History and humanities

Historically, the Australian Defence Force (ADF) has sourced all its blood supplies from the Australian Red Cross Blood Service. Recent ADF operations in the Middle East have highlighted a need to rely on other nations’ blood supply systems. In 2008, the ADF embedded a surgical and intensive care team into the Netherlands-led forward health facility at the Uruzgan Medical Centre at Tarin Kowt in Afghanistan. To date, three teams have provided 2-month rotations as part of the North Atlantic Treaty Organization International Security Assistance Force in Afghanistan. The Netherlands armed forces use a sophisticated system for supply of liquid and frozen blood products (frozen red cells, plasma and platelets). We review Australian experience with the Dutch system of supplying blood products for major trauma resuscitation in Afghanistan.

Susan J Neuhaus CSC, FRACS, PhD · Ken Wishaw MB BS, FANZCA · Charles Lelkens MD, SBB(ASCP)

Two phenomena are shaping physician assistants and their futures: change in human societies and change in health care delivery The physician assistant (PA) is a global phenomenon: a product of medicine that enjoys unparalleled success within the health profession in many societies. Born in the 1960s, nurtured in the 1970s, and grown in the 1980s, the PA proved to be a capable player in American health policy in the 1990s. By 2000, the PA had emerged in a handful of countries, and by 2015, PAs will surpass 100 000 worldwide.1 Various explanations regarding why this profession is growing have been advanced. Clearly, PAs fit well in the entrepreneurial American health care system; economic advantages, clinical flexibility and dependence on doctors are factors that contribute to their success. But it is other countries that are building on the original model. With a worldwide shortage of 4.5 million doctors and an inadequate number of medical schools, the sheer weight of population growth demands more medical personnel and resources.2 In addition, improvements in childhood survival and the control of archaic diseases (eg, malaria, tuberculosis, dengue fever, smallpox, polio) have resulted in people living longer and more comfortably than their parents. Technological advancements are limited only by the logistics of delivery to populations, both urban and remote.3 The increasing years of productivity of individuals indicates the need for an unprecedented cadre of health workers. Without more doctors and nurses, the next group of providers to look to is PAs. Canada, the United Kingdom, South Africa and the Netherlands are examining not only their present workforces, but also what will be needed in decades to come. The alternative to not growing their own workforces is recruiting overseas-trained doctors — a strategy with its own ethical considerations.4,5 A sociological explanation for the emergence of PAs is an evolution in the division of medical labour, not a loss of autonomy for doctors. Medicine has become infinitely more complex over the past several decades and the information base required to practise medicine is enormous, leading to greater levels of team-based care. Health care knowledge was once a vaunted supremacy of doctors, but now diagnostic and therapeutic tasks are shared with other health care professionals (in part because modern-day doctors cannot know and do everything in so vast a field). Throughout the 20th century, analytical technologies and therapeutic approaches produced new specialties, and today we have genetics, interventional radiology, robotic surgery and the resurgence of midwifery. Further expansion of medical activities and capabilities will necessitate the inclusion of additional trained personnel who share the domains of doctors but remain dependent on doctors for directing care. Other social forces have had a major influence on the PA movement. Changing lifestyles — doctors’ preferences for greater work–life balance grew during the 1970s. Today, most are eager to work (though not as hard as their predecessors) and desire help. Gender shifting — women have entered the workforce in a major way. They have tried out careers that are traditionally dominated by men, and have found them to their liking. For PAs, the education path is shorter than for medicine but has similar rewards. The opportunity to be engaged in a well respected career and successfully raise a family ranks high with many female applicants. Doctor dependency — the unwavering commitment of the PA profession to remain dependent on doctors bolsters widespread acceptance of PAs by medical professional bodies. National competency — the establishment of program accreditation and an independent national board overseeing the specific skills and competencies of PAs allows states to focus on licensure, roles and supervision. Primary care — for PAs, the emphasis on training in general medical care and obtaining core competencies creates a known entity. Such a model permits more role flexibility and mobility (beneficial characteristics in a changing health care environment) than exists for doctors and nurse practitioners. The PA succeeds, in part, because of the attributes of individuals. Early entrants saw themselves as change agents who wanted to prove that allied health individuals trained in this PA model could benefit society safely and effectively. The PA profession continues to attract those who feel dead-ended in their current health care roles but do not want the burden of a protracted medical school experience or investment. For example, an experienced military medic may seek to use his or her skills in civilian life or an indigenous health care worker who is isolated without options for career progression may wish to upgrade his or her role to enable a return to cultural roots. Looking forward, key questions emerge. What does the future hold for the PA profession? How will the changing faces of various health care systems affect the PA profession? Will a PA trained and certified in Utrecht, the Netherlands, be able to work in Mt Isa, Australia, and be effective? Two phenomena are shaping PAs and their futures: change in human societies and change in health care delivery. These are on convergent paths that predict the growth of PAs for many years to come — at least in many countries. How Australia will fit this new provider into its health care system is contentious for some. For those who want to expand the capacity of its highly skilled workforce, the pace of change leaves few options.6

Roderick S Hooker PhD, PA

A history of the ‘unfortunate experiment’ at National Women’s Hospital. Linda Bryder. Auckland: Auckland University Press, 2009 (vi + 250 pp). ISBN 978 1 86940 435 2. The so-called “unfortunate experiment” of this book triggered the 1987 New Zealand Cartwright Inquiry into cervical cancer treatment. Consultant gynaecologist Herbert Green of the Auckland National Women’s Hospital was the main target of a long and complex legal process hinging on allegations that he had prospectively studied two groups of women referred to the hospital with positive cervical cytology. One large group received treatment, following which most had no further problems (although some later developed invasive cancer). The second group, it was said, had no treatment but, despite positive cytology, were followed for years so that the natural history of what are now called high-grade epithelial abnormalities (formerly carcinoma-in-situ) could be studied; these women were 25 times more likely than the first group to develop invasive cancer, from which some of them died. Green was accused of callously disregarding the health of these women to satisfy his own scientific curiosity, and condemnation of his actions was central to the findings of the inquiry. However, as Linda Bryder painstakingly demonstrates, there was no such “experiment”. The two groups were a statistical construction in a 1984 paper by four of Green’s colleagues.1 Both groups had been treated but when positive cytology persisted, women were (unsurprisingly) more likely to develop invasive cancer. Green himself certainly advocated a less interventionist approach to the management of cervical pre-malignancy, which in the 1960s tended toward hysterectomy and in the 1970s to cone biopsy. A more low-key approach, now that we understand the role of human papillomavirus and have LLETZ (large loop excision of the transformation zone) procedures available, is universally practised — but, as I’ve observed over my own 30 years of gynaecological practice, it has required a great deal of clinical and scientific effort, much of it by people like Green, to reach this point. Bryder’s book is meticulously referenced and even-handed — although she does not conceal criticism of the feminist health activists who instigated the inquiry. Undoubtedly, the book will arouse much comment from those still able to recall these events, but as a work of medical history it will be a valuable and lasting resource.

Caroline M de Costa

New forms of journalism offer opportunities and pitfalls for health Newspapers and other forms of “old” media face an uncertain future because of withering traditional revenue streams, rising new media technologies, and changing audience expectations. Comparisons have been drawn between the demise of the Roman Empire and that of modern media empires.1 To date, the collapse has been most evident in the United States, where, between 1 January 2008 and 15 September 2009, 46 599 jobs in the journalism industry were lost and 201 media outlets closed.2 The journalism industry lost jobs at almost three times the rate of other industries.2 The number of full-time journalism positions in Australia fell from 8500 to 7500 between 2001 and 2007,3 and more losses are expected (Jonathan Este, Director, Communications, Media Entertainment and Arts Alliance, 20 October 2009, personal communication). The changing nature of the media landscape brings dangers and opportunities for those concerned with the health of societies and populations. The mass media, for all their flaws, have been a powerful force that have influenced and informed policy, practice and attitudes in the health sector and other spheres. The “fourth estate” has also had an important role in scrutinising society’s powerful institutions, and holding them accountable. Media coverage has contributed to significant advances in public health policy. Notably, according to the Advocacy Institute in the US: “News coverage has been the lifeblood of the tobacco control movement”.4 The demise of the traditional media, therefore, has serious implications if it means fewer resources for investigating important health and medical issues or related matters, such as social determinants of health. The traditional media are losing their monopoly on news gathering and dissemination as the Internet and related technologies enable a proliferation of new media outlets and applications. These include blogs, wikis and online social media tools such as Facebook and Twitter. The definition of a blog is a fluid one. Originally coined to mean an online journal in which the entries appeared in reverse chronological order, the term is now used to encompass a wide range of Internet publishing, including journalism.5 A wiki is a website that can be freely edited by participants, who can be either the public at large or a defined group working on a project or from within an organisation. The best-known wiki is the online encyclopaedia Wikipedia. Online social networking tools are evolving fast. One of the first was MySpace, where individuals could post information and send other members messages. Facebook has largely overtaken it as the most popular social networking site, whereas Twitter is a newer social networking tool that is possibly the most relevant for journalism, relying as it does on short, real-time 140-character “headline messages”. The transition from mass media to “masses of media” creates new opportunities. Never before has there been so much media choice or so many adept media users. Anyone with access to the Internet can publish news and views for the world to see. This is a first in human history, and has contributed to the rise of “citizen journalism”. The technology also enables news to reach larger audiences in more ways, and creates new ways of telling stories and engaging audiences. As Mark Scott, managing director of the ABC, stated: “The opportunities to connect and engage have never been more exciting”.1 At the same time, new media have undermined the business models of media institutions. Commercial free-to-air broadcasting remains the main way Australians get their news and information.6 It makes money by aggregating audiences and selling their attention to advertisers, but the audience is fragmenting as more choices become available. Once Australia’s National Broadband Network is complete, and more audiovisual material is delivered via the Internet, the audience will be everywhere at once. Meanwhile, newspapers, which have been the largest employers of journalists, have seen classified advertising decline as advertisers find the Internet is a cheaper and more efficient way of reaching buyers. Although all newspapers have an Internet presence, so far none of their websites make money in their own right once the costs of providing editorial content are factored in. Companies cannot charge as much for an online advertisement as they have been able to charge for a printed advertisement because there are so many online options. If the price is too high, there is always the possibility that industry groups — for example, real estate agents — might start their own online publication. Indeed, this has happened in the case of car dealers. Hence, over the past few years, Australian newspapers have radically decreased their editorial staff. Industry analysts anticipate that, within the next decade, major Australian mastheads will cease to exist, at least as print products and as major employers of journalists.7 However, there is no evidence to suggest that there is a crisis in terms of the public’s appetite for news and information. The health sector is exploiting the opportunities offered by new media. Organisations such as the Cancer Council Australia use social media tools to communicate health information and build communities of engaged supporters. Members of the public also use these tools for patient advocacy, to raise funds for medical research and to mount public health campaigns.8 Social media have also helped disseminate critical information during bushfires and other disasters. US academics who analysed the role of new media in President Barack Obama’s election campaign concluded that there were many lessons relevant to public health advocates, including the potential for increasing audience engagement.9 These lessons appear to have been absorbed by those responsible for the Australian Government’s health reform website (http://www.yourhealth.gov.au/), which encourages interaction from members of the public and health professionals. Health-related blogs compiled by media outlets, organisations, governments, commercial interests and individuals are also proliferating. They open up new avenues to communicate information and disseminate research, and they enable “bottom up” as well as “top down” exchanges. A survey of medical bloggers found that they wanted to share practical knowledge and skills, and their blog ideas were often reported by mainstream media.10 The authors of the survey concluded that blogs are an important vehicle for influencing medical and health policy. At the BlogWorld & New Media Expo held in the US in October 2009, the implications of new media for the health sector were widely discussed. The quality of bloggers’ information is enormously variable, but some, such as Effect Measure (http://scienceblogs.com/effectmeasure/), authored anonymously by senior public health experts in the US, enable more open and incisive discussion about health issues. The Pump Handle (http://thepumphandle.wordpress.com/) is another public health blog with an interest in issues that are “not getting the treatment we think they deserve in the mainstream media”. In Australia, staff at Katoomba Hospital have also harnessed the anonymity available to bloggers to raise matters of interest to their local community (http://whowillspeakforus.blogspot.com/). On the other hand, anti-health interests such as tobacco companies have been quick to seize online opportunities for marketing campaigns, often covertly.11 Meanwhile, media practitioners concerned with the public interest are attempting to develop new journalism models. In the US, several not-for-profit organisations, often funded by philanthropists or universities, commission investigative journalism projects, and some have covered important health issues. The Center for Public Integrity (http://www.publicintegrity.org/) has published investigations into illicit tobacco trafficking and the political influence of the pharmaceutical industry in US politics, for example. Another not-for-profit organisation, ProPublica (http://www.propublica.org/), commissioned an investigation into how hospital staff responded in the aftermath of Hurricane Katrina. A number of health stories are commissioned through an innovative project called Spot. Us (http://www.spot.us/) that experiments with different journalism methods, including the use of community funding and community-sourced news. Australia has been relatively slow to develop new journalism models, perhaps because the traditional media here have not been as hard hit as elsewhere. However, there are some notable examples, including online publications newmatilda.com, funded by a single philanthropist, and Inside Story, based at the Institute for Social Research at Swinburne University of Technology, which has run lengthy pieces on health issues.12 Both of us helped found and are on the board of the recently established Foundation for Public Interest Journalism (also based at the Institute for Social Research), which will develop and test new journalism models. The Foundation will give priority to issues that are under-reported by the traditional media, providing an opportunity to improve coverage of currently neglected health issues. New media ventures are not only expanding the range and type of outlets, but are also changing the nature of the relationship between media and their audiences. According to a US journalism academic, the audience has become “the people formerly known as the audience”.13 They are now also collaborators, antagonists and participants. This changes the relationships between professional news gatherers and their audiences in ways that can make them more interactive, open and transparent than they have been in the past. We believe this can lead to healthier public debate than existed in the era when only a few people had privileged access to the means of publication. However, the new media era involves many challenges and uncertainties, including the need to develop viable and sustainable business models to support journalism that is in the public interest. The proliferation of new media outlets may have some advantages, but it also risks fragmenting public debate — with all the attendant risks that this brings for policy processes and society more broadly. It also raises legitimate anxieties about the quality and reliability of information. Editors have a critical role in new media; in fact, curating masses of material and sifting for quality and importance may be one of the main roles of journalists in the future. There are also concerns about the impact of proliferating digital media on the development of children and young people; there is a need for research to help guide policy in this area.14,15 The new media revolution is underway, but it will be some time until its impact upon the health of our societies and populations is fully understood.

