Reflections

Disaster medicine. Gregory E Ciottone. Sydney: Mosby Elsevier, 2006 (952 pp, $157.00). ISBN 03230325531. What should you do if a terrorist organisation managed to use Q fever as a weapon? The modern world continues to throw up challenges to human survival from both manmade and natural disasters as well as deliberate attacks from terrorist organisations. Disaster medicine is an evolving subspecialty of medicine and this extensive text covers the broad principles of the subject, with detailed references to specific examples. The editor-in-chief, Dr Gregory Ciottone, is the Director of the International Emergency Medicine Section at Harvard Medical School. In this book, he and his United States-based editorial team have brought together an impressive 200 contributions to provide guidance on more than 100 specific disaster situations. Not surprisingly, much of the detail is US-centric. Nevertheless, the book covers an extensive range of topics, from prehospital management to public health, including the legislative changes made in response to disasters. The chapters are short, well written and informative. A disaster medicine novice would be able to readily digest the material. The second half of the book gives short lists of practical points related to just about every conceivable attack scenario. Disaster medicine is not for everyone. This book is an excellent text for those with a passion for the topic. For those with a lesser interest, it functions as a quick reference guide to many extremely unlikely disaster scenarios.

Andrew J Doley

From Kurmond kid to cancer crusader. Pioneering integrated cancer treatment . Fred Stephens. Adelaide: Wakefield Press, 2011 (xiii + 177 pp, $29.95). ISBN 9781862549579. The fascination of an autobiography persists. Can the reader gain insight into the riddle of life by peering into the experience of another? Troubles, tribulations, successes and joys are scattered seemingly randomly across the human journey. So it is with Fred Stephens’ tale, a gentle, interesting story, almost naively presented in first person, extending from early childhood to an international career as a cancer surgeon. Stephens’ life spans a period of extraordinary change in Australian life, and those of the appropriate age will find much to engage with. The younger generation, however, are unlikely to believe that such primitive mid 20th-century life ever existed. The themes which pervade this recital have ongoing relevance to Australian life. Parochialism and nepotism have been a curse on this “lucky” country. The small number of tightly held and isolated medical communities, not excluding Sydney and Melbourne, encouraged dynasties and empire-building. Stephens’ tale accurately documents the impact of these elements on personalities and individual careers. Patients came first with Stephens, but patient-centred health care existed only as a dream. The final acceptance of the concept of surgical oncology by the Royal Australasian College of Surgeons is one of the bright spots. This book tells of a dedicated surgeon of independent mind doing well for his patients and the discipline of surgical oncology, but perhaps never receiving the recognition his achievements deserved. For those of us in the business and still fighting the good fight this is an enjoyable read, and well known characters pop up regularly through the pages. Fred Stephens was a pioneering spirit and his good heartedness and sometimes confronting personal honesty shines through the book.

Robert J S Thomas

Safe, legal abortions and comprehensive reproductive health care are crucial for women, but there is still a long way to go It was the first autopsy I attended and it left a lifelong impression. The year was 1970, and I was a medical student in Dublin. A young woman had come from the country to work in a bank. She became unwell and was cared for by her landlady, who diagnosed the flu. When her condition worsened, she refused a doctor until she was moribund. By the time an ambulance was called, she had developed septicaemia, and she died soon after reaching hospital. The autopsy revealed extensive peritonitis and infected placental tissue in the uterus, which showed signs of interference, although by whom, or where, or when was never established, as was often the case. As a junior doctor in Papua New Guinea in the 1970s I was to see more such deaths among women who had wanted to conceal their pregnancies, consuming toxic herbs or using sticks to try to induce an abortion. In particular, I remember a nursing student from a distant province. Top of her class in her home village, she had come to Port Moresby to train. Like the Irish bank-teller, she was too terrified to seek help until it was too late. Those experiences provided much of my motivation for advocating — with many others — reforms in women’s reproductive health care in Australia, in particular the introduction of mifepristone (RU486) for medical abortion and the decriminalisation of abortion in state legislation. Over 40 years, I have seen many advances in my chosen specialty of obstetrics and gynaecology. When I began training, the only use of ultrasound was to locate the placental site after antepartum haemorrhage. Now, sophisticated ultrasound techniques are used on a daily basis to assess both normal and abnormal pregnancies. Perinatal mortality rates have dropped to a fraction of what they were due to closer fetal surveillance, and we have better management of diabetes and pre-eclampsia, and better facilities for care of pre-term babies. In-vitro fertilisation now enables many women, who would have previously remained childless, to give birth. There has been great progress in hormonal contraception, and the progestogen intrauterine device has made a huge difference to management of menstrual disorders, so that hysterectomy, common 20 years ago, is much less needed. However, I believe that among all these advances, the most dramatic and beneficial development in the provision of women’s health care in this time has been the change from unsafe, clandestine abortion to safe, open practice. In Australia, as in most other developed countries, there has been abortion law reform. Of course, there is still a long way to go. Only some states and territories have reformed or decriminalised their quaintly worded 19th-century legislation. But even without reform, case law has made the provision of abortion less uncertain for doctors, and more accessible for women. Medical abortion using mifepristone remains available only in restricted circumstances in Australia, and generally only to urban women; hopefully, in the near future, the drug will be accessible to all Australian women. Abortion is now much more widely discussed in society generally, as well as in the medical literature. There is increasing recognition that abortion is an important health issue for Australian women. However, there are still many countries in the developing world, including Papua New Guinea, where women die or suffer chronic ill health from complications of unsafe abortion. Making abortion, in particular medical abortion, widely and safely available has the potential to prevent many maternal deaths. Like everybody else interested in improving women’s health, I would like to see abortion rates reduced in Australia and elsewhere. However, this needs to be achieved by reducing the rates of unplanned and unwanted pregnancies, rather than by forcing reluctant women to continue their pregnancies. In Australia, certainly, effective contraception is available, including a variety of hormonal preparations. There are intrauterine devices with minimal side effects and long life spans, and the morning-after pill can be bought over the counter in Australian pharmacies. Yet our abortion rates are still more than three times higher than those of Belgium, the Netherlands and Scandinavia, where there are very liberal abortion laws and accessible abortion services. Clearly, we are not providing effective sex education at a standard equal to these countries. Little attention is given to contraceptive information and services in the course of antenatal and postnatal care, especially in the public sector. A more integrated system of women’s reproductive health care is needed, in which sexual health care, contraceptive advice and provision, prepregnancy and pregnancy advice, and care during and after pregnancy and birth would complement one another. Such a system would also incorporate abortion provision into mainstream health care. All women should have access to appropriate information and care in pregnancy, regardless of whether or not they intend to continue that pregnancy. I look forward to working towards improvements in abortion provision, and in other aspects of women’s reproductive health care, for the rest of my professional life.

Caroline M de Costa PhD, FRANZCOG, FRCOG

Jim Macken was born in Sydney on 24 January 1924, the eldest child of Irish immigrants. He grew up in Greenwich, Sydney, and was educated at St Aloysius’ College, Milson’s Point. In his final year there he was a prefect and a member of the first XV (rugby) and first XI (cricket). After school, he joined the Commonwealth Bank, while successfully studying for his economics degree part-time. He switched careers in 1953, commencing his medical studies at the University of Sydney at the age of 29. At university, he was often referred to as “Senator” Macken, as he was a mature-aged undergraduate representative on the university senate. Jim was a medical student at Royal North Shore Hospital. After graduating in 1959, he undertook his residency at the Mater Hospital, Sydney, before entering general practice at North Bondi. This was a dedicated community practice, with the doctors doing house calls, nursing home visits and obstetrics. Jim remained there for almost 40 years. As a visiting GP Obstetrician at St Margaret’s Hospital, Darlinghurst, Jim delivered many babies over the years, and gained his Diploma of Obstetrics from the Royal College of Obstetricians and Gynaecologists in 1980. He became a Fellow of the Royal Australian College of General Practitioners in 1981 and was an examiner at the College exams for a number of years. His wide-ranging interest in history, politics, sport, cards and literature enabled him to discuss virtually any subject with his patients, whether young or old. Jim was always immaculately groomed and had a great sense of humour and charming bedside manner. He was a lifetime member of the Balmoral Beach Club and swam in the inaugural Jack Cox Memorial 1500 m swim in 1946. He enjoyed playing golf at the Royal Sydney Golf Club. For 50 years, Jim was married to Marie, who died from ovarian cancer 4 months before Jim died from cardiac and renal failure on 19 January 2010. Jim is survived by his children Philip, Peter, John, Marea, James and Rosie.

Peter L Macken · V John Roche

Professor Sir Graham Collingwood Liggins (24 June 1926 – 24 August 2010)Sir Graham Liggins, who died last year aged 84, made arguably the greatest contribution of any Australian or New Zealand practitioner to modern obstetric practice. Educated at the University of Otago, his work in the 1960s on causes of prematurity led to the publication of a landmark randomised controlled trial. This 1972 report demonstrated a two-thirds reduction in the incidence of respiratory distress syndrome in preterm neonates who had received antenatal corticosteroids. Although not immediately universally accepted, subsequent work substantiated the benefit of this simple, ground-breaking treatment. The administration of antenatal glucocorticoids, now standard obstetric practice, is widely acknowledged as the single most effective therapy in minimising mortality from prematurity. Image courtesy: Bruce Jarvis, Auckland, New Zealand. Professor Ian Frazer (6 January 1953 –)Named Australian of the Year in 2006, Professor Ian Frazer’s development of a vaccine against the human papillomavirus (HPV) is arguably the most significant advancement in the prevention of gynaecological cancer in modern times. After completing medical studies in his native Scotland, he emigrated to Melbourne. Initial research into HIV-related immunodeficiency led to work on HPV and subsequently the creation of virus-like particles, from which the HPV vaccine would eventually develop. The recipient of numerous scientific and medical accolades, including the 2009 Australian Medical Association Gold Medal, he is currently Director of the Diamantina Institute at the University of Queensland. Sir Albert William Liley (12 March 1929 – 15 June 1983) Born and educated in Auckland, the “Father of Fetology” was a pioneer in maternal and fetal physiology. Practising at a time when Rhesus isoimmunisation was a major disease, he developed a graph that enabled interpretation of amniotic bilirubin levels into prognostic “Liley’s zones”, allowing more accurate prediction of stillbirth risk. Over 4 years, Rhesus-associated perinatal mortality in Auckland fell from 22% to less than 9%. Liley is also credited with the first successful intrauterine fetal transfusion, in 1963. This case laid the foundation for the evolution of fetal therapy and the acceptance of the fetus as a person in his or her own right in the decades that followed. Ian Alexander McDonald (1 April 1922 – 4 September 1990)Ian McDonald was born in Perth, Western Australia, but throughout his career practised mostly at the Royal Melbourne Hospital. His most significant contribution to modern obstetric care is the cervical cerclage (suture) that bears his name. The concept of inserting a stitch to close an incompetent cervix was first introduced by Vithal Shirodkar in 1955. In 1957, McDonald published a technically easier approach: a simple purse-string suture involving circumferential bites around the cervix at the level of the internal os, without the need for bladder dissection. The McDonald cerclage now forms part of the standard surgical armamentarium of the contemporary obstetrician. Image courtesy: Archives of the Royal Melbourne Hospital. George Simpson (14 May 1899 – 24 November 1960)Born in Clifton, Victoria, the young George Simpson was introduced to a number of ministers from the Presbyterian Church, including Reverend John Flynn. This was the beginning of a collaboration from which the Aerial Medical Service (later known as the Royal Flying Doctor Service of Australia) would eventually emerge. Simpson graduated from the University of Melbourne and, in 1927, undertook a 3-month survey to assess the medical needs of the Australian outback. In that year, he undertook the first unofficial flight of the Service, evacuating a miner with a spinal fracture from Mount Isa. Later, he established Melbourne’s first family planning clinic. Appointed an Officer of the Order of the British Empire in 1957, he died 3 years later aged 61. Image courtesy: National Archives of Australia

