Global health

To the Editor: The human costs of the war in Iraq are mounting. The war has already claimed the lives of about 3000 Coalition service men and women1 and well over half a million Iraqi men, women and children.2 Reports by the United Nations Assistance Mission for Iraq indicate that hundreds of thousands of civilians have been displaced, and that military operations in the country are limiting civilian access to health and education services, food, electricity and water supplies.3 Furthermore, the reports describe a generalised breakdown of law and order in the country, continued growth of militias and organised gangs, and abhorrent human rights violations such as torture in the form of electrical and chemical burns, injury inflicted to eyes and genitals, and wounds from power drills and nails.3 Currently, the Iraqi health system is unable to cope with the health care needs of its population. Iraqi health infrastructure has not escaped the damage or destruction of war. Hospitals lack basic medical supplies such as intravenous fluids, antibiotics, oxygen, disinfectants and bed sheets.4 The precarious security situation in the country has also contributed to a severe shortage of medical personnel. About 25% of Iraq’s physicians have left since the beginning of the war, while those remaining are the targets of violence, intimidation and kidnappings.4 Such an exodus of health personnel has required many of the remaining medical staff to undertake procedures for which they are not qualified.4 Recognising the need for action in Iraq, a workshop was arranged by the International Committee of the Faculty of Public Health, Royal Colleges of Physicians of the United Kingdom, in 2003. The workshop, which included representation from the World Health Organization and the Iraqi Ministry of Health, called for health organisations to be active advocates for improving the health of Iraqis and to provide technical support and assistance to their Iraqi health colleagues.5 Training and professional development opportunities for health staff and the provision of up-to-date health information were identified as specific areas of need in the Iraqi health sector to which health organisations could make a meaningful contribution. In Australia, there has been a small move in this direction, with the federal government providing in-principle support for an initiative to train three Iraqi physicians in emergency surgery. Australian health associations, agencies and professionals need to do more to respond to the humanitarian crisis in Iraq. Carefully coordinated training programs, particularly in the areas of medicine and public health, and the provision of medical aid, resources and information by Australian health organisations, would enhance the capacity of the Iraqi health system to alleviate the effects of war on its citizens. Furthermore, health organisations and professionals need to advocate on behalf of Iraqis, raise awareness of the inadequacies of Coalition government aid, and demand a more effective humanitarian relief effort for victims of the 2003 invasion.

Luke Wolfenden · John Wiggers

Results of studies on the use of antibiotics, alone or in combination with surgery, are encouraging Although Buruli or Bairnsdale ulcer (BU) was described in Uganda, Africa, in 1897, the causative organism, Mycobacterium ulcerans, was only identified in 1948, in Australia.1 Today, the disease has been reported in over 30 countries, mainly in tropical and subtropical regions of Africa, Latin America, Asia and the western Pacific.2 BU is poorly recognised within the medical community, and there is gross underreporting of cases. Australia is the only developed country that has major foci of infection, and BU is now a notifiable disease in the state of Victoria. Over the past decade, the World Health Organization has played a central role in quantifying the problem and bringing together scientists, health experts and funding organisations to increase understanding of the disease, improve management and broaden the delivery of care to patients. There are some differences in BU as it is seen in Australia compared with Africa. Small papular lesions are often seen in Australian cases, and this may not be entirely explained by patients presenting earlier — Australian strains of M. ulcerans produce a slightly different form of the toxin mycolactone.3 Outbreaks of BU in Australia have tended to affect small towns, and patients are usually adults, including the elderly. In Africa, endemic areas are poor rural farming communities, and the average age of affected patients is 5–15 years.4 Although the mode of transmission of infection is still unknown, M. ulcerans has been found in environmental water and water insects, and the epidemiology in both Africa and Australia suggests that people become infected through contact with a contaminated environment rather than with infected people. Much recent research has focused on the role of mycolactone in pathogenesis, and it is clear from animal studies that most of the tissue destruction observed in human lesions is caused by diffusion of this highly toxic macrolide molecule from clusters of M. ulcerans organisms replicating in subcutaneous fatty tissue. This raises the possibility that killing the organism with antibiotics, or even suppressing its ability to produce toxin, may be adequate management. Traditionally, BU is managed by surgical excision of the lesion followed by primary closure or skin grafting. Until recently, antibiotics were thought to have little role in management, despite the fact that M. ulcerans is sensitive to a number of drugs, including rifampicin, aminoglycosides, macrolides and quinolones, in vitro.4 Studies have shown that a combination of rifampicin and an aminoglycoside given to mice with footpad or tail lesions both healed the lesions and prevented recurrences. The combination of rifampicin and moxifloxacin is also effective,5 as is rifampicin alone. However anti-biotic-resistant mutant strains of M. ulcerans can emerge when single-drug treatment is used.6 Findings in animals provide no guarantee of success in humans, but it has now been shown that a combination of rifampicin and streptomycin for a minimum of 4 weeks kills M. ulcerans in early human lesions,7 and longitudinal studies of this combination of antibiotics in all forms of the disease for 8 weeks in Benin, in western Africa, showed that 50% of lesions, including ulcers, healed without requiring surgery.8 Although these results are very encouraging and have led to many physicians in African countries where BU is endemic using antibiotics without recourse to surgery, there have been no controlled trials to validate the treatment. Equally, there are no controlled data on the use of antibiotics together with surgery. The rate of recurrence after surgery is dependent on the surgeon’s ability to guess the extent of infection from the appearance of the lesion, and polymerase chain reaction (PCR) testing of excised tissue has shown that infection extends well beyond the visible margins of disease.9 In this issue of the Journal, O’Brien and colleagues report their experience of managing BU with surgery, antibiotics or a combination of the two.10 The main findings from this restrospective, purely observational study were that antibiotics appeared to reduce the recurrence rate when M. ulcerans was detected in the margin of the excised lesion and when the lesion was large (meaning that skin grafting was needed). The choice of antibiotics was not planned in advance, and depended on the preference of individual clinicians, but rifampicin was included in the regimen for most patients. Interestingly, the recurrence rate in this study was 10% after antibiotic treatment for up to 3 months in patients who had all had their lesions surgically excised, while the recurrence rate after therapy with rifampicin and streptomycin for 2 months in 208 patients in Benin was less than 2% with or without surgery.8 The Australians did not use intramuscular streptomycin in their older group of patients, and found amikacin poorly tolerated. We do not know if their favoured combination of ciprofloxacin with rifampicin adds any bacterial killing benefit, or whether this combination is sufficient to prevent resistance emerging. In the context of a disease that is mainly a problem for children in rural parts of humid tropical Africa, it is no surprise that the approach to management is different in south-eastern Australia where surgery is easily accessible. There is no doubt that more children in Africa are receiving treatment and at an earlier stage of disease now that physicians are offering antibiotic therapy. The opportunity to have lesions excised is available to relatively few of these patients, and they typically present late with large ulcers, both for economic reasons (treatment has a major impact on a family’s finances) and because they fear surgery. Treating large numbers of patients in Benin and Ghana has shown that most lesions become culture-negative after treatment with rifampicin and streptomycin for 8 weeks, and they go on to heal during or after that time.8 The combination of two orally administered antibiotics with powerful bactericidal activity is the therapeutic goal at present, and surgical grafting should only be necessary to speed the healing of ulcers. More work is needed to develop an ideal treatment strategy, in both developing countries and more sophisticated medical settings. The suggested guidelines for diagnosis, treatment and control of M. ulcerans infection in Victoria in this issue of the Journal11 mark a significant step in developing standardised protocols for local use. Although individual doctors in Australia see relatively few cases, if a standard management protocol is followed, considerable experience will be amassed, which may guide future research. It would be useful, for example, to establish whether after treatment with rifampicin and moxifloxacin for 2 weeks before surgery, the excised tissue is culture-negative and the recurrence rate lower. Australians have made major contributions to understanding and diagnosing this disease, and another article in the Journal highlights the role of PCR testing,12 originally developed in Melbourne,13 in tracing the source of infection by means of a PCR-based DNA fingerprinting method. Several new pockets of infection have been identified worldwide in recent years, and while the causes of outbreaks remain obscure, PCR has been a key tool in tracing environmental sources of M. ulcerans, as well as in diagnosis, where it is not only the most sensitive method available (> 90%), but also quicker than all except microscopy for acid-fast bacilli (sensitivity < 50%).14 The challenges now are to make this technology accessible to African countries, and to develop simpler diagnostic tools.

Kingsley Asiedu MD, MPH · Mark Wansbrough-Jones MB BS, MSc, FRCP

A national strategy for meeting the particular health needs of refugees would provide a more comprehensive approach The profile of refugees being resettled in Australia depends on global geopolitical conflicts, representations from the United Nations High Commissioner for Refugees to the Australian Government, and Australia’s response. Recent years have seen an enormous shift within Australia’s annual refugee intake, with 70% originating from countries in sub-Saharan Africa.1 The Australian Government requires those migrating under its Humanitarian Program to undertake certain health checks before being issued with a visa.2 Additionally, since mid 2005, the Department of Immigration and Multicultural Affairs (DIMA) has been rolling out an additional medical check known as a predeparture medical screen (PDMS) in the few days before departure (Kathy King, Director, Special Health Projects, DIMA, personal communication). This medical check was introduced in response to significant numbers of cases of communicable diseases being identified among new arrivals. Conducted mainly by medical staff of the International Organization for Migration (IOM), it is largely a fitness-to-fly check, although it does include screening for malaria, measles–mumps–rubella vaccination, and empirical treatment for intestinal parasites. Although DIMA is expanding the geographical coverage for the PDMS, not all current humanitarian entrants are subject to this screening. In this issue of the Journal, a collection of articles and a letter on refugee health indicate a high prevalence of various conditions among recent refugee arrivals (Chih et al, Outpatient treatment of malaria in recently arrived African migrants; Tiong et al, Health issues in newly arrived African refugees attending general practice clinics in Melbourne; Martin and Mak, Changing faces: a review of infectious disease screening of refugees by the Migrant Health Unit, Western Australia in 2003 and 2004; Cherian et al, Severe Plasmodium falciparum malaria in refugee children despite reported predeparture antimalarial treatment). Some of the data were collected before the introduction of the PDMS, which may have lowered the rate of malaria and intestinal parasite burdens. However, recent experience in New South Wales has been that cases of malaria continue to be detected despite antigen testing overseas. The detection rate for HIV among this previously screened population reported here by Martin and Mak (page 607) is low (0.12%), but is not zero. Further consideration of whether to repeat routine HIV screening after arrival is warranted. Hepatitis B tests are only conducted in a minority of entrants,2 yet this disease has important personal and public health implications. It is apparent that the screening conducted overseas, no doubt under difficult circumstances, remains suboptimal. Additionally, conditions such as anaemia, schistosomiasis and vitamin D deficiency flagged in the articles are, appropriately, not screened for overseas, yet warrant early detection and treatment. At the same time, the risk to the public from various conditions must not be exaggerated, as this is potentially detrimental to attitudes about already marginalised people, as shown by Leask et al (page 591). The fact that refugees have considerable health care needs is well documented, and these needs vary with region of origin and other factors.3,4 Health care professionals in Australia may be unfamiliar with some conditions, and diagnosis might be delayed if these conditions are not detected in their asymptomatic stages through adequate screening. The principles of prevention and early intervention, our existing knowledge about refugee health care needs, and the additional evidence from the articles in this issue of the Journal justify a call for nationally coordinated, comprehensive health assessments to be offered to all newly arrived refugees. This need for comprehensive health assessments was highlighted in a recent report on refugee children.5 However, entire families in this setting have the same requirements, and a family-centred approach is needed. Health assessments must not only focus on infectious diseases, but should take into account the refugee trauma experiences of families and individuals, and assess physical, psychological and psychosocial needs. Sufficient attention needs to be given to oral health, nutrition, undermanaged chronic conditions, and the impacts of violence. Currently, each state and territory has a different model and varying coverage for postarrival checks, as shown by some of the reports in this issue. Some jurisdictions have centralised clinics in public hospital venues, focusing mainly on infectious disease screening (eg, Tasmania, Western Australia). NSW, with an annual intake of 4000 refugees who are dispersed widely across the state, has a state-funded Refugee Health Service with some clinical role but which also supports mainstream health services to assist refugees. Victoria has a different model again, with a focus on general practitioners in community health centres and private practice, supported by refugee health nurses. Sheikh-Mohammed et al (page 594) and Tiong et al (page 602) highlight the important role that GPs play in providing health care services to refugees. However, there are limitations to GPs being able to perform comprehensive assessments, including time constraints, the challenges of using an interpreter over the phone, and the need for specialised knowledge. The release in May this year of a new Medicare item number for refugee health assessments goes some way towards supporting GPs who take on this role.6 Unfortunately, the opportunity to link the release of this item number to targeted GP education was missed at the national level. Indeed, a system of “accredited practices” could even be envisaged, with key GPs linked into, and supported by, clinicians and public health staff experienced in refugee health. As with health care provision to other special-needs groups, there are debates about the need for mainstream versus specialised services.7 In locations with significant ongoing refugee settlement, a mix of models is likely to be needed. Publicly funded clinics offer a number of advantages, including centralised knowledge and strong links with key refugee agencies. Specialised health care services targeting refugees also provide important education and support to GPs and other health care staff. Whatever the model for providing health assessments, newly arrived refugees need help to overcome the barriers they face in accessing health care.8 Increased availability of DIMA-funded case workers and of volunteers will help refugees negotiate our complex health care systems.9 Community education about available health care services is also important. Mainstream health care services must be capable of providing sensitive, culturally appropriate care to these vulnerable groups. At the national level, there are a number of initiatives underway in refugee health in addition to the new Medicare item number. In response to issues similar to those raised in the articles in this issue, the Department of Health and Ageing has, over the past year, convened a working group on refugee health, with representatives from all states and territories. This group has made recommendations to the Australian Health Ministers’ Advisory Council, some of which aim to address issues raised by Tiong et al (page 602). These include the cost of certain medications, such as praziquantel for schistosomiasis, and the limited availability of some vaccines for catch-up schedules. Refugee health is a varied field crossing multiple disciplines and presenting complex issues. The development of a national refugee health strategy would promote greater direction, coordination and standardisation nationally. One aspect should be data collation and monitoring of disease detection prevalence across jurisdictions. National guidelines relevant to refugee health, some of which are already being developed, are required. Finally, although clinicians and others working with refugees do network informally, more formalised networks between these health professionals will aid communication and collaboration across borders.

