in medicine. New Jersey: Lawrence Erlbaum, 1994; 255-310. Working party of the NHMRC Standing Committee on quality of care and health outcomes. Clinical practice guidelines: diagnosis and management of unstable angina. Canberra: National Health and Medical Research Council, 1996. Eslick GD, Talley NJ. Non-cardiac chest pain: squeezing the life out of the Australian healthcare system? Med J Aust 2000; 173: 233-234. <PubMed> (Received 9 Apr 2002, accepted 11 Apr 2002)

Thomas B Hugh · G Douglas Tracy

To the Editor: Comments made by Parker et al1 in response to Leeder and Rychetnik's article on evidence-based medicine (EBM)2 do not reflect the reality of the dilemmas clinicians face in practice — arguably, because of political misuse of the concept of EBM, which Leeder and Rychetnik warned against. Parker et al take issue with the "worry that EBM might be misused in public policy . . . where evidence is difficult to obtain", and argue that this is not the case. However, the previous Health Minister, Dr Wooldridge, was a great admirer of the Cochrane Collaboration, and, based on a perceived lack of evidence, he cut Medicare rebates in 1996 (by 50%) for patients needing long-term intensive psychiatric outpatient treatment. Although, after much protest, this decision was amended somewhat, Item 319 of the Medical Benefits Schedule remains today as a stark reminder of how some patients cannot access fully the treatment they desperately need. There is abundant evidence (international and local) as to the efficacy of this form of intensive treatment.3 There is also abundant and clear evidence that all who seek this treatment are traumatised by previous failed shorter treatments, often have comorbid disorders, and have established DSM-IV diagnoses of long standing.4 All this evidence was made available to the Minister — but Item 319 remains, with its exclusionary and discriminatory criteria to ration access, in my opinion due in large part to political misuse of the concept of EBM. Contrary to the assertion of Parker et al, there is a great deal to worry about. In addition, Parker and colleagues make the claim that mental health is attracting government attention and funding. Again, in reality, a great deal of money is being spent on promoting education and awareness — and certain kinds of treatment. There is no evidence that short-term treatments (which are heavily promoted) actually help the group excluded by Item 319 regulations. Yet public policy is being pushed along the lines of "one size fits all". It does not. All this is evidence of misuse of the idea of EBM reflected in public policy, and patients are suffering as a result. To make matters worse, cuts in one area are mindlessly used to push agendas that in clinical reality will be unworkable in other areas — all of which devalues professional expertise and judgement. Parker MH, Del Mar CB, Glasziou PP. Ethics and evidence-based medicine [letter]. Med J Aust 2001; 176: 138. <eMJA full text> Leeder SR, Rychetnik L. Ethics and evidence-based medicine. Med J Aust 2001; 175: 161-164. <PubMed> Doidge N. In: Cameron PM, Ennis J, Deadman JC, editors. Standards and guidelines for the psychotherapies. Toronto: University of Toronto Press, 1998. Doidge N, Simon B, Gillies LA, Ruskin R. Characteristics of psychoanalytic patients under a nationalised health plan: DSM-III-R diagnoses, previous treatment and childhood trauma. Am J Psych 1994; 151: 586-590. (Received 7 Feb 2002, accepted 25 Mar 2002)

Gil M Anaf

In reply: Anaf seems to have missed our point that the choice by Leeder and Rychetnik1 of mental health as an area relatively devoid of good quality evidence was a poor one — quality research has revealed mental health as an area of considerable need, and mental illness as a significant component of the global burden of disease. Despite the fact that evidence is often more difficult to obtain within the mental health area, much evidence exists — for example, the Cochrane Collaboration Depression, Anxiety and Neurosis Group has 11 500 controlled trials in its registry, and the Drugs and Alcohol Group has 3314. Anaf would agree with us here (on the basis of his assertions about the quality of the particular evidence he alludes to). On the narrower issue of the evidence base for long-term intensive psychiatric treatment, Anaf implies that this was ignored or distorted by the then Health Minister in deciding to amend the Medicare Benefits Schedule. We agree that EBM (and sound research) can be politically misused (as can any product of science), but that is no basis for rejecting EBM. Political misuse is a political mischief, not a failing in the particular instrument being misused. EBM itself is frequently blamed for all sorts of problems in health service, whereas, to use Anaf's example, the relative quality of the evidence for short or long term psychiatric treatment is a contingent matter for development and deliberation within and outside the psychiatric research community. Leeder SR, Rychetnik L. Ethics and evidence-based medicine. Med J Aust 2001; 175: 161-164. <PubMed> (Received 22 Mar 2002, accepted 25 Mar 2002)

