Environmental health

Worldwide, over 80% of primary liver cancers are attributable to chronic infection with hepatitis B or C virus. Over the past two decades, primary liver cancer incidence rates have been consistently rising in Australia. In New South Wales, the standardised incidence ratios for primary liver cancer in males born in Vietnam, Hong Kong and Macau, Korea, Indonesia and China and in females born in Vietnam and China are 6–12 times those in Australian-born populations. The incidence of liver cancer is likely to continue to increase unless a coordinated approach to disease control can be developed. Effective programs for chronic hepatitis B management need to link prevention, treatment and care, and enhance opportunities for research and surveillance activities. The evidence that suppression of hepatitis B virus replication could limit disease progression needs to inform the development of a public health response. Lessons learned in the development of the National Hepatitis C Strategy and the experience of international hepatitis B control programs need to inform this process.

Monica C Robotin FRACS, MApplEpid · Jacob George FRACP, PhD · Rajah Supramaniam BSc, MPH · Freddy Sitas MSc, DPhil · Andrew G Penman MACP, MPH

Objective: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory.Design and participants: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up).Main outcome measures: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates.Results: Mortality in the cohort was 964/100 000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42–0.89). CVD mortality was 358/100 000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23–1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population.Conclusion: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.

Kevin G Rowley PhD · Kerin O’Dea PhD, AO · Ian Anderson MB BS, FAFPHM, PhD · Robyn McDermott FAFPHM, MPH, PhD · Karmananda Saraswati MB BS, FAMAC · Ricky Tilmouth · Iris Roberts EN · Joseph Fitz · Zaimin Wang PhD · Alicia Jenkins MD, FRACP · James D Best MD, FRACP, FRCPath · Zhiqiang Wang PhD · Alex Brown BMed, MPH, FCSANZ

To the Editor: The case reports presented by Gunja et al1 are a serious concern from many perspectives. The health authorities should be commended for their rapid risk assessment and alerting the community, which led to the immediate withdrawal and recall of the toy beads from the marketplace. However, the question needs to be asked: Could this situation have been prevented, and if so, how? There are many toys in Australia that potentially pose risks to children. These can include physical dangers, such as the size of toys, with risk of choking, to toxicological dangers, as we have seen with Bindeez toy beads (containing 1,4-butanediol), and psychological and social concerns, such as the effects of sexually provocative toys on young girls and “aggressive” toys (which may encourage violence) on young boys. More research is required to test the psychological influence of such toys on children. The evidence should be used in the development of guidelines for safer toys. At present, toy manufacturers in Australia must adhere to the Australian Toy Standard (AS/NZ 8124), established by Standards Australia.2 Toys are monitored and regulated mostly by the state governments. While the manufacturers are expected to adhere to these standards, they are in fact voluntary standards and self-regulated, and many toys can enter and be sold in Australia without meeting these standards. When a consumer or state government inspector is concerned about the safety of a toy, or if it violates the regulation, they may contact one of the state offices of fair trading, which have the power to remove the toy from the marketplace. This is essentially a post-hoc auditing system and plays an important role in safety, but action is essentially taken after a problem is detected, such as is the case with the Bindeez toys. In view of potential concerns, I believe what we need in Australia are stronger regulations and guidelines that we can provide to manufacturers to help produce safer toys. Our efforts should be towards preventing any potential harm by strengthening existing regulations, establishing consistent national and international standards for all imported toys, providing more resources for the verification and testing procedures and more expertise and wider consumer input into the safety and suitability of the types of toys permissible in Australia. We have a duty to protect and safeguard our children from both psychological and physical dangers.

Vicki Kotsirilos

The Oxford Health Alliance is willing to work with organisations, public or private, whose business goals are aligned with promotion of health and human capital Some years ago, one of us (S P) left his job as a specialist physician in the Danish National Health Service to take up a position in the pharmaceutical industry, with the Danish diabetes care company, Novo Nordisk. He spent the next 15 years fielding the questions of worried people who wanted to know if he missed working as a (real, honest) doctor. Today, he heads the Oxford Health Alliance, a non-profit global collaboration for health — started with an industry grant from the same company. The Alliance is trying to find solutions to the huge problems arising from lifestyle disorders such as diabetes, cardiovascular diseases and chronic lung diseases.1 The Alliance includes not only academia, government and non-government organisations, but the private sector, including some global corporations. In some people’s minds, this makes it inherently untrustworthy. We find ourselves fielding another question: “Can you work with industry to improve the public’s health without sacrificing your professional and organisational ethics and integrity?” Surprisingly, the most vocal critics of any involvement of for-profit organisations in efforts to advance public health come from opposing camps. On one side are purist academics and certain non-government organisations, and on the other, some business people and fundamentalist economists.2 One obvious problem is conflict of interest arising from extensive alliances between scientists and academic institutions and the private sector.3 Another valid criticism is that the pursuit of self-interest comes at the expense of objectivity, demonstrated by studies that have found a significant relationship between industry-funded research and results that favour industry.4 The politically based critics of alliances with industry automatically assume that industry is motivated by the desire for improved public relations, the co-option of opinion leaders in the scientific community, or leverage to forestall legislative and regulatory efforts that may prove unfriendly to business. When companies are driven by the need to make profits for their owners and investors, corporate objectives are seen by many as inherently incompatible with initiatives to improve the health of the general public.5 In the business world, it is not uncommon to hear phrases such as “the business of business is business”, or that the only true responsibility is to the shareholders and any deviation from this is bad business. But, in the light of global warming and the magnitude of the social and health burden associated with contemporary lifestyles, these truisms do not hold up. We are not advocating naivety. After all, tobacco use has been fought for 50 years and still it increases in many countries, despite the World Health Organization’s Framework Convention on Tobacco Control and the irrefutable evidence that underpins it. The tobacco war has left almost everyone in the public health professions with the feeling that you cannot trust industry. At the same time, the powerful pharmaceutical industry has gradually lost much of its credibility by concentrating more on making money than finding new and better drugs. The pharmaceutical industry has also been repeatedly, and in many cases deservedly, criticised for suppressing unfavourable research results.5 However, while we unreservedly subscribe to the notion that “two wrongs don’t make a right”, we cannot quite come to terms with the different standards often applied to the self- interest of government and the self-interest of corporations. For example, there is considerable anecdotal evidence that government departments have declined to publish commissioned reports, or parts thereof, for fear of attracting criticism if they or the incumbent government fail to act on the content. What this tells us is that whenever two or more parties interact, regardless of whether the interaction is public–private or public–public, there will always be potential for interference and tensions between the self-interests of the parties concerned. Such conflicts are part of life, so the lesson is not to refrain from working together, but to put safeguards in place to control the dominance of the party whose interests may have detrimental consequences and, in the case of industry, to engage early and transparently to find solutions that produce mutual benefit. In the long term, business can only grow and thrive in societies that function well, and faltering economies, damaged human capital and global warming will also heat boardrooms. All businesses function within the legal frames defined by the societies in which they operate and will not survive in the long run if they do not. In an ideal world, business could be regulated in ways that are closely aligned with the goals of the democratic societies in which they function. But regulation is often too little, too late, and we do not always know precisely what will fix the problems we create. Furthermore, governments are far better at using regulation to punish bad corporate practice than at creating incentives for companies to compete on their contribution to improving health and the environment. However, the recent leadership of the climate change debate, adopted by many corporations previously opposed to change, is one example of how change is possible when the balance between punishment and incentives is shifted. The collaboration between the World Wide Fund for Nature and the large construction company Lafarge is an example of integrating sustainability into the company vision.6 The Forest Stewardship Council is an example of a successful worldwide collaboration for sustainable forestry among loggers, foresters, and environmentalists.7 Today, we see some early adopters — these are corporations that are adjusting their product portfolios and corporate social responsibility policies to contribute to solving big societal issues. For example, Novo Nordisk has for many years reported on its environmental impact. The company works to reduce harm through corporate programs and a foundation to support better access to health in the least developed nations.8 Some companies are redefining what it means to be a good business and playing important roles in finding solutions to the problems of health and environment, for a variety of reasons — social responsibility, or to grow and protect their future as well as their current business interests.9 Capitalism has many forms, and the Scandinavian model seems to show that a collaborative public–commercial approach can work if people want it to, and even in a way that creates happiness for the population, as evidenced by the consistently high rating of the Scandinavian countries on world happiness rankings.10 And, as well understood by Gro Harlem Brundtland when she called on relevant industries to collaborate on the global diet and physical activity strategy shortly before retiring as Director-General of WHO, markets can be shaped to promote better lifestyles if we can find the right levers.11 We will never know how successful Brundtland may have been in this had she remained at WHO, but we do know that the dialogue between WHO and industry has continued. A synergistic approach will take time, and we have little history of sustained interaction to guide us. We must therefore seek ground where profitability and public health coincide and challenge practices that place profits and public health in conflict. Market forces, applied appropriately, could be a powerful means of advancing health. Having no interaction with industry means missing the opportunities for using the unique skills and resources of all parties. Yet interaction, particularly when money changes hands, must not undermine public confidence or the common good, or distort what all progress must be based on — sound evidence from rigorously objective research and evaluation. So the answer to our question about working with industry and business is that we cannot afford not to. They make our world go around: their products, services and advertising shape our lives and construct our futures, and their capacity to employ people far outstrips that of governments. Health and the physical environment cannot be changed without them. We must put aside ideological trench wars and make a genuine and concerted effort to find ways of working together for health that satisfy and uphold transparency, accountability and community ethics. This will require experimentation and the will and innovation of public authorities to find appropriate and accountable ways of working with all stakeholders, including the food, agriculture, building and other industries. There will be mistakes, possibly even blunders, but if we are to achieve lasting, positive change, this must be tried and tested. The Oxford Health Alliance illustrates a new way of working with industry, that is, bringing public and private interests to the same debate at the same table. It intentionally works with industry and, in its short life, has been instrumental in taking the chronic disease prevention agenda out of the health silo and into the broader environment in which the agents of chronic disease are generated. The Alliance is conscious of the potential pitfalls associated with industry partnerships. It guards against these by: (1) making public its methods1 and the names of its collaborators and funders (see http://www.oxha.org); (2) having and following transparent guidelines for working with industry; and (3) prohibiting the use of its name in association with specific products. The Alliance will not work with the tobacco industry and has been a strong supporter of the Framework Convention on Tobacco Control. It is willing to work with any legally constituted, credible entity that wishes to align its business goals with promoting health and human capital, whether public or private, and which is willing to work within the Alliance’s philosophy and framework for transparency.

Stig Pramming MD · Ruth Colagiuri BEd, GradCertHlthPolMgnt

Objective: To determine which industries and occupational groups are associated with employment of older workers with chronic work-limiting health conditions in Australia.Design and participants: Analysis of data from the 2005 National Health Survey for 4228 workers aged 45–64 years.Main outcome measures: Rate of employment by industry and occupation of older workers with specific chronic conditions.Results: Compared with the reference industry of property and business services, workers in the retail trade industry were found to be more likely to suffer from musculoskeletal conditions (relative risk ratio [RRR], 1.56; 95% CI, 1.04–2.36), while those in health and community services had higher rates of cardiovascular disease (RRR, 2.17; 95% CI, 1.11–4.24). Compared with the reference occupation group of professionals, managers and administrators were less likely to suffer neoplasms (RRR, 0.25; 95% CI, 0.07–0.97). Similar rates of chronic disease were seen across other occupations.Conclusion: Increasing rates of chronic health conditions are unlikely to have an even impact across the workforce, as the rate of employment of older workers with these conditions varies between industries.

Deborah J Schofield PhD, BSpPath, GradDipComp · Susan L Fletcher BAppSc(Psych), PGDipPsych · Arul Earnest BSocSc, MSc · Megan E Passey BMed(Hons), MPH, MSc · Rupendra N Shrestha BSc, MSc(Statistics)

Human papillomaviruses (HPVs) are the major cause of cervical cancer. Cervical cancer mortality has been reduced in Australia because of effective screening programs, but there are still about 800 new cases and 300 deaths per year. Worldwide, mortality and morbidity are high. Australia was the first country to introduce fully funded immunisation with a quadrivalent HPV vaccine for girls aged 12 and 13 in schools. A 2-year catch-up program covers all women to the age of 26 years. Age stratification of HPV prevalence showed the highest rates in women under 25 years of age, a decrease in women from 30 years of age and a second smaller peak in those over 45 years. Recently, a bivalent HPV vaccine has been licensed for use in women aged up to 45 years. Older women have robust immune responses to the bivalent HPV vaccine, and so should derive benefit from the vaccine if exposed to HPV type 16 or 18 in the future. It is likely that this vaccine will need to be purchased by women in the older age group (27–45 years).

