Environmental health

Crikey is a daily electronic bulletin aimed at providing independent news. It was established in 2000. In 2007, journalists and public health advocates collaborated with Crikey to initiate an innovative health reporting project, the Crikey Health and Medical Panel (CHAMP). CHAMP members contribute articles and news tips to Crikey, broadening Crikey’s scope of public health coverage. CHAMP continues to evolve, and has expanded to include a freely accessible online health forum, Croakey. CHAMP was established to enhance public debate about health, to encourage public health advocates to engage in debate, and to help the media to identify public health advocates and issues as sources for articles.

Melissa A Sweet BA, MA(SciTechStud) · Simon Chapman PhD, FASSA · Ray N Moynihan BA · Jonathan H Green

Objectives: To determine the incidence and clinical features of acute rheumatic fever (ARF) in Fiji, and the clinical features of patients presenting to hospital in Fiji with rheumatic heart disease (RHD).Design and setting: A prospective surveillance study at the Colonial War Memorial Hospital in Suva over a 23-month period from December 2005 to November 2007.Main outcome measures: Incidence of ARF; clinical features of ARF and RHD.Results: The average annualised incidence of definite cases of ARF in children aged 5–15 years was 15.2 per 100 000 (95% CI, 9.0–22.6). The clinical features of ARF were similar to those in classic descriptions. Carditis was very common, occurring in 79% of cases. There were 103 admissions for RHD in which detailed information was collected, with the most common reason for admission being cardiac failure (51%). The median age at admission with RHD was 26.8 years, and there were 10 deaths of patients with RHD (case fatality rate, 9.7%).Conclusions: Although apparently declining in incidence since the middle of the 20th century, ARF remains a significant health problem in Fiji. RHD affects young people, leading to premature morbidity and mortality. There is an urgent need for effective control of ARF and RHD in Fiji.

Andrew C Steer MB BS, BMedSci, FRACP · Joseph Kado MB BS · Adam W J Jenney MB BS, PhD, FRACP · Michael Batzloff BSc, PhD · Lepani Waqatakirewa MB BS · E Kim Mulholland MB BS, FRACP, MD · Jonathan R Carapetis MB BS, FRACP, PhD

Available evidence indicates that rates of childhood overweight and obesity have been increasing over the past two decades, but inconsistencies between study methods moderate the strength of this evidence. Concomitant health problems and associated costs make it imperative that primary prevention initiatives are introduced to combat the obesity epidemic. Fundamental to informed action is anthropometric monitoring, which if properly implemented will identify changes over time in specific populations to inform policies, practices and services aimed at prevention and treatment. Sample representativeness is essential for valid trend and prevalence data, but efforts to obtain population-based anthropometric data from school children with the required written parental consent have been thwarted by low participation rates. Notable improvements in participation rates when utilising opt-out consent, in which participation is assumed unless otherwise indicated, are evident from local as well as international studies. Opt-out consent can facilitate anthropometric monitoring, delivering a more informed, best-value-for-money response to the obesity epidemic. Health and education ethics committees need to acknowledge the benefits of opt-out consent for “low-risk” anthropometric measurement, which ultimately upholds the individual’s rights.

Joanne M Stubbs BScPsychol(Hons), MPH · Helen M Achat BEd, MSc, ScD

Recent reports have suggested that the problem of childhood and adolescent obesity has been exaggerated in Australia, and that community-wide obesity prevention initiatives are not warranted; we argue that this is not an accurate reflection of the situation. Available data indicate that obesity affects 6%–8% of Australian schoolchildren, and that the proportion has continued to increase in recent years. Childhood and adolescent obesity is associated with a wide range of immediate health concerns, as well as increasing the risk of disease in adulthood. Some weight-related health problems are also found in overweight children. A range of strategies, including whole-of-community obesity prevention programs, will be required to tackle this problem. Concerns about disordered eating in children and adolescents should not preclude appropriate action on childhood obesity.

Timothy P Gill PhD, GradDipDiet · Louise A Baur PhD, FRACP · Adrian E Bauman PhD, FAFPHM · Kate S Steinbeck PhD, FRACP · Leonard H Storlien MA, PhD · Maria A Fiatarone Singh MD, FRACP · Jennie C Brand-Miller PhD, FAIFST · Stephen Colagiuri MB BS, FRACP · Ian D Caterson PhD, FRACP

Overweight and obese patients may develop paradoxical nutritional deficiency from eating high-energy foods with a poor nutrient content. In such patients, this condition is probably under-recognised, and thus untreated. The nutrient density of foods has recently been defined by a score — the naturally nutrient-rich (NNR) score — which assesses the contribution a food makes to the nutrient intake of a 2000 calorie (8360 kJ) daily diet and includes 14 key macronutrients. NNR foods are whole foods that provide the highest nutrient-to-kilojoule ratio. An awareness of the importance of the nutrient density of foods can assist health practitioners to recognise and effectively manage paradoxical nutritional deficiency. Knowledge of the nutrient density of foods helps people wanting to reduce their kilojoule intake to maintain a nutritionally sound diet, providing adequate vitamins, minerals and macronutrients.

Tania P Markovic MB BS, FRACP, PhD · Sharon J Natoli BSc, BND, APD

To the Editor: The pattern of invasive pneumococcal disease (IPD) in Western Australia varies from that described in northern Queensland in a recent article by Hanna and colleagues.1 Their study showed a decline in IPD caused by serotypes included in the 7-valent pneumococcal conjugate vaccine (7vPCV) among Indigenous children and adults after the introduction of the vaccine in north Queensland. Over the same period, there was an increase among Indigenous adults in cases of IPD caused by serotypes not covered by the vaccine. However, the authors reported that there had been no increase in IPD caused by serotype 19A, a non-7vPCV serotype that has been increasingly predominant in other populations.2,3 In contrast to the disease pattern in north Queensland, serotype 19A has become the predominant disease-causing serotype in Western Australia, particularly among non-Indigenous people. Data from the WA Notifiable Infectious Diseases Database show that the incidence of IPD in WA fell from 10.7/100 000 in 2001 (n = 203) to 6.3/100 000 in 2007 (n = 132). In children aged < 5 years, there was a significant drop in overall IPD rate, attributable to the decline in disease caused by 7vPCV serotypes, among both Indigenous children (from 70/100 000 to zero) and non-Indigenous children (from 50/100 000 to 1.6/100 000) (Box). The rate of IPD caused by 7vPCV serotypes also declined among Indigenous and non-Indigenous adults, suggesting a herd immunity effect. From 2001 to 2007, the proportion of IPD cases caused by non-7vPCV serotypes increased among children aged < 5 years (from 19% to 91%) and children ≥ 5 years (from 33% to 72%). Serotype 19A was the only serotype that became more predominant, being responsible for 11 (8%), 14 (10%) and 26 (20%) cases of ICD in 2005, 2006 and 2007, respectively. In 2001, it accounted for 2.5% of cases in children < 5 years (1.6/100 000) and 0.8% of cases in children ≥ 5 years (0.1/100 000). By 2007, these figures had increased significantly to 34% of cases in children < 5 years (7.8/100 000) and 25% of cases in children ≥ 5 years (0.8/100 000). Interestingly, the increase in serotype 19A cases was seen only in non-Indigenous people (particularly children), with the number of cases remaining stable among Indigenous adults and children. Although numerous reports describe increasing prevalence of penicillin-resistant 19A strains,3,4 none of the WA isolates were penicillin-resistant. In summary, after the introduction of the 7vPCV, the rate of IPD caused by 7vPCV serotypes decreased significantly in WA. However, the rate of IPD caused by serotype 19A, a non-7vPCV serotype, increased in non-Indigenous people and in the population overall. These early trends have significant public health implications for vaccine policy. State and territory vaccination programs exist within the framework of the national immunisation program. However, jurisdictional expert advisory groups need local ongoing post-marketing surveillance, coupled with an understanding of historical trends and emerging serotypes, when formulating vaccine recommendations for their populations. Incidence of invasive pneumococcal disease (IPD) caused by serotypes included in the 7-valent pneumococcal conjugate vaccine (7vPCV), by age group and Indigenous status, Western Australia, 2001–2007 * The 7vPCV was funded for Indigenous children from July 2001 and for all Australian children from January 2005.

Carolien M Giele · Anthony D Keil · Deborah Lehmann · Paul G Van Buynder

Objectives: To describe rates of occurrence of falls, injuries and fatalities to horse-racing jockeys in Australia.Design and setting: Retrospective analysis of data on race-day falls from stewards’ reports provided by the Principal Racing Authority of each state and territory of Australia, August 2002 – July 2006.Main outcome measures: Fall, injury and fatality incidence rates; comparison with overseas rates.Results: There were 3360 jockey falls from 748 367 rides. Falls occurred at a rate of 0.42 per 100 rides in flat races and 5.26 per 100 rides in jumps races. In flat racing, 54.6% (1694/3101) of falls occurred before the start of the race and 11.1% (344/3101) of falls occurred post-race. The 34.3% (1063/3101) of falls that occurred during flat races resulted in 61.7% (516/836) of the injuries sustained. In jumps racing, most falls occurred at a jump and 9.7% (25/259) of jockeys who fell were transported to hospital and/or declared unfit to ride. There were five fatalities resulting from falls during the study period, all in flat racing. Fall and injury rates were comparable with those found in the United Kingdom, Ireland, France and Japan.Conclusions: Being a jockey carries a substantial risk of injury and death. Although rates of injury in Australia are not exceptional by international standards, there can be improvement to safety standards in the Australian racing industry.