Malcolm H Parker · Chris B Del Mar · Paul P Glasziou

To the Editor: The Australian Red Cross Blood Service (ARCBS) introduced a national policy for therapeutic venesection in December 1999 which allows the collection of blood from people with haemochromatosis. There is no charge for this service. The policy outlines the principles under which ARCBS provides a therapeutic venesection service, conditions of management of the donors and the acceptability of the donations for clinical use.1 These conditions are: The patient's condition benefits from regular venesection and the patient does not have a transfusion-transmissible disease. The blood donation will be used in clinical or derivative products only if the donors fully meet the donor selection guidelines for clinical use. Responsibility for patient management remains with the referring physician. ARCBS is responsible for the collection and for ensuring donor safety during the procedure. We will liaise with referring physicians about the venesection protocol if necessary, and reserve the right to refuse to venesect if there is a concern for donor safety. A diagnosis of hereditary haemochromatosis (evidence of iron overload together with appropriate genetic studies2) is required before patients are accepted into the therapeutic venesection program. Contact your local ARCBS for copies of the therapeutic request form. Completion of this will facilitate the entry of people to the ARCBS therapeutic program. The full policy can be obtained from our website <www.arcbs.redcross.org.au>.

Margaret L Buring

To the Editor: Consensus exists that the provision of medical advice must be based on the correct interpretation of the evidence base. It is logical to assume that consideration should also apply to the provision of medical opinion in cases of medical litigation. The recent article on Sharp v Port Kembla RSL Club1 raises concerns which require wider debate. It is not our purpose to discuss legal niceties nor to contest the epidemiological evidence of an increased incidence, in active smokers, of cancers at several sites, including the head and neck. Rather, we wish to concentrate on a central conclusion in the report, namely the assertion that ". . . a relationship between exposure to ETS [environmental tobacco smoke] and an increased risk of head and neck cancer . . . is supported by the available epidemiology". The larger2 of the two studies quoted showed a crude odds ratio of 2.4 (95% CI, 0.9–6.8). This result is statistically non-significant. The authors also claimed a dose response between "moderate" and "heavy" exposure of 1.8 (95% CI, 0.5–7.3) and 4.3 (95% CI, 0.8–23.5) for non-smokers and 2.5 (95% CI, 0.9–6.9) and 5.3 (95% CI, 1.8–16.1) for smokers. Statistical interpretation of these results leads to a conclusion of no evidence of an increased risk compared with people who were "never" exposed to ETS. Leaving aside our considerable reservations regarding the overall design and analysis of this case–control study, the data as presented are at best suggestive. Significant doubt must remain regarding the role of ETS in head and neck cancer. That being so, two disturbing issues emerge which merit further debate. Firstly, there is an ethical issue as to whether the requirements for the correct interpretation of the evidence base for medical opinion should be any different in the clinic or the courtroom. Secondly, the judgment in this case highlights a dilemma in clinical practice. A clinician is not expected to practise according to non-significant differences in outcome. But, in the event of litigation, will the courts decide, as in this case, that bigger is better?