Jennifer N Lees MB BS · Colin A Walsh MB BCh, BAO, MRCOG

The 2010 winter saw an excess of serious adverse events linked to the CSL influenza vaccine. With another influenza season over, the MJA investigates what progress has been made to ensure it does not happen again. Eighteen months ago, Dr Darryl Maher received news that changed his working life. He learnt that the seasonal influenza vaccine made by CSL Biotherapies had been linked to serious adverse reactions in children, such as high fevers and febrile seizures. “It’s one of those things — I can remember exactly where I was. I was at a departmental off-site meeting with our previous medical director when she received a call. We were quite devastated by it. We were very concerned because it was so uncharacteristic, and they were quite serious events”, says Dr Maher, a haematologist by training and Medical and Research Director at CSL Biotherapies. Dr Maher was not the only one upset by the increased adverse events. Families across the country were reeling, as their previously healthy children experienced fever, pain, vomiting and prolonged seizures after receiving the vaccine. Most of the adverse events had been reported in Western Australia, the only state to fund a vaccination program for children. Many children required hospital admission — in some cases, admission to an intensive care unit.1 The most severe confirmed case was an 11-month-old girl who spent 11 days in intensive care in Perth suffering a global brain injury and organ damage after receiving the influenza vaccine. After 8 weeks in hospital, she was discharged with permanent neurological damage.2 In Brisbane, a 2-year-old girl died within 24 hours of receiving the vaccine. However, the coroner was unable to confirm or rule out that the vaccine caused her death.2,3 On 23 April 2010, Australia’s Chief Medical Officer, Professor Jim Bishop, made the unprecedented decision to suspend the use of all seasonal influenza vaccines for children 5 years of age and under. At that time, three seasonal trivalent influenza vaccines were licensed for paediatric use in Australia — Fluvax (CSL Biotherapies), Influvac (Solvay Abbott) and Vaxigrip (Sanofi Pasteur).1 Investigations found that the rate of febrile seizures following receipt of the CSL vaccine was about 1 for every 100 doses administered in children aged 6 months to 4 years.4 This is high when compared with a usual paediatric febrile seizure rate following influenza vaccination of 0.16 per 1000 doses, according to data from the United States Centers for Disease Control.1 Later research estimated the rate of febrile convulsions after receipt of the CSL vaccine to be 3.3 per 1000 doses, or more than 200 times the only published population-based estimate.5 The Therapeutic Goods Administration (TGA) found that the brand of vaccine was known in two-thirds of the 99 confirmed cases of febrile convulsions that were determined to be causally linked to influenza vaccines among children under 5 years of age. In all these cases, the brand was Fluvax or Fluvax Junior, manufactured by CSL.1 On 27 July 2010, Professor Bishop announced that influenza vaccination for children under 5 years could resume only with Influvac and Vaxigrip.6 This year, CSL did not seek approval for the use of Fluvax in children under 5 years, and a warning in the product information (PI) states that it is not for use in this age group. The vaccine is licensed for use without restriction in children aged over 9 years, and in adults. It is only recommended for use in children aged between 5 and 9 years when no alternative vaccine is available.7 A safe history?In general, for inclusion of vaccines on the Australian Register of Therapeutic Goods, data are required that support their quality, safety and efficacy, including clinical trials data. However, clinical trials are not required for seasonal influenza vaccines, because there is insufficient time between the selection of the seasonal influenza strains in October and the start of the vaccination program the following March.1 The strains included in the trivalent vaccine are selected every 6 months, depending on which viruses are circulating, in a process led by the World Health Organization.8 When there are no changes to the manufacturing process apart from the addition of a new strain, the TGA allows manufacturers to submit an application as a “strain change” rather than as a new product application. “This pragmatic approach is taken because the manufacturing process for the vaccine varies little from year to year, and there is lengthy experience with influenza vaccination”, the TGA says.1 Influenza vaccines do have a lengthy history in Australia. CSL has been supplying inactivated influenza vaccine since 1968, and the licence for Fluvax was granted in 1992. However, Fluvax was licensed without the need for supporting data: it was “grandfathered” onto the register, like other therapeutic products available at the time. Annual clinical studies have been conduted in adults since the mid 1990s (TGA spokesperson, Department of Health and Ageing, Canberra, ACT, personal communication, Oct 2011). The most recent Cochrane review on influenza vaccines in children, last updated in 2007, found that the vaccines were effective in children older than 2 years but said the lack of data in children under 2 years was “surprising”. “If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required”, the review concluded.9 Some experts are concerned about this lack of data. Professor Peter Collignon, Professor of Infectious Diseases at the Australian National University, says there has not been enough clinical research on influenza vaccines, particularly in paediatric populations. “For any drug or vaccine, you need prospectively collected data in large studies and that’s just not available for this vaccine. My strong view on this is that we need hard data.” Despite the lack of baseline data, influenza vaccines had an overall history of safe use in Australia for decades without any substantial safety concerns. Although the National Immunisation Program does not provide nationwide free influenza vaccination for all children, WA has offered a funded influenza vaccination program for all children aged 6 months to under 5 years since 2008. As such, influenza vaccines, produced by CSL and other manufacturers, were used to vaccinate tens of thousands of Western Australian children in 2008 and 2009 without serious incident.5 Warning signs?Was there any way to predict the events that unfolded in 2010? After Fluvax was linked to the febrile seizures in 2010, CSL re-examined its clinical research and has acknowledged that, in retrospect, there were some warning signs. “We’ve gone back and reanalysed all the clinical trials, including data that became available after the events in 2010, and they do show this tendency to fever in children”, says Dr Maher. CSL conducted a trial of its 2009 influenza vaccine in almost 2000 Australian children. The unpublished results showed that 424 of the 703 children aged 6 months to less than 3 years (60%) experienced any systemic solicited adverse event, such as fever, headache or myalgia, within 7 days of administration of the vaccine. Fever was reported for 201 children (29%), grade 3 fever was reported for 13 (2%), and one child had a febrile convulsion.10 Professor Collignon says these rates seem high, particularly when compared with the risks of influenza itself. “By my calculations, if more than one child in 1000 has a febrile seizure, the vaccine is doing more harm than good.” Another unpublished trial looked at almost 1500 children aged 6 months to less than 3 years who received a trivalent seasonal influenza vaccine during the 2009–2010 northern hemisphere winter. Among those allocated to receive a CSL vaccine, 37% experienced fever, compared with only 14% of those who received a US comparator vaccine.11 CSL did not receive the results of this trial until about a month after the adverse events came to light in 2010, but acknowledges their relevance. Additionally, the rates of paediatric fever seem to vary from year to year. A published Australian trial of CSL trivalent influenza vaccine found that among 151 children aged 6 months to less than 3 years, 22.5% experienced fever after vaccination with the 2005 formulation. This proportion increased to 39.5% among 76 participants who subsequently received the 2006 formulation. Among 272 children aged between 3 and 9 years, the rate of fever increased from 15.6% in 2005 to 27.0% in 2006, including one child who had a febrile convulsion.12 Surprisingly, only the 2005 data from this study were included in the PI for the 2010 Fluvax.13 Professor Collignon says this is concerning, and the TGA should require that the PI includes the most recent data. “It strikes me that the product information ought to reflect the latest data, particularly when the data show an increase in side effects compared with previous studies.” Dr Maher says the data from the 2006 season were not included in the PI because the increase in fevers seen in 2006 was not deemed “clinically substantial” at the time. “The fevers did go up in total, but they were mostly mild or moderate; there wasn’t a significant increase in severe fever”, he says. “But in retrospect, having had the events of last year and the results of the trial [comparing Fluvax with a US comparator], now when you look back on that data you think, well, maybe that was telling us something.” These results were not included in the 2011 Fluvax PI.14 However, Dr Maher says they will be added to next year’s PI. Unusually, for the 2010 southern hemisphere influenza season, , all three of the influenza strains were changed. “It happens every 20–30 years that all three are changed in one go. That’s something that we thought was a telling point in trying to understand what may have contributed to [the excess adverse reactions]. “Perhaps the way we make the vaccine is more inclined to cause fever in children, and maybe last year’s strain combination then tipped them over the edge and led to severe fevers and febrile convulsions. That’s our current thinking”, Dr Maher says. What went wrong?The 2010 seasonal influenza vaccine program was suspended almost 18 months ago, and there is still no definitive answer as to what caused the increased rate of adverse events. However, ongoing investigations by CSL and the TGA, in collaboration with the US Food and Drug Administration (FDA), the United Kingdom