History and humanities

On 28 March 2006, the World Health Organization Global Alliance against Chronic Respiratory Diseases, comprising 41 national and international organisations, was launched in Beijing. In 2005, four million people died of chronic respiratory diseases, and chronic obstructive lung disease is the fifth leading cause of death worldwide. Chronic obstructive pulmonary disease accounts for about 7% of the total burden of illness in Australia. I’ve come to visit him in his garb of house arrest — flannelette pyjamas from Kmart — he stands, greets me, hitches up his pants, exhausted, sits and speaks in tiny bursts: “Today is a good day! This morning I could do up my buttons without getting too much out of breath!” Each night the moon drags the tide an inch closer to the shore. Each day he cuts and glues balsa to shape model ships, perhaps today a papyrus raft to bear the brief message of his soul. He drove trucks for years, smoked, took dex and Coke for extra miles, and now sniffs oxy for the loo. He’s my age: The front door prison grille swings shut. I wave goodbye for both of us.

Stephen R Leeder AO, PhD, FRACP

The first Australian I ever met was a delightful lady doctor, recently qualified, who arrived in the wee Fife village of Kincardine in which my father had been the general practitioner for 17 years. She was to be his locum during his long and eventually fatal illness. Dr Patricia Hodgson (née Richardson) as a resident medical officer at Royal Adelaide Hospital (RAH) in 1937. (Photograph courtesy, Michael Holt, Assistant Archivist, RAH Heritage Office.) Her name was Pat Hodgson and she had just married when World War II broke out. Her husband, Guy, was a merchant seaman. His services were required on the very hazardous trans-Atlantic passage to keep Britain supplied with food and arms. Pat was certainly not going to sit at home in Adelaide while her newlywed was risking all on the other side of the world. At least she would be able to see him from time to time as he reached the eastern end of his voyages. As the ships most often docked in Liverpool or Glasgow, she was delighted to find a medical job in Scotland, within relatively easy reach of either port. Scottish villages were not used to lady doctors in the 1940s. They preferred middle-aged to elderly males clad in suits and spats and smelling of tobacco and surgical spirit — or even non-surgical spirits — rather than perfume. My father, having been carted off to hospital, had no say in the appointment. To get a locum at all in wartime was an unusual privilege, as most of the young medicos who normally cut their teeth on such jobs were in the services. The population of this small mining and farming community could not have been cared for by the neighbouring doctors, who were getting on in years and lived at some distance. Pat had to be accepted. Being only in my early teens at the time, I was not privy to the full impact that a large and vibrant Aussie woman had on the town. I am sure there was a considerable redistribution of the complaints usually seen in the surgery, and one can only imagine the boggling that eyes went through when first she paid a home visit to an unsuspecting patient with a painful set of piles. But the fresh air she brought with her was the first breeze of the winds of change about to overtake the professions in the postwar years. She became the most popular locum we had ever had. It wasn’t just Pat who awaited Guy’s visits eagerly. My family rejoiced as he bore two large cardboard boxes, bound by marvellously concocted string knots, up our steps every 3 months or so. These contained the miracles of America’s non-rationed society: the Hershey chocolate bars, the cans of Spam and, on one occasion, an entire case of Limburger cheese. This was a new experience in our household. Nothing so exotic had ever entered our doors — nor so quickly been banished to the outside laundry. The stench pervaded the waiting room and led to a downturn in surgery attendance. When we eventually screwed up the courage to get past the smell, we were surprised to find the taste so acceptable. Pat’s eyes twinkled from the depths of deep sockets above generous cheeks. Her figure was similarly cheerfully ample. In spite of rationing, Pat’s proportions failed to diminish. When she eventually returned for a visit before returning to Australia, she had put herself on a diet. This proved to be so successful that she was unrecognisable when I opened the door to her. Apparently, she used this to great advantage when she was interviewed, as so many returning passengers were, on the wharf at Fremantle. “Look,” she cried, “I left here a 12-stone dumpling. Now I am a 7-stone weakling. Send more food parcels, the Brits need them!” The village never really recovered. My father’s practice, sold after his death, was bought by another lady doctor. Unfortunately not endowed with a taste for cigarettes, whisky and good humour, that practitioner had more rigid views about life, death and the way to salvation.

Thomas F Sandeman MD, ChB, FRANZCR

During the early 1950s, I completed 2 years of hospital resident training in general and obstetric hospitals in Sydney, which in those days allowed for very little sleep! As a young graduate I had a desire to experience the responsibilities of patient care firsthand before attempting an extensive program of postgraduate training in orthopaedic surgery in the United States and United Kingdom. There was time, however, to get married before starting out as a solo general practitioner in Wellington, in central-western New South Wales. Clinical demands were arduous: the patients had high expectations and, at the same time, seemed to have great confidence in the practical judgement of their doctors. As a young graduate, this caused me to feel a degree of “professional anxiety”. As time moved on, my wife and I settled into the busy routine of general practice, with help and advice from the older, more experienced local practitioners. My obstetric work quickly increased, which meant blood work, cross matching and Rh typing — all part of our antenatal routine. One particular experience shows how the circumstances of 50 years ago influenced one’s actions. An “elderly” primipara (in those days, 32 years old was considered elderly) was easily delivered of a beautiful boy — her pride and joy. Initially all seemed well, but after the first few days, no meconium had been passed and the baby appeared to be distressed, with abdominal discomfort. I became concerned and phoned the paediatric surgeon at the Children’s Hospital in Camperdown, Sydney, for his advice. Feeling that there was clinical evidence of a developmental bowel obstruction, he too was anxious about the baby’s condition. At that time, no air-ambulance or helicopter rescue services were available in the area. The road ambulance could not be arranged and would take too long anyway. I thought of trying to charter a light aircraft from Dubbo, and phoned Dubbo airport. But the weather was most unsettled, and no charter flights were operating. The airport official explained how a Royal Australian Air Force training squadron had been grounded by the bad weather over the state. Was there any other option? The baby’s parents were so very anxious — they would agree to any suggestion to expedite the transfer of their child to the Children’s Hospital. While I pondered the situation, suddenly a new voice came on the phone line — he announced he was an ex-Royal Air Force (RAF) World War II fighter pilot, and, being an emergency, he offered to fly us to Sydney despite the weather. The flight would be in a De Havilland Chipmunk — an open-cockpit, two-seat RAF light training aircraft — if I was game! I agreed to be at Dubbo airport with the baby as soon as possible. We wrapped the small baby warmly, safely protected in a cane basket. The plane’s second control column was removed, enabling me to carefully place this important bundle away from the wind, set snugly between my legs in the instructor’s seat. In no time, we took off in the drizzly afternoon weather, passing through the overcast gloom and flying above full cloud cover. I found the experience exciting, and when comparing this with my later years of instrument flying in similar meteorological conditions, it’s clear that our pilot certainly demonstrated his expertise. Flying into Sydney airport was a relatively simple exercise in those days, compared with the hectic jet traffic, radar and intense air traffic control that are the norm today. While flying over the Blue Mountains on the approach into Sydney, above partly broken cloud, our pilot asked me through the intercom, “How far past the hills do you think? My dead reckoning indicates a further 10 minutes before commencing descent to Sydney.” I got a fleeting view of a long line of Katoomba street lights, confirming our pre-descent position. An ambulance was awaiting our medical emergency at the airport and raced us to the Children’s Hospital. I found this ambulance ride even more hectic than the air trip! Sadly, despite expert urgent surgery, multiple developmental bowel obstructions proved too much for the infant’s survival. The return flight holding this sad little bundle was not easy. Before take-off, interested kind folk kept asking to see the small baby in the basket. Happily, later, while I was studying overseas, news came that the bereaved mother had given birth to a healthy, bonny boy. Now in my retirement years, I constantly worry about young country mothers experiencing the return of isolation, the deterioration of country hospitals and the lack of medical expertise. Despite modern road transport and air travel facilities, political priorities continue to result in few improvements being made to these serious problems in the country. In the past, limitations to rural services were accepted as a fact of life. Every effort was made to compensate. Rural medical services must not now deteriorate because of political neglect.

Anthony H Hodgkinson MB BS, FRACS, FAOrthA

It was the mid 1950s in Newcastle, a time of world unrest from the expansion of communism, and balloted national conscription by birthday. To supplement the meagre income of a second-year resident (a princely sum of 12 pounds, 5 shillings for a 70–80 hour week), I would go and examine the “nashos” (national conscripts) for their induction into the army, when the work was available. It paid as much as two or three pounds for a couple of hours’ work. Towards the end of such a session, in a small break, I leaned back in the chair and stretched. In came a gangly, sinewed youth, ambling slowly forward. “Name?” I asked in a quiet voice. “Kev Browwwn.” Hearing’s OK — tick. “Good health?” “A’reckon.” A quick physical confirmed no flat feet, hernia or haemorrhoids. Grade A-1. Coming to the last item — “Stand on that line” I instructed, while filling in the form and pointing behind my back. “Read the lowest line you can see on the chart on that wall.” It’s 6/5, better than 6/6. A long pause — did the chart fall off? — no. I turned to have a closer look at the youth’s face — crystal clear eyes in deep sockets, slowly squeezing into a line, reminding me of Gary Cooper in his Oscar-winning role as sharpshooter Sergeant York. “Ahh — ’m gettin’ it . . .” Then in a great tumble: “W J Pettigrew, Government Printer.”