Allan O Langlands FRACR, FRACS · Val J Gebski BA, MStat

In reply: Our article1 outlined evidence presented to the Supreme Court of New South Wales. The paucity of epidemiological evidence concerning an association between exposure to environmental tobacco smoke (ETS) and laryngeal cancer (two studies available) was offset by biological plausibility concerning the carcinogenicity of tobacco smoke. To that extent, the epidemiological evidence in question "supported" a clear inference of causality from other data. The views offered by Langlands and Gebski do not alter this consideration, and are otherwise without merit for several reasons. To restrict the inference reasonably drawn from epidemiological data to whether or not statistical significance is achieved is inadequate. To offer an overall conclusion other than one based on all the data (in this instance, both studies) is unsound. To publish imputations concerning a specific study in a context denying right of reply by the authors concerned is unfortunate. To identify an ethical problem predicated only on a perceived discontinuity between evidence accepted by a court and evidence accepted by the medico-scientific community is spurious. The Court in Sharp v Port Kembla RSL Club was provided with vigorous criticism of the epidemiological data. Most of the eight weeks of court time was occupied by a painstaking analysis of this and other causative issues. The Court then made a determination consistent with the medico-scientific evidence. Stewart BW, Semmler PCB. Sharp v Port Kembla RSL Club: establishing causation of laryngeal cancer by environmental tobacco smoke. Med J Aust 2002: 176; 113-116. (Received 18 Mar 2002, accepted 21 Mar 2002) South East Sydney Public Health Unit, Randwick, NSW. Bernard W Stewart, PhD, FRACP, Head, Cancer Control Program, and Professor, UNSW School of Paediatrics. Sir James Martin Chambers, Sydney, NSW. Peter C B Semmler, MA, QC, Senior Counsel. Correspondence: Professor B W Stewart, South East Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. stewartbATsesahs.nsw.gov.au AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address.

Bernard W Stewart · Peter C B Semmler

To the Editor: Donovan and colleagues bring attention to the restrictions placed by the Health Insurance Commission via the Medicare system on clinicians investigating patients for sexually transmitted infections (STIs).1 In their study of Sydney general practitioners, they suggested that reform was required to the three-test pathology testing rule to improve gonorrhoea screening in high-risk individuals living in a region of epidemic gonorrhoea. In the Kimberley region of Western Australia, where we practise, syphilis, gonorrhoea and chlamydia continue to be endemic. Best-practice guidelines for primary healthcare providers in WA state that investigation for other possible STIs is essential to the care of patients with STIs or HIV infection.2 Health policy should be based on best-practice standards. For patients with confirmed or suspected STIs, this means that Medicare funding should meet the full costs of all tests for suspected STIs (as indicated by clinical need and best-practice guidelines) to enable and facilitate effective control of these infections at the population health level. An Australian legal precedent exists for medical practitioners regarding testing for STIs. In the New South Wales Supreme Court case of BT v Oei, it was found that a doctor has a duty of care to offer testing for other STIs to a patient with one STI or a suspected STI.3 In that case, a sexual partner of an HIV-positive patient brought successful legal action against her partner's doctor for failing to diagnose HIV infection in her partner. The doctor was found negligent in failing to offer an HIV test to a patient with ongoing symptoms who had been found to be infected with hepatitis B virus and whose only risk factor for this infection was unprotected sex. The doctor's duty of care was found to extend to the patient's sexual partner, who became infected with HIV after unprotected sex with her partner. Given that best-practice guidelines and a legal precedent exist which confirm that a medical practitioner should offer testing for other STIs to a patient with one STI or a suspected STI, what are the medicolegal implications of the Health Insurance Commission's three-test rule? Comment: The Journal sought a comment from the Commonwealth Department of Health and Ageing, but after three months had yet to receive a response.

Graeme H Johnson MB BS (Hons), BMedSci(Hons) · Donna B Mak FAFPHM, FACRRM

In reply: We disagree with Wodak and colleagues in a number of respects. If the results of a hydromorphone trial were as good as Wodak et al claim a heroin trial would be, then a heroin trial would be unnecessary. We accept, as did the Dutch and Swiss, that politicians have the authority to make decisions about what medical research is permitted. The heroin trials in Switzerland and the Netherlands were approved by parliament and supported by referenda in cantons and cities in Switzerland. The Australian survey data cited by Wodak and colleagues indicate that a heroin trial would not have been approved if a referendum had been held in 2001. Nor do we think it would be supported by a free vote in Federal Parliament, as it was not supported by a similar vote at the NSW Drug Summit in 1999. Wodak et al present no evidence to support their claim that the delivery of a treatment that costs between A$25 000 and A$45 000 per patient per year in the Netherlands1 to less than 5% of the heroin-dependent population would have a detectable impact at the population level. A hydromorphone trial would provide a way of evaluating the role of injectable opioids in the treatment of heroin dependence. It would not prevent Wodak and colleagues from convincing the community that injectable heroin is the drug of choice to treat refractory heroin dependence.

