Global health

The annual death toll from tuberculosis in the Indian Ocean region is 2–3 times higher than the toll from the recent tsunami A major earthquake measuring 8.9 on the Richter scale occurred off the west coast of Sumatra on 26 December 2004. 1 The quake even caused the earth to wobble in orbit. 2 The ensuing tsunami hit countries bordering the Indian Ocean. The estimated death toll exceeds 220 000. 1 The human and economic tragedy was evident to all, and national governments and international organisations have mounted an enormous relief effort. Coincidentally, seven of the tsunami-affected countries (India, Indonesia, Thailand, Bangladesh, Burma–Myanmar, Tanzania and Kenya) are among the 22 nations with the highest burdens of tuberculosis (TB). 3 Over three million new TB cases and 772 000 TB deaths occurred in these seven countries in the year 2000. 3 Similar annual statistics have been reported from these and other high-burden countries for more than 10 years. But the earth does not move! The human and economic toll is not appreciated, and an enormous global response is not mounted. The global TB situation is full of such paradoxes. It also highlights the global inequities in the distribution of healthcare services and other resources. 4 An estimated 8.3 million new TB cases and nearly 2 million TB deaths occurred worldwide in 2000. 3 Ninety-five percent of the TB cases and 98% of the deaths were in low-income countries. 4 Importantly, from Australia’s perspective, 60% of this global TB burden occurred in our neighbouring countries in South East Asia and the Western Pacific. 3 What is happening in low-income countries? In Africa, 38% of new adult TB cases in 2000 were in people who were HIV-positive. 4 HIV infection increases an individual’s susceptibility to infection and disease progression, and the increased burden of HIV-associated cases may increase TB transmission to those who are HIV-negative. HIV-related TB has swamped TB-control efforts in Africa, where case numbers increased 6.4% between 1997 and 2000. 3 Multidrug-resistant tuberculosis (MDR-TB), defined as Mycobacterium tuberculosis strains with resistance to at least isoniazid and rifampicin, is also perceived as a great threat to TB control. However, only an estimated 273 000 (3.2%) of new TB cases worldwide were multidrug resistant in 2000. 5 Mathematical modelling and other observations based on imperfect data suggest that MDR-TB strains are generally of lower reproductive fitness, and that MDR-TB will remain localised in foci such as the former Soviet Union. 5 Effective TB control in these MDR-TB-endemic foci may require additional measures, such as wider availability of drug-susceptibility testing and the use of second-line drugs under close expert supervision. 5 More mundane factors than MDR-TB are the real confounders of TB control in low-income countries. These factors include inadequate infrastructure (eg, roads, transport, electricity), weak primary healthcare systems, poor laboratory services, and insufficient engagement of private practitioners and other health providers in TB control. 6 A major impediment to TB control that must be highlighted is the lack of trained staff, particularly in HIV-endemic countries, where the epidemic has decimated the healthcare workforce. 6 What can be done in low-income countries? Effective TB control relies on halting transmission through the rapid detection and cure of infectious cases. International targets have been set to detect at least 70% of all new infectious cases and to cure at least 85% of those detected by 2005. 6 Attainment of these goals would result in a decline in TB incidence of 6%–7% per year. The World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease have recommended and validated a policy package entitled DOTS to achieve these case detection and cure rates. The DOTS strategy contains five elements: government commitment, accurate diagnosis principally by sputum-smear microscopy, standardised short-course chemotherapy with direct observation of treatment, provision of reliable drug supplies, and systematic program monitoring. 6 Unfortunately, the WHO annual TB reports to 2003 suggest that the global targets for case detection and cure rates may not be met by 2005. Additional initiatives have been recommended, including increasing government stewardship of TB-control programs, engagement of private health practitioners in DOTS programs, and involvement of local community groups. 6 Tuberculosis and HIV-control programs in Africa and other HIV-prevalent areas must also be coordinated and integrated to achieve enhanced TB and HIV case-finding, to institute TB preventive treatment, and to establish interventions against HIV, such as antiretroviral treatment (which will also indirectly control TB). 6 High-income countries with a low incidence of TB, such as Australia, confront different challenges.7 The incidence of TB in Australia was 4.9 cases per 100 000 population in 2003, which is one of the lowest rates globally, and this incidence has remained stable since the mid-1980s.8 However, people born overseas and Indigenous Australians remain at increased risk of TB (with 9.9 and 8.5 cases per 100 000 population, respectively).8 Maintaining awareness about TB among the medical profession and governments is difficult when the overall TB incidence is so low.7 Undergraduate and postgraduate education programs must ensure that clinicians consider TB, particularly in patients from at-risk subgroups.7 Governments must continue funding specialist TB treatment services (including specially trained staff and reliable drug supplies).7 The TB services themselves must realign policies and procedures towards TB elimination, and consider innovative measures for controlling TB in the subgroups who remain at increased risk of TB.7 The National Tuberculosis Advisory Committee has addressed these issues and published a strategic plan that includes performance indicators for evaluating our national TB-control efforts.9 World TB Day on 24 March is a reminder to Australian doctors that TB is not a vanishing disease. Rather, a “tsunami of TB” occurs every year overseas. What can we do? At the clinical level, Australian doctors must “think TB” when seeing patients, particularly those from subgroups at risk of TB. Australia has laboratory and clinical expertise in TB which is being shared increasingly with our neighbouring countries. Finally, we must advocate for the Australian and other governments to provide funds for TB-control programs in our neighbouring countries, as has happened for the tsunami relief effort. Australia must do so for humanitarian reasons and for self-interest.

Ivan Bastian PhD, FRCPA

Death from mushroom poisoning in Australia is rare and usually due to liver failure produced by Amanita phalloides. We report a 53-year-old woman in Queensland who died from an acute muscarinic syndrome 10 hours after eating mushrooms belonging to the genus Rubinoboletus. To our knowledge, this is the first death in Australia caused by non-amatoxin-producing mushrooms. It highlights the need for awareness of non-amatoxin-producing mushrooms as potentially lethal. Reports of significant morbidity or mortality from mushroom ingestion in Australia have predominantly involved the “deathcap” mushroom (Amanita phalloides),1,2 which contains amatoxins that cause hepatic necrosis and often renal failure. Most of these reports have come from Victoria and the Australian Capital Territory.1,3 We report a death in Queensland after mushroom ingestion producing a severe muscarinic syndrome. The mushrooms involved were identified as Rubinoboletus sensu lato pro tempe, from the bolete group, which includes several species known to produce muscarine. Clinical recordA 53-year-old woman, originally from Switzerland, presented to a community hospital with a 2-hour history of headache, chest and abdominal pain, recurrent vomiting and profuse sweating. Symptoms began suddenly about an hour after she had eaten two large mushrooms which had been collected from bushland near her home and partly cooked. The mushrooms were growing near the base of trees, including both native and introduced species. The woman was previously well, with no significant medical history, and did not take prescribed or alternative medication. Her partner had eaten a small amount of the same mushrooms but rapidly vomited them. He had no toxicological sequelae. On presentation, 3 hours after eating the mushrooms, the patient was flushed, with profuse sweating, vomiting, diarrhoea and confusion (Glasgow Coma Score, E3 M5 V4 = 12/15). Her condition deteriorated rapidly. She developed hypotension (systolic blood pressure, 60 mmHg) and bradycardia (heart rate, 30 bpm). The Glasgow Coma Score fell to 5/15 (E1 M3 V1). Her pupils were constricted but equal and reactive to light. Arterial blood gas analysis revealed severe mixed metabolic and respiratory acidosis (pH, 6.7 [reference range {RR}, 7.35–7.45]; HCO3, 8 mmol/L [RR, 22–33 mmol/L]; Paco2, 55 mmHg [RR, 35–45 mmHg]; base excess, − 28 mmol/L [RR, − 3.0 to 3.0 mmol/L]; arterial lactate, 13 mmol/L [RR, < 1.3 mmol/L]). The patient was intubated and ventilated. Fluids were administered (3 L crystalloid and 2.5 L colloid), along with intravenous atropine (2 mg) and an adrenaline infusion. She was transferred to a tertiary hospital intensive care unit for further management. On arrival at the tertiary hospital, 7 hours after ingesting the mushrooms, she remained in shock, with mean arterial pressure of 40 mmHg and heart rate of 50 bpm. She was treated with high-dose adrenaline and noradrenaline infusions (up to 50 μg/min), further intravenous atropine (12 mg in boluses) and fluid loading (total 3 L colloid), intravenous sodium bicarbonate solution (100 mL, 8.4% solution), metaraminol (total, 20 mg), calcium chloride (200 mg total) and glucagon (6 mg total). Two doses of activated charcoal were given via a nasogastric tube an hour apart (total, 100 g). Despite maximal doses of inotrope infusions, the heart rate remained at 50 bpm and mean arterial pressure at less than 60 mmHg. Dialysis was begun in an attempt to correct the severe acidosis. However, after about an hour of dialysis and despite ongoing maximal supportive therapy, the patient developed asystole. Resuscitation was ceased 10 hours after mushroom ingestion. Autopsy was performed at the Queensland Health Scientific Services Forensic Pathology facility. External examination was unremarkable. Internal examination revealed small, bilateral, straw-coloured pleural effusions, bilateral diffuse pulmonary congestion and a small focus of acute pulmonary haemorrhage within the right lung. The liver had a pale cut-surface appearance, and histological examination revealed centrilobular congestion and collections of neutrophils within the sinusoids, but no associated hepatocellular necrosis. No underlying disease or other pathological findings were identified. Toxicological analysis of blood collected post mortem detected midazolam, lignocaine and atropine (used during intensive-care admission before death). Neither alcohol nor α-amanitin was detected. The patient’s partner provided samples of the remaining uncooked mushrooms, and further similar mushrooms were collected from the bushland for identification. They belonged to the bolete group and were identified in consultation with the Queensland Herbarium as Rubinoboletus sensu lato pro tempe (Box). DiscussionTo our knowledge, this is the first reported death in Australia from poisoning by a mushroom other than A. phalloides. This patient had many of the classical features of muscarinic poisoning, which is characterised by cholinergic-receptor agonist activity. Features include hypotension, bradycardia, vasodilation, bronchospasm, bronchorrhoea, headache and tremor secondary to the hypotension, excessive salivation, abdominal cramps, vomiting and watery diarrhoea. Urinary incontinence, confusion, miosis and impaired visual accommodation may also occur.4 Some muscarinic compounds have a more histaminic effect, with flushing, hypotension and bronchoconstriction.5 Muscarinic compounds are found in a number of species of mushrooms. These compounds are typically thermostable, with a quaternary configuration, and do not cross the blood–brain barrier. They therefore do not cause direct central neurotoxicity. As muscarine does not contain an ester linkage, it is not metabolised by plasma cholinesterase. Some muscarinic mushroom species produce mild, self-limiting symptoms, while others have severe parasympathomimetic effects, as seen in our patient. Most commonly implicated in severe cases of poisoning are Inocybe and Clitocybe spp.6 Boletus and Rubinoboletus spp. also belong to the group of muscarine-producing fungi, but a search of the English language literature has revealed no previous reports of severe toxicity or death caused by Rubinoboletus spp. Deaths from muscarinic mushroom poisoning have been reported in Europe, involving Inocybe and Clitocybe spp.5,6 Most were in children with cardiac or pulmonary disease. The lethal dose of muscarine for humans is not precisely known, with estimates ranging from 40 mg to 495 mg (the latter equivalent to 150 g of fresh Inocybe mushroom).2 Boletes, including the Rubinoboletus sp. implicated in this case, form mycorrhizal (symbiotic) relationships with trees, including hardwood species and conifers. Boletes appear similar to the gill fungi (such as the commonly grown Agaricus spp.) in having a cap and stalk. However, unlike the gill fungi, they carry their spores in tubes opening onto the underside of the cap rather than on radial gills. The underside of the cap thus appears covered in tiny pores, hence the common name “fleshy pore fungi”. Hepatotoxicity and hepatic necrosis are not typical of muscarinic poisoning. In our patient, the postmortem histopathological features of the liver were non-specific. In the absence of hepatocyte necrosis, an acute toxic hepatitis cannot be definitively diagnosed. The changes indicated a reactive process and may have been secondary to hypoperfusion, representing ischaemic injury as a pre-terminal event. Australian doctors need to be aware that some mushrooms contain substances that cause severe muscarinic symptoms, which may result in severe illness or death. There is little evidence for treatment strategies in mushroom poisoning, and the role of gastric decontamination is unclear. Atropine, a rational antidote, has been used successfully to treat less severe poisonings with muscarine-producing mushrooms.7 Mushroom implicated in a fatal ingestion Mushroom (Rubinoboletus sensu lato pro tempe) found at the same place as the ingested mushrooms and identified as similar by the partner of the deceased woman. (Photograph courtesy of Nigel Fechner, Queensland Herbarium, Brisbane, QLD.)