Melissa A Sweet BA, MA(SciTechStud) · Margaret J Simons BA, DCA

When I took a call from MJA Editor Martin Van Der Weyden asking me to write a “Power of One” article for the Christmas issue of the Journal, I was excited and honoured. Here was an opportunity to reflect on the drivers and influences that led me first into medicine, then diabetes and public health advocacy. Baker IDI Heart and Diabetes Institute, Melbourne, VIC. Paul Z Zimmet AO, MD, PhD, FRACP, FRCP, FAFPHM, FTSE, Director Emeritus and Director of International Research paul.zimmetATbakeridi.edu.au In the beginningThe story starts in the small town of Tarnopol in Poland. My father, Jacob Zimmet, studied medicine in Vienna and graduated in 1935. He returned to an unpaid position in the Tarnopol Hospital — unpaid because Jewish doctors could not be “officially” employed in Poland. Realising there was no future for him there, and having experienced the mounting threat of Nazism in Austria, he applied for visas to Australia and the United States in 1937. The Australian visas arrived first, but my mother, Anna, wanted to burn them. She dreaded leaving their families; but my father was certain war was imminent. So, in December 1938, my parents and Rena, their first child, left for Sydney, arriving in January 1939. World War II broke out in September. The remaining family were taken to concentration camps; there were no survivors except my mother’s younger brother.1 My father found that his medical degree from Vienna, one of the world’s finest universities, was not recognised in Australia because Austria was under German occupation. So, after living virtually penniless in Sydney for 6 months, he moved the family to Adelaide where it would take him only 3 years to requalify, rather than 5 years in Sydney. My parents had to find supporting income and, as my mother had brought a treadle sewing machine from Poland, they established a leather business. Mother sewed, and father skipped lectures at the medical school and bicycled around Adelaide to obtain orders. Arriving on the scene — my start in lifeI was born in 1941, and my father graduated from the University of Adelaide in 1942. He obtained a position as a doctor with BHP, and we moved to Whyalla. It was here that the seeds of my future medical career were planted. My father had a wonderful bedside manner and was adored by his patients. I would accompany him on his rounds in Whyalla and to outlying cattle stations and mining communities like Iron Knob, sitting in the back seat of our old Chevrolet. This was my first taste of medicine. In 1950, we moved back to Adelaide. My father commenced general practice, working from our home so we always had patients around us. It was clearly a powerful influence. In later years, he was very proud that three of his children, Rena, Leon and myself, studied medicine and became Fellows of the Royal Australasian College of Physicians because, with the war interrupting his studies and changes in specialist recognition in Australia, he had been unable to practise as a consultant physician. My youngest sister, Miriam, was smarter and elected instead to join the teaching profession, and she has made a significant contribution to community activities. Today, my father would have been even prouder of my sons, Hendrik (cardiology) and Marcel (paediatrics), who have followed the same path, and another grandson, Adam Zimmet, a cardiac surgeon. Although I always wanted to study medicine, I had a less than impressive school record. Only when I reached the University of Adelaide did I come into my own, obtaining a Commonwealth Scholarship based on my first-year results. However, it was then that my medical career nearly ended. On the first day of second-year medicine, we were introduced to the anatomy dissection room. I lasted for 15 minutes before heading up North Terrace to my father’s consulting rooms to tell him I was ditching medicine! I was marched back to the medical school, and that was that. A fond memory of my student days was the clinic dinner at the end of each rotation when we wined and dined our consultants, but this was not for one of them, Basil Hetzel, who had a remarkable career in medicine.2 For Basil, it was a cup of tea and a sandwich in the ward clinic room! At this stage, I had no career aspirations apart from joining my father’s practice. However, because of the small Jewish community in the area, I moved to Melbourne in 1966 in the hope of finding a wife to bring back to Adelaide. I was offered a second-year residency at the Alfred Hospital but, as I had not consolidated my relationship with my wife-to-be, Vivien, by the end of that year, I needed to stay another year in Melbourne. Luck was on my side, as Don Cameron, who was Registrar of the Diabetes and Metabolic Unit at the time, told me that his boss, Pincus Taft, wanted to know if I was interested in the diabetes job. Thus, serendipity stepped in as a partner to Cupid — it seemed a good opportunity and gave me another year to court my future bride. So began a career in diabetes. The first taste of researchDuring that year (1967), I had my first real taste of the excitement of research. We had a case of intestinal lymphangiectasia with marked hypocalcaemia and tetany that was unresponsive to calcium replacement.3 Hal Breidahl, my consultant, and I were puzzled by this. While on a skiing holiday at Falls Creek, I was listening to the “Farmers Hour” on radio, and the penny dropped! They were discussing how magnesium relieved grass tetany in the local cows. Racing back to Melbourne, I arranged a test of the serum magnesium level, which demonstrated hypomagnesaemia. Following magnesium replacement, the tetany ceased and the serum calcium level rose. Thus arose my first publication, in the British Medical Journal.4 I carried the acceptance letter around in my pocket for months. Fortune smiled on me again and, as luck would have it, my next step profoundly influenced my career direction. Monash University was opening a Department of Medicine at the Alfred — I was determined to be their first registrar, and was subsequently appointed. Even though applications for all the other hospital jobs had closed by this time, Pincus Taft called me to say that Bryan Hudson, Head of the Monash Department of Medicine at Prince Henry’s Hospital, had called to ask why Zimmet had not applied to be his registrar. Pincus ordered me to see the charismatic Bryan immediately, and he told me I was to work for him! Hudson’s department had a powerful team including Henry Burger, Kevin Catt, Ken McLean, and Jack Hansky; Mel Korman was the other registrar. It was a wonderful training experience, not only in endocrinology but across internal medicine. Bryan was a fabulous and caring mentor, but a research career was still far from my mind. However, Bryan insisted that I must do a PhD and dispatched me off to the Monash Department of Biochemistry under the legendary Joe “Ginger” Bornstein (Box 1). My PhD was based around Bornstein’s belief that growth hormone fragments were involved in the regulation of glucose metabolism and insulin sensitivity. I slaved at the bench for 2 years, processing hundreds of litres of urine, and isolated a peptide with hypoglycaemic action5 which, some 35 years later, has commenced clinical trials as a drug for type 2 diabetes.6 Joe was convinced that my research was “cutting edge” and that his hypothesis needed better recognition, so he sent my thesis off to be examined by Professor Rolf Luft, the chairman of the Nobel Committee! My introduction to epidemiologyThe time had come for an “overseas” stint. I chose to work with Harry Keen at Guy’s Hospital in London, as I perceived he was a rising star in the field of diabetes and already a leader in diabetes epidemiology. Intuitively, I believed my PhD work needed a population perspective and that the only way to show its real significance in human diabetes would be to test it in an epidemiological framework. Harry stood out as the person to work with, so, with a Royal Australasian College of Physicians Travelling Scholarship, I headed off to spend a year and a half with him and John Jarrett, another outstanding figure in diabetes epidemiology. That well known pub the Bunch of Grapes was adjacent to the grounds of Guy’s and, between their office, the pub and the laboratory, we threw around many ideas. It was an intensely stimulating environment. Then came my next break, and again chance came into play. It was Christmas 1973 in London, and I was flipping through a pile of old Lancet issues when I came across a 1966 article by the famous New Zealand epidemiologist Ian Prior and his colleagues. They had reported a high prevalence of diabetes in Pacific islanders.7 Pincus Taft had a private practice that included the President of the Pacific island of Nauru, Hammer DeRoburt, and, struck by Prior’s findings, I convinced Pincus that we should undertake a diabetes survey in the Micronesian community of Nauru. This plan became the focus of my attention when I returned to Melbourne. By 1975, we were all set to go. I now had my first experience of the difficulties and logistics of undertaking a survey thousands of miles from home on a remote Pacific island. Nauru was a 7-hour flight from Melbourne and there was only one Air Nauru flight a week (but at least they served Château Mouton Rothschild with the meals!). Imagine our dismay on arriving to find that Air Nauru had left most of our equipment, including the oral glucose loads, at Melbourne Airport! Well, we had to thank the British, as a search through old stocks in the pharmacy left over from the colonial days revealed hundreds of bottles of British Pharmacopoeia 50% glucose, which we diluted and made palatable for the oral glucose loads. We tested 100 people on the first day, and I was stunned by the results — 33% of them had diabetes. Pincus, who I had convinced to join me, was certain it was something to do with incorrect dilution of the glucose, or that the blood glucose methodology was flawed. So sure of this was he that he decided to return to Melbourne, leaving me on Nauru. On the second day, another 33% had diabetes; and so on it went. We finished the survey with a prevalence of over 30%, the highest national figure ever reported anywhere in the world.8 The time was ripe to start warning the world about the potential epidemic of diabetes, a disease that still had “Cinderella” status. In 1976, I presented the Nauru results, reporting the highest diabetes prevalence ever recorded for the first time internationally, at the European Association for the Study of Diabetes (EASD) meeting in Helsinki. I spoke at the opening plenary session to a packed hall, wearing a bright red safari suit (Box 2) that made quite an impression on the audience. Its use was intentional, as I wanted my message to be remembered. I had seen the suit in Aquascutum’s window when I passed through London on my way to Helsinki. I thought that even if the participants forgot my message, they might at least remember the suit! Due to a chance meeting, Nauru provided me with further opportunities in epidemiology. In 1976, the Nauru Government asked me to act as physician to the heads of state attending the South Pacific Forum. While relaxing with my family on the beach at Anibare Bay, I started up a conversation with the only other person there. It was John Hirshman, the World Health Organization Representative for the South Pacific. Incredibly, it emerged that he had been a school classmate of my mother-in-law in pre-war Vienna! John was amazed by my Nauru findings and asked me to become a consultant to the WHO. As a result, I was then asked to undertake surveys in other Pacific Islands over the next few years, including Western Samoa, Fiji, Tuvalu, Kiribati, New Caledonia, Wallis and Futuna, the Cook Islands and Papua New Guinea. In each case, the same pattern emerged of high diabetes rates with modernisation of the islanders’ way of life. I “borrowed” the term “coca-colonisation” from Arthur Koestler9 to explain the impact of Westernisation in causing the high prevalence of diabetes in these Pacific communities. Even so, my predictions of an impending global diabetes epidemic and the potential time bomb in terms of morbidity and mortality were not taken seriously. Of course, sometimes my passionate message was misconstrued, as happened with a leading article in Melbourne’s The Age in 1992, titled “A Western killer let loose in paradise” (Box 3). Unfortunately, the message of the article was largely missed, as a photo of me was printed directly under the headline! But at least I now knew where my career was taking me — headlong into diabetes epidemiology and public health. Uncle Sam and the NIH to the rescueIn 1978, I applied to the National Health and Medical Research Council (NHMRC) to pursue the Nauru studies in greater detail, as it promised to be a goldmine of epidemiology. Requesting a modest $25 000 grant, I was rejected because they were not funding projects offshore. Around that time, the US National Institutes of Health (NIH) became a very strong supporter of diabetes epidemiology. This thrust was led by the enthusiasm and vision of Maureen Harris, from the NIH’s diabetes section, and Peter Bennett, internationally renowned for his research into diabetes in the US Pima Indian population. They suggested I apply to the NIH, as the agency was prepared to support overseas groups if they were undertaking work that would benefit the US. I added an extra zero to my NHMRC application and, in 1979, was fortunate to receive NIH funding. The rest is history, and over the next 20 years I received grants totalling in excess of $10 million for epidemiological studies in Pacific and Indian Ocean nations. From 1979 to 2000, my research was continuously funded by the NIH. It focused on the role of genetic susceptibility, obesity, physical activity, nutrition and sociocultural change in the aetiology of type 2 diabetes. My group also made contributions in the area of type 1 diabetes causation and detection with studies on glutamic acid decarboxylase (GAD), and we developed the first anti-GAD immunoassay for predicting type 1 diabetes.10 With Ian Mackay, and Leif Groop and Tiina Tuomi from Finland, we defined the condition of latent autoimmune diabetes in adults (LADA).10 With Mark Myers and Kalindi Hettiarachchi, I reported that bafilomycin, a food toxin produced in potatoes infected by potato scab, might cause β cell damage11 and type 1 diabetes. The founding of Australia’s first diabetes instituteMy clinical and other research strands came together in 1985 when I founded the International Diabetes Institute (IDI). On the way back to Australia from my stint in the United Kingdom, I had spent time in Denmark with Jørn Nerup at the Steno Memorial Hospital in Copenhagen. I was inspired by this unique facility, which brought together all aspects of diabetes research and care. I came home determined to try to replicate it. From a small base at the Royal Southern Memorial Hospital in Caulfield, my associate physician Matthew Cohen and I gradually built up a team covering diabetes education, care and epidemiology research. The IDI was the result, and it was officially opened by the Governor-General, Sir Ninian Stephen, in 1985 (Box 4). Over the next two decades, the IDI became a major force in diabetes both nationally and internationally and was designated as the first WHO Collaborating Centre for Diabetes. My epidemiology interests next took me to Mauritius in the Indian Ocean. Again we found a very high prevalence of diabetes.12 As the population of Mauritius is tri-ethnic — Asian Indian, Chinese and Creole — it represents almost 70% of the global population, making findings there of global relevance in predicting the chronic disease epidemic.13 A very exciting collaboration with Greg Collier at Deakin University commenced in the mid 1990s. I became aware of Psammomys obesus, a unique animal model of obesity and type 2 diabetes, and imported breeding pairs from Israel. Although better known as the Israeli sand rat, it’s actually a gerbil, having 85%–90% homology with the human genome. In its natural desert habitat, P. obesus remains lean and healthy on a low-energy diet of saltbush.14 However, when given access to standard laboratory chow, the animals develop insulin resistance, obesity, type 2 diabetes and the metabolic syndrome. Greg and I established a wonderful and productive collaboration to explore the genetic aspects of “diabesity”, resulting in numerous publications, patents and an exciting decade of research. Calling the diabetes epidemicBy the mid 1990s, it was even clearer to me that obesity and diabetes were destined to be the most important public health challenges of the 21st century, and that the combined diabesity pandemic was now set to affect most nations. Yet, I was very frustrated and saddened that I still could not get diabetes on the international agenda as a major public health issue. Fortunately, the message hit home in Australia in 1996 with the appointment of a new federal Health Minister. As Shadow Health Minister, Michael Wooldridge had seen a publication, The rise and rise of diabetes in Australia,15 that my Institute had prepared for Diabetes Australia. Struck by this, and after lobbying led by John Carter, a leading Sydney diabetologist, Michael committed the Liberal Party to a pre-election promise of $8 million for tackling diabetes. With the election won, he committed himself to projects that got the ball rolling, including a National Diabetes Strategy and eventually AusDiab, the first ever national diabetes and obesity study in Australia. I was fortunate to serve on a small ministerial advisory committee with John Carter and Stephen Colagiuri. Tim Welborn and I had long been advocates for AusDiab. We put together a national consortium and, with government funding facilitated by Michael, and support from the states, the pharmaceutical industry and some trusts, we were off and running in 2000 (Box 5). AusDiab became the largest national diabetes study in the world. We found that 1 million Australian adults had diabetes, another 2 million had prediabetes, and 60% were overweight or obese.16 The study, and its 5-year follow-up, have produced more than 80 peer-reviewed publications, and the data have been used extensively for health care planning both in Australia and internationally.17 National and international recognitionOur research has received global recognition and I have been fortunate to receive numerous national and international awards, including those from the American Diabetes Association, the EASD, Diabetes UK, the Australian Diabetes Society and the Canadian Diabetes Association, and an Honoris Causa Doctoris from the Complutense University of Madrid in Spain (Box 6). In 2007, I received the global Novartis Award for longstanding contributions in the field of diabetes. In fact, the IDI pulled off a trifecta, as it was a great thrill to see Jonathan Shaw, my Deputy Director, and our collaborating ophthalmologist, Tien Wong, receive the two Novartis Awards for younger investigators the previous year. But one award beat them all. In 2007, I was advised that I was to receive the Honorary Silver Breastplate of the All-Russian Diabetes Association. Further enquiries on my part revealed that this was usually a posthumous award that had gone to distinguished researchers such as Aretaeus (147 bc), Paul Langerhans, Elliott Joslin, and Banting and Best. After I informed the Russians that I was still alive, the award was elevated to a Gold Breastplate. As I was to be in St Petersburg soon after, they dispatched an official delegation from Moscow to make the presentation (Box 7). Vivien and I were rather concerned about how we would ship a large and heavy gold breastplate out of Russia, but we need not have worried — it turned out to be a gold lapel pin! The global epidemic and public health advocacyThe forthcoming and first ever national Health Risk Study proposed for 2010 has had its genesis in AusDiab and our advocacy. We can also take some credit for many of the new initiatives in diabetes, including those directed at preventing type 2 diabetes. The current scale of diabetes and obesity in Australia has serious ramifications. Through all of this diabetes “tsunami”, funding for health professionals to handle the epidemic has fallen very short. In parts of Australia, particularly in our Indigenous community, the prevalence of diabetes and its complications, especially renal failure and amputations, exceed those seen in developing nations and rate among the highest in the world. Prime Minister Rudd recognised this burden in an address to the Sydney Institute last year, stating that diabetes will be the number one disease in Australian men, and number two in women, by 2020.18 The studies in Nauru and Mauritius enabled me to confidently predict the diabetes epidemic that has now evolved,12 and we have estimated that the global number of people with diabetes will rise from 246 million in 2007 to 389 million by 2025.19 It was against this background that, in December 2006, the United Nations (UN) General Assembly unanimously passed Resolution 61/225 declaring diabetes an international public health issue — only the second disease after HIV/AIDS to attain that status. For the first time, governments have acknowledged that a non-infectious disease poses as serious a threat to world health as infectious diseases such as HIV/AIDS, tuberculosis and malaria. The UN resolution recognises that tackling diabetes is likely to be one of the most important challenges for the global public health community in the 21st century. Because of the close link between diabetes and heart disease, about 5 years ago I approached Garry Jennings, then Director of the Baker Heart Research Institute, with the idea of merging our two institutes. The marriage is now happily consummated. Together, as the Baker IDI Heart and Diabetes Institute, we have critical mass and will be a powerful force to face the mounting burden of diabetes and heart disease — two partners in crime. We will continue our strong public advocacy for fundamental alterations to how our lives are organised. Unless we learn the lessons from Nauru and Mauritius, and indeed our own Indigenous community, the epidemics of obesity, diabetes and heart disease will only worsen. ConclusionKey features of my career have been chance and the good fortune to have wonderful and inspirational mentors, a very supportive and loving wife, and two sons, Hendrik and Marcel, who continually challenge my social values and continue the family tradition in medicine, music and debate. I have had a great partnership with that towering figure in diabetes, Sir George Alberti, with whom I have chaired numerous WHO and International Diabetes Federation expert consultations on diabetes and the metabolic syndrome, and with whom I have collaborated, along with Jaakko Tuomilehto, in epidemiological studies. I have had other very supportive colleagues and a strong and dedicated team. In particular, Matthew Cohen and Jonathan Shaw have been devoted partners, as we built the IDI into an influential and innovative force on the world diabetes scene. The merged Baker IDI Heart and Diabetes Institute is now one of the largest forces in heart disease and diabetes research in the world. It has been a long road to travel, assisted by many episodes of chance, to achieve my ambition to see diabetes recognised as a major and serious international health problem and to catalyse action for better treatment and prevention. It has been a particular privilege to be a member of the National Preventative Health Taskforce selected by Nicola Roxon, federal Minister for Health and Ageing. The National Preventative Health Strategy, released in September 2009, embraces much of my own philosophy on preventing the escalation of the obesity-driven diabetes and cardiovascular disease epidemic.20 1 The 50th Anniversary of the Discovery of Insulin Congress, Jerusalem, 1971 L–R: Paul Zimmet, Pincus Taft, Joe “Ginger” Bornstein. 2 The red safari suit, Agra, India, 1976 L–R: Paul Zimmet, Professor Tom Johnson, Professor John Jarrett. 3 Report of a killer in paradise 4 With Governor-General Sir Ninian Stephen, opening the International Diabetes Institute in 1985 5 The AusDiab consortium at the 2003 annual meeting in Melbourne 6 Receiving the Honoris Causa Doctoris from the Complutense University of Madrid, Spain, 2002 7 Receiving the Honorary Gold Breastplate of the All-Russian Diabetes Association, St Petersburg, 2007