Peta L Hitchens BAppSci(Equine), MVPHMgt · C Leigh Blizzard PhD · Graeme Jones MMedSc, MD, FRACP · Lesley M Day BSc(Hons), MPH, PhD · James Fell BEd, MPhil, PhD

For Indigenous Australians, the “health of country” is inextricably linked with human health The impacts of climate change on human health are now being documented in Australia.1 Not surprisingly, these impacts are unequally distributed across our society, as vulnerability depends on a number of factors, including the degree of exposure, sensitivity and adaptive capacity. However, intranational heterogeneity of climate impacts on health has not been adequately documented to date.2 Using this lens, the vulnerability of Australia’s Indigenous people living in remote areas of the country is revealed. Their vulnerability to climate change is intensified by the social and economic disadvantage they already experience — the result of factors that include decades of inadequate housing and public services, and culturally inappropriate medical services. In addition, specific cultural ties between Indigenous people’s wellbeing and the “health” of their “country” create significant indirect impacts of climate change.3,4 We argue that it is vital to acknowledge the significance of this situation now, so that anticipatory adaptive policies can be implemented. Such policies should ensure that adequate resources are provided to mitigate some of the worst impacts of climate change on these communities, in a way that encourages community participation in decision making. We now know that, across northern Australia, climate change is expected to bring hotter day- and night-time temperatures.5 Elevated temperatures and increases in hot spells are expected to be a major problem for Indigenous health in remote areas, where cardiovascular and respiratory disease are more prevalent and there are many elderly people with inadequate facilities to cope with the increased heat stress. However, while the literature is not clear on the exact effects of increasing heat on people and communities, it does imply that these effects are likely to be less in regions where people are already acclimatised to hot conditions. Communicable diseases such as bacterial diarrhoea, which are more common in hot, dry conditions, may increase in incidence unless additional preventive action is taken. One study predicted that a 1.0–3.5oC increase in average temperature by the year 2050 would lead to an estimated 5%–18% increase in diarrhoea cases in Alice Springs.6 Dengue fever, spread by mosquitoes, also presents a climate-related risk to Indigenous communities. Although the virus is not currently endemic in Australia, there are sporadic epidemics, with occasional cycles over winter in the local mosquito populations in northern Queensland.7 The conceptual divide between Indigenous and non-Indigenous Australians about perceptions of “health” also needs to be recognised and accommodated.8 The Indigenous concept of health is broad and multifaceted, reflecting a different world view to that of the Western biomedical model. For many Indigenous people, a connection with “country” — a place of ancestry, identity, language, livelihood and community — is a key determinant of health.9 If community-owned country becomes “sick” through environmental degradation, climate impacts, or inability of the traditional owners to fulfil cultural obligations through ongoing management and habitation of their land, the people of that land will feel this “sickness” themselves. That is, the elements contributing to Indigenous health and wellbeing are often abstract and based on social interactions with people and the non-human landscape. Thus, as ecosystems change in response to biophysical impacts and extreme weather events, many traditional owners living in remote areas are likely to face increased physiological, psychological, economic and spiritual stress as it becomes more difficult to “look after their country”. At both international and national levels, there is some recognition of the specific needs of indigenous people in relation to the impact of climate change. The World Health Organization’s Commission on Social Determinants of Health and the United Nations Permanent Forum on Indigenous Issues have recently acknowledged the importance of tackling climate change, particularly with respect to health, for the world’s 350 million indigenous people. In Australia, the Garnaut Climate Change Review has recognised the importance of some non-quantifiable costs, including the specific intangible costs associated with improving Indigenous health.10 A challenge for medical practitioners dealing with this issue in the Australian context will be to look beyond the limitations of traditional epidemiology and scientific reductionism to embrace a more ecologically focused, social-determinants approach to health.11 This approach would enable the “health of country” and its inextricable links with human health to be considered in climate impact assessments. To address these different paradigms of health, the first step is to begin discussions with Indigenous people to prioritise activities. This process will certainly require a significant increase in the capacity of medical professionals and health systems in northern Australia, as well as increased education and training programs for Indigenous trainees and cross-cultural programs for nurses and local Indigenous support staff. Changes also need to be made in teaching practice across Australia. Currently, Indigenous health still occupies a peripheral place in many medical school curricula, with government funding and research disproportionally supporting high-cost, acute-care medicine at the expense of preventive and primary health care. In tandem with well planned, properly resourced programs that support strong livelihood activities in remote communities, there is the potential to begin to reduce the additional risk for many Indigenous communities from climate change. There are multiple co-benefits of this approach that would raise social and economic indicators. Ignoring the warning signs and failing to take action is no longer an option.

Donna Green PhD · Ursula King FACRRM, MPH · Joe Morrison MA

Recent publications have highlighted the impact of human rights violations, poverty and extraction of natural resources on the health status of the indigenous people of West Papua. However, the Australian medical literature has so far remained silent on this issue. Long-standing allegations of violence being perpetrated against Papuan civil society are supported by accounts given by West Papuan refugees involved in an Australian-based study. Health data collected by Médecins du Monde and other sources provide an insight into the poor health and lack of health care in the province, with high rates of infant mortality and morbidity, maternal mortality, and HIV/AIDS. Extraction of natural resources is causing major disruptions to the traditional livelihoods of indigenous Papuans, as a result of environmental degradation, mass displacement and an influx of migrant workers. Australian health professionals are urged to assist in remediating this dire situation, in keeping with our tradition of contributing to the health care of societies in our region.

Susan J Rees PhD · Remco van de Pas MD · Derrick Silove MB ChB, MD, FRANZCP · Moses Kareth