John L Pauli MB BS(Hons), BSc(Hons) · Carole L Foot MB BS(Hons), FACEM

The medical workforce needs of the Pacific islands, Papua New Guinea (PNG) and East Timor (see map) are vastly different from those of their richer neighbours such as Australia and New Zealand. In these developing nations, 50%–90% of the population live in rural areas (as opposed to 10%–15% in Australia). Their gross national product (GNP) is US$500–$2000 per capita, with 2%–5% of gross domestic product (GDP) spent on healthcare (compared with Australia’s $20 000 per capita, with 9.7% of GDP spent on healthcare). In Australia and New Zealand, there are about 2–2.5 doctors per 1000 population, while, in the Pacific, the ratios are about 20 times less, at 0.1–0.4. The age distribution of the population is also very different: 30%–40% of people are aged less than 15 years and only 5% are over 60 (compared with 20% under 15 years and 15% over 60 in Australia). The health of Pacific islanders is poor when defined according to standard indicators such as life expectancy at birth, infant and under-5 mortality, and maternal mortality (Box 1). The low ratio of doctors, nurses and other healthcare workers to the total population is unlikely to improve rapidly because of the lack of capacity for training. Today’s workforceThe current medical workforce in the Pacific region is made up of doctors who have been trained in a variety of ways: Locally trained graduates of Bachelor of Medicine and Bachelor of Surgery (MB BS) courses from the University of Papua New Guinea (UPNG) and the Fiji School of Medicine (FSM). Some of these doctors have also trained as specialists through local or overseas postgraduate training programs (see Kevau et al, page 608).1,2 Graduates from the Pacific Basin Medical Officers Training Programme (PBMOTP), which was run by the University of Hawaii in the Federated States of Micronesia from 1986 to 1996 (Box 2). The program trained 50 medical officers from Micronesia and 20 from Belau, the Marshall Islands and American Samoa. Most are now working in their own countries in the North Pacific region. Doctors from Pacific island countries who are employed in neighbouring countries on contracts that attract better remuneration, if not better hospital facilities, than that of their home country. Doctors from Europe, the Indian subcontinent, South-East Asia, or Australasia. Some are volunteers, some are associated with non-government organisations, and some are salaried members of the departments of health or universities in the countries in which they work. A small number are funded by overseas aid programs (eg, in East Timor). These doctors were the main providers of medical care until local training programs began. A handful have stayed on in specialties (eg, radiology, pathology) in which local trainees have not yet filled all the available posts or in remote hospitals funded by overseas aid or missions. Doctors from countries such as Cuba and China who have been sent to work in Pacific countries as a result of government-to-government discussions, but with little consultation with specialists in the Pacific region (local or expatriate). (This has occurred in East Timor and PNG.) The medical workforce in any Pacific island country represents a variety of attitudes and cultures as a result of doctors’ different backgrounds and training. For example, in Micronesia, there are 50 PBMOTP graduates with diplomas, six graduates with an MB BS from PNG or Fiji, and one with an MD from the United States (John Hedson, Chief Surgeon, Micronesia, personal communication). Knowledge and professional attitudes vary, despite the government classifying all doctors in the same way. There is reasonable mobility of specialists around the Pacific. For example, the Marshall Islands, Tonga, the Cook Islands and Fiji have all employed surgeons trained in PNG in recent years. Thirty per cent of doctors in Fiji are expatriates, as a result of the high attrition rate of local doctors — in the past 5 years, 40% of Fijian graduates have gone into private practice or left Fiji. Many Fijian doctors have gone to Australia or New Zealand, their residencies being supported by citing an “area of need”. As Australia is short of junior doctors and of doctors willing to work in rural and remote areas, governments and departments of health are only too happy to recruit well qualified overseas doctors to fill the local void, regardless of it being a case of “the rich robbing the poor” (see Baravilala and Moulds, page 602).5 Once these doctors leave their countries it is always difficult to return home. Medical salaries in the Pacific nations are not competitive with those in Australia and New Zealand (eg, the salary of a PNG doctor is about A$13 000–$30 000 a year). The longer a doctor spends working and training overseas, the harder it is to uproot the family, particularly if children are already established in school. There is, for example, no international school in the Solomon Islands. The first UPNG national graduate (Professor Sir Isi Kevau), who trained as a cardiologist and gained Fellowship of the Royal Australasian College of Physicians, has recently been knighted in recognition of his contribution to local medical school training and healthcare in PNG and for his sacrifice in making the decision to return home after living for some years in Sydney. Training the workforceUndergraduate training Scenario 1 Dr A did a 4-year specialist training program, one year of which was spent in Australia on a scholarship. His performance was impressive and his supervisors felt sorry for him having to return home to shortages, poor remuneration and fewer educational opportunities for his children. The consultants arranged a paid position and recommended he stay to study for a “Fellowship of the Royal College” — in their minds, a “real” qualification — rather than his MMed, a degree they knew little about. Dr A was smart and hardworking. After 4 years he gained his Fellowship, but by then he was more comfortable practising in Australia. He never returned home. His children were well educated and became Australians. Fiji, the Pacific islands and PNGThe predecessor of the FSM was founded in 1885.6 Until 1960, it was the only institution in the Pacific training doctors. Between 1951 and 1964, it also trained 16 national doctors for PNG before the Papuan Medical College was started in 1962 (see Kevau et al, page 608).1 Since the founding of its medical school in 1968, the UPNG has produced over 700 doctors, including 100 Pacific islanders and 50 expatriates. The attrition rate from the public service is about 50%.7 (Most of the doctors who leave the public service take up private or general practice or go to neighbouring Pacific countries. Some go into administration or politics.) The FSM commenced a 6-year MB BS course in 1982. The FSM is the principal medical school for the Pacific islands, and both undergraduate and postgraduate programs include a number of Pacific islanders. Together, the UPNG and the FSM have the capacity to produce about 120 doctors a year. In both institutions, courses based on problem-based learning have been adopted (see Duke, page 612).1,2,8 The majority of doctors working in the Pacific have been trained in the Pacific. However, the capacity of these countries to increase the medical workforce and improve doctor -to-population ratios is limited. There are not enough places in the two medical schools in the region and insufficient funds to recruit large numbers of doctors from elsewhere. Although the number of graduates is about half what is required, the available staffing and resources are stretched enough as it is and would be unlikely to be able to train more at today’s standard. Scenario 2 Dr B had the same experience as Dr A, but did return home. It was a difficult decision for him and his family after gaining his Fellowship. But he re-established himself back home, sent his children to the government school, was gradually promoted through the ranks of the local medical school and became an academic, one of the country’s leading doctors, and an inspiration to young national doctors. Workforce and training in East TimorEast Timorese doctors have been trained in Indonesian medical schools. After the vote for independence in 2000, the country’s infrastructure was destroyed by the departing Indonesians, although the hospitals were not damaged. There are currently 46 qualified East Timorese doctors, but only 23 are working for the government, with just 17 in clinical work. There are no practising local specialists. Non-government organisations staff some of the hospitals and health facilities in the provinces. Specialist care in East Timor is provided by a few doctors whose positions are funded by the Department of Health or by aid projects, such as those managed by the Royal Australasian College of Surgeons (RACS) and HealthNet (a Dutch non-government organisation, formerly CORDAid). The service provided is supplemented by visiting specialist teams (Box 3) (see Beckett, page 603).9 Postgraduate and specialist trainingSome of the benefits of running a local postgraduate program are that doctors-in-training work for most of the time in their own country, learn to diagnose and treat disease with the resources available, and are less likely to leave once qualified. Before the commencement of a local Master of Medicine (MMed) program in Fiji in 1997, only five of the 56 doctors who went overseas for specialist training returned. This led the FSM to believe it was training doctors for Australia and New Zealand! By contrast, local training, using external examiners, has been shown to encourage retention of doctors in the Pacific region, while still achieving a high standard. Scenario 3 Dr C was one of the first to graduate as a subspecialist. After working for a year on a low wage and feeling frustrated by constant shortages of essential items and equipment, she decided to go into private practice. For 2 years she continued to do some private specialty procedures, but gradually became less confident. She was not aware of the latest advances in her specialty and could not afford to attend overseas meetings. Ten years after graduating as a specialist, Dr C did only general practice. Her children were all well educated at private schools, but she never felt fulfilled. The local Department of Health felt resentful of the wasted investment in Dr C’s training. The main means of specialist training in both PNG and Fiji is university-run 4-year MMed courses. Both countries offer 1-year diploma courses in child health, obstetrics and gynaecology, and anaesthesia. Fiji also offers a surgery and medical diploma, while PNG offers a diploma in ophthalmology. Passage to the MMed course depends on a good grade at diploma level. Diplomates would be expected to be able to provide safe care in a rural district or provincial hospital. Since its inception in 1975, the MMed program at the UPNG has trained 132 specialists in medicine, surgery, child health, obstetrics and gynaecology, psychiatry, ear nose and throat, and ophthalmology (see Kevau et al, page 608).1 The program has successfully trained specialists from the Solomon Islands and Micronesia. In Fiji, diploma courses and MMed training were begun in 1997, with the first MMed students graduating in 2001. By the end of 2003, 74 diplomas had been awarded by the FSM (in anaesthesia, internal medicine, obstetrics and gynaecology, paediatrics, surgery, community and hospital practice), and 17 candidates had completed the MMed degree (in anaesthesia, internal medicine, obstetrics and gynaecology, paediatrics, and surgery). Of these graduates, 68 diplomates and 12 masters graduates were practising in Pacific island countries.2 About 10 medical officers trained under the PBMOTP have done a year of further training at the FSM to obtain a specialist diploma. A handful of these doctors have undergone further specialist training.4 Subspecialty trainingDuring the 1990s, PNG saw the need to train some of its general surgeons in surgical subspecialties. In 1994, programs in orthopaedic surgery, head and neck surgery and urology were started, with paediatrics and neurosurgery later added. These programs involve both in-country and overseas training for 2–3 years after obtaining an MMed and working as a general surgeon. Specialty associations in Australia have provided the trainers and hospital positions to support the program.10 Scenario 4 Dr D was a promising young specialist who, with the support of Australian aid, spent a year of training in Australia during his MMed course. This gave him a rewarding year of training and also provided him with a network of contacts and a desire to seek better remuneration. He finished his training back home and worked for a year as a specialist. Citing “area of need”, he was appointed to a general practice position in a remote hospital in Australia, and to this day works as a GP rather than in the specialty for which he was trained by his home country. A similar model was used to train orthopaedic surgeons in both Fiji and the Solomon islands through the support of Orthopaedic Outreach and the Australian Orthopaedic Association. Fiji’s experience of the specialist “brain drain” has led it to favour the PNG model of establishing a local subspecialty program rather than risk losing further specialists to Australia and New Zealand. Complementing specialist and tertiary health servicesVisiting specialist teamsDespite the improving standards of local specialists in the Pacific region, there is still a need to complement their skills and capabilities with the skills of visiting specialists. Teams visit one or two centres over a 2-week period, performing procedures on cases selected by the local doctor or specialist. Interplast,11 eye assessment and surgery teams,12 the Australian Orthopaedic Association and Orthopaedic Outreach have been performing this sort of work for some decades. In 1995, a Pacific Island Project was developed by the RACS to formalise Australian government support for visiting surgical teams.13 A similar program in PNG is the PNG Tertiary Health Services Program.7,10 The visiting teams treat patients using specialist equipment and expertise and pass on skills to local practitioners. They may also support local training programs. For example, a neurosurgeon on a 2-week visit may give undergraduate lectures and postgraduate teaching in neurosurgery course modules in addition to treating cases and handing on skills to a local subspecialty trainee.14,15 Sending selected patients overseasThe work of visiting cardiac teams led by Alan Gale and others has produced good outcomes in PNG and the Pacific. It has also resulted in improved nursing skills in intensive care.16,17 Although there are as yet no PNG or Pacific cardiac surgeons, much of the closed cardiac surgery is done by local surgeons during cardiac-team visits.10 Scenario 5 Dr E was a trained specialist providing a high standard of care until his marriage started to disintegrate. There was an acrimonious divorce and some violence. He was suspended from practice in the public health system and this resulted in many patients receiving suboptimal care until his case was heard and he was reinstated. It took over 2 years and the retirement of some opponents before he was reinstated and able to treat public patients. Although he was able to provide some specialist care in private practice, the majority of patients in need could not gain access to him. The funding available to send a small selection of patients overseas is limited. NZAid provides some funding for certain Pacific island countries. Rotary Overseas Medical Aid for Children and other groups arrange hospital care in Australia and New Zealand on a case-by-case basis. Although patients treated overseas derive benefit because they are usually selected on the grounds of being curable, the cost of treating one patient is often equivalent to the cost of bringing in a visiting specialist team for 2 weeks, who might consult on 50 patients and operate on 25. Using the Pacific workforce to provide specialist careDoctors and specialists in Fiji, PNG and the Pacific are well trained and already provide a broad range of services.9 Their abilities are limited only by lack of resources and supporting infrastructure. However, the remoteness of much of the population and the large number of patients mean that, in practice, their skills are only accessible to a small proportion of the population. Surgical MMed graduates from UPNG in 1999. From left: Simon Mete, Director of Medical Services Port Moresby General Hospital; Okti Poki, who qualified as Higher Surgical Diplomate in Paediatric Surgery 2004 after 2 years of training in Australia; Dudley Ba'aerodo, the surgeon on Malaita, Solomon Islands, who now has an RACS Rowan Nicks scholarship to train in urology; Lister Lun, surgeon on Manus, who also performs cardiothoracic surgery with visiting cardiac teams. The development of subspecialist training has enabled specialists in the Pacific to manage more complex conditions. A shining example of this is the development of paediatric surgery in PNG, where two surgeons, trained thanks to the enthusiasm of Paddy Dewan (Paediatric Surgery Coordinator, PNG Tertiary Health Services and Pacific Island Projects) and others, are now able to competently manage anorectal and other congenital anomalies. They make visits around PNG to perform specialist procedures, and earlier this year one also headed an RACS AusAid-funded team that visited the Solomon Islands. Two PNG-based specialists also made visits to Nauru to treat asylum seekers. As capabilities develop, Pacific island specialists will be the real experts in providing specialist care in their own countries. Aid programs will need to support them with the consumables and equipment necessary to use the skills with which they have been trained (usually with the help of AusAid funding). Future visiting teams will include specialists from PNG and the Pacific islands, as well as more narrowly trained Australasian specialists. However, as there will be a manpower shortage for decades, Pacific-based specialists will be limited in how much specialist care they can provide elsewhere. Visiting teams will comprise mainly Australian and New Zealand specialists for some time to come. 1 Population and health statistics for Australia, New Zealand, Papua New Guinea, East Timor and the Pacific islands* Country Population Life expectancy at birth (years) IMR† Under-5 mortality rate‡ MMR§/100 000 live births Doctors per 100 000 population Proportion of GDP spending on health (%) Spending per capita on health (US$) GNP per capita (US$) Australia 20 M 79 6 6 8 250 9.2 1741 19 860 New Zealand 3.8 M 78 6 6 7 220 8.3 1073 13 280 Papua New Guinea 5.1 M 54 73 102 370 7 2.3 27 580 Fiji 800 000 67 19 23 27 52 3.5 55 2 080 Solomon Islands 430 000 63 22 26 549 11 11.6 11 610 Samoa 175 000 68 22 27 70 38 5.8 91 1 440 Tonga 100 000 71 19 23 197 46 3.5 56 1 410 Vanuatu 200 000 61 38 49 68 10 2.5 29 1 110 Kiribati 93 000 63 54 74 225 15 12.7 94 980 Marshall Islands 53 000 66 63 92 na 43 4.6 85 2 270 Micronesia 120 000 68 20 34 226 46 9.1 171 1 960 East Timor 850 000 na 88 124 600 4 5.9 25 440 * Sources: World Bank, UNICEF, World Health Organization. †IMR (infant mortality rate) = number of infant deaths per 1000 live births. ‡Number of deaths in children under 5 years per 1000 live births. §MMR = maternal mortality rate. GDP = gross domestic product. GNP = gross national product. na = data not available. 2 Pacific Basin Medical Officers Training Program The Pacific Basin Medical Officers Training Program (PBMOTP) was a 10-year program (1986–1996) funded by US government aid and run by the University of Hawaii. It introduced an experimental 5-year problem-based learning course, with the first 3 years being spent in rural areas and community health clinics and the last 2 years being spent in urban hospitals. The program, which ran for a strict 10-year period because funding was limited, produced 70 doctors, 50 of whom were from the Federated States of Micronesia.3,4 These doctors had practical public health and clinical skills, but not as deep a knowledge of basic medical sciences and pathology as a graduate of the University of Papua New Guinea or the Fiji School of Medicine. Their degree would not be recognised in Australasia or the United States as an MB BS or MD equivalent. However, it is recognised for entry into postgraduate programs in Fiji. 3 Specialist surgical aid program in East Timor East Timor, a small country with a population of 850 000, is among the 10 poorest nations in the world (Box 1). It receives considerable support from donor countries such as the United States, Japan, Australia and Portugal. East Timor had an organised health service similar to that of the rest of Indonesia before the independence vote in 2000. After independence, East Timor had to rebuild its health service after almost all health infrastructure and records had been destroyed and experienced doctors had departed. Hospital services were reactivated in 2000 in the capital, Dili, by the International Committee of the Red Cross and in Bacau by Médecins Sans Frontières. These programs ended in mid-2001. Since then, the running of the national referral hospital in Dili has been assisted by Healthnet (formerly CORDAid), a non-government organisation. Specialist staff in the major disciplines of surgery, anaesthesia, obstetrics, paediatrics and internal medicine have been recruited by the East Timor Department of Health, Healthnet and an AusAid program managed by the Royal Australasian College of Surgeons (RACS). The RACS program is based primarily in Dili and provides a resident surgeon and anaesthetist and visiting specialty teams. Each month, a specialist surgical team comes to undertake procedures not normally performed by the resident general surgeon. Cases are selected on the basis of requiring specialist skills and having a chance of success in a situation of limited postoperative care and follow-up. Such cases include cataract removal by ophthalmology teams and repairs of cleft lip and palate by plastic surgery teams. Paediatric surgery teams have repaired imperforate anus in a number of children who previously had only a colostomy performed at birth. Visiting cardiac surgery teams have, to date, undertaken patent ductus repairs but not open heart surgery, even though rheumatic fever, with subsequent rheumatic heart disease and congenital heart disease, is common. Common procedures performed by visiting urologists are removal of bladder stones, prostatectomy, and repair of urethral strictures. Orthopaedic teams are involved in managing congenital disease (eg, club foot) and malunion or non-union of fractures in trauma victims. Patients with cancer usually present late, staging is based on clinical assessment and plain x-rays, and surgical treatment is limited. There are currently no East Timorese surgical specialists. The future specialist workforce in East Timor will be made up of a hotch-potch of graduates from training programs in a variety of countries. Part of the RACS program is to assist in developing specialist skills in-country. To obtain recognition of their specialist training, three East Timorese doctors are starting surgical training in the UPNG program (two in general surgery and one in ophthalmology). Other East Timorese doctors have gone to other countries, including the Philippines and Portugal, for postgraduate training. Anaesthetics in East Timor are mostly given by nurse anaesthetists. Australian anaesthetists have developed an appropriate 1-year program for nurses that includes a 3-month rotation to an anaesthetic teaching department in Indonesia. Perioperative theatre nurse education has been incorporated into this program, and two primary trauma-care courses using Indonesian-speaking doctors have been successfully conducted. The challenge in training the workforce in East Timor is to develop skills appropriate for the facilities available, the local disease mix, and health budgets for the foreseeable future. It has been an important policy direction for Ministry of Health planners to design a health service that is sustainable in the medium to long term with the level of expenditure likely to be available from their own resources and firm donor country commitment. These good intentions can be overwhelmed from time to time when some overseas aid teams arrive without the necessary language skills or interpreters and with minimal financial resources to provide the technical supplies they consume in the hospitals. The concept of specialist surgical aid programs providing tertiary care has been questioned as an appropriate priority in countries with underdeveloped health services. The conventional argument is that money would be better spent on clean water, vaccination programs and village-based health centres that deliver simple, effective services. We agree that supporting primary health services is important. Nevertheless, the community also gains from access to acute hospital care for common problems such as trauma, acute infections and obstructed labour. Relatively simple surgery requiring short hospital stays can restore patients to normal health and prevent much disability. Beyond this, tertiary surgical services — again with simple surgery and short stay for conditions such as cleft lip and palate in the young and blindness due to cataract in the elderly — can restore large numbers of patients to active and economic participation in their communities. The statistics from our visiting teams support this view.