Wayne D Hall PhD · Richard P Mattick PhD · Jo Kimber BSc (Hons)

To the Editor: Lamberth stated in his case report that Antarctic tourist ships should be equipped to provide life support, as well as better screening and education of Antarctic tourists.1 I recently travelled to both the Arctic and Antarctic as a medical officer on small ships, caring for seven passengers injured in a helicopter crash in the remote Russian Arctic and a 12-year-old with diabetic ketoacidosis in the Drake Passage, as well as numerous people with minor ailments. To compare these ships with large tropical cruise liners is unrealistic. Ships' medical supplies are selected with an appreciation of the casemix. A study of 16 Antarctic trips in 1997 and 1998 found that most problems were respiratory tract complaints, acute soft tissue injuries and complaints, sea sickness and dermatological problems.2 Few major incidents have been reported, and equipment for advanced life support is tailored to this. Paralysing agents and ventilators are not supplied. A single doctor with no nursing staff cannot safely care for a ventilated patient for 72 hours, as suggested by Lamberth, and the additional staff needed for this would be a huge additional expense for a very rare occurrence. While some ingenuity and adaptability may be required, the equipment supplied is adequate for the vast majority of events. Safety and preventive medicine are very much part of the ship's doctor's role. Most doctors give a brief lecture as part of the initial briefing of passengers. Seasickness, appropriate medication and safety on the ship are usually part of this. The passengers are predominantly elderly and, in my experience, many are fulfilling a long-held ambition to travel to the polar regions. Reputable companies require a fitness-to-travel assessment from passengers' general practitioners before the trip is confirmed. This assessment is tailored to potential problems in remote regions. I believe that excluding people from the wonders of polar travel on the basis of age or previous coronary artery disease would be a terrible shame, while accepting that there will always be a risk in travelling to remote locations. Having shared in the 90th birthday celebration of a woman with chronic obstructive pulmonary disease in the Arctic, I hope that I will still be able to enjoy such experiences at that age.

Eve R Merfield FACEM

To the Editor: Lamberth raised some worthwhile issues about small-ship adventure tourism to Antarctica in his recent case report describing the death of an 82-year-old tourist.1 This occurred in 1999, the season I started as medical director for the leading polar adventure tour company that chartered the vessel involved. I have some comments and an update. The former Soviet oceanographic research vessel was converted in the 1990s to carry 78 passengers. She had a two-bed infirmary and a procedure room with Russian and German medical supplies for passengers and crew, and carried a German- and English-speaking Russian doctor experienced with passenger ship medicine. The tour operator provided additional medical supplies and an emergency physician. Ventilatory support could have been provided, although not to the standard of a contemporary Australian intensive care unit. Polar adventure operations are very different from "tropical" cruise lines, which generally operate their own ships from home ports and cater for up to 3000 passengers with very different expectations.2 Operators require that prospective passengers submit a medical information form and a declaration from their personal physician that they are fit for the journey. The 82-year-old who died was a retired physician who did not declare the extent of his limitations, and who acted as his own medical advisor. His is the only death I am aware of after seven years' involvement in the industry. The medical declaration form has been modified and now addresses the risk factors identified by Lamberth. Prospective clients with questionable health are referred to the medical director. However, operators cannot verify declarations of good health, and physicians have been known to collude with passengers to avoid risk of rejection. Furthermore, "ageism" is as unacceptable as sexism and racism. I was present on the first passenger-circumnavigation of Antarctica in the company of several octogenarians and a 90-year-old, and on the first circumnavigation of the Arctic Ocean, with other octogenarians and a 92-year-old. Short trips to the Antarctic Peninsula are very different from scientific expeditions; Lamberth's suggestion that advising doctors should consider scientific expedition criteria is inappropriate. The International Association of Antarctic Tour Operators (<www.iaato.org>) is a voluntary association of competing adventure eco-tour operators whose purpose is to self-regulate the industry and to develop good standards. Standards for provision of medical supplies and capabilities are under development by this association.