Mitchell M Smith MB BS, MPH, FAFPHM

The dark storm clouds on the horizon at dusk are typical of the wet season in Sudan. On this particular day, the wind that normally heralds the daily drenching of our compound had abated. It almost seemed it was in reverence to Tik, an 8-year-old Dinka girl, walking home leaning on her father and using a stick to compensate for her stiff-legged gait. A simple leg wound for Tik had translated into 3 weeks of painful muscle spasms as a result of tetanus. After successful treatment with diazepam, antibiotics and nutritional support, she was going home to her tent in the refugee camp. Another tent in the camp sheltered severely malnourished children receiving food and medicine from a non-government organisation in this remote area of war-torn Sudan. Tik returning home after treatment for tetanus (pictured with Katherine Hale) Children like Tik are not alone. At the start of 2005, there were 19.2 million people “of concern” to the United Nations High Commissioner for Refugees (UNHCR).1 This included refugees, civilians who have returned home but still need help, people displaced internally within their own countries, asylum seekers and stateless people. Most refugees are fleeing war, famine or insecurity. Large numbers have recently returned home to Afghanistan, but refugee displacements have actually grown in Darfur, western Sudan. There are almost 7 million and 5 million people of concern in Asia and Africa, respectively.1 Afghanistan, Sudan, Burundi and the Democratic Republic of the Congo (DRC) are the top four countries in terms of numbers.1 Australia resettled about 13 000 refugees in the 2004–05 financial year.2 At least 1500 of these came from large refugee camps in Sudan, Guinea and Tanzania.3 Understanding the conditions in the refugee camps and the medical facilities available before arrival in Australia will help health care providers meet the needs of these new arrivals. Camp conditions and medical servicesRefugee camps are often set up in countries neighbouring the conflict (Box). They can be assembled with little forward planning and virtually no infrastructure. There may be geographical difficulties — the area may have minimal food, water and shelter.6 Health care in refugee camps is provided by local authorities, and may be supplemented by international non-government organisations (NGOs) such as Oxfam or Médecins sans Frontières. Basic clinics provide primary health care and medicine for common acute conditions such as malaria, respiratory infections and gastroenteritis. Diagnosis is primarily clinical, with fundamental laboratory services such as malaria films and tuberculosis smears a luxury. Clinics are run by nurses, clinical assistants (with 2–3 years’ training in medical diagnosis and treatment) or doctors. There may be expatriate staff. Conditions can be very basic and a clinic may consist of wooden support poles and plastic sheeting. Local staff are adept at diagnosing and treating common acute conditions, but have more difficulty with chronic diseases such as diabetes and asthma. For example, in a malaria-endemic area, there will rightly be a low threshold for diagnosing and treating malaria in a febrile child. Limited vaccinations are available in these countries (commonly BCG, oral polio, measles and tetanus toxoid, with others less so). Medications also vary in availability, quantity and quality. However, access to essential medicines provided by the NGOs is life-saving, and advances are being made in the ambulatory treatment of acute severe malnutrition with high-energy protein paste based on peanuts.6 An example from Meheba, Zambia Meheba is a refugee settlement in north-western Zambia. It was set up in response to an influx of refugees from Angola fleeing civil war in 1971. In 2001, the population was about 47 000, most of whom originated from Angola, mixed with smaller groups of Congolese, Burundians and Somalians. Imelda and Jane (pictured with their mother in the clinic at Meheba, Zambia) are 2-month-old twins. They were born in the camp to Mary, who had recently fled unrest in Angola. Mary’s husband had disappeared in the war. Their birthweights were 1.6 kg and 1.7 kg, respectively. Their gestation was unknown, but they were presumed premature. It was Mary’s third pregnancy and she had no antenatal care. Mary received nutritional supplements and the babies were fed expressed breast milk through a nasogastric tube for 6 weeks until they were able to suck adequately. They received close attention to their temperature control, prompt treatment of a respiratory tract infection, and vitamin supplementation. They weighed 2.8 kg and 2.9 kg and were well when discharged. With the death of one of the rebel leaders in Angola, in 2002, peace after three decades of civil war enabled repatriation of large numbers of refugees from Meheba, and its population fell to 13 000 in 2005.5 Health screening of entrants into AustraliaRefugees apply for refugee status at the local UNHCR office. If it is approved, their settlement in western countries, including Australia, is negotiated by UNHCR. Predeparture medical and character checks are mandatory prerequisites for the granting of permanent resettlement visas. A medical examination and the following medical tests are currently performed: Chest x-ray for tuberculosis screening (if over 11 years); HIV serological testing (if ≥ 15 years); Syphilis serological testing (if ≥ 15 years and from a camp); and Urinalysis may or may not be performed.7 The health checks are carried out by panels of doctors and specialists nominated by the Australian Government Department of Immigration and Multicultural Affairs (DIMA) in the country of departure. If the results of these checks are deemed satisfactory, a residency visa is granted and travel arrangements awaited. If a medical problem is discovered, then these entrants are subject to health undertakings, in which specified medical treatment on arrival in Australia is an obligation. Further predeparture medical screening 72 hours before departure for Australia was introduced in mid 2005 for refugees and some sponsored humanitarian entrants departing from eastern and western Africa, Egypt, Sudan and Thailand. It consists of a rapid malaria test and treatment, intestinal parasite treatment and measles–mumps–rubella vaccine if aged < 30 years. This is recorded on an electronic health manifest, which is made available to the local settlement service provider through DIMA.7 The success of this predeparture screening had not yet been fully evaluated. There continue to be anecdotal reports of major medical problems that have been missed (including malaria, HIV, tuberculosis and sickle cell anaemia), and communication to final health care providers (refugee health clinics and general practitioners) of what had been done is inconsistent. The timing and quality of the health checks are also variable. Entrants who have been sponsored by family or friends do not always benefit from the above screening. These entrants are not routinely enrolled into settlement services on arrival and thus provision of health care in Australia may be delayed. ConclusionHere, we have described life in refugee camps and highlighted differences in health care quality between developed and developing countries in terms of conditions, resources, diagnosis, treatment, patient expectations, and sophistication. Predeparture screening can potentially detect important medical problems. Medical providers for refugees in Australia need an awareness of these complex issues.

Katherine Hale MB BS FRACP · Nicholas J Wood MB BS, FRACP · Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci

To the Editor: Predeparture screening and treatment for Plasmodium falciparum malaria is increasingly administered to humanitarian refugees from malaria-endemic areas immediately before resettlement in Australia. It is undertaken by the International Organization for Migration (IOM), under contract from the Department of Immigration and Multicultural Affairs (DIMA).1 Combination therapy (usually an artemisinin derivative in combination with another drug, or chloroquine) is used for both adults and children. The first dose (of what is usually a 3–5-dose treatment course) is supervised, and written documentation of the treatment should accompany the refugee to Australia.1 Giving predeparture antimalarial treatment has the potential benefit of reducing the incidence of malaria after arrival, as well as reducing the risk of local transmission in malaria-receptive areas of Australia. Onshore health assessments are performed in about 80% of humanitarian refugees resettled in Western Australia (A Thambiran, Medical Director, Migrant Health Unit, Perth, WA, personal communication). Between August 2005 and March 2006 — a period of increased offshore predeparture management of malaria (in line with DIMA/IOM policy in response, presumably, to the increasing burden of imported malaria in refugees coming to Australia) — 336 African refugee children were screened on arrival in WA. Thirty-two children (9.5%) with P. falciparum malaria were identified, of whom 20 (10 Burundian, eight Congolese and two Sudanese) had received predeparture antimalarial medications. Eleven children who presented in a 3-week period had all been treated at a single centre in Kenya with pyrimethamine–sulphadoxine and artesunate, according to sighted IOM documentation. Of the remaining nine children, some had transited through countries other than Kenya, but not all had complete documentation. Three children presented with malaria parasite loads ranging from 6% to 14% within 7–10 days of arrival in WA. One child had severe malaria (14% parasite load), was obtunded at presentation and required intravenous quinine therapy and resuscitation. Overall, 15 of the 20 children treated before departure required hospital admission, despite our selective non-admission policy for uncomplicated P. falciparum malaria. No child had long-term sequelae and all had parasitological cure at Day-28 follow-up. Possible explanations for these apparent failures of predeparture treatment include: (i) incorrect documentation of treatment; (ii) poor compliance; (iii) lack of supervision; and (iv) inactive or expired medication. Delays in departure must also be considered at assessment, as these allow potential re-infection — in this cohort, the time between treatment and migration was poorly documented. Subsequent clinical presentation in WA ranged from 24 to 31 days after treatment in Africa (in cases where documentation was available). As all children were not treated at a single centre offshore, these cases are likely to reflect more widespread and multifactorial issues about the effectiveness of predeparture antimalarial management. Another concern is the rise of multidrug-resistant strains of P. falciparum, particularly throughout sub-Saharan Africa and South-East Asia. Combination therapy with artemisinin derivatives is now recommended by the World Health Organization as first-line treatment.2 However, many of the patients in this cohort received treatment with pyrimethamine–sulphadoxine and artesunate, despite reported high levels of parasite resistance.3 IOM protocols are evolving in an attempt to reflect the rapidly changing multidrug-resistance patterns in these malaria-endemic regions.1 A recent Ugandan study reported high Day-28 cure rates with artemether–lumefantrine (despite a relatively complex dosing schedule) because of lower drug resistance.4 These cases highlight the continuing need for comprehensive and timely onshore assessment (including malaria screening), irrespective of predeparture treatment. P. falciparum malaria remains a major global cause of morbidity and mortality — there were an estimated 515 million clinical infections in 2002, with 70% occurring in Africa.5 P. falciparum has a significant case-fatality rate (up to 20% in cerebral malaria6), even when managed appropriately. It results in 1–2 million deaths each year,3 mainly of children, and about 18% of all child deaths in sub-Saharan Africa are directly attributable to malaria.7 Australia resettles more humanitarian refugees per capita than any other nation8 and many are from malaria-endemic regions. Predeparture antimalarial treatment should reduce the number of clinical episodes of malaria presenting within Australia, but the efficacy of this unproven intervention warrants prospective study. Importantly, documented predeparture antimalarial treatment should not distract health care providers from considering this potentially life-threatening infection in a febrile child recently migrated from a malaria-endemic area.