National Institute for Biological Standards and Control and other authorities, have identified a number of possible contributing factors (Box). One factor that is still under investigation, according to the TGA and CSL, is the way the virus was split during the manufacturing process. “That is still an element of intense investigation”, Dr Maher says. Split-virion vaccines, such as Fluvax, use a detergent or solvent to “split” the virus and inactivate it.13 A recent MJA report stated that CSL is one of only a few manufacturers worldwide to use deoxycholate as a splitting agent. Deoxycholate use has been linked to previous clusters of adverse events, particularly in Canada in 2000–2001.15 “We hypothesise that suboptimal virus splitting or other mechanisms relating to the use of deoxycholate may have played a role in adverse events linked to the 2010 CSL trivalent influenza vaccine”, the MJA authors said.15 Dr Alan Hampson, a virologist with over 40 years’ experience working with the influenza virus, says when it became clear that the febrile convulsions were linked specifically to the CSL vaccine, his first thoughts were that it was somehow related to splitting conditions. “The splitting process is what detoxifies the vaccine for young children”, says Dr Hampson, who is chairman of the Influenza Specialist Group. Dr Maher from CSL says his company used sodium taurodeoxycholate, a slightly different form of chemical from that used in Canada, and had been using the same splitting process for decades. “We have been doing it this way for a long time without a problem . . . nevertheless, it’s a hypothesis that has been included in our investigations over the past 18 months.” The FDA also raised concerns about the splitting process in a warning letter to CSL in June this year. “You failed to determine the optimal splitting conditions for new virus strains before the strains are used in production”, the letter stated.16 The FDA letter raised several other concerns. For instance, it states that some batches of sodium taurodeoxycholate failed identification tests but were still used, and that CSL failed to investigate the potential impact of these failed tests. CSL said these particular batches were not those used in the vaccines that caused the adverse events in 2010; however, they were still accepted for use. The FDA continues to work with the TGA to monitor CSL’s compliance on some of the issues raised in the letter. Rating the responseIn the aftermath of the 2010 influenza season, several experts and reports have called for improvements to Australia’s post-marketing surveillance system for adverse events following immunisation. Australia’s current system is based on state-by-state passive surveillance, which relies on voluntary reporting of adverse events. A review prepared for the Department of Health and Ageing by Professor John Horvath outlined the multitude of avenues for reporting adverse events and the variation between the states.6 “Each jurisdiction has its own report form, and data collection differs across the states”, he wrote. Professor Horvath called for improved governance and more timely reporting of adverse events, but said the system had several strengths. It “was able to detect the safety signal associated with the use of the 2010 seasonal influenza vaccine, take appropriate action and undertake a rigorous investigation”, he wrote.6 In contrast, a review prepared for WA Health by Professor Bryant Stokes, published in August 2010, described “a serious deficiency” in current adverse-event reporting mechanisms. Professor Stokes described the system as “confusing”, “not timely” and “cumbersome”.3 Dr Paul Effler, Medical Coordinator, Prevention and Control Program at WA Health, says Australia needs to develop a nationally consistent system because “denominators matter”. “Typically, adverse events for vaccines are so low that if you have a tiny denominator you won’t pick up the signal as fast as you could have if you had a large population.” In addition, he recommends the development of a prospective, active surveillance system. He says data from the Australian Childhood Immunisation Register (ACIR) — which collects information on all vaccinated children under 7 years of age — could be linked to medical records from some or all hospitals nationwide. For example, this system could detect if children were admitted to hospital for febrile seizures within a week or two of receiving a vaccine. “Australia is positioned to be the leader in vaccine safety with [the ACIR]”, he says. The Horvath report highlighted problems with the way the “denominator data” — the number of vaccines administered — was collected by the ACIR in 2010, which made calculating adverse events rates difficult. Nevertheless, Professor Horvath agreed that the ACIR dataset could prove “very useful in signal investigations”.6 The review also called for greater transparency of TGA investigations, to improve access to vaccine safety data. In the US, for example, adverse events data that are reported passively are available online to the public in deidentified form. Dr Effler says he finds this amount of openness “refreshing”. “It also inspires confidence because people think, ‘well they’re not hiding anything’.” Professor Collignon from the ANU also calls for the establishment of an active surveillance system and says it is particularly important for influenza vaccines. “The vaccine changes its formulation each year. And for people who say, ‘Oh well that doesn’t matter’ — look at the CSL vaccine problems. It shows that it does matter.” “The trouble with a passive surveillance system is that it takes a long time to find a problem and it really underestimates the size of the problem”, he says. He suggests that, for example, 50 to 100 general practitioners around Australia could be paid to collect data on the first 200 patients they vaccinate each season, through a system funded by a levy on vaccines. Patients and their families could keep a diary of any adverse events experienced within 7 days of receiving the vaccine. “You would suddenly have a lot of data, without really a huge expense”, he says. Some changes to Australia’s adverse-event reporting system have been made since 2010. The TGA now reviews adverse events reports weekly (rather than monthly), and state and territory health departments are provided with a weekly summary of adverse events related to their jurisdiction. A working group has been established to move towards implementing the Horvath report’s recommendations. “In addition, work has commenced on refining case definitions and standardised reporting between the TGA and state and territory health departments”, said a TGA spokeswoman. This year, the TGA required that CSL conduct active surveillance of Fluvax among children, which is almost complete. As the vaccine was not licensed for use in children under 5 years of age, and was not recommended for use in children aged under 9 years, there were very little data in these age groups. However, CSL says that no safety signal has been detected among children aged between 9 and 18 years, or among adults. In WA, a new website was launched before the start of this year’s influenza season, allowing health providers and the public to directly report adverse events online. Dr Effler says a very low rate of adverse events was recorded on the website in 2011. “We could reassure the public and providers that things were different this year.” Restoring confidencePerhaps the biggest legacy of the 2010 influenza season is diminished public confidence in vaccine safety. However, experts emphasise that the serious adverse events have been clearly linked to one manufacturer’s vaccine, only in children aged under 5 years, and that that vaccine is no longer indicated for use in this age group. Dr Alan Hampson says the episode has “absolutely not” shaken his confidence in the importance of seasonal influenza vaccination. “We really shouldn’t be asking the question of whether the paediatric influenza vaccine program is valuable: that’s a given . . . to confuse the overall program with that one-off event is counterproductive.” Dr Effler from WA Health believes that improving adverse events surveillance is one way of building public confidence in what is usually a very safe and effective program. “Advocating for robust adverse events surveillance, to me, doesn’t imply a lack of confidence in vaccines. Really, it’s the other way. We want adverse events surveillance because the vast majority of times it will show that there’s not a problem . . . it ultimately builds confidence in the vaccine programs”. In the end, though, it is unlikely there will be much confidence in CSL Fluvax until there is a clear explanation of what went wrong. As Professor Collignon says, “If you don’t know what the problem is, how do you fix it?” At this stage, CSL is not making any promises about when — or even if — the vaccine will be available to children aged under 5 years in the future: “At the end of the day, if there’s not a resolution, it wouldn’t be responsible for us to market the product for that age group”. The investigation continues . . . The Therapeutic Goods Administration says it is likely that “a matrix” of factors contributed to the increased adverse events seen in 2010. These areas are under ongoing investigation by CSL Biotherapies and the TGA: Splitting: The possibility that the way the virus was “split” during manufacture contributed to the adverse events has not been resolved. Neuraminidase: CSL’s 2010 Fluvax appears to have more neuraminidase activity than the 2009 Fluvax and other 2010 influenza vaccines. Proteins such as neuraminidase are thought to play a role in the pyrogenicity of vaccines. However, the TGA says no direct causal link has been established and CSL says it has almost completely ruled out the neuraminidase hypothesis, because there was no significant difference in the amount of neuraminidase in its vaccine compared with comparators. Cytokine release: CSL’s 2010 Fluvax has been found to stimulate certain cytokines, known to be associated with pyrogenicity, to higher levels than competitor vaccines. CSL has conducted numerous in vitro experiments to try to explain this, and has made special lots of vaccine with engineered changes to examine which strains were causing the cytokine release. Studies have also been conducted in a host of animal models such as rats, ferrets and primates, and using gene-chip technology to examine cytokine genes.