Paul Z Zimmet

Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe The most rewarding aspect of a career in mental health is that you get to spend time with truly inspiring people. My clinical work has focused on people whose lives have been affected by depression, bipolar disorder or schizophrenia. For any doctor who wants to connect with the most fundamental aspects of what it is to be human, nothing beats a career in mental health. However, the big frustration that I face on a daily basis is the impoverished mental health system in which we provide services. Too often have I run up against the comment, “That’s all true, Ian, but we won’t see any real change in our lifetime”. Brain & Mind Research Institute, University of Sydney, Sydney, NSW. Ian B Hickie AM, MD, FRANZCP, FASSA, Professor of Psychiatry and Executive Director ianhATmed.usyd.edu.au Getting into medicineI was fortunate to grow up in a large, academically oriented family. A rather strong Irish cultural legacy on one side and a printers’ union background on the other left me (and each of my siblings) at odds with the status quo. My early exposure to multiple perspectives, endless rounds of negotiation, and the need to come up with a collective rather than personal solution proved more valuable later in life than much of my professional training. Given my father’s distinguished career in academic medicine, my own journey down that same path may seem to have been rather predictable. Indeed, it now appears that there are strong transgenerational elements at work (Box 1).1,2 Unfortunately, like other rather glib narratives that are common in psychiatry, it’s an interpretation that doesn’t really fit the data. Having a father in academic medicine actually seemed to result in a household with an oversupply of lawyers! Perhaps we all do share a common sense of social justice. However, from my parents’ perspective, having only one of their seven university-educated children pursue a medical career always seemed a rather poor return on investment. While I enjoyed my early medical training at St Vincent’s Hospital in Sydney, the time I spent working for a bookmaker gave me a much better introduction to the more colourful aspects of everyday life. The real highlight of my undergraduate years was the time I spent in the Philippines during the later years of the Marcos regime. Not often can one so clearly experience the direct relationship between the impoverished state of a nation and the grossly inadequate health care that its citizens receive. The time spent with health professionals who took direct social actions to improve the lives of others also left a lasting impression on me. Pursuing psychiatryOn graduating, I jumped at the opportunity to be a resident medical officer at the still rather new and often chaotic Westmead Hospital. Here was a medical centre that was critical to the future of the community in which it was based. While working there, it became very clear to me that, although the rewards of procedural medicine were great and the challenges of internal medicine considerable, only psychiatry was really challenging from a personal and intellectual perspective. At that time, one training program stood out in terms of its academic rigour and breadth of teachers. Consequently, I moved to Prince of Wales and Prince Henry Hospitals to pursue my specialist training. Promoting medical paradigms in psychiatry researchOne of the difficulties that young psychiatrists face is the apparent drift away from conventional measures of pathophysiology. In the absence of clear laboratory markers, there is a recurring tendency to invoke more narrative accounts or other pseudo-sophisticated illness models. Fortunately, I was spared these distractions through my early research collaboration with two great physicians; namely, Andrew Lloyd and Denis Wakefield. Although our shared interest in post-infective fatigue syndromes has always aroused great controversy, it allowed us to work with a robust model for the onset of neurocognitive disturbance following a discrete medical event.3 Twenty years later, this work is now firmly based in more respectable models of cytokine-induced cognitive and mood disturbance.4 More importantly, very few psychiatrists ever receive the collegiate support that I have had from Andrew and Denis over the past two decades, and this collaboration put me in contact with a collection of international experts in medicine and psychiatry who share a much broader world view. Mood Disorders Unit at Prince Henry HospitalTowards the end of my registrar training, I was fortunate to work with the newly established Mood Disorders Unit at Prince Henry Hospital. The concentration of clinical researchers assembled under the leadership of Gordon Parker and Henry Brodaty was crucial to its success. While the work borrowed heavily from Leslie Kiloh’s earlier focus on the subclassification of depression, it used a range of neuroendocrine, neuropsychological and brain imaging technologies to develop a more specific fronto-subcortical model of severe mood disorders.5 During this period, I was lucky enough to lead projects that used magnetic resonance imaging. Although our neurological colleagues were aghast at our “waste” of such expensive tools, conveniently, the Professor of Radiology did not share their narrow view. Consequently, in partnership with Dr Liz Scott at Prince Henry Hospital, we were among the first groups internationally to demonstrate the clinical utility of these new techniques in people with severe depression.6,7 It kick-started a line of work that moved rapidly from detection of an underlying vascular abnormality in late-life depression to the development of large-scale preventive and early intervention programs.8,9 Growing more politicalWe should be active and loud advocates of the mentally ill and be in the forefront of their battle to realise their rights. This might require that we relinquish some of our professional role and add some political activism to our daily chores. Norman Sartorius, 199810 By its nature, the discipline of psychiatry is both philosophical and political. While many prefer the former path, I’ve always thought that Norman Sartorius was on the right track. In the early 1990s, I was very fortunate to win a Harkness Fellowship to pursue both my sociological and brain imaging interests at Duke University in North Carolina. Packing up a family with four young children and shifting continents proved to be quite an adventure. The Fellowship provided me with fundamental insights into the way in which communities could act collectively across a whole range of health and social issues. The emphasis on community action rather than government-based initiatives is central to social progress in the United States. Throughout this period, I had the good fortune of being assisted by an eminent clinician and Dean of Medical Education at Duke University School of Medicine, Dan Blazer. Dan is not only an international leader in depression research but, more importantly, he is gentle, educated, spiritual and community-oriented. His ongoing contributions are thoughtful and particularly relevant to those of us who work at the interface of society and biological medicine.11 Too few medical schools promote role models of this calibre. Joining forces with health administrationSoon after returning to Australia in 1995, I joined Dr Margaret Tobin at Sydney’s St George Hospital. She was determined to drag mental health services into the late 20th century. Margaret and I shared an ongoing joke over who would sustain this charm-free campaign after we had both moved on. Although the facilities were limited, the services were stretched, and the whole process appeared unnecessarily disruptive, it was a great learning experience. Margaret’s tragic death some years later robbed Australia of a person who was truly committed to changing the system. During my 5-year stay in southern Sydney, I learnt what it was possible to achieve with a small group of people who shared a common view of a better future. The deeply personal and broader collegiate relationships that I formed during this period continue to sustain me through tough times. Around this time, my own interests moved rapidly to the substantive issue of the lack of adequate management of depression in primary care settings.12 Working with Liz Scott, Tracey Davenport and a team of young psychologists, we were able to roll out SPHERE: a major national educational and service evaluation program.13 We conducted an audit of over 46 000 consultations in primary care settings. The study emphasised the low rate of detection and active treatment of common mental disorders, highlighted the lack of access to skilled non-pharmacological therapies, and set in place an enduring national general practitioner training program. Over a decade later, that program alone has provided various forms of general practice-based mental health training to more than 10 000 primary care practitioners. This work, in combination with my later advocacy work with beyondblue,14 provided the impetus to correct one of the major flaws in our Medicare funding system; namely, the lack of financial support for psychological services. By 2001, we had convinced the Australian Government of the need to provide specific payments for well trained GPs and clinical psychologists who provided psychological services.15 From my perspective, this was the first in a series of “not in our lifetime” predictions to be defeated. beyondblue and the Kennett eraIn the late 1990s, the Kennett Government in Victoria had moved to confront major health and social problems such as mental illness and drug misuse. In 1999, Kennett’s proposal to establish a national depression research institute appeared to have died with his election loss. However, immediately after that election, the federal Health Minister, Michael Wooldridge, set about resurrecting the plan. In 2000, beyondblue: the national depression initiative was born and Jeff Kennett was appointed as the chairman. It was a credit to the Victorians involved that they were able to put together this very smart deal. I jumped at the opportunity to become the inaugural chief executive officer of beyondblue (Box 2). Sadly, through a bizarre combination of state-based and professional rivalries, my home state of New South Wales refused to join. Despite the resistance, we set an ambitious agenda not only for improved community awareness of depression, but also for significant reform of primary care services, establishment of large-scale postnatal depression and secondary school-based preventive research, and investments in smaller-scale community-based and translational research programs. Importantly, we achieved major changes in other key industries such as life insurance and income protection.16 In the longer term, beyondblue has proven to be the major national driver of increased community awareness of depression and other common mental health problems.17 The wider significance of this to the field of mental health, and specifically the lives of those who live with depression, cannot be underestimated — we have seen major changes in community attitudes in our lifetime. Some have described my relationship with Mr Kennett as a rather odd example of a very odd couple. I always preferred the description provided by a Victorian taxi driver — he thought we could easily double for the comedians Roy and HG! In truth, Mr Kennett has many skills that are invaluable to our field. He also respected the fact that those with technical or clinical skills needed to take the lead on illness-related issues. If not for the offer of a lifetime from Max Bennett and the University of Sydney, I would have been happy to have spent a much longer period in Melbourne. Establishing the Brain & Mind Research InstituteThere is no doubt that the lack of a solid evidence base, and the long periods between genuine breakthroughs in clinical therapeutics, discourages some young doctors from pursuing a career in mental health. By the end of the 20th century, it had become clear that a fundamental change in direction for psychiatry was possible. The opportunity to forge real links with other clinical and basic neurosciences was emerging. Thanks to the foresight of Gavin Brown, then Vice-Chancellor of the University of Sydney, and the unrelenting drive of Professor Max Bennett, the Brain & Mind Research Institute (BMRI) was created (Box 3).18 In 2003, I left Melbourne rather prematurely to become its inaugural executive director. The BMRI is a unique campus, now combining over 20 major research teams that span key disciplines and technologies. I am proud that at least one major Australian educational institution has chosen to value mental health research so highly. The federal and state governments have responded positively to this movement, and we can now boast that the facilities provided for both patients and researchers are as good as any that one would expect for the management of cancer, infection or heart disease. This has been the third major “not in our lifetime” moment that I have experienced. Our ongoing focus on discovering how dysfunctional glial cell–neuronal networks give rise to the major mental disorders will keep us busy for some time to come. The BMRI is now the home of my own interdisciplinary and clinical research program. From 2007, this has been supported by a National Health and Medical Research Council (NHMRC) Australia Fellowship for health and medical research. Some of those close to me suggested that the NHMRC would be unlikely to back a clinical and health services-oriented psychiatrist under this scheme — just another “not in our lifetime” prediction that proved erroneous. It has enabled my talented