Sarah Cherian · Joanna M Fagan · Aesen Thambiran · Janet Geddes · David Burgner

Five months in Cambodia restored my perspective I knew very little about Cambodia before I landed at the airport in Phnom Penh. I imagined luminous green rice paddy fields, smiling brown faces, and the perfect antidote to my disillusionment with medicine after only 2 years working in the Australian public health system. My medical resident jobs had seemed to require more secretarial ability than clinical skills, and hours were lost begging for an urgent investigation or trying to secure an outpatient appointment within the next 6 months. I wanted to witness the power of basic medical treatment — to save lives with a course of penicillin, to save sight with a few doses of vitamin A. I had teamed up with a small Australian non-government organisation called Awareness Cambodia and agreed to take on the task of establishing an outpatient medical clinic in the rural province of Kampong Speu. I had 5 months in which to do it. The van ride into Phnom Penh from the airport was enough to trigger a surge of panic as I tried to digest a series of confronting images. A mother clutching her very young baby with one hand and, with the other, manoeuvring her motorbike through a sea of traffic; a barefoot boy with a swollen belly, his naked younger brother in tow, begging at a busy intersection; pre-pubescent girls in make-up and pyjamas loitering outside ramshackle wooden brothels. The brutal realities of living in a developing country hit me hard in the face. The next few weeks were spent doing the necessary groundwork around Phnom Penh and Kampong Speu, visiting the local hospitals and established clinics. From what I could see, a bed in a public hospital was no more than a bed in a cheap guesthouse. Only the intensive care unit had any equipment — a few oxygen tanks and perhaps one functioning cardiac monitor. To my horror, I discovered that it was not uncommon to use blocks of ice for postoperative analgesia (applied, for example, directly over a patient’s midline abdominal wound), and that, because of sheer lack of staff, the patient’s families performed almost all of the nursing duties. Hospitals run by foreign non-government organisations were so overloaded that patients would literally have to win a lottery to receive care in these hospitals. In the clinics I attended it was rare to see a doctor listen to a patient’s chest before prescribing three antibiotics for a chest infection, and intravenous (IV) drips were consistently the favourite therapy among Cambodians, who believed that they could cure anything from a headache to a sore toe. It was not unusual to see an IV pole protruding through the window of a passing car, or held up by a devoted parent as the family rode home on their trusty motorbike. In a corner of Phnom Penh, I discovered a network of pharmacies stocked wall-to-wall with the latest broad-spectrum antibiotics and a never-ending stream of patients buying them, without prescription. In the countryside, Western doctors had to compete with village doctors, some of whose remedies were like something out of a bad fairytale. A colleague told me that she asked why a child in one village had a glass eye and was told that the eye had been used in a concoction to cure the child’s mother of a serious illness. I personally remember a woman with scabies who was non-compliant with the standard topical permethrin treatment, opting instead to pour hydrochloric acid on her wounds to take away the itch. I faced different problems in my interactions with the government health centre that we planned to work with. The centre appeared to have all the fittings required for a clinic, including a wealth of power outlets, light fittings and taps, but there was no electricity or running water. Instead of being glad that we were providing doctors and free medicine, our initial proposal for a fortnightly outpatient medical clinic for the villagers in Kampong Speu province was met with hesitation because of fears that it would increase the workload of the health centre staff. As they only earned US$18 per month, out of necessity, they ran their own private clinics in the afternoon. We ended up having to supplement the government workers’ salaries before we were allowed to provide our free service to the villagers. To save myself from jumping on the next plane back to Australia I had to focus on small goals and achievements. I began to take pride in our clinic and the fact that when we examined patients we spent a good 10 minutes with them, instead of the usual 2 minutes. We checked people for anaemia with simple laboratory tests, and we gave them vitamin supplements and treated them empirically for worms — but it was a far cry from what I had imagined. The sickest patients, who needed our help the most, were the hardest to treat. A 21-year-old man with pancytopenia readily comes to mind. We referred him to the local hospital because he could not stand up and was bleeding from his gums. But his family could not afford the blood transfusions he needed, let alone the hospital costs and the further investigations required. He ended up relying on herbal remedies and died six weeks later. It was not uncommon to find families falling deep into debt trying to save their loved-ones, often to no avail. Other families would put their sick relatives in a hut on the outskirts of the village and leave them there to fend for themselves — out of sight, out of mind. Nothing was easy. If we decided to refer a patient to the local hospital or to Phnom Penh, we needed to spend the next few hours working out the logistics of finance for transport, meals, compensation for lost income, and a carer for the six or seven children left behind. Ethical dilemmas emerged on a daily basis. An elderly woman presented with fatigue and occasional per rectal bleeding and, on examination, was slightly pale. In Australia she would have been on the next colonoscopy list. In Cambodia this would mean a long trip to Phnom Penh to the only public hospital that performed colon-oscopies. But who was going to pay for the colonoscopy? And, more pertinently, what would we do if we found something? Was it ethical to submit an otherwise well 70-year-old woman to an abdominoperineal resection or partial colectomy when she might not survive the operation? Was it worth sending her family deep into debt? Or was it more ethical to treat her anaemia with iron tablets and improve her quality of life? Working in Australia was beginning to seem like a dream. But having said all this, I will never forget one woman’s smile as we helped to secure an operation for her granddaughter’s cleft palate, and I still treasure the bowed thanks from the villagers for making them feel better, if only by turning up every week, listening to their problems and giving them our time. My 5 months in Cambodia may not have unfolded as I expected, but I do not regret it. I learnt that I am lucky to live in a country where I, and my patients, have access to free health care and where I can practise medicine with the knowledge that there are good referral systems in place. I thought I would go to Cambodia and change people’s lives, but instead when I went there it changed mine. The experience gave me perspective, not only in my medical practice but in all aspects of my life. My time in Cambodia has helped me see an abundance of resources and opportunities that I couldn’t see before.

Melanie Cheng MB BS

Objectives: To determine the impact of the Australian provisions for temporary rather than permanent protection for asylum seekers found to be genuine refugees.Design and setting: A comparison of the mental health of Persian-speaking refugees with temporary (n = 49) versus permanent (n = 67) protection visas attending an early intervention program in Sydney, New South Wales, 2002–03.Measures: Standard measures were used to assess past trauma, detention experiences, postmigration stresses, symptoms of post-traumatic stress disorder (PTSD), anxiety, depression and functional impairment.Results: The two groups had experienced similar levels of past trauma and persecution. Nevertheless, holders of temporary protection visas (TPVs) returned higher scores on three psychiatric symptom measures (P < 0.001). Multivariate analyses showed that TPV status was the strongest predictor of anxiety, depression and particularly PTSD. Further analyses suggested that, for TPV holders, experience of past stresses in detention in Australia and ongoing living difficulties after release contributed to adverse psychiatric outcomes.Conclusions: The sequence of postmigration stresses experienced by TPV holders appears to impact adversely on their mental health.

Shakeh Momartin PhD, BA(Hons) · Zachary Steel MPsych(Clinical), BA(Hons) · Marianio Coello MPsych(Clinical) · Jorge Aroche MPsych(Clinical) · Derrick M Silove MD, FRANZCP · Robert Brooks PhD, BA(Hons)

Australian doctors have a particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions Most people in the scientific community believe that global warming is occurring, and that it will cause dramatic changes in climate patterns, with potentially serious effects on human health in the form of widespread epidemics, trauma, malnutrition and, in vulnerable areas, famine.1,2 The special danger to children has been stressed.3 Recent observations on the shrinking Antarctic ice mass suggest that the pace of these changes far exceeds that previously predicted.4 There is now little contention that global warming is largely the result of carbon dioxide and other greenhouse gas emissions resulting from human energy consumption,2 and that these effects are just within reach of reversal only if worldwide emissions are rapidly stabilised. Medical debate about global warming has so far emphasised planning and response.2,5 It is therefore timely that we draw a parallel to medical involvement in the nuclear weapons disarmament movement in the 1980s. At that time, it rapidly became clear to physicians that civil defence planning for a medical response to nuclear weapons attack was not only futile, but dangerously counter-productive because it fostered a false community belief in a medical fix, thereby reducing the political incentive for preventive action. A remarkably unified international medical response helped turn political attention to prevention of accidental or intentional use of nuclear weapons through political initiatives. Economic factors may have ultimately secured the end of the Cold War, and nuclear weapons have not disappeared. However, the influence of the Nobel Peace Prize-winning organisation, International Physicians for Prevention of Nuclear War, was significant in the withdrawal from the brink of catastrophe, particularly because its protagonists had the ear of both United States and Soviet leaders.6 Doctors now have a similar particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions. Firstly, we can point to the futility of expending our energy, enterprise and long-term investment in advancing health care in the absence of action to preserve a liveable planet. Secondly, we can measure and communicate the effects of the threat of global environmental destruction on the current mental health of our children. At the height of the Cold War, when nuclear war appeared imminent, through accident or pre-emptive strike, school children reacted with despair and loss of motivation.7,8 Many children thought they would not survive to adulthood. We can actively contribute to the debate on global warming by providing good data on this specific issue, but the nuclear weapons experience suggests that our children and grandchildren will react to expanding knowledge of climate change with despair. Thirdly, we are in a strong position to draw attention to the psychology of denial, despondency and paralysing helplessness that characterises human response to the threat of overwhelming catastrophe.9 We can help professionally in the educated and rational process of action that can reverse this paralysis, pointing to the astounding historical successes that can result when an active community converts hopelessness into anger and political action. The abolition of slavery and the end of apartheid are just two examples. In each case, the central humanitarian principles that underpin medicine were guiding principles for those who went into the battle for change, in both cases against seemingly insurmountable economic odds. Australian doctors have a special responsibility because of the influence of Australia in Asian, American and European discussions on reducing green house gas emissions. We can inform the debate with reliable data on the mental and physical health consequences of global warming, and use our professional voice and leadership to instil it with urgency.

Richard F Kefford MB BS, FRACP, PhD

Third World health. Hostage to First World wealth. Théodore H MacDonald. Oxford: Radcliffe Publishing, 2005 (xi + 297 pp). ISBN 1 85775 769 6. There has probably never been more interest in Third World health than there is now. And there has probably never been a greater appreciation of the causes of Third World illness, and the interrelationship of these causes with First World wealth, trade and politics. At times, there also seems to be First World political will to do something about it all — but that soon peters out. Any book that starts with a glowing endorsement from Archbishop Emeritus Desmond Tutu deserves serious attention. What really works about this book is the mixture of personalised case studies, with a serious, rational and evidence-based exploration of data on such macro issues as trade deficits, World Bank loans and multinational companies’ trade practices. The link between Sath, a 27-year-old Cambodian woman who we meet on the first page, and who dies in complicated childbirth, and structural adjustment, the International Monetary Fund, the Group of Eight and (dare I utter it) globalisation, is made explicit. While there may be little in this book that is new to the serious student of these issues, what is provided is a thoroughly comprehensive review and explication of the issues. The writing is clear and accessible, although I rapidly tired of the use of “etc”. From personal experience through travelling and talking to colleagues working in the Third World, there seems to be little positive progress in terms of turning back the tide of poverty, illness and economic stagnation. In many ways governments have failed, as have United Nations agencies. Now it seems to be the turn of the mega-philanthropists; witness the work of the Gates Foundation and the Ellison Institute. Only time will tell whether they make any difference. At a time when the world is richer than ever before, there are more acutely poor people than ever before, and this is clearly a deep tragedy. At least we can continue to try to understand the multiple, complex and interrelated reasons for it, and try to do something about it. David WilkinsonDeputy Head of School, Professor of Primary Care, University of Queensland, QLD

David Wilkinson

SARS. How a global epidemic was stopped. World Health Organization. Geneva: World Health Organization, 2006 (x + 307 pp). ISBN 92 9061 2134. The title of this book suggested to me that it might well be a self-congratulatory review by an organisation trying to claim credit for stopping a brief but frightening epidemic in its tracks. The fact that it was published by the World Health Organization also led me to believe that it might be a dry chronology of events and difficult for the average medical reader to penetrate. So I was pleasantly surprised to find that I enjoyed reading SARS and that facts are presented in a balanced manner. The best feature of this book is that it presents a worldwide phenomenon in easy-to-read prose, with excellent diagrams, pictures and tables, in just over 300 pages. There are detailed accounts, with expert content from each region. In particular, judging from my personal experience, the account from Hong Kong is accurate and concise. The authors start and finish the book by commenting that the lessons learnt from the SARS (severe acute respiratory syndrome) epidemic have not been analysed and promulgated widely enough. This is a view with which I strongly concur. Surveillance and control measures, the process of developing new tests and vaccines, clinical management of unknown viral conditions, and adoption of evidence-based infection control procedures were areas of controversy during the epidemic. The different approaches taken by different groups give important insights and should help guide us in planning for the next epidemic. The reality is that we are still not sure where the SARS epidemic came from, how it spread rapidly sometimes and not others, and why it disappeared completely after only a few months. We do know that many lives were saved by a swift, well coordinated global response, limiting the number of cases and confining the epidemic to just a few regions of the world. This is a great book for anyone interested in the SARS epidemic (or future pandemics) wanting a balanced, well referenced, accessible and concise summary. Peter A Cameron Head, Pre-Hospital and Emergency Trauma Group, Alfred Hospital, Melbourne, VIC