S Rachel Skinner MB BS, PhD, FRACP · Suzanne M Garland MD, FRANZCOG, FRCPA · Margaret A Stanley OBE, FMedSci · Marian Pitts PhD · Michael A Quinn MRCP(UK), FRCOG, FRANZCOG

To the Editor: I note the concern expressed by Byard and Matthews about the safety of three-wheel strollers.1 Surely a safer method of control would be for the brake to be on at all times other than when the stroller is in use? This could be done by having a lever that had to be held in position by the user in order to move the stroller. Should not this be required in the safety standard?

Charles Bridges-Webb

Australia, like other high-income countries with a low TB incidence, faces special challenges in controlling TB Books with optimistic titles such as Triumph over tuberculosis, The retreat of tuberculosis and The miracle of empty beds were published in the 1970s and 1980s. Readers of the Journal may therefore be surprised to find six articles on tuberculosis (TB) in this one issue in 2008.1-6 Far from having dis-appeared, TB is the dis-ease that still affects the dis-placed, the dis-advantaged, the dis-possessed, the dis-rupted and those with dis-abled immune systems. Displaced persons and migrants accounted for 85.5% of the 1201 TB cases in Australia in 2006.7 Overseas-born TB patients commonly come from India, Vietnam, Indonesia, China and the Philippines. Sudan and Somalia have more recently joined this list, following the shift in Australia’s immigration policy to accept more African refugees. These national figures are reflected in the letter from Robinson et al, which describes a retrospective review of TB cases seen at The Children’s Hospital at Westmead, Sydney, between 2004 and 2006 (&rarr Tuberculosis in children: a tertiary centre perspective).5 Of the 23 children with active TB disease, 18 (73%) were born overseas, mainly in Africa and the Indian subcontinent. Compared with data from 1982–1991, the proportion and number of latent TB infections diagnosed in children had increased due to active screening of refugee populations. The article by Dobler et al highlights the successful outcome of directly observed treatment for TB cases in Australia, while alerting Australian doctors to the fact that migrants with treated TB who visit their TB-endemic country of birth may develop a second episode of TB that represents a new infection rather than a relapse of their previous disease (→ Recurrence of tuberculosis at a Sydney chest clinic between 1994 and 2006: reactivation or reinfection?).1 TB also affects the disadvantaged and dispossessed, as illustrated by the fact that the TB incidence in Australia’s Indigenous population has been 7–15 times higher than in the non-Indigenous Australian-born population over the past decade.7 TB affects those with disabled immune systems. People infected with HIV have nearly 10 times the lifetime risk of developing TB compared with HIV-negative people.8 HIV/TB coinfection is not considered a major problem in Australia, with only 11 HIV/TB patients identified in 2006.7 However, the national TB notification system recorded the HIV status of only 35.2% of TB patients in 2006.7 Emerson and Post rightly exhort Australian clinicians to offer HIV testing to all TB patients (→ To routinely offer testing for HIV infection in all cases of tuberculosis: a rational clinical approach?).2 In fact, establishing the HIV status of TB patients could be regarded as an expected standard of care. Other immunocompromising conditions — such as chronic renal failure, transplantation, or treatment with glucocorticoids or tumour necrosis factor α inhibitors — also increase the risk of TB reactivation twofold or more.8 For patients about to receive tumour necrosis factor α inhibitor therapy, Gupta et al propose a screening strategy for latent TB infection using an interferon γ release assay, such as QuantiFERON-TB Gold (Cellestis, Melbourne, Vic) or T-SPOT. TB (Oxford Immunotec, Oxford, UK) (→ Tumour necrosis factor α inhibitors: screening for tuberculosis infection in inflammatory bowel disease).6 The optimal application and interpretation of these assays is controversial. For example, although various versions of the QuantiFERON assay have been approved by the United States Food and Drug Administration and endorsed by the US Centers for Disease Control and Prevention, Australian and Canadian TB authorities are continuing to recommend the tuberculin skin test for diagnosing latent TB infections in most patient groups until the sensitivity, specificity and cost-effectiveness of interferon γ release assays have been better defined.9,10 Finally, like many other infectious diseases, TB affects populations that are disrupted or disorganised due to socioeconomic upheavals, rapid urbanisation, persistent poverty, conflict or war, and where public health systems are therefore either weak or non-existent.11 In a speech to the Lowy Institute in July 2007, Kevin Rudd (then Federal Opposition Leader) highlighted the “arc of instability” to Australia’s near north, noting the recent political unrest in East Timor and several Pacific Island countries and the continuing impoverishment in parts of Indonesia.12 The link between TB and this arc of instability is amply demonstrated by the articles in this issue about illegal foreign fishermen with TB (→ Tuberculosis in illegal foreign fishermen: whose public health are we protecting?)4 and people with multidrug-resistant TB from Papua New Guinea seeking medical care in the “Torres Strait Protected Zone” (→ Evidence of primary transmission of multidrug-resistant tuberculosis in the Western Province of Papua New Guinea).3 For example, Gray et al4 estimated the prevalence of all TB diagnoses among illegal fishermen screened in Darwin over a 15-month period to be 1360 cases per 100 000 population! How should Australia respond internally to this persisting TB problem? Limiting migration and ostracising migrants is not indicated, acceptable or practicable in the “global village” of the 21st century. We require migrants and temporary visitors for our economy, for plugging skill gaps in our workforce, and for nation building. Moreover, molecular epidemiological studies in Australia and overseas have demonstrated that there is negligible transmission of TB from migrant communities to the general population.13,14 The appropriate interventions are to optimise pre- and post-migration detection of active TB disease, to familiarise migrants with the TB clinical services that are freely available if they develop disease, and to detect and treat latent TB infections among subgroups of migrants who would benefit from this intervention (eg, children under 15 years old). The 2006 annual report of the National Tuberculosis Advisory Committee does highlight one migrant subgroup requiring particular attention by documenting that the number of TB cases among health care workers (HCWs) has risen from 34 in 2001 to 65 in 2006.7 This rise is attributable to the increasing recruitment of HCWs from high-incidence TB countries. There were no reports of TB transmission from HCWs to patients in 2006.7 Nonetheless, public and private health institutions, particularly those recruiting HCWs from high-incidence TB countries, must ensure that adequate TB screening is undertaken before and during employment. In common with other high-income countries with a low TB incidence, Australia faces special challenges in controlling TB.15 Continuing undergraduate and postgraduate education of medical and nursing personnel is required to ensure that health professionals remember to “think TB” in at-risk patients. Despite the low incidence of TB, federal and state governments must be encouraged to continue funding TB control efforts and must be dissuaded from devolving TB care from specialised TB services to general clinics in city hospitals. The closure of specialised TB services contributed to the TB epidemic in New York City in the 1980s and 1990s, which may ultimately have cost several billion dollars to control.16 The low incidence of TB may also discourage pharmaceutical companies from selling small volumes of anti-TB drugs at narrow profit margins in Australia, which is a geographically isolated market with stringent regulatory requirements. Federal administrators may need to develop novel solutions to ensure reliable anti-TB drug supplies into the future. How should Australia respond externally to the persisting problem of TB? As long ago as 1993, the TB problem was declared a global emergency requiring a global response. Rudd’s 2007 speech to the Lowy Institute proposed a new strategic partnership with our northern neighbours that emphasised proactive socioeconomic development and promised an increase in Australia’s official development assistance (as a percentage of gross national income).12 TB is one issue for which this rhetoric should become action. In responding to TB as a global emergency, Australia needs to provide direct continuing TB care in specific circumstances to foreign nationals, such as people with multidrug-resistant TB entering the “Torres Strait Protected Zone” and illegal fishermen entering Australian waters.3,4 Addressing only “acute life-threatening conditions” in these groups, as quoted in the article by Gilpin and colleagues,3 is short-sighted in view of the fact that TB is both communicable and potentially deadly. A collaborative approach is necessary in Australia’s border areas. More generally, Australia’s clinical and laboratory expertise in TB control could be harnessed to assist with national TB programs in neighbouring countries through properly funded bilateral partnerships. Such collaboration would be to our mutual benefit. Investment in TB programs in neighbouring high-incidence countries is one control strategy that has been largely ignored by high-income countries with low TB incidence. One analysis suggested that US-funded expansion of TB care into Mexico, Haiti and the Dominican Republic could reduce TB disease among migrants from these countries and would produce net savings for the US.17 The authors suggested that their findings could be generalised to other developed countries with large migrant intakes and should encourage those countries to fund TB control efforts abroad. TB really is where philanthropy and self-interest meet!

Ivan Bastian MB BS, PhD, FRCPA · Vicki L Krause MD, DTM

Objective: To document demographic details, prevalence of tuberculosis (TB), and completion of TB treatment in illegal foreign fishermen detained in Australia.Design and participants: Clinical audit of 1471 illegal foreign fishermen who underwent health assessments in Darwin between 28 September 2005 and 31 December 2006.Main outcome measures: Demographic details, diagnoses of smear-positive and culture-positive TB, drug sensitivity results and treatment completion.Results: 1471 illegal fishermen underwent health assessments, including chest x-ray screening. All were male and 93.8% were from Indonesia. Of the 31 fishermen (2.1%) admitted to hospital with chest x-rays suggestive of TB, 20 were diagnosed with TB (15 culture-proven; 5 according to clinical and radiological criteria) and 18 commenced treatment. There were 8 smear-positive cases and one multidrug-resistant TB case. The prevalence of culture-positive TB was very high at 1020 per 100 000 patients. All fishermen were deported before treatment completion, and all were lost to follow-up.Conclusions: The health assessment process successfully detected cases of TB in illegal foreign fishermen, enabling treatment to commence and the local public’s health to be protected. Treatment completion in illegal foreign fishermen may be as low as zero; deporting fishermen before curative treatment is completed undermines TB control efforts and may lead to an emergence of drug resistance and an increased burden of active TB disease in our region.

Natalie J Gray MB BS(Hons), MIPH(Hons), BSc/LLB(Hons) · Meredith Hansen-Knarhoi RN, RM, DipTropNsg, MPH · Vicki L Krause MD, DTM

Objective: To estimate the incidence of recurrence of culture-positive tuberculosis (TB) and the relative contributions of reinfection and reactivation (based on DNA fingerprinting).Design, setting and participants: Retrospective analysis of all culture-positive TB notifications between 1994 and 2006 from Liverpool Chest Clinic in the south-west of Sydney. Patients with more than one notification of culture-positive TB during this period were identified. Genotyping of Mycobacterium tuberculosis was used to determine whether recurrence was due to reinfection or reactivation.Main outcome measures: Estimation of the incidence of recurrence of culture-positive TB (cases per 100 000 person-years of follow-up), and the proportions of reinfection and reactivation.Results: Three cases of recurrent culture-positive disease were identified (incidence of recurrence: 57.7 per 100 000 person-years of follow-up). All three patients were treated with directly observed therapy. Two of these patients had evidence of reinfection with different strains; both were natives of a country with a high incidence of TB and had returned to that country after the initial episode. The other patient had evidence of reactivation of the initial strain, indicating secondary failure of treatment. This patient had poor adherence to treatment.Conclusions: Our observations suggest there is a very low rate of reactivation of tuberculosis. The low incidence of recurrence due to reinfection reflects the low incidence of tuberculosis in Australia. When reinfection does occur, this probably has been sustained during residence in a country with a high incidence of tuberculosis.