David A K Watters ChM, FRCSEd, FRACS · David F Scott MD, MS, FRACS

For more than a century, doctors who received training at the Fiji School of Medicine (FSM),1 the University of Papua New Guinea,2 or, more recently, the Pacific Basin Medical Officers Training Program3 in Pohnpei have been the mainstay of the medical workforce in Fiji and the Pacific island nations. Recently, an attempt has been made to make Fiji and its neighbours self-sufficient in medical personnel by enlarging the undergraduate student intake into the MB BS course from 50 to 70 and by establishing postgraduate specialist training programs at the FSM. However, these plans have largely been thwarted by the shortage of doctors in countries such as Australia and New Zealand, creating a vacuum that has resulted in an enormous “brain drain” of FSM graduates into those countries. Two political coups in Fiji, in 1987 and 2000, have only exacerbated the problem. Fiji School of Medicine students and consultant on rounds, Colonial War Memorial Hospital, Fiji. The size of the problemFiji has a population of about 850 000 people, and the other main Pacific island nations (excluding Papua New Guinea) have a total population of about the same size. Hence, a medical workforce is required for about 1.7 million people. The current intake into the MB BS course at the FSM is 70 students per year — or about one student per 25 000 people. By comparison, Australia, with a population of about 20 million people, has a total intake into medical courses of over 1200 per year — or at least one student per 17 000 people. The exact number of Fijian graduates from the FSM who end up working in Australia, New Zealand, the United Kingdom or the United States is unknown. However, between 1987 and 2002, a total of 510 doctors left the Fijian government health service (Fiji Ministry of Health, September 2004, unpublished data). During this time, the FSM produced 284 graduates for Fiji. Most of the doctor “drain” is to the abovementioned developed countries — so much so that a cynic might conclude that those countries are simply using Fiji and the other Pacific islands as a cheap training ground. To fill government vacancies, the Pacific island nations rely on expatriate doctors from Australia or similar Western countries, or from Asian countries such as China and India. Expatriate doctors have given excellent service to the people of the Pacific islands. However, there are problems with relying on expatriates for a medical workforce, including difficulty and cost of recruitment, language and cultural differences, and frequent mismatches in expectations between the doctors and the employing country. The morality of recruiting doctors from other developing countries whose needs are just as great as, if not greater than, those of the Pacific island nations is also obviously an issue. Are there any solutions?A lot more can be done within countries to develop incentives (and remove disincentives) for our graduates to remain in their home country rather than seek “greener pastures” abroad. For instance, the employment conditions of doctors should allow more flexible and attractive career paths for young graduates. However, the economies of the Pacific island nations will never be able to afford salaries competitive with those offered in developed countries. Appeals to national pride also tend to fall on deaf ears when the political elite are seldom good models of personal sacrifice for the good of the country. It has been suggested that any country that employs a medical graduate trained in a developing country should reimburse that country the cost of his or her training.4 This seems a good idea, but it is hard to see where the political drive will come from to force a country like Australia to reimburse Fiji the full cost of training, for instance, a specialist surgeon. Another suggestion is that the FSM should deliberately alter its curriculum to make its graduates less competent to practise medicine in a developed country. However, this would be absolutely counter to the philosophy of excellence in teaching that is at present a fundamental mission of FSM — as it should be. And the practice of medicine in the Pacific is not so different from that in a developed country as to really make this a feasible proposition. The first step must be for Australia and similar countries to admit there is a problem that must be addressed, and that it is morally unacceptable to actively recruit medical graduates from countries such as Fiji to make up shortfalls in their medical workforce resulting from their own poor forward planning. Once this is agreed, all the stakeholders should devise appropriate responses to assist the requirements of the developed countries for more health professionals, while not overly depleting Pacific countries of their doctors. A suggestion is to genuinely try to reduce the requirement for more doctors in Australia by utilising other health professionals in roles traditionally filled by doctors. Market forces cannot, and should not, be entirely removed when it comes to employing doctors. However, an unfettered market will usually lead to one party going out of business, and no one wants healthcare in the Pacific islands to go out of business.

Wame R Baravilala MRCOG, FRANZCOG, FACTM · Robert F W Moulds PhD, FRACP

How did I come to be in East Timor? That is the exact question I asked myself upon arriving in Dili, the national capital, with my husband Ben, our 2-year-old son Oscar and 6-month-old daughter Chloe in tow. It was very hot and humid and there was a real threat of a looming dengue epidemic from Indonesia. My anxiety for the health of our children was in no way eased when, a few days after our arrival, an Australian expatriate asked, “What sort of a place is this to bring kids?”. Main entrance to the Dili National Hospital I had been aware of a program coordinated by Eugene Athan, an infectious diseases physician, whereby Australian physicians could work at the Dili National Hospital. As an infectious diseases physician with an interest in medicine in developing countries, and having been assured of the political stability of the country, I put up my hand to go. Ben was able to take time off work to care for our children. After many months of planning, multiple vaccinations, and reassuring family and friends of our safety and wellbeing, we arrived in Dili in late January 2004. The Dili National Hospital is run by the East Timor Ministry of Health. The hospital medical staff consists of overseas visiting specialists, Indonesian emergency department doctors, and Timorese resident doctors working on the wards and in the outpatient department. There are no locally trained specialists — a major limitation to the long-term goal of having an autonomous Timorese hospital. I worked on the women’s medical ward for 2 months. While not arduous, the work was emotionally draining. In my first week, there were three postpartum deaths due to presumed sepsis. Like anyone, I found this difficult to deal with, but being there with my family, and still breastfeeding Chloe, made it even harder. My emotions were fuelled by the thought that one family now consisted of a husband without a wife, and four kids without a mum. The harsh reality of the estimated maternal mortality in Timor (around 800 per 100 000 live births) is that this family circumstance is not uncommon. Despite Portuguese being the official language, the majority of Timorese people speak either Tetum, Indonesian, or one of 16 indigenous languages. As my Tetum capabilities were limited to pleasantries, I relied heavily on certain hospital staff to interpret for me. Needless to say, taking an adequate history and communicating with the patients and hospital staff proved to be a challenge — like a combination of charades and Pictionary. The language barrier became even more difficult towards the end of my stint, when a Chinese medical team arrived that included doctors, a nurse and a translator. They had spent 6 months learning Portuguese, which, despite the best of intentions, was of no practical use to the majority of people at the hospital. One of the beaches within an hour’s drive of Dili. These were a favourite place for expatriates and United Nations staff to gather on Sunday afternoons. The hospital was serviced by hospital and national laboratories that performed basic testing, which was intermittently available and of variable standard. Malaria films were regularly performed, with frequent positive results. Biochemical tests, including tests for urea and creatinine, were not available during my stay. Minimal microbiological investigations (including tuberculosis smears, and serology for HIV, hepatitis B, hepatitis C and syphilis) were available. Pathology specimens were sent to Australia, with a 6–8-week turnaround time. The major medical problems I encountered at the hospital included tuberculosis, malaria, renal failure, heart failure, thyroid disease and hypertension. As all patients had varying degrees of malnutrition, I kept them in hospital for as long as possible, knowing that the hospital would provide nutritious meals. Of concern was the lack of a single positive sputum smear test for acid-fast bacilli during my stay. For whatever reason (be it deficiencies in collection, transport, processing, laboratory technique or reporting), all sputum smears were negative. Aware that this could not be accurate, I introduced antituberculosis therapies in patients for whom there was a high suspicion of tuberculosis based on clinical features and x-ray results. Of greater public health concern was the lack of mycobacterial culture and sensitivity testing facilities. A national tuberculosis control program has been established to monitor patients during treatment, but some patients did not complete their therapy and it is unclear whether drug resistance is a problem. It was hard to believe we were only a 1-hour flight away from Australia. Drug therapy options were limited to an essential drug list; however, even these, at times, were unavailable. Although we had previously worked in Africa, we found it difficult to comprehend that the national hospital of one of Australia’s close neighbours could have such limited resources. Despite their many hardships and difficulties, I was touched by the loving nature and strong sense of family among the Timorese people. They were very receptive to us as a family, but we certainly raised some eyebrows. For starters, I was working while Ben stayed at home with the kids, which many locals found amusing! Ben spent most of the time fighting off malaria and dengue-carrying mosquitoes and keeping the kids and himself cool by whatever means, including a staple diet of ice-cream for the kids and beer for himself. During weekends off, we were able to hire a car and explore many beautiful parts of the country. Having spent only a short period of time at the Dili hospital, I was grateful for the welcome I received and the warmth of the hospital staff. Upon leaving, I felt I had contributed to the health of my patients, and yet had a deep sense of sadness because it seemed that the healthcare system may worsen before it improves. So, were we foolish to take our kids to Timor? On the contrary — we believe that we took them to a place full of caring, loving and welcoming people who deserve the chance to live a better life.

Carolyn L Beckett MB BS(Hons), FRACP

I wanted to work somewhere exotic, experience a different lifestyle and contribute to health advancement in a developing country. So I was delighted when Australian Volunteers International offered both me and my partner, also a doctor, a 2-year placement (February 2002 to February 2004) in Makira Province, previously the Eastern Solomon Islands. The village of Gupuna, Ugi Island, farewells our touring team. Life in the Solomon IslandsThe Solomon Islands have a subsistence agricultural economy. Of a population of 450 000, 85% live self-sufficient lifestyles involving small-scale farming, fishing, fetching water, cooking on wood fires, building and weaving. Outside events, even major ones like terrorist attacks, seem far away. Life on fertile volcanic soil surrounded by the Pacific Ocean maintains Solomon Islanders in good health. They work hard physically and enjoy a diet rich in fruit, vegetables and fish. However, they increasingly seek to supplement their traditional diet with rice, flour, canned meats and instant noodles. Healthcare in Makira ProvinceThe major causes of death in the Solomon Islands are infectious diseases and perinatal conditions.1,2 HIV/AIDS has not yet had a significant impact there.1 Makira Province, with 33 000 people, had no doctor working either when we arrived or when we left. Kirakira, the provincial capital, has a small hospital with 86 beds — plenty for patients, with spare beds for relatives. Coping with the hospital’s unreliable medication supply was a challenge — sometimes it was well resourced, while at other times we struggled to manage, using the most suitable medication available at the time. People suffered for want of paracetamol, and died for want of oxygen. Nurses helped us manage patients with malaria, tuberculosis and congenital syphilis, as they knew more about managing these conditions than we did. The most common diagnoses of the 2322 patients admitted during our stay are shown in the Box. There is a national referral hospital in the capital, Honiara, where we could refer patients we were unable to manage in Kirakira. Together with specialist eye, reproductive health and tuberculosis/leprosy nurses, I established a program of touring the 34 clinics in the province to provide support to clinic staff and treat patients. Most clinics are in coastal villages, accessible by aluminium dinghy and outboard motor. As the villages may see no shipping for months, people must be totally self-sufficient. Clinic nurses manage most cases of malaria, pneumonia and gastroenteritis that are not managed at home. Under national policy, every village should be within 3 hours’ walk of a clinic, but the country’s economic situation has not enabled this policy to be fully implemented. Nevertheless, the patients I saw while touring were in remarkably good health. Common referrals to me were for back pain, hip pain, and dysmenorrhoea. It was difficult to advise the staff in the clinics that had no supplies and no means to transport patients. Australia is currently funding the purchase of solar-powered two-way radios for each clinic (radios must be solar-powered because supplies of consumables are unreliable). Trauma and related infectionsSkin and soft tissue infections, abscesses, joint and bone infections, and pyomyositis were common in Makira. These infections may be occupational hazards of subsistence farming, but young children and even neonates were affected. We drained copious amounts of pus under ketamine anaesthesia, but, unfortunately, we often had no suitable antibiotic treatment. We treated many cases, including osteomyelitis and septic arthritis, with oral doxycycline, erythromycin or chloramphenicol. There were about 12 motor vehicles in Kirakira, and the first-ever motor vehicle accident happened during our stay. A passenger in a utility tray was crushed against another vehicle. He fractured seven ribs on one side and nine on the other. We had no intercostal catheters to manage the haemopneumothorax, no intubation facilities, and no resources to evacuate him. Yet, amazingly, he survived with analgesia, oxygen, intravenous fluids and basic physiotherapy (“Hold your chest and blow hard!”). His high level of physical fitness, as a subsistence farmer, most likely saved his life. Non-communicable diseasesNon-communicable diet- and lifestyle-related diseases that are major causes of morbidity and mortality in Australia are only beginning to reach rural Solomon Islanders. We saw mouth cancers among betel-nut chewers, and liver and cervical cancers. Diabetes manifests with peripheral vascular disease, and hypertension with stroke. No myocardial ischaemia was diagnosed during our stay. Challenges and rewardsThe general standard of health and health services, despite the country’s economic difficulties, highlights the fine personal qualities of the people. Nurses continued working during periods when they were not paid. I recall one nurse who visited the hospital on a day when she was off duty. Noting that no nurses were working, she went home, put on her uniform, and returned to cover the day’s shift. As there was no stationery provided for health services, people carried exercise books for their health records. Patient-held records provide continuity of care from village health workers to visiting overseas specialists, and also give patients ready access to the information.3 We spent a memorable 2 years in the Solomon Islands, proving to me that overseas volunteer work is enriching and rewarding. It provides an opportunity to support colleagues in countries where healthcare staff are difficult to recruit and retain. Common diagnoses of patients admitted to Kirakira Hospital (excluding admissions for childbirth), Jan 2002–Dec 2003 Discharge diagnosis* Infants Children 1–5 years Children 5–15 years Adults Total Malaria 45 77 81 336 539 Skin infections, abscesses, cellulitis, carbuncles, impetigo 12 37 32 129 210 Trauma 0 9 37 82 128 Pneumonia 48 29 9 27 113 Gastroenteritis 11 17 0 13 41 Osteomyelitis, pyomyositis, septic arthritis 0 3 13 21 37 Tuberculosis 2 1 3 17 23 Cancer 1 0 0 19 20 * Not mutually exclusive.