Sophie McNamara

War and Medicine. Canadian War Museum, Ottawa, Ontario, Canada 27 May to 15 November 2011. Medicine is, and has always been, the ambiguous, uncertain and reluctant handmaiden of war. Nowhere is this more evident than in “War and Medicine”, an impressive collaborative effort between the Wellcome Collection, London, and the Deutsches Hygiene-Museum, Dresden. The exhibition was developed to better understand the role of medicine and its practitioners in the context of war. It reminds us that the involvement of medicine in armed conflict is not straightforward. Medical staff and their patients are put in difficult situations, which potentially compromise the main objectives of patient care, but which have resulted in important medical advances for everyone. Wounded World War I veterans sit outside the Orthopaedic Military Hospital and artificial limb factory in Toronto. Some veterans informally called the intersection of Davisville Avenue and Yonge Street, “Whizz-Bang Corner”, after a similarly named spot on the Western Front. The streets of Toronto were not nearly as dangerous, but veterans had new challenges to face as they reintegrated into postwar society. A war record. Painted by Stanley Francis Turner. Beaverbrook Collection of War Art. CWM 1970261-0766. Image and caption courtesy of the Canadian War Museum. The exhibition, covering 300 artefacts and taking 3 hours to view, is currently showing until 15 November 2011 at the Canadian War Museum in Ottawa (http://www.warmuseum.ca/medicine), a city chosen in the 19th century to be capital of Canada as much for military, strategic and tactical purposes as anything else. The exhibition is also strategic — the Wellcome Trust and the Hygiene-Museum both have a mission to get the public to think of science (and medicine) as a cultural phenomenon. The intersection of war and medicine provides an ideal opportunity to explore this issue, which transcends the history between two former adversaries in the 20th century. Frequently graphic, the material for the exhibition is wide-ranging and simply explained, and highly effective for that reason. There are diaries, manuals, highly crafted portable surgical toolkits used by the “sawbones” (somewhat eye-watering, given their intended use), Florence Nightingale’s charts documenting epidemiological patterns in military hospitals, educational (and sometimes propaganda) film footage from times long gone, pathology specimens and anatomical casts, artwork and photographs of traumatised soldiers, and army issue boots and clothing torn through by shrapnel and mortar. The totality of the exhibits gives a solid sense of how medicine in war evolved from the “four humours” theory of health and disease through to the application of modern medicine. Timely care, the systematic use of evidence-based knowledge, and a more inclusive view, akin to that of humanitarian relief, of the physical and mental effects of war for both combatants and civilians are issues now integral to military medicine. This evolution has occurred in tandem with the development of warfare from fighting at close quarters by massed forces in squalid environments, through to present-day, remotely conducted military assaults, and asymmetric warfare against adversaries dispersed in civilian populations or in exposed or difficult terrain, such as the current conflict in Afghanistan. Medicine in the war zone has also had to adapt to novel, sometimes unconventional, military technological developments in transport, weaponry, personal protection, communications and intelligence, as well as incorporating advances in medicine. In many senses, military medicine, because of the unique conditions under which it operates, is at the forefront of clinical practice. The exhibition successfully conveys the essential tensions that pull at military medicine. Doctors in the war zone concentrate on applying science-based skills to the patient in front of them. After all, they are there to provide help, and, in war, there are so many who need it. Why would doctors not be there? However, at the same time, the role of medical personnel, though committed to the principle of “do no harm”, is to work within an environment where (mostly) men deliberately and systematically try to kill each other. To what extent are doctors, by extension, involved in acts of war, where military objectives may run into professional and moral duty? Is a doctor a witness, a participant or an advocate in the context of war and its casualties? May ethical and professional compromises be the price to pay for the undeniable advances in medical care these doctors make? These questions prompt us to try to make sense of how doctors and the medical system work with and within war, and how the practice of medicine is consequently changed. An exhibition such as this is vital to enable us to think through these issues. “War and Medicine” sensibly organises the issues into three strands: the system (how medical care is organised at the battlefront), the body, and the mind. At all of these levels, it reminds us that important innovations in medicine and health care, which we now take for granted, took place during wartime. In the 19th century, Florence Nightingale acted to curb mortality in the Crimean War. Wars in the 20th century have given rise to many surgical procedures (in particular, those in orthopaedics, plastic surgery and neurosurgery) and the techniques of physical, psychological and social rehabilitation following disfiguring injuries and procedures. The terrible psychological consequences of war recognised by the military doctors led to more general recognition and management of post-traumatic psychiatric syndromes in both serving personnel and civilians, where trauma does not necessarily occur in armed conflict. The C-Leg, a computerised leg invented in 1987 by Canadian engineer Kelly James, is a modern example of a prosthetic leg that mimics the normal human gait. Developed by Otto Bock HealthCare, the C-Leg uses sensors, a microprocessor in the knee joint and hydraulics to adjust to different terrain. It was first issued to injured Canadian military personnel in 2006. Photograph courtesy of Otto Bock HealthCare Canada Ltd. Caption courtesy of the Canadian War Museum. However, medicine’s involvement in war has been a double-edged sword. Medicine in war has helped countless soldiers and civilians, and has contributed to advances in medical understanding (Box 1), but at the same time, there have been many untoward consequences. As a result of the military’s tight control of information, relatives at home have never known for sure about the welfare of an injured family member at the front. The focus on military operations has meant that compassion for casualties and their families has often been neglected by the military, and medical staff have not been able to intervene. Then there is the unintended or unavoidable harm of medical procedures, with its attendant ethical issues, and — notoriously — the experiments that doctors in wartime performed on unwilling or unknowing subjects. Did the original members of the Guinea Pig Club (Box 2) — the self-named personnel in World War II who received novel pedicle flap grafts to treat extensive facial burns — think their surgeons were treating them, experimenting on them, or both? What counted as consent, and what do we make of their black humour about the surgeons’ work? It is true that the sheer extent of casualties in war, the need to develop medical strategies in response, and the pressures that medical staff work under to give their patients a chance, provide an important laboratory for significant medical innovations and lessons that apply well beyond the battlefield. But equally, some medical procedures are a warning of unintended consequences, and of the areas where medicine should not go. In some respects, “War and Medicine” may seem incomplete for the Australian audience. It is significantly contextualised for Canada, with about half the artefacts coming from Canadian archives. For an Australian audience, this necessary adaptation of the themes to the Canadian audience unavoidably leaves some holes. There is not as much coverage of issues such as Agent Orange, and how medical care was organised in tropical environments. In contrast to Canada, Australia’s military has had to respond to incidents on home soil or nearby — the bombing of Darwin in 1942, the numerous natural disasters in Australia, bombings in South-East Asia. Australian medicine has learned substantially from these events, and one wonders, were this exhibition to make it to Australia, how the curators would attempt to provide the local perspective. Any travelling exhibition has a personality of its own and evolves in some way. How would an Australian contribution change this exhibition? Another difficulty is that the exhibition does not flesh out the contemporary practice of medicine in war as well as it does that of the past. Yes, we do see footage of a British soldier with a penetrating chest injury being helicoptered out of Afghanistan with a medical evacuation team, and the detail of the Canadian Army’s medical equipment kit, but one feels that something is missing to gain a good overall understanding. Maybe time is needed to develop the required perspective. Or perhaps military organisations have not made all medically relevant information available to the exhibition organisers. Modern medicine thrives on information sharing, and such filtering of information runs counter to good medical practice. In this situation, how can civilian and military medicine fully help each other? Do the wishes of medical staff to freely share medical information come a poor second to military security? Does medicine have to be the handmaiden of war in this way? Despite these minor shortcomings, “War and Medicine” offers an important and rewarding experience for any doctor. It is a reminder that much of what we take for granted in modern medicine came into existence at times when humans and societies were at their worst. It reminds us of the difficult ethical issues that medical staff face in the field, but also of their lasting innovations. There is still much to be done for medicine to keep up with the ways in which warfare evolves, and to bring our better nature to bear on a nature that we would rather did not exist. 1 Medical advances during wartime or as a result of war* Humanitarian and disaster relief: The International Committee of the Red Cross was founded in the 1860s by Jean Henri Dunant, who was horrified by the casualties of the Austro–Sardinian War. French Red Cross doctors who had worked during the Nigerian Civil War in the late 1960s created Médecins sans Frontières. The concept of the blood bank was pioneered by Oswald Hope Robertson while he served with the United States Army Medical Corps in 1917 in France. World War II was the spur for the mass production of penicillin to treat injured soldiers. Initially, stocks were so precious that all urine from the first few patients was collected to recover the penicillin for reuse. The US MASH (mobile army surgical hospital) units developed in World War II and the Korean and Vietnam wars greatly influenced the management of trauma in civilians. In the 1970s, US Vietnam War veterans, with the support of psychiatrists, successfully persuaded the American Psychiatric Association to recognise post-Vietnam syndrome (later renamed post-traumatic stress disorder) as an illness. * Information sourced from the “War and Medicine” exhibition media site (http://www.warmuseum.ca/medicine). 2 The Guinea Pig Club* This club was originally formed out of Allied airmen in World War II who had suffered severe burns, and who were treated by New Zealand surgeon Sir Archibald McIndoe by (often multiple) reconstructive surgical procedures. These procedures (such as the walking-stalk skin graft) were new and were developed, along with specialised equipment, at the Queen Victoria Hospital in East Grinstead in the United Kingdom. Initially a “drinking club” at the hospital, the Guinea Pig Club eventually became dedicated to the psychological and social rehabilitation of patients, which was novel at the time. The club is still active and meets annually at East Grinstead. * Information sourced from the “War and Medicine” exhibition media site (http://www.warmuseum.ca/medicine).

Astika Kappagoda

What can we do to avoid discrimination against the obese? A few years ago I had the pleasure of tutoring groups of medical students in their communication course. One topic on the syllabus was discrimination — an opportunity for the students to reflect on their own potential biases. During these sessions I discovered that most students could overcome racism, homophobia and religious prejudice quite readily, but had considerable difficulty in being non-judgemental about Australia’s most prevalent health condition: obesity. In an effort to help my students, I would recount the following anecdote. In the 1980s, I worked in a small endoscopy facility that employed some nurses who were significantly obese. One of these nurses, whom I shall call Janet, was not normally especially friendly to patients. One day I was struck by a particular encounter. A patient was wheeled in, on an extra wide trolley — a patient with morbid obesity. Janet started to stroke the patient’s forehead and call her “dear” and “darling” in the gentlest tone of voice. I had never seen Janet so compassionate before. This made me realise that Janet herself must have experienced negative attitudes from health professionals. My students have now graduated and will be fine non-judgemental doctors, I hope. But discrimination against obese people in health care settings is still common. Take this example from a blog written by “Midlife Midwife” in the United States: I have to admit. I have a hard time emotionally with severely overweight people ... I have to really work at not being judgmental of them. I get a sinking feeling in my stomach and frustration bubbles up into my chest when I see a patient’s weight is over 250 pounds. I have to really work to put on my smile and be as kind as possible.1 Midlife Midwife goes on to discuss the technical difficulties of doing a Pap smear, including lack of appropriate specula, in obese women. The negative attitudes held by Midlife Midwife have been shown to be held by a large percentage of doctors, students, nurses and others.2 Overweight people suffer inferior care, negativity and even ridicule, and they become reluctant to access health care. They are then at risk of further deterioration in health. Critical attitudes and stigmatisation of obesity do not make weight reduction more likely — in fact the reverse is true. Discrimination has been shown to lead to worsening of unhealthy eating patterns. Conversely, it has been shown that empathy enhances weight reduction. Overweight people are now claiming the moral high ground. There is a fat acceptance movement, which has spawned various societies, such as the International Size Acceptance Association. However, critics of the fat acceptance movement aver that societal acceptance of obesity will reduce the aspirations of the community to lose weight. If I were tutoring medical students today, they might ask: what do we do? Do we treat obesity as a disease or simply a physical attribute? If we overcome our prejudices and show empathy, are we normalising obesity? To help in my answer, I might reflect further on my own practice. Over the years I have seen many patients with non-alcoholic fatty liver disease, and so counselling on weight reduction has become part of my bread and butter (thin scrape only!). I think I have been able to empathise with the patient without normalising obesity — obesity is a chronic medical condition. Fat acts as a huge metabolic organ, producing cytokines that cause symptomatic bad health. I have learned that if you add a few E-verbs to a good spoonful of Empathy you will help your patient achieve weight loss. The mix should include some Empathising, some Evoking of the patient’s reasons to change, a good helping of Enabling (with simple strategies such as a daily walk), some Educating and some Empowering the patient to take control, all while Enjoying the collaboration. If you work with your patient as a team — acting as an ally and an Equal (the final E-word) — you will have a great recipe for success. Midlife Midwife may have learned a thing or two from one of the responses to his or her blog: Maybe speculums should be made to fit the people who need them. And maybe fat people are human enough to KNOW that you don’t like them and that you automatically think less of them, and that’s why many would rather go for years without medical care than subject themselves to a snotty, superior attitude and knowing that they’ll be snickered at behind their backs. Oh, and my husband has no trouble finding where to put the “speculum” in, and I’m 350 lbs. And I regularly walk 5 miles for the hell of it. Put that in your pipe and smoke it.1 Yes, a daily walk is good for everyone — but the most important walk for doctors is the walk in our patients’ shoes.

Katrina J R Watson MB BS, FRACP, MPH

Respiratory disease. From advanced disease to bereavement . Anna Spathis, Helen E Davies, Sara Booth. Oxford: Oxford University Press, 2011 (297 pp, $58.50). ISBN 9780199564033. There is no shortage of material in the medical literature on the latest advances in technology. So when a book comes along in which the emphasis is on the palliation of symptoms in patients with advanced lung disease, my first thoughts were that this is a publication that will meet an unmet need. All three authors are specialists based in the United Kingdom. Spathis is a consultant in palliative medicine, Booth has developed a breathlessness intervention service and Davies is a specialist registrar in respiratory and general medicine. So, what does this book bring to our understanding of this subject? I suspect that readers will be both satisfied and frustrated by this offering. The most frustrating aspect is that these descriptions are often very short on detail and not particularly relevant to the Australian medical scene. For example, the section on lung cancer makes no mention of PET (positron emission tomography) scanning in staging. In the section on cystic fibrosis no mention is made of the use of either macrolides or nebulised hypertonic saline. The description of advanced lung diseases is followed by a discussion of the management of the common symptoms of severe lung disease. Overall, this section is far more useful for clinicians, with clear-cut recommendations regarding the investigation and management of pain, dyspnoea, constipation, mood disturbances and sleep disturbance. However, even this section is frustrating in parts. We are regularly told that health professionals are good neither at predicting prognosis nor at discussing it with patients. The authors make unsubstantiated, unhelpful statements such as: “Anecdotally patients prognosticate more accurately than health care professionals, and those that verbalize suspicion of a short prognosis are often correct”. I find such statements of limited use in clinical practice. I would have found this book more useful if it had concentrated on the palliative care aspects rather than on an incomplete description of advanced lung diseases. A bargain at $58.50? I don’t think so.