Henry Kan BSc, MB BS

To travel hopefully. An autobiography. Charles Bridges-Webb. Melbourne: Sid Harta Publishers, 2005 (v + 470 pp). ISBN 1 921030 26 7. Charles Bridges-Webb (CB-W) had two professional lives. He was a country GP in Traralgon from 1960 to 1975 and then Foundation Professor of Community Medicine at Sydney University from 1975 to 1994. Active in the research and disease classification committees of the RACGP and the World Organization of Colleges of General Practice, he has had a major influence on Australian general practice research and education. His autobiography traces the influences through which his natural curiosity became organised. A family tradition of keeping a personal journal began with his paternal great-grandfather, the architect of the Windsor Hotel in Melbourne. His maternal grandfather, a farmer dependent on rural finance and weather conditions, impressed upon him the importance of keeping meticulous records. As a medical student and young doctor, his original questions aroused the nurturing instinct of teachers, such as professors Sydney Rubbo and Basil Hetzel and the physician, John Bolton. His descriptions of the development of his research interests, projects and collaborations should be of interest to budding GP researchers. CB-W describes his simple philosophy of life based on travelling quietly but hopefully towards ideals that he knows he will probably never reach. So his disappointments are understated and he ignores the contemporaneous political controversies of Sydney University and the Royal Australian College of General Practitioners. He considers that “the important parts of life are dependent on the little matters”. There is much in this book on family, children, travel, churches, acting, cricket and gardening. All is shared with his “can do” wife and soulmate Anne. They are a package where their friends and acquaintances always get two for the price of one. Like most doctors, CB-W tells some good medical tales. My favourite is when he was asked to do a house call to an elderly lady whose son reported that she had had “a bit of a shock”. On arriving at her house he discovered that it had been hit by lightning. This is an honest autobiography. It avoids the pitfalls of self-aggrandisement and self-pity. CB-W has many friends. His autobiography enables us to know him better. Max KamienEmeritus Professor of General Practice, University of Western Australian, Perth, WA

Max Kamien

Medicine in quotations. Views of health and disease through the ages. 2nd ed. Edward J Huth, T Jock Murray, editors. Philadelphia: American College of Physicians, 2006 (xvi + 581 pp). ISBN 1 930513 67 4. Why, in these times of rapid electronic access to information, do we need books that compile the wit and wisdom of the famous and not so famous? Could it be that these tomes conveniently satisfy an abiding human curiosity to know what was said about what, who said it and where? And doctors are no exception. Medicine is a treasure trove of quotations made by its practitioners from antiquity to modern times, and this rich tapestry is on display in Medicine in quotations. Edited by EJ Huth, Emeritus Editor of the Annals of Internal Medicine, and TJ Murray, a past Chairman of the board of trustees of the publisher, the American College of Physicians, the book details more than 3500 quotations distilled from submissions by 106 contributors. It presents the quotations under broad headings arranged in alphabetical order. The currency of the quotations is reflected by topics such as AIDS, Gulf War syndrome, chronic fatigue syndrome, health policy and so on. The quotations are identified by their authors and source and are arranged in chronological order. Finding relevant quotes is a breeze using the book’s comprehensive subject index. For the more curious, there is also a listing of the publication source of each quote. It should not be surprising that the most frequent quotations are by Hippocrates and Sir William Osler. The only modern person with a substantive entry is biologist–author Lewis Thomas. Medicine in quotations, despite its expense, will supersede its ageing competitor, Familiar medical quotations (published in 1968). The book should be an obligatory addition to medical libraries and be on the shelves of medical writers, editors, lecturers and after-dinner speakers. After all, to quote Dorothy Sayers, the British author and scholar: “I always have a quotation for everything — it saves original thinking”. Martin B Van Der Weyden Editor, Medical Journal of Australia

Martin B Van Der Weyden

I know what men want. Men want to be really, really close to someone who will leave them alone — Anonymous The ideal man — Philip Patston, comedian, consultant, columnist and (among other things) recovering social worker and human rights activist. He is gay, disabled, vegetarian and English. Six years ago, Philip created Diversityworks, now a multi-faceted enterprise that includes a business group offering expertise in managing diversity and change, and a trust that runs projects to improve diversity and professional participation in the arts <http://www.diversityworks.co.nz>. Philip lives in Auckland and travels regularly in New Zealand. His work has taken him to Australia, the United States, Canada, the United Kingdom and Belgium. In 2004, in making a radio documentary on romance which played in 10 countries around the world, I spoke to several people who experience disability. For the blokes, the theme of being disabled and male in society came up repeatedly, including issues of responsibility, dependence, dominance, and public perception. Compared with the traditional role of the strong male provider, men who experience disability are often perceived as vulnerable, needy and dependent. Over the years, I have come to understand that in many ways, like gay men, disabled men can choose to feel either shackled or liberated by the perception that they are less “manly” than their non-disabled counterparts. As a gay man who experiences disability as a result of cerebral palsy, I have a unique experience of being male. I am bound by neither heterosexual nor non-disabled role stereotypes. I feel no compulsion or expectation to be “a real man”. And yet, at the same time, I cherish my distinctive maleness, which I experience to be a healthy balance of masculine and feminine. In some ways, as I argue here, I am the ideal man. Men, function and disabilityThe four themes that emerged from my conversations with men with disabilities — responsibility, dependence, dominance, and public perception — correspond to a set of traditional male role attitude items that I stumbled across in an article about masculinity and its impact on adolescent male heterosexual relationships.1 Here are some laments of the real man: It is essential for a guy to get respect from others. A man always deserves the respect of his wife and children. I admire a guy who is totally sure of himself. A guy will lose respect if he talks about his problems. A young man should be physically tough, even if he’s not big. It bothers me when a guy acts like a girl. I don’t think a husband should have to do housework. Men are always ready for sex. I subscribe to a definition of disability based on a model that acknowledges that attitudes and barriers in society disable people more than their impairment, and this may lead to a loss of function. But what is function? Function has a vast array of meaning, ranging from the very pragmatic and physical to the somewhat esoteric or spiritual. Function is implied in all of the following: Task — work or assignment, often important or difficult. Job — paid trade or profession, something needing to be done or dealt with. Utility — the quality or state of being useful. Occupation — an activity on which time is spent; may be paid or unpaid. Role — the usual or expected function of someone, the part played in a given social context. Meaning — what something means, what someone intends to express. Purpose — the reason something or someone exists. I believe that, in our culture, men are mostly valued for the more pragmatic, physical realms of function (task, job, utility, occupation), whereas women are more valued for the esoteric, spiritual elements (role, meaning, purpose). This is, of course, a generalisation, but one that corresponds to the traditional male role attitude items listed above. When I compare what disabled and non-disabled men are valued for, aspects of function stand out as the great divide. For example, I am seldom asked the obligatory question, “What do you do?” People assume I don’t do much of any import, because I have a physical impairment. I’ve also noticed that men are far less comfortable than women with issues of impairment and disability. It’s women, far more often than men, who offer assistance, unless it’s something overtly physical like putting my wheelchair in my car. And it’s women who are far more prevalent as workers in the disability sector. However, when you examine the impact of the loss of function for men, women and people who experience disability, one thing is very clear: men have a lot more to lose. Loss of function particularly pushes blokes’ buttons. Why? It seems to me that, in a primal sort of way, male identity is situated in the realm of physical function. Male creativity is concerned with external manipulation — making things, building things, doing things — so impairment and disablement fundamentally threaten male identity. I have argued that the essential difference between the sexes is that men create “without” and women create “within”. Consider these differences between men and women: men’s sexual organs are outside the body; women’s inside. Men cannot conceive and create children, as women can — inside them. Men gather information primarily through their sense organs located primarily on the outside of their bodies whereas women gather much information through their intuition, their feelings, inside their body. And finally, without getting too much into the sex stereotype debate, look at household roles — women’s domain is generally inside and men’s, outside. My conversations with the men in the documentary made me realise that when men are threatened with loss of function, they experience huge levels of fear. I consider fear to be the absence of love (and, conversely, love the absence of fear). When people act out of fear, their actions are characterised by drive (fear of not succeeding), low creativity and judgement. Conversely, when people act out of love, they are passionate, highly creative and accepting. The idea of losing function leaves men uncreative, intolerant and driven by the fear of losing control, independence, positive public perception and responsibility. The ideal man?So how does all this make me, a gay man who experiences disability, an ideal man? Firstly, I think I have successfully surrendered control. There are aspects of my life — the result of stigma, disablement, homophobia and the like — that I cannot control. I no longer expect to control everything. More than anything, I have developed the ability to trust that everything is perfect. Secondly, I accept that, to live the busy, autonomous lifestyle that I have chosen and created, dependence on personal assistants and funding to employ them is necessary. Thirdly, I ignore public perception. Simply put, though it is still hard sometimes (especially when he’s cute), I have learnt to reject rejection. Finally, I take responsibility. I am not a victim of circumstance. I’ve moved away from my personal “fight for rights” towards a quest for creativity and identity, and a spiritual understanding of the purpose disadvantaged people have (and choose) to help humanity evolve. Sure, disabled gay men have rights and we are not yet well afforded them — this is indeed the last bastion of human rights, and breaking it down will require recognition by society that the mix of disablement and homophobia that blokes like me experience is a complex social construct, not a catastrophic personal tragedy. But while humanity catches up, I’ve chosen to move on and create an identity based on who I am rather than who I am not. Part of my creative process has been to understand and believe I am here to raise human consciousness about diversity. At the same time, I am empowered by the notion that even though it’s bloody hard at times, my soul made a choice to live this life. Which leads me to believe that that soul must be a masochist, but such is the sacrifice one makes to be the ideal man!