Rosalie Schultz MB BS, MPH

The theme of the 2004 Annual Papua New Guinea (PNG) Medical Symposium, held at the University of PNG (UPNG) in Port Moresby in September, was “Medical and Health Education”. Running through the symposium were the threads of the many impressive and innovative developments in health education occurring in the country, and the ever-present threats to these having an optimal impact on the health service. Keynote speakers included Professor Leslie Eastcott (Vice Chancellor, UPNG), Professor (Sir) Isi Kevau (Professor of Medicine, UPNG), Professor Wame Baravilala (Dean, Fiji School of Medicine [FSM]), Professor Ian Maddocks (Emeritus Professor, Flinders University) and Professor Ian Riley (Professor of Tropical Health, University of Queensland). PNG’s Prime Minister, Sir Michael Somare, opened the symposium. Problem-based learning in medical trainingProblem-based learning (PBL) has been a part of the UPNG and FSM medical curricula for 4 years. This was achieved at UPNG with a remarkably short run-in phase — introducing a completely new curriculum in 4 of the 5 undergraduate years in 2000 and extending to the 5th year in 2001. The UPNG curriculum was described in detail by Professor Isi Kevau and Professor John Vince (Professor of Child Health, UPNG). It is immensely experience-rich — considerably more so than many such courses in Australia (see Kevau, page 608).1 The curriculum changes made at UPNG were not without controversy. Dr Adolph Saweri, one of the pioneers of health in PNG and among the first graduates of the Papuan Medical School, gave a personal view “from silly mid-on” (as he described it). In 2000–2002, criticism of the new course was voiced within UPNG, in newspapers, and even in the national parliament. This resulted in much public and private debate. But, 4 years into the course, the detractors are few, and the prolonged and vigorous debate has resulted in the new curriculum having widespread ownership and support. Criticism, noted Dr Saweri — without any hint of bitterness for former colonial attitudes to indigenous education — was an almost essential part of social or institutional reform. Specialty trainingMajor developments in medical specialty training were highlighted throughout the conference. Forty general surgeons have been trained through UPNG, and there remain sufficient numbers in the public system to staff every major hospital in the country. Subspecialty training in paediatric surgery, orthopaedics, urology and neurosurgery has occurred in the past decade (see Kevau, page 608).1 Dr McLee Matthew, the first Papua New Guinean paediatric surgeon, spoke of plans for a service covering all regions of PNG. Surgical subspecialty training has been achieved through collaboration with Australian colleges and the work of wonderfully committed individuals in both countries. The conference welcomed the arrival from Hong Kong of Sydney Chung, the new Professor of Surgery at UPNG. Are we placing the major proportion of the budget and emphasising training for the wrong end of the professional scale, when 85% of the population don’t really need [this] sophisticated manpower? (quote from a senior university lecturer) Reforms in paramedical trainingHealth reforms in other areas were highlighted during the symposium. In the 1960s, the position of health extension officer (HEO, formerly medical assistant) was designed to address the workforce needs in rural areas, where doctors are few. HEO training, which has undergone major changes in recent years, has produced over 900 graduates, of whom about 400 are still in the workforce. An increasing proportion of HEOs are women. The Divine Word University, a Catholic university in Madang, now runs HEO training. The HEO training school has a new, dynamic Dean, Dr Billy Selve, who is strongly committed to healthcare delivery in rural and remote areas. Nursing education is also undergoing changes, with a shift towards independent clinical skills training and away from a Western model of theoretical university training that was popularised in recent years. There are also increasing opportunities for postgraduate courses in child health and midwifery in provincial areas. With the planned expansion of surgical services in PNG, the “gap” between surgical availability and safe anaesthesia will probably increase in the short term. Professor Garry Phillips (Director of Professional Affairs, Australian and New Zealand College of Anaesthetists [ANZCA]) described a modular anaesthetics training program that has been introduced with support from the ANZCA. The modular system will train both anaesthetic technical officers, who receive a Diploma of Anaesthesia, and doctors, who do the training as part of their Master of Medicine. Threats to optimal impact of improvements in medical and health educationWill the changes to undergraduate training produce better doctors? This is a question that is often asked in PNG and in other countries where PBL curricula have been introduced. Perhaps the more relevant question is whether the new undergraduate medical curriculum, the reforms and developments in HEO and nursing education, and progress in specialty medical training will lead to a higher-quality, more equitable healthcare system. The very strong feeling from the symposium is that they will; however, the answer needs some qualification — the road, like others in PNG, has many potholes. Many of the threats to equity and quality in healthcare were highlighted. One problem is the uneven distribution of doctors and services in PNG. PNG has an overall doctor to population ratio of 7 per 100 000, the lowest ratio among the Pacific nations (see Watters and Scott, page 597).2 Some rural provinces have fewer than two doctors per 100 000, while Port Moresby has 30 per 100 000. The real problem is that there aren’t enough doctors prepared to work in rural areas. (quote from a senior university lecturer) To make matters worse, the public health system can only afford low numbers of doctors. Severe restrictions on the numbers entering undergraduate training (one report suggested cutting intake from 60 to 20) and areas of specialist training have been proposed by overseas consultants. While such restrictions acknowledge the limited medical workforce that is sustainable without increases in government funding, as well as the high cost of training and employing medical officers compared with primary healthcare workers, they often fail to take account of attrition rates and the need for skilled leadership in healthcare if primary health is to function effectively. They also give fodder to economic rationalists and opportunists within government. Also highlighted was the need for junior doctors to be supported and mentored throughout their residency in provincial areas. Few rural hospitals are adequately equipped for continuing medical education, although some, with no additional funding, have built libraries, hold regular journal clubs and have programs of resident teaching. Internet access is still a pipedream for hospitals in PNG, many of which do not have out-dialling telephones. Innovative (but often frustrated) efforts to support junior staff by committed doctors and hospital administrators were evident time and time again. Numerous other instances were cited of limited resources impairing the impact of quality health education. For example, months of delays in salary payments to resident medical officers crippled the hospital system in early 2004. Moreover, a chronic lack of equipment and supplies leads to low morale among hardworking healthcare workers. Several of the speakers highlighted some of the barriers to development of a good healthcare system: lack of genuine political commitment, political instability in the provinces, inadequate funding of health services, and poor maintenance of health services. Reform of management training and a transparent system of appointments (based on qualifications, merit and experience) were explored as solutions. “Brain drain” is another great threat to medical workforce development in the Pacific. This particularly affects Fiji, as highlighted by Professor Baravilala (see page 602),3 but, increasingly, PNG is also feeling its impact. As health budgets diminish in real terms and creation of positions within the government sector fails to keep pace with the number of new graduates, highly trained and capable medical graduates are being attracted by better financial and lifestyle prospects elsewhere. Migration of graduates to Australia and New Zealand, as well as moves to the private sector or to non-government organisations, are stifling many recent efforts made to improve medical education and workforce capacity in Fiji. Many factors are involved (Box). The solutions are complex and will require richer countries like Australia viewing their problem of low numbers of doctors in rural areas in the broader context of regional rather than national need. Some countries, such as the Philippines, deliberately train (for “export”) more doctors than they require, but Pacific medical schools will never have the resources to do so. Proposed solutions include a system of bonding of doctors after graduation to service in their country of origin, but innovative reforms that improve workplace opportunities and conditions in the government health system in developing countries may be more important. It is time that Australia’s view of aid for human resources development moved beyond supporting high-quality training courses in the Pacific to focus on assisting countries with all the elements of retention and career-long development of individuals within the workforce. It is also time governments in the Pacific saw the morale and wellbeing of nurses, doctors and other health workers as being worthy of strong and tangible support. Factors affecting migration of doctors from regional developing countries to Australia and New Zealand Push factors Pull factors Low remuneration Remuneration differentials Work overload Career opportunities Absence of a career structure Professional development Personal safety concerns Personal and family safety Social and political insecurity Freedom from political influence Quality-of-life issues Active recruiting

Trevor Duke MD, FRACP · Nakapi Tefuarani MMed, PhD · Wame Baravilala MRCOG, FRANZCOG, FACTM

The training of Papua New Guinean doctors began in the 1950s, when students were sent to the Fiji School of Medicine, graduating with a Diploma in Medicine and Surgery. The Papuan Medical College (PMC) was established in Port Moresby in 1962, training all health professionals, including doctors, nurses, x-ray and laboratory technicians. Medical graduates received a Diploma in Medicine and Surgery. In 1965, when the University of Papua New Guinea (UPNG) was established, the PMC became the Faculty of Medicine. The first medical students graduated in February 1973 with a Bachelor of Medicine and Bachelor of Surgery (MB BS); the first graduating class comprised four expatriates and only one Papuan. In September 1975, PNG became an independent nation. In 2000, with the restructuring of the UPNG, the School of Medicine and Health Sciences became responsible for training in nursing (postgraduate), dentistry, pharmacy, diagnostic imaging and medical laboratory sciences. PNG students are selected for medicine and health sciences on the basis of their results in a common foundation year at UPNG or Pacific Adventist University. Other Pacific islander students who meet the academic criteria enter the MB BS course directly. Approximately 40 students are admitted to the MB BS course each year. Health extension officers (allied health workers with administrative and basic clinical training), who, together with nurses, are responsible for much of primary healthcare, are trained at Divine Word University in Madang. In 1998, as part of a general restructuring at UPNG, a curriculum committee of the Faculty of Medicine articulated concerns that the traditional curriculum was focused on didactic teaching, that students were not actively engaged in learning and that clinical experience was compressed. The committee examined international trends in medical education and concluded that the most appropriate model was that of an integrated, problem-based curriculum. At a workshop in mid-1998, academic staff, together with senior clinicians from Port Moresby General Hospital and the Department of Health, defined the desired personal qualities, skills and knowledge for a UPNG medical graduate. These now form the basis of the undergraduate program objectives of the new curriculum. These objectives are clustered into five domains of learning: community health; individual medicine (prevention, diagnosis and management of illness); professional and personal qualities and skills; critical analysis and information management; and life-long learning and teaching skills. These domains provide the educational and administrative framework for the new MB BS curriculum, which was introduced progressively between 2000 and 2003. The curriculum is fully integrated and entirely problem-based, with 112 “patient and community problems” studied over the four years. The problems reflect the burden of illness and the health issues confronting PNG (Box). They open up important areas and impart relevance to teaching, rather than replacing didactic teaching. The group work implicit in a problem-based curriculum, the early clinical experience and the emphasis on independent learning skills have all contributed to improvements in student motivation and application, and students are more articulate and confident. Medical graduates in PNG practise in a resource-poor environment, lacking many of the basic diagnostic tests that are taken for granted in developed countries. There is no computed tomography scanner at Port Moresby General Hospital, and basic tests are often unavailable (eg, serum potassium measurement has been unavailable for several months). Graduates may also be posted, in their first year, to regional hospitals and rural areas where there is limited supervision (see Poka).1 They require good clinical diagnostic skills and must be competent to perform common clinical procedures. In years 4 and 5 of the MB BS program, students are required to admit a minimum of 97 patients, to present 45 of these patients to a senior clinician, to assess a minimum of 20 patients presenting to the emergency department, and to assess and treat more than 100 patients in their urban clinic rotations — these activities must be certified. Experience with procedures (a total of 245 in years 4 and 5) is also specified and certified. The first graduates of the new MB BS program are now working as resident medical officers. While it is too early to make a judgement on their performance, feedback has been very positive. The UPNG Faculty of Medicine and the achievement of national independence also provided impetus for the training of clinical and public health specialists. The options for clinical training were to send graduates overseas to obtain membership or fellowship of Royal or other learned Colleges, or to establish local training programs specifically designed to meet the needs of specialists working within PNG. The second option was chosen, and the Faculty introduced the Master of Medicine (MMed) in 1975. The MMed is the degree recognised by the Medical Board of PNG for registration as a specialist. The basic structure consists of two parts: 1 year with an emphasis on basic medical sciences, followed by a minimum of 3 years with an emphasis on acquiring knowledge, clinical skills and experience in the specific discipline. This basic structure has been maintained over the 30 years since its inception, although a research component has been added in recent years. By 1980, the first graduates in surgery, paediatrics, internal medicine and anaesthesiology were employed as fully qualified specialists, followed rapidly by graduates in obstetrics and gynaecology. Within a relatively short time, the MMed program has produced specialists in ophthalmology, otorhinolaryngology, pathology, dermatology and, most recently, medical imaging. A program in emergency medicine has also now been established. All the programs have been developed and maintained with considerable assistance and support from Australian institutions (learned Colleges and hospitals) and individuals. Standards of training have been set and are maintained by the mandatory participation of external examiners, many of whom are examiners for Australian Fellowship examinations. Almost 30 years after its introduction, the wisdom of the decision to embark on specialty training based within PNG is clear. One hundred and thirty two PNG clinical specialists have been trained, of whom 93 (71%) are working within the public health service (including the UPNG School of Medicine and Health Sciences). The program has trained 16 specialists from other Pacific Islands, including 10 from the Solomon Islands. Although most of our graduates have spent part of their training in Australian hospitals, their feet have, for the most part, remained firmly on PNG ground. All are “generalists” within their specialty, and able to function effectively and efficiently in a poorly resourced environment. However, some have also developed expertise in subspecialty areas, and UPNG has now introduced a Higher Postgraduate Diploma in the clinical and pathology subspecialties. The best indicator of the success of the MMed program is that PNG is approaching a situation in which all the available hospital specialist positions will be occupied by fully qualified and highly competent PNG doctors. PNG has also made an important contribution to the training of Pacific Islander specialists. However, nine PNG specialists and three (of 16) Pacific Islander specialists are known to be working outside their own country. While this does not represent a huge “brain drain”, the fact that five of the nine PNG specialists have left since 2000 is a cause for concern. The history of training public health specialists is more complex. Early postgraduates were trained overseas. In the early 1980s, UPNG introduced a Master of Community Health, primarily based on research, but this has recently been replaced by a Master of Public Health, based on coursework and supervised research. This commenced as a combined program between the University of Queensland and UPNG, with coursework being done in Brisbane, but it is now run completely by UPNG. It is probably too early to assess the outcome of this program. The financial and logistical support provided by AusAid, together with the National Department of Health and UPNG, has been central to the success of our undergraduate and postgraduate training programs in medicine and the allied health professions. The interdependence of the health professions is of particular importance in a country like PNG. Medical undergraduates gain experience of primary care in both urban and rural settings and learn to appreciate the importance of the contributions made by other health professionals. It may well be time to consider adding postgraduate training in primary healthcare to our specialty training options to ensure that all graduates have the opportunity to further develop their skills and contribute to the health of urban and rural communities. In addition, there is a major need to introduce continuing professional development programs for all health professionals to ensure that the achievements in basic and specialty training are maintained, consolidated and extended. Medical students in a “patient and community problem” tutorial, University of Papua New Guinea Sample problems (patient names are fictitious): Scenario 1 Gala Tobwagau is brought by his son to the emergency department at Port Moresby General Hospital. His son tells you that Gala is a subsistence farmer from Losuia, in the Trobriands, and that he has been visiting him in Port Moresby for about a week. Gala has been complaining of a headache for most of the time he has been in Port Moresby, but it has been getting worse over the last three days. He was convinced that his headache was due to sorcery, so he went to a traditional healer two days ago, but that has had no effect. Gala is about 40 years old and has only a few words of Pidgin and English. (Final diagnosis: meningococcal meningitis) Scenario 2 Lyn ToRobert, a 35-year-old accounts clerk in Kokopo, presents to her local general practitioner complaining of a lump in her right breast. She noticed the lump about nine weeks ago, while she was preparing for a traditional sing sing. She was rubbing coconut oil and other body decorations on her skin when she felt the lump. She has had lumps in her breasts before, around the time when her breasts get a bit swollen and tender just before her periods, but these always go away over a few days. She tells you that this one also feels different. (Final diagnosis: breast carcinoma)