team of clinicians and scientists to pursue large-scale national and international collaborative research. In partnership with Pat McGorry and his team in Melbourne, and led by Liz Scott and Sharon Naismith at the BMRI, we are rapidly developing a world-leading program of youth services19 and clinical research.20,21 This is complemented by our academic (with Helen Christensen at the Australian National University) and community (with the Inspire Foundation) partnerships in developing relevant e-health services. Achieving real political and social changeTwice in the space of a recent month I had senior political people say to me, “I know that needed to be said, but did you have to be the person who said it?!” One of the more obvious responsibilities associated with working in mental health is to speak out on behalf of those who are marginalised, neglected or abused. Fortunately, my peer relationships have grown to include a wider group of community and political leaders. Collectively, we have tried to push the political and social agenda. While the world of mental illness is no longer characterised by the more obvious abuses of human rights, it is still plagued by systematic failures in access to basic health care (only 35% of those with a common disorder receive treatment, and this has not improved in the past decade22), a lack of focus on early intervention for young people,23 too much reliance on the old restrictive ways,24 and disconnection from essential social, economic, employment, education and housing supports.25 As recently emphasised by the National Health and Hospitals Reform Commission,26 mental health continues to be an area of great inequity. Traditionally, politicians, health and educational institutions or philanthropists do not rush to identify with this form of suffering. At times, however, there have been notable exceptions. In 1993, the Keating Government responded positively to the findings of the Burdekin Royal Commission into mental health services and backed the first National Mental Health Strategy (1993–1998). This was continued as a second 5-year strategy (1998–2003) by the Howard Government. Sadly, leadership of that reform process was left under the control of a state-based committee that had little stomach for real change. By 2002, the community’s frustration with the lack of progress was palpable, and my colleagues and I decided it was time to revisit the community’s experiences. Working through the Mental Health Council of Australia, and with the assistance of the Human Rights Commissioner, Sev Ozdowski, we were able to complete a national evaluation that once again highlighted the disastrous consequences of our fundamental lack of investment in key mental health services and related social supports.27 The launch of the resulting report, Not for service: experiences of injustice and despair in mental health care in Australia,28 at the BMRI in 2005 indicated that our new academic home was not only committed to fundamental scientific advances but would also continue to engage in the issues that affected the daily lives of those with severe mental disorders. Although the Health Minister of the day sought to lay the blame at the feet of the states, a few days later, Prime Minister John Howard made it clear that mental heath reform was indeed a major social and economic issue that demanded a serious response. This rhetoric was matched by real action in mid 2006 when Prime Minister Howard and NSW Premier Morris Iemma enacted the Council of Australian Governments’ new National Action Plan on Mental Health 2006–2011.29 This national political action was a direct result of our 4 years of sustained campaigning. It was accompanied by over $4 billion in new investments and led directly to key structural changes. The most important of these was the introduction of new Medicare rebates for psychological treatments. Once again, this was a genuine “not in our lifetime” breakthrough. Prime Minister Howard went on to support the development of a new stream of youth services under the headspace initiative,23 while Premier Iemma backed substantial new infrastructure investments in youth mental health (Box 4) and research into the biological basis of psychotic disorders. Since its election in 2007, the Rudd Government has promoted much discussion about the future of our health system and, importantly for mental health, the development of the concept of social inclusion. At this stage, we are still waiting to see whether the rhetoric will be backed by decisive action.30 Although I have been appointed to the Health Minister’s new National Advisory Council on Mental Health, it is clear we need a government that genuinely prioritises improved access to mental health care, as well as linking health with other key areas of social services and disability support. The struggle to achieve another “not in our lifetime” moment is ongoing. Trying to find new ways to achieve real changeMost of my own community and advocacy work has sought to develop new styles of social and political partnerships. The key roles that the media, the business world, industries, community organisations and other professionals can play in improving the lives of those with mental illness have been obvious. I’m now deeply suspicious of those who seek either a largely government-delivered solution or, on the other hand, promote a simplistic, laissez faire approach. As in other areas of health care, developing services that respond personally to the particular needs of those we serve remains the biggest challenge. Staying in the businessA sustaining influence for much of my academic and social advocacy work has been the intellectual prowess of my professional colleagues. When asked why I chose to pursue psychiatry, I remark that the most interesting people I met throughout my medical training were psychiatrists. Real characters and genuine thinkers like Neil McConaghy, Gavin Andrews, Issy Pilowsky and Scott Henderson stand out. While leaders in other areas of medicine are identified by their technical skill or their lifetime dedication to patient care, psychiatry thrives on the daily contest of ideas. Although too few senior psychiatrists have engaged in the broader struggle to overcome the fundamental inequities that people with mental illness face, I have immensely enjoyed my work with the leadership of the Mental Health Council of Australia (and, specifically, the late Dr Grace Groom and then Mr John Mendoza). These days, I have the pleasure of the company of a new generation of Australian-based but international leaders in mental health such as Pat McGorry, Chris Pantelis, Helen Christensen and Nick Martin. Looking to the futureFor my colleagues and me, the past two decades have really been about working with the wider community to set a clear reform agenda in mental health. While our collective minds remain firmly focused on key issues of health equity, promotion of early intervention and youth-specific services, protection of human rights, access to evidence-based health services, and provision of appropriate social, employment and housing supports, real progress will remain dependent on our capacity to engage genuine community and political support. From a personal perspective, there are many more challenges ahead. 1 Three generations of medical research Ian Hickie (standing), with daughter Megan Hickie (left), partner Elizabeth Scott (right), and father Professor John Hickie AO (seated). 2 Launch of the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, July 2002 L–R: The Hon Bronwyn Pike (Victorian Minister for Community Services), The Hon Jeff Kennett (Chairman, beyondblue), Ian Hickie (Chief Executive Officer, beyondblue), Professor Bruce Singh (University of Melbourne). 3 Opening of the Brain & Mind Research Institute research laboratories, 2006 Ian Hickie and Prime Minister John Howard. 4 Opening of the clinical and translational research facilities at the Brain & Mind Research Institute, 2007 L–R: Premier Morris Iemma, Professor Max Bennett AO, Ian Hickie.

Ian B Hickie

In October 1918, an Allied army (Egyptian Expeditionary Force) in Palestine experienced simultaneous epidemics of falciparum malaria and influenza during the cavalry campaign that defeated the Turkish Army. Malaria infection occurred 2 weeks after the advance of cavalry units into areas without environmental mosquito control. Pandemic influenza, now thought to be an A/H1N1 strain, struck at the same time. In the Egyptian Expeditionary Force of 315 000 soldiers, 773 died from malaria and 934 from influenza–pneumonia. Disease casualties outnumbered those due to combat by more than 37 to 1. Simultaneous infectious disease epidemics can cause mass casualties, capable of overwhelming any health service.

G Dennis Shanks MD, MPH

Charles Darwin visited New Zealand in December 1835, and Australia from January until March 1836, on the return portion of his voyage around the world in HMS Beagle. Despite the shortness of these visits, he retained an interest in these countries throughout his life, maintaining correspondence and receiving many biological specimens. His experiences in these places influenced his thinking on evolution, particularly on the evolution of man. Aspects of his health recorded during this part of the voyage support a new hypothesis for the diagnosis of the illness that Darwin endured for most of his life.

John A Hayman MB BS, MD, FRCPA

Body and mind. Historical essays in honour of F B Smith. Graeme Davison, Pat Jalland, Wilfred Prest, editors. Melbourne: Melbourne University Press, 2009 (ix + 243 pp). ISBN 978 0 522 85717 7. Francis Barrymore “Barry” Smith, Emeritus Professor at the Australian National University (ANU), is one of Australia’s most outstanding and influential historians. This festschrift is a fine collection of essays by a very well respected group of historians, all of whose work has in some way been influenced by Smith. Retiring in 1997 (to continue his work as a Visiting Fellow), Smith spent most of his career at the ANU. Much of his work was concerned with British, rather than Australian, social and medical history and, reflecting this, six of the 10 chapters focus on aspects of British history. These include Alex Tyrrell’s delightful study of the mid 19th century British water cure, Pat Jalland’s thought-provoking piece on the treatment of tens of thousands of civilians killed during the Blitz, and Joanna Bourke’s insightful discussion of “malingering” and the complex relationships between members of the medical profession, especially psychologists, and those who seek to be certified as officially sick. Among the essays dealing with Australian topics is one on a major study in historical demography and epidemiology currently still being conducted by Janet McCalman, Ruth Morley and Gita Mishra. It draws on a range of sources of historical statistics, particularly the records of the Lying-in Hospital for Melbourne, and follows large numbers of individual lives from birth to death, by linking to other sources such as birth, marriage and death records, criminal records, school records and war service records. The essay “To die without friends: solitaries, drifters and failures in a new world society” examines the relationship between poverty, marginalisation and the absence of family and friends. Australian chapters also include Peter Edward’s study of Agent Orange and Australia’s Vietnam veterans, Philippa Mein Smith’s history of the concept of “Australasia” and Susan Margarey’s biographical sketch of Catherine Helen Spence (writer, preacher, reformer, feminist and leading woman in public affairs in Australia at the end of the 19th century).

Sally Wilde

With healing hands. The untold story of the Australian civilian surgical teams in Vietnam. Gary McKay, Elizabeth Stewart. Sydney: Allen and Unwin, 2009 (xvii + 286 pp). ISBN 9781741750744. Even after the passage of more than 30 years, Australians retain a collective memory of the war in Vietnam. But the volunteer surgical teams, sent by the government to work in local hospitals and treat the civilian population, have largely been forgotten. From 1964 to 1972, about 450 doctors and nurses served for periods of 3 to 12 months in one of four locations — Long Xuyen, Bien Hoa, Vung Tau and Ba Ria. Some returned for a second or third term. They were exposed to considerable personal danger and, on occasion, were under attack by the Viet Cong. Using diaries, letters and reminiscences of many team members, the authors (McKay, a Vietnam veteran, and Stewart, a historian at the Australian War Memorial) paint a vivid picture of the difficulties and frustrations of medical and surgical practice in primitive conditions with inadequate equipment, in the face of cultural indifference and lukewarm government support. This situation will be familiar to every doctor and nurse who has worked in developing countries in more recent times. More than half the patients treated were the victims of war; many others had been involved in road accidents. The stress under which the team members worked was unrelenting. Many have since suffered physical impairments to their health, with some developing post-traumatic stress disorder. Unlike Vietnam veterans, members of the surgical teams have no entitlement to repatriation benefits. The government has acknowledged their service to Australia by awarding them the same campaign medals given to soldiers, but has withheld the same entitlements. It is not too late, the authors believe, to redress this injustice. They conclude by posing the question, “Was it worth it?” Most of those interviewed seemed to think so, even if little of a permanent nature was achieved. After all, is not the relief of suffering the foremost of a doctor’s duties?