Philip Patston

Medical statistics from A to Z. A guide for clinicians and medical students. B S Everitt. Cambridge: Cambridge University Press, 2003 (vi + 230 pp). ISBN 0 521 53204 3. Medical research articles are increasingly populated by statistical terminology. Many non-statistical readers of the literature would therefore value a resource providing a quick sense of the broad meaning of statistical terms. This book is such a resource, written by a respected world expert on medical statistics. Don’t expect a textbook. Despite its title, this book will not teach you medical statistics from A to Z. It is written in dictionary style, with bite-sized, non-technical references to an extensive range of topics relevant to the application of statistics in medicine and public health. Each entry provides a few lines of information, sufficient for a quick exposure to the term’s meaning. This will leave some readers wanting more, so references to further reading are provided for many of the terms. This is one of the best features of the book, greatly expanding its usefulness. The book can be effectively used as a first point of reference, and as a pointer to a wider and more in-depth body of literature. More than 1500 terms are covered in just over 200 pages. At one end of the spectrum are items such as “relative risk”, for which the terms, but not necessarily the meanings, may already be known to the reader. At the other end are terms of a more esoteric statistical nature, to which many readers will have had little exposure. This feature, combined with the alphabetical ordering, means that readers will find themselves wandering from their chosen term to other previously unfamiliar concepts. For example, referencing the advantages and disadvantages of a “multicentre study” will lead to an overview of “multicollinearity”, while those wanting to brush up on “age standardisation” will soon find themselves exposed to “agglomerative hierarchical clustering methods”. The back cover proclaims that Medical statistics from A to Z will be a lifesaver for doctors and students alike. Whether or not this is true, the book is a genuine timesaver — a quick reference for a plethora of medical statistics terms and an efficient pointer to more in-depth literature. Ian C MarschnerDirector, Asia Biometrics Centre, Pfizer Australia Sydney, NSW

Ian C Marschner

. . . a ceaseless flow of students, nurses, doctors, orderlies: fetching and carrying, advising; servants to the patient and their attendant team. Half a dozen medical students have spent the night in the Emergency Department, as the first flight from Bali brings in a dozen or so patients at 2 am. Twenty-six hours earlier, bombs destroyed two nightclubs packed with tourists and local residents at Kuta Beach, Bali.1 Most of the first casualties to arrive are able to walk and, although their injuries are severe, they are soon ministered to in Area 3 (the “walking wounded”) and sent off to the ward. At 5 am, as the first shift of students retires to sleep, the next batch arrives: six 3rd years (of which I am one), Matthias from Switzerland and a couple of 4th years. Didier, Director of Emergency, fills us in on what is happening and tells us to distribute ourselves into the three emergency rooms and two wards: our job is to act as runners, gophers, and extra hands. There is an unseemly wrangling for the best position, but as it turns out we all play our part. In fact, as it turned out, there weren’t enough of us to go round! Word comes that the next flight is due at 6:30 am, so there is time for a bit of a snooze and some nervous chitchat: a seasoned nurse confesses to feeling terrified that she will not be able to cope, that she won’t know what to do. Didier is on the phone constantly; there is a busy flow of information from the airport, from Bali, from interstate hospitals (Box 1). He keeps everyone updated on events as they unfold. Finally, the plane has landed; there are 30 patients, all are severely burnt, one so severely that we can’t tell if it is a man or a woman; six are already earmarked for the Intensive Care Unit. There is a flurry of last-minute instructions and reminders: Didier does his Churchill speech: “. . . great medicine . . . important . . . teamwork . . . faith in you all . . .” It could sound trite, but he means it and he will be proved right. The first ambulance arrives. An ambulance crew wheels in a patient, wrapped in a space blanket, drips and oxygen in a nurse’s hands. An anaesthetist from the airport team reports to Didier: broken forearm, estimated 20%–30% burns to the back and legs, fluids OK, obs stable. An unhurried inspection, a brief conversation with the patient and despatch into the second emergency area: he is not one of the seriously injured patients. The automatic doors at the entrance close on the next stretcher; nobody knows how or if they can be held open — mysteriously, they break and stay open. Ambulances bring patients every 5 minutes, with the same routine: update from the airport doctor, inspection, and triage to the appropriate area (Box 2). The airport team and Didier work in concert to manage the flow: there is always an emergency team waiting to receive each patient, no one is parked in a corridor or left unattended. An ICU patient arrives and is swept upstairs. He’s lucky, a retrieval expert has flown with him from Bali, complete with four bags of emergency equipment. This will mean extra help in ICU for the rest of the day. Emergency Area 1 looks like the inside of an anthill. I have a camera . . . Kerrie, one of the emergency specialists, has asked for some pictures. It’s too early yet for the hospital photographer, so I stand on a table in the resuscitation room, photographing the busy scene below. It looks like madness, but there is a pattern, a disciplined chaos, that resolves into four trolleys — each surrounded by a team of doctors and nurses, standing, quietly busy, playing their parts in a static choreography (Box 3). In between there is a ceaseless flow of students, nurses, doctors, orderlies: fetching and carrying, advising; servants to the patient and their attendant team. A surgeon appears, the first of many, moving from patient to patient, assessing needs and planning the next step in treatment. On my patient, a surgeon is cutting down into the inguinal fold, looking for the femoral artery to plug in a line . . . burns patients leak their body fluids at an alarming rate and we can’t find a vein in his arms or legs to pour liquid into him. Our patient has two bags of fluids up at a time, one with a pressure cuff to squirt it in. I clingwrap a leg which has full thickness burns down one side, while others wrap his arms, back, and buttocks; then we logroll him and see the full extent of the burns on his back. Someone compares the qualities of the different brands of clingwrap — which is the best for burns, which clings and which doesn’t. Jacqui, our team leader, asks the patient if he can remember what happened: “I was sitting at the bar, there was an explosion and I caught fire . . . I rolled on the ground to put it out . . . ” We can tell which side was closest to the bomb — the burns are worse on that side. The nurse asks if he has been in contact with anyone; she brings a mobile phone, so he can phone his mum. The human cost of the bombing strikes home: the burns, shrapnel wounds, infected wounds, blood, urine, moans of pain as we prod and poke. All these make up the professional part of the unfolding drama. We examine and analyse, put up drips, take blood, carefully record the location and extent of burns, peel off bandages, clingwrap body parts. It isn’t hard, it’s not horrific. Not at the time. It’s what we do, the bread and butter of medicine. We fold our professional armour around us with our white gowns. But hearing a young man, twenty-something, good-looking, strong, ask to speak to his mum on the phone — that is the hard part, the side that isn’t protected by a white gown. He’s letting her know he’s alive, that he’s in safe hands (we’ve told him, “you’re in the Royal Darwin Hospital . . . we’ll take care of you”), that he’s going to be all right. But we know he isn’t going to be all right: OK, he will live but, in between our thoughts of what to do next, we know that his future is going to be full of pain and disfigurement and mental trauma, and many of his hopes and dreams were burnt up along with his back and legs. Over on the far trolley, one patient is really seriously ill . . . off to ICU, but not just yet. His arms are burnt all round and the tissue under the burnt skin is swelling, compressing the muscles, slowly killing them, releasing toxins that will inevitably poison him. A surgeon carefully cuts full length down his arm and into his hand, releasing the tight sheath around his muscles, giving them a chance to stay alive. It looks like an anatomy lesson. The surgeon methodically cauterises small arteries, gently holding the patient’s hand as though reading his palm, while the smell of burnt flesh is sucked from the room by the air conditioning. Didier complains about the lack of medical students . . . I think everyone is here; we are all part of the team. Hours pass, and the last patient heads off to the ward: time for a break. There are 10 family-sized pizzas in the tearoom, ordered from the local pizza shop by a wellwisher in Adelaide. I photograph the empty resuscitation room, then snap an emergency nurse beside a neatly made-up trolley, waiting for the next patient — it all looks so normal. Tired people sit and drink tea, eat curry, pizza, sandwiches from downstairs in catering. We go for a walk, up to the ward. Everywhere there are signs of planning and preparation: boxes of fluids, dressings, trolleys, instruments. In the cafeteria are trays of food, cold drinks, desserts . . . the whole hospital plays a part, the “sharp end” functions so well because of those backstage. We hear later of the office staff phoning the families of patients, working as hard as we did to inform, reassure, sympathise; they are at a different sort of sharp end. The next plane lands with 20 more patients and the performance begins again: slick, smooth, fast. After all, we are seasoned now. The first night has been a success, even the students look professional; we are not just runners now. There are tasks to do which are ours: organise bloods; remove dressings; record the history, examination and assessment; clingwrap there, lift here. There are moments of time to watch and appreciate the choreography, the choreographers and the dancers — the emergency teams move with familiar precision and practised teamwork. The ring-ins slowly integrate into their rhythms, so by the end of the day it all seems like some grand ritual. The emergency specialists are like satellites, constantly orbiting each team, assessing, coordinating, advising, helping. By the middle of the afternoon it is pretty much all over for the students. The next plane has just two patients and then there are no more. We walk up to the ward . . . “is there anything we can help with?” We take some blood, struggling to find any sort of vein, finally going for the foot because there is nowhere else. The patient says, “they all find it hard”. One of us has to take blood from a line and doesn’t know how to do it, so I guide her through it: set up a sterile field, glove up, clean the bung, take 10 mL and discard, take the sample, flush the line, flush it again, clean it, clean it . . . it’s precious. It’s time to go home; 12 hours of adrenaline needs dissipating, we need to talk to each other. Someone offers his place, another cooks dinner; we have a beer and begin the debrief, reliving the day. For the next 2 days we are tired. There is a sense of anticlimax. The normal world has gone on around us and it goes on still. Suddenly, the hospital looks no different, except for odd stacks of boxes here and there that have yet to be returned to stores. We have an official debrief and hear the big picture — the confidence that Darwin could handle it, the thoroughness in the planning. We hear the stories from other places, and we praise the work of Denpasar Hospital and the Balinese, and our colleagues there, and on the tarmac at the airports. We feel important and proud to have been part of the grand dance. But someone asks about our patients: where have they gone and how are they and will they be all right; and there is a moment’s quiet, and we each have our own thoughts. 1 “Didier is on the phone constantly” 2 “Ambulances bring patients every 5 minutes” 3 “Trolleys — each surrounded by a team of doctors and nurses”