The association between smoking and lung cancer is now an accepted fact. Every day, doctors base management decisions on cardiovascular risk calculated using the Framingham equation. It is because of such findings and practical implications that the British doctors study and the Framingham Heart Study from the United States are among the world’s best known longitudinal studies. The stories of these landmark studies in the fields of epidemiology and public health have already been told;1,2 but longitudinal researchers have also been at work in Australia, with implications for our particular population and the wider world. We selected just a few of these (Box 1) — studies that have already demonstrated some longevity and which we judged would be of particular interest to our readership — and interviewed some of their key investigators. What are their stories? How will they make their mark in medicine? The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)Interviewee: Professor Paul Zimmet“How many Australians suffer from diabetes? How many new cases are diagnosed annually? ... How many people have complications of diabetes that are threatening to their vision or even to their life? ... These are not questions from ‘Trivial Pursuit’ nor is the answer to each of these questions readily available”, wrote Professor Paul Zimmet in the Medical Journal of Australia in 1985.3 At that time, Zimmet was frustrated that there had been little research into the growing problem of diabetes in Australia. Even Papua New Guinea, then one of the poorest countries in the world, had better diabetes data. Zimmet’s involvement in the epidemiology of diabetes had begun a decade earlier when, in 1975, he had gained funding from the US National Institutes of Health (NIH) to conduct a diabetes prevalence survey on Nauru, a Central Pacific island. The President of Nauru, Hammer DeRoburt, had invited Pincus Taft — his Australian physician and a colleague of Zimmet’s — to the island because he thought diabetes was a problem on Nauru; he was right! Zimmet and Taft’s survey found the highest prevalence of diabetes in the world — about a third of the adult population were affected.4 With further NIH funding, Zimmet and his team were able to survey other Pacific countries and Mauritius, and also, in 1985, to set up the International Diabetes Institute (IDI) in Melbourne as a World Health Organization collaborating centre for the epidemiology of diabetes. “It was really that NIH funding which allowed me to create the institute and establish the framework and the infrastructure that was then able to do AusDiab”, said Zimmet. In 1996, Australia’s health ministers agreed that diabetes would become one of the national health priorities. Spearheaded by Dr Michael Wooldridge, the then federal Minister for Health and Aged Care, the National Diabetes Strategy was launched in 1998. Arising from (but only partly funded by) the Strategy, the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) was commissioned, with Zimmet and Professor Timothy Welborn as the lead investigators. AusDiab was a population-based, cross-sectional survey of the national prevalence of diabetes and associated risk factors in people aged 25 years or older. The study involved an initial household interview, followed by a biomedical examination that included an oral glucose tolerance test, and questionnaires. It was conducted between May 1999 and December 2000 in 42 randomly selected districts in the six states and the Northern Territory of Australia. “It was akin to an army exercise”, said Zimmet. Team members would go in advance to work out logistics of transport, motels and meals, as well as to identify suitable study centres, which might be schools, town halls or local bowling clubs. Blood sugar-level tests were done immediately on site at a mini-lab, and blood samples were then sent by car or plane to the main lab for other testing and storage. In the initial cohort, 11 247 people attended the biomedical examination. The most alarming finding was that almost a million Australian adults had diabetes — equating to 7.4% of the adult population and a 300% increase since 1981.5 A further 16.3% had pre-diabetes, and there was a 60% prevalence of overweight and obesity and a high prevalence of untreated hypertension. Further funding, now with Professor Jonathan Shaw from Melbourne as co-investigator, allowed a 5-year follow-up study of 6537 participants in 2004–2005. This determined, among other things, that about 100 000 adults in Australia develop diabetes each year; that is, about 275 people every day. AusDiab is the largest national study of diabetes in the world. To ease ongoing funding concerns and to provide critical infrastructure, the IDI has recently merged with the Baker Heart Research Institute in Melbourne. There is no longer any argument that diabetes is a global epidemic with devastating human and socioeconomic effects. However, Zimmet says other questions related to diabetes now need answers, such as “Will preventing type 2 diabetes prevent cardiovascular disease?” Bettering the Evaluation And Care of Health (BEACH)Interviewees: Associate Professor Helena Britt, Associate Professor Graeme MillerEach year in Australia, more than 100 million general practice services are provided to about 85% of the population — to the tune of about $4 billion in Medicare payments.6 What really happens in these consultations? What is being diagnosed? In whom? And how is it being treated? Although Medicare statistics can provide some information about general practice services, it is data from the Bettering the Evaluation And Care of Health (BEACH) program that have been able to inform health care policy and clinical practice by answering these questions. Now in its 11th year, the BEACH program is a continuous national study of general practice activity in Australia — the only such study in the world — conducted by the Australian General Practice Statistics and Classifications Centre, a collaborating unit of the University of Sydney and the Australian Institute of Health and Welfare. Since its inception in 1998, 100 000 encounters between general practitioners and patients from a random, changing sample of 1000 GPs have been added to the BEACH database each year. The database now includes details of more than a million encounters. The BEACH program has provided independent data about a range of often controversial topics, including consultation length, payment structures, doctors’ prescribing practices, and adverse drug events, to various stakeholders, including researchers, educators, government departments and agencies, pharmaceutical companies and health care professional organisations. The program has produced 23 books (freely available for download from the BEACH website) and about 100 articles published in recognised journals. Most recently, the group has reported on the prevalence and patterns of chronic disease in Australia, finding that one in four Australians suffer from two or more chronic conditions.7 When asked to comment on the program’s impressive productivity, Associate Professor Helena Britt was quick to point out that: “What makes the productivity level so high is a fantastic team of excellent health services researchers”. There were also many years of methodological development and validation before BEACH was launched. “We didn’t land on the BEACH without preparation. It did take 20 years to get to that point ... and some more from [Emeritus Professor] Charles Bridges-Webb before that.” Between 1978 and 1990, Britt, a research psychologist by training, worked in the University of Sydney’s teaching and research general practice. The practice, run by Bridges-Webb, used a continually evolving data collection system that was based on his work in the 1960s and 70s with patient-based data collection from all general practices in the Victorian town of Traralgon. In 1990, the team successfully secured funding from the National Health and Medical Research Council (NHMRC) and the General Practice Evaluation Program for the first national study of general practice for more than two decades, and for a comparative study of rural and metropolitan general practice. These studies were reported in supplements to the MJA. Thanks to their distinctive covers, they became known as the purple report (Morbidity and treatment in general practice in Australia 1990–1991) and the green report (A comparison of country and metropolitan general practice).8,9 Some very lean years followed these two studies, with the team only managing to stay together by taking on smaller jobs from different groups, such as doing quality research for clinical trials for pharmaceutical companies, and, from 1993, by offering (for a fee) the method they’d developed as a quality assurance option to about 4000 GPs, thus gaining further evidence for and experience in using their method. Then, in 1997, with growing interest in how new drugs were being used in clinical practice, the team managed to “stitch together” sufficient funds from government and other sources, including the pharmaceutical industry, to launch the BEACH program the following year. Since the launch of BEACH, funding has remained mixed and uncertain, being renegotiated with all involved parties on an annual or biennial basis. In 2004, the government contribution to funding was withdrawn and, in 2006, there was a real concern that the program would be forced to close. However, this fear was not realised, as the government’s contribution to the program was re-established in mid 2007.6 Why does the BEACH team keep persisting in its efforts despite the ongoing funding challenges? According to the Centre’s Medical Director, Associate Professor Graeme Miller: “It’s a commitment to the importance of general practice, and of reliably describing general practice to justify what it’s doing and its place in the health care system”. The Blue Mountains Eye Study (BMES)Interviewee: Professor Paul MitchellDoes smoking cause blindness? What effect does visual impairment have on daily living? Observing the impact of eye disease on individual patients might explain why a clinical ophthalmologist would develop an interest in epidemiological research. The notion becomes even less surprising when one learns that Australian legend Professor Fred Hollows is one of two mentors whom ophthalmologist Professor Paul Mitchell credits with inspiring him to develop the Blue Mountains Eye Study (BMES) — the first large Australian population-based study of eye disease. Mitchell says that it was Hollows who talked him into doing an MD in Newcastle, New South Wales, in the 1980s, to research the prevalence of and risk factors for diabetic retinopathy. His other mentor is US-based Professor Ron Klein, who began (and still runs) the Wisconsin Epidemiologic Study of Diabetic Retinopathy in 1979 and the Beaver Dam Eye Study in 1987. When the two met at a diabetes conference in Australia, Klein invited Mitchell to the US to see how the Beaver Dam Eye Study had been done. It was after being appointed to the University of Sydney’s Department of Ophthalmology in 1990 that Mitchell designed the initial BMES to study visual impairment and common eye diseases in a representative older Australian community sample, and obtained NHMRC funding. Study participants were identified in two postcode areas in the Blue Mountains region, west of Sydney. The area was ideal because of the residents’ demographic similarity to the overall Australian population (for most characteristics); and its geographical separation from Sydney meant that publicity could be well targeted. In the first wave of the study (BMES-1), 3654 residents aged 49–97 years were examined during 1992–1994, with Mitchell personally conducting the eye examination for all participants. There have since been 5-year and 10-year follow-up studies, and an extension study in 1999–2000 of further residents who became eligible to participate (BMES-E). A 15-year follow-up study is currently underway. Since 2001, the BMES has been incorporated into the research activities of the Westmead Millennium Institute’s Centre for Vision Research in Sydney. When asked about the study’s highlights, Mitchell nominates the finding that visual impairment has an impact on quality of life that is similar to that from most major systemic conditions, and doubles the need for earlier institutionalised care; it is also associated with about an 80% risk of increased mortality. Further, the BMES was among the first studies in the world to demonstrate the link between smoking and blindness (now a warning on cigarette packets sold in Australia and elsewhere) (Box 2).10 Among the most important of more than 300 papers published from the study, Mitchell includes a New England Journal of Medicine report of the link between using inhaled steroids and developing cataracts.11 According to Mitchell, one of the core strengths of the BMES is the collection of objective data. All eye photographs are graded using standard protocols developed for the Beaver Dam Eye Study, which allows for the independent assessment and pooling of data from the BMES with data from other national and international cohorts. A further strength is that, right from the start, the BMES was designed to be much bigger than “just an eye study”. A wide array of data was collected and then expanded upon in the follow-up studies, including fasting blood tests, various detailed questionnaires, and hearing assessments, with the project also extending into genetic studies. Ever looking forward, Mitchell believes that a valuable area for future investigation is a possible link between basic vascular signs in the eye and systemic events, particularly cardiovascular events, stroke and mortality. “The eye is the only place you can see vessels — microvascular vessels — naked”, said Mitchell. “These