Claudia C Dobler MB BS, MD · Guy B Marks MB BS, PhD, FRACP · Sheila E Simpson RN, MPH · A B Hamish Crawford MB ChB, FRACP

Five cases of methaemoglobinaemia after ingestion of sodium nitrite occurred in two clusters in Sydney in 2006. All cases were unintentional poisonings following use in cooking of an imported compound sold as a food additive. In all cases, methaemoglobinaemia was recognised early and treated promptly, with all patients making a full recovery. These cases highlight the importance of accurate food labelling and surveillance of imported goods. Clinical recordIn 2006, at Liverpool Hospital in Sydney, two separate clusters of patients presented to the emergency department with cyanosis after consuming home-prepared food to which sodium nitrite had been added. In the first cluster, a husband and wife of Vietnamese–Chinese origin developed cyanosis and dyspnoea after consuming homemade rice cakes containing “Nutre Powder” and “Borax Powder”, which were commonly available from local Asian food stores in the area. Both patients arrived by ambulance and, despite oxygen therapy, remained cyanotic. Their blood samples had a distinctive chocolate brown appearance, and laboratory testing confirmed methaemoglobinaemia. The husband, who was the more unwell, had a measured methaemoglobin level of 57%. After treatment with intravenous methylene blue, his condition rapidly improved. The wife, who had a methaemoglobin level of 21%, was treated supportively with oxygen and monitored closely. Both patients were admitted to the intensive care unit for a brief period of observation before being transferred to the haematology unit. Their subsequent progress was uneventful, and both patients were discharged from hospital 2 days later. On request from medical staff, the couple brought into the hospital the two packets used, both containing whitish powder. The first was labelled “Goldfish” brand “Borax” and the second, “Goldfish” brand “Nutre Powder” (Box). No further information about the contents was printed on the packaging. The packets were imported through a specialty Asian food distributor based in Melbourne, and the wife claimed they were commonly available food additives. She had used both ingredients in the meal she prepared that evening from a recipe given to her by her mother. She also claimed her mother had previously used the products in China without incident. Neither patient knew the composition of the products, and questioning of the product’s importer by the medical team yielded no further information. Two weeks later, a second cluster of three new cases, involving a Vietnamese family unrelated to the index cases, presented to Liverpool Hospital emergency department with identical symptoms after eating a pork dish prepared using an unidentified white powder. Laboratory testing again confirmed methaemoglobinaemia, with levels ranging from 39% to 51%. Intravenous methylene blue was administered, leading to rapid clinical improvement. All three patients made uneventful recoveries after being observed in the emergency department overnight and were released from hospital the next day. In both clusters, the onset of initial symptoms, such as vomiting, shortness of breath and dizziness, was dramatic, within minutes of consuming the contaminated food preparations. In the second cluster, two family members who had eaten the contaminated pork dish noticed the symptoms just after leaving home. They called back to warn the others that the food might be contaminated, but the others had already consumed the dish as well. A fourth person in that cluster also became ill, but had much less severe symptoms, having eaten only a small amount. She was seen by paramedics but not transported to hospital with the others. On review by her local doctor the next day, she had made a full recovery. Investigation by the New South Wales Food Authority and staff of the Public Health Unit of Sydney South West Area Health Service found that identical Goldfish brand Nutre Powder had been used in food consumed by the patients in the second cluster, reportedly as a flavour enhancer. The packages were purchased from separate local retailers. Importantly, this group was found not to have been exposed to any other known causes of methaemoglobinaemia. Residual Nutre Powder from both clusters and Borax Powder from the first cluster were submitted to the Division of Analytical Laboratories in Lidcombe, Sydney, for testing. Those labelled Nutre Powder contained 100% sodium nitrite, while the packet labelled Borax contained 100% sodium tetraborate. On the day that laboratory results on the additives used by the first cluster patients became available, NSW Health alerted hospital emergency departments and the public to the risk of methaemoglobinaemia associated with ingestion of Nutre Powder. As Goldfish brand Nutre Powder was imported via Victoria, the Victorian Department of Human Services initiated a national recall after the discovery of nutritional information on some packets of the products, implying that they were intended for human consumption. The Borax packets and two other packets labelled “Natural Powder” and “Natural Baking Powder”, which were also found to contain sodium nitrite, were recalled as well. Nevertheless, packets labelled Nutre Powder were found for sale in Asian grocery stores in NSW several months after the national recall, and the proprietors denied any knowledge about the product being potentially harmful or illegal for sale as a food additive. They were directed to the NSW Food Authority and have since stopped selling these products. DiscussionMethaemoglobinaemia is a potentially fatal condition in which native haemoglobin loses its ability to carry oxygen due to oxidation of the ferrous iron component of the haem molecule to the ferric state. Ferric forms of the haem molecule are unable to bind oxygen, and the oxygen affinity of accompanying ferrous haems in the haemoglobin tetramer is increased. As a result, the oxygen dissociation curve is “left shifted”, and oxygen delivery to the tissues is impaired.1 Ferric forms of the haem molecule are generated physiologically by deoxygenation, but are kept at low levels by endogenous haemoglobin reduction mechanisms, so that blood concentrations of methaemoglobin do not normally exceed 1%–2%.2 Hereditary causes of methaemoglobinaemia are well described but rare.3 Most reported cases arise from exposure to an oxidising agent, including those containing nitrites. Symptoms include nausea, vomiting, lethargy, shortness of breath, obtundation and coma. Patients typically present with profound cyanosis and have a deeply greyish-blue appearance. Blood samples from affected individuals often have a characteristic chocolate brown colour. The degree of oxygen desaturation varies with the degree of methaemoglobinaemia, but may not correlate well clinically and therefore is not necessarily a reliable predictor of outcome. Pulse oximetry readings of oxygen saturation are generally inaccurate, and arterial blood gas measurements frequently show normal dissolved oxygen and carbon dioxide tensions with falsely elevated oxygen saturations.4 The observed cyanosis is refractory to standard oxygen therapy. Despite this, management of methaemoglobinaemia comprises both supportive measures, such as oxygen therapy, and intravenous methylene blue administration in moderate to severe cases. Methylene blue is reduced by the action of a normally minor enzyme pathway involving reduced nicotinamide adenine dinucleotide phosphate (NADPH) — methaemoglobin reductase. The reduced form of methylene blue, leukomethylene blue, can then go on to reduce methaemoglobin to haemoglobin.5,6 Methylene blue (2 mg/kg bodyweight as a 1% solution) is administered to patients with methaemoglobin levels exceeding 25%–30% and to patients with underlying anaemia or cardiac or respiratory disease, in whom tissue oxygen delivery might already be impaired. While methylene blue is generally well tolerated, it must be administered with caution to people with severe renal impairment and is relatively contraindicated in those with glucose-6-phosphate dehydrogenase (G6PD) deficiency, as it may lead to profound oxidative haemolysis in these individuals without lowering methaemoglobin levels, and, indeed, has been reported to cause methaemoglobinaemia itself.7 Of interest, follow-up of one of the patients who was given methylene blue demonstrated G6PD deficiency, although no adverse effects were seen clinically. G6PD deficiency is more common in South-East Asian populations, where it is believed to offer some protection against malaria.8 Thus, although an effective antidote for nitrite-induced methaemoglobinaemia exists, it is not without risk, which can present a management dilemma in an emergency setting where rapid assessment for G6PD deficiency is not available. Rapid administration of methylene blue has also been associated with local pain and tissue necrosis.9 While sodium tetraborate is used as a food additive in some countries — particularly in noodles, where it is believed to improve colour, texture and flavour — this use is prohibited in Australia. Though potentially fatal in large doses, it is not known to cause methaemoglobinaemia.10,11 Nitrites, on the other hand, are a well known cause of methaemoglobinaemia, although the mechanism underlying this process has recently been disputed.12 Numerous cases have been reported worldwide, most commonly associated with drinking contaminated water6,13 or ingestion of meat products in which nitrite compounds have been used as a preservative.14,15 Both sodium and potassium nitrite are permitted for use in Australia in the preparation of processed meat, poultry and game products, where they are used both as a preservative and to improve appearance. However, their sale is prohibited for use in home cooking.16 Fortunately, in the cases reported here, all patients promptly sought medical attention, and there were no deaths or persistent adverse outcomes. The cases we report here highlight the need for accurate labelling of all potential food products and surveillance of these products to ensure that imported goods meet local standards. Overall, the recall delivered an effective and rapid response, with national media coverage (including community media in local spoken languages) and the alerting of hospital emergency departments. However, the cases also highlight potential problems in putting these measures into practice. Unlabelled or inappropriately labelled goods are able to slip into Australia undetected if they are not specifically imported as food additives. The Australian Quarantine and Inspection Service works with Food Standards Australia New Zealand on a national level, and the responsibility for products released into the marketplace passes to state and territory authorities. If improperly labelled goods have entered the country undetected and been locally distributed, coordination of their recall is complex, requiring cooperation of numerous parties across levels of government as well as bridging communication and cultural barriers. A packet of “Goldfish” brand “Nutre Powder”

Peter Maric MB BS(Hons) · Sayed S Ali MD · Leon G Heron FRCPA, FAFPHM · David Rosenfeld FRACP, FRCPA · Matthew Greenwood FRACP, FRCPA