Isi H Kevau MMed, FRACP, PhD · John D Vince FRCP, MD · Jean V McPherson FRCPA

There are some experiences in medicine that are hard to forget. Mine took place in my second year of residency (between November 1998 and January 1999) during my rural medicine block on the volcanic island of Karkar, in Madang, a maritime province of Papua New Guinea (PNG). The Gaubin Rural Hospital, run by the Lutheran Church, serves the island’s population of over 50 000 people. Karkar volcano (reproduced with permission of Hervé Sthioul). I was a relatively junior resident, having graduated from the Medical Faculty at the University of PNG in 1996 and spent 23 months training at the Goroka Base Hospital in the Eastern Highlands Province. One fateful afternoon, a health centre referred a pregnant nulliparous woman with prolonged labour and splenomegaly. She was in shock, her abdomen was tense and distended, and there was a distinct non-tender mass occupying the left lower and upper quadrants — was this the spleen? The central abdomen was tender, and no fetal heart sounds were heard. Pelvic examination revealed that the woman had severe cephalopelvic disproportion, which was not unexpected, as she was only 1.5 m tall. She had a minimal pelvic bleed. I resuscitated her and whisked her into the operating theatre to do an emergency caesarean section. I administered spinal anesthesia (there are no anaesthetists or general anaesthesia in rural PNG), then scrubbed and put on surgical shoes. The parietal peritoneum was tainted blue, heralding the presence of haemoperitoneum, and, sure enough, the peritoneal space was bubbling with blood — heaps of it. Certain that she had a ruptured uterus, I immediately felt for the uterus to examine the site and severity of the rupture, but, to my amazement, the fundus was small and well contracted and there was no fetus in the uterine body. There was, however, a huge, nasty, transverse wound on the uterine body. I was perplexed — where could the baby be? I tried to feel for the spleen and got the shock of my life when I felt the legs of the baby! The spleen wasn’t enlarged at all. The dead 3 kg fetus was removed. The uterus was sutured and a tubal ligation was performed. During recovery the outcome of the surgery was explained to her and she accepted the fact that she would no longer be able to conceive. Seven days later she was discharged. The health of women and children in rural PNG is still a significant problem that consumes most of a rural doctor’s day-to-day practice. A major issue for the training of doctors in PNG is the need for senior doctors to guide and assist resident medical officers with practical on-the-job training in patient management. This practice should be continued, encouraged and strengthened.

Harry Poka MB BS, DCH

The Papua New Guinea Institute of Medical Research (PNGIMR) conducts research into the priority health problems of the people of PNG to improve treatment, control and prevention of disease. PNGIMR research programs encompass vector-borne diseases (particularly malaria), respiratory diseases, sexual health, disease surveillance, infectious diseases and operational (health systems) research. There can be no doubt that this capacity for high quality, evidence-based intervention has had a very positive impact on health in PNG. National malaria treatment policy, development of filariasis and malaria control programs, and the development of a pigbel vaccine are but a few of the areas in which the Institute’s research has been translated into action. Postgraduate research officers at the PNGIMR. The success of the PNGIMR has been due to an uncompromising attitude towards excellence in science. A crucial factor in maintaining these standards is the training of young PNG research scientists. Currently, there is an acute shortage of postdoctoral PNG scientists who have an internationally competitive track-record of achievement and publication, the ability to attract competitive scientific funding, an interest in research areas of national health priority, and the potential to be research leaders of the future. Priority must obviously be given to training PNG graduates to fill these gaps. However, it is not sufficient to increase the number of people with postgraduate qualifications by simply allowing them to accept scholarships to work overseas — we must target our graduates’ development to the things that matter in PNG. PNG has two advantages in formulating a PNG-centred research training program. Firstly, the PNGIMR is already carrying out research of acclaimed international standard, focusing on PNG health problems. It has many externally funded scientific projects, solid international networks, a high-level publication record, and internationally recognised scientific supervisors. Secondly, the University of PNG (UPNG) is a fast-maturing academic institution with a strong appreciation of the value of research. In September 2004, the two institutions signed an agreement to pool their resources to address the shortage of PNG scientists. The key to developing PNG health-research scientists is to base their training firmly in PNG, in areas of national importance with long-term potential. The cornerstone of this strategy is using PNGIMR projects as a vehicle for UPNG postgraduate degrees. Our developing model sees graduate students (from UPNG or returning from overseas) being recruited by the PNGIMR and rotated through its laboratories to top up practical skills, then being attached to a project for honours research, under supervision of a PNGIMR scientist, while registered at UPNG. Students who achieve a high standard then register for a masters degree or PhD course, developing the same research themes. Although still focused on PNG, these students will also spend periods of time in overseas laboratories, learning relevant technologies and expanding their international networks. By the time they complete their PhD they will have built a firm foundation for a career in their chosen area of research and already be established in their PNG workplace. At this stage, they can be insulated for a few years from teaching and administration to develop their own independent program of research. An important assumption of this model is that it is not always necessary to go outside PNG to get well regarded postgraduate qualifications. As a researcher, the most important things about your PhD are the relevance and novelty of the project, the quality of the work done, the international reputation of your supervisors, and productivity in publishing peer-reviewed papers in international journals. In PNG we have all the components to excel in this area, and the collaboration between the UPNG and the PNGIMR is a landmark step in making a UPNG research PhD an internationally recognised and competitive qualification, with full relevance to the PNG context.

John C Reeder PhD

Sirus Naraqi, an inspiring and warm-spirited doctor with a deep commitment to bettering the lives of the underprivileged, died in Sydney on 18 August 2004, after a two-year illness. Sirus Naraqi spent much of his free time visiting remote areas of Papua New Guinea, providing medical treatment and giving advice to Baha’i communities. (Reproduced with permission from the Baha’i World News Service.) Born in Persia on 30 September 1942, Sirus Naraqi served as a general practitioner to the Persian army before emigrating to America in 1969. There he completed postgraduate training at the University of Chicago and the University of Illinois, followed by numerous consultant physician and academic appointments. Sirus used his interest in infectious diseases to express his strong humanitarian desire to serve in areas of greatest need, such as Papua New Guinea (PNG), where he took up the Chair of Medicine at the University of PNG in 1983. During his time at the university, he led major research projects on severe forms of malaria, snakebite and meningitis. His warmth and style were important in preparing junior colleagues for positions of leadership. Because of its research and educational programs, the university’s Faculty of Medicine achieved international recognition. In 1998, after Sirus had spent 15 fruitful years in PNG, the University of Sydney appointed him Professor of Medicine and Associate Dean at Nepean Hospital, Penrith. Sirus had a lifelong commitment to community service. This included continuing participation in public debate; work with the World Health Organization on tuberculosis, malaria and HIV/AIDS; research and rural health work in PNG; and promotion of international human rights, literacy, hygiene and nutrition for the underprivileged. He also held numerous positions of leadership within the Baha’í congregation. The Queen made Professor Naraqi a Commander of the British Empire in 1998 for his service to PNG. The entirety of Sirus — his personal and professional actions — was inspired and strengthened by his Baha’i faith, an inclusive belief that expresses the oneness of humanity and the permanence of the human spirit, and that considers work in the spirit of service to others as worship of God. As a former colleague in PNG said, Sirus was the embodiment of equanimity, graciousness, clarity and generosity. Sirus was treasured by many people. Medical students respected his generosity of spirit and his dedication to teaching and to the profession. He did not seek effect or popularity. He was a world citizen who gave respect spontaneously and received it in return. His academic colleagues delighted in his integrity, commitment, firm principles and intellectual capacity. He is survived by his wife Mitra and children Ladan, Naysan, Anisa and Gulita.