microvascular signs are quite important for a whole range of diseases, and can now be imaged very easily without dilating the pupil and assessed automatically with computer programs.” The Busselton Health StudyInterviewees: Dr Digby Cullen, Associate Professor Alan James, Professor Bill MuskWho should benefit from a community-based study? Most obviously, “the general population”, but Busselton-based GP Dr Kevin Cullen, who founded the Busselton Health Study in 1966, nominated the community itself. One of the study’s five original aims specified that the study should “provide a community service in the detection, treatment and prevention of disease and in the education of a population”. For more than 40 years, and persisting beyond Dr Cullen’s death in 1994, the study’s dedication to the people of Busselton, a picturesque coastal town in the south-west of Western Australia (Box 3), has been returned in kind. This has not only been in terms of study participation, but also in enthusiastic ongoing support, fund-raising and volunteering. As an example — at one time, the local milkman was delivering bottles of glucose solution for the recipients to drink before blood testing for diabetes on the same day.12 The Busselton Health Study is now one of the longest running epidemiological research programs in the world. The predominantly Anglo-Saxon adult community of Busselton Shire took part in cross-sectional health surveys every 3 years from 1966 to 1981, with surveys of all schoolchildren each following year. A “hiatus” for a few years was followed by several surveys of special groups; and, in 1992, a specific family-based genetic study was conducted. In 1994–1995, 5500 surviving participants from the early surveys were successfully recalled. In 2005–2007, an NHMRC project grant enabled a further study of a randomised sex- and age-stratified sample of adults and of all schoolchildren, followed by studies of chronic airflow obstruction and sleep apnoea, with ongoing studies of diabetes and healthy ageing in “baby boomers”. So far, a total of around 16 000 people have been studied at least once. The earliest descriptive reports in Australia of the prevalence of common diseases including asthma and other lung problems (the study has always had an emphasis on respiratory disease), diabetes and coronary heart disease are those from the “population laboratory” of Busselton. Numerous papers have been published: interviewees Professor Bill Musk, Associate Professor Alan James and Dr Digby Cullen (son of Kevin) nominated research describing the decline in lung function related to asthma and cigarette smoking,13 and genetic studies into asthma14,15 and haemochromatosis16 as their recent favourites. From the community perspective, there has always been a policy of providing feedback to survey participants, with recommendations made to seek medical advice from the family doctor if indicated. Dr Digby Cullen said, “We have made an attempt to create a therapeutic community in Busselton and to a significant extent I think we have been successful ... certainly, when you look at the health statistics of Busselton, there is good evidence for a creation of a therapeutic community with, for instance, very low rates of smoking in the population — about 12% in our most recent survey”. In addition, the prevalence of coronary artery disease has been shown to be lower in Busselton than in the nearby state capital, Perth. What of the future? Since 1966, Busselton has grown sixfold from a small town with a population of about 5000 to one of around 30 000, as people, particularly retirees, have moved into the area. However, the population has remained relatively stable, ethnically and socioeconomically speaking, and wine growing, tourism and farming remain the main industries. The Busselton genetic resource is in international demand. Associate Professor James said, “We’re now matching the phenotypes that we have collected in Busselton with genotyping in our own studies and with an expanding number of international collaborators; there’s plenty of scope for genetic epidemiology to go from strength to strength in Busselton”. Regardless of how the study develops, the community focus will persist. Professor Musk said, “We very much feel the community around us and behind us. All of us worked with Kevin Cullen briefly or for various times before he died. He instilled in me, and I’m sure in plenty of other people, that our first duty was to the community. We plan to keep that, as a mantra, if you like, into the future”. The Dubbo StudyInterviewee: Professor Leon SimonsWho among us will live to a ripe old age, physically well and mentally able? In the 1980s, when Associate Professor Leon Simons of St Vincent’s Hospital, Sydney, decided to conduct a longitudinal study, he was aware that older age groups had been relatively neglected in research studies up to that time. He also realised that by studying “survivors”, some characteristics of healthy “long-livers” might be identified. The decision to embark on the Dubbo Study of the Health of the Elderly — now known more simply as the Dubbo Study — was preceded by a raft of other decisions. Initially a neurophysiologist, then a lipid clinician–researcher, Simons followed the 1980s evolution in his field by retraining as an epidemiologist while on sabbatical in Jerusalem. Simons’ Israeli mentor, Professor Yechiel Friedlander, remains a collaborator to this day. A key decision was where to locate the study. Simons said, “We selected Dubbo [a major regional centre in NSW, home of the renowned Western Plains Zoo] in reverse, after working out the size of the town we needed — a community of 35 000 to 40 000 people”. Another decision was what data to collect. At the time, there was much data available in the form of aggregated health statistics — how many people each year go to hospital, how many go home, how many die — but not much was known about the people themselves. “We decided to study what is loosely called ‘healthy ageing’ but with a focus on cardiovascular disease risk factors, because they were a little bit more controversial — did what we knew in middle-aged people also apply to senior citizens?” said Simons. “And when you study the elderly, you open up a Pandora’s box of sociology.” Thus, the Dubbo Study came into being as a prospective, longitudinal community study of the health of all non-institutionalised residents of the Dubbo local government area who were born before 1 January 1930. The cohort, first examined in 1988, was composed of 2805 residents (1233 men and 1572 women) aged 60 years or older. Initial study aims included identifying patterns and predictors of mortality, hospitalisation and the need for residential care. As well as extensive biomedical investigation, including a resting electrocardiograph, peak expiratory flow measurement, and blood testing for lipid and glucose levels, there was also to be a social science investigation of healthy ageing and health service use. Cardiovascular diseases and dementia were conditions of special interest. Subsequent data collections were made in 2000 and 2002–2003 as part of the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD) investigation; and there has been continuing “cold pursuit” of death, hospitalisation and residential care data. Pragmatically, Simons’ favourite reports are those most recently published17 or currently in preparation. Our favourite may be the 2005 article which reported that having a “green thumb” (daily gardening) can guard against dementia.18 Less than half of those in the original cohort are still living, making further active data collection unlikely. Nevertheless, more papers are on the way to add to the 50 already published. Today, as the shape of Australia’s population pyramid changes to reflect our ageing population, there is heightened interest in healthy ageing and the provision of health care and other services to our older citizens. Over the next 10 to 15 years, as the most resilient of the cohort retire to their gardens, Simons anticipates that the Dubbo Study’s database will continue to be accessed and continue to contribute to our knowledge of ageing. Tasmanian Longitudinal Health Study (TAHS)Interviewees: Associate Professor Shyamali Dharmage, Professor John Hopper, Professor E Haydn WaltersHow do childhood factors affect adult-onset asthma? How do issues around the time of puberty influence the risk of breast cancer? When a disease “runs in the family”, is it because of environmental or genetic reasons? Today, the Tasmanian Longitudinal Health Study (TAHS) is attempting to answer these questions and more. However, very different questions were at the forefront when the study began in the late 1960s. The study, originally known as the Tasmanian Asthma Survey, was the brainchild of Dr Heather Gibson, a pioneering doctor working with the school medical service in Tasmania. Professor Haydn Walters, one of the current TAHS team, said: “At that time, the main interest was in how much asthma and how much other respiratory morbidity there was in young children, and what the risk factors were”. The baseline study in 1968 surveyed all 8500 schoolchildren in Tasmania who were born in 1961 and were then 7 years old. Particularly novel for the time were the lung function tests performed on all of these schoolchildren, known as probands. The probands’ brothers, sisters and parents were also surveyed, taking the total number of participants at the time of original survey to 45 900. Follow-up studies were conducted in 1974, 1979, 1992 and 1996, often involving a specific subset of the original participants. The first time that blood samples were collected from participants in the TAHS was in 1996, from a relatively small sample of families. The aim of the current and next phases of the study is to investigate the total original cohort of 45 900. Ninety per cent of the probands have now been traced, with 80% of them participating in a recently completed follow-up study. The sibling follow-up is underway, with 70% traced so far, and 60% of them participating in the study. The TAHS researchers are seeking to collect blood samples from all probands and siblings for genetic testing, to tease out the different effects of “nature” versus “nurture”. Today, the original probands are around 47 years of age, and include such prominent figures as a Deputy Lord Mayor and leading medical researchers. The TAHS researchers say their most cited article to date is one published in the BMJ in 1994. It reported that only one in four probands who had asthma in childhood continued to have asthma at age 32, and that one in 10 probands who didn’t have asthma as a child developed it later on.19 Among more recent interesting findings, the TAHS found that, for girls, being overweight at 7 years of age triples the risk of developing adult-onset asthma.20 The TAHS is unique internationally because it is the world’s largest and longest running respiratory health study. However, because of the population-complete nature of the cohort, the length of follow-up and the opportunities for a general health study, research is now extending to other areas such as breast cancer, eye disease and social science. As TAHS team members say, on the one hand, “It’s now a very rich dataset in terms of early life exposure ... and the original questionnaires asked about symptoms rather than diagnosis — a real strength from a research point of view”. On the other hand, “In terms of a cohort, the group are now starting to get very interesting because they’re getting older. They’ve gone through the healthy part of their life and now the major diseases are starting to emerge”. In keeping with the study’s original respiratory focus, the TAHS will enable the study of lung ageing. Although the TAHS was originally (and, essentially, still is) a Tasmanian study, 30% of the original probands now live outside Tasmania — mostly on the eastern Australian mainland in Victoria, NSW and Queensland — and, as current TAHS team leader Associate Professor Shyamali Dharmage explained, the study now involves a national collaborative family of researchers. But the TAHS has always been a family study. As Professor John Hopper, a long-standing TAHS team member, said, “The thing that differentiates this from a lot of other longitudinal studies is that it involves families, and its strength is that Australian families tend to know where each other are. The next stage will be to study the offspring”. Wittenoom cohort studiesInterviewees: Professor Nick de Klerk, Associate Professor Lenore Layman, Professor Michael Hobbs, Professor Bill MuskWhat would you do if you could see an accident waiting to happen that would hasten the deaths of hundreds of people? In 1948, Dr (later, Professor) Eric Saint, who had emigrated from the United Kingdom to Australia, was horrified by dust levels in the crocidolite (blue asbestos) mine and mill at Wittenoom in the Pilbara region of Western Australia, more than 1000 km north of Perth (Box 4). Saint wrote to the head of the WA Health Department advising that the mine would produce the greatest crop of asbestosis the world had ever seen. Unfortunately, responsibility for any decision to halt mining in the area rested with the Department of Mines, and the Health Department could only stand on the sidelines in frustration. Tragically, in time it became clear that there was another even more lethal health risk to the workers and residents of Wittenoom. The first Wittenoom-related case of mesothelioma was diagnosed in 1960,21 shortly after the initial suggestion of a link between exposure to crocidolite and mesothelioma.22 However, the Wittenoom mine continued to operate until 1966 when, ironically, it was closed for economic rather than health reasons. The mine may have been losing money then; today, the loss in life