Legislation has the potential to reduce chronic disease, but political will and leadership are essential If the law required restaurants to tell you the total calories and the grams of saturated fat, trans fat, carbohydrates and salt in the food you order, would it make a difference to your food choices? The California legislature thought so. In September 2007, it passed a law requiring food facilities with 15 or more outlets to prominently display nutritional information for all fixed-menu food items, together with the statement: “Recommended limits for a 2000 calorie daily diet are 20 grams of saturated fat and 2300 milligrams of sodium”.1 The Bill was hotly contested by the food industry and subsequently vetoed by Governor Schwarzenegger.2 New York City, meanwhile, recently reintroduced its own restaurant labelling law, which requires calorie information to be displayed in a typeface as large as the price.3 Although governments are increasingly using legislation in innovative ways to support the prevention of chronic disease, the law’s role remains controversial. The food, tobacco and alcohol industries have lucrative markets to protect, and there is a pervasive assumption that the solution to galloping rates of obesity, diabetes and other lifestyle diseases lies in individuals exercising greater self-control. But preaching self-control will not work if healthy choices are constantly being undermined by other, more powerful influences. While the law is not a complete answer, it can help to create supportive environments for changing the average behaviour of populations. Successful tobacco control programs illustrate this point. Success has not come by merely insisting that smokers exercise more willpower. Nor have laws been drafted with the aim of persecuting smokers or seeking to micromanage their lives. Instead, tobacco control laws have taken a population focus: addressing the price of tobacco through taxation and regulating businesses through laws that dictate smoke-free environments, point-of-sale controls, advertising restrictions and warning labels. This has resulted in conditions that discourage people from starting smoking and better support of individual attempts to quit (eg, the Quitline). The law and behavioural risk factorsLaws can influence the behavioural risk factors for chronic disease at three distinct levels: First, by better supporting interventions led by health care providers. Although Medicare now covers a range of allied health services aimed at improving care for chronic diseases,4 the challenge remains to design incentives for preventing such diseases in primary care,5 building on Lifescripts (tools for general practitioners to use when providing lifestyle advice to patients)6 and the new Medicare item for a health check for chronic disease risk factors at age 45 years (Medicare Benefits Schedule item 717).7 Laws can seek to change behaviour directly. In the United States, federal regulations permit health insurance premium discounts for people who control their weight and other lifestyle risks.8-11 In Australia, this approach would have the risk of creating disincentives to private health coverage and increasing the burden on Medicare. Laws can influence risk factors by addressing the social, economic and environmental influences on lifestyle choices (Box 1).12,13 While this is where we see the best opportunities for the law, the combined weight of multiple legal interventions will be needed if our aim is to slowly reverse broad population trends. Information policiesInformation is a powerful tool for fighting chronic disease. Laws can mandate the provision of information to consumers and, more controversially, can restrict advertising to consumers. Consumers have difficulty understanding the significance of nutrition information. Despite this, we still lack nationally agreed and standardised criteria for a front-of-pack, readily understandable labelling scheme to flag products that are high in saturated fat, salt and sugar. The United Kingdom’s “traffic-light” labelling system uses visual signposts (red, amber and green) to flag these levels in food (Box 2).14 This approach is simple to use, in real time, in supermarket aisles. Food labels can also support healthy choices by showing the amount of fat, sugar and salt as a proportion of the daily recommended intake for a normal adult. In takeaway food outlets, appropriate labelling might alert customers that the “large meal deal” delivers 52% and 77%, respectively, of the average daily energy intake for men and women.15 A “child protection” model is evident in the UK, where the Office for Communications has banned the advertising and promotion of foods with high levels of salt, sugar and fat in television programs likely to appeal to children. Some states in the US are using the law to improve the nutritional quality of food sold in schools. Any serious attempt at regulation in this area must also confront the increasing complexity of food advertising, encompassing television, the Internet, mobile phones and print media.16 The built environmentWhile improvements in the built environment could facilitate and encourage physical activity, the legal processes for making these changes are not well understood.17-19 Many aspects of the built environment are shaped by zoning and planning policies and laws, and all levels of government have a role to play. The possibilities go well beyond using the law to create mixed-use neighbourhoods that encourage walking and cycling and that are well integrated with public transport. For example, in the US, zoning laws have been used to “thin out” the density of fast food outlets. Economic policiesThe workplace is an important setting for interventions to reduce lifestyle risks. In the US, employer-funded health insurance coverage, which includes chronic disease prevention, is seen as central to reducing rising care costs.20 There are proposals before Congress to deepen this trend by partial tax relief for companies offering prevention programs that meet specified criteria.21 While Australian employers do not have the same responsibility for employees’ health insurance, the opportunity remains for Australian companies to improve productivity and reduce absenteeism by investing in workplace health promotion and disease prevention programs.22 Tax relief for companies that invest in employee wellbeing could encourage this. Other economic policies include taxing unhealthy foods to raise revenue for health promotion initiatives or to create price disincentives for overconsumption of these foods. How can this come about?Successfully addressing the broader influences on lifestyle will require policies that engage with the food production system, address public health nutrition, the built environment, transport and urban development, key settings such as schools and the workplace, and issues like food advertising and taxation. No health department, state or federal, is currently mandated to begin doing this. Successful coordination of policies across multiple sectors requires governance structures that can rise above the boundaries and entrenched cultures of existing bureaucracies and agencies, and a clear legal mandate to get things done. The central choice is between politically owned structures with cabinet-level leadership and independent-of-government agencies with clear powers and cross-sectoral reach. Either could work, but the point is that current structures are failing.23,24 Australia has a brand new federal government with a clear mandate for policy change. Will it maintain the reactive model of its predecessors — directing all its resources to disease treatment by the health care sector — or opt for a more preventive approach that engages with the socioeconomic and environmental determinants of health and illness? Most importantly, will it grasp the nettle and establish a national overarching structure — with adequate funding, support and leadership from the highest levels — to make effective intersectoral and interagency action a reality? Or will we be left, yet again, with only the rhetoric? 1 How the law can improve the health of populations10,11 The law can influence behavioural risk factors for chronic disease through: health infrastructure and governance: improving the quality and implementation of public health policies and programs through agencies that have a clear mandate to follow the evidence and to engage with stakeholders across all sectors; shaping the information environment and creating “information assets”; taxing, spending, making grants, subsidising and creating economic incentives; designing and altering the physical and built environment; economic policies addressing the socioeconomic gradient: confronting and addressing health inequalities; and command and control regulation: directly regulating persons, professionals, businesses and other organisations. 2 Traffic-light food labelling14 This traffic-light label shows the shopper, at a glance, that the labelled food is high in fat (> 20%), particularly saturated fat (> 5%), but low in sugar (< 5%) and moderate in salt (0.3–1.5%).

Roger S Magnusson BA/LLB(Hons), PhD, GDipManDev · Ruth Colagiuri BEd, GradCertHlthPolMgnt

Objective: To describe the magnitude and distribution of health problems in Australia, in order to identify key opportunities for health gain.Design: Descriptive epidemiological models for a comprehensive set of diseases and injuries of public health importance in Australia were developed using a range of data sources, methods and assumptions. Health loss associated with each condition was derived using normative techniques and quantified for various subpopulations, risks to health, and points in time. The baseline year for comparisons was 2003.Main outcome measures: Health loss expressed as disability-adjusted life years (DALYs) and presented as proportions of total DALYs and DALY rates (crude and age-standardised) per 1000 population.Results: A third of total health loss in 2003 was explained by 14 selected health risks. DALY rates were 31.7% higher in the lowest socioeconomic quintile than in the highest, and 26.5% higher in remote areas than in major cities. Total DALY rates were estimated to decline for most conditions over the 20 years from 2003 to 2023, but for some causes, most notably diabetes, they were projected to increase.Conclusion: Despite steady improvements in Australia’s health over the past decade, there are still opportunities for further progress. Significant gains can be made through achievable changes in exposure to a limited number of well established health risks.

Stephen J Begg MPH, GradDipPopHlth, BA(Hons) · Theo Vos PhD, MSc · Bridget Barker BSoc(Hons), BBus · Lucy Stanley BHlthSci, GradCertAppEpi · Alan D Lopez PhD

In Australia, 2.9 million people continue to smoke daily, and tobacco still accounts for 8% of disease burden. Tobacco harm-reduction strategies, such as the use of Swedish snus, have been suggested as a way to further reduce this disease burden. In Australia, the most dangerous tobacco products (cigarettes) are the least regulated, while oral tobacco products, including snus, cannot be sold legally. Recent epidemiological modelling indicates that there are only small differences in life expectancy between smokers who quit and those who switch to snus. There is a case on public health and ethical grounds for allowing inveterate smokers who want to reduce their health risks to access snus. At a minimum, the recent increase in tax on smokeless tobacco should be reversed, and the ban on the commercial importation and supply of low nitrosamine smokeless tobacco should be reconsidered in light of the epidemiological evidence on its potential to reduce tobacco-related disease in smokers.

Coral E Gartner BHlthSci(Hons), PhD · Wayne D Hall BSc, PhD

We need to be sure any introduction of smokeless tobacco will actually reduce overall harm In the mid 1980s, I assisted in South Australia becoming the first Australian state to ban the sale of smokeless tobacco products.1 In 1991, the ban went national, effectively restricting access to small quantities imported for personal use. New Zealand and the European Union imposed similar bans, although in almost all other nations smokeless tobacco products are sold openly, with many also allowing advertising. The bans sought to prevent the tobacco industry from building demand for an uncommon form of tobacco use known to increase the risk of oral cancers.2 Since that time, growing understanding of differences in the risk profiles of different smokeless tobacco products has generated often volatile debate on whether such bans had the unintended consequence of preventing genuinely less harmful products being available to smokers who might be interested in switching from cigarettes. The emergence of low nitrosamine smokeless tobacco (LNST) products such as Swedish snus, which pose far less risk than smoking,3 and the emerging, compelling epidemiological evidence of an association between rising LNST use in Swedish men and their low rates of tobacco-caused disease,4 has led to widespread debate on whether this form of tobacco should be made more accessible. Gartner and Hall have articulated a strong case for the affirmative (→ Should Australia lift its ban on low nitrosamine smokeless tobacco products?).5 They and others6 have correctly excoriated those who continue to mislead the public by obfuscating the reduced risks associated with LNST use, and have raised important ethical concerns of denying reasonable access to less harmful forms for adults who wish to continue to use tobacco products. Nonetheless, several broad concerns demand that any liberalisation should be subject to strict access controls and that the tobacco industry be prevented from using the issue as a wedge to subvert advertising bans and undermine the important benefits of reduced smoking caused by smoking restrictions. Much is made of the example of Sweden. However, in nations where no bans exist, demand for smokeless products has not mirrored the Swedish experience, with use remaining marginal. In 2002 in the United States, where there is a long tradition of use and the products are aggressively advertised, only 1.5% of men and 0.16% of women used smokeless tobacco.7 In Canada, use is similarly marginal.8 There has been little reflection on why, outside Sweden, LNST use remains apparently unacceptable to most consumers despite the best efforts of transnational tobacco companies. Sweden has a 200-year history of smokeless tobacco use, which may explain a great deal about why an intuitively strange form of tobacco use, typically involving holding the product in the mouth for up to 15 hours a day, holds little attraction for today’s consumers elsewhere. Advocates for the liberalisation of access in nations that ban sale of LNST products are thus almost certainly over-hyping their potential for widespread adoption. The core of Gartner and Hall’s argument is the objective of assisting “inveterate” smokers to access smokeless tobacco products. The term is shorthand for smokers who either do not wish to stop smoking, or whose repeated failed attempts at quitting have resigned them to be reluctant, continuing smokers. The size, characteristics and stability of this group merit close consideration. In recent years, daily smoking prevalence in Australia has been falling faster than at any time (Box). In 2006, daily smoking prevalence in New South Wales fell to 13.9%,10 following unprecedented but still relatively modest campaign expenditure by the Cancer Institute NSW. If national effort could match this commitment and, conservatively, we halved the most recent relative annual rate of decline experienced in NSW (ie, − 10.06% to − 5.03%) and applied it nationally, we would see smoking prevalence fall below 10% by 2013. Some claim that today’s remaining smokers are “hardening” and that those still smoking are mostly inveterate, with poor prospects of ever stopping. A US review of the evidence for hardening found “little evidence that the population of smokers as a whole” was hardening.11 Twenty-nine per cent of Australian smokers now describe themselves as only occasional smokers,12 and daily consumption is reducing — facts incompatible with hardening. Moreover, around 70% of smokers are planning to quit and making attempts to do so,13 meaning that only about 4.2% of adults say they want to continue using tobacco. Nonetheless, many of these will subsequently quit without previously planning to do so.14 So, it is an unknown but plausibly small fraction of this “smoking committed” group that harm-reduction advocates believe might be interested in using LNST. The potential for LNST to reduce health risks for this group needs balancing against any collateral negative effects of re-introducing smokeless tobacco. Few analysts of the tobacco industry doubt that its ambitions for LNST products lie well beyond servicing nascent demand from the small proportion of smokers likely to be interested in switching to these products. With youth smoking prevalence at an all-time low in Australia, the industry would be vitally interested in the potential of LNST to rekindle tobacco use in the group which is its future customer base. By naming smokeless products with cigarette brand names (Marlboro, Lucky Strike, etc) the industry hopes to heighten brand name prominence, with spin-off benefits in promoting cigarettes. Most obviously though, LNST provides would-be quitters with a reassuring product to use “for those times when you can’t light up”. Nowhere is there any evidence of companies seriously urging smokers to abandon smoking. The investment advisors Citigroup are very clear on the potential for dual use: “The [retail] trade believes that snus will be consumed in addition to cigarettes. Given the increased bans on smoking, snus products seem like an obvious substitution.”15 These sentiments are echoed in the US retail trade newsletter Brandweek: “There’s money to be made from municipal smoking bans as another cigarette maker chases after smokers who get their nicotine fix between their cheek and gum during those many moments when they can’t light up.”16 Smoking bans have depressed daily consumption17 and stimulated cessation.18 If widespread dual smokeless/cigarette use were to occur to the delight of the industry, the net population effect of this would be to increase harm if the cessation effect was reduced and the numbers switching to snus marginal, as has occurred outside of Sweden. Some argue that the dual use concern is over-stated because in Sweden the phenomenon is typically a transitionary phase as smokers wean themselves on to snus. But, as argued, the Swedish experience has not been replicated elsewhere, so it is prudent to be cautious. Overt tobacco advertising is banned in Australia, so some argue that tobacco companies will be unable to promote dual use. However, with the demise of overt advertising and promotion, the global industry is now harnessing “below-the-line” strategies like viral, buzz and stealth marketing,19-21 where covert efforts are made to spread interest in products. The Internet provides unparalleled opportunities here,22 with major sites heavily dominated by youth traffic already showing fingerprints of tobacco industry involvement.23 On 16 September 2007, for example, on the massively popular Facebook website, there were 242 “friendship” networks incorporating the word “snus” and 105 with “smokeless tobacco”. Many of these are overt promotional sites. Although the rationale is compelling for allowing what is likely to be a small proportion of smokers to access LNST, precautionary health policy should tread warily. Optimists can point to Swedish-style outcomes of widespread smoking substitution, or at the very least to the small-scale uptake seen in the US, where choice is at least available to inveterate smokers wanting to switch. But other scenarios are plausible. The tobacco industry has shown itself to be resourceful, rapacious and duplicitous in the service of sales maximisation, and any notion that they would be disinterested in the youth market, in providing nicotine substitutes for smoking “downtime”, and in preventing smokers from abandoning tobacco use altogether is naïve. Thus, the challenge remains of how to provide choice to smokers without repeating the catastrophic legacy that the history of allowing cigarettes to be sold from every conceivable retail outlet, packed and advertised beguilingly, has brought. Tobacco retailers have repeatedly been shown to ignore the law prohibiting sales to minors, and so inspire little confidence in being trusted to confine distribution of smokeless products to adults, should the ban on smokeless tobacco sales be partly repealed. Trials of allowing LNST products to be scheduled S3 and made available under the counter from pharmacies offer a model of highly controlled access that could be investigated. These should investigate whether dual use with smoking is occurring so that the net public health benefit of permanently allowing such access could be assessed. LNST brand names using cigarette names, symbols or colours should be banned. Public awareness of the products’ reduced harm status could be generated via health authorities, with parallel investigation and prosecution of tobacco industry efforts to promote the products via below-the-line strategies. Pharmacists who might baulk at the thought of dispensing a tobacco product24 can reflect on the many precedents already embraced in medical practice, where lower risk agents and procedures are prescribed or implemented in the hope of achieving more important health benefits than the risks being posed by treatments and (for example) diagnostic radiation. In the meantime, the recent tax increase on the importation of smokeless tobacco products should be reviewed, so that it discriminates between LNST and the very much more harmful varieties of smokeless products, such as those now openly sold illegally from most South Asian groceries.25 Changes in daily smoking prevalence, Australia, 1985–2006, for people aged 14 years and older9 Year Daily smoking Absolute percentage change per year Relative percentage change per year 1985 29.0% − 0.78 − 2.70 1991 24.3% +0.35 +1.44 1993 25.0% − 0.60 − 2.40 1995 23.8% − 0.67 − 2.80 1998 21.8% − 0.73 − 3.36 2004 17.4% − 1.75 − 10.06 2006* 13.9% Total 1985–2006 − 0.72 − 2.48 * 2006 figure is for New South Wales only, for people aged 16 years and older10 (national data unavailable).