Peter A Cameron

They call it the “Rat Village” — a small community of 17 families in south-eastern India’s Tamil Nadu province, which gained its unenviable name as a consequence of dietary necessity. Indirectly affected by the Boxing Day tsunami of 2004, Vadapattanam has no claim to receive help from government organisations. With no employment, no income, no funds for schooling and no aid, the people of this small village captivated us with their resilience, optimism and friendship. The rat catcher uses a small earthen pot stuffed with dry wooden debris. A small fire is started inside and the mouth of the pot is aimed towards the rats’ burrow. By blowing through a mouthpiece at the opposite end, a steady stream of smoke is forced into the rats’ sanctuary, eventually suffocating them. The burrow is raided not just for the meat within, but also the rice that the rats have sequestered from nearby paddies. These are the staple foods of Vadapattanam, one small meal a day sustaining the residents. One month volunteering as a doctor with the non-government organisation Earthaid introduced me to this community and many similar ones. Earthaid’s post-tsunami relief efforts are concentrated on several small communities that were devastated by the disaster but do not meet the criteria for receiving foreign donations. This village never saw the rising water and no one drowned. However, the occasional employment from farmers and nearby villages that they relied on for income dissipated with the destruction caused by the tsunami. Five months later, most villages directly affected by the tsunami have received government relief and are faring well with adequate food, access to health facilities and a higher than ever proportion of children attending school. Villages like Vadapattanam, which was indirectly affected, are still suffering. Vadapattanam would be described by a real estate agent as “rustic”, consisting of 20 clay huts with thatched roofing on one side of a dirt track and a small, stagnant backwater lake on the other. This water is shared by villagers for bathing, attempts at catching seafood, toileting, and the washing of clothes, vegetables and rice. A shallow bore providing precious, unsalinated drinking water is only a kilometre away and, thankfully, separate from backwater run-off. On a typically stifling, hot, pre-monsoonal afternoon, we were dropped off by our driver for the first time on the dirt road that ran alongside Vadapattanam — one nurse, one doctor, an Indian translator, six large bottles of drinking water and a suitcase stocked with precious donated pharmaceuticals and other basic medical provisions. We were provided with mats in a shady area where we spent the next few hours assessing the community and providing basic medical aid. Our first patient was the village head, who had an open fracture of his middle finger on the dominant hand, sustained a month previously. The finger was almost as wide as it was long, green with frank pus and excruciating just to look at. He seemed impervious to the pain but genuinely concerned that it was preventing him from attending to his normal working activities within the village at its most desperate time. After being slightly miffed that we couldn’t fix his finger on the spot, he gave us an interesting history of Vadapattanam and an insight into the villagers’ way of life and their current problems. The villagers of Vadapattanam are descendents of Indian tribes who were once famed for cultivating herbs and producing traditional medicines. This industry was gradually lost over generations, with displacement. In more recent times, occasional woodcutting and farmhand jobs have provided a meagre income. After the tsunami, the loss of sporadic employment meant things got worse very quickly. Regular meals ceased and education became unaffordable. The ailments seen by the mobile medical clinic over the next month were generally infectious or traumatic in nature, with Vadapattanam the only village in the area to have obvious nutritional deficiencies. Not surprisingly, given the poor community knowledge about links between poor hygiene and disease, typhoid fever was present and parasite infestations seemed ubiquitous. One young patient dutifully self-diagnosed his intestinal infestation by coughing up a sample of his resident worms. Skin infections (scabies, fungal infections or infected wounds) and otitis media and externa were also relatively common, particularly in the children. Occasionally, we encountered infectious diseases interesting enough to excite a microbiologist, including filariasis, malaria and leishmaniasis. A large component of the mobile clinic’s time was allocated to community health education on issues such as hygienic toileting, safe methods to prepare water for drinking and washing of food, methods of transmission of intestinal worms and typhoid fever, and many other topics aimed at disease prevention. All the villages we were involved with seemed keen to adopt our recommendations, and in Vadapattanam, after one particular education session, separate areas for toileting and washing of food were introduced immediately. While food donations and mobile medical clinics from non-government organisations help in the short term, they are not sustainable and do little to encourage self-sufficiency. The other arms of Earthaid address these issues by attempting to place children in education and train the adults in income-producing activities. On initial assessment, the most senior villagers in Vadapattanam expressed a strong desire to return to the industry of their ancestors. It was difficult not to be impressed by the motivation and determination of this community. In partnership with another non-government organisation and after appropriate soil testing, funds were set aside to purchase land on the opposite side of the backwater to be used for cultivating herbs and vegetables. Equipment for working the land and the initial crops is being organised, and education sessions by experienced farmers have begun. With these major hurdles breached and with some good fortune in weather patterns, the community of Vadapattanam will hopefully be less reliant on outside help in coming years. However, in the short term, necessities remain unaffordable and need to be provided by outside aid agencies. A gift of 16 goats and a regular, once-weekly rice donation were organised by Earthaid to address the immediate food shortage. The children have also been provided with tuition fees, bags, schoolbooks, and footwear for the 2-kilometre walk to school. With further short- and long-term support, it is hoped that the village of Vadapattanam will once again begin to deserve its currently ironic name, “vada” meaning “food” and “pattanam” meaning “town” in the local Tamil dialect.

Rohen White MB BS

The Indian Ocean tsunami of 26 December 2004 has drawn attention to the need for a process to ensure that health aid is provided in an efficient, coordinated and appropriate manner. In response to this, and with support from various medical colleges and the Australian Government, we have established the Australian Health Alliance to Assist with Post-tsunami Reconstruction. In Sri Lanka, some of the current challenges include shortages of medical staff, damaged infrastructure and changing demands due to population shifts. Psychological services are particularly scarce. The psychological and cultural implications of disaster require specific attention when designing aid programs. The goals of the Health Alliance include providing a forum for discussion, identifying specific local needs, coordinating health services and helping local organisations to develop action plans.

Paul A Komesaroff MA, PhD, FRACP · Suresh Sundram PhD, FRANZCP

Taking a risk and embracing opportunities may yield unexpected benefits I didn’t really know back then why I had to go, but something within me was pushing, and so, I went. I grew up in the United Kingdom and trained there in medicine. During my internship, I realised that I wanted to go to Africa for what were, then, a variety of ill-formed reasons. They included travel, adventure and an attraction to the notion of mission doctoring — doing “everything” while working in an underserved community. Without doubt I was, in part, naïve, but in 1987, straight after internship, I was on my way to Jane Furse Hospital in the black South African “homeland” of Lebowa, 3 hours’ drive north of Johannesburg. It was only later that I learned I had been employed after the other hospital doctors had left because of local violence. Vignette 1: the changing colours of Africa Awake. My first morning in Africa. The night before, my journey from the airport to the hospital had been a nightmare. In a decrepit truck, with companions who spoke no English. On rough roads, in a dense darkness the like of which I had never experienced before. It had taken hours and I had never felt more alien in my life. The scene that next morning, as I wandered across the mission hospital campus, is etched in my mind. The very light itself was different. A cloudless blue sky. Deep red earth carpeted with purple flowers that had fallen from the jacaranda trees. The pinks, purples and reds of the bougainvillea. And, of course, the smiling black faces of the nurses contrasting with their radiantly white uniforms. Yes, this was where I needed to be. I recall having said at my medical school interview that I wanted to do medicine because it offered me the opportunity to help people less fortunate than myself. I’m still not sure who cringed more — me, or the interviewer — but I did mean it. I enjoyed medical school and my internship in a district hospital in northern England, and had been accepted into a general practitioner training program in the Midlands. But first of all I was going to do a year in Africa. Vignette 2: on practising “grass roots” medicine Vusi was 22 years old and had been caught stealing. He was brought into our rural district hospital in poor shape, with a spear through his abdomen and lower chest — some punishment. However green I may have been, I was the only doctor available and so, with help from the nurses, I stabilised him in the emergency room before moving him, as quickly as possible, into theatre. I knew there were only two units of blood in the hospital that weekend. I intubated and anaesthetised him and handed over his care to the student nurse on duty. Then, scrubbed up and with a theatre nurse assisting, I opened his abdomen and repaired multiple small and large bowel lacerations and a liver tear. Vusi left hospital a week later and, in subsequent years, I was often greeted cheerfully by him as I moved around the village. Members of a local church celebrate the opening of a new clinic I had gone to Africa against the advice most teachers and mentors provided — “too risky”, “bad for your career” and “go later, do your training first”. But I went, and after a year I knew that if I wanted to make a real difference, to do something meaningful, to give, then I needed to stay. It seemed to me that those who only stayed for a year or two took more than they gave. I stayed for 12 years and regret not a moment. I gained extraordinary clinical experience, as the workload was so high and we had so few doctors. Within 18 months of arriving, I recall noting that I had seen almost every fracture covered by my orthopaedics textbook — and had become adept at their conservative management. I gave of my limited clinical training and skills, and I received more in return by way of experience. By staying on, as I learned more and more I was able to give more. Always, I received yet more in return. Vignette 3: from patients to protocols and programs Mhlambe watched me, disinterested, with a dull, glassy stare. Eighteen months old but very underweight, he had all the stigma of kwashiorkor — peeling skin, oedema, and thinned red hair. He had the worst type of malnutrition, kwashiorkor plus marasmus. Malnutrition was our second most common paediatric problem (gastroenteritis was the most common). Mhlambe prompted me to develop an evidence-based protocol for the management of malnutrition in place of the previous ad hoc approach, and mortality rates fell as a result.1 A few weeks later, Mhlambe was discharged well and went on to be treated for tuberculosis through another newly developed community program. He finished treatment successfully and his mother became involved in a women’s group developing a vegetable garden and making crafts, helping to address the underlying cause of Mhlambe’s admission — poverty. I spent most of my time at Hlabisa Hospital in KwaZulu-Natal, perched on top of a ridge looking down across the plains to massive forested sand dunes and the Indian Ocean coast. It was a 450-bed hospital with 10 000 annual admissions, serving a population of around 250 000. Usually we had about five doctors, sometimes up to around 10. At times, I was the only doctor available. Vignette 4: evolving research A lazy Saturday morning spent mulling over the events of the week. Obstetrics had been busy that week — I had done 15 caesarean sections, two vaginal breach deliveries and had successfully managed a shoulder dystocia. But I had also signed six stillbirth certificates on Friday. None of the bereaved mothers had been seen antemortem by a doctor and I could still hear their wailing. Something was not right. I wandered over to the obstetrics ward and made a list, from the maternity register, of all the perinatal deaths I could find in the previous 3 months. Then, on to the medical records office where I could obtain and examine the records of these deaths. I estimated the perinatal mortality rate to be about 60 per 1000 (about 10 times higher than the best in the UK at that time). Most of the cases had never been seen by a doctor and it was obvious that at least a third were associated with an error or omission in care. Without knowing it, and with no training, I was doing some health systems research. In response to my findings, I wrote some simple protocols, developed a training program for midwives and doctors in the hospital and village clinics, and visited all clinics monthly to implement the protocols and support the staff. I was doing public health medicine. Within a few months, perinatal mortality was significantly down and hardly any deaths were classed as avoidable. Most importantly, we embedded the changes into routine practice, disseminated our results through publication, and helped others implement similar programs.2,3 Completing one of the 2000 caesaean sections I did during my 12 years in Africa. It soon became obvious to me that clinical services, although very necessary in this environment, were insufficient if the goal was improved population health outcomes. Organisation, systems, processes, an evidence-based and protocol-driven approach to care — all within a population health ethos — are crucial too. In reality, there is no divide and distinction between clinical medicine and public health; each feeds off and complements the other. As we organised and strengthened the clinical service, so we organised and strengthened the community services. We worked hard to integrate the hospital with the clinics, and so to develop a truly engaged service. We also worked hard on priority, high burden diseases such as tuberculosis,4-6 sexually transmitted infections and HIV/AIDS. Vignette 5: engaging the community Petros, thin as a rake, was coughing, bent over, almost retching with the effort. We saw hundreds of cases of tuberculosis each year; the incidence had risen dramatically as the prevalence of HIV increased. A simple audit showed that only about 20% of diagnosed TB cases could be shown to have completed the prescribed 8 months’ course of treatment. Clearly, the practice of 4 months’ hospital admission followed by 4 months’ treatment through the village clinics was not working. First, we adopted a shorter and simpler 6-month drug regimen with admission for only 2 weeks. Then we developed community-based, directly observed treatment using village clinics, with community health workers and a wide range of lay people as supervisors. Documented treatment completion rates rose to over 80%.4 The benefits of community participation included managing an ever-increased disease burden, at lower cost, and with much improved outcomes.6 I went to Africa on an impulse and against all advice. In all honesty, I considered that I was a risk and had very little to give. But I gave what I could — myself, my time, and my commitment. I received so much more in return — extraordinary clinical experience and skills, a deep appreciation of the importance of public health medicine, a range of opportunities to develop clinical, research, and leadership skills, and the privilege of meeting a wide range of fascinating people. Research based on my observations blossomed and, over time, I published more than 100 papers. Seven years ago, I came to Australia as new opportunities and challenges presented themselves. Aspects of the transition were hard, while others were easy. My African experience certainly eased meeting the responsibilities of my appointment as Foundation Chair in Rural Health at the University of Adelaide, where I was instrumental in establishing the Department of Rural Health and the Rural Clinical School. There followed a stint in senior university management, and I am now preparing to take over as Head of the School of Medicine at the University of Queensland at the end of 2006. However, every 6 months I return to Africa to foster my ongoing research there, and for some reason it always feels like going home.

David Wilkinson MB ChB, PhD, DSc

Osman Mansoor,* Nick Wilson† * Public Health Physician, Public Health Consulting Ltd, Wellington, New Zealand; † Senior Lecturer, Department of Public Health, Wellington School of Medicine, Otago University, PO Box 7343, Wellington South, New Zealand. nwilsonATactrix.gen.nz To the Editor: How marvellous to see the recent editorial by Zwi and colleagues on Australian overseas aid.1 They elegantly (and disturbingly) make the case for increasing development aid, and more specifically, for AusAID support of health programs. They suggest investments are needed in health and education primarily because we care about other people. But there are many other reasons (including enlightened self-interest) for Australia and New Zealand to increase health development assistance, especially in the South Pacific region.2 One reason for reluctance of donors to provide aid is concern that the aid will not be effective or sustainable. Therefore, we would like to briefly report about a joint Australian and New Zealand aid project that has not only been very successful and effective, but has probably saved the taxpayers of both countries millions of dollars in future costs. The two countries jointly funded a 5-year Pacific hepatitis B project that successfully integrated hepatitis B vaccine into the immunisation program of 10 Pacific island countries. The project provided technical support and 5 years’ funding for hepatitis B vaccine on a reducing scale: from 100% (1996–1998) to 75% (1999) to 50% (2000). Since 2001, the Pacific island countries have taken over the funding of hepatitis B vaccine (as they do for the other Expanded Programme on Immunization vaccines). Thus this short-term intervention has provided sustainable gains in hepatitis B control in the Pacific — one of the areas with the highest rates of hepatitis B infection in the world. An initial evaluation in four Pacific island countries demonstrated reduced transmission as a result of the project. For these four countries, the program was estimated to have reduced chronic hepatitis B virus (HBV) infection among preschool children by 81% (95% CI, 69%–88%), with an estimated cost of US$190 per premature death prevented.3 Reducing HBV transmission in the Pacific is likely to reduce disease transmission in Australia and New Zealand (associated with travel movements and migration). But it will also affect health services, as some people born in Pacific island countries will either become long-term residents of these developed countries or travel there for specialist care. The cost of a single case of chronic HBV infection to a developed country’s health services is likely to cover several years of vaccine cost for many of the smaller Pacific island countries. In summary, Australians and New Zealanders should be proud of this particular project. It supports Zwi and colleagues’ call for much more investment in development assistance in health.