continues. In the mid 1970s, when it became apparent that an epidemic of asbestos-related disease was emerging in Wittenoom workers, Australian researchers began a cohort study. Mine workers’ employment records, giving detailed information about the identity of the workers, their length of employment and the duties they performed, were made available to the research team. Although only several hundred people were employed at any time, about 7000 workers (mostly men) had passed through the mine or mill over the years. Most worked for only a few months; many were post-war migrants, several hundred of whom returned (and were traced) to Italy. Resulting studies have reported that asbestos-related diseases, particularly malignant mesothelioma, lung cancer and pneumoconiosis, continue to be the main causes of excess mortality in the former blue asbestos miners and millers of Wittenoom. Further, mesothelioma appeared much earlier in these people than had been seen after exposure to other types of asbestos in UK industrial studies. By the early 1980s, people who had lived in the town of Wittenoom without working in the mine or mill were also developing asbestos-related disease at an alarming rate. In the 1950s and 60s, crocidolite tailings had been spread around the town as a cheap gravel and sand substitute. Professor Bill Musk said, “They brought the crocidolite in from the gorges and laid it around the township to counter the dust or the mud, depending on whether it was raining or not. So everybody living in town was exposed”. Professor Michael Hobbs continued, “The school playground had been layered with asbestos tailings as a better surface for children to be running about on, rather than hard dirt”. Thus, a residents cohort study involving more than 4500 former residents of Wittenoom, including Indigenous residents, was embarked upon. Intervention and other studies have continued in that group to this day, giving, as Associate Professor Lenore Layman said, “some support and comfort to people who live with this terrible fear about their children getting mesothelioma”. Together, the Wittenoom studies have provided evidence that (unlike with smoking) the risks of mesothelioma do not diminish with increasing time since exposure. Most importantly, Professor Nick de Klerk says that dose–response curves were able to determine, once and for all, that, “When it comes to blue asbestos, there is no such thing as a ‘safe’ level of exposure”. The evidence from these studies has influenced asbestos policy in Australia, assisted in legal deliberations, inspired a hit song by Australian rock band Midnight Oil (“Blue sky mine”), and even led to Wittenoom becoming a designated contaminated site that has been literally wiped off the map. However, asbestos is still being used in developing countries around the world. Hobbs said: “The first world has sort of recognised the dangers of asbestos and stopped using it. I think we have a moral obligation to go on pushing this barrow to make sure that our colleagues in China and India are equally armed with the information they need to try and stop things happening there. Because, if not, whereas we’ve seen hundreds of cases of mesothelioma, they will see thousands”. Women’s Health Australia (WHA)Interviewees: Professor Julie Byles, Professor Annette Dobson“I am woman, hear me roar; in numbers too big to ignore ...” proclaimed the lyrics of Australian-born Helen Reddy’s song “I am woman”. The song won Reddy a Grammy Award in 1973 and is now famous as the anthem of the Women’s Movement. But how much did we really know then about ordinary women’s lives and the influences on their health? In 1985, after much lobbying, Prime Minister Bob Hawke’s government committed to forming a National Women’s Health Policy. The Policy, which would provide a framework and planned strategy to improve the health of women in Australia, was to incorporate a wide perspective — recognising that women’s health was much more than just reproductive and sexual health. In the early 1990s, a tender was put out by the federal government for a national longitudinal study on women’s health — one that could collect scientifically valid information relevant to the development of health policy and practice, and that would enable women to gain greater power over shaping the nature of health care. On seeing the advertisement for the tender, a group of researchers from different academic disciplines (including medicine, sociology, psychology and statistics) met over coffee in Newcastle, NSW, and decided to put in a submission. Thus began Women’s Health Australia (WHA), also known as the Australian Longitudinal Study on Women’s Health. The study’s overall goal was (and still is) to clarify relationships between women’s health and a range of biological, psychological, social and lifestyle factors. Professor Annette Dobson said: “We’ve never claimed to have just one clear hypothesis. Rather, what we felt was needed was enough power in the study to be able to address new questions as they emerged. We did have some concrete examples of the sorts of hypotheses that could be answered, but we didn’t say this was a study to address this or that question. We were saying it’s a study to look generally at factors that influence the health of women”. Extensive surveys have been mailed at regular intervals to a national sample of thousands of women in three different age cohorts (18–23, 45–50 and 70–75 years at baseline in 1996). These age groups were chosen because they represented times before which major changes could be expected in women’s lives; so, for example, there would be baseline data for young women before most of them had babies. Further, the women were recruited from the national Medicare database, allowing a link to health services data. More than 41 000 women (14 792 young women, 14 200 middle-aged women and 12 624 older women) responded to the baseline surveys in 1996;23 and now, about 10 000 completed questionnaires are received each year. Over time, themes explored have included health-related behaviour (eg, diet and exercise), time use (eg, paid and unpaid work, and leisure), life stages and key events (eg, childbirth, divorce and widowhood), violence against women, and chronic disease. Because WHA does not focus on a specific exposure, disease outcome or social problem, publications are highly diverse (http://www.alswh.org.au/public.html). Dobson said, “We’re contributing to the story of the health of Australian women”. There is sustained work on overweight, obesity and physical activity, and in the unfashionable area of incontinence. Professor Julie Byles said, “We’re dispelling the myth that incontinence is just a condition for older people”. WHA is also one of the significant studies of ageing in Australia. In addition, there are add-on studies and collaborations. WHA has passed the 10-year mark and is currently funded to last the desired 20 years. However, the researchers see possibilities for expansion and extension. Byles said, “We have found that the cohorts’ experiences are likely to be different as they age, so we have put a suggestion to the Department [of Health and Ageing] that we recruit a new young cohort — precisely because of those differences”. The WHA study has certainly fulfilled Reddy’s command that women not be ignored. And, to make sure of it, Byles would like the study to “hang around” at least until the older women reach the milestone age of 100. Australians advancingThese eight longitudinal studies, all conducted “on our selection” (to borrow an Australianism from Steele Rudd), have already contributed much to our knowledge of diseases in Australia. Although they cover disparate topics and range in cohort size from several thousand to many tens of thousands of participants, there are some common elements to their stories: committed investigators who are capable of thinking into the future; dedicated and often longstanding research teams; sustained support and enthusiastic participation from the community; and the need to endure and persist through periods of extreme funding uncertainty. A striking feature of these longitudinal studies is their capacity to produce valuable results with relatively little funding overall — many of those interviewed said that their work had been conducted on “the smell of an oily rag”. Reports from the studies have been published in prestigious high-impact journals, such as Nature, the New England Journal of Medicine and the BMJ, as well as high audience-impact journals, such as the MJA, thus influencing discourse, attitudes and policy. These Aussie battlers are rightfully proud of their achievements, as are we. Despite some successes, none of the researchers are content to rest on their laurels. All are eyeing a future for their studies, carefully watching the emergent literature for new ideas that may be a natural fit for their study populations. Many are actively engaging productive collaborators in cutting-edge areas, like genetics, and seeking a greater international contribution through the integration and comparison of their data with those of others. Both of these advances are enabled by making their data available online. Does a longitudinal study have a natural lifespan? Maybe, but all our interviewees are more concerned that it will be a lack of funding rather than relevance or researcher interest that sounds the death-knell for their study. If these studies are stopped too soon, we will all miss out on “the gold coins at the end of the rainbow”. As Miller (from BEACH) said, “Enough of the past must be seen before we can begin to predict the future with any certainty”. To achieve sustainability, many argue that a different kind of funding is needed than that usually available to epidemiological researchers. Hopper (TAHS) said, “The work is generally funded by project grants, scientific project grants, but what is needed is core funding”. Several interviewees said there needed to be some sort of formal research policy providing long-term support to cohort studies. Whatever the lifespan of their own study turns out to be, most of the researchers want a future that is better for all longitudinal study investigators. WHA has published a practical guide to conducting longitudinal studies — how to store data, track people, manage collaborators and more.24 Dharmage (TAHS) dreams of establishing a supportive collaboration of longitudinal researchers, all helping each other forward. What will be the next great Australian longitudinal study? Zimmet (AusDiab) says the time is ripe for Australia to establish a comprehensive longitudinal national health survey, conducted every 5 years, which would give an idea of the burden of disease and the opportunity to monitor interventions. Hopper sees a future where the historically fostered culture of institutionalised non-cooperative research groups is turned on its head. “Even now, the concept of having national cohorts that are run as resources for the general scientific community is becoming more and more established. The general thinking is growing — not just in Australia but internationally — that these resources are precious, that they need to be open and accessible to a wide range of research; and that people who do research using these resources need to put that data back into the resource so that others can build on it.” Australian longitudinal research is making its mark in medicine at home and beyond. With renewed commitment, vision and adequate ongoing resources, we hope that these stories, and others like them, will continue. 1 On our selection: characteristics of some Australian longitudinal studies Study title Location Year of initiation No. in baseline cohort(s) Funding* No. of publications† Study website Initial funding Total funding The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) National 1999 11 247 $1 500 000 $2 600 000 80 http://www.diabetes.com.au/research.php?regionID=181 Bettering the Evaluation And Care of Health (BEACH) National 1998 na $1 200 000 $11 000 000 53 http://www.fmrc.org.au/beach.htm The Blue Mountains Eye Study (BMES) Blue Mountains, NSW 1992 3654 $163 819 $7 255 400 332 http://www.cvr.org.au/bmes.htm The Busselton Health Study Busselton, WA 1966 5008 £6000 > $7 600 000 > 250 http://www.busseltonhealthstudy.com The Dubbo Study Dubbo, NSW 1988 2805 $250 000 $400 000 51 http://www.dubbostudy.org Tasmanian Longitudinal Health Study (TAHS) National 1968 45 900 nd $4 000 000‡ 30 — Wittenoom cohort studies Wittenoom, WA 1974 11 684 $50 000 > $4 000 000 100 http://www.sph.uwa.edu.au/go/research-programs/oee/schools-and-centres/schools/school-of-population-health/projects#asb Women’s Health Australia (WHA) National 1995 41 616 $3 500 000 > $18 000 000 252 http://www.alswh.org.au na = not applicable. nd = data not available. NSW = New South Wales. WA = Western Australia. * Amounts shown are estimates and may not include institutional funding for costs such as investigator salaries or postgraduate students, and may comprise a mix of federal funding, support from trusts and industry, and in-kind support from various states and territories. Total funding is an estimate of funding received so far. † Number of published (or in press) articles in peer-reviewed journals only. See study websites for details of other publications. ‡ TAHS funding information is only available since 1992. 2 Macular degeneration Neovascular macular degeneration in the right eye of a 71-year-old woman who smoked heavily. 3 Busselton, Western Australia At nearly 2 km, Busselton’s iconic jetty is the longest in the southern hemisphere. 4 Wittenoom miners Underground Wittenoom miners having a lunch break in a dusty crypt room.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Tanya D Grassi MB BS(Hons), BSc(Vet)(Hons) · Bronwyn Gaut MB BS, DCH, DA · Martin B Van Der Weyden MD, FRACP, FRCPA