Simon Chapman PhD

For the first time, there is a real opportunity to deal comprehensively with the shameful situation of Indigenous communities in Australia — but the commitment needs to be huge The girl undergoing a health check in a remote community in the Northern Territory has a delightfully cheeky grin. Recently arrived from a town camp on the outskirts of Alice Springs, she is in the care of a woman unrelated to her. About 9 years old, she pops up everywhere, desperate for attention. The health check reveals that she has ringworm, dental problems and a perforated eardrum from a chronic middle-ear infection. She also has a heart murmur brought on by an earlier bout of rheumatic fever. It is vital that she undergo an echocardiogram as soon as possible. A boy aged 5 years is brought in by his mother, who is 36 weeks’ pregnant and has had no antenatal care. He and his mother have been camping rough. Although he is not here for a health check, the opportunity is taken to give him one with his mother’s consent. Although he looks happy and healthy, he is found to be anaemic and is given iron injections as well as the vaccinations he has missed. A boy of about 14 seems depressed, although this has not previously been diagnosed. The only male adults he has to model himself on are dependent on drugs and alcohol. He frequently plays truant from school. He is on a slippery slope, and much needs to be done if he is not to slide into disaster. There is so much promise for these Indigenous children, but it will only be fulfilled if their living conditions are fundamentally changed. Health crisis in a land of plentyIt is remarkable to contemplate that in parts of Australia, there is a health crisis that is in some respects more devastating than anywhere else in the world. The Australian Medical Association has called the state of health and lack of health services endured by Aboriginal peoples and Torres Strait Islanders a national tragedy and a national shame. The former president of the association, Dr Mukesh Haikerwal, wrote earlier this year: “I think we are being kind in that assessment.”1 The figures for renal and coronary heart disease among Indigenous peoples could well be the worst in the world. For instance, Indigenous Australians are three times more likely to have a major coronary event than other Australians, and 1.5 times more likely to die after such an event.1 Through my two decades of involvement with the health of Aboriginal communities, I have watched in frustration as health levels improved only marginally and self-esteem and pride were destroyed. When the “sit-down money” arrived each fortnight, in the form of numerous government handouts, many communities went into self-destructive alcohol binges for 3 or 4 days, during which time women and children were abused, children did not go to school and remained hungry. Those of us working in the field of Indigenous health have watched this happening and have tried to influence the outcome, but despite this, both the health of Indigenous peoples and the level of their education have continued to show great disparity with the rest of the population. We all know that social factors such as overcrowded housing, lack of education and limited employment opportunities, along with environmental health issues such as lack of clean water, washing facilities and functioning septic systems, all influence health outcomes of individuals and the community. These factors, combined with a cycle of welfare dependency, lead to a loss of pride and low self-esteem. Substance (particularly alcohol) misuse is a direct result. Therefore, any targeted medical strategy must have a broad focus and address all these wider issues which have an impact on the health of individuals. Some good things have been done, but not on a scale to make a real difference — until now. Massive interventionThe Australian Government’s Northern Territory Emergency Response2 is without precedent in Australia. It is the largest and most significant whole-of-government initiative yet carried out in this country. The government set up the Northern Territory Emergency Response Taskforce (Box) to provide advice and to oversee the implementation of the emergency measures. The intervention has three broad objectives: stabilisation to protect children and secure their communities; normalisation of services and infrastructure; and in the longer term, sustainability, bringing Indigenous Australians fully into line with the choices other Australians enjoy. The government committed $587 million for the stabilisation phase in the 2007–08 financial year. This is for urgent and immediate actions. It includes over $83 million specifically for improving child and family health, with $205.8 million for employment and welfare reform and the balance for promoting law and order, enhancing education, supporting families and for housing and land reform.2 On 18 September 2007, the government announced further funding of $740 million to highlight its long-term commitment, bringing the total committed so far to $1.3 billion. This includes $100 million over 2 years from the 2008–09 financial year for more doctors, nurses, allied health professionals and specialist services.2 When the response was announced on 21 June 2007, many were concerned about its motivation and methods.3 Was this not paternalism or yet another attempt to dominate Indigenous communities? Well, while it is still early days in an intervention to which the Australian Government has committed itself for at least 5 years, I have seen how this response is already bearing fruit and believe everyone with concern for Indigenous health should continue to support this initiative. We cannot let this opportunity go. For instance, the introduction of strict controls over alcohol consumption had a huge impact almost immediately. An Indigenous woman told me that, for the first time she could remember, she had had a week of sleeping peacefully. A sharp reduction in the physical abuse of women and children has also been seen. The Chair of the Northern Territory Emergency Response Taskforce, Dr Sue Gordon (Box), reports that in communities across the NT, women are talking about the positive effects of alcohol bans in reducing violence, abuse and antisocial behaviour. The same thing is probably happening with levels of child sexual abuse — the horror which sparked off this emergency response — although it will only be when more trust has been built up that we will be able to explore this more fully. A comprehensive program of health checksOne of the pillars of the initial phase of the Northern Territory Emergency Response from a health point of view is the health checks to be carried out on up to 17 000 children aged 15 years and under in 73 target communities. By 19 October 2007, medical teams had already completed checks on more than 3200 children. The findings of these checks are sobering, and underline the need for the intervention. We already knew that the children in many of these communities had very high rates of chronic diseases, but have found that the situation is even worse than the official picture. The Indigenous population has a burden of disease up to six times higher than in the non-Indigenous population.4 Probably 80% of the Indigenous children have middle-ear diseases. Intestinal parasites and skin infections are rife. An absence of water for washing — taps don’t run, toilets don’t flush, there is no soap — has led to skin hygiene so poor that pathogens thrive. This in turn contributes to the devastating levels of renal disease and heart disease, the latter particularly associated with rheumatic fever. Type 2 diabetes is also increasingly common in children.5 Of course, painting a full picture of the burden of disease is only the start. It must lead to a massive increase in treatment resources, and, beyond that, to a transformation of these communities. Only the synchronous rollout of many measures will be truly effective. This will take a lot of time and a lot of money. Fortunately, the government is committed to this initiative for at least 5 years. Step by stepStrategies in the stabilisation and normalisation phases of the initiative include: voluntary health checks available for all children aged under 16 years in target communities; development of a range of special services for children and their families who have suffered trauma from physical, sexual and emotional abuse or neglect; increased police presence to guarantee safety and security for community members; implementation of alcohol-management plans; a focus on getting children to school; support for and an extension of the current nutrition programs for Indigenous children; establishment of crèches in communities; funding for new housing and renovations; a focus on creating real jobs within the communities and incentives to develop local businesses; the appointment of government business managers in each community; government assistance to the Northern Territory Government to expand child-protection services and increase the number of safe houses; changed welfare payment rules to ensure money meant for children is spent on them, including quarantining welfare payments to parents or carers if children do not attend school; a licensing program for community stores to ensure families have access to a range of healthy foods; acquiring 5-year leases over the main townships to ensure the job is done quickly; and opening up communities by changing the permit system so that people can visit common areas within them. A well resourced primary health care system — enough doctors, health workers and nurses — is integral to long-term sustainability. Further, interventions to manage the diseases identified by both the child health checks and data from the Northern Territory Government will need to be implemented. Talks have already started about this. I would like to think that extensive treatment programs will be underway within a year to deal with the ear, dental, cardiac and renal problems. Along with educating children and parents about the importance of personal hygiene, we need to make this feasible. Installing taps that work will make a huge difference. However, a sustainable solution will require much more than this, and the key will be education. That is the only way out of poverty, and away from the debilitating system of government handouts. Pride has to be restored to shattered communities. Seize the opportunityThis intervention is not going to be perfect; there will be many problems to overcome, but it gives us a tremendous opportunity. Of course, some people, particularly those with vested interests (like those making money out of selling alcohol), will feel threatened. Others will claim the response is paternalistic. To them, I have two things to say. First, in many of these communities, there is a complete breakdown of normal mores. It is not paternalistic to be firm about what is not acceptable. Second, the ultimate aim is to restore these communities, their resources and self-esteem to the point where they are in charge of their own destinies. I believe this initiative offers a real chance to restore the health not just of the rural and remote Indigenous communities of the NT, but of Australian society, wounded by these enormous disparities. It is up to us to seize this one-time opportunity to finally solve a problem that has been decades in the making. We dare not let the momentum be lost. Northern Territory Emergency Response Taskforce2 The Taskforce was established to advise the Australian Government on how best to protect Indigenous children in the Northern Territory, oversee the Northern Territory Emergency Response Taskforce Operational Group, and promote public understanding of the issues involved. It is made up of people with experience in areas such as medicine, government, the law, education and business. Its members are: Dr Sue Gordon AM (Chair), a magistrate in the Perth Children’s Court and chair of the Australian Government’s National Indigenous Council. Major General Dave Chalmers AO, CSC (Operational Commander), who has considerable organisational and command experience, notably in East Timor and as commander of the joint taskforce that provided humanitarian relief to Sumatra after the 2004 Boxing Day tsunami. Dr Bill Glasson, ophthalmologist and former president of the Australian Medical Association, who has worked on a voluntary basis in a number of Aboriginal communities and in East Timor. Roger Corbett AM, member of the Reserve Bank of Australia Board and former chief executive of Woolworths. Miriam Rose Baumann AM, principal of St Francis Xavier Catholic School in Daly River, a member of the National Indigenous Council, and chair of the Aboriginals Benefit Account Advisory Committee. Dr Peter Shergold AC, secretary of the Department of the Prime Minister and Cabinet. Paul Tyrrell, chief executive of the Northern Territory Department of the Chief Minister.