Robert K Likeman

Each year, medical editors at the MJA read thousands of peer-review reports recommending the acceptance, revision or rejection of hundreds of manuscripts. This advice is generally sound and based on data, information and knowledge. It is always gratefully received and highly valued. Most rarely received, but most prized of all, are comments steeped in wisdom. What is wisdom? It seems that data progress to information and then on to knowledge. British physicist, experimental psychologist and revolutionary futurist Peter Russell suggests that knowledge then progresses to a new level of thinking — what we call wisdom.1 The essence of wisdom is discernment — of right from wrong, of helpful from harmful, and of truth from delusion. Here, we string together some of our reviewers’ pearls of wisdom that appeared on MJA medical editors’ screens this year. When one is not enough“On its own, monitoring cannot combat rising obesity levels. If this argument were to hold for Indigenous health, we would have closed the gap between Indigenous and non-Indigenous morbidity and mortality well before now.” Timing matters“This is a ‘work-in-progress’ report on an important initiative, although the fruits have yet to ripen, let alone be gathered.” Apples and oranges“Petrol sniffing and filling up your car with petrol are comparable — yes, the end result is acquiring petrol, but they should not be mentioned together.” Nothing will happen“The trouble with the term ‘judicious use’ is that it results in no meaningful change in behaviour.” Anyone for a purge?“The only way to tell the difference between the sheep and the true believers is by the occasional bloody purge (no, not the swear word, the literal meaning). Thomas Jefferson said: ‘A little revolution [sic] now and then is a good thing... The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants’.2 So publish I say, and let the blood run free.” Woof! Peer review can be a tricky business. Although it is not uncommon for a content expert to suggest a revision that is at odds with the statistical advice received, it is indeed uncommon for the content reviewer to be proven right. After seeking further advice to resolve one such contentious point, our arbitrator delightfully quipped: “You should give this content expert a gold star! A big one. About the size of a small dog. He is absolutely correct in his points and I support his concern about the suggestions of the statistical reviewer.” The reviewer who received the compliment was just as quick-witted: “Let’s hope the ‘small dog’ does not bite me!” Food for thoughtBlissfully, MJA authors display an equal share of wisdom, not only in the Journal pages but also in their correspondence. Author: “There is not much one can put in 850 words and 10 references, but an editorial should probably be an invitation to think rather than a recipe to follow.” TouchéReviewer: “The editorial needs to be much more critical, eg, pointing out the preliminary nature of the studies and that they are at best hypothesis-generating. It might even stipulate the definitive studies that are needed and the confounders that need to be overcome...” Authors’ reply: “We would like to quote Sir Austin Bradford Hill: ‘All scientific work is incomplete — whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand ...’”3 Whereas online publishing is a relatively recent innovation, wisdom is ancient and enduring. In the 17th century, Thomas Bartholin, the Danish physician, physiologist and anatomist, penned what has become one of my favourite quotations: Unfortunately, there are enough people who are so infatuated with their specialized studies that they are ignorant and unaware of other disciplines. If fate happens to lead them to fields other than their own, they are helpless and lost. May God protect you from an infection with the germs of haughty contempt for the efforts of scientists in other branches of science. Your country demands more than one-sided proficiency. Only the correlation of extensive knowledge will bring us closer to actual wisdom.4 Perhaps depth comes with a breadth of experience?

Ann T Gregory MB BS, GradCertPopHealth

For Susan * Richard Bronson’s collection of poetry Silent music is published byPadishah Press (New York, 2009). This poem is reproduced with permission. You lit a candle at Chartres, a prayer from one mother to another and placed it with the hundred others, white wax in red glass, a light burning in the deeps of this Earthly palace which men of all stations had labored to build for the Queen of Heaven. Neither of us believers in the faith that told of God incarnate born of a woman to rescue all men from Death — yet in this ancient place, in the quiet shadows of its holiness, you felt the need to say your fervent prayer for the world.

Richard Bronson,* MD

“I vont to do an emergency caesar, quick!” Andre’s voice crackled into my heavy, hand-held emergency telephone, which I had not yet mastered. Andre was a tall, good-natured Dutch general practitioner who had been working at Dili National Hospital for over a year and did much of the obstetrics when the hospital lacked a specialist obstetrician (a frequent occurrence). I had warmed to him immediately; he was one of the very few people employed in the hospital who spoke English, and he had an air of confidence that was reassuring. He told me that the operating room was already preparing for the procedure, he would be there in 30 minutes, and he hoped I could have the patient anaesthetised and ready by that time. It was my second day as the only anaesthetist at the only tertiary referral hospital in East Timor, and I had just discovered that, at that time (August 2001), I was the only specialty trained anaesthetist in the country. I was already finding my job challenging. Dili National Hospital (formerly, the Indonesian State Hospital) had had an eventful recent history. After the referendum supervised by the United Nations in August 1999, when the people of East Timor voted overwhelmingly for independence from Indonesia, the Indonesian army and its local militia withdrew — burning, looting and killing as they went. When the International Committee of the Red Cross took over temporary management of the hospital in September 1999, they found that the buildings were intact but much of the equipment had been looted or damaged, and only 10 nurses remained caring for 37 patients. With the support of the Red Cross and the local population, the hospital was re-established and handed over to the new Government of East Timor on 30 June 2001. The hospital’s bed capacity was 226, and it was greatly in need of external support, especially specialty medical staff, technical assistance, equipment and drugs. The challenges for an anaesthetist at this time in East Timor have been well described.1 The limited facilities for anaesthesia, the minimal laboratory and radiological investigations available, the lack of drugs, and the scarcity of blood for transfusion were major daily concerns. However, by far the greatest difficulty I faced was the language barrier. The languages spoken in East Timor are Indonesian, Tetum and Portuguese. Apart from a few expatriate medical practitioners, very few of the more than 300 East Timorese hospital staff spoke any English, and it was rare to find a patient with any understanding of English. In particular, none of the staff working in the operating room spoke or appeared to understand English. My initial approach was that commonly used by English speakers when faced with people who don’t speak English. I would speak very slowly, opening my mouth wide and carefully enunciating my words, which of course they didn’t understand. Next, I would raise my voice in the hope that loud English words would penetrate further into the brain of the listener, perhaps to a part of the brain that somehow understood English. Failing this, I would add some crude improvised hand and arm movements in an attempt at sign language. Finally, if my listener still had that gentle, bemused look that I was becoming very familiar with, I would reach into my pocket for my Indonesian–English dictionary. I would find the appropriate word and point at it repeatedly, while staring at my listener hoping for some indication that all was now clear and that he or she understood what in the hell I was talking about. This was a slow process to be sure and, as I was to discover, fraught with risks. Part of my responsibility was to instruct the East Timorese male nurse anaesthetists when they were in the operating room. So, on my first day, when confronted with a patient who developed tachycardia during anaesthesia, I decided this was an excellent opportunity to begin my teaching sessions. Applying the communication techniques described above, I soon had the attention of the entire operating room staff. With a raised voice, I slowly and loudly enunciated the words “too fast”. I then repeatedly pointed at the rapid electrocardiogram trace on the patient monitor, saying “too fast”. Unconvinced that I was being fully understood, I took out my dictionary, found the word “fast” and pointed at the word and then at the monitor. Suddenly, to my delight, the two nurse anaesthetists both smiled knowingly, but then strangely began to make blowing noises through their pursed lips, much to the amusement of the rest of the operating room staff. Somewhat bemused, I finally looked down at the dictionary and found that my finger had inadvertently been pointing at the word “fart”, not the word “fast”. This early incident, although highlighting the difficulties I would face in communicating easily and effectively, also paradoxically helped me rapidly establish a casual rapport with the staff that lasted for my stay at the hospital! Responding to Andre’s request for my anaesthesia services, I hurried to the maternity ward to see my first obstetrical patient in Dili. Neither the patient nor the staff spoke or understood English but, by observing the patient and looking up her records, I did glean some important clinical details. She was a distressed 32-year-old multigravida with severe pre-eclampsia. She was in strong labour with ruptured membranes and meconium-stained liquor. Her eyes were puffy, she was photophobic, her blood pressure was between 180/140 and 240/170 mmHg, and there was protein in her urine. There were no antihypertensive drugs on the ward; in fact, there were none in the entire hospital. This was indeed an emergency situation. There was no time for me to practise my communicating skills, so I hurried to the operating room, trusting that Andre and the nursing staff had explained the need for a caesarean section to the patient. I arrived in the operating room closely followed by the patient on a trolley. Two male nurses were present. They were scrubbed and gowned and busily preparing instruments as I moved the patient onto the operating table and positioned her on her side in preparation for a spinal anaesthetic. I was about to place monitors and insert an intravenous line when she suddenly had a strong, painful contraction. I stopped my preparation and began massaging her lumbar region, while murmuring quiet, reassuring English words (gibberish to her ears) and waited for the end of the contraction. Without warning, there was a sudden thud and a loud cry. Looking down at my feet, I saw a wailing, meconium-stained baby on the floor. I looked at the mother and saw, emerging from between her legs, an umbilical cord that had obviously broken off as the baby fell to the floor. The two nurses standing behind their instrument trays were wide-eyed and aghast and appeared unable to move. I picked up the now screaming, slippery baby boy and was holding him in my arms when a midwife entered the theatre. I immediately tried to communicate to her that the baby had fallen on the floor, and probably on his head. This I did by repeatedly hitting my head with my free hand, as I held the baby in my other arm. At the same time I was imploring the scrub nurses, who still seemed unable to move, to “Get Andre! Get Andre!” Meanwhile, the mother had now rolled onto her back and was staring in disbelief at the long umbilical cord between her legs and then at my antics with the baby. I felt completely out of my depth and very far from home. Here I was in a foreign country, in an operating room full of people who didn’t understand a word I was saying, holding a baby in one arm and repeatedly banging my head with my other hand, while talking excitedly to a midwife who was looking at me as though I was crazy. Flashing through my mind were visions of my O and G professor from medical school days. I kept thinking of the delight he would have taken in reprimanding me in his usual aggressive, sarcastic manner for this utterly inept performance. I eventually recovered some degree of composure and handed the screaming baby over to the bemused midwife, so I could turn my attention to the mother who seemed completely overwhelmed by these events. I placed monitors, gave her some intravenous syntocinon, and then massaged her lower abdomen while gently pulling on the umbilical cord. To my astonishment and relief the placenta delivered with ease. Five minutes later Andre arrived to smiles all around. The mother was now holding her new baby boy, and was obviously relieved at not having to have an operation. The baby appeared well and unaffected by his precipitous birth. The staff were talking excitedly, presumably about the events they had just witnessed, but I had no idea what they were saying about the strange behaviour of the doctor from Australia. I had settled somewhat, although I still had visions of the out-of-control events and was eager to change out of my operating theatre garb. During my 3 weeks in East Timor, I continued to have many communication difficulties and frustrations, but my saving grace was the East Timorese people. They are a gentle, kind, fun-loving people and their response to my pathetic attempts at communication was always tolerant and often accompanied by a bemused smile, if not gentle laughter. The East Timorese have suffered much in their long history of invasions, civil war and interactions with foreigners. Perhaps, out of necessity, they have developed a resilient and tolerant attitude to the presence of foreigners. They have been invaded in the distant past by the Portuguese and, in World War II, by the Japanese. In more recent times, there have been invasions by the Indonesians, followed by United Nations peacekeepers, and now most recently by the most subtle of invaders — the aid worker. I learnt to greatly respect and admire the courage of the East Timorese people, especially the way they coped with their tragic past, the uncertainty of their everyday life, and the sad events that we faced at times in Dili National Hospital. As with my other sojourns in developing countries on “aid missions”, I have learnt much more from the people I met than they have from me. The gentle, tolerant and bemused smiles of the East Timorese remain with me still.

Geoffrey C Mullins MB BS, FANZCA

Some years ago, a woman in her late 30s was referred to me for consideration for an amniocentesis on the basis of advanced maternal age. She had had three previous pregnancies, all resulting in healthy babies. An ultrasound confirmed a single, viable intrauterine pregnancy, and a fetal size consistent with dates. The amniocentesis was performed without complications. However, the results of the chromosome culture showed there was a balanced 2 on 17 translocation (Box). This was of concern to me — if this was a new mutation, there would be a significant risk that the fetus could have a neurological disorder, ranging from mild cerebral dysfunction, through to severe intellectual disability. However, most cases that I see with a translocation are not new mutations; they are a reflection of the chromosome makeup of one of the parents. I contacted the patient, and told her of the result, and requested that her blood and her husband’s blood be analysed for evidence of a translocation. After 72 hours, the laboratory issued the report showing that neither the patient nor her husband had the translocation. This did alarm me, but when I told the patient about the results, she asked whether it would be reasonable for her boyfriend to have chromosome analysis done as well. I assured her that this would be very useful, and contacted her boyfriend. He supplied blood and, sure enough, it showed that he had a balanced 2 on 17 translocation. I explained to the patient that, under these circumstances, the fetus was very unlikely to have an intellectual disability, and she seemed quite relaxed about this information. I discussed the result further with the patient’s boyfriend, pointing out to him that it may be possible that his siblings could also have a balanced translocation. If he or his siblings had any further children, these children could be affected. The patient’s boyfriend told me categorically that he was not going to be having any more children. He had a sister who had three children, and she was not going to have any further pregnancies. Nevertheless, his sister agreed to have a chromosome analysis done, which confirmed that she had a normal chromosome complement. The boyfriend also told me that he had a brother who lived on a farm. When I asked if it was likely that he would have children, he said that his brother was 28 years old and had been damaged by obstetric forceps during a difficult delivery, leaving him with an intellectual disability. This brother agreed to have chromosome analysis, and surprise, surprise, it showed that he had an unbalanced translocation. This then would explain his intellectual disability. I doubt very much whether the obstetric forceps played any role in his condition. When my patient’s baby was born, a physical examination showed that the baby was normal. I recount this history to reinforce that sometimes the obvious is not as clear cut as one may first think. The country general practitioner who delivered the boyfriend’s brother 28 years ago has probably laboured under the weight of blame being ascribed to him for the poor outcome in this young man. Chromosome translocations If two chromosomes break, genetic material can be exchanged between the chromosomes. This is called a translocation. If the person with the translocation has lost or gained no genetic material, and is phenotypically normal, the rearrangement of the genetic material is said to be balanced — a balanced translocation. If the person has an excessive or decreased amount of genetic material after the breakage, the rearrangement of the genetic material is said to be unbalanced — an unbalanced translocation.