Despite the availability of a range of Australian self-management support programs targeting the individual patient and/or health professional, three-quarters of Australians have at least one long-term medical condition, suggesting that a more comprehensive public health approach is needed. Use of mass media to deliver community health messages is a well established public health strategy. It may enhance more targeted approaches with its ability to reach large numbers of people simultaneously, including those difficult to identify, high-risk groups and those difficult to reach through traditional medical delivery. By simultaneously influencing large numbers of people, well designed health messages have the potential to promote and maintain behavioural change over time. Back Pain: Don’t Take It Lying Down (1997–1999), a mass media campaign of the Victorian WorkCover Authority, can be seen as a prototype of a successful public health strategy designed to enhance people’s self-management abilities. One of the main messages of the campaign was that there is a lot you can do to help yourself, which emphasises shifting the responsibility of control onto the individual. The success of the campaign makes a compelling evidence-based case for using a similar strategy to enhance the self-management abilities of the population.

Rachelle Buchbinder MB BS(Hons), PhD, FRACP

Objectives: To ascertain changes in: women’s knowledge of the role of folic acid in the prevention of neural tube defects (NTDs); intake of folic acid among pregnant women; and prevalence of NTDs in South Australia.Design, setting and participants: Computer-assisted telephone interviews of South Australian households from 1994 to 2007 over a period encompassing a statewide folate promotion campaign (1994–1995), continuing folate promotion, as well as the introduction of voluntary folate fortification of foods (1996); ascertainment of the total prevalence of NTDs from births and terminations of pregnancy from 1966 to 2007.Main outcome measures: Changes in women’s knowledge of the role of folic acid in the prevention of NTDs; changes in the prevalence of NTDs.Results: From 1994 to 2006 and 2007, knowledge about the role of folic acid increased from 25% to 77% (P < 0.001) and knowledge that folic acid needs to be taken in the periconceptional period increased from 12% to 39% (P < 0.001). The proportion of pregnant women who increased their periconceptional intake of folate rose from 61% in 1998 to 81% in 2006 and 2007 (P < 0.001), with significant increases in the consumption of fortified cereals (from 15% to 29%) and folic acid tablets (from 37% to 64%). The total prevalence of NTDs fell from 2.06 per 1000 births in 1986–1990 to 1.23 per 1000 births in 2002–2007 (relative risk, 0.60; 95% CI, 0.48–0.74; P < 0.001).Conclusions: Folate promotion and voluntary fortification of certain foods with folic acid were associated with increased awareness of the role of periconceptional folic acid, increased folate consumption and a reduction in the prevalence of NTDs in South Australia by 40% (95% CI, 26%–52%).

Annabelle C Chan DPH, DCCH, FAFPHM · Phillipa van Essen BHSc, MPH · Heather Scott · Eric A Haan BMedSc, MB BS(Hons), FRACP · Leonie Sage RN, RM · Joan Scott RN, RM · Tiffany K Gill MAppSc, CertHealthEc, PostGradDipHlthSc · Anh-Minh T Nguyen BSc(Hons)

Objective: To describe the prevalence of neural tube defects (NTDs) in Victoria, and to evaluate women’s knowledge and awareness of the importance of folate after the introduction of voluntary food fortification.Design and setting: Descriptive study, set in Victoria, Australia, based on routinely collected data from the Victorian Birth Defects Register (VBDR) for 1998–2006, and responses by women aged 18–50 years to five questions relating to folate on the 2005 and 2006 Victorian Population Health Surveys (2314 and 2488 women, respectively). Main outcome measures: Prevalence of NTDs, and extent of women’s knowledge of the importance of folate in NTD prevention, comparing the period before and since voluntary food fortification and a folate awareness campaign.Results: The total prevalence of pregnancies affected by NTDs declined from approximately 17 to 14 per 10 000 births from 1997 to 1999 (coinciding with the period when voluntary food fortification was introduced, and a 1-year folate awareness campaign was held). It has since remained static. Over the 9-year study period, the termination of pregnancy rate was 79%, resulting in three NTD-affected babies per 10 000 livebirths. Compared with women aged 30–34 years (the reference group), those aged 20–24 years had the greatest likelihood of having a baby with an NTD (adjusted odds ratio, 1.70; 95% CI, 1.33–2.18; P < 0.001). Women aged 18–24 years had the lowest rate of folate supplement use (15.9% in 2006), while women aged 30–34 years had the highest rate (30.3% in 2006).Conclusions: There has been no further reduction in prevalence of NTDs in Victoria since 1999, and this prevalence remains well above that achievable through adequate folate intake. Accurate knowledge of folate consumption, population-based NTD prevalence data and folate awareness data are essential in monitoring the effectiveness of the mandatory fortification program to be implemented in Australia in the next 2 years.

Louise du Plessis BSc(Hons), MB ChB, FRACP · Rod W Hunt BM BS, MMed, PhD · Ashley S Fletcher BSc, MEpi · Merilyn M Riley BApplSc, GradDipEpi, Biostat · Jane L Halliday BSc, PhD

In April 2008, the Australian Government established the National Preventative Health Taskforce to develop a National Preventative Health Strategy by June 2009. The Strategy will provide a blueprint for tackling the burden of chronic disease currently caused by obesity, tobacco and excessive consumption of alcohol. The Taskforce has produced a discussion paper, Australia: the healthiest country by 2020. It presents a wide range of options, some of them contentious, to achieve this ambitious target.

A Rob Moodie MB BS, FAFPHM, MPH

To the Editor: The Australian Transport Council should be commended for approving the National Transport Commission’s revised road rules for the safety of children in motor vehicles.1 A key requirement is that children aged 4–7 years are to be restrained in an approved forward-facing child restraint or booster seat. It is expected that such changes, once enacted by states and territory governments, will result in fewer children being injured and killed. In a letter in the 4 August issue of the Journal, Zurynski and colleagues argued that these changes will bring Australian rules closer to — but nevertheless fall short of — overseas jurisdictions, where children up to 12 years of age or 145 cm in height must be restrained in booster seats.2 Notably, a wider selection of booster seats is available in these jurisdictions, including seats suitable for children weighing up to 36 kg. In contrast, the Australian/New Zealand Child Restraint Standard (AS/NZ 1754) stipulates that an “approved booster seat” is one that has a maximum design weight threshold of 26 kg.3 Mandatory consumer information notes that booster seats are “to be used only with lap-sash seatbelt or with a seatbelt and child harness for a child weighing from 14–26 kg”, and that they are not to be used if the child’s eye level is above the top of the booster back, or above the top of the car seat back or headrest when restrained in the booster seat.3 The matter of children exceeding the maximum weight threshold of 26 kg while failing to meet the transition height to adult seatbelts is far from trivial. Previous research published in the Journal found that about 50% of 7-year-olds whose height fell between 100 cm (the upper recommended height for child car seats) and 145 cm (the recommended seatbelt transition height) exceeded 26 kg, with only 27% having an age- and sex-adjusted body mass index > 25 kg/m2.4 Consequently, due to the current range of approved booster seats available in Australia, children may be placed at some unquantified risk in the event of a crash, as optimal protection above this weight threshold cannot be guaranteed. Further compounding this scenario is that pursuant to r266 of the Australian Road Rules, if a child “cannot safely be restrained as required . . . because of his or her height or weight”, the use of a seatbelt may be deemed acceptable.1 To avoid this scenario, it is essential that booster seats with a higher maximum weight threshold be made available in Australia as soon as practicable.

Michael P Fitzharris · Diana M Bowman

Objective: To evaluate the immune status and vaccination needs of first-year medical students in relation to bloodborne viruses and common vaccine-preventable diseases.Design, setting and participants: Survey of first-year medical students at the University of New South Wales, Sydney, NSW, attending a mandatory screening and vaccination clinic, 2002–2005.Main outcome measures: Self-reported history of vaccination or natural infection; serological evidence of immunity to measles, mumps, rubella and varicella (presence of specific IgG) and hepatitis B (presence of hepatitis B virus surface antibodies) or infection with hepatitis B and C viruses and HIV; and Mantoux test results.Results: 733 students attended the clinic (85% of those enrolled). Four students were positive for HBsAg and four had hepatitis C antibodies. None were HIV-positive. Twenty-nine per cent (216/733) were not immune to hepatitis B, 33% (238/724) to mumps, 26% (190/724) to measles, 13% (91/724) to rubella and 10% (75/724) to varicella. About 23% (91/237) needed further testing for tuberculosis. Immunity corresponded poorly with self-reported history of vaccination. More students reported vaccination against rubella (96%), measles (81%) and mumps (80%) than were immune, and fewer reported vaccination against hepatitis B (44%).Conclusions: Many students were not immune to vaccine-preventable diseases, and a small number had a previously undiagnosed bloodborne virus infection (hepatitis B or C). The level of immunity to vaccine-preventable infections was unacceptable and justified the provision of an easily accessible program for screening and vaccination.

Adrienne J Torda FRACP, GradDipBioethics, PhD

Mumps has re-emerged as an infection in the developed world. Its epidemiology has changed, with the majority of cases now primarily affecting adolescents and adults. While mumps is easily suspected if parotitis is present, parotitis is absent in 10%–30% of symptomatic cases. Mumps is a systemic infection with a variety of extra-parotid complications. In Australia, mumps diagnosis is confirmed by antibody testing and reverse transcriptase-polymerase chain reaction techniques. Suitable specimens for testing are serum, saliva, urine and cerebrospinal fluid. Treatment is generally supportive, although intravenous immunoglobulin therapy may have a future role in mumps management. Interferon alpha-2b treatment may be considered specifically for mumps epididymo-orchitis. Mumps vaccine is included in the measles–mumps–rubella (MMR) vaccine. In Australia, this vaccine is routinely administered at the ages of 1 and 4 years. Serious reactions to the mumps components of the MMR vaccine are rare.