William J H Glasson FRACO, FRCOphth, FRACS

The Alliance continues to tackle the problem of chronic disease by bringing the right people together With its self-described goal of “confronting the epidemic of chronic diseases”, the Oxford Health Alliance aims to fill the leadership void decried by Beaglehole and Yach,1 the Lancet2 and others. To this end, the Alliance enlists key thinkers and doers, to harness, shape and amplify the energy that is converging worldwide, to address socially and environmentally generated determinants of chronic diseases. It concentrates on high-level approaches, through government and industry, to tobacco control, physical inactivity and unhealthy diets. These, via chronic illness, are responsible for over 50% of the world’s mortality.3 Two years after the launch of the Oxford Health Alliance’s Asia Pacific Regional Centre,4 it is timely to review its progress. Locally, the Alliance is gradually reaching the consciousness of the public health, food and beverage, media and pharmaceutical industries, health departments, non-government organisations (NGOs), and urban designers and planners. Its progress will, no doubt, be accelerated by the global Oxford Health Alliance summit, scheduled for Sydney in February 2008, to debate issues concerning environmental determinants of chronic diseases and make recommendations about “building a healthy future”. Internationally, the Alliance has achieved surprising penetration, participating in World Health Organization, World Economic Forum, Youth Forum and similar high-level meetings and advising governments. It has a formidable network of academic institutions and public health luminaries (see http://www.oxha.org) and is currently conducting an innovative multicountry demonstration program, Community Interventions for Health, to illustrate models for successfully translating the evidence on chronic disease prevention into real life. The Oxford Health Alliance will shortly release the results of an international Delphi survey — spearheaded by the University of Toronto — of 200 international experts to identify “grand challenges” for chronic disease research. It has no qualms about drama, as exemplified by its full-page “global warning” against chronic diseases in The Times (London) last year (Box). Since the launch of its hub in Sydney, the Oxford Health Alliance board, headed by the Regius Professor of Medicine, John Bell from Oxford University, has focused the organisation on six work streams: mounting the economic case for action against chronic diseases; the physical environment (especially urban design) and health; health and wellness protection in the workplace and the role of industry and business in health promotion and prevention; youth — “20% of the present, 100% of the future” (an intention to engage young people, who can contribute to determining the kind of societies they will inherit as adults); the law and health policy; and community interventions for health, and barriers to chronic disease prevention in research. Interaction among these themes promotes rather different thinking about strategies for preventing chronic disease. To develop and promulgate this thinking, the Alliance brings together, through its annual summit meetings and to a lesser extent a series of smaller, local Oxford Dialogue meetings, players who are central to achieving change. Its primary method centres on: Finding the right people: looking outside health systems to other government administrations and the private sector; including people and organisations that influence health but do not often participate in the health debate; engaging those whose business activities are health determinants (eg, food and building design); choosing people who are at the cutting edge of their businesses and can influence colleagues, peers and decisionmakers; and finding and fostering champions of chronic disease prevention. Encouraging debate from a diversity of perspectives: respecting and taking account of differing views; being unafraid to mix youth with experience, left with right, establishment with alternative, and developed with developing world; and bringing to the planning table those who do not normally sit at the same table (eg, grouping food, building and other industries with organisations such as the WHO and the People’s Health Movement). Fostering a collaborative approach: avoiding “good guys versus bad guys” attitudes and approaches; and transforming combatants into collaborators. The Oxford Health Alliance is equally interested in the developed and the developing world and is currently working with Ovations (an arm of the largest private health insurer in the United States, United Healthcare) to establish three to five clusters of excellence to combat chronic diseases in developing countries. Yes, the Oxford Health Alliance works with industry and thereby incurs a risk, but firmly believes that the risk of not doing so is far greater. The Alliance is a United Kingdom-registered charity but, as the progeny of an academic–commercial collaboration between Oxford University and NovoNordisk A/S, Denmark, has sought to work with industry. It is under no illusions about the importance of the bottom line to business, and, like its own law work stream, does not consider that a legislative framework is irrelevant to confronting the problems of chronic disease. For example, the Alliance is a fierce defender of the WHO Framework Convention on Tobacco Control. However, it sees its role not as a legislator or enforcer, but as seeking commitment and involvement from the business sector, through discussion and debate and through recognising and working with companies that are prepared to embrace the necessary changes. The origins of the current chronic disease and environmental crises are located deep in society, suggesting that their resolution will require a complex and inclusive response from society, spanning business, government, academia, and civil society more generally. Hence, the 2008 Sydney summit will bring a diverse group of people together for 2 days to design and issue a formal challenge to government, business, industry, unions, universities, activists and bilateral and multilateral funders to progress the Alliance’s ambition of “healthy people and a healthy environment”. There are risks, but the potential gains are great, and as the Sydney summit will attest, the Oxford Health Alliance is ready to take the gamble.

Ruth Colagiuri BEd, GradCertHlthPolMgnt · Stig Pramming MD · Stephen R Leeder BSc(Med), MD, PhD

Government actions to protect the public’s health are not always consistent What, if anything, will move a government to intervene to improve the health of its population? Government action seems to depend not on how many people will die if it fails to act but rather who they are and how they will die. When almost 3000 people died after aircraft were flown deliberately into buildings in Washington and New York in 2001, the United States government moved rapidly, with no regard for cost. In an unprecedented move, it immediately grounded all aircraft flying over the US, allowing them to fly again only subject to sweeping restrictions on what could be taken on board. Had the government failed to act rapidly, it would undoubtedly have faced widespread condemnation, not least from the representatives of corporate America, which had, in the attack on New York, been the target of mass murder. Yet, of all the Americans who died in 2001 as a result of violence, only a fraction were killed in the attacks on 11 September. More than 10 times as many fell victim to firearms, either at their own hands or the hands of others.1 Successive US governments have steadfastly refused to enact effective gun control, seemingly unmoved even by tragedies such as the mass shootings at Columbine High School in Colorado in 1999 and Virginia Tech (Virginia Polytechnic Institute and State University) in Blacksburg, Virginia, in 2007. In 2004, President George W Bush allowed a law banning sales of semiautomatic assault weapons to lapse at a time when his government was enacting unprecedented security measures in what is termed the “war on terror”. Utilitarian principlesIf it is not the body count that drives politicians to act, what is it? Perhaps, in the rational world that we often aspire to inhabit, it is pragmatism. Knowing what works is purported to be a key principle by some politicians who ask us to vote for them on the basis of their technical ability and experience. Unfortunately, this does not seem to be the answer either. In 1967, the US Federal Government held back funding for highways from states that did not mandate the use of motorcycle helmets. Deaths among riders fell markedly. In 1976, under pressure from bikers’ groups, the US Congress reversed this policy, leading to a marked increase in deaths in those states repealing the laws.2 When should governments act?When, if ever, is a government justified in taking action to improve the health of its population? It is easy to see why this seemingly simple question leaves so many people confused. Maybe we can look to philosophers for guidance. The most frequently quoted, in this respect, is the 19th century British philosopher, John Stuart Mill. In his classic text, On liberty, he argues that “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others”.3 Yet, he also recognised that individuals are not always able to make free choices, a view shared by Karl Marx, who argued that “men make their own history, but not of their own free will; not under circumstances they themselves have chosen but under the given and inherited circumstances with which they are directly confronted”.4 The question of how these arguments apply in any given circumstances is at the heart of the dilemmas that confront public health advocates. In applying philosophy to public health, the first question is whether an action threatening an individual’s health causes harm to others. In some cases, such as drunk driving, the answer is obvious. In others, such as the harm caused by passive smoking, epidemiological research has been required to provide the answer.5 These examples deal only with situations in which there is direct physical risk to others. It has also been argued that, by consuming collectively funded health services, an individual engaging in self-destructive behaviour is harming others by using resources that would otherwise be available to those falling ill through no fault of their own.6 This argument can be taken further. There is now compelling evidence that ill health in a population weakens economic growth, because, with illness, people reduce their labour supply and productivity.7 Is this a justification for governments to act? Certainly, governments intervene in many other ways to promote growth, through fiscal policy and direct investment in research, skills and physical infrastructure. So far, few have accepted explicitly the importance of investing in the health of their population as a strategy to promote growth, even though, in some analyses, this provides a greater return than investment in education.7 The second question is whether individuals really are making free choices. In some cases, it is apparent that they are not. Therefore, almost all governments act decisively against narcotics, although many have yet to recognise the equally addictive nature of nicotine. As a result, some have failed to support effective “quit smoking” programs using nicotine replacement therapy. This may be only a matter of time. Government action against opiates is now widely accepted, but it was only 150 years ago that the United Kingdom went to war with China to protect its right to trade in opium.8 Addiction is only one way in which the choices of individuals are constrained. It is self-evident that behaviour is shaped by the environment. At the extremes, a person living in Mongolia has little option but to eat an unhealthy diet, dominated by animal fat and bereft of fresh vegetables. In contrast, an inhabitant of Crete may find it difficult to eat anything but a healthy diet. Similarly, an inhabitant of rural Nepal has little choice but to walk, while someone in Los Angeles may search in vain for a sidewalk. Governments can do little to change things such as climate and the topography of a country, but they can change many others, by ensuring that health is included in policies for (among others) transport, agriculture, fiscal management, and regional development, so as to remove the constraints that individuals face when making healthy choices.9 Governments have few reservations about using these policies for other goals, including promotion of economic growth, so why not health? Current inconsistencies in policyGovernments are often extremely inconsistent. They are willing to intervene actively in the lives of individuals to protect the health of their populations in some circumstances, but not in others. The war on terror has yet to be matched, in intensity and resources, by a war against tobacco. Governments that promote individual choice see no incongruity in their support for a small number of companies that, through their domination of the retail sector in some countries, constrain our choices about what to eat.10 It seems that no universal theory can explain when a state will act to safeguard the health of its population. Maybe this should not come as a surprise. Policy making is messy. Otto von Bismarck, unifier and first Chancellor of Germany, is reputed to have remarked that two things should never be made in public — laws and sausages. Policies are often a product of events (frequently following tragedies rather than pre-empting them) and interest groups, many of whom see promotion of health as a threat.11 The pursuit of health is as legitimate a goal for governments as national defence or economic growth. All involve balance between individual and collective interests. The challenge for public health is to advocate a greater degree of consistency than currently exists.