Stephen R Leeder

Child health will only improve when local structures are further strengthened, enabled and supported Most countries in the western Asia-Pacific region have made consistent gains in child survival over the past 25 years (Box 1).1,2 Notable exceptions to this positive trend are Papua New Guinea (PNG) and East Timor. Sadly, a static child mortality rate such as has occurred in PNG, where the population has doubled over the past 25 years, means that, in this new century, about twice as many children are dying per year as in the mid-1970s. The health inequities between Australia and its nearest neighbours are many, and breathtaking in magnitude. In this issue of the Journal, McGain et al (page 687) document 87 deaths from snakebite at Port Moresby General Hospital (PMGH) (the largest hospital in PNG) over a 10-year period.4 This hospital serves a population of about 500 000 people. By comparison, throughout the whole of Australia since 1981 there have been an average of 2.6 snakebite deaths per year.5 McGain et al point out that lack of antivenom is a major reason for the high mortality, and that the cost of antivenom in real terms is 40 times greater in PNG than in Australia. The reasons for this include a per-capita gross national income that is 2.9% of that in Australia,2 price mark-up with privatisation of overseas distribution from Australian suppliers, and an Australian government subsidy for antivenoms sold in Australian hospitals that does not apply elsewhere. It is not difficult to suggest some feasible solutions to this problem: an Australian government subsidy for overseas developing-country purchasers, and/or direct supply from the manufacturer to the PNG Department of Health. However, snakebite is just one small piece of a very large puzzle of poor child health outcomes in PNG and the Asia-Pacific, and lack of antivenom is only one factor in high death rates from snakebite. Other factors are more systemic: limited access to health services, limitations in the quality of health systems, inadequate manpower, and poor management and financing. These problems are greater in rural areas, where 85% of the population lives; they have a major impact on all causes of avoidable child mortality, and are more difficult to solve than the lack of snake antivenom. PerspectiveAt PMGH, for every child who dies from snakebite, more than 50 die from other conditions that have been eradicated or controlled in Australia. In a 12-month period in 2001–2002 there were 238 child deaths at PMGH, of which four were from snakebite. Of 195 deaths in which the cause could be certified, 29 were from measles, 35 from meningitis (about a third of which were caused by Haemophilus influenzae type b [Hib]), 14 from HIV, 7 from tuberculosis, 66 from pneumonia and 11 from acute gastroenteritis.6 Throughout PNG, about a third of Hib isolates are resistant to available antibiotics (principally chloramphenicol),7,8 and rates of HIV are rising rapidly. The persistence of these infections in PNG despite the existence of effective methods of prevention or control should be a cause for concern and action in Australia as well as in PNG. Two-thirds of all child deaths are associated with moderate to severe malnutrition. On the role of aid and economic developmentAustralia currently allocates $435 million in aid to PNG (representing 20% of Australia’s official development assistance and 0.26% of its gross national income9 — far short of the benchmark of 0.7% agreed to by rich nations at the Earth Summit in 1992, and only achieved by Scandinavian countries and The Netherlands10). Much of Australia’s aid is now tied to strengthening law-making and law-enforcement facilities and financial management, but a proportion is allocated to social services (principally health and education). Aid programs in PNG often find themselves “between a rock and a hard place”. Sustainable development cannot occur in an environment of poor governance. When existing systems are not functioning well, one outcome, sometimes occurring by default and sometimes by design, has been the development or evolution of “parallel projects”, which circumvent existing government structures to achieve a flow of services or information to the periphery. There is a tension between this project approach and the building of genuine long-term capacity (ie, the resources and structures that enable self-sustainability) within government programs. However, if inequity within PNG and between PNG and Australia is to be reduced, aid allocated to social services must be spent in ways that will strengthen local systems so that services reach the most marginalised communities. One example of this dilemma is the Women’s and Children’s Health Project, funded by the Australian government and launched in PNG in 1997 (funding will cease at the end of 2004). The project has allocated $10 million a year to improve child and family health services. Credit must be given for its achievements, such as improvements to the vaccine “cold chain” (previously a major limitation on the quality of vaccines distributed in remote areas) and training and capacity support in some rural areas. However, results have generally been disappointing. Only a small proportion of the aid money has filtered down to the villages and settlements where child mortality is highest. Much has been consumed by large infrastructure costs in Port Moresby. In an attempt to tick off activities as completed achievements, weak and sometimes frustratingly inefficient government systems have often been circumvented using a “parallel project” mentality, rather than taking the much slower approach of working with and strengthening existing local structures. In a thought-provoking but pessimistic review, Professor Helen Hughes, Senior Fellow at the Centre for Independent Studies, has argued that aid has failed the Pacific nations.11 She believes that aid has created an ambiguity of independence, an environment in which government funds are spent on consumption rather than economic development, elevated exchange rates, and provided fodder for political corruption. These factors, plus high tariffs, have hindered manufacturing for domestic markets and export of agricultural products; reduced employment opportunities, skill development and entrepreneurship outside the government sector; and encouraged dependent welfare states. A partial solution suggested by Hughes11 is to make receipt of aid conditional on achieving certain goals, under an agreement of mutual obligation. This would require removing aid from government budgets, with mutual agreement between recipient and donor countries on its use, mutual monitoring, and disbursement subject to regular account auditing. Successful examplesPapua New Guinea (PNG) needs human capacity to provide a quality health service. In some areas of endeavour, this has been achieved. The Paediatric Society of PNG is one example of the slow and successful development of indigenous technical and professional capacity. This is a story of committed engagement by many paediatricians over four decades, building on the foundation laid by the late Professor John Biddulph. Progress has been based on the principles of quiet example and mentorship, working together at the front line of healthcare and grappling with everyday problems. In the past decade there has been increasing development of a few subspecialty areas and extraclinical skills, such as public health, research, evidence-based understanding, policy development, advocacy and child health nursing capacity. Australian public hospitals and individual paediatricians have played key enabling roles in this development, and, in turn, their support has been greatly assisted by AusAID through the PNG Medical Officer, Nursing and Allied Health Professional program and its predecessors. The outcomes are impressive. Locally trained PNG paediatricians now provide services in most of the 20 provinces, and contribute substantially to all areas of public child health, policy and service delivery.12 The PNG standard treatment manual,13 along with the National Government Health Plan, is a blueprint for a quality child health service in a resource-poor setting, and has been reproduced in many other developing countries and in internationally adopted strategies. These advances have only been achieved through the work of vital national child health institutions, the PNG Paediatric Society and the Department of Child Health at the University of PNG, with aid projects providing background support at various stages. Limiting factors to progressDespite some successful programs, many activities in PNG have not resulted in health gains where they are needed. Support areas of the health service remain weak: health and human resources management at all levels, drug and vaccine procurement, distribution and stock management, and health financing. Primary care, the most essential form of healthcare in rural areas but the least robust and most vulnerable level of the health service, has suffered the most because of these deficiencies.14 There needs to be a similar concentration on building capacity and commitment in these areas, improving efficiency, and minimising waste of resources and squandering of funds.15 The beginnings of progress in some of these areas have occurred. Health management is stronger in some provincial health services and hospitals now than it was 10 years ago, partly as a result of structural reforms and support and mentoring for management capacity provided by the AusAID-funded Health Sector Support Program. More needs to be done, but sustainable change will only occur slowly, tailoring strategies to individual situations — an approach that is at odds with some aid projects, whose designers often propose a “one size fits all” formula for rolling out the latest Big Idea, with little critical evaluation of outcomes. Equity and conditionality as principles of aidConditional aid, as Hughes suggests,11 might be a useful strategy, providing direct funding to carefully selected high-priority areas, with an agreement that certain process milestones will be reached. Potential examples might be Australian government funding of Hib vaccine, conditional upon completion of the national supplemental immunisation activities16 and achieving coverage of over 80%; or subsidising the purchase of snake antivenom, nevirapine and ceftriaxone, conditional upon improvements in drug procurement and national distribution systems. A further condition to ensure commitment and sustainability would be the understanding that the PNG government would take over responsibility for funding after a mutually agreed period of time. These targeted interventions would have broad benefits to the health service, would enable the implementation of new (to PNG) and highly effective interventions, and would enhance equity within PNG and between our two countries. However, there are some risks with conditional agreements. The withholding of interventions if conditions are not met would continue to hurt the people who are innocent of any waste or corruption — nurses and doctors who struggle every day to provide good healthcare, and the patients who suffer from the effects of a lack of quality services. Support should be given to local training institutions rather than aid projects running unsustainable training programs. A portion of the aid budget could be provided to build key areas of capacity by financially supporting individuals or groups committed to collaboration in ways that are appropriate to Melanesian society. AusAID and the PNG Health Department are currently proposing a step in this direction by establishing a Capacity Building Service Centre, which will place more emphasis on engaging locally successful individuals to act as mentors, build capacity, and result in significant changes to external contracting. The approaches outlined above are complementary and would reduce inequity between Australia and its Pacific neighbours. In some ways, they would be a departure from some current large aid projects, whose economic benefits often spin back to the donor country, and whose resources are consumed by project infrastructure that duplicates government institutions. I can see little place in a country like PNG for health projects that are managed by overseas private consortia. International tendering for health projects in a country that has no structured health management organisations can scarcely improve equity. This model has worked better for some aid development projects, such as road and water supply contracts, in which local engineering companies have won contracts, thus contributing to local development, employment and economic growth. However, the idea that health aid should be corporatised in a country that desperately needs an effective public health system is fundamentally flawed. No easy answersThere are no easy answers to how Australia can best assist regional countries. Ongoing engagement remains necessary at many levels — between governments, professional societies, institutions, and individuals. Without this there can be no mutual understanding, which provides the basis for progress and is crucial for regional peace. Some of the best examples of success suggest that sustained, quiet and modest-budget collaboration by committed groups or individuals who treat each other as equals will be the most effective strategy. As yet I have not addressed the problems of child mortality in the worst-affected country in the region — East Timor. A sustained collaborative approach would be of great benefit to this small country (Box 2). The view of PNG as a “failed state” is wrong. Progress is being made in many areas. Now is not the time for Australia to abandon PNG or our closest Pacific neighbours, but to learn from institutions and areas that have achieved much, to support them to do more, and to tailor approaches to specific situations. Australia also has much to learn from Pacific countries — quiet persistence, patience and a sense of community are qualities that might help us have a more realistic view of what progress really means. 1 Trends in mortality in children under 5 years (per 1000 live births) in the Asia-Pacific region over the past 50 years1-3 * In a Demographic Health Survey (DHS) in East Timor in 2003, the mortality rate in 2003 among children under 5 years of age was estimated to be 107 per 1000 live births. Mortality rate estimates from the previous eras, represented on the graph, are also based on retrospective data from the 2003 DHS, so the accuracy of these trends is uncertain. Reliable data from previous years are not available. 2 Increasing East Timor’s capacity to meet its child health needs The problems of capacity in East Timor are even deeper than in Papua New Guinea (PNG), and the child health system is in a much more embryonic stage of development. Currently, there are no East Timorese paediatricians, which is a major impediment to sustainable progress, local leadership, autonomy and direction. However, collaboration between the East Timorese Ministry of Health, the University of PNG and the Royal Australasian College of Physicians (RACP) will hopefully see East Timorese doctors trained in child health, largely in PNG, with some additional clinical experience in rural hospitals in Australia, over the next 5–10 years. This will provide training in settings that are similar to those of East Timor, foster personal and institutional connections between two developing countries, promote a developing-country university as a regional centre for high-quality specialist training, and minimise the risk of “brain drain” that would exist if specialist RACP Fellowship training were done in Australia.

Trevor Duke MD, FRACP, FJFICM

Absence of coherence in the way Australia employs overseas-trained doctors is a problem for our healthcare system and for the doctors themselves In the 1880s, the head of the statistics unit of the Registrar-General’s office in London noted that the shortage of medical practitioners in England was such that there was “imminent danger” that qualified medical care might become “quite inaccessible to vast numbers of people”.1 This shortage was a direct outcome of the Medical Act of 1853, which prescribed strict criteria for the education and registration of medical practitioners. Its effect was to reduce recruitment into the profession because of more formidable courses while concomitantly phasing out unqualified practitioners.1 Now, at the beginning of a new century, we find that the predicament of Victorian England has become a global problem. There is a shortage of doctors worldwide, and Australia is no exception.2-4 OTDs must not be seen as a long-term solution to our doctor shortage. A number of factors have contributed to our doctor shortage. Prominent among these is federal government policy in the 1990s, which limited the number of medical school places in Australia, as all the while the Australian Medical Workforce Advisory Council maintained there was no shortage of doctors.5 Having miscalled policy, the federal government is now rapidly seeking to remedy its gaffe. Five new medical schools have recently been established6 and the number of bonded medical places (requiring graduates to work for a minimum period in districts of workforce shortage) in our existing medical schools has been increased by 234.7 The projected outcome of these initiatives is that the number of Australian medical graduates will increase from about 1200 in 2004 to about 2200 in 2014 (Warwick Hough, Director of Workplace Policy, Australian Medical Association, Canberra, personal communication). Whether this number will meet society’s demands a decade from now is anyone’s guess, but one thing is certain: Australia’s healthcare will be dependent on overseas-trained doctors (OTDs) for some time to come. Our increased dependence on OTDs is reflected by recent bureaucratic activity attending the government’s announced Strengthening Medicare package, with its additional 725 OTDs working in Australia by 2007.8 One consequence has been the generation of a report on OTDs submitted to the Medical Training Review Panel of the Australian Department of Health and Ageing in February 2004. It outlines a bewildering array of Australian policies and guidelines, and differing surveillance and stewardship of OTD programs. The report identifies: enormous inconsistencies in terminology; lack of national coordination in collection of data on OTDs; inadequacy of data held by different agencies and departments; differing entry points of OTDs controlled by different jurisdictions (eg, through the state and territory Areas of Need program or the federal Districts of Workforce Shortage program); a multitude of stakeholders, all focusing on their individual programs, with poor communication among themselves; doubts about the adequacy of assessment and supervision of OTDs entering Australian medical practice by medical boards and about the adequacy of the Australian Medical Council (AMC) examination. Finally, the report on OTDs found there were inadequate resources for orientation, ongoing training and supervision of OTDs, and suboptimal support for their families. Some progress has been made, such as the recruitment of OTDs through contracted recruitment agencies, reduced “red tape” in the assessment and recognition of OTDs, some flexibility in immigration arrangements to allow OTDs to stay longer,8 and fast-tracking of selected applicants to provisional registration and assessment by the AMC. However, the reality is challenging. The data on birthplaces of OTDs in the article by Birrell in this issue of the Journal () reflect the reality of the global village we now live in.9 Yet, while the backgrounds, knowledge and skills of OTDs are diverse, evaluations of competence may be bypassed when employing OTDs in Australia, and formal assessments of communication skills (as distinct from linguistic proficiency) and cultural awareness are not included in current assessments.10 This has the potential to compromise patient care. To facilitate an orderly integration of OTDs into the Australian healthcare system, McGrath () calls for a national body to establish uniform standards in licensure, to review and, where needed, to boost training resources and capacity. He argues that these are the minimum requirements to meet our duty of care to both the public and OTDs.11 We would also argue that recommendations by this body and coherent, relevant OTD data should be regular agenda items for the Australian Health Ministers’ Conference. Focusing on OTDs as the primary short-term solution to our doctor shortage has serious ethical and global implications. The “brain drain” of healthcare professionals from many developing countries compromises their healthcare systems and demoralises their healthcare workforces already struggling to cope with major public health problems such as HIV and malaria. It constitutes a major loss in financial as well as human capital — particularly as any remittances sent back by emigrants (estimated at US$72.3 billion in 2001 and the second-largest source of external funds for developing countries) are not necessarily reinvested in healthcare.12 Unless recruiting countries like Australia adopt policy options such as creative employment contracts that also subsidise the country of origin, it is likely that “borrowing” OTDs will continue to broaden the gulf between developed and underdeveloped countries. OTDs must not be seen as a long-term solution to our doctor shortage. The Australian Health Ministers’ Conference’s recent National Health Workforce Strategic Framework states: “Australia should focus on achieving, at a minimum, national self sufficiency in health workforce supply, whilst acknowledging it is part of a global market.”13 In the meantime, OTDs make a valued and essential contribution to our society and to the provision of healthcare to Australians. We should respect their contribution with the attention and care it deserves.

Martin B Van Der Weyden MD, FRACP, FRCPA · Mabel Chew FRACGP, FAChPM

Since the late 1990s Australian employers have recruited an increasing number of overseas-trained doctors (OTDs) to hospital and “area of need” general practice positions. While assessment standards vary by state and field of medicine, most OTDs are appointed without a formal assessment of their medical knowledge and clinical skills, with registration to practice being conditional only on their working in hospitals and “areas of need”. By comparison, formal assessment is required before an OTD can practise medicine in the United States, the United Kingdom and Canada. Most of these doctors hold temporary resident visas, but a minority are permanent residents who have not completed their Australian Medical Council accreditation examinations. In 1997–98, most OTDs arriving under temporary resident visas were from the United Kingdom and Ireland, and by 2002–03 this had dropped to under 50%; OTDs now come from a greater diversity of countries.

Robert J Birrell PhD

Australian healthcare is greatly enriched by its overseas-trained doctors (OTDs). There is no national approach to support the integration of OTDs into the workforce. The problem areas are well defined — the need for better information access; better orientation to our healthcare systems and the workplace; improving communication with patients and healthcare workers; standardised assessment of knowledge and skills; and education and training support —so, let’s get on with it.