David E Chapman BA, BM BS

The new National Health and Medical Research Council toolkit is designed to help Effective communication between health care consumers and professionals is fundamental for evidence-based clinical practice.1 Clinicians and consumers recognise how difficult it is to exchange even apparently simple information with each other, while difficulties with more complex information are usually obvious to either or both. With increasing expectations of health care consumers that they will share more in decision making, and with greater access to information of variable quality outside of consultations, including the media and Internet, effective communication during consultations becomes even more necessary than before. One consequence of poor communication between consumers and clinicians is limited understanding by consumers of the benefits and risks of tests and treatments. This can result in decisions that might have been different with better understanding. For example, fewer men are interested in prostate-specific antigen (PSA) testing, and fewer women in adjuvant therapy for breast cancer after receiving more detailed or applicable information about these interventions.2,3 Other strategies that enhance communication have been shown to lead to improvements in understanding. A systematic review found that communication tools in most formats (eg, verbal, written, illustrative diagrams, cartoons and graphs, video, provider-delivered, computer-based) can increase patients’ understanding, especially if they are structured, tailored and/or interactive.4 The style in which data are presented also influences comprehension: “framing” numerical data about benefits and risks of interventions in either negative or positive and relative or absolute ways influences how data are perceived, not only by consumers but by clinicians as well. Addressing these issues has been shown to increase both consumer satisfaction and involvement in decision making, to result in more realistic expectations of outcomes, and to reduce decisional conflicts.4 Better communication contributes to consumer satisfaction in other ways, and with better outcomes. For example, agreement between physicians and patients about diagnosis and management of back pain is not only associated with higher patient satisfaction, but with better health status outcomes as well,5 suggesting that communication which promotes clinician–patient agreement leads to better outcomes. However, the extent to which poor communication contributes to clinician dissatisfaction, and also to other unfavourable outcomes, such as inappropriate underuse and overuse of investigations and treatments, and to health care costs, is unclear at present. There are many barriers to effective communication between health care consumers and professionals. They include physical impairments such as hearing and vision loss; learning disabilities; differences in languages spoken, and in cultural, educational, religious and socioeconomic backgrounds of the clinician and consumer; anxiety; and problems associated with illness and poor literacy. As consumers become more able to access information from an increasing array of sources, the skills of reading, writing and numeracy assume even greater importance. Patients with lower literacy skills are more likely to have problems communicating with health care professionals and to have less understanding about their medical conditions and choices.6 Not all clinicians have the skills to communicate well with a broad range of consumers with differing needs, or to involve consumers in making decisions when consumers want this. In addition, many consumers are not accustomed to having their views heard, or sharing in decisions about their care.7 Implementing better communication also requires negotiation and agreement about the particular arrangements for decision making within specific consumer–professional partnerships.8 The National Health and Medical Research Council has extended and applied the recommendations from two earlier publications to develop a toolkit, based on the best available evidence, to help consumers and clinicians learn the principles for better communication.9 The toolkit highlights common communication problems and provides practical strategies, from both consumer and provider perspectives, for recognising, exploring and solving these problems. The toolkit aims to help both health care consumers and professionals expand their communication skills and use them more effectively in a variety of clinical encounters. The toolkit recognises five principles for effective communication (Box). Each principle is presented in an identical and structured format: background; what the principle means for both health care consumers and professionals; and examples, with tools to put the principles into practice. To apply these five principles, illustrative scenarios, with questions for health care consumers and professionals, and sources of relevant additional information are included. Communicating benefits and risks of interventions between health care consumers and professionals is complex, to say the least. While there is a growing body of research evaluating ways to improve communication between health care consumers and professionals,10,11 we have only just begun to integrate this information into routine clinical practice. Improved communication tools and more effective techniques to overcome the barriers to better communication are likely to result in greater mutual understanding, better decisions and better health outcomes. However, as there is often a long period between communication during consultations and tangible health outcomes, and as the effects on health outcomes may also reflect other interventions and changes, it is easier to establish the effectiveness of communication strategies on shorter-term processes like knowledge, understanding and satisfaction. More research is needed, not only to prove whether communication strategies lead to better health outcomes, but also whether such strategies can be effectively taught and learned. Five principles for effective communication Good communication between health care consumers and health care professionals has many benefits. Health care consumers vary in how much participation in decision making they desire. Good communication depends on recognising and meeting the needs of health care consumers. Perceptions of risks and benefits are complex, and health care consumers and health care professionals may have different priorities. Information on risks and benefits needs to be comprehensive and accessible.

Peter B Greenberg MD, PhD, FRACP · Christine Walker PhD · Rachelle Buchbinder MB BS, MSc, FRACP

BARD in the practice. A guide for family doctors to consult efficiently, effectively and happily. Ed Warren. Oxford: Radcliffe Publishing, 2006 (xi + 136 pp). ISBN 1 85775 665 7. Dr Ed Warren is an obviously learned and wise middle-aged general practitioner who practises in Sheffield, in the United Kingdom. His thesis is that doctors have much to learn from actors, whose skill is to understand human motivation and communicate to their audience how it influences behaviour. So he has come up with the “BARD” approach to improve performance in a consultation. B is for behaviour, with an emphasis on the non-verbal kind through which over 50 per cent of interpersonal communication occurs. A is for aims — the broad direction in which a GP wishes to progress the patient and other stakeholders in the achievement of said aims. Here Warren introduces the concept of “the good enough consultation”. The essential components are securing the patient’s safety and ensuring that both patient and doctor are proceeding in the direction of their aims. The doctor/actor doesn’t have to compress the whole play into one 12-minute scene. There will be more scenes and acts to follow. R is for room and is equivalent to the theatre in which the action takes place. This includes the approaches to the building, the interior layout and the costume of reception, nursing and medical staff. D is for dialogue — the process by which doctor and patient try to adjust their transmitters and receivers to the same frequency. A novel suggestion is the use of voice lessons. The last two chapters in this book are on training for, and the ethics of, becoming a BARD GP. But this is not a syrupy “How to win friends and influence people” book. At no stage does the author suggest readers adopt behaviour incongruent with their beliefs and personality. Rather, the author wishes to transpose elements of Stanislavski’s “be yourself” method acting to the medical consultation. This book is an innovative addition to the literature on improving one’s consultation skills. Actors and sportspeople train to optimise their performances, as do spokespeople for the Australian Medical Association. So why not GPs? Reading this book is guaranteed to improve the consultation skills of even the most accomplished GPs. It has particular relevance for registrars and their mentors. Max KamienEmeritus Professor of General Practice, University of Western Australia, Perth, WA

Max Kamien

Manual of travel medicine: a pre-travel guide for health care practitioners. 2nd ed. Allen Yung, Tilman Ruff, Joseph Torresi, et al. Melbourne: IP Communications, 2004 (xxiii + 334 pp). ISBN 0 9752374 0 3 As the Asian tsunami disaster has so tragically shown, travel is not always safe or predictable. Making travel as safe as possible is, however, the goal of travel medicine, which has emerged as a specialised discipline as well as an interesting and challenging part of the work of many general practitioners. The popularity of the first edition of this Manual of travel medicine, published by the Victorian Infectious Diseases Service in 1999, demonstrated that doctors and other health professionals providing pre-travel health advice were looking for a desktop reference of high quality information. The fact that the manual comes from a group of very experienced and qualified Australian authors is of substantial value, as it complements the information available in other publications such as the Australian immunisation handbook and the WHO publication, International travel and health. Controversies and differences in opinion, such as whether to recommend hepatitis B vaccination to all or only higher risk subgroups of travellers and the use of bacille Calmette – Guérin (BCG) vaccine in travellers, are discussed, and the recommendations of key authorities, and the authors’ own opinion are provided. The manual focuses on pre-travel health advice and does not cover assessment and treatment of the unwell returned traveller. Although this is a substantial omission, it is not a major drawback for a GP readership who are mainly providing pre-travel health advice. As might be expected with an author list entirely made up of infectious diseases specialists, there is a focus on vaccine preventable diseases plus substantial chapters on malaria prevention, and prevention and management of travellers’ diarrhoea. Non-vaccine preventable diseases including severe acute respiratory syndrome (SARS) are covered, and there are sections on non-infectious problems such as venous thrombosis, altitude sickness and jet lag. Though not as inexpensive as the first, this edition of the Manual of travel medicine is still reasonably priced, and has the advantages of a more professional look and the welcome addition of an index. Nicholas A ZwarProfessor, General Practice Unit, Fairfield Hospital, NSW

Nicholas A Zwar

Preventing chronic diseases: a vital investment. World Health Organization. Geneva: World Health Organization, 2005 (xiv + 182 pp). ISBN 92 4 156300 1. Of the 58 million deaths in 2005, two thirds were due to chronic diseases. Up to one third of these occurred among people of working age. Although health improvement is central to three of the eight United Nations Millennium Development Goals (MDGs) that seek to halve poverty by 2015, chronic diseases are not mentioned. This is epidemiologically way off beam and politically erratic. This handsomely presented monograph produced by a World Health Organization team with Robert Beaglehole, an outstanding global health epidemiologist once from New Zealand but now in Geneva, as editor-in-chief, lifts the discussion about chronic disease by providing a practical approach to its prevention in developing countries. The authors offer strategies to reduce annually projected chronic disease death rates by 2% between 2005 and 2015. This is audacious, but so are the MDGs, and so for the first time we have a goal to energise and manage our response to chronic disease. The monograph provides a summary of the current and projected burden of chronic diseases, the urgent need for action, and a review of successful actions taken in controlling chronic diseases in less developed countries. A stepwise approach is proposed, similar to that produced by Ruth Bonita (also from NZ), and WHO colleagues for the evaluation of health gain programs more generally, as a guideline for ministries of health, beginning with “core”, moving on to “expanded” and then on to “desirable” actions. Each step is accompanied by milestones, which strengthen the proposed planning procedure. The monograph departs dramatically from previous volumes about chronic diseases that, although lacking the bright cover, resembled the White Pages telephone directory in layout, tedious content and ability to inspire. Here instead are modern graphics, coloured and boxed stories of individuals struggling with chronic disease, and case studies of national success, bringing the challenge of chronic disease to life. This is done without recourse to tabloid sensationalism: the facts presented are sound and serious. The WHO was beaten up many decades ago by organised medicine (from the United Kingdom and the United States especially) when it showed an interest in matters other than infectious disease — taking business away from the lads in the white coats. Its recent efforts in tobacco control have been spectacular and exceptional but occurred at a high price to those involved, with American tobacco lobbies dealing heavy blows. Time for a change. There’s more to life and death than germs, and if this volume signals WHO’s return to an interest in health as a whole, it is thrice welcome. Masoud Mirzaei and Stephen R LeederAustralian Health Policy Institute, University of Sydney, NSW Competing interests: Professor Stephen Leeder was one among a large panel of reviewers of drafts of the monograph.