Francis V Carmody FRCOG, FRANZCOG, DDU

The first rat I met in South Vietnam in 1967 was a hairless pup, jiggled by the tail in front of a bawling infant in a clinic we were holding in a refugee camp in sand dunes on the central coast, south of the city of Tuy Hoa. His mother had produced it from inside her shirt for tranquilising purposes, and it did the trick. As his eyes focused, the infant’s larynx relaxed, and everyone began to feel better until stubby hands groped for the rodent. With a twist of the wrist, however, the mother avoided a spectacle that might have lingered in our minds. I met my second rat later that day. He was a hairy thing, bolting across the sandy road between the barracks, and I wondered what he was doing out in the sun. I was surprised when he came to a sudden stop, and incredulous when he began to move backwards in a limb-whirling shower of sand. I blinked to clear my eyes of perspiration and found the reason for the rat’s reverse: fishing line connecting a rear leg to the hand of a small boy squatting with friends in the shade beside one of the huts. The rat was being reeled in to be released again, and yet again, by serious captors. I met more rats when I went into one of the barracks on a “home visit”. The huts were all the same, erected on the sand from corrugated iron and jammed with 30–40 people and their belongings. The inmates had been relocated from war zones for their own “good” and passed their days in idle misery, eating grain delivered by the government and throwing their refuse into open pits. It was very hot in the barracks — literally like being in an oven because each family cooked its meals over open fires, inside the tin sheds, in the sand dunes, under the blazing sun. The huts were stifling with smoke and humanity. I made my way to one fire to see what was on for lunch and found a frying pan filled with rats. Denuded, disembowelled and beheaded, they sizzled flank by flank under the care of an older woman in black pyjamas. Nearby lay the first of my patients: a man who was sick, febrile and immobilised by a large, painful lump in his groin, which was covered by oedematous, bluish skin. An abscess, I thought, and injected the only antibiotic I had, streptomycin, before moving to the next patient, who also had an abscess. And then, another. This seemed odd, but I remembered the holiday I had once endured as a small boy on a waterless farm in Queensland and the crops of boils that had erupted in the nether regions of several of us children after sharing an inch or two of black bath water. I suspected poor hygiene. It never crossed my mind the abscesses might have had something to do with the rats. But these “boils” were so large, and the people so sick, I aspirated one and sent pus to a nearby United States Air Force laboratory. Returning in a few days for the results, I had barely begun to savour the delicious air conditioning when a door was flung open and the technician announced with great excitement: “It is P. pestis! P. pestis! [Pasteurella pestis; now known as Yersinia pestis]” So what? I wondered, trying to recall any mention of that organism in my recent undergraduate experience at the University of Sydney. The technician informed me that we had discovered an outbreak of plague. Plague in Vietnam did not begin or end in our refugee camp. It was first recorded in 1898 in Nha Trang, south of Tuy Hoa, and the absence of any local name seemed to confirm its novelty.1 It was assumed it had been transported by ship from Hong Kong, where the Chinese epidemic had reached in 1894.1 In 1906, it was reported in Saigon (now Ho Chi Minh City), where it became endemic and caused about 1000 cases a year until the strict French administration managed to restrict it to about 25 cases a year in the 1930s. It increased again in the 1940s, during World War II. From 1962, however, the incidence in South Vietnam soared —5000–10 000 cases were reported annually until 1973,1,2 after which it fell. What caused this apparent outbreak? Where did it come from? Why did it stop? Marshall and colleagues denied an outbreak, stating it had been endemic since importation, and this notable increase merely reflected better identification by the increased numbers of doctors and laboratories associated with the Vietnam War.3 As confirmation of endemicity, they cited outbreaks in refugees and Viet Cong prisoners from regions beyond the reach of allied hospitals.3 Most rejected these denials but, if endemic, where was the fertile reservoir? Rural or town rats? It was argued “if there is no evidence that plague has come from outside sources” it must be based in “local wild rodents”,4 who transmit it either directly to humans, or indirectly, via urban rodents they have infected. Historically, plague has occasionally been associated with rural disruption. In India in 19945,6 and Algeria in 2003,7 outbreaks were preceded by rural earthquakes. Did burrows of rodents in rural areas collapse, forcing their residents to join — and infect — human refugees? Did broken buildings provide access to more food and permit proliferation? In South Vietnam, during the Vietnam War there were two massive disruptions in rural ecology: the bombing campaign and defoliation. Coincident with the outbreak of plague, 7.5 million tons of bombs (plus other ordnance) were dropped on rural South Vietnam: three times the weight dropped in World War II and with 100 times the combined impact of the atomic bombs dropped on Japan.8 Did these artificially made earthquakes drive rural rodents to the towns? Did they rupture grain stores, allowing access to food sources? Was there a limit to how much even a rat could take? Did defoliation alter their eating habits, with the same result? In 1962, Operation Ranch Hand was launched to deprive the Viet Cong of food and cover. It peaked in 1968–1969 and ended in 1971, after the spraying of over 6 million acres of rural land.9 Deforestation increases contact between humans and sylvatic sources,5 and Akiev noted that 86% of cases of plague in South Vietnam between 1966 and 1970 occurred in the most defoliated provinces.10 In many of these provinces, plague appeared for the first time. Although plausible, the theory that rural mammals were the source of plague was contradicted by field studies that found the disease to be surprisingly restricted to town mammals. Although trapping in the countryside was a dangerous pastime in those days, restricting research, Marshall and colleagues found that 99% of infected animals were the town rats, Rattus norvegicus, R. rattus, R. exulans, and the house shrew, Suncus murinus.11 After the war, researchers found that zoonotic foci were restricted to human settlement. Moreover, the flea vector, Xenopsylla cheopis, “exist[ed] only on indoor, commensal rodents”.12 Later, Suntsov and colleagues found only one rare flea to be common to rural and urban rodents, making it unlikely plague would be transferred from one to the other.13 If the rural mammals were not abandoning their homes, humans were. Around 3 million people (10% of the population) were relocated to camps such as ours in Tuy Hoa, and plague has long been recognised as a disease of the poor, crowded in slums where rats proliferate on rubbish.14 Certainly, there was inadequate disposal of rubbish in our camp, but proliferation of the urban rodents may have been even more encouraged by the practice of feeding refugees with grain shipped from central deposits and stored imperfectly in the camps in the provinces.3 This promoted transportation of rats from sites of endemicity and ensured they were well fed for reproduction. Perhaps eating habits further contributed to disease. Human skinners of infected camels15 and marmots have contracted plague through breaks in the skin, and consumers of undercooked meat have become infected.16 The former are likely to present with axillary buboes and the latter cervical, but our cases were predominantly inguinal, suggesting flea bites on the legs. Also, the rats I saw being cooked were more in danger of being over- than underdone. Fleas quickly abandon the cooling bodies of their dead hosts. I suspect the refugees in our camp were infected as they prepared the corpses for dinner. The weather affects the incidence of plague and our outbreak occurred in the drier months, as observed elsewhere. It is argued that eggs and larvae of fleas perish in the wet season.17 However, the onset of the wet can hardly explain the pattern of illness, restricted infectivity and low mortality in the outbreaks in Vietnam compared with historical accounts of other epidemics. In South Vietnam generally, the classic signs of the disease were observed: the bubonic form (after the Greek bubo, for groin), in which lymph nodes draining the infecting bite of the flea are severely affected in association with the usual systemic poisoning by gram-negative bacteria; the septicaemic form, in which the lymph nodes are not prominent; and the pneumonic form, in which bacteria invade the lungs and can be very infectious.3,18 In our outbreak, however, we only recognised the bubonic form, which also seems to have predominated in other regions. Despite the crowding in the barracks, we recognised no pneumonic forms or transference. Less common features of plague were also observed in Vietnam: asymptomatic pharyngeal carriage;19 pharyngitis and cervical adenopathy;20 and meningitis, particularly if undertreated21 — but we recognised none of these forms. Vietnam, however, did not conform to the historical concepts of expanding disaster. Many outbreaks were described, but they remained contained in numbers and sites. For example, we only recognised 15–20 patients with plague, and the disease did not spread to nearby camps or the city of Tuy Hoa; nor, mercifully, did any of our team become infected, despite the lack of any preventive measures. Early diagnosis and treatment was considered “the single most outstanding facet of plague control” in Vietnam, reducing the overall mortality to 1%–5%.3 Our practice of widespread injections of streptomycin, therefore, must have been blindly successful. We did not observe any deaths. Mass vaccination with live attenuated strains of some 10 million South Vietnamese would have contributed to control, but we did not even know this existed. Our public health management bore no responsibility for the containment of plague in our camp. There was none. Did the high ambient temperature inhibit spread? Infectivity in the flea is promoted by a “blockage” in the gut, which allows the bacteria to multiply before being regurgitated into the next host, but Cavanaugh and colleagues showed that blockage was reduced when the temperature of the flea exceeds 27.5°C, and I doubt our camp ever got below that temperature.1 Hinnebusch and colleagues found all fleas fail to block at temperatures greater than 30°C and, moreover, that their lifespan at that temperature is severely reduced, arguably due to dehydration.22 Perhaps the hot, dry environment in the camp, especially in the huts where rats were killed and prepared for food, restricted the passage of the disease by its effect on fleas. The outbreak from 1962 to 1973 was probably due to proliferation of rats and refugees and catalysed by recipes (that involved cooking rodents to prevent starvation), with the bombing and defoliation more a cause of human than rodent displacement. After the war, the reported incidence fell to several hundred cases annually until 1997, and to 22 in 2000.23 No cases have been reported since 2002.24 This progress may reflect better living conditions and patient care in Vietnam, but the natural history of plague has always been episodic, with the disease emerging and disappearing for reasons not understood.7 Pham and colleagues report a reduction in the number of rodents and fleas trapped in central Vietnam from 2000 to 2007, and absence of Y. pestis in both rats and fleas in recent years, and suggest that Vietnam may have entered one of the “silent period[s]” that have historically preceded “sudden explosions of rodent or human plague”.24 Although we did not observe any plague-related deaths in the epidemic in our camp, it might have been close. One night, feeling the need to give a sick child an extra injection (and, it must be confessed, to pursue adventure), three of us set out to visit the camp, which lay on the other side of a wide river, the Song Ba, beyond the security of the town. The road bridge had been destroyed and cars had to traverse the kilometre-long railway bridge on planks of wood that covered the sleepers, about 60 feet above the fast-flowing water. To add to the challenge, no one dared use headlights. We travelled in our old Land Rover whose gears were as disinclined to engage as the brakes, and whose muffler was as loud and steering as loose as the ladies in the “entertainment” area between the camp and the Air Force base. But when we arrived at the camp, and shut down the roaring engine, we were astonished by the silence and emptiness of the streets. It was a moonless night and we had difficulty in finding the right barrack, searching along the road with increasing dismay. The people were slow to open the door, and stood silently while we gave our needle. Firelight flickered on unsmiling faces. Just how “pacified” were these people? Let’s go! We held our breath until the car started and hurried back to the bridge to begin the slow, lurching crossing to safety. Then, about a quarter of the way across, a shape loomed from the darkness in front of us and a huge truck ground to a halt, followed by some others. We had run into an American convoy on its way to war. I was driving and, looking up, against the stars I could see the shape of a machine gunner hunched down upon us. There was a pause, with engines growling like dogs gearing for savagery; then Bruce Hansen, my team leader and good friend, swung open his door, bounded across the sleepers and pounded on the door of the truck, demanding they “back up” because “we were on the bridge first” and we were “Australians”. The driver of the truck did not take long to respond. A head appeared from above me with a simple message delivered with a southern drawl. Stripped of embellishments it was, “You back up right now, or I will push you off”, and it was confirmed by a roar of his engine and a lurch of his mighty truck. There were two practical problems with our gears: finding the right one and holding it in place. Crashing through several, I found reverse and, holding it in place, began the long, backward retreat. My leader maintained criticism of my cowardice — but from the safety of the sleepers. The machine gunner maintained his downward menace. I could have drowned like a rat. Would they have counted me a victim of plague? At least I would have been spared the injections. Boys in South Vietnam play with a lizard and rats, 1967. Reproduced from the Bruce Hansen Collection with permission of his widow, Miranda Hansen. The interior of one of the barracks in the refugee camp near Tuy Hoa, South Vietnam, 1967. Reproduced from the Bruce Hansen Collection with permission of his widow, Miranda Hansen.

John S Whitehall FRACP, MRCP(UK), DCH

Patients often have difficulty remembering drug names accurately. Two instances, from my time as a junior doctor in the United Kingdom in the 1990s, have stayed in my memory. The first occurred during a long and busy night on call. I was admitting an elderly woman and I was tired and fed up. I asked her about her medication and she gave me a handwritten list. Halfway down, in quavery capitals, was FROLIC ACID. It made my night. It also triggered a memory, from several years earlier, of another patient, encountered on a consultant’s ward round. She had been prescribed omeprazole, which was still under patent at the time and marketed under the trade name “Losec”. The consultant asked her if her indigestion had improved. “Oh yes, doctor”, she replied, “it’s been ever so much better since you gave me that Slosex tablet”. We had to stop the ward round for several minutes to compose ourselves. Even though more than 10 years have elapsed, the memory still makes me smile.

Paula H Johnson

Objective: To determine whether slow or fast bandaid removal is less painful.Design, setting and participants: A prospective, randomised, crossover trial was carried out at James Cook University, Townsville. Participants were healthy volunteers from Years 2 and 3 of the James Cook University medical school program.Interventions: Medium-sized bandaids were applied bilaterally in three standard body locations and removed using slow and fast techniques.Main outcome measures: Pain scores were assessed using an 11-point verbal numeric pain scale.Results: 65 participants were included in the study. The overall mean pain score for fast bandaid removal was 0.92 and for slow bandaid removal was 1.58. This represents a highly significant difference of 0.66 (P < 0.001).Conclusion: In young healthy volunteers, fast bandaid removal caused less pain than slow bandaid removal.