Sanjaya N Senanayake BSc(Med), MAppEpid, FRACP

Leading international health organisations are concerned about high use of artificial tanning services and the associated risk of skin cancer. Similar concerns exist about the growing Australian solarium industry. Pre-teens appear to be ignoring sun safety messages in their desire to tan and use solaria. A significantly elevated risk of melanoma exists among people exposed to artificial ultraviolet radiation; the risk is higher for those younger than 35 years at first solarium use. For all users, the risk of squamous cell carcinoma is more than doubled compared with non-users. We estimated the numbers of new melanoma cases and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states and indirectly quantified potential costs to the health system that could be saved by effective regulation of the solarium industry. Annually, 281 new melanoma cases, 43 melanoma-related deaths and 2572 new cases of squamous cell carcinoma were estimated to be attributable to solarium use. The annual cost to the health system — predominantly Medicare Australia — for these avoidable skin cancer cases and deaths is about $3 million. By successfully enforcing solarium regulations that ban use by people younger than 18 years or with fair skin, favourable health and cost benefits could be expected.

Louisa G Gordon MPH, PhD · Nicholas G Hirst BComm, BEc · Peter H F Gies PhD · Adèle C Green MB BS, PhD

Trachoma: a blinding scourge from the bronze age to the twenty-first century. Hugh R Taylor. Melbourne: Haddington Press, 2008 (282 pp). ISBN 978 09757695 9 1. Why would a substantial scholarly work devoted solely to trachoma be published in Australia? For two good reasons: firstly, trachoma, a disease of poverty and poor countries, is still found in Australia. Secondly, it is written by a world renowned trachoma expert, the University of Melbourne’s Professor Hugh Taylor. Taylor’s passion is evident in this comprehensive review of trachoma from antiquity to the present, a scientific work of great detail and scope. Copies and extracts of documents, photographs and images, both from the author’s own collection and from sometimes obscure sources, support the text. Many of the photos were taken by Professor Taylor during his extensive field studies in Africa, Mexico and Australia, as well as in his laboratory studies. To this extent, the book provides a record of Taylor’s many years in the field and in the laboratory, his work ranging from vaccine development to simple, practical but effective means of eliminating trachoma in children at risk. Taylor draws our attention to the fact that the establishment in the 19th century of many now-famous ophthalmic hospitals was due to the trachoma epidemic in Europe, and even in Australia. He describes how improved living conditions in Europe and much of Australia at the beginning of the 20th century led to the almost total disappearance of trachoma. There is a clear exposition of why trachoma still exists in some remote areas of Australia, offering evidence of control measures and, importantly, evidence for advocacy to policymakers so that they may make evidence-based decisions on the subject. This book is an invaluable reference work for medical researchers, providing an in-depth knowledge of the subject. For public health planners, sections on the prevalence and natural history of the disease, with proven interventions detailed, will be invaluable. Students will find that this work covers much of what they need to know about a disease all but eliminated, yet which still persists in pockets of disadvantaged areas around the world.

Jill E Keeffe

To the Editor: Snowboarding is increasing in popularity, but Australian snowboarders have been shown to have 2.4 times as many fractures as skiers, with 35% of upper limb injuries being fractures.1 The most common site of injury is the wrist, accounting for 21.6% of all snowboarding injuries.2 It has been suggested that the use of wrist guards could reduce the risk of injury, particularly as snowboarding injuries tend to be impactive rather than torsional.3,4 However, concern has been raised that use of wrist guards will redistribute the impact of the force to more proximal areas of the arm, causing elbow injuries.5 We conducted a case–control study at the Mount Buller Medical Centre, Victoria, during the 2004 and 2005 ski seasons to assess: the association between wrist guard use and wrist fracture in snowboarders in Australia; and the association between wrist guard use and the severity of wrist and elbow injury. Cases were defined as any snowboarder seen at the clinic with a fractured wrist (n = 119). Controls (n = 375) were snowboarders — identified by their boots — who attended the clinic, either as companions to case participants or other patients, or as patients presenting for a reason other than wrist fracture. Study participants completed a questionnaire about wrist guard use and snow-sport behaviour. The site and severity of fractures were recorded by clinic staff. Logistic regression was used to determine adjusted odds ratios for risk factors against the main outcome measure of wrist fracture and injury in snowboarders with and without wrist guards. Characteristics strongly associated with wrist fracture were being of school age (odds ratio [OR], 2.37; P < 0.001) and being a novice at snowboarding (OR, 3.41; P < 0.001) (Box). After adjustment for all significant variables — sex, age, days of snowboarding and snowboarder ability — the odds of having worn wrist guards were lower in snowboarders with a wrist fracture (cases) than in those without such a fracture, but the difference did not reach significance (adjusted OR, 0.58; 95% CI, 0.32–1.04; P = 0.07). Full analysis of all factors considered is available from the authors. Among the sample of 494 snowboarders, 15 had elbow injuries, comprising: five with soft tissue injuries (4/86 wearing wrist guards v 1/391 not wearing wrist guards; adjusted OR, 17.6; 95% CI, 1.93–160.2; P = 0.01); and 10 with elbow fractures or dislocations (3/86 wearing wrist guards v 77/391 not wearing wrist guards; adjusted OR, 1.84; 95% CI, 0.46–7.30; P = 0.39). The association between wrist guard use and increased soft tissue elbow injuries, but not elbow fractures and dislocations, supports the value of wearing wrist guards to reduce overall injury severity. Despite a lack of overall statistical significance, the clinical context and consistency in direction of the findings suggest that snowboarders who wear wrist guards in Australian snow conditions could benefit from a reduction in wrist fracture injury of approximately 42%. This is consistent with reports from other countries that show a protective effect of wrist guards of 52% to 87%, with the greatest benefit in novice snowboarders.4 We suggest that wrist guard use should be strongly recommended for novices, and should be mandatory for school-aged snowboarders. Local schools in the Mansfield district, near Mt Buller, have adopted a policy of “no wrist guard = no snowboard”, and we hope that other schools visiting Mt Buller, and indeed other ski resorts in Australia, will follow this lead. Characteristics associated with wrist fracture among snowboarders Characteristic Cases (n = 119) Controls (n = 375) Odds ratio (95% CI) P for difference Wearing wrist guards today No 100 (84%) 299 (80%) 1.00* Yes 18 (15%) 75 (20%) 0.72 (0.41–1.26) 0.25 Missing data 1 (0.8%) 1 (0.3%) Age (years) 0–19 72 (61%) 149 (40%) 2.37 (1.55–3.63) < 0.001 > 19 46 (39%) 226 (60%) 1.00* Missing data 1 (0.8%) Ability of snowboarder Novice 60 (50%) 112 (30%) 3.41 (1.79–6.49) < 0.001 Intermediate 43 (36%) 173 (46%) 1.58 (0.82–3.04) 0.17 Advanced 14 (12%) 89 (24%) 1.00* Missing data 2 (2%) 1 (0.3%) * Reference category.

Graham M Slaney · Judith C Finn · Angus Cook · Philip Weinstein

To the Editor: During the recent international cricket series between Australia and India, we were alarmed by the sight of our Australian cricketers prominently badged with the logo of the fast food giant KFC. Australia is experiencing an epidemic of overweight and obesity, a problem that is especially affecting children, adolescents and young adults.1 This epidemic is worsening as a direct result of unhealthy eating habits and low levels of physical activity. Obesity is associated with chronic and costly diseases that lead to premature death and ill health. These include diabetes, cardiovascular disease, respiratory problems, sleep apnoea, certain cancers, mental illness and osteoarthritis, which can begin in adolescence.1 Cricket in Australia enjoys considerable popularity and a strong national following. Our cricketers are national sporting heroes who enjoy widespread support and respect throughout the community, particularly among younger members of the community, who aspire to emulate them. Against this background, we are increasingly concerned and disappointed that Cricket Australia has a sponsorship agreement with, and consequently promotes, KFC — going as far as publicly declaring the company the “official fast food restaurant of Cricket Australia”.2 This advertising uses the standing of cricket and its players to endorse and promote unhealthy eating habits, one of the major root causes of obesity in Australia. KFC products have caloric and fat contents well above the national dietary guidelines, which recommend < 30% energy from total fat and < 10% energy from saturated fat.3 For example, a standard serve of original-recipe chicken contains about 58% total fat and 24% saturated fat.3 Furthermore, we have shown that even one common KFC meal per week can adversely affect recommended healthy diets.4 It is ironic and regrettable that Cricket Australia, while having done so much for the sport, encourages the promotion of unhealthy, high-fat, high-calorie KFC products that negate the benefit of increased physical activity associated with playing cricket. With the explosion of obesity-related illness, we need champions to encourage health-promoting behaviours, particularly healthy eating and increased physical activity. The enthusiastic encouragement of unhealthy and undesirable eating habits should have no place in sporting sponsorship. Not so long ago, similar sentiments were being expressed about tobacco sponsorship of sport, which fortunately has been eradicated. Cricket Australia should consider its responsibilities to Australia’s children and youth and review its sponsorship by KFC. This would benefit the health of the community and demonstrate leadership and social responsibility by Cricket Australia and Australia’s elite cricketers.