Martin McKee CBE, MD, FRCP · Ruth Colagiuri BEd, GradCertHlthPolMgnt

Further progress may require business and public sector partnerships Chronic diseases in low-to-middle-income countries have continued to increase. At the same time, calls for prevention have grown.1-3 The World Health Organization resolution on diet and physical activity, published in 2004, recommended several specific actions for food companies and the broader private sector.4 Among these were: Limit the levels of saturated fats, trans fatty acids, free sugars and salt in existing products; Continue to develop and provide affordable, healthful and nutritious choices to consumers; Practise responsible marketing that supports the strategy, particularly with regard to promoting and marketing foods high in saturated fats, trans fatty acids, free sugars or salt, especially to children; Issue simple, clear and consistent food labels and evidence-based health claims; and Assist in developing and implementing physical activity programs. PepsiCo’s strategyEven though foods from PepsiCo contribute a modest proportion of calories to a typical diet in most of its markets, we believe we should continually improve nutrition so that each calorie has the optimum fat, sugar and salt content. We do so by reducing certain nutrients and increasing others. We have developed methods of measuring the current use of fats, sugar and salt in all our products in all countries where they are sold. On the basis of these measurements, we have set targets for reducing the levels of food constituents such as fats, sugar and salt by 2010. The example of trans fatty acids and our use of oils illustrates how commitment and actions need careful thought. We continue to reduce trans fatty acids in all markets and have eliminated them from virtually all our oils used for cooking potato chips and snacks. In Europe, introduction of a new oil, Sunseed, which is higher in monounsaturated fats and lower in saturated fats has led to a 50%–70% reduction in the saturated fat levels in our potato chips and snacks compared with the same products in 2005. Further progress on reducing trans fats and saturated fats awaits further research generally on alternatives to trans fats and the optimal mix of fats and oils in food products. Food companies need to ensure the long-term supply of the crops needed to produce high-quality oils. This has become increasingly complex in a world of globalised trade and when the future demand for biofuels is likely to affect the price and availability of oils. It is likely to be an even bigger problem in small and medium enterprises in low-to-middle-income countries. Public demand for reduced sugar in food and beverages has stimulated research efforts to find natural sweeteners with the same taste but fewer calories than current products. Similarly, companies are actively seeking ways to maintain taste and the other qualities that salt brings to foods with healthier alternatives or formulations. In the United Kingdom we have lowered salt levels in all packaged chips by 25% through reformulation. Further progress in the UK and elsewhere requires industry-wide collaboration and agreement on acceptable levels, supported by governments. Public health partnershipsFood industry investments in product reformulation will yield major public health gains, but product reformulation is only part of the solution. Well grounded insights into country-specific consumer preferences drive our decisions about when and how to introduce new products. We now seek ways of working with public health researchers to share our perspectives on how best to truly change the behaviour of consumers for public and private good. Our experience in the United States, for example, suggests that well designed, science-based logos can influence consumer behaviour. Sales of products that carry our Smart Spot logos (Box) are growing far faster then others, leading to more healthful consumption, and profits. To date, most of the public sector research effort in relation to obesity or diet has tended to favour medication solutions over food-based solutions. We believe a shift in focus would stimulate new partnerships between corporations and public health scientists that could lead to healthier food products being developed through innovative science — as we have seen with new pharmaceutical products. A renewed and more forward-thinking nutrition-science agenda should go beyond a focus on reducing “harms” to identifying how the global underconsumption of fruit, vegetables and cereals could be partly addressed through new products; how nutrients might enhance physical and mental performance; and ways of addressing satiety and weight management. Research partnershipsProduct reformulation is only part of the company’s solution. The PepsiCo Foundation, the primary charitable arm of the company, is deeply engaged in developing new models of partnership that will lead to health gains in communities and new research insights.5 There are still no documented successes in reducing obesity in a large community setting anywhere in the world. We are supporting research aimed at meeting this gap.6 For example, in the US, foundation support for Tufts University has helped to develop one of the few examples of a community-based approach that may reduce obesity in children.7 Internationally, we have announced support for Community Interventions for Health, a partnership with the Oxford Health Alliance.8 The partnership will carry out large-scale, community-based research projects in India, China, Mexico and the UK aiming to reduce the effects of the major risk factors for chronic diseases. Further, both the company and the foundation are involved in a range of initiatives aimed at increasing physical activity around the world in settings as diverse as Mexico (through Vive Saludable which addresses healthful eating and physical activity in primary schools) and in the US (through America on the Move). ConclusionNo single company can turn around the current threat of chronic disease. That is why we seek corporate and public sector partners. The role of the medical profession has been decisive in the battles against so many causes of ill health. This is the time, in our view, for them to review their clinical and public health roles in supporting patients and communities to tackle the major public health issue of obesity. PepsiCo is ready to join them in this task. Smart Spot product criteria Smart Spot beverage and food products: contain at least 10% of the daily value of a targeted nutrient (eg, protein, fibre, calcium, iron, vitamin A, or vitamin C); and meet the limits of the Institute of Medicine (the United States independent advisory body on health) or the US Food and Drug Administration for fat, saturated fat, sodium and added sugar; or are formulated to have specific health benefits; or are reduced in calories or nutrients like fat, sodium or sugar. This packet of chips displays the Smart Spot logo.

Derek Yach MB ChB, MPH · Antonio Lucio BA · Carlos Barroso BChemEng

During 2007, the human species became predominantly urban. Australia is highly urbanised, and health varies within Australian cities. Australian urban life is characterised by sedentariness, excess food intake, reliance on cars for transport, a high level of exposure to media and marketing messages, and a consumer culture. These characteristics are linked to obesity, diabetes, heart disease, some cancers, chronic respiratory disease, injury, depression and anxiety. The evolution of cities has been characterised as a four-stage process: poverty, industrial, consumption and eco-city. Each stage but the last has defining health disorders. Transition to healthy and sustainable cities requires infrastructure investment in new urban areas (including mass transit, education and health services), better conditions for walking and cycling, access to healthy food and encouragement of suburban economic development. There is a role for everyone in the transition to healthy and sustainable cities.

Anthony G Capon BMedSc, PhD, FAFPHM

Objective: To investigate morbidity and mortality associated with heatwaves in metropolitan Adelaide using ambulance, hospital admission, and mortality data.Design, participants and setting: Case-series study comparing health risks in the Adelaide metropolitan population during heatwaves and non-heatwave periods.Main outcome measures: Daily observations for ambulance transports (1993–2006), hospital admissions (1993–2006), and mortality (1993–2004), categorised using International classification of diseases (ninth and tenth revisions) codes for the relevant disease groups.Results: During heatwaves, total ambulance transport increased by 4% (95% CI, 1%–7%), including significant assault-related increases for people aged 15–64 years. Reductions were observed in relation to cardiac, sports- and falls-related events. Total hospital admissions increased by 7% (95% CI, − 1% to 16%). Total mental health admissions increased by 7% (95% CI, 1%–13%), and total renal admissions by 13% (95% CI, 3%–25%). Ischaemic heart disease admissions increased by 8% (95% CI, 1%–15%) among people aged 65–74 years. Total mortality, disease- and age-specific mortality did not increase, apart from a small increase in mental health-related mortality in people aged 65–74 years. Significant decreases were observed in cardiovascular-related mortality.Conclusion: In contrast to evidence from extreme heatwaves in the northern hemisphere, we found no excess mortality during heatwaves in metropolitan Adelaide, perhaps because of adaptive behaviour to regular hot weather spells. Projected temperature increases and evidence of modest increases in morbidity during heatwaves indicate the need for a heatwave response plan for Adelaide.

Monika Nitschke PhD, MPH · Graeme R Tucker BSc · Peng Bi MB BS, PhD

To the Editor: Egger makes novel and valid points in his portrayal of individual human effort as a potential contributor to offsetting greenhouse gas emissions by personal carbon trading.1 Of course, there is an even more potent strategy humans should adopt to modify climate change through their own activities — population control. Anthropogenic greenhouse gases constitute the largest source of pollution, with by far the greatest contribution from humans in the developed world. Every newborn baby in Australia represents a potent source of greenhouse gas emissions for an average of 80 years, not simply by breathing, but by the profligate consumption of resources typical of our society. What then should we do as environmentally responsible medical practitioners? We should point out the consequences to all who fail to see them, including, if necessary, the ministers for health. Far from showering financial booty on new mothers and thereby rewarding greenhouse-unfriendly behaviour, a “Baby Levy” in the form of a carbon tax should apply, in line with the “polluter pays” principle.2 Every family choosing to have more than a defined number of children (Sustainable Population Australia suggests a maximum of two3) should be charged a carbon tax that would fund the planting of enough trees to offset the carbon cost generated by a new human being. The average annual CO2 emission by an Australian individual is about 17 metric tons,4 including energy usage. As the biomass of trees in a mature forest sequesters about 6 metric tons of CO2 per hectare (104 m2) per year,4,5 each child born should be offset by planting 4 hectares of trees, to allow for the time they take to reach maturity, and attrition through crop losses, bushfires, dieback and so on. This infers a levy per child of at least $5000 at birth (to purchase the land needed and plant trees) and an annual tax of $400–$800 thereafter for the life of the child (for maintenance of the afforestation project) (based on 1990 figures,4 and probably much more now). By the same reasoning, contraceptives, intrauterine devices, diaphragms, condoms and sterilisation procedures should attract carbon credits for the user and the prescriber that would offset their income taxes, and lead to rewards for family planning clinics and hospitals that provide such greenhouse-friendly services. As David Attenborough said: . . . instead of controlling the environment for the benefit of the population, we should control the population to ensure the survival of the environment.6 As doctors, I believe we need to think this way. Our responsibility extends further than the patient on the other side of the desk. As Australians, I believe we need to be less arrogant. As citizens of this world, I believe we deserve no more population concessions than those in India and China. In reply: I agree with Walters. One must wonder why population control, which was such a popular topic during the 1970s, is spoken of today only in whispers. Is this because of the discovery of new oil in the 1980s, taking resource scarcity off the public agenda? Is it because of politicians and economists, so keen on the growth trail that “. . . one for mum, one for dad and one for the country”1 seems an easy solution? Or is it the great religions, intent on outnumbering each other? Environmental groups have also gone silent on the issue — perhaps afraid to alienate their growing support on other environmental issues. Population remains crucial to all environmental (and subsequently, health) considerations. The debate needs to be reopened as part of a second ecological revolution (following the failure of the first in the 1960s and 1970s).2 Doctors, as opinion leaders in the community, must be at the forefront of this debate.

Barry N J Walters · Garry Egger

A severe storm that began on Thursday, 7 June 2007 brought heavy rains and gale-force winds to Newcastle, Gosford, Wyong, Sydney, and the Hunter Valley region of New South Wales. The storm caused widespread flooding and damage to houses, businesses, schools and health care facilities, and damaged critical infrastructure. Ten people died as a result of the storm, and approximately 6000 residents were evacuated. A natural disaster was declared in 19 local government areas, with damage expected to reach $1.5 billion. Additional demands were made on clinical health services, and interruption of the electricity supply to over 200 000 homes and businesses, interruption of water and gas supplies, and sewerage system pump failures presented substantial public health threats. A public health emergency operations centre was established by the Hunter New England Area Health Service to coordinate surveillance activities, respond to acute public health issues and prevent disease outbreaks. Public health activities focused on providing advice, cooperating with emergency service agencies, monitoring water quality and availability, preventing illness from sewage-contaminated flood water, assessing environmental health risks, coordinating the local government public health response, and surveillance for storm-related illness and disease outbreaks, including gastroenteritis. The local ABC (Australian Broadcasting Corporation) radio station played a key role in disseminating public health advice. A household survey conducted within a fortnight of the storm established that household preparedness and storm warning systems could be improved.

Michelle A Cretikos MB BS, MPH, PhD · Tony D Merritt MB BS, MPHTM, FAFPHM · Kelly Main BAppSc, MPH · Keith Eastwood MAppEpi · Linda Winn MN · Lucille Moran BComm, CPA, GradCertPubSecMgmt · David N Durrheim DrPH, MPHTM, FAFPHM