Chris H Curry

In reply: I welcome Curry and Merfield's interest and comments. The patient described in my case report1 was not, as Curry states, "a retired physician". Nor did he provide his own health assessment, but had his assessment form filled out by another physician. Unfortunately, this form, along with those of 60 other passengers, was not made available to any doctor before embarkation. Curry confirms that many older passengers are travelling to Antarctica.2 Merfield's experiences attest to the potential for serious (including multiple casualty) incidents in this remote location. I agree that ageism per se is unacceptable. Rather, the issue is the provision of adequate facilities to deal with potential problems or, alternatively, warning as to the hazards. Advertising for Antarctic cruises emphasises the medical facilities provided. The public may not realise that a doctor with minimal equipment cannot deliver the same care available in a First World hospital. Curry's assertion that ventilation could have been provided illustrates this. Ventilation is more than placement of an endotracheal tube. It is ludicrous to suggest that, without oxygen, paralysing drugs, positive end-expiratory pressure or means to suction the copious thick secretions, hand-bagging for 36 hours while crossing the heavy seas of the Drake Passage might have altered the tragic outcome for this patient. I recommend a book by Levinson, a seasoned polar physician, and Ger on health aspects of polar tourism.3 They have collated the findings of a conference held on this topic at Cambridge in the United Kingdom in 1995. The book addresses what Levinson describes as "the often inadequate medical care which exists in these regions". He notes "major concerns . . . expressed by travel experts, the American Medical Association, the American College of Emergency Physicians, and other professional organisations."3 The survey by Curry and Johnston found that illnesses among their company's Antarctic tourists in 1997 and 1998 included cardiac arrest, acute myocardial infarction, severe pneumonia, diabetic ketoacidosis due to seasickness, haematemesis, anaphylaxis, ruptured ectopic pregnancy and acute appendicitis. The fact that polar trips are short does not seem to protect against potentially lethal diseases. Given the stress of this travel and the nature of the population involved, maybe the contrary applies.

Paul G Lamberth FACEM

To the Editor: The experience described by Jones on books as carriers of disease in a recent issue of the Journal,1 following Ferson's article in the Christmas issue,2 reminded me of my experience in about 1933 at the Coast Hospital (now Prince Henry Hospital) at Little Bay, Sydney. My mother was a medical resident at the Coast, which was the infectious diseases hospital for NSW. She developed acute diphtheria and was admitted. I (aged five) and my sister had been immunised and were not sick. However, we were throat swabbed, and the swabs were positive for Corynebacterium diphtheriae. We spent three weeks in the hospital with no treatment until we returned negative throat swabs. While waiting to be admitted to the "blocks", we saw children with shaven heads through glass doors, and I've always assumed they were the ones with scarlet fever, as did Jones.1 I was given The Anzac book, on Gallipoli, to browse through. This is now a collector's item and very valuable. Then, much to my chagrin, I was not allowed to take it home. Later, in 1953, I was to return to my old ward as a resident medical officer, although I was never to find out what happened to all those books!

John V Roche MB BS, FRACGP, D(Obs), RCOG, DRACOG

To the Editor: Hall et al1 argue that a hydromorphone trial would break the current deadlock in Australia over prescription heroin research. But would it? If hydromorphone was demonstrated to be an effective intervention for treating refractory heroin users, researchers would then wish to compare both hydromorphone and prescription heroin against the gold standard, oral methadone. The Prime Minister has stated publicly that proceeding with a prescription heroin trial "would send a wrong message". This claim is still unsupported by evidence. Clinicians and researchers should steadfastly oppose political interference in medical research from however august a level, especially when there is such a strong rationale for the trial and when researchers have so scrupulously followed scientific process. Such interference would not be tolerated in other areas of medical research and should not be tolerated in this field. The results of a recent large randomised controlled trial2 of prescription heroin in the Netherlands, while yet to be published in a peer-reviewed journal, provide strong additional support for an Australian trial. In contrast, Hall et al1 cite no previous evaluation of the efficacy of hydromorphone in managing heroin dependence. In Switzerland, prescription heroin is reserved strictly for treating refractory patients and accounts for fewer than 5% of all treatment provided.3 The importance of attracting and retaining this group in treatment is probably far greater than their small numbers might suggest, as there is reason to believe that they contribute disproportionately to the immense social costs of heroin use in the community. (By analogy, the heaviest-drinking 10% in a community account for half the total alcohol consumed.) Those who inject heroin very much more frequently than the community mean are probably responsible for a disproportionate share of crime and enlisting new recruits. Prescription heroin was selected as the experimental intervention in studies in Switzerland, the Netherlands, Germany and Spain and is now being considered seriously in Canada. The reasons advanced by Hall et al1 are all cogent arguments for conducting a trial of hydromorphone additional to an evaluation of prescription heroin. Hall et al are concerned about lack of community support for a heroin trial in Australia, but in a recent national opinion poll4 45% of respondents expressed support, while 47% were opposed. The case for an Australian heroin trial, with or without additional trials, remains compelling.