Jeremy S Furyk MB BS, FACEM, MPHTM · Carl J O’Kane FACEM · Peter J Aitken MB BS, FACEM, EMDM · Colin J Banks MB BS, FACEM · David A Kault MB BS, BSc, PhD

If you want a challenge, and need a laugh, try a day as a hospital switchboard operator! The telephone switchboard is the nerve centre of the hospital, and the people working there are our unsung heroes. In my hospital, they handle at least 6000 calls a day, which is around 250 calls an hour. They work under extreme pressure, fielding questions and demands that range from the routine to the rude or the ridiculous. A sense of humour is an essential requirement to work there. One caller, a doctor, asked to have me paged. When the operator said, “Yes, we will page him”, the caller replied, “Yes, thanks, on his pager please”. Apparently, when a particularly weird call came through, one operator was heard asking the other, “Is it a real person or a doctor?” Another caller asked to talk to a “doctor with some medical background”. The major challenge is how to deal with distressed callers. For example, one woman rang to see whether she could talk to a doctor because she was getting palpitations and wanted to know whether it was menopause. A younger woman rang to ask what time the maternity delivery hours were! What about the young man who asked to be connected to a ward and, when told that the line was busy, said, “I want an answer from my grandmother whether she is alive or dead”. Another caller enquired about his son who was brought in with a “Caesar”, while a young man rang to find out about his pregnant wife who was full term and had come to hospital to have a “seizure”. The operator did not know where to forward the call from the young woman who was worried about dyeing her hair: “Could the dye seep over to the baby, since I’m 14 weeks pregnant?” What about the caller who wanted to know where to get spare parts for the baby? He was actually after a car “capsule” (baby seat) for his newborn. Was the young couple who rang to be connected to the “infidelity” clinic trying to patch up their relationship? And where do you find the neon-natal ward? Maybe it is dark and not well signposted? It must be hard sometimes to pick the comedians from those who are just too clever — many people ask for the “imagining department” (as I do when I look at MRI scans). Others want the “extensive care unit” (what a compliment to my ICU colleagues!), the “numerology department” (acalculia can be a consequence of stroke) or the “incompetence clinic” (incontinence is often an “incompetency” of dementia). How did the woman who rang to speak to the “neo-native intensive care unit” know that we have lots of foreign doctors? When a caller asked to be put through to Ward D, the operator wanted to know whether it was “d” for dog or “b” for baby; the answer was, “They never told me”. When someone asked for Bob Reynolds and the operator wanted to know which ward he was in, the answer was, “I don’t know, but he will know” (even if Bob was demented?). Then there was the woman who rang to speak to the crisis team in mental health. When the operator said the on-call person would be paged, the caller said she had paged someone 2 weeks ago and had not heard back! Another time, somebody wanted the registrar of the psychiatric crisis team and was given the number 53732. The response was, “Is this his name or pager?” My favourite was the call from an anxious young man about his wife who was having labour pains. To try to calm him down, the concerned operator asked, “Is this her first baby?” His answer was, “This is her husband, you stupid?” The switchboard operators have a tough job, but it has its moments!

Balakrishnan R Nair FRACP, FRCP

Ron Lucas (“Rowdy” to his mates) was one of the most outstanding infectious diseases physicians of his generation. He was a physician’s physician, and the person you would want caring for you if you were ill. Born in Ballarat on 13 August 1932, he was educated at Ballarat Grammar School, where he excelled at football and cricket and was school captain. He studied medicine at the University of Melbourne, graduating in 1956. After a brief period at Horsham Base Hospital, Ron joined the staff at Fairfield Infectious Diseases Hospital, where he remained until his retirement in the early 1990s. Ron’s career spanned a most exciting and eventful era, as the field of infectious diseases was transformed from a largely descriptive branch of medicine, with limited diagnostic tools and therapeutic options, to the science-based discipline of today. Empowered by Medical Superintendent John Forbes’s view that clinical practice would only progress if it was based on strong relevant research, Ron formed a partnership with the laboratory team and helped not only to improve clinical practice but to define many important features of the epidemiology, natural history and control of some of the most common viral diseases. He pioneered techniques for managing patients with fulminant hepatitis, established the first dialysis unit for chronic carriers of hepatitis B virus, established dedicated clinics for the care of patients infected with HIV and, in his role as founding Secretary/Treasurer of the Australasian Society for Infectious Diseases, guided the growth of that organisation. Although shy and quiet to the point of taciturnity, and often hidden beneath a cloud of pipe smoke, Ron had a profound impact on a generation of medical students and was a marvellous mentor of young physicians and laboratory personnel. After his first marriage ended, Ron married Jo Cornish. They built a wonderful mud brick house in Eltham overlooking the Yarra River. With Ron’s craftsmanship and Jo’s cooking and decorative flair, their home became a haven for their host of friends. Some time after his retirement, Ron began to develop signs of the debilitating neurological disease which was to claim his life. He became increasingly immobile and was forced to give up most of the pleasures that sustained him. Eventually, confined to his favourite chair and in the loving presence of Jo and his children Kate, Eric, Michael and David, he continued with calm and dignity to receive a stream of visitors until his death on 13 June 2009.

Ian D Gust · Edwina J Wright · Suzanne M Crowe

The case that established the lawfulness of terminating pregnancy to preserve women’s health Aleck W Bourne (4 Jun 1886 – 27 Dec 1974) “I . . . decided to bring forward a test case, in which there would be no real danger to life . . . but in which one might strongly suspect great danger to health. I was also concerned to establish in the eyes of the Law that mental health was just as important as physical health, and in certain cases perhaps even more so.”4 Europe, July 1938: Hitler and his Nuremberg rallies are gaining strength; invasion of Czechoslovakia seems imminent; German concentration camps are under construction; and Chamberlain is seeking appeasement. Meanwhile, in London, the Old Bailey criminal court is staging an unusual trial. In the dock of the austere Edwardian building stands Mr Aleck Bourne, FRCS, FRCOG, Consultant Gynaecologist to London’s St Mary’s Hospital, charged under the Offences Against the Person Act 1861 with unlawfully using an instrument to procure an abortion.1 Following the introduction of the harsh measures of the 1861 Act, prosecutions for abortion had been relatively common.2 However, in virtually all cases the defendants were women with little or no medical training, who performed abortions for small fees — so-called backstreet abortionists.3 At any one time, around 50 women convicted of the crime were incarcerated for up to 14 years in London’s Holloway Prison. Motivation was not necessarily purely financial. One woman said, “I knew it was against the law but I didn’t think it was wrong. Women have to help each other”.2 Bourne, an eminent medical practitioner, was different, though he shared some of the altruistic motivation, performing the procedure with no thought of a fee. On 14 June 1938, he openly carried out an abortion in St Mary’s. The 1861 Act stated that “therapeutic” abortion was legal — justified if the woman’s life was in danger — but the definition of “therapeutic” was unclear. Very familiar with the disastrous consequences of unsafe abortion for many women, Bourne had previously performed, without publicity, a small number of “therapeutic” abortions he believed to be justified on strong medical grounds. He now felt an urgent need to test the law in court, and was prepared to risk conviction to do so.4 Bourne’s 1975 obituary in the British Medical Journal described him as “a man of great compassion and understanding”.5 In May 1938, he was asked to see a girl of 14 years who had been raped by five officers of the Royal Horse Guards at their London barracks. They had enticed her there promising to show her a horse with a green tail — she was clearly an inexperienced child. Following the rape, the girl and her parents had first sought treatment at St Thomas’s Hospital. It soon became evident that the girl was pregnant, and abortion was requested. The response of the consultant at St Thomas’s was that, as the rapists were officers and therefore apparently gentlemen, “she might be carrying a future Prime Minister of England”, and anyway, “girls always lead men on”. He refused the request.1 At St Mary’s, Bourne had no such class illusions. He carefully considered the case, noting that the girl was “not mentally defective and not of the prostitute type”.1 Bourne concluded that, although a plea of danger to her life could not be substantiated, termination of the pregnancy was justified because of the risks to her physical and mental health. He could not, he later told the Court, “draw a line between danger to life and danger to health; if one waited for danger to life the woman would be past assistance”.1 He performed a surgical curettage, then deliberately informed the police.1 Justice Macnaghten presided over the case. Bourne’s defence lawyers called several of his colleagues, who testified that there were significant risks of both physical and psychological damage if the pregnancy had continued. Macnaghten took the view that, if there was “unlawful” abortion, there should also be situations in which abortion was “lawful”. He extended the meaning of “the life of the woman” to include her health, and in his directions to the jury said that “if the doctor is of [the] opinion on reasonable grounds . . . that the probable consequences . . . will be to make the woman a physical and mental wreck, the jury are quite entitled to take the view that the doctor . . . is operating for the purpose of preserving the life of the mother”.2 Bourne was acquitted, and his actions were widely applauded by the medical profession. The Lancet commented that, although the acquittal “left the legal position . . . only a little less obscure than before . . . [c]ompulsory pregnancy for the victims of criminal assaults . . . is an idea abhorrent to civilised Society”.6 Bourne was commended for “an example of disinterested conduct in consonance with the highest traditions of the profession”.6 A week later, Bourne himself wrote to the Lancet: “The Attorney General admitted that abortion is legally recognised when life is in danger. Now we know it is also admitted when there is serious danger to health . . . the majority of the profession would feel they are on safer ground if the precedent just established were incorporated in a new Act, passed in days when much more knowledge of medicine, surgery and psychology is available than was the case in 1861”.4 In the same issue, another writer called for “the law [to be] amended in an open and straightforward way to meet the demands of justice and humanity”.7 However, it would be 30 years before such changes came to pass. In that time, R v Bourne (1939), while not providing complete legal clarity for practitioners, nevertheless acted as a definite precedent — in Australia and the United States as well as in Britain — allowing doctors to undertake therapeutic abortions when they honestly believed the woman’s health was at risk if the pregnancy continued. The Bourne case was significant in the 1969 landmark ruling of Justice Menhennitt in the prosecution of Dr Ken Davidson for procuring abortions in Victoria.8 Menhennitt believed that Macnaghten had used the principle of “necessity” in composing his judgment, meaning that an act which would usually be a crime can be excused if it was done to avoid otherwise inevitable and undesirable consequences. Menhennitt ruled that abortion would be unlawful if the person performing the abortion did not honestly believe on reasonable grounds that the abortion was necessary to preserve the woman from serious danger to her life or her physical or mental health, or if the person did not honestly believe that in the circumstances the abortion was in proportion to the danger to be averted.9 Menhennitt’s directions to the jury were favourable to Dr Davidson, who was acquitted. The Menhennitt ruling became the basis on which abortion was safely and openly offered to women in Victoria from 1969 onwards, and subsequently the basis for the 1975 Levine and 1986 McGuire judgments, which similarly made abortion more accessible to women in New South Wales and Queensland, respectively.9 Nevertheless, it is worth noting that abortion remains in criminal legislation in NSW and Queensland, and was only removed from the Victorian Crimes Act 1958 in late 2008. In England, the decision in R v Bourne made little immediate difference to most women seeking abortion, whatever their reasons — economic, social or medical. Backstreet abortion was as common as ever, with a high mortality for women, although those who could afford it could obtain a safer surgical procedure from a discreet private clinic. This was the subject of the film Vera Drake (2004) in which Vera, an English factory worker who, in the early 1950s, provided abortions at no charge for poor women in their own homes, went to prison, whereas the doctor running a lucrative private abortion practice faced no such penalty.10 During the 1960s, there was increasing pressure from the new women’s liberation movement and other groups for changes to abortion law in Britain. There was also concern among some politicians about the huge discrepancy between the law and the practice of abortion, and this led Liberal MP David Steel to introduce a bill to decriminalise abortion that resulted in the The Abortion Act 1967 (UK). This Act, with some modifications since, allows induced abortion when continuing the pregnancy poses a greater risk to the life or physical or mental health of the woman, or her existing family or children, than if abortion is carried out. This legislation obviously built on the principles underlying the ruling in the Bourne case.11 Interestingly, Bourne himself did not support the introduction of the 1967 Act. He had written in 1938 that: “I would not have it believed that I have worked for a loose interpretation of the law”,4 and after 1967 he campaigned for the Society for the Protection of the Unborn Child, believing the new legislation to be too liberal. As noted in his obituary, “he never lacked the courage to express in public views which he held with great conviction and sincerity”.5 He made many contributions to the wider sphere of his discipline, including the struggle to have the importance of psychological factors recognised in gynaecological disorders. A keen yachtsman who often invited his junior staff to join him on board, he retired, reluctantly, from both active medical practice and sailing in 1964, at the age of 77 years. The place of R v Bourne in the history of the decriminalisation of abortion in the English-speaking world should not be forgotten. The British Medical Journal noted: “Bourne rightly deserves great credit for his determined and courageous action . . . based as it was on a deep sense of responsibility and compassionate understanding”.5

Caroline M de Costa FRANZCOG, FRCOG, MPH

Dick Smidlin was born in Sydney on 15 March 1932. He was educated at “Shore” (Sydney Church of England Grammar School) and the University of Sydney, graduating in medicine in 1956. His father was a dermatologist and his mother a gynaecologist. His grandfather Frank Smidlin, an electrician at Sydney Hospital, took the first x-ray in Sydney in 1896. Dick was a Resident Medical Officer at Sydney Hospital, the Royal Alexandra Hospital for Children and the Royal Hospital for Women. He went to England in 1960, where he worked as a Surgical Registrar at West Hertfordshire Hospital and at St John’s Hospital and West Middlesex Hospital in London. Returning to Australia after 5 years, he did further training in anaesthesia at Sydney Hospital and became a specialist anaesthetist. He was a Visiting Medical Officer at the Rachel Forster Hospital for many years. In 1966, Dick spent 3 months working as a Flying Doctor with the Bush Church Aid Society in Ceduna, South Australia, and in 2008 he wrote a book called Flying doctor praying about his experiences with the service. He also visited Antarctica as a ship’s surgeon in the 1990s. Dick had many interests, including farming, travel, military history and sailing. He owned a 10 000 acre cattle property called “Wicketty Wees” at Putty, north-west of Sydney. As a foundation member of the Second Anzac Medical Society, he made many overseas trips to places such as Gallipoli and Europe to pursue his interest in military medicine and military history. From his youngest years, Dick shared his father’s love of sailing. He was a member of the Middle Harbour Yacht Club for more than 60 years, and sailed with the Sydney Amateur Sailing Club and the Cruising Yacht Club. He had numerous boats — the last one, named “Trim” after Matthew Flinders’ cat, having a black cat outlined on the mainsail. He was an excellent skipper and won many races. Dick visited France most years. He had a barge called “Wilma” moored in Paris, and would spend up to 2 months each year exploring the canals of France and entertaining friends on board. Dick died on 6 October 2008 of lung cancer. He is survived by his sister Anne and wife Jeanette, from whom he was divorced in the 1960s. He was buried at Waverley Cemetery in a position that has a wonderful view of the ocean.