Osman Mansoor · Nick Wilson

Stephen E Cains Medical Director, The Fred Hollows Foundation, Locked Bag 3100, Burwood, NSW 1805. scainsAThollows.org To the Editor: I read with interest the personal perspective by Baker, describing her recent visit as part of an ophthalmic surgical team.1 Such teams from Australia have a long and creditable record of service in the Pacific, and their work has been of great value to the people in the countries involved, and of considerable personal satisfaction to those who have taken part in them. The experience of ophthalmic surgeons working with The Fred Hollows Foundation in developing countries certainly confirms Baker’s observations that the density of the cataracts found in these circumstances commonly makes them unsuitable for phacoemulsification. This does not, however, lead to the conclusion that modern small-incision surgery is not suitable for cataract patients in the developing world. Sutureless small-incision cataract surgery (SSICS) by manual means has been practised in many parts of the developing world for many years, with a range of techniques being used to extract the nucleus without phacoemulsification.2,3 Such techniques have been shown to give better uncorrected vision when compared with standard extra-capsular surgery, and are quick4 and economical, with fewer problems requiring follow-up than extracapsular surgery.5 The Fred Hollows Foundation, along with many other non-government organisations and authorities, is actively teaching and promoting the use of SSICS in its programs as the operation of choice for cataract extraction in the developing world. In light of this, I was surprised to see mention of the introduction of phacoemulsification to the Solomons by the team. Not only is this procedure not suitable for a large proportion of the presenting cataracts, but the cost of equipment and consumables in phacoemulsification is several times that of SSICS, and the time taken for surgery is often longer. In an environment where people suffer vision impairment simply from lack of glasses, and where surgeons are available who can perform modern small-incision sutureless cataract surgery, I wonder if this is an appropriate technology to introduce to the region.

Stephen E Cains

John L Szetu Ophthalmologist, Vanuatu National Eye Care Program, Port Vila, Vanuatu. fhfvaneyeATvanuatu.com.vu To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program. The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”. Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs. The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara. Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams. Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner. Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.

John L Szetu

Michelle L Baker,* Geoffrey T Painter† * Resident Medical Officer, Neurosurgery Department, Royal Melbourne Hospital, 46-58 Drummond Street, Carlton, VIC 3053. † Ophthalmology Coordinator, Royal Australasian College of Surgeons Pacific Islands Project, Melbourne, VIC. michellelouisebakerATyahoo.com In reply: Despite increased efforts over the last decade, the burden of blindness due to cataract is still immense. With over 18 million people in the world blind because of cataract1 there is an obvious need for an affordable and efficient cataract surgery technique. We agree that sutureless small-incision cataract surgery (SSICS) does have an important place in cataract surgery in the developing world. It has advantages over extra-capsular cataract extraction (ECCE) in the longer term, such as decreased cost,2 reduced astigmatism and decreased surgery time.3 There is increasing interest in SSICS among Australian ophthalmologists, and instruction courses are to be held at the forthcoming Royal Australian and New Zealand College of Ophthalmologists meeting. On the other hand, SSICS can be more difficult to learn, and for inexperienced surgeons, there are risks of complications when it is used for a bulky dense cataract.3 ECCE is continuing to evolve, with modern surgical blades giving significantly shelved wounds, which are potentially safer and require fewer sutures, and still has a place. In the Solomon Islands, ECCE and SSICS are the predominant techniques because phacoemulsification is unsuitable for most patients as their cataracts are too dense.3 SSICS was used successfully for suitable cases by Szetu, who is very experienced in the technique. The phacoemulsification machine was brought to Honiara to perform vitrectomy (which the machine is capable of) for diabetic retinopathy in patients who otherwise would have needed expensive treatment in Australia. Phaco-emulsification was purposely used only as a trial (hence, in only three patients), but in the subsequent Pacific Islands Project (PIP) visit, six children with congenital and traumatic cataracts were successfully treated with with phacoemulsification/lensectomy and the insertion of folding intraocular lenses (these were six of a total of 260 operations). In this group it is an ideal technique.4 Currently, it is sustainable to use phacoemulsification because of generous donations. With the advent of low cost phacoemulsification machines (as presented at the Australasian Society of Catar-act and Refractive Surgeons conference in Broome in 2004) and low cost disposables, it is likely the technique will be increasingly used when the backlog of dense cataracts are reduced. Phacoemulsification is the accepted standard of care for cataract surgery in the developed world,2 and there are valid reasons for introducing it into developing countries. Professional development is important, and we must consider the aspirations of our colleagues; the appropriate introduction of phacoemulsification can aid this. We are pleased to hear of Szetu’s return to Honiara, and are sure this technology will have a small, but useful, place in his clinical practice in the future. We cannot agree more strongly that so-called “medical tourism” is wrong. It provides no significant benefit to the community and is disruptive, unhelpful and is, at worst, a burden to the local medical and nursing staff. Unrequested, unhelpful and short-term visits should not be undertaken. The PIP was specifically set up to avoid the abovementioned problems by providing aid that was substantial and well funded (by AusAID), and teaching trips to countries that have made specific requests at the government level for assistance. Such assistance is provided only with the total cooperation and support of local ophthalmic staff, and is run to the highest standards by experienced and committed volunteers. It has been well received in all Pacific countries visited. Ultimately, PIP was intended only as a transitory phase in Pacific development and, as each country achieves self-sufficiency through infrastructure development, visits will be scaled down. We are looking forward to the Solomon Islands regaining the place it once had in Pacific ophthalmology before the civil unrest, and look forward to continuing to help develop the Eye Department in the years ahead. We hope that the close to 1500 operations the PIP team have performed over the eight visits since 2000 have been of help during this troubled time.

Michelle L Baker · Geoffrey T Painter

Millennium Development Goals for the world’s poorest nations need to be matched by Health Priority Goals for prosperous nations, to relieve the burden of wealth-related disease We have a set of clear and challenging goals — the Millennium Development Goals, adopted by the United Nations in 2000 — to improve the health of the poorest 760 million people on earth,1 but none for health development for the rest of us, and it is time that we did. Twelve per cent of the world’s population, inhabiting 50 countries, live on US$3 a day or less.2 Four and a half billion people live in less impoverished circumstances in Asia (excluding Japan), Latin South America, the Caribbean and some of Africa.1 Their countries have built the economic, legal and political infrastructure to attract investment, and they have achieved prosperity through the commercial, industrial and financial processes of global market participation. Birth rates and infant mortality have fallen, life expectancy has risen, and infectious diseases have been brought more or less under control. A further 1.2 billion people live long and prosperous lives in economically sound nations. Let us call these three groups Worlds A, B and C. The health needs of World A are those of people caught in desperate poverty, where infant and maternal mortality is high, infectious disease is out of control, and essential medical care for readily cured life-threatening illness is hard or impossible to obtain. HIV, malaria, respiratory and gastrointestinal infections and tuberculosis are the warlords that molest and kill. In 2000, the UN adopted the Millennium Development Goals to help World A gain its feet. The Millennium Development Goals called for global assistance through debt relief, direct aid, and scaling up of critical infrastructure, to cut in half the prevalence of abject poverty by 2015.3 The Millennium Development Goals correctly and appropriately concentrate on infant and maternal deaths, HIV and other diseases, but there are things that should be done now to prevent future chronic disease epidemics, for example, in tobacco control. For US$70 billion a year, less than the cost to the United States of the Iraq war, it would be possible to put in place a graded program of infrastructure development and community strengthening as a springboard for health gain and development. Part of poverty entrapment is health entrapment, and it may be easier to tackle this than try regime change as a means of social uplift. Although World A struggles desperately, it is now on the global radar. International aid agencies commit most of their resources to its relief. The Group of Eight (G8) summit recently agreed to a doubling of aid for Africa by US$25 billion a year by 2010, as part of an overall increase of US$50 billion for all developing countries. The G8 partners also cancelled 100% of the multilateral debts of the Highly Indebted Poor Countries.4 No one who understands the Millennium Development Goals claims that money is the whole answer, but while not sufficient, it is necessary. World B, meanwhile, is coming to terms with the impact of diseases that stem from the urbanisation, changing diet, tobacco, and transport changes that characterise their growing prosperity. Birth rates and infant mortality have fallen, and life expectancy is converging on that of World C, so that the global average life expectancy today is 65 years.1 Cardiovascular disease is now the truly global disease, evenly spread through Worlds A, B and C. World C has succeeded in pushing cardiovascular disease (both its death toll and much of its morbidity) into people’s late 70s and beyond. Not so in World B, where a third of deaths and suffering from cardiovascular disease occur among men and women, of working age.5 While the needs of World A are now on aid agendas, those of World B receive scant attention. Heart disease and stroke top the list of causes of disease burden worldwide. While the World Health Organization, the World Bank and the International Monetary Fund (to a lesser extent) have been steadily producing regional and national reports on the continuing and serious illnesses afflicting World B, no global commitment equivalent to the Millennium Development Goals has yet been proposed. As a result, efforts to control these problems are poorly directed and effective interventions all too rarely applied. A different set of goals — Health Prosperity Goals — is needed for World B. These goals should specify cuts in the toll of chronic disease, which is rising in developing countries. Specifically, smoking should be reduced by 20% in 10 years, and death from cardiovascular disease among people aged under 65 should be reduced by 15%. These goals could be discussed with town planners, food producers and retailers, insurers, employers (whose workforces cardiovascular disease adversely affects), unions (whose members suffer from cardiovascular disease), doctors and nurses, ministries of finance, educators, and the other people who must help us define the problem and solve it. Four benefits would follow from articulating a set of Health Prosperity Goals that would clearly define our intentions and bring to global attention the need to act on these conditions. First, Health Prosperity Goals would redirect us from repeatedly describing the size of our current health problems to concentrating thought on how to relieve them. To take cardiovascular disease again, we do not need to prove repeatedly that it is a serious problem. More to the point, we know we can achieve much through programs that manage people at elevated risk medically, combined with efforts to modulate the social and economic forces that promote those risks. Let us therefore aim for a 15% reduction in death from heart disease in people aged less than 65 by 2015 throughout Worlds B and C. Second, Health Prosperity Goals would establish accountability. Those who manage health programs then have an aim for which the community can hold them accountable. Third, we might frame the Health Prosperity Goals so that they specify broad strategies, based on evidence of effectiveness, but leave the details to individual nations to determine. Fourth, by concentrating on intervention, we will see how crucial it is that those involved in producing prosperity and its untoward side-effects contribute ideas and support to preventing and relieving those side effects. Discussion with city planners, developers, insurers, employers, union representatives, and non-government organisations may lead to a redefinition of health problems such as cardiovascular disease and proposals for their solution that introverted public health professionals, meeting in closed seminar rooms, might not think of in a decade.