Masoud Mirzaei · Stephen R Leeder

Intimate partner abuse and health professionals: new approaches to domestic violence. Gwenneth Roberts, Kelsey Hegarty, Gene Feder, editors. Philadelphia: Churchill Livingstone, 2006 (xvi + 240 pp). ISBN 0443074933. How times have changed! Fifteen years ago, intimate partner abuse was not an issue discussed in medical circles. Indeed, researchers in this field were often vilified and taken to task on publication of studies exposing the prevalence of this issue and the resultant morbidity associated with it. By contrast, today we see government advertisements on television telling us that “Australia says ‘No’” to domestic violence. Health professionals have a worthy resource in this book edited by Gwenneth Roberts and Kelsey Hegarty from Australia and Gene Feder from the United Kingdom. Intimate partner abuse and health professionals: new approaches to domestic violence gathers together and presents with great rigour the vast literature that has accumulated in this field over recent times. It covers the impact of intimate partner abuse, how common it is, and how health professionals can identify it and respond effectively. Difficult issues are addressed, such as the impact on children and challenges faced by general practitioners in dealing with both the perpetrator and the victim, as well as domestic violence in Indigenous communities and among gay and lesbian couples. The editors are experienced researchers in the area of intimate partner abuse, and the authors they have assembled provide a comprehensive and scholarly text. While practitioners and students may find the book too detailed, this text is ideal for researchers and teachers who require an in-depth understanding of the field, and for whom it provides a valuable synthesis of our current understanding of intimate partner abuse in the health care setting. Danielle MazzaAssociate Professor of General Practice, Monash University, Melbourne, VIC

Danielle Mazza

New thinking about mental health and employment. Bob Grove, Jenny Secker, Patience Seebohm (editors). Oxford: Radcliffe Publishing, 2005 (xxii + 162 pp). ISBN 1 85775 769 6. Sigmund Freud stated that the pillars of psychological wellbeing are love and work. Unfortunately, it is work that is most sensitive to the impact of mental illness. Return to work has always been a key aim of psychiatric rehabilitation. At times, the illness proves a turning point in life, motivating positive change and greater achievement of life goals. The majority of patients get back to work, but for a minority, work outcomes are bleak. The impact of treatment has even, at times, been negative (for instance, conventional neuroleptics causing the “zombie-like” state of drug-induced Parkinsonism). The response of the community and employers has been an even greater handicap. Discrimination is still rife. Given that 49% of the population will develop a mental illness in their lifetime, the impact of the new dismissal laws may create enormous social upheaval in Australia. Very little has been written about employment and mental health, and I keenly looked forward to reading New thinking about mental health and employment, only to be seriously disappointed by contributions from the editors. The book opens with the statement, “Most people who suffer from periods of mental ill health would like to work and yet less than 20% are in employment”. This statistic applies to sufferers of chronic schizophrenia, not mental illness in general. While it is totally legitimate for the editors to concentrate on people with chronic psychoses, they should say they are doing so. After all, the editors indicate that they advise government authorities on employment for the mentally ill. Yet only one is identified professionally as a professor of nursing, and the other two, for reasons I cannot discern, omit their professional backgrounds. The editors argue that the “all-pervasive medical model” has created a system that actually excludes people from employment. This is a tired old argument. There is much in public psychiatry that deserves profound censure, but doctors’ alleged lack of concern about employment is not one of them (the capacity to do much about it may be another story). It is absolutely undeniable that effective medical treatment will improve the capacity of patients to return to work, and hence will facilitate any assistance given by employment services. Much more justifiably, the editors tackle therapeutic nihilism in schizophrenia, again with anecdotes of doctors telling patients they will never work again, where this was manifestly wrong and damaging. The issue is difficult as people with schizophrenia often do have a poor outcome, but I also see patients who continue to work at the highest professional levels despite suffering chronic illness. Rather than pointing to the heterogeneity of schizophrenia, and how differently patients may be affected, the editors run the old argument that schizophrenia does not actually have a poor prognosis if only clinicians developed better attitudes. A new paradigm “of intervening to halt and reverse the journey to exclusion” is the way to go. Who could disagree? What saves the book is that most of its content comes from contributors other than the editors. There is a great deal of useful information. The biographical accounts, feedback on services, and perspectives of the users are both articulate and enormously instructive, although recounted treatment experiences are often tragic. Chapters such as “What do service users want?” and “What’s kept me working?” are invaluable. The evidence of “what works” is well presented but the conclusions fall down by attempting to generalise where there are enormous differences in individual needs. Accounts of actual services and how to develop interventions are useful. On balance, this book is worth reading because it contains information that will assist clinicians to help patients with chronic psychoses get back to work. Nicholas A KeksProfessor of Psychiatry, Monash University, Melbourne, VIC

Nicholas A Keks

CorrectionRe: “Challenges, conflict and change”, by David G Penington, in the 5/19 December issue of the Journal (Med J Aust 2005; 183: 585-589). On page 587, the article states that Australia became the first country in the world to test every single blood donation for HIV in May 1995. This should have read May 1985. The html and pdf versions of this article were corrected on 7 February 2006.

David G Penington AC

CorrectionRe: “Doggonit, it’s Christmas”, by Mervyn D Cobcroft and Charles Pembroke-Corgi, in the 5/19 December 2005 issue of the Journal (Med J Aust 2005; 183: 656-658). An acknowledgement for this article was inadvertently omitted. The acknowledgement should have read: Professor Denis Brosnan, University of Queensland, is responsible for coining the term “interposita”. The html version of this article has been corrected.

Mervyn D Cobcroft MB BS, FANZCA · Charles Pembroke-Corgi

Clinical sports nutrition. 3rd ed. Louise Burke, Vicki Deakin, editors. Sydney: McGraw-Hill Medical, 2006 (xxvi + 822 pp). ISBN 0074716026. Those familiar with previous editions of Clinical sports nutrition are most likely as excited as I am about the release of this latest version. The second edition has had pride of place on my bookshelf since it was purchased, with only this to knock it off its perch. New features include expert commentary on antioxidants, immune function and the female athlete triad. The International Olympic Committee consensus conference in 2004 provided an update on current thinking in sports nutrition (eg, guidelines for carbohydrate intake), which Clinical sports nutrition has incorporated. As in previous editions, both the editors and the chapter authors are leaders of their field, making this book an unofficial consensus statement for sports nutrition in Australia. Each chapter of the book (now “easy find” with shaded tabs) includes an appraisal of recent research on the topic and follows with practice tips. This combination of theory and practice provides a valuable tool for practitioners. Food products, nutrient reference values and units will be familiar to Australian health professionals. All of the key areas of sports nutrition are discussed, as well as several topics not usually covered by other sports nutrition texts (including athletes with special needs such as diabetes or disabilities, young athletes, and the older sportsperson). There are sections on catering for athletic groups, travel, and nutrition for special environments such as high altitude and extreme climates. All in all, those working primarily in the area of sports nutrition are likely to read the book cover to cover, despite its 800+ pages. Other practitioners, particularly sports physicians or exercise physiologists, may find it useful as a reference text. Bronwen LundySports Dietitian, Sydney Sports Medicine Centre, State Sports Centre, Sydney, NSW Order this book

Bronwen Lundy

The beginner’s guide to winning the Nobel Prize. A life in science. Peter Doherty. Melbourne: Melbourne University Publishing, 2005 (304 pp). ISBN 0 522 85120 7. Nobel laureates are particularly prone to publishing their memoirs and sharing their wisdom. Examples include James Watson’s The double helix: a personal account of the discovery of the structure of DNA and Macfarlane Burnet’s Changing patterns: an atypical autobiography. The latest addition to this passing parade is Peter Doherty’s The beginner’s guide to winning the Nobel Prize. The title stimulated me, but it may deter other readers. Doherty and Rolf Zinkernagel won the Nobel Prize in Physiology or Medicine in 1996. The book has many themes: selected autobiographical details; forays into the history of the science of medicine; the story of the progress of immunology in the 20th century and the many Nobel Prizes gained along the way; the immunological research that won Doherty and Zinkernagel the Nobel Prize; the human aspects of the modern research enterprise and its culture; and the people and areas of research that are contenders for future Nobel Prizes. More accessible topics are Doherty’s views on science and religion, politics and the media, and the importance for a nation’s economy of supporting the research enterprise. All these topics are embellished with Doherty’s wisdom and wit. The book’s encyclopaedic coverage is both its strength and its weakness. Its continuity is broken at times by poorly placed and unnecessary diversions. Despite this, I persisted, in pursuit of the advice promised in the book’s title. Ultimately, the answer was revealed, but you will have to read the book yourself for the revelation. It is difficult to know to whom to recommend the book. It could be for anyone, from the curious citizen to the young scientist wanting to become street-smart for his or her journey to Stockholm and the Nobel Prize. Martin B Van Der WeydenEditor, The Medical Journal of Australia

Martin B Van Der Weyden

Climate change. Turning up the heat. A Barrie Pittock. Melbourne: CSIRO Publishing, 2005 (viii + 316 pp). ISBN 0 643 06931 3. This is no doomsday book. Rather, it is a compilation of hard scientific data that the author uses to make projections about the sort of world our children and grandchildren will be living in in the future. Climate models are based on various types of human behaviour extending from “business as usual” to a scenario with reductions in material intensity and the introduction of clean, resource-efficient technologies. The “business as usual” scenario predicts an increase in extreme climatic events during this century. Worst hit would be low latitude countries. Flooding due to sea level rise, increased hurricane activity, and storm surges would displace millions of people on the Indian subcontinent. Australia and New Zealand would be obliged to take refugees. None of the Western nations are immune to the effects of climate change. The United States is particularly vulnerable. To quote from the book, “The city of New Orleans already lies below sea level and could be drowned by a combination of river flooding, storm surge and sea-level rise” (the book was already in the hands of the printer at the time of Hurricane Katrina). Difficult for the layman and politicians to understand are the long lag times in the climate system. Warming that has already occurred has set in place an irrevocable chain of events such as coral bleaching in the Great Barrier Reef, decreased snow fall on the Australian Alps, melting of the Greenland ice cap and the permafrost in Alaska, and breaking up of ice shelves in the Antarctic. The chapter on mitigation gives courses of action to limit global warming and offers some reason for hope (the author’s original title was Climate change: turning down the heat!). Intriguing is the potential of developing countries to “leapfrog” the industrialised nations by adopting clean technologies and achieving sustained economic growth without the pollution that characterised the Industrial Revolution in Western countries. The author, a world expert on climate change, has researched outside his field to analyse the socio-economic effects and health impacts. The book contains a comprehensive index and bibliography, and detailed notes can be accessed via a website. Robert M HareAnaesthetist Cabrini Hospital, Malvern, VIC