Barry P McGrath MD, FRACP

Weeks after beginning its winding journey, a redirected letter finally finds its destination. In our eagerness to open it, we almost tear in half the neatly folded crisp white sheet that lists a series of results: angina, pass; asthma, pass; preeclampsia, pass; bulimia, fail, could not elicit history of vomiting; croup, pass. The list continues to a dispassionate conclusion that the candidate has demonstrated adequate knowledge at the examinations of the Australian Medical Council (AMC) to secure a passing grade. The accompanying card graciously thanks us for our tutoring 1 year ago. We stare wordlessly at the sheet, our joy obliterating its sterility. So far, he has fled state persecution, worked 10 years in a factory, and supported a family of four on a minimum wage. The iatrogenic death of his father served as a powerful impetus to return to his calling in life, medicine. Forty years old, he has juggled swimming and soccer lessons, school homework and, lately, running a small business to steal time to prepare for his own examinations. “I promised myself at my father’s bedside that I would go back to medicine. Every day in the factory, I used to dream about becoming a doctor again, but we needed that job to survive.” Now he will forever be known as an “AMC”. As we exuberantly write him a congratulatory note, a vision of his journey ahead involuntarily crosses our mind. As he begins his quest for a job, he will quickly learn that, although all foreign graduates seeking to enter the Australian medical system must take the AMC exam, the term “AMC doctor” automatically carries the connotation of inferiority. Irish, American and German doctors will be identified by country, while he and his peers from the developing world will be separated by an invisible, but distressingly tangible, line. Deeming himself unsuitable for the elite hospitals, he will apply instead to those considered more “foreigner-friendly”, their reputation earned not necessarily for their greater tolerance of foreign graduates, but because of their inability to attract the more aspiring. These hospitals too will first select local graduates before yielding the leftover spots to the AMCs. At the scant interviews he secures, he will be summarily discarded at some on account of his thick (yet understandable) accent and his slow (yet considered) speech. At others, he is unlikely to receive ticks in the boxes that say “team player”, “enthusiastic” and “makes good eye contact”, because he is unfamiliar with the buzzwords and gestures (although not the inherent concepts) that interviewers seek. His first job is almost certain to be in a hospital staffed largely, if not almost exclusively, by foreign doctors. Collegial support will be tentative, the focus being on surviving each day without raising the staff’s ire. He will be greeted cautiously, unaware of an unspoken probation, and he might only enjoy a few days’ grace before barbed remarks escape their loose restraint. Despite his commitment, he will be slow, never having had the benefit of observing local protocol as a student or a subintern. Despite having passed his exams, he will hesitate with most tasks, including the essential ones of documenting directions, checking blood tests and making a physiotherapy referral, because he is a stranger to them all. Some doctors and nurses might lend a kind and guiding hand, but he is more likely to (over)hear the following: “You are the resident — it’s your job!” “Why do I always end up with the AMCs?” “He might be a nice person, but he doesn’t have a clue!”. Occasionally, the remarks will be deliberately hurtful: “Excuse me, this desk is for doctors only!” “Why don’t they just go back where they came from?”. He is most likely to miss tutorials because of unfinished work, and, when he does get to one, he is the diminutive figure in the corner, too self-conscious to ask a legitimate question. He is the one you will see biting on a stale sandwich most evenings as he ploughs through piles of paperwork between braving phone calls to the registrar, irate at his inability to articulate a problem in 30 seconds. When the desperately needed interpreter is hours away, he will meekly announce his grasp of two other languages. Relief and gratitude on the part of the staff will be somehow inexplicably replaced by righteousness. “At least he can do that!” He will often wonder why his best attempts to contribute meaningfully seem antagonistic, why there is such a glaring lack of encouragement, and why he is finding this initiation harder than he had ever imagined. In a private wish list, he craves for a little more understanding and a little less hostility; then, scoffing at such imagined luxuries, he returns to face another day. Slowly, one unit then another shares the AMC burden, each one “preparing” the next, so that his perceived shortcomings always precede him. Soon he must think about the following year’s jobs. What should he do? Who knows him well enough to provide the references? Who are his role models? Should he follow the majority of his AMC peers and enrol in general practice training or should he make a concerted attempt to pursue a long-desired specialty? The obstacles seem magnified in advanced training. Even if he manages to enter a specialty program, who will supervise the children’s homework? Who in the hospital appreciates the needs of an older foreign doctor, also a son, father, husband and small business owner? The conflict between personal aspirations and life’s larger concerns routinely ravages his mind. In the course of our own training, we have been frequent witness to, and no doubt creators of, the hurdles that the medical community puts in the way of foreign medical graduates. These hurdles are not only academic, but also personal, based on our uninformed and unchallenged perception of their culture, education and work ethic. Every foreign graduate we have taught has understood the rationale for an Australian exam, but, after attaining the very standard demanded by the profession, it is the indignity of working in an unsupported and hostile environment as a second-class doctor that turns out to be the insurmountable hurdle. Although the issues surrounding foreign medical graduates are genuinely difficult and bear no glib resolutions, we suggest the following considerations. Integrate foreign medical graduates preparing for the AMC exam into hospitals by allowing them to observe educational seminars, outpatient work and grand rounds. Knowledge of local medical practice is far more accessible in this manner than by spending countless lonely hours in the library in search of assimilation. Access should not be limited to peripheral hospitals, which are often difficult to travel to and lack consistent teaching programs. Expand the educational program for foreign graduates by encouraging local physicians to teach. (With the assistance of just one other colleague, each of us spent just 2 hours a week to adequately address the exam syllabus.) It is crucial that program directors sanction such activity rather than be dismissive of its goals — a volunteer teaching program will enjoy success only if personal gain is sometimes set aside. Assign a specific mentor for foreign doctors at each institution. Such a mentor must be sensitive to the different goals and needs of foreign doctors compared with those of their local counterparts. Neither excessive pressure to conform nor total immunity from compliance with local standards should take the place of a deliberate process of integration. Practise what we preach. Medical students are taught from inception about the value of empathy and communication. We repeatedly examine their grasp of such skills, yet, once they are doctors, these skills are perceived to be an optional extra. Apply the open-ended question to foreign doctors: “Tell me how you feel.” Appreciate the worth of foreign doctors as a pillar of our increasingly cosmopolitan society. The very doctors we may deride will go on to serve entire populations, which the average Australian graduate is ill-equipped, and hence uncomfortable, to serve. The statistics on migrants, ageing populations and chronic illnesses do not bear repetition, but the overwhelming need to help our foreign doctors to help us take care of all our patients does. In medicine, the road is long for us all, but for the foreign medical graduate it is inevitably more winding and rough. It is our obligation to not abandon our colleagues along the way, but to seek to ease their journey with small, personal gestures and larger, administrative measures. While they tend our society’s sick, we must not deny them their own bruises that often lie just beneath the surface. It is only then that as physicians we can truly call ourselves healers.

Ranjana Srivastava MB BS(Hons) · Declan J Green MB BS(Hons)

There is currently no need to panic At a recent forum of the Australian Health Policy Institute in Sydney, the Editor of the Journal expressed concerns about Australia’s ability to cope with avian flu, and asked whether he could sleep soundly in his bed. We attempt to answer his concerns. Influenza is justifiably feared. In 1918–1919, 40 to 50 million people (2%–3% of the world’s population) died in the “Spanish” influenza pandemic.1 Subsequent influenza pandemics occurred in 1957 and 1968. Although the mortality of the later pandemics was far less, the potential for another major pandemic is ever present. Annual influenza outbreaks have caused more deaths overall than pandemics, but gentle antigenic “drift”, caused by minor mutations in the viral genome, allows the annual development of a new influenza vaccine, matched as closely as possible with predicted circulating strains. Pandemic strains caused by antigenic “shift” are, by definition, unpredictable, and unlikely to be prevented in the short term by vaccines. In 1999, stimulated by human infections caused by avian influenza in Hong Kong, the World Health Organization (WHO) published a pandemic preparedness plan, and urged countries to make their own plans.2 How well prepared is Australia? The origin of pandemics: The segmented genome of the influenza A virus favours genetic reassortment, which can lead to antigenic shift to a new, potentially pandemic, strain. Pandemic strains arise when a new type of haemagglutinin is introduced into humans. Pigs may act as a mixing vessel for reassortment by supporting growth of both avian and human viruses, or a human might be co-infected with both avian and human strains. Pandemic influenza spreads rapidly and affects children and young adults, causing enormous social disruption.1 Avian influenza: Birds, particularly aquatic and migratory species, are natural hosts of all 15 haemagglutinin subtypes of influenza A virus, whereas only a few of these viruses have established transmissible infections in humans, pigs and other mammals.1 Avian influenza strains readily infect domestic poultry and are highly pathogenic to birds.3 Since mid-December 2003, there has been a catastrophic outbreak of avian influenza in Asia, caused by a highly pathogenic H5N1 strain. Eight countries have confirmed outbreaks, mostly in commercial poultry, although wild birds have been infected. In 2 months, over 100 million birds in Asia died or were culled.3 There was great alarm when human infections with this avian strain were reported, with high mortality in both adults and children. However, despite the extent of the outbreak in birds, very few human cases have been reported. By 24 March 2004, 57 cases had been notified from Vietnam (37) and Thailand (20), of which 23 (40%) were fatal. All cases followed exposure to infected poultry. The number of unreported human cases is uncertain, but the absence of documented human-to-human spread is reassuring.3 The greatest concern is that there will be reassortment between the current avian H5N1 strain and circulating human or porcine influenza viruses, producing a novel, virulent human strain. Pandemic planning: Australia has been actively planning action to cope with an influenza pandemic since 1997. The framework for a pandemic plan was published in 1999,4 and an action plan was published in 2003.5 A National Influenza Pandemic Action Committee (NIPAC), formed in 2003, continues to plan for future pandemics and has closely monitored the avian influenza situation. Although NIPAC is an anagram of “panic”, the message so far is that there is no need to panic. A major concern of the audience at the health policy forum was the large number of different agencies involved in planning for a pandemic — a veritable “spaghetti junction”. Who should coordinate these agencies? Given the complexity of pandemic planning, we believe it is entirely appropriate that there are many different players, coordinated, as is now the case, by the Australian Department of Health and Ageing.6 Planning for pandemic influenza overlaps to an extent with planning for outbreaks of other viral infections. Australian pandemic planning has benefited from the need to develop plans to cope with a potential epidemic of SARS (severe acute respiratory syndrome)7 and possible bioterrorist attack with smallpox virus.8 NIPAC is addressing many facets of planning, including: Border protection. Although Australia is an island, modern air travel and the high infectivity of influenza preclude total exclusion of a pandemic. Because influenza can be transmitted before symptoms appear, screening incoming passengers for reported symptoms, as was done for SARS, would be less effective, but might delay widespread introduction of influenza. Even weeks of delay could be invaluable for vaccine development and distribution. Immunisation. It would probably take at least 6 months after the onset of a pandemic for significant quantities of vaccines specific to the pandemic strain to become available.9 WHO is currently developing H5N1 viruses suitable for vaccine production as rapidly as possible. Antivirals. The H5N1 virus is resistant to amantadine, but sensitive to the neuraminidase inhibitors oseltamivir and zanamavir, which can be used for both treatment and prophylaxis. It has been suggested that countries should stockpile antivirals.10 There was some evidence of their benefit in humans during the 2003 outbreak of highly pathogenic avian H7N7 influenza A in Dutch poultry farms.1 However, antivirals are very expensive and in short supply, and realistically could only be used as a stop-gap measure to “buy time” by treating early cases and protecting essential staff. Laboratory diagnosis. Influenza is difficult to differentiate clinically from “influenza-like illnesses”, necessitating laboratory testing of appropriate respiratory samples for confirmation. However, testing is not often done routinely (at least in adults). SARS and the threat of avian influenza suggest testing should be more widely available to facilitate decisions about infection control, but few laboratories provide rapid viral diagnosis. The network of WHO influenza and other public-health laboratories in Australia is actively developing rapid tests to detect H5N1 influenza. Infection control measures to limit spread. Children are at high risk of contracting and dying of influenza,1 and are an important source of infection for the elderly.11 In a pandemic, it would almost certainly be necessary to close schools, childcare centres and public gatherings to reduce spread. Respiratory hygiene. Simple respiratory hygiene, such as covering the nose and mouth when sneezing, and disposing of used tissues promptly in “no-touch” receptacles, is as important as the use of masks.12 Communication. The level of public concern and, in many countries, panic during the SARS outbreak vividly illustrates the importance of effective public communication. It is vital that authorities do not leave the dissemination of information about outbreaks to the popular press. There is currently no need to panic about avian influenza, as human cases are extremely rare and have followed close exposure to birds. Human-to-human spread of avian influenza has not been described. While Australia is well prepared to cope if an influenza pandemic started tomorrow, the unpredictability of these pandemics, their rapid spread and high attack rates mean it is impossible to be totally reassuring. Like the rest of us, the Editor of the Journal, if he wants to sleep soundly, will just have to cope with uncertainty.

David Isaacs MD, FRACP, FRCPCH · Dominic E Dwyer MD, FRACP, FRCPA · Alan W Hampson MSc, MASM

The ultimate consequence of failing to live sustainably is that we push our own species to extinction “In search of sustainability” was predominantly an Internet conference held over 9 months. Each month was dedicated to a particular theme, and a keynote paper and several related discussion papers formed the basis for an Internet debate on each theme (www.isosconference.org.au). The nine themes were water, human health and wellbeing, land use and natural ecosystems, energy, equity and peace, economic systems, climate, labour force and work, and transportation and urban design. The Internet conference culminated in a one-day face-to-face meeting at the Shine Dome in Canberra on 14 November 2003, which was attended by 190 delegates from around Australia. Twenty-four eminent Australian scientists and researchers presented papers summarising the nine core themes, with an emphasis on defining a path towards sustainability. I attended as a self-funded delegate, motivated by my passion and engagement in a spectrum of environmental issues. In this report, I have chosen to concentrate on the themes of greatest relevance to health and sustainability, and have given preference to contributions from the medical profession. Doctors, because of their credibility in public debate and their knowledge of the devastating health effects of environmental degradation and pollution, have an important role to play in community discussion about sustainability. Several of the speakers were members of the newly established Doctors for the Environment (www.dea.org.au), which has been established to provide an educational role for colleagues and a forum for the profession to add its voice to the sustainability debate. The term “sustainability” was defined very broadly in the opening session as the capacity of human systems to provide for the full range of human concerns over the long term. Human health and wellbeingTony McMichael (Director, National Centre for Epidemiology and Population Health, The Australian National University [ANU], Canberra) proposed that human health be embraced as a key indicator for sustainability, emphasising that current measures of national “wellbeing”, such as gross national product, do not correlate with a population’s health or wellbeing. He stated that gains in longevity and population numbers have come at the cost of depleting the world’s natural capital and degrading the ecosystems on which our survival ultimately depends. He offered several examples of how the impact of human activity on our biosphere is having increasingly detrimental effects on human health: damage to the stratospheric ozone layer, widespread degradation of productive land, the depletion of fresh water supplies, and overfishing and exhaustion of many of the ocean’s fish stocks. Modelling of human-induced global climate change indicates that, at present, 45% of the world’s population are exposed to the Anopheles mosquito, and at risk of contracting malaria. A rise in global temperature of merely 3°C would lead to an expansion of the range of the Anopheles mosquito, increasing the at-risk population world-wide to 60%. Other vector-borne diseases, such as Ross River virus, could be similarly affected. Tord Kjellstrom (National Centre for Epidemiology and Population Health, ANU) stated that “sustainability is the health promotion challenge of the 21st century”, adding that many of the changes needed at an individual level to improve our personal health are synonymous with the changes that will lead to a more sustainable way of living. Examples included taking the opportunity to walk or cycle in preference to burning fossil fuels in personal motor vehicles, and eating fresh local produce in preference to imported processed foods. He concluded that all members of society have a role to play in making “sustainability-based behaviours” the social norm — just as non-smoking has become the norm. Colin Butler (National Centre for Epidemiology and Population Health, ANU) pointed out that many factors may disrupt health, including environmental influences (floods, earthquakes, and climate change) and human activities (war and terrorism). “. . . denial of our increasingly unsustainable lifestyles will simply deepen the crisis we are in.” The goal to live more sustainably needs to become the primary objective of human endeavour. Transportation and urban designChris Johnson (NSW Government Architect) alluded to studies in the UK comparing “battery-raised kids” (those driven to school in a four-wheel-drive and bundled through the gates) with “free-range kids”, who were allowed to walk or cycle to school. The findings showed that free-range kids had better psychological development and school performance. He explained the concept of the “ecological footprint”,1 a scientific approximation of the area of land that each individual requires to meet his or her material needs and assimilate waste. “While this is an increasingly useful tool to assess the impact of our consumption patterns, we need to incorporate the element of liveability when we look at how we might design the cities of the future.” A proposed model of future city design included multiple-storey apartments with rooftop gardens and urban greenbelts. This greater density of living would allow more land for agriculture and biodiversity conservation. Economic systemsRichard Denniss (The Australia Institute, Canberra) argued that “economic growth is not only the target of economic policy and treasury but has become the priority for all areas of government policy”. But gross domestic product (GDP), as a measure of economic growth, does not correlate with a healthy, sustainable society. Paradoxically, loss of human life through trauma or natural disaster contributes a gain in GDP, whereas if members of society were to choose more leisure time and to engage in healthy activity this would be reflected as a downturn in GDP. Denniss urged the adoption of measures such as the genuine progress indicator2 as an alternative to GDP, and proposed that sustainability, encompassing human wellbeing and environmental integrity, should be mandated in all government policy and decision making. Equity and peaceSue Wareham (President of the Medical Association for the Prevention of War [Australia]) emphasised the waste of resources in war and preparations for war. As the sophistication and cost of weaponry increase, there is an increasing potential for even wealthy nations to overstep their capacity to support their own people. Expenditure on basic services, including health and education, are often the hidden casualties of war. The changing nature of weaponry is also having a devastating impact on human health. The contamination of both urban and rural environments in Iraq by the use of depleted uranium munitions will leave a legacy for the health system that will last long after the US-led occupation. The debateThe day concluded with a panel discussion. General agreement was reached that the Australian population, and most populations of the “developed” world, are no longer living within the Earth’s ecological limits. The ultimate consequence of failing to live sustainably is that we push our own species to extinction. While this seems fertile ground for pessimism, the core focus of the debate was how we might transform this situation. Some promoted technological and market-based solutions, working essentially within the existing frameworks established by industry and government. This generated considerable controversy, as others were seeking a more radical departure from our current societal norms, with the view that we already have much of the required knowledge and technology to bring about effective change. Here the emphasis was on generating cultural change through empowering individuals to take personal action, complemented by the development of positive role models. Jenny Goldie (National Director of Sustainable Population Australia) expressed concern that the issue of population size had been neglected throughout the conference. To highlight the population issue, she pointed out that, on the basis of our current consumption patterns, our population would need to be halved if we are to live within the ecological limits of our country. Our current consumption patterns are sustained by exploiting the resources of other countries. Bryan Furnass, a retired physician, gave his perspective on the issues surrounding sustainability: “The problem lies in the three P’s: population, pollution and poverty; the solution lies in three E’s: ecology, education and ethics”. In his conference summary, Ian Lowe (Griffith University, Queensland) suggested that further debate and action towards sustainability would not occur until more people understood the true meaning of sustainability. “If you look at the Earth from space, where’s the economy? The reality is that you see a ball of blue and green surrounded by a thin atmosphere of gases; you see the environment that sustains us. If you look closely you can make out borders of continents, some landmarks which roughly define country boundaries; this is the society that we have established, and then you have the economy which is a creation of our society.” Any human endeavour that leads to a compromise of ecosystem integrity will not be sustainable in the long term. OutcomesThe context of the debate and recommendations from the conference were summarised in a communiqué.3 In addition, the conference organisers are producing a book (expected to be available this year), with contributions from 14 of the conference speakers, which will reflect the breadth, urgency and relevance to national and international human health of the sustainability debate.