Alex D Wodak FRACP · Alison J Ritter PhD · Charles RR Watson PhD

To the Editor: I read with interest the accounts of de Costa, Walton, and Flynn and Atkinson dealing with the Professional Standards Committee (PSC) of the NSW Medical Board and the behaviour of the Health Care Complaints Commission (HCCC).1-3 I would like to add a few comments arising from my personal experience of appearing before the PSC. The PSC is supposed to be non-adversarial. The Medical Practice Act 1992 (NSW) states that the doctor under investigation and the HCCC are not to be represented by a solicitor or barrister, but could be assisted by one. In my case, I soon realised that the HCCC Hearings Officer opposing me was dauntingly competent in court craft. She was, in fact, a very experienced solicitor who had for a long time been in practice outside Australia but was not registered as a solicitor in New South Wales. As a result of my application to the Supreme Court, this malpractice was stopped by Justices Dunford and O'Keefe.4, 5 Note that Justice O'Keefe ruled that a person qualified in law could represent the HCCC in PSC hearings, provided the person had never been registered as a legal practitioner. I would like to pose three questions. Firstly, why was it left to me, someone inexperienced in legal processes, to call a halt to this inequity? Secondly, why did the Medical Board countenance this malpractice, when it was manifestly in breach of the Medical Practice Act and most unfair to the medical practitioners whose welfare is its responsibility? And thirdly, why did legal representatives of the medical defence organisations continue to permit this obvious imposition on the doctors whom they had been paid to defend? In my case, evidence obtained in confidence from peer reviewers has been published in the journal of the Health Care Complaints Commission, even though the action against me has not yet come to hearing. The HCCC's practice of publishing such information prior to hearings has been sanctioned by the Medical Tribunal.6 It is my belief that the HCCC has brought the NSW medical regulatory bodies into disrepute by its malpractices, its disrespect for the wishes of Parliament and its lack of a long-term perspective.

Richard F Gorman MBBS DO FRACO

To the Editor: I am a general practitioner who has specialised solely in the field of cosmetic medicine since 1988. I have been the subject of an investigation by the Health Care Complaints Commission (HCCC) and a resultant Professional Standards Committee (PSC) hearing, in which peer reviewers with significant conflicts of interest were used. The process was triggered by a complaint from a patient who had developed blisters and superficial crusting after facial laser hair removal treatment. This is a recognised complication that the patient was aware of when giving consent for the procedure. The HCCC briefed a dermatologist, Dr "X", to comment on the treatment of which the patient had complained. The HCCC further instructed Dr X: "Your report need not be confined to the above questions [relating to such treatment] but should include any other matters you consider relevant and significant." I was referred to the PSC primarily on matters unrelated to the treatment that had led to the patient's complaint. Before the PSC hearing I submitted various documents to the HCCC: (a) a copy of a newspaper advertisement for laser hair removal in which Dr X had stated "Trust only a dermatologist to recommend a safe and reliable method of managing unwanted hair" and "Prospective clients should closely check the qualifications of their laser practitioner and look for the letters FACD"; (b) a report from another dermatologist stating that Dr X "does have a history of a negative attitude to general practitioners who specialise in lasers. He has been seen on television on several occasions espousing this view."; (c) expert reports from two dermatologists expressing views contrary to the opinions of Dr X that had triggered my PSC referral; and (d) statutory evidence from a patient treated in his practice that Dr X's own clinical practice was contrary to that which he had advised the HCCC I should have followed. The NSW Medical Board appointed as a PSC representative at my hearing a dermatologist who was a co-advertiser for laser hair removal with Dr X. The dermatologist in question was later removed (with difficulty) on objection. The PSC systematically disregarded expert evidence I had presented in favour of evidence presented by the HCCC. I have been told that this is a common occurrence. I sincerely hope that the NSW Government Inquiry into the HCCC, to be released in 2002, will address the abuse of this system by biased reviewers. However, justice cannot be guaranteed when the HCCC and NSW Medical Board both effectively collude to prosecute these cases. PSC hearings should be administered by an independent body.