Stephen R Leeder PhD, FRACP, FFAPHM

In the competition for official development assistance, health is losing out to governance and security Governance, law and justice were “big ticket” items in the 2005–06 Australian federal budget, reflecting the increasing focus on national security in Australia and elsewhere. Our current aid budget reflects this trend. Australian official development assistance (ODA) seeks “to advance Australia’s national interest by assisting developing countries to reduce poverty and achieve sustainable development”.1 According to AusAID, the agency responsible for the ODA program, poverty reduction remains central, reflecting Australia’s humanitarian values and its economic and security interests. The Australian Government has committed to a number of interrelated policy, program and partnership initiatives. In 2005–06, these initiatives seek to promote a closer partnership with Indonesia and engagement with fragile states, to stimulate broad-based economic growth, to strengthen efforts to promote better governance, to tackle transnational threats (notably HIV/AIDS), and to contribute to greater stability and security. A fair contribution?Australian contributions to ODA, now $2.49 billion a year, have been increasing over the past 5 years — a step in the right direction. Budget allocation has risen from 0.25% of gross national income (GNI) in 2001–02 to 0.28% in 2005–06. However, this gradual rise must be seen against the much larger decline over the past 30 years: in 1975–76, 0.45% of GNI was allocated to ODA, falling to 0.43% in 1985–86, 0.32% in 1995–96; and 0.28% in 2005–06.2 Current levels are well below the 0.42% committed, on average, in 2004 by nations belonging to the OECD (Organisation for Economic Co-operation and Development).3 This prompts questions about how Australia will achieve the ODA targets required to meet the United Nations’ Millenium Development Goals, to which we committed in 2000. If it is to do so, a timetable for achievement should be reiterated, with Australian ODA reaching 0.5% of GNI by 2009, nearly double the current level, and 0.7% by 2015.4,5 Without allocating considerably more resources, Australia will be substantially under target. Who benefits?Australia’s ODA is increasingly directed to near neighbours; around 42% is allocated to just three countries — Indonesia, Papua New Guinea and the Solomon Islands. The allocation to the whole continent of Africa, where poverty and conflict cut deepest,6 and where the impediments to achieving the Millenium Development Goals are greatest, stands at only 3% of Australia’s ODA. Support for other resource-constrained countries in South and East Asia is not much greater. Assistance to those in greatest need remains crucial if the benefits of greater equity, stability7 and control of infectious diseases,8 for example, are to be achieved. Attainment of the Millenium Development Goals needs better governance, but also increased and more effective aid for basic services in the poorest countries. One of the agreed indicators of effective aid targeting is the proportion going to countries classified as “Least Developed” by the UN’s Economic and Social Council. As little as 0.05% of Australia’s GNI goes to Least Developed Countries, one of the lowest rates of all OECD donors.9 A notable trend in Australia’s latest aid budget is the increased focus on governance, which now attracts 36% of ODA, squeezing out other commitments (Box). Almost half of this governance expenditure goes towards law and justice, with large tranches allocated to the Department of Defence and the Australian Federal Police for their activities overseas. This commitment to a “whole of government” approach has seen greater involvement of Australian experts with limited experience of developing countries, and inadvertently undermines the concentration of development expertise within AusAID itself. A healthy contribution?In 2005–06, Australia is devoting only 12% of ODA to health, substantially less than countries such as the United Kingdom (22%),10 and much the same proportion as in the past few years. Within this health allocation, an increasing share is devoted to multisectoral HIV/AIDS programs; their funding has increased from around $25 million in 2001–02 to around $70 million in 2005–06. While increased HIV/AIDS funding is necessary and welcome, commitment to non-HIV health-related expenditure has declined, in some cases markedly. Countries such as Laos, Cambodia and Vietnam no longer receive AusAID funds for health and, in the case of Laos, had primary health care funds cut precipitously. Health is significantly linked to poverty, but there are no short-cuts or easy solutions to re-establishing, reforming, and reshaping functional, efficient, and more equitable health systems. Basic health care requires sustained investment in human resources, infrastructure, community-level health promotion, and essential services for primary care, as well as attention to the social determinants of ill health. While supporting basic services is not the most glamorous issue, with neither the profile of HIV/AIDS nor the visibility of uniformed police and defence force personnel, these services remain the cornerstone to promoting health and to ensuring that communities can participate in, shape and control their own development. The Australian Council for International Development (ACFID), an independent association of Australian non-government overseas aid and development agencies, estimates that a fair Australian contribution to the global aid requirements for health would be around A$580 million, substantially above our current commitment of A$299 million.2 Keeping track of where ODA goesKeeping track of ODA is important. Otherwise, we cannot assess the range of activities underway and their outcomes. In recent years, the monitoring of ODA has been made more difficult because of the greater proportion devoted to governance and security, the control of funds by government departments other than AusAID, the failure to separate HIV/AIDS from general health sector reporting, and a reduction in detailed statistical presentation (eg, AusAID has not published a detailed listing of all funded projects since 2001). The level of funding allocated to Australian government departments exposes us to the criticism of “boomerang aid”. The ability to track and account for where funds have actually gone, the proportion tied to purchase of Australian products,11 and the share that goes into basic infrastructure and service delivery in the social sectors, or other forms of direct poverty reduction, should be enhanced. Aid effectiveness remains a key challenge.12-14 While there are no simple answers, numerous international organisations have made a commitment to promoting evidence-informed policy and allocating resources to learning lessons and reflecting on current practice, in partnership with academic and country-based experts.15 Australian commitment to this trend is to be encouraged. Will government follow the lead of a generous public?The response of the Australian community to the 2004 earthquake and tsunami in the Indian Ocean demonstrated popular concern for the needs of others. In fact, even before the tsunami, private contributions by Australians to aid and development were increasing by around 10% per year in real terms (from around $380 million in 2000 to $443 million in 2004, both figures in 2004–05 dollars [G Luke, Policy Adviser to Australian Council for International Development, personal communication, June 2005]), indicating strong interest and support for development cooperation. We need to tap into this public solidarity and ensure that ODA, despite its limitations, obtains more resources and attention. Increasing commitment to health and education will reinforce governance and security, but this is not why they should be supported. Health and education should attract funds because we care about other people,16 because we have a commitment to promoting human security in the region, and because we find it unacceptable that women die in childbirth because of lack of health services, that preventable diseases kill so many children before the age of 5, and that infectious and non-communicable diseases are decimating economies. Basic services require support, which cannot be provided within the existing aid envelope. The Australian Government White Paper on aid, currently being drafted and due in early 2006, is an opportunity to reinforce commitments to dramatically increase ODA and should place health firmly back on the agenda. The Australian public has demonstrated a willingness to contribute directly. Can we mobilise a matching political commitment? Australian official development assistance by sector* * From analyses of AusAID budgetary data (G Luke, Australian Council for International Development, personal communication). Funds not earmarked for a particular sector (either because they go to multisectoral initiatives, such as gender and environment, or to development banks and United Nations agencies) are excluded. †Expressed in 2004–05 Australian dollars.

Anthony B Zwi PhD, FAFPHM · Natalie J Grove BOccThy, MPH · Maria-Theresa Ho MHP, MD

Ashwin Swaminathan,* Iain B Gosbell,† Nicholas A Zwar,‡Mark W Douglas§ * Infectious Diseases Registrar, † Director and Associate Professor, § Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Liverpool Hospital, South Western Area Pathology Service, Locked Bag 7090, Liverpool, NSW 1871; ‡ Director and Professor of General Practice, Sydney South West Area Health Service General Practice Unit, Fairfield Hospital, Sydney, NSW. Iain. GosbellATswsahs.nsw.gov.au To the Editor: Infestation with the sandflea Tunga penetrans, or “chigoe flea”, is rarely encountered in Australia, but has been noted in children recently arrived from Central–East Africa. There have been only two previous Australian case reports of this parasitic infection, both in adult travellers returning from Africa.1,2 Several families who had been living in crowded refugee camps in Tanzania underwent routine screening for infection within 2 weeks of arrival in Australia. Four of 14 children examined had cutaneous lesions on their feet — mainly on the toes, nail beds and interdigital spaces (Box). These lesions were papular, less than 1 cm in diameter, pale yellow with dark centres, and were variably painful and/or itchy. Chronic, adjacent skin and nail bed changes were evident, as were small, loosely attached seed-like objects. Papules could be lifted with a sterile needle, leaving a small, non-bleeding cavity. Tunga penetrans, with numerous attached eggs, was identified by microscopy. Tungiasis occurs when an impregnated female sandflea burrows into the unprotected skin of a warm-blooded host. There is a predilection for the feet, although the perineum, buttocks and arms may also be infected.3 The head of the sandflea breaches the upper dermis to feed on blood vessels, while the abdomen traverses the epidermis, with its posterior components (anus, genital opening and respiratory spiracle) reaching the surface, forming a papule. Over several weeks, the flea releases hundreds of eggs before dying. After hatching, the larvae thrive in dust, soil and sand; they are found on beaches and in animal stockyards of tropical countries.3,4 Infection of pigs and other livestock, the usual host reservoirs, has led to significant problems in the livestock industry.1,4 Apart from pruritis and pain caused by local inflammation, morbidity results from ulceration and secondary bacterial infection, including tetanus and gas gangrene.1,2,4 Fleas can be removed using a sterile needle and forceps, and secondary complications prevented with tetanus prophylaxis, and antibiotics as appropriate. Successful outcomes with antiparasitic agents, such as ivermectin and thiabendazole, have also been recently reported.5 Tungiasis is indigenous to Latin America and the Caribbean, but was introduced to Africa, where it is now endemic, and to parts of South Asia.4 Given the current influx of African refugees into Australia, including the tropical north, the obvious concern is whether Tunga penetrans could establish itself here. We encourage medical practitioners dealing with newly arrived African refugees to examine for tungiasis in their screening evaluation. If, as suspected, this condition is prevalent, national infection control guidelines aimed at preventing establishment of the disease in Australia may be needed. Lesions caused by Tunga penetrans, the “chigoe” sandflea A characteristic Tunga penetrans lesion (thick arrow), with pale-yellow papule and dark centre, and a less obvious lesion (thin arrow) with surrounding chronic skin changes and multiple, loosely attached eggs.

Ashwin Swaminathan · Iain B Gosbell · Nicholas A Zwar · Mark W Douglas

The Solomon Islands is a nation of warm people, tropical islands, shipwrecks and malaria. It is also a nation in urgent need of specialised medical care. This is the story of my short time volunteering in the Solomon Islands for the ophthalmic division of the Royal Australasian College of Surgeons, Pacific Islands Project (PIP) in 2004. The PIP, in operation since 1996, is funded by the Australian Agency for International Development (AusAID) and encompasses specialists from 10 surgical specialties who volunteer their time to help address the shortage of local specialists in 11 Pacific Island countries. The ophthalmic team for the Solomon Islands is sponsored to make an annual trip. Eye disease is such a serious problem that they made a second trip in 2004 to the islands of Guadalcanal, Malaita and Gizo, their 11th since the project’s inception The Solomon Islands, formerly known as the British Solomon Islands, gained independence in 1978. They were the scene of some of the bloodiest land, sea and air battles of World War II, and are now emerging from 6 years of ethnic conflict. The predominantly Melanesian people of the Solomon Islands are among the poorest in the South Pacific.1 Honiara is a 3-hour flight from Brisbane, where I first met the PIP team — ophthalmologists Geoff Painter and Jeremy Smith, and ophthalmic nurses Bev Baily and Louise Fowler, all from Sydney — at the Solomon Island Airlines check-in counter. Honiara, GuadalcanalAfter arriving at Honiara-Henderson airstrip, we bounced and weaved along dilapidated roads to make our way to the National Referral Hospital in dusty Honiara. It is the only hospital in the archipelago that has an anaesthetist and the option of performing major surgery. However, it has no intensive care facilities and endures a chronic shortage of medical supplies. The team arrived to the sounds of an animated Christian preacher engaging the crowd of more than 500 patients on the hospital verandah. The patients had been queuing since dawn and many had walked for days on hearing of the impending arrival of an eye team. Essential to ophthalmic care in the Solomon Islands are the specialised eye nurses, headed by Wanta Aluta. Sister Wanta runs the eye clinic at the National Referral Hospital, provides training for the eye nurses at regional eye clinics, and is responsible for the essential triage before each overseas team visits. Dr Qalo, a Solomon Islander, is currently in an ophthalmology training program in Papua New Guinea, sponsored by Foresight Australia. At the clinic, the patients were lined up in rows and the two ophthalmologists moved along the rows using a portable slit lamp to diagnose the ophthalmic condition, most commonly, cataract. Patients had brought their own medical histories, which varied from a small exercise book to a scrap of card. Patients were put on the list for cataract surgery if their visual acuity was measured at less than 6/60. However, many could only discern hand movements and up to 30% were profoundly bilaterally blind. Only a select few with pressing reasons for securing surgery (such as driving a taxi or working as a teacher) were operated on at 6/60. Standard cataract surgery was extracapsular cataract extraction with the insertion of a posterior chamber intraocular lens. In most patients, the density of the cataract made phacoemulsification, and thus, modern small-incision cataract surgery, unsuitable. There were a significant number of young people with cataracts. One unforgettable patient was a 14-year-old boy with bilateral cataract who had lived most of his life being led around by his mother. His left cataract was removed during the team’s last PIP tour, and he now had uncorrected 6/4 vision in his left eye, a big smile, and was ready to have his right cataract removed. The severity of eye conditions is compounded by the delay in presentation. Most patients’ first port of call is a traditional healer for topical application of herbs termed “Kastom medicine”, which, at best, does nothing, and often introduces infection. Auki, MalaitaAfter 2 days in Honiara, Dr Painter and I joined Dr Qalo and Sister Wanta for a 3-hour speedboat trip to Malaita Province. No ophthalmic team had visited Malaita since 2001. We went straight from the port to the eye clinic at Kiluufi Hospital to begin consultations with the 112 patients. We greatly appreciated that Stephen, the Malaitan eye nurse, had measured the visual acuity and divided the group into cataracts and other disorders (mostly pterygium and infections). A disturbing number of children had lime burns on their corneas caused by touching lime hydroxide used by their parents in the preparation of their betel nut mixture. Many elderly patients had decreased visual acuity because of uncorrected refractive errors, for which there were no spectacles available. The general state of patients in Malaita was sobering. They were literally in rags. Worse still, many were hungry. Families generally subsist on vegetable plots with little cash income. Some had made the long journey to the eye clinic by canoe or on foot with scarce provisions over many days. One patient even had a hypoglycaemic attack on arrival at the clinic. Malaita is one of the poorest islands in the country because of its direct involvement in the ethnic conflict. After years of tension, the civil war came to a head on the main island of Guadalcanal in 1998. During the conflict, Malaitan settlers (many second-generation) fled Honiara and went back to Malaita. The impressive organisation at Kiluufi Hospital enabled us to commence surgery on the second day. The team was mostly self-sufficient, bringing two portable microscopes, ophthalmic instruments, an autoclave and disposables with them. Patients were given a peribulbar local anaesthetic by a Solomon Islander resident medical officer, and walked in and out of surgery. Insect repellant was a must to ward off malaria-laden mosquitoes from our exposed legs. The air-conditioned theatre made operating in the humid climate tolerable to us, but the patients needed blankets during the half-hour cataract procedure. After their surgery, the patients were led out to rest until review the next morning. Many slept on vacant benches, under desks or on straw mats on the floor. The pharmacy had no paracetamol for postoperative analgesia. Despite the environmental conditions, the rate of nosocomial infections and endophthalmitis was low. Each morning, I reviewed the postoperative patients and re-measured their visual acuity. Patients, many of whom were seeing for the first time in many years, were intensely grateful and said “Thank you for coming to Malaita”. Patients’ uncorrected visual acuity was tested preoperatively and then one day postoperatively (Box 1). Ideally, visual acuity would be tested again a few months later, but patients’ return to their far-flung homes after treatment makes long-term follow-up unrealistic. While we were working in Auki, Dr Smith and Dr John Szetu (who joined our Team from Vanuatu) worked diligently in Honiara performing a large number of procedures on the Guadalcanal patients we had triaged on arrival. They also introduced more modern technology in the form of phacoemulsification and posterior segment vitrectomy for treating retinal detachment, for the first time to the Solomon Islands. GizoThe third place on the PIP schedule was the beautiful island of Gizo, renowned worldwide as a diving Mecca. The team reunited, which increased surgical efficiency and enabled us to perform a record number of operations overall. ReflectionsWe completed 287 procedures in 2 weeks (Box 2), and provided valuable supplies and teaching. Despite this, time constraints meant that we were not able to extract all of the cataracts of the patients on the surgical list in Honiara or Auki. This left me feeling despondent, as the patients had waited so patiently for up to a week and were so gracefully resigned in their disappointment. Of course, they will be given priority in the future, but the sadness on their faces was obvious. I obtained invaluable experience on neglected ophthalmic disorders and the difficult conditions under which the Solomon Islander nurses and doctors work. It was a privilege to witness the work in the Solomon Islands by the PIP team, but especially the work done by Sister Wanta and her nurses. I now understand and appreciate how Australian development projects are assisting in the development of primary eye care in the Pacific Nations. Sadly, compared with their Pacific neighbours, the Solomon Islands are relatively well resourced. The PIP teams provided ophthalmic surgery, in addition to valuable supplies and teaching; VISION 2020 provided specialised training for eye nurses, who in turn provided a buffer of sustainable eye care during the ethnic conflict; and Foresight Australia provide the opportunity for specialised ophthalmic training. On a broader front, additional assistance is provided by the Regional Assistance Mission to the Solomon Islands (RAMSI), established by Australia and with other Pacific Island Nations at the request of the Solomon Islands government in 2003. RAMSI has authority for peacekeeping and the restoration of basic services, particularly in health. This has been broadly welcomed by most Solomon Islanders.2 The Solomon Islanders have been through difficult times, but their future is looking brighter. 1 Improvement in uncorrected visual acuity for 72 patients after extracapsular cataract surgery at Kiluufi Hospital, Malaita, Solomon Islands* * Vision tested preoperatively and one day postoperatively. Symbols and adjacent numbers indicate the number of patients with preoperative visual acuity as indicated by their position along the horizontal axis that improved postoperatively to the position shown on the vertical axis. The smallest symbols indicate one patient and are not labelled. 2 Presentations and surgery for eye disorders in the Solomon Islands during a 2-week visit by a Pacific Islands Project ophthalmic team in August 2004 Surgery Hospital Patients screened Cataract Pterygium (excision/ graft) Entropion (repair) Diabetic retinopathy (laser) National Referral Hospital 344 151 2 2 4 Kiluufi Hospital 112 72 1 1 na Gizo Hospital 124 38 10 6 na Total 580 261 13 9 4 na = not applicable.