Robert M Hare

My early research career has benefited greatly from chance and the right environment. It was not my intention to solve major problems in my postgraduate studies. I was simply interested in the possibility that a virus, discovered by Ludwik Gross in the United States, was involved in the pathogenesis of mouse leukaemia. Although I had no plans to work on immunological problems, I was very much influenced by lectures given by two giants in medical research — Peter Medawar (who, along with Macfarlane Burnet, was awarded the 1960 Nobel Prize for physiology and medicine for their contributions to immunology) and James Gowans (who was Professor of Experimental Pathology at Oxford). Both were responsible for elucidating the phenomenon of immunological tolerance and the function of recirculating small lymphocytes. Their expositions helped me greatly in my subsequent work on the immune system. Early years and how I ended up in medical researchMy parents were born in Paris in 1896. During the first World War, my father Maurice Meunier (English translation, Miller) was an interpreter for British forces in France. In 1919, he married and left for China to join a French bank in Peking. He spent some 22 years in China and Japan, eventually becoming manager of the Franco–Chinese Bank in Shanghai. In 1930, my mother (for health reasons) and my two sisters returned to France by boat. My mother found that she was pregnant, so, having been conceived in China, I was born in Nice, France, in April 1931. The following year we (my mother, my eldest sister Jacqueline, Jeanine and I) returned to China, but we were back in France again 3 years later, because of my mother’s delicate health, and to allow Jacqueline to receive a “good” education at a French boarding school. One year later, when we were on the verge of returning to China, Jacqueline was diagnosed with pulmonary tuberculosis. The four of us instead went to live in Lausanne, Switzerland, which at that time was the place where tuberculosis was supposed to be cured. On the outbreak of World War II, the family hurriedly moved back to Shanghai where, unfortunately, Jacqueline had a relapse of her disease and died in December 1940, aged 17, sadly a few years before the discovery of the anti-tuberculosis drug, streptomycin. In 1941, my father, believing that Japan would enter the war, decided that we should move to Australia. We took the last available cargo ship out of Shanghai and arrived in Sydney a few weeks before Pearl Harbour was attacked. From an early age, and having witnessed my sister’s illness, I wished I could study medicine. Even though I was 10 years younger than Jacqueline, I remembered well her doctor telling my mother how little was known about the body’s resistance to infection, and that intrigued me. In Sydney I went to a Jesuit school, St Aloysius. There, I became friendly with an Austrian boy from Vienna, Gus Nossal. Our paths were to cross in later years. Having achieved a maximum pass in my last year at school, I was accepted into Sydney University medical school. In those days, the course lasted 6 years, but after the 4th year, I did a year’s research. I pursued a Bachelors degree in medical science in Professor de Burgh’s bacteriology department at Sydney University, investigating an experimental model of virus infection. This experience gave me a taste for basic research. PhD studies: virus-induced mouse leukaemiaAfter passing my finals and doing an internship at the Royal Prince Alfred Hospital in Sydney, in 1957 I applied for a Gaggin Research Fellowship, advertised in The Medical Journal of Australia. It was sponsored by the University of Queensland, and offered a return fare to the United Kingdom and a salary for 2 years in a research institute. With this Fellowship in hand, I was accepted as a postdoctoral student for the PhD degree at the Chester Beatty Research Institute in South Kensington, London. I arrived in 1958 with no clear idea of what I might be doing. Many of the scientists at the Chester Beatty were involved in searching for new chemical carcinogenic compounds. Adding more compounds to an ever-growing list did not particularly interest me, as I preferred to use the experience I gained in my BMedSci year to work on some model in which pathogenetic mechanisms had to be elucidated. There was no space for me in the London laboratories, and I was sent to one of the two Chester Beatty satellites, “Pollards Wood”, in Buckinghamshire. It had a splendid Tudor-style mansion in which the rooms had been refurbished to first-class laboratories and offices. There, Dr RJC Harris was working on the development of sarcomas in turkeys, induced by the Rous sarcoma virus. This interested me. Instead of working in his group, he suggested that I might investigate the pathogenesis of lymphoblastic leukaemia induced in mice by what was presumed to be a virus recently discovered by Ludwik Gross. I was very pleased to do this. The only space available was in a shack and in part of a converted horse stable near other horse stables that had been converted to animal holding rooms. Six months after I arrived, Harris was offered the directorship of the Division of Virology of the Imperial Cancer Research Fund at Mill Hill, London. He packed up and left, leaving me without an immediate supervisor, but it was some consolation to acquire his animal space. In the late 1950s, Gross (at the Cancer Research Unit, Veterans Administration Medical Center, the Bronx, New York) had induced leukaemia in some “low-leukaemic” strains of mice by simply inoculating newborn mice with filtered extracts of leukaemic tissues from “high-leukaemic” strains of mice that spontaneously develop the disease at around 9 months of age. Repeating Gross’s observations using the Pollards Wood strains of mice might have taken months or years, and so I wrote to Gross asking him whether he would be kind enough to send his virus and the mice harbouring it. I was grateful that he did so. It was known at that time that acute lymphoblastic leukaemia in mice somehow involved the thymus, and that adult thymectomy prevented the disease from developing spontaneously in high-leukaemic-strain mice, and from induction by ionising radiation and chemical carcinogens in low-leukaemic-strain mice. As no one had hitherto investigated the role of the thymus in the leukaemia induced by Gross’s method, I thought that this would be a good topic for my PhD studies. I had many questions to answer. Why did leukaemia develop only when mice were inoculated with the virus at birth and not later? Could adult thymectomy prevent the disease in virus-inoculated mice? Could the virus multiply only in thymus tissue? What would happen if a normal thymus was grafted into virus-inoculated mice that had their own thymus surgically resected? I was soon able to confirm Gross’s initial work and, in addition, showed the following: Mice given the virus at birth did not develop leukaemia when thymectomised after weaning, but did develop leukaemia when grafted in later life with normal thymus tissue. Grafting normal thymus as late as 6 months after adult thymectomy still enabled leukaemia to develop. The virus could be recovered from the healthy non-leukaemic tissues of neonatally inoculated mice that had been thymectomised at around 6 weeks of age. All these findings led me to wonder whether the virus could multiply in tissues other than the thymus, and to test whether day-old mice inoculated with virus after neonatal thymectomy would develop leukaemia when grafted 2–4 months later with thymus tissue. From leukaemia studies to immune deficiencyNeonatally thymectomised mice grew well at first, but after weaning, many lost weight and died prematurely whether inoculated with virus or not. Adult thymectomy, on the other hand, had never shown any untoward effects such as weight loss, immune deficiency or obvious abnormalities. The onset of wasting and premature death after neonatal thymectomy led me to conclude, “that the thymus at birth may be essential to life”.1 Histological examination of the tissues of neonatally thymectomised mice showed a marked deficiency of lymphocytes in the circulation and the lymphoid tissues, and many wasted mice had liver lesions suggesting infection by a hepatitis virus. I might not have followed up these results had I not been aware of the brilliant work of two famous immunologists, Jim Gowans and Peter Medawar. Gowans had recently shown that, unlike thymus lymphocytes, circulating small lymphocytes were not short-lived cells, as had been widely believed — they were long-lived immunocompetent cells, recirculating from blood through lymphoid tissues into lymph and well equipped to initiate immunological reactions when appropriately stimulated by antigen. Medawar and his colleagues had proven that these lymphocytes were involved in rejection of foreign tissues. Clearly, my neonatally thymectomised mice, that had so few lymphocytes, must have been immunodeficient. So, I tested their immune competence by grafting skin from foreign mice and from rats and by testing their antibody responses to several antigens. The results were striking; unlike mice thymectomised as adults, which had been shown by many to be perfectly able to mount all types of immune responses, my neonatally thymectomised mice were immuno-incompetent. I concluded that during embryogenesis, the thymus would produce the originators of immunologically competent cells, many of which would have migrated to other sites at about the time of birth. This would suggest that thymus lymphocytes leaving the thymus are specially selected cells.2,3 As had to be expected, thymus grafting restored immunological potential to thymectomised mice, but when the thymus donor was foreign to the host, the latter was specifically tolerant of the donor’s tissue antigens. I therefore suggested that tolerance is established within the thymus by the deletion of potentially reactive cells (“selective immunological thymectomy”).3 I next turned my attention to adult thymectomy. It seemed to me that, as total body irradiation damaged the lymphoid system and its immune function, recovery following irradiation should be thymus-dependent. This was found to be correct.4 In those days, most immunologists considered the thymus a useless organ that had become obsolete during the course of evolution and acted simply as a graveyard for dying lymphocytes. They could not fault my data, but criticised my interpretation. The most valid criticism was that my mice, having been bred in converted horse stables, must have had so many intercurrent infections that the additional trauma of thymectomy made them immuno-incompetent. I was able to silence this criticism in 1963, when I obtained an Eleanor Roosevelt Fellowship enabling me to spend a year at the National Institutes of Health in the United States, at that time the only country where germfree mice were available. As neonatally thymectomised germfree mice were also immuno-incompetent,5 immunologists finally agreed that the thymus did have an immune function. However, it was not clear whether it produced all the body’s lymphocytes, then widely believed to function as a single homogeneous population, or whether it influenced the lymphoid system by some unidentified humoral mechanism. Back in AustraliaIn 1965, I was invited back to Australia by Gus Nossal, who had just been appointed director of the Walter and Eliza Hall Institute of Medical Research in Melbourne, to succeed Burnet. I was to lead a new laboratory at the Institute, and Gus had kindly chosen the brilliant young Graham Mitchell, who had just graduated with first class honours from the University of Sydney Veterinary School, as my first PhD student. Our first task was to understand how the thymus contributed to the pool of immunocompetent recirculating small lymphocytes. To achieve this, we investigated how various cell types might restore immune functions to thymectomised mice and what happened to these cells. At that time no “CD” (cluster designation) markers were available to trace cells, and the fluorescent-activated cell sorter had not been invented. We therefore used genetic markers (H-2 disparate strains of mice) and anti-H-2 sera to follow the fate of the injected cells. By the use of such markers, we were able to show how thymus-derived cells and bone-marrow-derived cells interacted in the formation of antibodies (Box 1).6-9 The data in these classical papers established unequivocally for the first time that: (i) thymus-derived cells (later known as T cells, short for “thymus-derived” and coined by Ivan Roitt in London) could be activated specifically by antigen; (ii) they were not the precursors of antibody-forming cells; (iii) they were essential to help, through some form of collaboration, other lymphocytes derived from bone marrow (later known as B cells, short for “bone marrow-derived” cells, also coined by Ivan Roitt) to respond to antigen by producing antibody; and (iv) the mammalian equivalent of the avian bursa (that had been shown by various investigators to have a unique function in antibody formation) was the bone marrow. As to the mechanism of interaction, I made various suggestions, notably that T cells would “focus” cells’ antigen onto specific B cells, or that T cells might secrete antigen-non-specific pharmacological agents. How did the immunological community react to our findings? There was complete surprise, of course, but there was also disbelief when I presented these results at meetings held in the US and Canada in 1968. I was accused of “complicating things”, but the commonest and quite valid criticism of our view of how T and B cells collaborated was that two rare clonally individuated cells would never find each other. The most sarcastic criticism came from Bede Morris, then the Professor of Immunology at the John Curtin School of Medical Research in Canberra, who likened B and T cells to the first and last letters of the word “bullshit”! In spite of all this scepticism and criticism, Graham and I persevered in our work. It was urgently necessary to re-examine a multitude of immunological phenomena and diseases of immune aberration in terms of the two-cell system — tolerance, memory, autoimmunity, immune deficiency, genetically determined unresponsive states, mode of action of immunosuppressants, among others. Within 2–3 years, the entire immunological community jumped on the bandwagon, and since then, hardly an article has appeared in any immunological journal without mentioning the words T or B cells. Over the years my work with colleagues has attracted prestigious awards (Box 2). The two I appreciate most are the Copley Medal from the Royal Society and the Prime Minister’s Prize for Science. I treasure the former because it is the highest award granted by the Royal Society, and the oldest, the first medal being awarded in 1731. It is also a scientific award for outstanding achievements in any branch of science and previous medallists have included Charles Darwin, Francis Crick and Albert Einstein. I treasure the Prime Minister’s Science Prize because it is a distinctly Australian Prize and is, at present, the highest award that is given here. What does the future hold?In 1971, Macfarlane Burnet stated, “None of my juniors seem to be worried as I am by the fact that the contribution of laboratory science to medicine has virtually come to an end”.10 Burnet would be greatly surprised and pleased by the technological breakthroughs, such as transgenic technology, and novel experimental approaches, such as gene targeting, that have given us so much new knowledge in immunology. Although we can employ numerous strategies to allow better survival of transplanted tissues, to deal with various forms of immunological aberrations, and to produce new vaccines, we still have much to learn, in particular, how to apply the fundamental knowledge obtained from our bench work in clinical situations. I am thus in full agreement with the scientific philosopher Karl Popper, that “the deeper our learning, the more conscious, specific and articulate will be our knowledge of what we do not know, our knowledge of our ignorance”.11 1 Development and migration of T and B cells Haemopoietic stem cells originate in the bone marrow (and in the yolk sac and liver in the fetus) and are disseminated in the bloodstream. Some that have already differentiated to lymphoid stem cells reach the thymus where they differentiate to T lymphocytes that migrate out to circulate in the blood and lymph and to colonise the T-cell-dependent areas of the lymphoid tissues. B cells differentiate in the bone marrow and migrate out to colonise the B-cell-dependent areas of the lymphoid tissues and to circulate in blood and lymph. 2 Principal awards received Encyclopaedia Britannica (Australia) Award, 1966 Gairdner Foundation Annual International Award; Toronto, Canada, 1966 Scientific Medal of the Zoological Society of London, 1967 Paul Ehrlich-Ludwig Darmstaedter Prize; Frankfurt, Germany, 1974 Rabbi Shai Shacknai Memorial Prize; Jerusalem, Israel, 1978 Elected Foreign Associate for the United States National Academy of Science, 1982 International St Vincent Prize; World Health Organization, 1983 Sandoz Prize for Immunology, 1990 Peter Medawar Prize for the Transplantation Society, 1990 Croonian Prize, Royal Society; London, 1992 J Alwyn Taylor International Prize for Medicine; London, Ontario, Canada, 1995 Copley Medal, Royal Society; London, 2001 Prime Minister’s Prize for Science; Australia, 2003