David J Barnes

Understanding troubled minds. A guide to mental illness and its treatment . Sidney Bloch. Melbourne: Melbourne University Press, 2011 (371 pp, $39.99). ISBN 9780522857542. This is a new version of a similar volume published over 10 years ago (The foundations of clinical psychiatry), co-edited by Bruce Singh and Sidney Bloch. The influence of the original work can be seen in the coverage of standard psychiatric topics — the history of psychiatry, perspectives of understanding mental illness, the work and role of psychiatrists, stress and coping, clinical syndromes, special clinical populations, drugs and physical treatments, psychotherapies, mental health promotion and ethics — and, perhaps, in the practitioner-centric view of the field. Since that first edition, much has happened in the field of mental health. This progress (and, in some instances, backsliding) has been included in the current volume, which has Bloch as sole author. Bloch is emeritus professor of psychiatry at the University of Melbourne and an honorary consultant psychiatrist at St Vincent’s Hospital, Melbourne. He is a respected academic with a wealth of clinical experience in adult psychiatry and psychotherapy, and in the role of ethics in psychiatric practice. It would be difficult to find a colleague with better qualifications to author a book of this nature. But this is not a textbook. It is a guide to mental illness for the general public, and for patients, their families and friends. The single authorship has allowed Bloch the opportunity to add valuable personal insights and experiences to the text. Indeed, this is one of the most enjoyable aspects of the book. He uses literature and art to illustrate ideas and clinical phenomena without overwhelming the basic narrative of describing mental illness and its treatment. The level of language used requires a relatively sophisticated readership; probably one with at least secondary-level education. The book will fill a gap in providing authoritative information about mental illness for patients and concerned individuals, as well as for non-clinical workers and government and non-government agencies in the mental health area. I can see it being used in general practices, and in the libraries of community service providers and advocacy agencies. The price is modest and should not be a barrier to access. Understanding troubled minds is a valuable addition to the literature on mental illness, aimed at the educated layperson.

Philip L P Morris

Hardworking rural doctors make an unrecognised but large difference During my career as a city-based gastroenterologist, I was fortunate to make many trips to Victorian country towns to give educational talks. I often met inspiring people, and one of these was a senior country surgeon on the verge of retirement. This is his story. The older surgeon and I had been chatting with a younger surgeon, new to the town. The new surgeon had proudly told us about the lovely home he had just purchased, some 2 kilometres from the local hospital. The older surgeon sighed and confided to me that he would never have been able to live so far from the hospital, but had always lived within 500 metres because he often had to get to the hospital quickly. He had taken almost no holidays in 35 years of practice because there was rarely anyone to cover his absence. The surgeon gave me an example of his lifestyle over that time. One Easter Thursday he was having his first mouthful of dinner, thinking it was quiet and that he might even get a rest over the Easter break. The phone rang — a multiple-car crash had occurred on the Princes Highway, with a couple of fatalities and several casualties — and that was his Easter gone. He tried to send the patients with head injuries to Melbourne. He rang four hospitals and gave the same details to four admitting officers, to be told four times that there were no beds for them. So he managed the head injuries as best he could, together with all the other injuries, and spent most of his Easter in theatre. The city folk all survived, and were eventually transferred to city hospitals. There were no thanks and no chocolates. In fact, he said he could not remember ever receiving a thankyou letter from any city-based patient. A couple of years later, a trauma helicopter service was introduced and he was informed most decidedly, in a castigatory tone, that he must never manage any neurosurgical patient again. There was no thankyou for past services. I knew this surgeon had an outstanding local reputation for dedicated, expert and compassionate care, but such a reputation would not have carried much weight with city doctors. He had known the limits of his expertise, and had asked for help when appropriate, but often had not received it. His story moved me profoundly. It reminded me of an event from my distant past, when I was a first-year intern in another Victorian country town, on rotation from a city hospital. There were two of us interns, and we thought we were pretty smart. We also thought all the local general practitioners were basically hopeless — they could not read echocardiograms, knew nothing about electrolytes and prescribed old-fashioned drugs. One Sunday morning I was in the shower about to wash my hair, having been in the wards most of the weekend, and my beeper went off. I grudgingly got out of my shower. “It’s the children’s ward; Jason doesn’t look too well; he’s had diarrhoea all weekend.” I wanted to wash my hair and knew I would not get a chance for the rest of the day, so said I’d be there shortly, and continued washing my hair. My beeper went off again: “Jason doesn’t look too well at all,” and I thought “What a nuisance, I’m not even dressed.” Jason was a thin, pale child aged about 5 years who seemed to have been in hospital for weeks, appeared to have no proper family, was always sniffly and was frequently being treated for head lice or scabies; he was none too adorable. Then a third page sounded: “You’d better come right away, Jason has collapsed.” I hurried to the hospital and ran to discover a cold, clammy, blue Jason with a thready pulse and no detectable blood pressure. I panicked: I tried butterfly needles in his hand and in his foot, but it seemed there were no accessible veins. “Should we call Dr Jones?” asked the nurses. “Yes!” I squeaked in desperation. Fortunately, Dr Jones (one of the “hopeless” local GPs) was close by. He did a cut-down in Jason’s cubital fossa, found a vein and ran some fluid in. Jason started to pick up with a bit of saline: his blood pressure became recordable, he opened his eyes, and suddenly seemed quite adorable after all. He lived. I learned many lessons from that episode: that I should always trust the nurses and respond quickly to their call for help; that I, in turn, must ask for help quickly when I need it; that looking after someone engenders love; and that country doctors actually do know quite a lot. So, what of the senior country surgeon? I hope he is happy and relaxed in retirement. Many people owe their lives to him — not only country people, but city people who have been scraped off the roads into his care. I sent a summary of his life to the staff of Australian story (ABC Television), suggesting that he would be a great subject for the program. They never wrote back. Maybe they didn’t think it was much of a story after all.

Katrina J R Watson MB BS, FRACP, MPH

Peter Schmidt was born on 29 December 1922 in Beaudesert, Queensland, where his father managed a sawmill. He was the youngest of three children. Peter attended St Joseph’s Nudgee College in Brisbane and studied medicine at the University of Queensland. After graduating in 1945, he took up residency at the Mater Hospital in Brisbane. In 1948, he established a general practice in Greenslopes, Brisbane, which he maintained until he fully retired in 1996. Peter had a long association with the Queensland Faculty of the Royal Australian College of General Practitioners (RACGP). In 1967, he became a member of its Board, where he served for over 20 years. In 1970, Peter gained Fellowship of the RACGP. He served on the medical education committee, was Chairman of the courses committee for several years before the formation of the Family Medicine Programme in 1974, and was elected Chairman of the accreditation committee, a position he held with distinction until 1997. From 1975 to 1996, Peter was Director of the postgraduate medical education committee of the University of Queensland. The Australian Medical Association acknowledged his services to medicine when he was elected to Fellowship in 1984. In 1993, Peter was awarded a Medal of the Order of Australia, in recognition of his services to postgraduate medical training and to his local community. Peter died on 18 June 2011. He was predeceased by his wife Fay and is survived by his children Peter and Mary.

John A Comerford

Fast facts: brain tumours. 2nd ed. Lauren E Abrey, Warren P Mason. Oxford: Health Press, 2011 (143 pp, $19.50). ISBN 9781905832873. Brain tumours are the cause of the greatest loss of life-years per person from any cancer, but account for only 2% of all cancers. The first Australian Guidelines were published only in 2009. There is overwhelming consensus that brain tumours should be managed by a dedicated multidisciplinary team of neurosurgeons, medical and radiation oncologists, and nursing, social work rehabilitation and palliative care specialists. It is not clear who needs Fast facts. The authors, a neurologist and medical oncologist from major oncology centres in North America, have written it in a style that is only suitable for clinicians. Specialists will not find much that is new. Allied health practitioners new to neuro-oncology and medical students may be interested in a concise précis of current practice for the modest price of $20 but may prefer the Australian Guidelines, which are more detailed and are available for free from the Cancer Council Australia website. A version of the guidelines has been written for patients and carers. Fast facts discusses epidemiology, diagnosis and treatment and includes chapters on the more common types of brain tumours; however, rehabilitation, palliative care and supportive care are not covered. Brain tumour patients are rarely fit to drive, yet this important restriction is not mentioned. Older people are frequently undertreated because of concerns about their prognosis. The authors recommend treatment strategies based on the fitness of the patient rather than their age. The standard of illustration is good with many images of a wide range of clinical conditions. Brachytherapy, a disproved technique, is illustrated but radiosurgery is not. References are lacking but further reading is given at the end of each chapter, although some of the readings are over a decade old. The management of brain tumours should not be in the hands of those who need to fill gaps in knowledge “fast”. It is a complex and difficult area best managed by expert multidisciplinary teams.

Michael B Barton

Gambling and diagnostics are related, but strangely reversed, in the way that prior events can affect our clinical judgements The year was 1913; the location, the roulette tables of a Monte Carlo casino. For the previous 10 spins of the wheel, the ball had landed on black. A red was overdue, so the punters began to bet more aggressively against the trend. But the 11th spin produced yet another black number. As did the 12th, and the 13th ... and the longer the run of blacks continued, the more convinced the gamblers became that the subsequent spin would yield a red. Their wagers accelerated. Their losses snowballed. For it was only after 26 consecutive black numbers (by which time few could afford to continue betting) that the streak finally came to an end. It was perhaps the most profitable night in the casino’s history: records were set, fortunes were lost, and the “Monte Carlo fallacy” was born. Also known as the “gambler’s fallacy”,1 it describes the erroneous belief that the outcomes of recent random events have some bearing on future random events. It dictates that if a flipped coin yields 10 consecutive heads, then the likelihood of a subsequent tails is increased, because the coin seems “due” for a tails. Intellectually, we know this law of averages makes no sense: a coin has no memory, so every time it is flipped, there is an equal chance of either side appearing face-up, regardless of what happened on previous flips. Certainly, the odds of flipping heads 10 times in a row are remote — one in 1024, to be exact — yet this number also represents the odds of having any other pattern of heads and tails in a 10-flip series. Although we know this to be the case (undoubtedly, so too did many of the gamblers on that night in Monte Carlo), it is all too tempting to disregard the laws of probability and be seduced by pseudologic. In our clinical practice, it is similarly easy to be fooled by apparent patterns, and unduly influenced by any recent experiences that remain prominent in our minds.2 However, for clinicians, the Monte Carlo fallacy seems to work in reverse: rather than a string of similar events prompting us to think we are “due for a change”, we may instead feel that the “run” is more likely to continue. For example, if, within a short space of time, two patients presenting with hypotension are found to be hypoadrenal, then it may be tempting to look for this unusual diagnosis in all future hypotensive patients, even though other diagnoses may be more common, more likely, and easier to diagnose without expensive investigations. If a patient has a fall while in hospital, and then dies unexpectedly from an unidentified intracranial bleed, we may feel compelled to request a brain scan for any subsequent patient who has such an accident. We may do this even when the patient appears unhurt, and our clinical judgement would otherwise suggest that such a test is not indicated. While the outcome for the first patient was tragic, it in no way affects the likelihood that a second patient’s (unrelated) fall will also have life-threatening complications — just as the first 25 black roulette numbers had no bearing on the outcome of the 26th. Our approach to any clinical situation is guided by the accumulation of our previous experiences, but somehow the most recent ones seem to bear the most weight. Ultimately, we are human, and humans are pattern-seeking creatures. We see faces in amorphous clouds, and stars scattered across the night sky form images before our eyes. And to this pattern-seeking ability we owe much of our understanding of medicine: the linking of infection outbreaks to geographical areas has identified sources of contamination, and the observation of disease trends has revealed unrecognised side effects of drugs. A great deal of our knowledge today has been acquired through observing the unusual, the unexpected and the uncommon, and continuing to do so will certainly teach us more. However, in day-to-day clinical medicine, the old maxim rings true: common things occur commonly.