Michelle L Baker MB BS

Early experience confirms that riluzole improves survival and is well tolerated The recently established Australian Motor Neurone Disease Registry estimates that 1200 Australians are living with motor neurone disease (MND), and 370 new patients are diagnosed each year. Most patients die within 3 years of diagnosis. Aetiological mechanisms implicated in the development of MND have been linked to the glutamatergic neurotransmitter system, with excessive activation of glutamate receptors at the synaptic cleft now believed to trigger destruction of motor neurones.1 This “excitotoxicity” theory of MND gave rise to the development of new therapeutic approaches and, ultimately, clinical trials involving riluzole. This drug was initially thought to act solely as an inhibitor of glutamate release, although subsequent postulated effects include indirect antagonism of glutamate receptors and inactivation of neuronal voltage-gated sodium ion channels. Regardless of the precise mode of action, two large trials in the 1990s established the efficacy of riluzole in the treatment of MND.2,3 A double-blind, placebo-controlled study undertaken in 155 patients with MND showed a significant prolongation of survival and an improvement in functional outcome measures for those treated with 50 mg of oral riluzole twice daily.2 A larger, dose-ranging study undertaken in 959 patients confirmed the beneficial effect of riluzole on survival, being in the order of 3–6 months.3 In the original study,2 the therapeutic effect of riluzole was more prominent in patients with bulbar-onset MND, while the second study found no significant differences in the responses of bulbar- and limb-onset groups.3 Subsequent retrospective analyses suggest a survival benefit even longer than 6 months in both patient groups, but these data have been confounded by recent general improvements in the care of MND patients, particularly the use of percutaneous endoscopic gastrostomy for nutritional support and non-invasive ventilation for respiratory insufficiency, in the setting of a multidisciplinary approach to care.4 Riluzole remains the only medication to slow the progression of a neurodegenerative disease, leading to an increased survival for patients with MND.5 In some countries including Australia, riluzole’s manufacturer had difficulty gaining a listing for the medication on pharmaceutical benefits schemes, in part due to issues related to “quality of life”, despite trial data documenting improvement in patient longevity.2,3 Quality of life is a nebulous measure and the findings using quality-of-life scales in MND clinical trials have proved inconsistent to date.6 After dissecting arguments related to quality-of-life issues, and with intense lobbying by the MND community — patients, clinicians and care groups — riluzole was finally listed by the Australian Pharmaceutical Benefits Scheme (PBS) in June 2003 (see Box for criteria). Linked to the original riluzole trials were studies conducted to establish the safety profile of riluzole in MND patients, including the Riluzole Early Access Program run here in Australia. The primary objective of these open-label, single-treatment studies was to enable patients with MND to receive riluzole therapy pending its commercial availability, health authority approval and, in the case of Australia, listing on the PBS. Through such a process, the safety profile of riluzole was expanded. These later studies established that riluzole was generally well tolerated by patients with MND. Adverse events were predominantly gastrointestinal, with nausea, weight loss and dysphagia being the most frequent,7 although it may be argued that the latter symptoms more likely reflect disease activity itself. Measurement of full blood count before initiation of therapy is suggested, as, rarely, blood dyscrasias may develop with riluzole. As riluzole is metabolised hepatically and significant hepatotoxicity occurs in about 0.2% of patients,7 testing liver function monthly for the first 3 months and then at 3 monthly intervals remains important. However, patients with MND can have or develop abnormal liver function for many reasons other than taking riluzole, including the use of alternative therapies, emphasising the need for baseline measurements before initiating riluzole therapy and withholding the drug if liver function is grossly abnormal (eg, liver enzymes elevated above five times normal). When should MND patients commence taking riluzole? Certainly, any patient with clinically probable or definite MND (based on a combination of upper and lower motor neurone abnormalities in two to three spinal regions) warrants consideration. It could be argued that, given suggestions that patients benefit most from therapeutic intervention in the early stages of MND, the earlier riluzole is started the better. It is inevitable that, by giving riluzole to patients in whom MND is suspected, a few patients in the “possible” and “probable” clinically diagnosed categories will receive this treatment for conditions other than MND, with the correct diagnosis only becoming apparent over time.8 However, given the putative neuroprotective properties of riluzole, this approach has no identifiable drawbacks. Giving riluzole to patients with advanced disease is problematic, and the current PBS guidelines for authority prescriptions of riluzole stipulate that the date of MND diagnosis (disease duration, ≤ 2 years) and the results of respiratory testing (forced vital capacity, ≥ 60%) must be supplied with the initial authority application. Obtaining adequate measures of vital capacity may be difficult in patients with bulbar onset, although the use of face masks in specialised respiratory units may circumvent this difficulty. Finally, patients must be aged ≤ 75 years to qualify for PBS subsidisation, primarily because there is limited information regarding the benefits of riluzole in the older age group.9 Questions remain about the benefits of riluzole on survival in patients with advanced MND, and whether the effect of riluzole on motor neurones diminishes over time. Certainly, there is no evidence to suggest that riluzole reverses motor neurone degeneration and, despite extensive counselling about what to expect, patients may have unrealistic expectations of riluzole therapy. My own experience in the trial setting was that when their deficits did not diminish, some patients ceased taking riluzole, believing it not to be beneficial. This reinforces the need for a detailed discussion between the treating physician and the patient with MND at the time of commencing riluzole. Patients need to understand the role of riluzole therapy; specifically, that it is not a cure, but that it has been established to slow the rate of deterioration in muscle function and thereby increase longevity and quality of life. Clearly, good communication skills and empathy are needed when conveying this information to the patient and their family. Pharmaceutical Benefits Scheme (PBS) criteria for riluzole authority (June 2003) Approved indication Treatment of motor neurone disease PBS indication for authority Initial treatment of motor neurone disease, as diagnosed by a neurologist, in patients aged 75 years or less, with disease duration of 2 years or less and who have at least 60% of predicted forced vital capacity within 2 months prior to commencing riluzole therapy and who: 1) are ambulatory, and a) have not undergone tracheostomy, and b) have not experienced respiratory failure; OR 2) are not ambulatory, and a) have not undergone tracheostomy, and b) have not experienced respiratory failure, and c) are either able to use upper limbs or able to swallow. The date of diagnosis and the results of spirometry (in terms of percentage of predicted forced vital capacity) must be supplied with the initial authority application.

Matthew C Kiernan PhD, FRACP

A major theme of the 2004 World Congress of Clinical Pharmacology and Therapeutics was worldwide equity of access to medicines The 8th World Congress of Clinical Pharmacology and Therapeutics was held in Brisbane in August 2004. There were 940 participants from 60 countries, with Japan, Germany, Korea, South Asia and the United Kingdom well represented. The Congress featured three themes: Medicines and Society; Therapeutic Horizons; and Drug Discovery, Development and Disposition. Our report focuses on the Medicines and Society theme, which was strongly emphasised at the 8th Congress, differentiating it from previous Congresses. The prominence of this theme was to encourage the participation of clinical pharmacologists from South Asia and the Pacific regions, where access to lifesaving medicines and confidence in their quality are matters of everyday importance. The Congress also sought to encourage clinical pharmacologists from the developed world to engage with the serious global inequities in access to medicines for the major infectious diseases in the developing world, such as tuberculosis, malaria and HIV/AIDs, as well as the emerging developed-world lifestyle disorders, notably cardiovascular disease. Equity of access to medicinesSeveral plenary lectures focused on access to medicines in developing countries. Suwit Wibulpolprasert (Senior Advisor on Health Economics, Ministry of Public Health, Thailand) gave an inspirational and challenging presentation Philanthropy for the few — equity of access for the many?, tackling the difficult issue of donated medicines. He exposed the increasing gap between rich and poor in both developed and developing countries, and the many interacting social, political and financial influences that conspire to take resources away from the people who most need medicines. He concluded with practical steps that clinical pharmacologists could take to alleviate problems of access to medicines, such as promoting the use of the World Health Organization (WHO) model list of essential drugs in their own countries.1 This theme was reinforced by Sri Suryawati (Head of the Department of Clinical Pharmacology, Gadjah Mada University, Yogyakarta, Indonesia) who challenged all clinical pharmacologists to become involved in achieving the three “As” of medicine use in their own countries: access, affordability and appropriate use. An important and contentious recent issue has been access to cheap, generic versions of fixed-dose combinations of antiretro-viral drugs to deal with the HIV epidemic in Africa. Lembit Rago (Director of the WHO Division of Quality and Safety of Drugs, Geneva, Switzerland) discussed the difficult progress towards international acceptance of WHO guidance regarding registration of these products. Attention was also given to the rapidly expanding complementary medicines sector. Charlie Xue (Program Leader, Division of Chinese Medicine, RMIT University, Melbourne, Vic) outlined the WHO’s perspective on traditional medicine, and provided examples of the role of complementary medicine as a mainstay of public health systems in South-East Asia and the Pacific regions. Chu Quoc Truong (Director of The National Hospital of Traditional Medicine, Hanoi, Vietnam) related that the Vietnamese government has formally integrated traditional medicine with Western conventional medicine, with apparent good effect, notably wide acceptance of both traditions, allowing selection of cost-effective options from each. Tony Smith (Emeritus Professor of Clinical Pharmacology, University of Newcastle, NSW) summed up the unfinished business for clinical pharmacology and world health. He reminded Congress participants that clinical pharmacology arose as a discipline largely in developed countries and continues to be vital to the stellar advances in drug discovery, providing guidance to early-phase human studies, interpretation of pharmacokinetic, clinical and adverse-effects profiles, and development of product information for virtually every significant new chemical entity entering clinical practice. However, many of the needs of developing countries remain unmet, partly because of the limited numbers of clinical pharmacologists. He highlighted the vital tasks of these “few”: political advocacy for appropriate drug use; elaboration and implementation of national medicines policies; and specific “bread and butter” tasks, such as the collaborative development of standard treatment guidelines and essential medicines lists, and the promotion of rational prescribing, especially through training programs in medical schools. All the plenary speakers uniformly encouraged the international umbrella organisation for clinical pharmacology, the International Union of Basic and Clinical Pharmacology (IUPHAR), to continue to become more proactive in these areas, particularly through strong collaborations with WHO and similar organisations. This paradigm shift was strongly endorsed at the IUPHAR council meeting held during the Congress. Proper use of medicinesAnother theme running strongly through the meeting, and prominent in the Medicines and Society stream, was the concept of QUM (quality use of medicines), which was developed in Australia in the early 1990s. The Congress was an important opportunity for Australia to showcase our progress in QUM, through the gathering of evidence about what actually works, followed by implementation of effective strategies through networks, products and services. The major sponsorship of the Congress by our own National Prescribing Service — itself a prominent outcome of the QUM movement — effectively emphasised the importance of the movement in Australia and its potential for other parts of the world. Tom MacDonald (Professor of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK) delivered an entertaining contribution with the important message that large returns in population health outcomes would accrue if we could better implement evidence-based guidelines and improve patients’ adherence to therapy. For the prevalent cardiovascular disorders, lowering blood pressure is the intervention with the best evidence. Despite its proven benefits, blood-pressure control is poor worldwide. There are good arguments to support a more aggressive approach to blood-pressure management and treatment of younger individuals, but long-term compliance is a problem. Drug safetyAn increasing concern echoed in the Congress is the safety of medicines in older people, who are likely to have multiple comorbidities and increasing exposure to multiple, potent medicines. The future conduct of pharmacovigilance for new drugs is being shaped by interesting therapeutic risk management initiatives across the world, some of which were presented in a lively symposium entitled Medication safety and pharmacovigilance. These initiatives seek to better identify, evaluate and minimise the impact of adverse reactions, and to communicate evolving safety risks throughout the life cycle of a drug. Susana Perez-Gutthann (Senior Director, Global Epidemiology, Safety and Risk Management, Pfizer Worldwide Development, Barcelona, Spain) emphasised the need for this process to be proactive. The techniques of pharmacoepidemiology and use of advanced information technology to “mine” large automated health databases have revolutionised pharmacovigilance. The problem of the “therapeutic orphan” status of children was examined in depth by speakers from Europe, the United States and Australia. Incentives to pharmaceutical companies to evaluate already marketed medicines in children, along with mandatory studies for new medicines in this age group (provided they are potentially useful) has been a successful strategy in the US since the mid-1990s and is now having a positive impact in Europe. A paediatric working party has advised Australian Health Ministers via their Advisory Council on steps to improve access to prescription drugs registered for use in children and the quality use of these medicines. However, the Congress heard that political pressure still needs to be maintained to overcome this problem for children in all countries. Advertising medicinesA symposium on the controversial topic of direct-to-consumer advertising of prescription pharmaceuticals drew great interest, as the situations in Canada, the US, Europe, Thailand, New Zealand and Australia were compared. This advertising is legal only in the US and New Zealand. There were two main themes: first, that regulation is difficult; and secondly, as presented most forcibly by Barbara Mintzes (Postdoctoral Fellow, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada), that there are many, and increasing, instances of advertisements that skirt the boundaries of existing laws and regulations in jurisdictions where this advertising is illegal. In developing countries, Krisantha Weerasuriya (Regional Adviser, Essential Drugs and Medicines Policy, WHO Regional Office for South-East Asia, New Delhi, India) pointed out that there is, in reality, often no distinction between supposed prescription and over-the-counter medicines in terms of access. It is very difficult to control direct-to-consumer advertising of so-called prescription drugs when prescription-only status is not upheld at law — the case in most countries in South-East Asia. However, in countries where direct-to-consumer advertising is currently illegal, there appears little appetite for its introduction because of concerns about quality use of advertised medicines, consumer demand leading to distortion beyond the “reasonable” need for medicines, and finally, morbidity and mortality from the adverse effects of medicines whose use was unnecessary. However, it was emphasised that there is continuous and considerable pressure from industry and advertising interests to reverse this attitude. We have concentrated on the theme Medicines and Society, not because the other core themes of the Congress were less important, but because the urgency of addressing inequities in access to essential medicines around the globe is overwhelming. We were delighted that there was strong support to build on this focus at the 9th World Conference of Clinical Pharmacology and Therapeutics, which will be held in Montreal, Canada, in 2008 (http://www.cpt2008.com/).