Geoffrey K Heber MB BS DipRACOG MBA

To the Editor: The Acts constituting the NSW Medical Board and Health Care Complaints Commission (HCCC) unfortunately permit inequitable joint functioning of these agencies. The provision that the complainant may appeal an unsatisfactory decision of a Medical Board's Professional Standards Committee (PSC) to the Medical Tribunal is misleading.1 The HCCC chooses its peer reviewer in any matter, investigates, recommends that the Board take action (or not), prosecutes matters at a hearing (or not) and is the only complainant allowed to appeal.2 Clearly, the skills, methods, and decisions of the HCCC and the Board must be beyond reproach. The HCCC selects peer reviewers to consult during the investigation of a complaint.3 They are paid to report on documents and to appear as witnesses before any committee or tribunal of inquiry — either before an in camera PSC of the Board or at a Medical Tribunal, chaired by a judge in open court. Peer review reports, which are legally privileged and generally inscrutable, may be selectively biased. My own involvement (as a complainant disallowed appellant standing from the PSC, and as an occasional consultant to a complainant and to the defence in other, separate psychiatric complaint matters) has led me to conclude that some peer review reports are inconsistent with minimal professional requirements or even duplicitous. Blind faith in a system comprising these two statutory bodies and an anonymous peer reviewer is inappropriate. The NSW Administrative Decisions Tribunal (ADT) has judged disclosure of the membership lists of HCCC peer review panels to be in the public interest. In 1999, the ADT inquired into the selection of the list of psychiatrist peer reviewers when dealing with an application for disclosure based on the Freedom of Information Act 1989 (NSW).4 The list proved to have evolved over an unknown period, through unknown differing methods (such as recommendations from unidentifiable practitioners or staff), for unknown precipitating reasons, and at unknown times. There was no general awareness within Medical Colleges or other medical associations of the selection process or of the members who may be thus empowered. This, when we know that, as a profession, we cannot be uniformly sensible, ethical or emotionally stable. The HCCC and the NSW Medical Board are thus vulnerable to corrupt influence. The NSW Parliamentary Committee on the HCCC has sought submissions from the public and has been conducting an inquiry since November 2001 to determine necessary improvements to the functioning of the HCCC. I believe professional bodies need to take a resolute lead, declare their intentions, identify their roles, consult with their members and heed their responses. Ideally, each will clarify its policies and procedures for regulation and will demand proper functioning from the agencies with statutory responsibilities.

Eleanor Dawson

In reply: A Medical Board's role is to protect the public by ensuring that appropriate standards of conduct and practice are maintained by registered medical practitioners. In New South Wales, the NSW Medical Board administers the disciplinary provisions under the Medical Practice Act 1992 (NSW). Included in this legislation is the Medical Tribunal/Professional Standards Committee (PSC) model that has been the subject of comment in recent correspondence. It is important to note that the Medical Board, the Health Care Complaints Commission (HCCC), the Medical Tribunal and PSCs are all independent bodies in their own right. The Medical Board welcomes constructive comment on the system and its administration. It meets regularly with the major parties (HCCC, United Medical Protection, and the Australian Medical Association [AMA] as the doctors' professional body) to discuss the workings of the disciplinary system, to identify problems and shortcomings, and to develop solutions. Inevitably, there will be aspects of the process that participants do not like — who enjoys being taken to court, in any circumstances? As in all legal and quasi-legal processes, the parties are unlikely to uniformly praise the impartiality or quality of witnesses, experts, and the judiciary. Processes are in place to minimise the possibility of conflict of interest, or the perception of bias. On the rare occasion when a panellist is challenged, a conservative approach is generally taken, and a replacement found. Heber raises concerns about an inquiry extending beyond the parameters of the original patient complaint. In a protective jurisdiction, it would be quite wrong to limit a case to what the complainant had been able to articulate. Not infrequently, a patient's unhappiness is focused on what, from a medical perspective, is relatively minor, while seriously poor conduct or practice is not recognised as such. The legislation specifically envisages an "inquiry", which, subject to natural justice requirements, may go beyond the original complaint. To deny this would be inconsistent with the protective nature of the jurisdiction. The issues raised by Dawson and Gorman concentrate on procedures adopted by the HCCC regarding peer review and representation before hearings. The Board understands that the HCCC has a detailed policy document, prepared in consultation with stakeholders including the AMA and United Medical Protection, regarding the selection and utilisation of peer reviewers and expert witnesses. The Board is also aware of wider concerns in the legal system regarding the use of "hired guns" as distinct from impartial peers or experts, and when concerns have been brought to its attention suggesting even a perception of bias it has taken steps to address them. The Board and members appointed to sit on PSCs and Medical Tribunals take their roles very seriously, and do so with a sense of professional responsibility, while acknowledging the difficulty of sitting in judgement on their peers. Criticisms are carefully considered and practices changed where appropriate. At all times, the Board must ensure that it acts fairly and in accordance with its charter of public protection.