Alexander M Owen MB BS(Hons), BSc(Med)Hons

Readers who may contemplate referring patients to practitioners of complementary medicine may be interested in the fate of Dr Frederick Axham. He was an English anaesthetist, who was struck off the medical register for medical malpractice in 1911 at the urging of the General Medical Council, having been found guilty of “covering” (ie, professionally assisting a person not on the medical register). Axham had — despite dire warnings — anaesthetised eight patients of Herbert Barker, a renowned bone setter (now a lost art), who had successfully set and stabilised the complex fractures of seven of these eight patients whose fractures had been found to be inoperable by a number of eminent surgeons. Axham, who died in 1926 aged 86 years, still deregistered, was posthumously rehabilitated when the medical faculty of the University of Edinburgh made him a Licentiate of the Royal College of Physicians some weeks after his death.1 The whole affair caused a huge outcry throughout England, leading to a petition to Lambeth Palace, the residence of the Most Reverend Lord Randall Davidson, Archbishop of Canterbury, to make Barker a Doctor of Medicine, in reliance on the Ecclesiastical Licences Act 1533 (25 Henry VIII, c 21). The petition included not only leading members of the aristocracy, but, more importantly, Sir Henry Morris Bt, former President of the Royal College of Surgeons, Sir Alfred Downing Fripp, “Surgeon in Ordinary” to King George V, Sir William Arbuthnot Lane Bt, consulting surgeon to Guy’s Hospital, and physician Sir Bruce Bruce-Porter, all testifying to Barker’s coampetence. It also led George Bernard Shaw to write: Until the General Medical Council, which at present exhibits every constitutional vice that a trade union or professional association can have, is completely reformed by its legal constitution, we shall continue to hasten more and more precipitously to the not far distant day when the vogue of the unregistered practitioners, already very great (Mr. Barker is only a specially famous example of a large and growing body), will become so irresistible that the registered will be shunned by the public and driven to earning a scanty wage by signing death certificates for their unregistered employers.2 Alas, the Archbishop declined to award the degree. A press cuttings file at Lambeth Palace (Davidson’s Papers Vol 404, page 110) shows that he stated on 21 June 1920: The legislation which limits registration to men qualified by the ordinary professional training expressly, and I think rightly, provides that the status acquired by registration is not given by the Degree which the petitioners invite me to confer on Mr Barker.2 In frustration, King George V did the only thing he could do, which was to make Herbert Barker a knight of the realm. Sir Herbert continued bone setting till he died in 1946. Medicine. An Illustrated History

Paul Gerber LLB, DJur

Ken Paver was an outstanding dermatologist with broad vision and a remarkable ability to get things done. To paraphrase one of his maxims, Ken had great ability to which he applied a lot of effort. He was born in Kensington, Sydney, on 24 May 1920 and grew up in Mosman. After gaining his Intermediate Certificate in 1933, he left school to work at an insurance firm to help his family, because his father suffered from debilitating rheumatoid arthritis. During World War II, Ken served as a Private and then Captain in the Coastal Artillery. After the war, Ken studied medicine at the University of Sydney, where he met Elaine Kerr. They married in 1948 and graduated together in 1952. In 1953, after a year of residency at Royal North Shore Hospital, Ken joined a general practice at Merrylands. While working as a general practitioner, he obtained membership of the Royal Australasian College of Physicians (RACP). He received his Diploma of Dermatological Medicine in 1964 and was subsequently awarded the medal of the New South Wales branch of the British Association of Dermatologists. He gained Fellowships of the Australasian College of Dermatologists in 1966 and the RACP in 1971. Ken established a successful private practice in dermatology at Blacktown and was appointed Honorary Dermatologist at St Vincent’s Hospital, Sydney, where he was Chairman of the Department of Dermatology from 1966 to 1975. In 1978, Ken’s drive and momentum led to the establishment of the Skin and Cancer Foundation Australia, of which he was the first Chairman. He was appointed a Member of the Order of Australia in 1988. In 1989, Ken retired to the NSW Central Coast. He became a keen woodworker, an Associate of the Securities Institute of Australia and, in 2005, a Fellow of the Financial Services Institute of Australasia. He also acquired a Bachelor of Arts in sociology and worked on writing the history of the Skin and Cancer Foundation Australia. Ken died on 18 March 2011, and is survived by Elaine and children Graham, Rob, Phil and Cathy.

William Regan

Understanding and responding to pharmaceutical promotion. Mintzes B, Mangin D, Hayes L (editors). Amsterdam: Health Action International Global and World Health Organization, 2010 (online, free). THIS BOOK is a collaborative project by Health Action International Global — an organisation based in Amsterdam and committed to promoting the rational use of medicines — and to increasing access to essential medicines, and the World Health Organization. The editors (Barbara Mintzes, Assistant Professor in the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada; Dee Mangin, Director of the Primary Care Research Unit at the University of Otago in New Zealand; and freelance scientific editor Lisa Waller-Hayes) all have a background in writing about pharmaceutical promotion. Information on the influence of promotion on medicine use is often lacking. This book is an attempt to remedy this by bringing together studies on various aspects of promotion, including medical journal advertisements, sales representatives, conference sponsorship, physician opinion leaders and direct consumer advertising. There are contributions from many countries including Australia, a world leader in promoting the rational use of medicines. Health professionals are the target of aggressive and sustained promotional pressure by the pharmaceutical industry but are often not sufficiently educated about understanding and responding to such promotion. This book is intended to fill this gap, and it does so admirably. It also teaches readers the importance of using unbiased sources of information. It has been designed as part of a student module on pharmaceutical promotion, but the easy-to-read style incorporating pictures, graphs and well designed boxes and logical organisation ensures that it can be read on its own. I am currently using it to conduct small-group activity-based teaching sessions for second-year students and consider it superior to other initiatives I have used. I especially liked the chapters dealing with pharmaceutical sales representatives and how to avoid the “pharmaceutical industry tango”. The references at the end of each chapter are comprehensive, and numerous web links are provided. However, it lacks an index. The book can be freely downloaded from the Health Action International website (www.haiweb.org) and is sure to be of interest to all health professionals.

P Ravi Shankar

A city specialist consulting in the country ponders the tyrannies of life, including health care, in the bush One of the many privileges I had while in clinical practice as a gastroenterologist was to work in the country. I consulted and did procedures in the beautiful regional city of Bairnsdale — in East Gippsland, about 3 hours’ drive from Melbourne — for 2 days in 1 week every month, for several years. The secretaries in my rooms in Melbourne used to dread my “Bairnsdale weeks”, because I would leave the office with a large suitcase half-full of files, and return with the same suitcase completely full of files, plus multiple dictation tapes. They also dreaded the letters, which were very long because they usually contained detailed information about the patients for the referring general practitioners, so that much of the management of the patients could be done without the need to see me again, given that I was not in Bairnsdale full-time. Bairnsdale is a lucky town when it comes to medicine. It has an outstanding collection of GPs, many of whom have worked in developing countries, so they have excellent skills in anaesthetics and obstetrics which they are keen to maintain. They are empathic, compassionate and strong advocates for their patients. Bairnsdale has a few specialists of its own, and used to have an unusually strong program of visiting specialists. But the Bairnsdale visiting specialist program has been cut back severely. People can get to the city, can’t they? Just give them a subsidised train fare. Apparently it is better to make 60 patients travel a 600 km round trip, rather than just one doctor. On my drives back to Melbourne I would have the feeling that I had done more good in 2 days’ regional practice than in a month of city practice. It felt similar to my thoughts on returning from a trip to the developing countries in which I had worked — Samoa and Zimbabwe, for example. The people of Bairnsdale, I gradually came to realise, faced multiple tyrannies, starting with the tyranny of distance. I remember once apologising to a patient for running late. “I’ve had a 3-hour drive this morning, from Melbourne”, I said. “Well so have I”, the patient shot back, “from Mallacoota” (240 km from Bairnsdale). Another patient commented to me somewhat bitterly that city folk were always reluctant to come to the country, but country people have no choice but to make trips to the city: “It’s a lot longer from Melbourne to Bairnsdale than Bairnsdale to Melbourne”. But it was not only the tyranny of distance: it was the tyranny of poverty. I could see its mark in many of the patients I saw. There were demographic patterns — the young drug users, now clean because they had moved away from “the valley” (the industrial Latrobe Valley, an hour’s drive to the west of Bairnsdale). There were the thin, careworn young mothers of four children by four different fathers, one child with autism, one or two with ADHD, and one with epilepsy. A history of childhood and domestic abuse seemed to be the rule rather than the exception. There were the toddlers destroying the consulting room — in the city, toddlers did not often come with their mothers; perhaps there was more support at home. And there were the young men with alcohol dependence, perhaps chronic pain syndrome, living in trailers in forestry towns, who could never come to Bairnsdale for review because of the cost of petrol. The tyranny of isolation meant that middle-aged farmers with body mass indices over 30, waist measurements over a metre, and abnormal liver function couldn’t walk for exercise because they didn’t have the time or company. Single mothers with chronic hepatitis C could not join an interferon program because there was no one to support them or help with the children. And then there was the tyranny of nature: in January 2003, many men and women, including all the orderlies in the hospital, had gone to fight bushfires, and the town’s economy was suffering. In February, Bairnsdale itself was threatened, the sky dark and the sun red. In March, a farmer with tears in his eyes told me about his cattle burning, and then — laughing sarcastically about government bushfire “relief” — that the authorities decided the new funded fences (replacing the burnt ones) had to be dingo-proof, with wires down to 10 cm from the ground. His farm had steep ups and downs, and this new fencing was “bloody impossible to build”, “bloody expensive” and “bloody stupid”. In April, his new fences all washed away into the Gippsland Lakes during floods. In my work in Bairnsdale, I know I changed peoples’ lives — people with gastro-oesophageal reflux disorder, hepatitis C and colitis. If I had not gone there, those people would still be suffering; they just could not, or would not, have come to the city. Subsidised train fares for them to come and see me in Melbourne would not have fixed their problems. However, many other specialties easily available in Melbourne are just not available in East Gippsland, even though we, in both the city and the country, all pay (and are effectively paid by) the same taxes. Overservicing in the city and no servicing in the country? Yes, it’s a long way from the city to the country, and distance is not the only tyranny.