Richard O Day MD, FRACP · Donald J Birkett FRACP, DPhil · John Miners PhD · David A Henry FRCP · Gillian M Shenfield PhD, FRACP, FRCP · J Paul Seale PhD, FRACP

Objectives: To report the incidence of multispecialty surgical conditions in patients presenting to a procedural general practice.Design and setting: A more than 18-year survey (1 August 1983 – 31 January 2002) of the surgical records of a general practitioner–surgeon in an urban general practice.Participants: 211 patients each with multiple, elective, surgical problems (mostly non-major) treated at one operation.Results: The 211 patients represented 9.03% of the practitioner’s elective, non-referred, general practice surgical workload. Two separate procedures were performed at one surgical episode for 155 patients (73.5%), three separate procedures for 53 patients (25.1%), and four separate procedures for three patients (1.4%). Having all surgical conditions treated in a single episode resulted in considerable savings in time, convenience and expense for both the patient and the health care system.Conclusion: There appears to be a place, at least in our major cities, for an appropriately trained and recognised general surgeon, to service patients with more than one minor condition requiring surgery.

Raymond E Wilson MB BS(Hons), FRACS, FRCS

1 Tsunami damage in Kandholhudoo on the Raa atoll Photograph: Andrew Robertson. Mention “the Maldives” and everyone immediately conjures up images of unspoiled coral islands, holiday resorts, spectacular diving sites and great surf. The Maldives (from the Sanskrit “mala-dvipa”, meaning “garland of islands”)1 is all that and more, from the bustling capital city of Malé to the 200 serene inhabited islands where the traditional occupations of fishing and boat building continue as they have for centuries. When the earthquake and subsequent tsunami struck Aceh on 26 December 2004, most Australians were contemplating the public holidays ahead of them. The tsunami, travelling at speeds of up to 800 kilometres per hour, struck countries around the Bay of Bengal and across the Indian Ocean. Tremors were felt in the Maldives at about 06:25 local time, and the tsunamis hit the Maldive atolls between 09:00 and 09:30. As the 1–4-metre waves struck the islands, 82 people died, 200 people were severely injured and a further 1100 required treatment. Twenty-six people remain missing. An estimated 2167 households (15 000 people or almost 5% of the population) were displaced from their homes,2 as over half the inhabited islands sustained damage (Box 1). The Australian responseLike many on Boxing Day, we had missed the early reports of the evolving disaster in Asia. However, we were soon thrust into its midst by the early morning news on 27 December 2004, and by an urgent teleconference of the Australian Health Disaster Management Policy Committee, as we considered what medical support might be needed. This Committee, chaired by the Commonwealth Department of Health and Ageing, and with State, Defence Force and Emergency Management Australia representation, played a key role in advising the Australian Government on what response could be mounted quickly. By early on 28 December, it became obvious that we needed to send civilian medical teams into the tsunami-affected areas. While the Australian Defence Force had prime responsibility for deploying medical teams into areas affected by both the 1998 Aitape (Papua New Guinea) tsunami and 2002 Bali bombing,3,4 Australia has not often deployed civilian medical teams into disaster areas. Most states and territories base their internal disaster relief medical teams around major hospitals; this is a practice which has been questioned since the 1997 Thredbo disaster.5 However, as the Western Australian State Health Coordinator in times of disaster, I knew we could put a medical team together at short notice. For the first teams, we relied on advice from Chief Health Officers and Directors of Medical Services within Australia as to who might be appropriate, available within hours and experienced in providing health care in developing countries. While effective, personal preparations were ad hoc, the initial choice of team members has since been debated, and issues such as in-country operating funds, team expenditure and telephone costs are still being resolved. 2 Destruction on Vilufushi in the Thaa atoll Photograph: Gavin Coppinger. Our key problems were time and distance, particularly as teams comprising members from different states were all leaving from Sydney (28 in two teams to Aceh and one team of 17 to the Maldives).2 For once, the “red-eye” overnight flight for those travelling from Perth to Sydney was to our advantage, enabling us to get the team to Sydney rapidly. The logistics of assembling a team, equipping it (for medical work and to live in the field), reassembling it when its role changed from surgical care to public health, and deploying it in it the 24 hours after arrival, was challenging. The team bound for the Maldives included a team leader (Andy Robertson), three general practitioners (Mark Adamski, Vince Duffy, and Grahaeme Hatfield), two public health physicians (Krishna Hort and Danny Csutoros), three emergency physicians (Colin Myers, Michael Novy and Peter Roberts), an infectious diseases physician (Dominic Dwyer), an anaesthetist (Gavin Coppinger), three nurses (Muriel Leclercq, Jeff Williams and William Kerr), a paramedic (Greg Gibson), an environmental health officer (Paul Miller) and a logistics officer (Chris Sykes). With great assistance from the NSW Ambulance Counter Disaster Unit, Westmead Hospital, Queensland Health, the NSW Fire Brigade and Emergency Management Australia, this team, along with tonnes of cargo, deployed on a loaned QANTAS 747 early on 30 December 2004, and arrived in Malé that evening. During this flight, it became clear that a doctor was required to accompany 70 injured Australians from Colombo back to Sydney, and emergency physician Peter Roberts readily volunteered. 3 Members of one of our small teams being conveyed in a small fishing boat (dhoni) Photograph: Colin Myers. In the MaldivesThe significant number of dead and injured had been well managed in the central Indira Gandhi Memorial Hospital in Malé and in regional hospitals and island medical centres.6 Having survived the initial onslaught, the Maldivians were now concerned about subsequent epidemics and other public health issues (including food and water supply), as well as primary care; our team, with its public health and infectious diseases physicians, environmental health officer and GPs had been structured with that in mind. The damage to the affected islands and the bravery of the people was noteworthy. Many reported the tsunami hitting from both sides of their island, leaving them with nowhere to run. There was a strong sense of community among the Maldivians, who banded together in this time of devastation. Maldivians pride themselves on cleanliness, and many went to neighbouring islands to help clean up. On islands such as Vilufushi and Madifushi, where near total destruction reigned and rubble lay everywhere (Box 2), “Where do you start?” was the question in everybody’s mind. The enthusiasm of the Maldivian people meant the teams were universally well received and the communities were keen to work with the teams to address local issues. Health care delivery across 200 islands was never going to be easy (Box 3). Moving personnel, equipment and resources and patients was a challenge, as virtually all transport meant traversing water. The teams used everything from small fishing boats (dhonis), Coastguard landing craft, hospital boats and ocean-going ships to seaplanes and Indian Airforce transports. 4 Reviewing patients at a clinic in Madifushi, Thaa atoll Photograph: Vince Duffy. It was critical to work closely with Maldivian Ministry of Health staff to “value add” to their efforts. This meant working in small teams with local staff throughout the Gaafu Alifu, Thaa and Raa atolls, south and north of Malé.6 Several islands had not seen medical staff since the tsunami and many were running short of pharmaceuticals — we were able to provide both (Box 4). There was a range of public health issues that needed addressing, from discouraging the use of chlorine on dead fish and animals, with resultant shortages of chlorine for the wells (Box 5), to monitoring the populations for outbreaks of dengue, scrub typhus and diarrhoeal diseases. Public health team members worked closely with the Ministry of Health’s Water and Sanitation division to implement strategies for accommodation, children’s health, water and sanitation, solid waste management and asbestos disposal. Strategies included acquiring bedding for islanders evacuated to other islands and arranging the supply of fruit and vegetables, especially for children, where local crops had been destroyed. There were also continuing problems with tsunami-related injuries. Many people on the worst affected islands had been swept out to sea, and presented with chest infections in resultant “near drowning” syndromes. Infected wounds, abrasions and crush injuries were also evident. Outbreaks of gastroenteritis and respiratory disease were fortunately uncommon, and exacerbation of locally endemic infectious diseases (including dengue and scrub typhus) had not occurred. Anxiety and depression, as the islanders struggled to come to terms with the destruction, were common. In giving health support, it was important not to become a burden on the local government. There were unfortunate cases of well-intentioned, but misguided, attempts by other international medical teams to take over the local health system or provide services that weren’t needed (eg, trauma surgery), and this placed further strain on Ministry of Health staff. 5 Damage to wells in Viligili, Gaafu Alifu atoll Photograph: Michael Novy. Courtesy of WA Health Department. ConclusionThe health response by the Maldives government was one of the few success stories after the tsunami. This rested on a well-organised, pre-existing infrastructure encompassing effective inter-island transport and island-based health care centres. Many issues remained, however, including profound anxiety about further waves; loss of the breadfruit, guava and other fruit trees following salt water contamination; contamination of drinking water; future withdrawal of foreign health care personnel; and concern that the Maldives may be forgotten in its recovery phase by both tourists and charities. Australia’s health response was rapid, effective and appropriate, but we did learn some lessons (Box 6). In the future, our response could be improved with the establishment of pre-selected state-based Disaster Medical Assistance Teams.7 Teams that later went to Aceh were state-based, and had the benefit of enough time to select, prepare and equip their personnel before deployment. The multi-jurisdictional nature of the earlier teams, however, captured the spirit of the Australian desire to assist all those affected by the tsunami. 6 Lessons learnt for team deployment Health intelligence Accurate health information needs to be provided to the teams before deployment. Team selection Military, developing country and/or rural and remote medical experience and disaster medicine training is useful. Team member flexibility is critical, especially being able to improvise and adapt to constantly changing circumstances. Interpreters, or team members who speak the local language, are highly desirable. Equipment National modular checklists of both self-sufficiency and medical stores need to be further developed, incorporating sections on primary care, paediatrics, chronic care and public health (including vaccines). There is a need for team-identifying clothing, principally vests and headwear. Communications A clear command and control structure is essential. Satellite phones with international coverage, and international roaming mobile phones are critical. Logistics Funding, insurance and indemnity issues should be resolved before deployment, including cash advances (US dollars were widely accepted) and credit cards. Guidelines on what will be funded on deployment (eg, mobile phone use, purchase of clothing) are necessary. Transport Agreements with commercial airline companies to rapidly deploy team members should be explored further.

Andrew G Robertson CSC, FAFPHM, FRACMA · Dominic E Dwyer MD, FRACP, FRCPA · Muriel G Leclercq BSc(Nursing)