Meningitis and mentors seeded a passion to remedy health inequalities in Africa We have the capacity to feed everybody on our planet. We have the capacity to ensure that everybody has clean water . . . [and] affordable health care. We can prevent many of the diseases to which our children in the poorer parts of the world succumb . . . A person is a person through other persons . . . You can’t be human in isolation; you are human only in relationships. — Archbishop Desmond Tutu I’ll never forget the pounding, throbbing headache that heralded meningococcal meningitis. I remember leaning against the wall in the bathroom of my local doctor’s waiting rooms, steaming with a temperature of 40°C, and thinking “This is it. I must be dying”. The pain was so intense I just couldn’t see how my body could survive. Every skerrick of light seeping through my shut eyelids felt like lasers beaming through to burn my brain. As I was a boarder in a rural school, I was alone — I was afraid — and I was 14. After losing consciousness and a helicopter flight to Sydney, I awoke after a week, in the intensive care unit of the Children’s Hospital at Westmead. One week later, when I could stomach food, I was moved into a ward. I was sharing with a 2-year-old boy who also had meningitis, but whose septicaemia had taken hold of his young body more aggressively than it had of mine. I remember watching him being wheeled out of the room one morning, only to return 6 hours later with no lower legs. The author, surrounded by orphans in Nairobi, Kenya. Days passed, and much to everyone’s shock, I continued to recover, with no residual disability. The months to full health were many, yet the realisation of surviving a fatal disease, completely unscathed, began to sink in. I was left with a sense of “survivor’s guilt” — an intense appreciation of life and how fortunate I was, a realisation of the gift that life is, and a yearning to make the most of every living, breathing moment that remained. My first decision was to study medicine, to fulfil a desire to give something back to the profession that had saved my life. A month in a children’s hospital is the best work experience one could have, and despite coming from a family with generations of strength in the arts, especially music, I decided to take up chemistry at school and begin to focus on the sciences. Unprepared, I sat the undergraduate medicine admission test in my final year of high school, and my marks were nowhere near those required for entrance. Undeterred, I headed off on a gap year abroad, working as a music and drama teacher in the United Kingdom before studying Italian in Florence. I returned in 2001 to the Australian National University (ANU) in Canberra to study for a Bachelor of Science (Psychology)/Bachelor of Arts, following my sister’s footsteps to John XXIII College. A year later, a summer internship on the trading floor at Macquarie Bank in Sydney saw me shift to a Bachelor of Commerce/Bachelor of Science, and I returned to Macquarie Bank for three more challenging summers in finance. Equity markets and medicine are deceptively similar: both are fast-paced, intellectually demanding, unpredictable and exciting work environments. Yet despite the “buzz” of my experience in the financial world, I couldn’t shake my medical aspirations. During lunch hours in Martin Place, I would sit and stare at the homeless people seeking shelter under the buildings in which others were making millions, and I knew that a profession in medicine would be the only way to satisfy my desire to help people while challenging me intellectually. Education session and distribution of subsidised insecticide-treated nets by Hands of Help volunteers and health workers in Uganda. After two more unsuccessful attempts at the undergraduate medical admissions test, I turned to the postgraduate admission procedure. In the penultimate year of my undergraduate course, I sat the Graduate Australian Medical Schools Admissions Test (GAMSAT) as mere practice for the following year, but fortunately, my marks were high enough to result in a placement at the University of Sydney. I was bursting with enthusiasm to begin the postgraduate medical course after 4 inspired years as an undergraduate. To pay the bills during my days in Canberra, I had worked as a therapist for children with autism, conducting applied behavioural analysis for children with profound disability at a special education school in Woden. What began as a job soon turned into a passion as I learned how to communicate with children who had no speech, honing my empathy skills as I tried to learn to read their expressions and mannerisms to understand how they were feeling and what they were trying to say. These children, with beautiful personalities frustratingly stuck in less useful bodies, absolutely grew on me. My appreciation of life continued to grow and, while I hope the hours of therapy I did with those children helped them become a little more capable, ultimately they taught me far more. In my last holidays before beginning medicine, I made a trip to Africa, a continent which had fascinated me since reading Bryce Courtenay’s The Power of One as an impressionable teenager. In my commerce degree, I had majored in development economics and was inspired by a senior lecturer at the university, Dr Alan Martina, who brought to light for me the inequalities existing in our world today. My passion for the subject saw me begin to devour novels on the area, and an inspirational meeting with Nobel Prize nominee Professor Jack Caldwell, who has devoted much of his life to demography in Africa, sealed my interest. Thanking the Bufuula community for their hospitality at the end of the volunteers’ 3-month stay to build a primary school in 2005. I spent a month in East Africa those holidays, and was changed forever by the experience. In Africa, the continent on which we all began as Homo sapiens, it is impossible not to feel alive. There is a magic about the place and its absolute determination to defeat the myriad obstacles that have been placed in its way — geographical disadvantage, slavery, colonialism, and continuing epidemics — and this fiery determination burns through to your heart, making it impossible to walk away unchanged. I remember my plane taking off from Nairobi and promising to myself that I would return, but next time with more money, more time, and more people to make a difference. I graduated from the ANU and started studying medicine 6 months later. I had already emailed all my family and friends to rally interest in working and raising funds for the continent, but as the work began, the interest dissipated. Not knowing a soul in my new medical course, I took the plunge to email my entire year group about my idealistic plan. The response was amazing. The following summer, in December 2005, 17 volunteers, including 12 medical students from the University of Sydney, headed to Uganda to live in a remote community for 3 months, with no water or electricity, as we built a primary school for 650 children. We paid our own way to get there, juggling part-time jobs on top of full-time medical degrees, and left with our backpacks and $100 000 in the Hands of Help bank account — the result of an exhausting year of fundraising and the generosity of those supporting our idea. On the back of such enthusiasm, I set in motion the wheels to register ourselves as a charity, and Hands of Help was born, with a grassroots commitment to ensuring all funds raised reached the areas of the world that needed them most. To date, over 98% of our hundreds of thousands of dollars has been spent “on the ground” in Africa or Indigenous Australia, something we are proud of, and a figure not often achieved in the world of charitable organisations. A young girl in Bufuula, proudly wearing a Hands of Help armband. Living in an African community, experiencing life the way Africans do, is a once-in-a-lifetime opportunity. We grew close to the children, their parents and the local community council, and developed an understanding of health care in the developing world through visits to local clinics and hospitals. I rustled together a survey, which we conducted with local interpreters, of every household in Bufuula — the tiny village we were living in, located 3 hours south-east of Kampala, the capital of Uganda. As we sat in each home, showered with papayas, fresh milk from their cows and raw peanuts or coffee beans, we listened intently to their stories. We swallowed hard past the lumps in our throats as we heard recollections of their many children lost to malaria, while smiling toddlers sat in the corner of the hut eating cardboard to ward off their grumbling tummies. We stood humbly at the grave sites of mothers lost to AIDS while holding the hands of their children left behind, and we listened to their desperate pleas for access to health care and education. The first Hands of Help group of volunteers. Inspired, we headed off to Kampala to meet with Dr Ian Clarke, of the International Hospital Kampala (IHK), who agreed to support us to begin a community health project in Bufuula, training and employing Ugandans selected by their own communities to become grassroots health workers in areas where hospitals are out of reach. The project began in Bufuula and surrounding villages, and this year will reach as far afield as the war-torn areas of northern Uganda. Over 50 Ugandans have been trained as health workers by a public health specialist. Subsidised mosquito nets have been distributed, water sanitation satchels have been added to jerry cans, and HIV testing has been made available, along with education sessions on all relevant diseases, by these health workers who are proud and honoured to be trained as such. They see their new knowledge as such a privilege that they feel a responsibility to spread it to as many towns as possible. That summer was the beginning of years of achievements for Hands of Help. Seventeen volunteers, to whom I — and Africa — are forever indebted for believing in me and my ideas, left that initial project enlightened and inspired to be part of improving the inexcusable health inequalities facing so many in our world today. On the way home, our chance trip to an orphanage with unparalleled atrocious living conditions resulted in a commitment to help 250 orphans in Nairobi, Kenya. These orphans are now being given a chance at life, receiving a secondary school education through our child sponsorship program. Yet, also conscious of the issues in our own backyard, we returned to Australia and established a project to allow medical students to work with local Aboriginal medical services in remote Indigenous communities. And so I approach the final year of medical school, with years of hard work, sleepless nights and exhaustion from overwork behind me — and that’s before internship has even begun! It would be unrealistic, and lying, to say it has been easy, and I often look longingly at those enjoying a weekend off or a holiday. Yet, thanks to the hard work of dedicated committee members, a balanced partnership with medical student and Vice-President Joe Dusseldorp, who believed in Hands of Help from its inception, an extremely supportive family and partner, and the generosity of the Australian public, the charity has achieved more than I could ever have hoped for in that moment my plane took off from Nairobi. Over 100 volunteers have now given up their summers to build three new primary schools in Uganda, 50 Ugandans have been trained as community health workers, 250 Kenyan orphans have been given another chance at life, and a further 25 medical students have spent their holidays experiencing health care for Indigenous Australians. Meanwhile, awareness of African issues, and a chance for Africans to speak with their own voice, is provided by our Sydney African Film Festival1 and photographic exhibitions every year by a professional photographer (my partner, Hamish Gregory, who travels the globe with me). This summer, a further 30 volunteers will travel to the war-ravaged areas of northern Uganda to build a fourth school, while the Community Health Project will expand to service the two million people displaced by years of civil war in Gulu. Conducting hut-to-hut health surveys with local interpreters in Uganda. As I approach the coming years of my junior medical and specialty training with trepidation and curiosity as to where the path of medicine will take me, I find solace and inspiration from the thought that dozens of medical students now have a passion for our world’s health inequalities. I am continuously supported and encouraged by my parents and motivated by the work of doctors such as Catherine Hamlin, whose work with women with obstetric fistulas in Ethiopia has turned around the lives of 32 000 women, and Rowan Gillies, the former President of Médecins Sans Frontières. I am encouraged by supportive lecturers and honours supervisors, and always astounded by the passion of selfless doctors who take the time to pass on the secrets of medicine by teaching and motivating young students every day. But without a doubt, the thoughts that stay closest to my heart are the memories of an African child’s piercing stare delving deep into my soul, and the throbbing pain of that meningitic headache — and I pinch myself and remember how lucky I am to be here, where I am today, and I think of how much there is to squeeze into these short years — and how wonderful it is to be alive.

Phoebe C M Williams BComm, BSc

Regulation of tobacco products and their emissions is long, long overdue The modern cigarette is an unmitigated public health disaster, more so than tobacco used in any other form. Together with other types of tobacco product, cigarettes are responsible for several million global deaths annually and expected to cause about 10 million annually by 2030.1 Modern cigarettes are uniquely efficient nicotine delivery devices because of sophisticated technology that controls such elements as pH and droplet size, and consequently provides rapid absorption and a rapid nicotine “fix” while using less tobacco, but many more additives, than its Second World War predecessor.2 Australia is at the forefront of the battle to control diseases caused by tobacco through the use of regulation of marketing and vigorous antismoking campaigns. The result is that “only” about a fifth of Australians smoke, and index diseases such as lung cancer and heart disease are declining in prevalence. There is, however, a strong social-class factor evident among continuing smokers, with the less educated and less well remunerated being over-represented in this population.3 Given Australia’s exemplary role in the regulation of cigarette marketing, it is bizarre that no regulations at all are applied to the product or its emissions. In this respect Australia is no different to most other countries as, apart from meaningless restrictions on tar, nicotine and carbon monoxide in Europe, no country worldwide has established control over cigarette emissions. A potential exception may be the United States, which currently has a bill before Congress that would empower the Food and Drug Administration to regulate cigarette emissions. The World Health Organization is moving to change this with its publication, The scientific basis of tobacco product regulation.4 This technical report sets out a practical rationale for regulating tobacco smoke, and makes specific recommendations for setting upper limits for two of the best understood carcinogens, the tobacco-specific nitrosamines, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N-nitrosonornicotine, with the indication of more proposals to follow, plus discussions of design features that contribute to toxicity and marketability, such as candy flavourings, and recommendations for future research. Consumer products of virtually all types are regulated. Controls apply to almost every marketed product, from the proportion of rat droppings permitted in wheat, to the amount of fat allowed in sausages, and even to the amount of mint allowed in nicotine replacement therapy. With this background, it seems astonishing that the federal Minister responsible for drug and alcohol policy recently rejected claims that a new tobacco product (a “heatbar” which heats but does not burn tobacco) should be subject to regulation and said there were no plans to even investigate the product.5 This product is unlikely to be any worse than other tobacco products. It may even be an improvement, but we won’t know if it is not to be investigated. There seems to be a general view that all cigarettes are dangerous, which is true, but also that they are all virtually the same. Not true. Nitrosamines, for example, are potent carcinogens whose level can readily be reduced, almost to the point of elimination, by the manufacturers, but this would increase production costs and the tobacco industry is moving very slowly, in most places not at all, to reduce them. A global analysis of the Philip Morris brand, Marlboro, in 1996 showed a ninefold variation in the amount of NNK per cigarette.6 This would be unremarkable if it was merely a flavouring agent. However, it is a carcinogen and such unnecessary variation should not be allowed. Most industries would move in this direction voluntarily, but the tobacco industry long ago gave up trying to make cigarettes “safer”.7 Instead, their research has focused on ways to make nicotine better absorbed, and for cigarettes to be more flavoursome as well as less harsh.8 The need to regulate the constituents of cigarette smoke is not trivial. With one in five Australians still smoking, and with even higher proportions among the blue-collar end of the social spectrum, the tobacco-associated death rate will remain unnecessarily high. It is high time to regulate to reduce those major toxins and carcinogens that can be reduced, as this is one way to help continuing and addicted smokers. The WHO has led the way and will continue to recommend practical changes. Countries as sophisticated as Australia should be able to move ahead of other less developed countries and, in the case of a new and untested product, could be expected to do so as a matter of urgency. The Australian Government should recognise the WHO recommendations and set in train a process of tobacco regulation — one that is flexible and can be updated as the WHO continues to develop its regulatory program. This would be consistent with the approach taken to both pharmaceuticals and other consumer products, and is very long overdue. Now that the WHO has set out a practical approach, the federal government has few excuses for further delay.

Nigel J Gray FRACP