Jacques FA Miller AC, AO, MD(Hon), PhD, DSc

Growing up in a medical household with a father who was a consultant physician, the idea of becoming a doctor was with me as early as I can remember. As a teenager, however, deeper thinking about life led me away and then back to medicine. I was fascinated by the wide diversity of human personality, and was an avid reader of biographies. One that influenced me greatly was that of Sir James Mackenzie1 (pictured, Figure 1). He was an Edinburgh graduate who became a general practitioner in Burnley, Lancashire in the second half of the 19th century. From clinical experience, he became keenly interested in the way the heart behaved in arrhythmia. He developed the application of the smoked drum polygraph to interpret the venous waves in his patients’ necks and their relationship to various forms of arrhythmia. As his findings eventually became recognised, he moved into the limelight. He moved to London, practised in Harley Street, headed a new cardiac department at The London Hospital (Figure 2), was knighted, and became the father of clinical cardiology. He was never as happy as he had been as a country family doctor, a role to which he finally returned in Scotland. I was fascinated by the story of how he applied science to resolve problems in a very human context. During my 2nd and 3rd years at Melbourne University medical school, I was confronted with huge masses of information to be reproduced in examinations — particularly in anatomy. Physiology, on the other hand, offered, under “Pansy” Wright, an opportunity to explore ideas. (Wright was Professor of Physiology and the enfant terrible of anti-establishment Australian academia — later Sir Douglas Wright AK, Chancellor of the University!) Nearing the end of my 3rd year in 1950, I was aware that my grasp of science was too shaky to enable me to distinguish fact from the arrogant assertion then so common among clinical teachers. I jumped at the chance of a scholarship to Oxford, offering 2 more preclinical years and 3 years of clinical education at the Radcliffe Infirmary. The years in EnglandLife as an undergraduate in Oxford was all I had dreamt of. There were opportunities to explore ideas of every kind among able people. On arrival in Oxford, I was told by the Professor of Anatomy that I could forget most of the topographical anatomy taught in Melbourne, just study his book The tissues of the body,2 and go anywhere library reading led me. Lectures, he told me, did not matter! Tutorials were a great experience, encompassing independent learning and critical discussions with a tutor who was a senior scientist. Perhaps the most memorable teaching I ever experienced was Howard Florey lecturing on general pathology, covering topics such as inflammation, tissue regeneration, cancer, immunology and responses to infection. There were many other fascinations at Oxford — music, theatre, and sport. My College in Oxford (Magdalen) was second in the intercollegiate “summer eights” (rowing). In my 2nd year, after a major falling out between the several “public school” factions and others, and dire predictions of disaster in the next intercollegiate contest, I was asked to become captain of the boat club. I spent every afternoon over five terms rowing. I missed many classes, but learned a great deal about building a team amid conflict and dissent. Clinical education in Oxford again offered a great clinical experience in an environment where conventional wisdom could be challenged and innovative ideas (such as treating haemophilia with animal Factor VIII produced there in the laboratory, and new approaches to managing severe poliomyelitis, or multiple sclerosis using tuberculin) were being explored. After graduating, I married an Oxford medical graduate whose clinical years had been spent at The London Hospital. We had four children over the next 8 years, and my wife committed herself to bringing up our children rather than pursuing her own career. Our marriage was to last for 26 years. A career in medicineMy early resident positions in Oxford led to an exciting 6 months as senior resident at the Hammersmith Postgraduate School, with challenging discussion of cases before leaders such as John McMichael, who headed medicine with a commitment to advance practice based on research, and John Dacie, who was an inter-national figure in haematology. On gaining membership of the Royal College of Physicians (MRCP), I accepted a Junior Lecturer position at The London Hospital in 1957. There I found a very different environment. There were many outstanding senior clinicians, but the academic medical unit was stuck in a time-warp, grounded in views on renal disease formulated in the 1930s. Recent research on renin and angio-tensin was regarded as a passing fad of no relevance to human disease. However, the position offered great clinical experience and a major commitment in clinical teaching, along with an isotope laboratory for measuring red cell survival in renal failure. I was fascinated by experimental reports on erythropoietin as a regulator of red cell production, thought to be produced by the kidney. I set about devising an assay, using hyper-transfused rats, assessing erythropoiesis with Fe59. After 6 months, my boss, Professor Clifford Wilson, asked what I was doing. I told him about erythropoietin and he sensibly asked me to prepare a literature review. Three months later, I asked him what he thought and he replied that he “did not really believe in humoral factors in disease”. However, by then I was successfully assaying erythropoietin in several forms of anaemia. He relented and let me get on with it! The publication of my first independent research paper in The Lancet in 1961,3 reporting absence of elevated erythropoietin in renal anaemia, led to an offer of a research fellowship in Boston with Ted Astwood (the man who had first isolated adrenocorticotropic hormone) at the New England Medical Centre. A year of full-time research in Boston, seeking to isolate erythropoietin, was exciting, and exposed me to first-class people. After returning to The London Hospital in 1963, I was appointed Consultant Physician at the age of 33, and gained research facilities supported by the Medical Research Council. Life as a teaching hospital consultant, with clinical duties, teaching and research, was challenging. I established the hospital’s first haematology clinic which grew rapidly. As my National Health Service appointment was part-time, I succumbed to urging from colleagues to begin private consulting in Harley Street. This practice grew like Topsy. While it involved dealing with many interesting people as patients, and was highly remunerative, it was not what I wanted to do with my life. I could never find sufficient time to do justice to my developing research on control of platelet production or to keeping my teaching fresh and vigorous. In 1966, I visited Australia for the first time in 16 years, attending an International Haematology Congress in Sydney. I seriously thought about returning to Australia and to academia. In 1967, Carl de Gruchy, Professor of Medicine at St Vincent’s Melbourne and renowned author of Clinical haematology in medical practice,4 approached me with the offer of a post as his first assistant, at a salary about half that of my London income. While I also considered a comparable post in Oxford, the lure of Australia was strong. Colleagues at The London Hospital suggested I must have been in need of psychiatric help to think of resigning, but at the end of 1967, my family and I shipped out to Melbourne. An academic career in MelbourneMy next 2 years at St Vincent’s Hospital were splendid, with time for research, for teaching and clinical practice. I completed an Oxford doctorate with research on megakaryocytes. However, when Carl unexpectedly resigned, I was appointed Professor of Medicine. The hospital at that time was staffed primarily by generalists, as honoraries. The few salaried specialists who provided diagnostic services were not regarded as part of the senior staff of the hospital. For St Vincent’s to become a modern teaching hospital, providing appropriate tertiary services, education and postgraduate training, there was a great need for development of clinical specialties nurtured by research. A real challenge! As an “outsider” in a tight-knit Catholic hospital, tackling this was not an easy task. Although the University of Melbourne was in dire financial straits at that time, I finally got agreement to make two new academic appointments — one in gastroenterology, and the other in endocrinology. Development of specialties, with research facilities initially within my unit, became the pattern for change. Hospital grand rounds, of the calibre of those at Hammersmith, were part of my vision. Resistance by vested interests — those who had previously controlled the destiny of the hospital — was inevitable and had to be lived with; but some senior honoraries who had experience of leading centres in the United States and the United Kingdom were strongly supportive. At the end of 1972, following Whitlam’s election victory, it was clear that Medibank would bring a new pattern of health care delivery with many opportunities for the public sector. Money became available for developing community health centres. In the preceding year I had become Chairman of the university’s Board of Social Studies and saw a health centre, with cross disciplinary collaboration, as both a useful community service and an opportunity to provide a new environment of undergraduate teaching in primary health care. When I formed a planning group, the Victorian branch of the Australian Medical Association (AMA) was outraged, and I was “declared black”. I was brought before hospital authorities and castigated