James B Roche

To the Editor: On my way to Canberra for the Charles Darwin exhibition at the National Museum of Australia, I diverted to Pambula, on the far south coast of New South Wales, for two reasons. Pambula is part of the Australian connection with Darwin through Syms Covington, who, at the age of 15, sailed as a cabin boy on the Beagle in 1831. Darwin soon came to rely on Covington to collect specimens, excavate fossils and act as his personal assistant. During the Beagle’s brief visit to Sydney, Covington was impressed by the colony. In 1840, after a period of employment with Darwin in England, he returned to Australia and eventually became a wealthy man. At first he lived in Sydney, but by 1854 had moved to Pambula, where he became postmaster. His entrepreneurial activities included buying large tracts of land around the Pambula River and the little township of Pambula. On a large block, he built a house of solid sandstone bricks with cedar woodwork throughout — “Covington’s Retreat”. Covington continued to correspond with Darwin and, at the latter’s request, collected specimens for him. He died in 1861. The house, at 28 Quondola Street, still stands and has been listed by the National Trust of Australia (NSW) in Heritage Council File HC32549. After being used for various purposes, including as an inn and as a police station, it became the residence of the local doctor, probably around the start of the 20th century — hence my second reason for visiting Pambula. The subsequent careers of some of the Pambula general practitioners, all of whom lived in the house, are of considerable interest. All came to Pambula from outside the area. Grace Cuthbert (later Cuthbert Browne), MBE, left Pambula in 1929. She was Director of the Division of Maternal and Baby Welfare of the NSW Department of Public Health (1937–1965) and, among many other positions, President of the Australian Federation of Medical Women. Naomi Wing, CBE, and her husband Lindon practised in Pambula from 1929 to 1936. She was an early advocate of rehabilitation medicine as a medical discipline and became President of the Australian Association of Physical and Rehabilitation Medicine. The Naomi Wing Rehabilitation Centre in Zetland, Sydney, was named in her honour. Her husband, Lindon Worlledge Wing, KStJ, was an early practitioner of occupational medicine in Sydney. Their son, Emeritus Professor Lindon Michael Harper Wing, was Dean of the Medical School at Flinders University, Adelaide, from 1998 to 2007. From 1936 to 1945, the house was owned by Keith Jones, who went to World War II from Pambula and whose name is on the town’s war memorial. After the war, he became a surgeon and, over the years, undertook a wide range of community activities. He was President of the Australian Medical Association (1973–1976), Chairman of the Australasian Medical Publishing Company Limited (1976–1982) and, for a time, Acting Editor of the Medical Journal of Australia. He was knighted in 1980. Covington’s Retreat is now a Thai restaurant called “Covingtons Thai”.

George D Repin

The opening session of the Australian Medical Association’s national conference this year was once again the venue for the presentation of the Medical Journal of Australia’s two annual awards, the MJA/Wyeth Prize and the Dr Ross Ingram Memorial Essay Prize. In an MJA “first”, the 2008 MJA/Wyeth Award was presented to a familiar face. Dr Lindsay Grayson and colleagues won the 2005 MJA/Wyeth Award for their report of a multifaceted hand hygiene program at Austin Health in Melbourne, which increased hand hygiene compliance by hospital staff and reduced the rates of methicillin-resistant Staphylococcus aureus infection. Following their initial success, they were able to expand the program to several other Victorian hospitals and eventually to roll it out statewide. They described and evaluated this process in a report entitled “Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out” (published in the 2 June 2008 issue), which was assessed by the Journal’s Content Review Committee as being the year’s best research report. In presenting the $10 000 prize, Dr Michael Lee, Medical Director of Wyeth Australia, reaffirmed his company’s commitment to preventive care, and congratulated the authors for their ability to build on their earlier findings to promulgate a widely beneficial intervention. Improving the health of Aboriginal people in prison was the subject of the winning essay in this year’s Dr Ross Ingram Memorial Essay Competition and, indeed, is its recipient’s life work. Beverley Spiers, a Justice Health Aboriginal health worker and education officer based at Cessnock Correctional Centre in New South Wales, has worked in the criminal justice system for over 20 years and believes that all Aboriginal offenders should be encouraged into the caring hands of Aboriginal health workers. Her prize-winning essay, “Antecedents of chronic kidney disease in Aboriginal offenders in New South Wales prisons” (published in the 18 May 2009 issue), describes a single day at the Centre, in which she and a Justice Health nurse screened 88 Aboriginal offenders for markers of kidney disease. In accepting her $5000 prize, donated by the Australasian Medical Publishing Company, Beverley reminded the conference about the real human stories behind the gap in life expectancy between Indigenous and non-Indigenous Australians, and called for more funding for Aboriginal health workers in all areas where Indigenous Australians require access to medical care. From left: Rosanna Capolingua, Ruth Armstrong, Beverley Spiers, Martin Van Der Weyden, Lindsay Grayson, Michael Lee. Dr Ruth Armstrong, MJA

Ruth Armstrong

Tom Wills. His spectacular rise and tragic fall. Greg de Moore. Sydney: Allen & Unwin, 2008 (xvi + 336 pp). ISBN 978 1 74175 499 5. Greg de Moore, a Sydney psychiatrist, has undertaken an amazing amount of research in compiling this account of the interesting life of one of Victoria’s sporting identities of the 19th century. Born on a sheep run on the Molonglo River in 1835, Tom Wills was sent in 1850 to England for education at Rugby, where he was no great scholar but excelled in cricket, football, athletics and other sporting activities. On returning to the colony, Wills soon established himself as the best batsman and bowler in the colony of Victoria and achieved celebrity status. He was later described by the English doyen of cricket, Dr W G Grace, as “the greatest cricketer in the land”. At that time, cricketers were given such prominence that the sitting times of Parliament were adjusted to facilitate members watching the match. Employers were expected to release workers for the same reason. Football was a winter game played after the cricket season was completed and was virtually a free-for-all without rules. In a hotel on 17 May 1859, Wills and three others wrote the first rules of the Australian Football Code (a copy of the original hand-written document is reproduced in the book). Wills’ family, and later Wills himself, moved to a cattle station in Queensland. His father was later killed there by Aboriginal people. To the surprise of many, years on, Wills coached the well known all-Aboriginal cricket team. Unfortunately, Wills was a heavy drinker, and ultimately suicided.1 De Moore has located original records held by numerous organisations, including Rugby school. In addition to the details of Wills’ life, he gives an interesting insight into Victorian society as it was in Australia. His book is well priced and worthwhile reading for anyone interested in sport or sporting history. 1 de Moore GM. The suicide of Thomas Wentworth Wills. Med J Aust 1999; 171: 656-658.

Michael C Kennedy

Lessons from the past for today’s researchers in general practice In January 1971, a randomised controlled trial of management of depression by general practitioners was published in the British Medical Journal by Tim Blashki (T G B) and his colleagues Robert Mowbray and Brian Davies (Box 1).1 Although there had been two earlier trials of antidepressants conducted in general practice (one British and one American), this was the first in the world to have extractable data in general-practice-only patients that could be used in a meta-analysis. It is therefore the earliest study included in this year’s published Cochrane Reviews that examines antidepressants versus placebo for depression in primary care; the review’s authors were Bruce Arroll (B A), Grant Blashki (G A B) and colleagues.2 Tim Blashki, the first author of this historically important article, was a Melbourne psychiatrist who had been a GP before he commenced the study. Tim Blashki’s son, Grant (G A B), has continued the family tradition of researching the management of mental illness by GPs,3 and he recently took up Bruce Arroll’s suggestion to interview Tim to document some of his experiences from this early clinical trial. This interview took place by phone on 8 January 2009. The interviewCould you say something about your medical training?I graduated from medical school in Sydney in 1964, having had only about 12 lectures in psychiatry in total. My first real contact with psychiatry was as a second-year resident at Royal Melbourne Hospital, where I worked as a medical officer under Professor Brian Davies. Psychiatry interested me and came easily to me, and this sparked an interest which has continued for the rest of my life. As a result of this experience, I went to a typical psychiatric hospital of the time. There were some very good and dedicated people working there, but, for the most part, treatments at that time were only partially effective, and there was a large custodial component in the function of the institution. My first job was unsupervised, and involved looking after a ward for young women (adolescents and those in their early 20s), many of whom had psychosis with poorly controlled symptoms. I left after 6 months and began working in general practice, as I wanted to help people experiencing mental illnesses in the community. The general practice I joined practised in a traditional manner for that time. The focus was on patients’ somatic symptoms and on somatic treatments. Patients had great faith in the doctors, whom they had known for many years in what was a rather tight-knit community. Psychological problems were generally ignored or ascribed to some somatic problem or social difficulty. Treatment consisted of support, advice, and a variety of what were essentially placebo treatments, ranging from rose-coloured water (dill water), vitamins, Waterbury’s compound, the pharmacist’s special concoction (often a bromide-containing medication), and night sedation with drugs such as chloral hydrate and barbiturates. The use of tricyclic antidepressants, monoamine oxidase inhibitors and minor tranquilisers, often in minute doses, was just beginning. Depression was just starting to be acknowledged as an illness; most depressions were perceived as reactions to events or a failure of will. Anxiety more or less went with the depression, with the exception of phobias and “panic” states. It became clear to me that much of what I was seeing in general practice — I thought about 70% — was psychologically based, and so I returned to psychiatry at Royal Melbourne Hospital, where I again worked under Professor Brian Davies. It was in this dual setting of psychiatry and of general practice that I began to think about psychological disorder in the community, and depression and anxiety in particular. How did the idea of a randomised, placebo controlled trial of antidepressants in general practice come about?In the late 1960s, I decided to do a doctorate in medicine. I chose to do this with a focus on general practice for a number of reasons. First, as I’ve already mentioned, many of the problems that I’d seen in general practice were of a psychological nature. Second, while most mental health problems were being seen in general practice, most of the research was done in hospitals on inpatients and the results were being extrapolated to general practice patients. The assumption was that these patients were part of the same cohort, but, having worked in both places, I believed this to be incorrect. Third, I was interested in the notion of placebo as an effective treatment, and I had wondered whether some of the “antidepressant effect” seen in patients treated in general practice for depression was possibly the result of such a placebo effect. Fourth, I thought that some of the response to antidepressants in this mildly to moderately affected group might be occurring because of reduced anxiety, rather than to a specific antidepressant effect. Finally, I could find very little published research on what was essentially a large group of people in the community who had some type of mental disorder. What was involved in getting the study off the ground?Initially, I had two problems. The first was that GPs were said to be not particularly interested in psychiatry.4 However, I felt that given half a chance, many GPs would respond to an offer of some help and of an opportunity to be involved in a research project. This indeed proved to be the case. It involved me visiting GPs in their practices and talking about the sorts of issues that they faced, which facilitated the study and was central to its successful completion over 9 months in late 1969 and early 1970. The Research Committee of the Victorian branch of the Royal Australian College of General Practitioners were well acquainted with the project and approved it. The second problem was that of constructing a study that had the same scientific rigour as previous studies that had been conducted in institutions, and to apply this rigour in a general practice setting. To accomplish this, it was necessary to ensure randomisation, placebo control, double blinding, and for the patients to be rated both subjectively and objectively with the use of rating scales such as the Hamilton Rating Scale for Depression5 and the Taylor Manifest Anxiety Scale.6 To confirm whether the patients did actually take the tablets that were prescribed, riboflavine was included in the formulation, and patients’ urine was tested for compliance with treatment. The coauthors of the study, Robert Mowbray and Brian Davies, made important contributions to the planning of the study. What did the study find?For me, the most fascinating and important finding was that clinical improvements occurred in 55% of patients who had received placebo after 7 days, and in 61% at 28 days. Indeed, there was a handful of patients who wanted to continue taking the placebo even after they were told it was a placebo, and we managed to obtain more placebo from the pharmaceutical company, so that they might continue taking their “medication”. With respect to the specific treatments, I was not surprised that the higher dose of amitriptyline (150 mg per day) was the most effective in relieving depression and anxiety. Anecdotally, I thought that the smaller dose of 75 mg might also be effective in relieving symptoms, but this proved not to be the case. I was interested to read a recent study by Furukawa et al, published in the British Medical Journal in 2002, in which they found a good response to low-dose tricyclic antidepressants.7 With respect to side effects, there was no difference between the groups. This was very surprising, but I think it might be attributed to a problem in the study design. Participants were given a list of possible side effects before starting the medication — something I thought to be important because some might well have been troubled with the higher doses — and this may have created a bias that was reflected in the side-effect profile across all groups. What was the social context in which the study was conducted?I have already alluded to the apparent lack of interest in psychiatry among GPs in those days, to the stigma associated with psychiatric illness, to the notion that depression was induced by life circumstances or was a failure of will; certainly, “madness” was something to be avoided at all costs. While there was some acknowledgement of a biological tendency or disposition often reflected in a family history, when this was discerned, patients were generally sent off to the psychiatrist and the case considered exceptional. The other social factor was that while women came to their doctors for treatment, men generally did not. Men saw it as a weakness, unmanly, and indicative of failure; their way of expressing their distress was often through aggression, excessive alcohol consumption or, at worst, carefully planned or violent suicide. So, I saw mainly depressed women who seemed more ready to say something about how they felt and express something of their vulnerability. Hence, the idea of studying only women in this project came to mind. What is your view of mental health management in general practice today?The management of mental health in general practice is far removed from that of 40 years ago. GPs are more educated in mental illness, and mental illness is less stigmatised. Research has provided a greater understanding of mental disorders and the treatments available, whether they be biological, social or psychological, and much therapy is now evidence-based. It is important that mental health research continue in the setting of general practice, and there are at least three important lessons for future researchers that I’d like to share (Box 2). Fortunately, mental health is now seen as a community responsibility, and there is commensurate financial commitment. Powerful support structures now exist — community, psychiatric, psychological and social. GPs have rightly become an integral part of this process. 1 About one of the world’s first randomised controlled trials of management of depression by general practitioners1 The study was a double-blind randomised controlled trial of amitriptyline (two different doses: 75 mg and 150 mg per day), amylobarbitone (150 mg/day), and placebo, for 4 weeks. It was conducted between 1969 and 1970, and involved 82 women with depressive illness, recruited from 21 general practices in Melbourne, who were randomly allocated into the four groups (61 women completed the study). Improvement at 7 and 28 days was noted on several measures of depression and anxiety in all treatment groups. Of the treatments, amitriptyline at 150 mg/day was the most consistent in relieving depression and anxiety. Troublesome side effects were equally distributed among the four groups. 2 Lessons for researchers undertaking mental health studies in the general practice setting The success or failure of research in general practice will usually depend on the trust established between GPs and their patients. All modes of treatment should be assessed in the setting in which they are to be used, and this is especially true in general practice. Research needs to be scientifically rigorous and objective, while remaining sensitive to the subjective experience of patients.

Bruce Arroll PhD, FRNZCGP, FAFPHM · Timothy G Blashki MD, MRCPsych, FRANZCP · Grant A Blashki MD, MB BS, FRACGP