Brian C McCaughan MB BS FRACS

To the Editor: A number of recently published articles indicate that the prevalence of overweight and obesity in children is increasing at an alarming rate on a national1 and international2 level. Overweight children are more likely to become overweight adults and to experience chronic health problems associated with adult obesity. We report results obtained from a survey of primary schoolchildren on the New South Wales Central Coast which extends the time series from that in the article by Magarey and colleagues (1985 and 1995 data)1 to the year 2000. We undertook a cross-sectional study of children at a Central Coast primary school in November 2000 as part of a community study. This study was approved by the Central Coast Health Ethics Committee. All children in each class were asked to take part. With parental consent, weight and height were measured in children from all class groups (aged 7–11 years) by child health nurses using standardised procedures. Children were classified as overweight or obese using the standard international cutoffs for body mass index.3 They were compared with data obtained during the 1985 Australian Health and Fitness Survey (AHFS85) and the National Nutrition Survey of 1995 (NNS95).1 A total of 268 children (127 girls, 141 boys) were surveyed (average of 25 girls and 28 boys of each age). This represented a 70% response rate. The Table shows that the incidence of overweight and obesity in Australian children has continued to increase, with relative risks for the increase between 1985 and 1995 of 1.37 (95% CI, 1.07–1.75) for boys and 1.82 (95% CI, 1.49–2.22) for girls, and relative risks for the increase between 1995 and 2000 of 1.71 (95% CI, 1.21–1.43) for boys and 1.21 (95% CI, 0.87–1.67) for girls. Our findings indicate a marked increase in proportions for boys in only five years since NNS95. While the increase for girls was not statistically significant, the pattern is consistent. Prevalence of overweight and obesity in children aged 7–11 years for 1985, 1995 and 2000 Sex Year Number Overweight (%) Obese (%) Overweight + obese (%) Boys 19851 2425 9.7 1.5 11.2 19951 457 11.6 3.7 15.3 2000 141 16.3 9.9 26.2 Girls 19851 2443 11.0 1.9 12.9 19951 430 17.2 6.3 23.5 2000 127 21.3 7.1 28.4 Thus, the incidence of overweight and obesity in Australian children is steadily increasing. Importantly, according to the 1996 Census Socio-Economic Indexes for Areas,4 the school we surveyed is situated in an area ranked in the middle quintile for relative socioeconomic disadvantage (state and national average), and is immediately adjacent to one 4th- and several 1st-quintile and 2nd-quintile areas. We believe our findings are representative of the Australian population of children. The challenge to healthcare workers is significant. The National Health and Medical Research Council's Acting on Australia's weight5 identifies goals for preventing further weight gain in adults, and eventually reducing the proportion of the adult population that is overweight or obese, and to ensure the healthy growth of children. Recommended strategies range from national dietary and physical activity guidelines to increasing physical activity through the design of towns, transport systems and public recreational facilities. Effective strategies are urgently needed to alter food intake and physical activity at individual, school, community and population levels.

Susan Goodman · Peter R Lewis MB BS, FAFPHM · Andrew J Dixon · Cheryl A Travers