Katrina J R Watson MB BS, FRACP, MPH

The death of John Buckingham on 29 March 2011, after a courageous battle with pancreatic cancer, robbed the Canberra medical community of its leading breast cancer surgeon, whose knowledge and skill was paired with devotion and kindness to his patients. John was born in Sydney on 19 July 1947. He attended St Ignatius College and graduated in medicine from the University of Sydney in 1971. He completed his advanced surgical training in the United States at Mayo Clinic in Rochester, Minnesota. In 1978, John returned to Australia and attained Fellowship of the Royal Australasian College of Surgeons in 1979. In that year, he commenced as a consultant general surgeon at the newly opened Calvary Hospital in Canberra, where he concentrated his practice for his entire career. In addition to his clinical commitments, he filled roles in the hospital as Head of the Division of Surgery and Chairman of the Medical Staff Council. His inclusive style and collegiate approach allowed all views to be heard and acknowledged. His wise counsel was valued by the Sisters of the Little Company of Mary, board members and clinicians. Throughout his career, John was involved in the broad expanse of general surgical conditions. He was a cautious, methodical and technically proficient operator, who was diligent and attentive in the postoperative care phase. Over time, he came to concentrate exclusively on breast cancer surgery. He developed a comprehensive model of care, involving colleagues from nursing, radiology and oncology, and suffusing it with his virtues of care and compassion. The development of a graduate medical program at the Australian National University Medical School in Canberra allowed John to expand his interest in teaching to both students and registrars. His excellence in this role was recognised with his appointment as Clinical Associate Professor when he retired in 2011. His contribution to the wider ACT community was recognised when he was named ACT Senior Australian of the Year in 2010. John was a remarkable man, who, despite his many achievements, was humble and self-effacing. He was interested in the lives of his coworkers and was unfailingly courteous to everyone he encountered. He was a man of deep religious conviction, and his Catholic faith sustained him in his final illness. Indeed, he lived all his life demonstrating the faith principles he so strongly embraced. John is survived by his wife Sue and children James, Peter, Kate and Michael.

Michael J Gillespie · Stephen A Deane

Current practice in forensic medicine. John Gall, Jason Payne-James, editors. Oxford: Wiley-Blackwell, 2011 (327 pp, $120.00). ISBN 9780470744871. Recent times have seen a growing interest in forensic medicine among members of the public, although not necessarily among medical practitioners. An involvement in forensic medicine requires more than just a passing interest, and this publication examines aspects of the discipline that apply to both the living and the dead. The editors are both specialists in the field. John Gall is a forensic physician with the Victorian Paediatric Forensic Medical Service in Melbourne and Jason Payne-James is a forensic physician based in the United Kingdom and is editor-in-chief of the Journal of Forensic & Legal Medicine. In this book, they cover many areas of clinical forensic medicine and also touch on aviation disasters, but not toxicology. At least once in their careers doctors are likely to be called upon to give evidence in court. This book includes excellent instructions on how to prepare reports for medicolegal cases. For this alone it is a worthwhile reference text for a medical practitioner. For those who practise forensic medicine relating to the living, as in the case of sexual assault, this book should be required reading — it covers essential areas, such as how to assess, describe and interpret injuries, and how to collect specimens for biological or toxicological purposes. The book goes into some detail about the proper classification and description of wounds. However, it cautions against being too robust in attributing causes for wounds in medicolegal cases unless practitioners have the experience to back their judgement. The editors of this text have compiled an authoritative review of the topic, with contributions from leading international experts in the field. They provide enough detail about the forensic sciences to give practitioners some insight into these areas without attempting to turn them into experts.

Tony F Moynham

Desley and Les Carbon are preparing for a much-anticipated road trip from their home in Perth up the Western Australian coast to Exmouth. “I’ve just purchased a couple of large fishing rods”, says Mr Carbon. “My wife loves fishing but she’s allergic to fish — so if she catches any I’ll eat them!” The couple in their 60s are looking forward to a few weeks of relaxation after what’s been a difficult 18 months. Early last year, Mrs Carbon began experiencing recurrent flu-like symptoms, with a hacking cough and difficulty breathing. Multiple courses of antibiotics did little to relieve the symptoms. Her asthma worsened, and she was diagnosed with pneumonia. She had a litre of fluid drained from her lungs, but continued to experience chest pain. “I saw a specialist and said ‘why do I still have pain, when all the fluid’s gone?’” She had various chest x-rays and a CT scan, but nothing showed up. In April, after a PET scan followed by a biopsy, Mrs Carbon was diagnosed with pleural mesothelioma. “The first question I asked was, ‘How long have I got?’ The doctor said 12 months. But I hope I will get a bit longer than that.” **** Mesothelioma is a rare and fatal cancer of the pleura or peritoneum, almost always caused by exposure to asbestos. As Nola Olsen and colleagues write in this issue of the Journal, asbestos was mined and used widely as a building material for decades in Australia. Until the 1960s, 25% of all new homes used asbestos cement cladding. The legacy of this era is that Australia now has the highest mesothelioma rate in the world.1 Historically, mesothelioma was mainly an occupational cancer, but Mrs Carbon is one of a growing number of people with the disease who were exposed to asbestos at home, particularly during renovations or home maintenance. Olsen and coauthors find that although the number of cases associated with occupational asbestos exposure has plateaued, those related to domestic exposure continue to rise. “Malignant mesothelioma cases associated with home maintenance and renovation have increased markedly over the past 10 years and remain on an upward trend”, they write. This group of mesothelioma cases has been called the “third wave”, and it is not known when this wave will peak. The first wave affected workers involved in mining, milling and manufacturing asbestos products, while the second wave comprised workers who used asbestos products in industry, such as builders and plumbers. Margaret Kent, practice group leader in asbestos litigation at Slater & Gordon lawyers, has been obtaining compensation for people with asbestos diseases for the past 15 years. Like Olsen and colleagues, she has noted a “gradual and very discernible” trend in the nature of asbestos exposure among people seeking compensation for mesothelioma. “The decrease in occupationally exposed people and the increase in non-occupationally exposed people have been very obvious. Once upon a time most people who called us would be occupationally exposed but that’s not the case any more.” Clients have included people who developed mesothelioma after washing the clothes of their husband or father who worked in the asbestos industry, people living near a business that used asbestos, or painters who’ve sanded back asbestos-laced walls. Although most of Slater & Gordon’s clients are over 60 years of age, some are in their 30s and 40s. The youngest that Ms Kent has worked with was only 22 years old and may have been exposed as a toddler. **** As an indication of how ubiquitous asbestos is in Australia, Mrs Carbon has identified six occasions when she may have inhaled asbestos fibres, starting from when she was a young girl watching her uncle build extra bedrooms on to their farmhouse. “I used to help my uncle hold the big asbestos sheets while he was cutting them. We would play with the bits that fell off.” At age 25, and newly married, she lived in a house in Albany, WA. When Cyclone Alby tore the asbestos-laden roof off the house in April 1978, she and her husband lifted the pieces of broken roof to be cleared away. The newlyweds renovated their house, including sanding down the eaves, which also contained asbestos. “We used a steel wire brush, and sometimes we used sandpaper. There was lots of dust going everywhere.” Mrs Carbon knew other people with mesothelioma at the time of her diagnosis, but she was shocked to be diagnosed herself. “I had thought it could be cancer, but I never for one minute thought that it was mesothelioma.” **** Ms Kent from Slater & Gordon says there is still a public perception that mesothelioma is an occupational disease. She says most people exposed to asbestos during home renovation had no idea of the dangers and receive a “particularly bad and huge shock when they discover they have an asbestos-related illness”. She is concerned that there is a lot of misinformation in the community about the nature of asbestos and the potential risks of home renovation. “It worries me. We’re a great renovating country and the estimate is that one in three houses has some asbestos in it. Increasingly, people don’t know what it looks like, and they don’t understand that it’s very hazardous, potentially even in small quantities.” She adds that do-it-yourself TV shows have a role to play in increasing awareness of the risks of home renovation. “If they show pictures of people hacking with sledgehammers into asbestos sheeting, then it’s incredibly irresponsible, but if an explanation of the hazards is given, and some attempt to demonstrate doing it properly — then that could be a good thing.” Ms Kent’s concerns are shared by Unions NSW, which passed a unanimous resolution last month, calling on home renovation TV shows to include on-air warnings about the dangers of asbestos. Network Ten’s TV program The Renovators did not respond to the Journal’s request for a comment. Mrs Carbon agrees that there needs to be greater awareness of the risks of home renovation. “You have to be very careful; it only takes one fibre. You really have to wear masks, but we didn’t. We didn’t know anything about it.” **** Mrs Gladys (Joyce) Hyde, aged 78, was similarly surprised when she was diagnosed with mesothelioma 18 months ago, particularly given that she had never worked with asbestos or handled it during home renovation. Her asbestos exposure was indirect and probably occurred when she was living with her family in south-west Melbourne. They were next door to an agricultural company that conducted substantial building work in the late 1970s and early 80s. No one warned the family of possible risks and she had no idea her health was potentially in danger. “We didn’t think about it at all.” She was admitted to hospital 18 months ago because she was having difficulty breathing. “I could barely get to the bathroom to have a shower, it was that bad.” She ended up having five litres of fluid drained. “When they found the mesothelioma, it was a shock.” Professor Bill Musk, a Perth-based respiratory physician, says patients with mesothelioma typically present to their GP with chest pain or breathlessness. “The GP then does a chest x-ray and finds something on it, particularly pleural effusion.” A cell sample to confirm the diagnosis is usually obtained by aspirating the pleural effusion, but false negative results are common. A closed biopsy, a video-assisted thoracoscopic biopsy, or occasionally an open biopsy, can also confirm the diagnosis of mesothelioma. **** Mesothelioma is an unpredictable disease. Once diagnosed, the median survival is 9 to 12 months, but it is difficult to give an accurate prognosis. “Occasionally, a patient survives 10 to 15 years”, says Professor Musk. And although the cancer is almost always linked to asbestos exposure, it’s impossible to predict who, of those exposed, will develop the cancer. Mr Carbon has luckily not developed the disease, despite having sanded back the same eaves with his wife in Albany in the late 1970s. He also had a career as a ship’s master, which involved putting asbestos lagging on exhaust pipes, and later breaking it off when it became hard and brittle. “It was the most dangerous thing we could do to it, but I’ve never experienced any problems”, he said. Mrs Hyde is also acutely aware of the unpredictability of mesothelioma. “My oncologist said that a man could work with asbestos all of his life and never get it, but his wife could wash his clothes and get it. His view was it’s just the luck of the draw.” **** At the urging of her grandson, Mrs Hyde approached the law firm Slater & Gordon to seek compensation. Slater & Gordon’s defendants have included everyone from asbestos manufacturers, James Hardie and Wunderlich (a subsidiary of CSR), to state and federal government bodies. Legal claims focus on proving that there was a failure to warn of the dangers or of the need to take precautions, or to provide ways of minimising the asbestos dust. “It ranges from failure to put a warning on the product to failing to inform the public of the known dangers”, says Ms Kent. As lawyer John Gordon writes in this issue of the Journal , neither James Hardie nor CSR have ever taken any steps to systematically warn people of the dangers of asbestos products in their homes, or “of the potential for fatal consequences in 20 to 40 years if they demolish those products today”. **** Both Mrs Hyde and Mrs Carbon have had chemotherapy. “I’m waiting for 4 weeks to see if the cancer has shrunk. I’m a bit in limbo at the present”, says Mrs Hyde. A grandmother of 10, she is enjoying time with her family. Twice a week she helps with reading lessons at the school where her daughter works. “That’s been fabulous”, she says. She used to be a keen lawn and tenpin bowler, but the cancer and treatment have tired her out. “I was always reasonably active, and then to get something like this and it mucks everything up. It is hard but I’ve got a good family. You just have to keep on going.” Mr and Mrs Carbon are also pushing on. With the oversized fishing rods packed in their motorhome, they’re taking their minds off the diagnosis for a few weeks. “When I was first told it was mesothelioma I thought, ‘how am I going to get this out of my mind? I was thinking about it all day’”, Mrs Carbon says. Mr Carbon says the couple are only now coming to realise the full impact of the diagnosis. “But we’re boxing on and trying to enjoy life, making the most of every minute.”