Nick J Towle MB BS(Hons), BMedSc

Double standards in medical research in developing countries. Ruth Macklin. Cambridge: Cambridge University Press, 2004 (viii + 280 pp). ISBN 0 521 54170 0 Inequity, when looked at steadily, is appalling. Here we see it, like a Dementor straight out of Harry Potter, staring us down and threatening our sanity in the middle of nice, clean drug trials. Increasingly, pharmaceutical companies conduct clinical trials of new drugs in developing countries because, without adequate mechanisms for the protection of human subjects and the interference of busybody ethics committees, they can obtain rapid answers and get on with the business of profiteering. Clinical trials of new medications conducted in developing countries first provoked comment in 1997, when a study of relatively low dose AZT, given late in pregnancy to HIV-positive mothers about to give birth, was compared with treatment with a placebo. By then we knew that high-dose AZT (expensive) given for a longer period during pregnancy had positive consequences for the newborn child. The idea of not treating the controls caused uproar. Why worry? Firstly, the cost of the new treatment under test is often unaffordable for the country in which the trial is being conducted. When the trial ends, questions arise about continued use of the drug in that country. Secondly, trials using placebo controls bother some observers. They feel that the control subjects should be offered best care as provided in the country from whence the drug trial emanates. This is difficult when standard care is well beyond the reach of the country where the trial is running. What a mess! Thirdly, others worry when a trial is conducted, say, in Botswana of a drug of limited relevance there but highly relevant in Germany, where the costs of the trial would be much higher. Rip off? Ruth Macklin is a New York-based bioethicist with a legal background, which makes her a formidable commentator. She has served on many prestigious international bioethics agencies and inside the NIH. She writes compellingly, lucidly, and in deep detail. She examines the three questions mentioned above, and explores the interplay of science with concerns for human rights, justice, equity, and development. This is not a book for anyone in search of a quick fix or a slick answer. It is, however, chock-full of up-to-the-minute, sophisticated, sound and helpful ethical reasoning and reflection in an area that challenges our humanitarian values head-on. Stephen R LeederProfessor of Public Health and Community Medicine University of Sydney, Sydney, NSW

Stephen R Leeder

The health of refugees. Public health perspectives from crisis to settlement. Pascale Allotey (Editor). Melbourne: Oxford University Press, 2003 (xxiv + 232 pp). ISBN 0 19 551593 5. The health of refugees has generally been regarded as the health of people in “camps” in far-off places like Pakistan, Iran, Sudan, or Kenya. However, this book looks at refugee health from an Australian community perspective. We are brought very quickly from the view of the refugee as “the other”, “the stranger”, “the queue jumper” or “the legitimate refugee” and “the asylum seeker” to see them as people who live in our community, but are often excluded as legitimate members of it. By focusing on this minority within Australia from a public health perspective, our national responsibilities in helping to solve this global health problem are brought into sharp contrast. The book begins with a very good overview of the general health problems faced by those forced to migrate, and moves rapidly to focus on the specific health needs faced by refugee and asylum seekers in Australia. We begin to see this marginalised group as a vibrant resource to be nurtured, rather than one to be further excluded, persecuted and denigrated. This book provides us with timely and detailed health data which could be used to develop a rational refugee health policy. We are also given new data on the long-term effects of forced migration on the many children, accompanied and unaccompanied, who become caught up in these situations. We are asked to play a creative and healing role in this trauma cycle rather than exacerbating the damage. The tension between specialised service funding models and the ability for broader integrated mainstream services to adequately meet the health needs of minority groups is dealt with in the book. There are no easy answers offered, but it focuses on the need for building reasonable and auditable capacity into mainstream services, and so offer hope that better-integrated and more grassroots, community-based healthcare will be developed in the future. The building of cooperative approaches with advocacy groups, volunteers, asylum seekers and refugees, to work with mainstream health services to assess their capacity to respond to individual health needs and to work out creative solutions, stands well with current thinking worldwide on building integrated health partnerships. This book presents many excellent vignettes that make it fascinating and powerful reading. It also provides well-researched references gleaned from those who have built up expertise in refugee and asylum seeker health over recent years in Australia. Based on the information in this book we could, as a nation, develop a refugee healthcare policy to be proud of, and we could show leadership in our region and provide an example to other nations. This book provides food for thought on our public health policies on many levels and is highly recommended as a very practical manual for action. It is an excellent book for anyone with an interest in health, social justice and human rights. Rohan VoraEx-convenor, Brisbane Refugee and Asylum Seeker Health Network Registrar in Palliative Medicine, Brisbane, QLD

Rohan Vora

In the shadow of “Just wars”. Violence, politics and humanitarian action Fabrice Weissman (editor). London: Hurst, 2004 (xi + 372 pp). ISBN 1 8506 5757 8. Medicins Sans Frontières has a reputation for brave and persistent activity aimed at relieving global human suffering. The group reports here on humanitarian aid efforts in 13 situations of conflict and violence — many in Africa, but also in the Middle East, Kosovo, Chechnya, East Timor and North Korea. Most of its 18 authors are French: some are health workers, the others are journalists, academics, lawyers or anthropologists with formidable credentials and extensive experience in international affairs. Ninety per cent of conflicts in developing countries are internal, between factions or regional groupings within a country, and most continue longer than 5 years, causing complex humanitarian emergencies with cycles of war, civil strife, displacement, food shortages and significant mortality. There have been seven million casualties from these internal wars over the past 15 years, and 75% were civilians. Responses by the Western powers, whether of intervention or abstention, are often justified on the basis of high moral purpose, defending values of liberty, human rights and the rule of law, but can be devastating in their consequences. The relationship between bodies that seek to offer humanitarian aid and the prevailing powers in any situation is equally complex. Thoughtful analyses here show how aid efforts to succour the desperately damaged are always constrained, and sometimes completely negated, by sociopolitical realities, particularly those influencing the major powers. “We must do something” is a common cry when reports are received of terrible cruelty, rape, forced recruitment of child soldiers, casual massacres and genocidal policies. But even the best-prepared and well-supported aid agencies face the risk of tragic failure when they confront unacceptable political imperatives and are forced to compromise their own values or clash openly with authorities. “Helping” resource-poor countries is no easy task; it needs informed and global debate, and here is an excellent start. Ian Maddocks Emeritus Professor of Palliative Care Seacliff, SA

Ian Maddocks

Improving global health requires foreign policy reform and more aid Health and foreign affairs are inextricably linked. No day goes by without news reports on health and its global dimensions, whether focused around HIV/AIDS, the rise of non-communicable diseases, the implications of ageing populations, bioterrorism, or other topics. While global population health indices have improved considerably, many countries — both rich and poor — are experiencing health crises, and, in a globalised world, proactive policies are essential in all regions to protect and promote public health. In a number of countries discussion is under way about how best to respond;1 Australia is adding its voice to these debates. What are the links between health and foreign policies? How consistent and coherent are they? What are the benefits or dangers of improving these links? In this special issue of the Journal, we present a selection of papers presented at a symposium entitled “Health and foreign policy: scope for Australian engagement”, held in Sydney in September 2003. The Symposium was a collaboration between the School of Public Health and Community Medicine (University of New South Wales), the Institute for International Health (University of Sydney) and the Nuffield Trust, a leading health charity and research organisation in the United Kingdom.2 What is Australia’s contribution to overseas aid?Australia’s geography provides a particular focus on the Asia–Pacific region. The total Australian aid program for 2003–04 is budgeted at $1.894 billion,3 representing 0.25% of gross national income (GNI). Although this is above the donor average in 2002 (0.23%), this proportion has declined from close to 0.5% in the early 1970s,3 and remains well below the target of 0.7% of GNI set internationally several years ago.4 AusAID, the agency charged with implementing Australia’s overseas aid policy and delivering the Government’s overseas aid program, has highlighted five key themes for its activities: governance — “promoting democratic and accountable government and effective public administration”; globalisation — “assisting developing countries to access and maximise the benefits from trade and new information technologies”; human capital — “supporting stability and government legitimacy through improved delivery of basic services”; security — “strengthening regional security by enhancing partner governments’ capacity to prevent conflict, enhance stability and manage trans-boundary challenges”; and sustainable resource management — “promoting sustainable approaches to the management of the environment and the use of scarce natural resources”.3 The overarching objective of AusAID’s program remains “to advance Australia’s national interest by assisting developing countries to reduce poverty and achieve sustainable development”,5 elements of which are the focus of ongoing debate and critique.6,7 A particularly fundamental challenge is to take account of the new focus on global security, terrorism and governance, while still addressing fundamental health and development concerns, as expressed, for example, in the Millennium Development Goals.8 Alexander Downer, the Australian Foreign Minister, also draws attention to the need for greater involvement of recipient countries in determining what is done with foreign assistance resources; greater emphasis on building developing country capacity to achieve development objectives; greater coordination among development partners; and less reliance on standalone projects.9 Within this broader context, AusAID itself is currently reviewing its health strategy and approach, although this process is at an early stage. Development assistance for health has increased globally from 3.8% of total overseas development assistance to 6.8% in 2002. AusAID anticipates devoting 13% of its 2003–04 budget allocation to health sector support.3 AusAID has previously directed such funding to health sector reform, mental health and non-communicable diseases, and promoting primary healthcare with a focus on the Asia–Pacific region. Australia has devoted particular attention to action on HIV/AIDS, one of the key success areas for the Millennium Development Goals, and HIV/AIDS consumes an ever-increasing share of the health aid budget. Moving beyond aidGlobal health inequality is mirrored by global patterns in health research — less than 10% of health research concerns the major health problems affecting 90% of the world’s population.10 This is now the focus of concerted international action, and Australian research contributions, many of which have great potential, could be greatly facilitated by more extensive support and engagement by AusAID, the National Health and Medical Research Council and the Australian Research Council. It is notable that increasing aid alone will not solve global health problems; reform of broader policies on trade, debt and globalisation are needed if global health is to be promoted and protected. Direct foreign investment is four times greater than the transfer of aid from wealthy to developing countries, and is likely to have a major impact on health.5 The complexity of global governance means that diverse international linkages and structures are needed. Australia’s active membership and involvement in a reforming United Nations, as well as in the Commonwealth of Nations, and regional Asia–Pacific structures, all present avenues for strengthening multilateral commitment to global health and ensuring that it endures as a global priority beyond the current window of opportunity. The debateThe global health and foreign policy articles presented here reflect concern with a number of the major issues of the debate. What is the nature of globalisation and who benefits from it (Lee, page 156)? How do changes in the global trade environment affect health (Labonte, page 159)? What are the challenges and impediments to ensuring that those responsible for forging our foreign policy include health issues on their agenda (Harris, page 171)? What are the dangers of seeking a closer relationship between health and foreign policy, given that security and national interest inevitably are higher on the agenda than concerns for development or poverty reduction (McInnes, page 168)? How does the growing acknowledgement of health as a human right affect health-related foreign and development policies (Reid, page 163). The debate in Australia is at an early stage. The articles that follow highlight many of the key challenges and constraints, but also the promise and potential, of fostering a more inclusive and humane globalisation. Promoting intercountry and intracountry equity, alongside tackling poverty, is consistent with Australian values of a “fair go” and should contribute to multiple desirable and integrally related objectives — promoting health, economic growth, development, poverty reduction, and regional stability (see workshop recommendations, page 166). Read on . . .

Anthony B Zwi MB BCh, P hD, FFPHM · John Wyn Owen CB, MA(Camb) · Alan Ingram MA, PhD

The term “globalisation” tends to be misused and overused. We need greater clarity in our understanding of the globalisation process, including the distinct changes involved and their relation to human health. The health impacts of globalisation are simultaneously positive and negative, varying according to factors such as geographical location, sex, age, ethnic origin, education level, and socioeconomic status. Globalisation is not an unstoppable force. Our key challenge is to create socially and environmentally sustainable forms of globalisation that provide the greatest benefits and least costs, shared more equitably than is currently the case. The health community must engage more directly in current research and policy debates on globalisation and encourage values that promote human health. At the same time, those at the helm of globalisation processes must recognise that attending to health impacts will strengthen the long-term sustainability of globalisation.

Kelley Lee MPA, MA, DPhil

Foreign policy, especially trade policy, can have dramatic but rarely considered effects on public health. International human rights covenants oblige governments to scrutinise their foreign policy, including trade policy, for its impact on the progressive realisation of the right to health. Health is both a means and an end of development policy, but government investments in health are inadequate to reduce health disparities within and between nations. Few donor countries provide the agreed target of 0.7% of gross national income for development aid or toward reaching the Millennium Development Goals. The progressive liberalisation requirement of the General Agreement on Trade in Services (GATS), if applied to commitments in health care, education, and water and sanitation services, may conflict with the progressive realisation obligation of the right to health. Alternatives to regulating trade in such essential services are proposed in this article.

Ronald Labonte PhD

International human rights law affirms that everyone has a right to the enjoyment of the highest attainable standard of physical and mental health. States that are parties to human rights treaties are obliged under international law to observe these rights. Australia has ratified all international human rights law instruments in which the right to health is enshrined, and so is obliged to ensure that its foreign policy, including its development assistance program, contributes towards the progressive realisation of the right to health. International trade regulation should be consonant with the progressive realisation of the right to health globally.

Elizabeth A Reid AO, FASSA