Stephen Colagiuri · Ian D Caterson

In reply: Cricket Australia (CA) actively supports physical activity, healthy eating and healthy lifestyles and continues to invest considerable effort in encouraging Australians to play cricket, in everything from formal, organised competitions to social games in the backyard, in parks and schoolyards and at the beach. In a time of declining community physical activity, we are heartened to see that active participation in cricket is growing strongly, and note that female cricket is the fastest growing female sport in Australia. As a community-based, not-for-profit organisation, we are heavily dependent on the support of all of our sponsors, including KFC, to be able to implement the activities we undertake. These range from community-based programs that get kids running around outside to programs in schools, clubs and Indigenous communities, and further activity needed to develop and put elite international cricketers onto the field. In relation to KFC, we believe in a little of everything and everything in moderation. Setting aside the truly elite athletes, the formula that is going to work best for most cricketers and cricket fans is reasonable, not extreme, training and physical activity, together with a balanced diet, not one that features total abstinence from high-energy foods. Our view on alcohol is the same. Our CA advertising featuring Merv Hughes encourages fans to enjoy a beer, but not at the rate of one per over. The overall issue is about balance. Consumer research — commercially confidential, so it can’t be referenced here — shows that KFC consumption in Australia is an occasional treat, not a dietary staple. More broadly, CA is comfortable that Australian cricket’s collective activity has a net positive impact in encouraging healthy and active lifestyles.

Peter Young

A 66-year-old, previously well man presented with colicky abdominal pain and vomiting. He was a cigarette smoker and consumed homemade spirits daily. On physical examination, the patient had poor dentition, a bluish pigment along the gingival line (Figure, arrow), and generalised abdominal tenderness with no peritonism; he was afebrile with a heart rate of 68 beats/min, blood pressure of 190/90 mmHg with no postural drop, and oxygen saturation of 99% in room air; and all other results were normal. Full blood examination revealed normocytic anaemia (haemoglobin, 90 g/L; reference range, 130–180 g/L) and basophilic stippling. The patient’s blood lead level was elevated at 7.10 μmol/L (reference range, < 0.48 μmol/L), but fell to 2.28 μmol/L after 3 weeks of treatment with the chelating agent 2,3-dimercaptosuccinic acid (DMSA). Burton’s lead line indicates lead poisoning and occurs due to deposition of lead sulfide, the result of a reaction between sulfur produced by oral flora and lead.1,2 The source of this patient’s lead exposure is unknown. Distilling equipment, especially for spirits, can be a source of lead exposure,3 but testing of this patient’s equipment ruled it out as a source.

Jayne E Camuglia · George Grigoriadis · Christopher P Gilfillan

Cervical cancer associated with human papillomavirus (HPV) affects approximately 1000 Australian women each year, causing about 300 deaths.1 The newly licensed HPV vaccines Gardasil (CSL Limited), a quadrivalent vaccine (4vHPV), and Cervarix (GlaxoSmithKline Vaccines), a bivalent vaccine (2vHPV), induce protection against the two most common strains of HPV, which cause 70% of all cervical cancers.2,3 The quadrivalent HPV vaccine was included in the government-funded National Immunisation Program from April 2007 for females aged 12–26 years. The initial phase targeted secondary schools, vaccinating girls aged 12–17 years in Years 7, 10, 11 and 12. This program was conducted by local government vaccination teams in Victoria. The reactogenicity of 4vHPV reported in clinical trials was acceptable, with serious adverse events following immunisation (AEFI) reported in less than 0.1% of vaccine recipients.4 In Australia, AEFI are reported to the Adverse Drug Reactions Unit (ADRU) of the Therapeutic Goods Administration, either directly or via state authorities. In Victoria, to enhance AEFI surveillance and clinical support, the state government funded a new service, SAEFVIC (Surveillance of Adverse Events following Vaccination in the Community) in April 2007. Details of a mass psychogenic eventOn 7 May 2007, 720 girls aged 12–17 years received 4vHPV at a girls school in metropolitan Melbourne. Within 2 hours of vaccination, 26 girls presented to the school’s sick bay with symptoms including dizziness, syncope and neurological complaints. Four were transported by ambulance to a nearby paediatric hospital with a range of symptoms, including palpitations (1), dizziness (4), syncope or collapse (3), weakness (3) and aphasia (1). Further history-taking and examination, including specialist paediatric neurological review, found no organic basis for the reported symptoms. The results of all investigations, including neuroimaging and electroencephalography in one patient and electrocardiography in another, were normal. Two patients recovered spontaneously and were discharged from the emergency department, while the other two were observed overnight and discharged the following day. One was readmitted 2 days later after a further episode of syncope with subsequent lower limb weakness, but was discharged the following day. The four girls transported to hospital were reviewed in the SAEFVIC clinic. Three received subsequent doses of 4vHPV under supervision, with no further AEFI. One girl declined further doses. The Victorian Government asked the ADRU and the National Immunisation Committee if they knew of any similar reports, but no significant 4vHPV-related AEFI were identified. Searches of the United States Vaccine Adverse Event Reporting System and by the vaccine manufacturer failed to identify any similar reactions from pre-licensure trials or post-licensure surveillance. A review of the school vaccination processes showed that all recommended procedures had been followed: each vaccine was administered to seated children without others watching, there were separate entrances and exits for vaccinees, and a single class queued at any one time. Importantly, the entire school was built around a central quadrangle, with each of the 26 symptomatic girls taken to the sick bay being led through there in view of all classrooms. DiscussionWithout evidence of an organic aetiology or similar reports of AEFI elsewhere after the initiation of population vaccination with 4vHPV using the same vaccine batch, it is highly likely that this cluster was the result of a psychogenic response to mass vaccination in a school setting. With the implementation of a community-wide immunisation program, mass school programs are highly cost-effective and most effective for maximal coverage. However, similar psychogenic responses are well documented.5 Mass psychogenic illness has been defined as “the collective occurrence of a constellation of symptoms suggestive of organic illness but without an identified cause in a group of people with shared beliefs about the cause”.5 Minimising the risk of this phenomenon should routinely be considered when planning mass vaccination campaigns. All AEFI reported by patients, parents and clinicians must be investigated appropriately. This is especially important for potentially serious events. AEFI may be caused directly or triggered by a vaccine or the process of vaccination, or may have occurred coincidentally. It is important that all such events be responded to in the same manner, regardless of suspected cause. Post-licensure surveillance of AEFI is critical for all vaccines and therapeutic drugs, as pre-licensure trials are not large enough to reliably detect rare adverse events and are conducted in well controlled conditions that are less influenced by the vagaries of community interpretation. Prompted by a talkback radio telephone call by the mother of one of the four girls taken to hospital, there was considerable media interest in and public anxiety about this series of events, with national and international coverage.6 The national response included radio interviews with the then federal health minister and the Victorian state premier.7 Responses of this type may be expected with the mass introduction of a new vaccine to adolescents in a school setting. The requirement to complete a course of three vaccinations for a large population by the end of the school year limited the time available for education and consultation before commencement of vaccinations. As for any population-wide strategy of giving injections to healthy individuals, immunisation programs will continue to be challenged by reports of adverse event clusters in the future. The ability to rapidly detect and assess these cases to determine whether they represent real vaccine-associated AEFI or are due to other factors is critical to maintaining long-term community support for vaccination.

Jim P Buttery MB BS, MSc, FRACP · Simon Madin MB BS · Nigel W Crawford MB BS, FRACP, MPH · Sonja Elia RN · Sophie La Vincente MSc · Sarah Hanieh MB BS · Lindsay Smith MB BS, FRACP · Bruce Bolam MB BS, MPH

Worried sick: a prescription for health in an overtreated America. Nortin M Hadler. Chapel Hill: University of North Carolina Press, 2008 (viii + 376 pp). ISBN 978 0 8078 3187 8. Public and professional debate about health services has traditionally been dominated by concerns that needy patients are missing out on helpful care. In recent years, another perspective has been gaining ground: that too many people are having unnecessary, ineffective or even harmful tests and treatments. This argument is strongly and provocatively put by Nortin Hadler, Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and attending rheumatologist at UNC Hospitals, in his second book examining this issue. Professor Hadler argues that the institution of medicine has become self-serving in its medicalisation of the everyday complaints of life. He describes as “type II medical malpractice” doctors doing the unnecessary, albeit very well, and argues that health insurance should only underwrite interventions with a meaningfully advantageous benefit-to-risk ratio. His critique of the evidence used to back many common interventions is scathing, and he gives particularly short shrift to the claims of interventional cardiologists and cardiac surgeons. Others in his sights include the New England Journal of Medicine’s Editor-in-Chief, Dr Jeffrey Drazen, and epidemiologists involved in such practices as data dredging. Professor Hadler has little respect for holy cows, finding faults with evidence-based medicine, systematic reviews, large randomised controlled trials, and the quality movement. But he is not a nihilist. He wants to bolster people’s resources for coping with the everyday complaints of life, whether they be heartburn, backache, or insomnia. To be well, he points out, is not the same as feeling well. Readers may disagree with Professor Hadler’s interpretation of the literature or philosophical view. But don’t let this put you off. Apart from providing plenty of food for thought, his self-confessed “diatribe against medicalisation” is an engaging read. “We are”, he rails at one point, “a country of obese, hypercholesterolemic, hypertensive, diabetic, osteopenic, depressed, pitiful creatures perched on the edge of a cliff staring at condors: cancer, heart attacks, strokes, dementia, fractures and worse. We fear for our future. We teach our children that they, too, must live in fear for their future.” Something similar might be said of Australians, perhaps.

Melissa Sweet