Sophie McNamara

Rowan Nicks was born in New Zealand on 24 February 1913. He studied medicine at the University of Otago in Dunedin and, on graduation in 1937, worked as an intern at Auckland City Hospital. After his internship, he moved to the United Kingdom to further his surgical studies, working as a demonstrator in anatomy at Middlesex Hospital, London. Rowan served as a Surgeon Lieutenant in the Royal Navy during the Second World War. In 1945, he was appointed Officer of the Order of the British Empire and became a Fellow of the Royal College of Surgeons. After the war, he turned his attention to cardiothoracic surgery, and worked at Royal Brompton Hospital, London. In 1947, he returned to New Zealand to pioneer cardiothoracic surgery at Greenlane Hospital in Auckland. In 1956, Rowan was appointed Staff Specialist in Cardiothoracic Surgery at Royal Prince Alfred Hospital in Sydney. He was involved in the beginning of open-heart surgery in New South Wales in 1957 and played a leading role in the design and development of the first automatic cardiac pacemaker. After the death of his wife Mary in 1969, Rowan travelled widely, visiting hospitals in Africa and India in particular. This was the beginning of his second career as a significant philanthropist. After his official retirement in 1973, Rowan continued to travel and work in hospitals in East Africa, India and Malaysia, as well as in remote Aboriginal communities in Australia. Rowan established a series of scholarships and fellowships for young surgeons from Africa, India, Asia, the United Kingdom and Ireland, and the Western Pacific region. In 2005, he established the Rowan Nicks Russell Drysdale Fellowship in Australian Indigenous Health and Welfare. Throughout his life, Rowan had a sustaining love of nature and gardening. In his later years, he developed his interest in chamber music, symphony and opera. Rowan died on 26 May 2011, and is survived by his extended family in Australia and New Zealand.

John Masterton · and Brian Morgan

I was raised by my mother with my two older sisters and attended the local state schools, where I did it all — sport, music, even public speaking competitions. I’m not really that different, although I do remember clearly being told by some of the other kids, “You’re not like other black people”. I find that comments like this are made more commonly than they should be. They are generally unsettling and, ultimately, amusing for a number of reasons. What is it about me that was different to “those other black people” that I would stand out? My education is unexceptional in modern Australia: 12 years of school followed by an undergraduate degree in medical science. I have recently completed the Master of Applied Epidemiology through the Australian National University, which has started me on a career in health research. Why should anyone regard this as “different”? Many times when I was starting out in research I felt a deep sense of obligation to work in Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) health. I thought my career would only ever be in Indigenous health or involve Indigenous “issues”, and my growing expertise would only ever be appreciated in that arena. I do feel compelled to be somewhere at the forefront of Indigenous health research trying to rectify the history of colonisation that, let’s face it, is always the crux of our peoples’ issues. Over the past few years I have been involved mainly in cancer research projects. Cancer provides a typical example of the inequity experienced by Indigenous peoples. Compared with non-Indigenous Australians, our cancer incidence rate is similar, if not lower, for all cancers combined,1-3 and yet our mortality rate is estimated to be 50% higher for many cancers.4 Our cancer patients have more comorbid disease;5 their cancer is more advanced when diagnosed3,5,6 and they are less likely to take up and complete treatment.5 These factors contribute to their poorer survival, but they do not fully explain the disparity. This disparity is almost absurd in our modern times but, sadly, is our country’s reality. The most profound moment of my career so far took place in a small remote community. I had the privilege of conducting an interview with an Indigenous cancer patient who was receiving palliative care. I had an almost out-of-body experience as I sat intently listening to this person share her cancer journey. As a researcher and as an Indigenous person I was powerfully moved by her story, her family history and the circumstance of what she and her family were facing. She told me she had to leave her community, on her own, to go to two different cities for chemotherapy and radiotherapy when she was first diagnosed. The doctor at the local hospital in their community “didn’t do that much” even when the patient “knew it came back”. When the doctor did do something, he said, “Don’t like the look of that”. The most heartrending part of our interview was hearing firsthand about the stigmas within that community — “There is no community support, people are scared to visit”. To me, this person embodied the documented literature describing the many barriers that are experienced by Indigenous people in response to their dire health issues: living remotely, having to travel for treatment, and enduring social and even cultural isolation. Until that time, I had thought my obligation towards Indigenous health came from outside pressure and expectations; after that interview, I knew that these feelings were deeply personal. In recent years, our governments have given much greater attention to improving Indigenous health. I believe now is the time to reflect on how we conduct research with Indigenous people, to adapt with changing times and to maximise the application and benefits of research findings across the continuum of health. We can take no more chances with the health of our Indigenous peoples. The right methods, the best practice and the leading researchers and health professionals must be involved in rectifying the health and livelihood of our first nations. We know that the interconnection between health and its social determinants — housing, education, opportunity for employment, socioeconomic status and the like — is central to health improvement. The interconnected web of social habits and social status reflects the health of all people. As a society we seem slow to be shocked by the disparity in health issues, even life expectancy, for Indigenous peoples, and much quicker to blame individuals for not taking responsibility for their own health. While this can be true, it’s not central to the reasons why Indigenous peoples’ health is so poor. We seem to “forget” that there are many social problems that exist that stem from years of oppression, including fear of having to access mainstream health services, low socioeconomic status, disease from poor housing conditions and overcrowding, and lower levels of education that lead to lower rates of employment. We need to reconsider our approach to research to properly account for these factors and not just describe them as a fact that will remain unchanged. Indigenous health research remains Westernised — the “one disease at a time” approach. I believe that, until we move towards the holistic health approach with which Indigenous people identify, we will lessen the impact of current research by underselling the outcomes to government, thereby failing to secure future funding, making research findings non-transferable to policy and practice. This is where the next generation of researchers can take us, to enforce the inclusion of those social determinants and look holistically at research. I don’t know the “ideal” way of performing such research, but I believe there is a tangible method that we can find. In a perfect world, I see great health research being performed with good policy and practice outcomes that directly influence change in other social determinants, such as education. In essence, everything fundamental to my opportunity and progression contributes to “not being like other black people”. Some still consider my opportunity and success in education rare, or against the norm. Statements like this are not only made by non-Indigenous people. In fact, I find the most unsettling and upsetting comments are made by other Indigenous people. It saddens me when I hear them dismiss or denigrate the value of education. As more Indigenous people achieve a level of education equal to other young Australians, these attitudes will change, as they must if all Indigenous Australians are to overcome educational, economic and social disadvantage. We will then no longer be seen as different, but as skilled and educated people who bring a wealth of knowledge and inner culture that only an Indigenous person can have. Our skills will be valued and respected and our contribution will not be considered tokenistic. The achievement of education for Indigenous people and their employment in health-related roles is essential to improving health among the Indigenous population. My primary reason and motivation for working in Indigenous health is because it is the greatest area of need in Australia — it’s morally the right thing to do, regardless of what my cultural heritage is. However, when I reflect on my inner driving force to work in Indigenous health, I believe it comes from an inner obligation of personal connection and contribution. This obligation is not something I have always felt at peace with. I have never wanted to be boxed into thinking that I could or would only work on Indigenous issues, as I am made to feel when I hear other people comment that only Indigenous people should conduct Indigenous research. In some situations, this is very true, appropriate and culturally safe, but in other ways this is a perfect example of resistance to change. We have a long way to go, and I believe that it is a step in the right direction for as many people as possible to come on board and offer their skills. We have a lot to learn, but we also have a lot to teach. I’m sure any other Torres Strait Islander or Aboriginal person can relate to the sense of pride inspired by our community occasions — not pride in oneself, but in our community. What an incredible journey our people have had and are still on; after the years of oppression we can still come together and be proud of what we have achieved together. The list of health problems is long for our Indigenous peoples. They can appear overwhelming and sometimes disheartening to someone working in the health field. However, if any population is resilient enough to overcome these health issues, it certainly is the Indigenous population of Australia. Now we need to use that same sense of community pride and dedication to drive improvements in better health outcomes. I often think about the woman I interviewed a little while ago. Her story alone is a motivator for working in Indigenous health; from diagnosis, to treatment, to palliation, there are improvements to be made. Indigenous health needs commitment. It needs focus and continuous drive. So, where can I be the most useful and make the biggest contribution for Indigenous health? I don’t know the answer yet, but I feel privileged to be part of it. And I will have a story to tell.

Lisa J Whop BMedSc, MAppEpid

DiPHD Diagnostic imaging pathways, an iPad application. University of Western Australia and DIP Team. UWA, 2011 ($25.99). DiPHD is a clinical decision support tool in the form of an iPad application, developed by the University of WA in collaboration with the Royal Perth Hospital. For this review, I loaded the DiPHD app (search the iTunes App Store for “Diagnostic Imaging”) onto an iPad 2 (64 GB wi-fi and 3G). I then ran a comparison on the same iPad against the WA Department of Health website Diagnostic Imaging Pathways (http://www.imagingpathways.health.wa.gov.au/includes), from which the app was developed. With a broadband wi-fi connection, the app was noticeably quicker. The app does not include the Image Gallery or the Normal Anatomy from the website, but it does contain the important “Diagnostic Imaging Pathways” section. It is a valuable resource that my hospital has already adopted as its guideline for imaging pathways. It is difficult to think of an acute clinical condition that is not included. The app content is almost the same as the website, with some slight changes in layout that make it easier to access. The layout is also a little different in that you are presented with an anatomical diagram with pointers to the various conditions. The diagram itself does not serve any real purpose and, in some body areas, appears as a picture next to a list of clinical conditions. Like other pathways, these are also open to some debate. For example, “suspected testicular torsion” is directed to urgent surgery, even though many emergency departments have ultrasound capability to exclude torsion. Medical apps for the iPhone and iPad have become the clear leader for bedside clinical information, and the DiPHD is well constructed and accessible. My advice to potential users is to look at the WA Department of Health website first and decide if Imaging Pathways on an iPad is going to be more useful in your clinical practice. In an office-based practice, would you access an iPad, when the same information is available on your desktop computer? Or, as a clinician or junior doctor seeking information at the bedside, does this app fill a niche? Its utility will depend on your clinical practice.

Robert P Dowsett