for involving St Vincent’s in what was deemed to be a socialist experiment which would inevitably be involved in doing abortions and other wicked things! However, I had accepted the challenge and was not going to let go. I thanked both for their views and continued on my way! The state Liberal government would only approve the clinic if it had a fee-for-service doctor, complying with AMA demands. This was agreed. By mid-1975, after many battles, the clinic was built and opened within a high-rise housing estate near the hospital, managed by the local community. It had strong input from the Royal District Nursing Service, and social workers were integral to its team. Its doctor had just completed a PhD in my laboratory. To this day it provides service to its low-socioeconomic-status community with many immigrant groups. Deanship and what followedIn 1976, returning from a sabbatical year in laboratory research in Oxford, I became Deputy Dean of the Faculty of Medicine and was also recruited to chair the National Blood Transfusion Committee of the Red Cross. In 1978, I became Dean of Medicine, succeeding Sir Lance Townsend, but continued as Professor at St Vincent’s, with patients, research and teaching. I embarked on seeking to transform medical education from its preoccupation with peddling facts to a process of teaching students to think, to solve problems and to understand broad clinical responsibilities. Quality of teaching mattered enormously and needed attention. A critical decision by the faculty to change the curriculum to reflect these objectives was won on a vote of 57 for and 55 against, after two recounts, in a meeting attended by many faculty members who had not been near the university in years! From that point reform rolled on. The faculty needed change. Its resources were concentrated in the older, established departments rather than in those growing in research and doing new things. Again, vested interests were strong, but with persistence we shifted resources to clinical departments with strong research and away from anatomy and some other pre-clinical departments that justified their “wealth” on historical decisions and a large teaching load of questionable quality. The AIDS challengeThe National Blood Transfusion Service was an amalgam of independent state fiefdoms. It badly needed better decision making and regulation to safeguard standards, but this was strongly resisted by state directors unwilling to concede any authority. In my last meeting (February 1983), at which I announced my intention to retire, the news of AIDS cases linked to the use of fresh cryoprecipitate for haemophilia was reported in the New England Journal of Medicine.5 I relayed this to the council of the National Health and Medical Research Council (NHMRC), on which I then served, and was asked to set up a committee to advise on possible public health implications. Ian Gust, a virologist from Fairfield Infectious Diseases Hospital, Melbourne, joined me and played a key role in all our activities. Ron Penny of St Vincent’s Hospital, Sydney, who diagnosed the first Australian case of AIDS, covered immunology, and others contributed in further areas. As the story unfolded over the following year, there was great public fear of the unknown, and great potential threats to the male homosexual community. The gay community welcomed discussions early on, but a decision by the Sydney Blood Transfusion Service to exclude gay donors led to protests and cries of discrimination. We established good links with the Centers for Disease Control in Atlanta, Georgia, and benefited from weekly, if not daily updates on developments in the spread of AIDS and the search for its cause. The challenge was to ensure the crisis was handled objectively, on the basis of evidence as it became available, and that rational safeguards were put in place to minimise spread. The NHMRC provided funds to support research, but we resisted pressure from the Sydney gay community for them to control our research, as we could not accept their view that the disease was primarily a social or political problem. A huge amount of my time was devoted almost daily to press interviews to ameliorate scare stories of a “new black death about to sweep the world”, and also to oppose inappropriate moralistic haranguing of gay people, which threatened serious social disruption. Applying experience in epidemic control was essential. As evidence moved strongly to a viral cause, liaison with research laboratories in Paris and the US through Ian Gust became enormously important. Development of a national network of viral laboratories was supported, and when testing became possible, Australian Factor VIII concentrate was shown to be contaminated. Matters came to a head late in 1984, when three Queensland babies were shown to have died following transfusion from a single donation by a gay man. A National Health Ministers Summit was called by Neal Blewett (then federal Minister for Health). Our committee was expanded and renamed the AIDS Task Force (Figure 3). A second advisory committee, the National Advisory Committee on AIDS (NACAIDS), chaired by Ita Buttrose, was established with special responsibility for advising the public, for liaising with affected community groups and with Neal Blewett’s office, which maintained close links with the gay community. That committee channelled valuable support to the gay community in their development of very important “safe sex” education programs. Neal Blewett’s national leadership was critically important in gaining government support and funding. Our advice continued to be sought on containment of risk, and we made preparation for widespread testing for the HIV virus as soon as it became possible. In May 1985, we became the first country in the world to test every single blood donation for HIV. I had many memorable meetings with special interest groups. The gay community feared the consequences of being found to have a positive test, and repeated attempts were made to have the task force wound up over 2 years. The telephone used to ring at 6 am almost daily, with requests for comment on the latest story from Australia or overseas. Maintaining public dialogue was important for preventing inappropriate behaviour and to get the public to see the problem as a virus which could be handled rationally, rather than as a gay plague. A different challengeIn 1984, another public issue became a challenge. I was asked to chair a Committee of Inquiry into Rights of Private Practice in Public Hospitals. This arose from a heated dispute between the federal government and the AMA, and withdrawal of specialist services over the introduction of the new Medicare. The committee included Dr Brendon Kearney of South Australia representing government, and Dr John Cashman, a private radiologist nominated by the AMA. We had a protracted chase to get data from the federal government which purported to show excessive private use of pathology and radiology facilities in public hospitals. In reality, the rapidly expanding use of such services was outside the public hospitals, but the advisors who developed the legislation thought control could only be achieved in public hospitals. Apart from gaining access to the necessary data, public hearings across the country over 4 months, attended by the AMA and many specialist groups as well as by government, played a part in gaining a fragile consensus which largely defused the dispute. Finding common ground was the key. Oversight of diagnostic testing in hospitals was a reasonable expectation of government, and was finally agreed. After a general election at the end of the year, Prime Minister Hawke intervened to resolve the remaining issues with New South Wales surgeons and made available new funding to update equipment in public hospitals. My role when first appointed to the task had been damned by the Victorian AMA on the grounds of being a known “left-winger”, but in the end I received an apology and was later invited to address an AMA National Conference on the role of the profession.6 Two weeks after completing our inquiry, I remarried — a haematology colleague, Sonay Hussein, who still shares my life. By the end of 1986, I was so busy with AIDS issues that I stepped down as Dean of Medicine, continuing as Professor of Medicine. My last research paper was published in 1989.7 Life as a Vice-ChancellorEarly in 1987, I was appointed to be Vice-Chancellor of the University of Melbourne from the start of 1988. Before I took up the appointment, however, John Dawkins became Minister for Education with an agenda for radical reform. He was dismissive of what he termed “ossified old universities” and, at the end of the year, announced his intention to create the “unified national system” of higher education. While there was no doubt need for reform, the model of central ministerial control had many dangers, including those inherent in research policies which were to be shaped according to perceived national priorities. I was surprised to find fellow Vice-Chancellors reluctant to speak publicly about what many agreed privately was wrong with many aspects of the Dawkins reforms. While there was a good case for several major institutes of technology being upgraded to universities, a Commonwealth Tertiary Education Commission review of efficiency and effectiveness in higher education in 1986 had advised against combining the university and advanced education sectors.8 Other good aspects of that report had been incorporated into the Dawkins package, but when I declared myself as supporting some of these, Dawkins was outraged that I had publicly opposed others, particularly those relating to research and amalgamations. A review of research policy was finally agreed, which led to many improvements and additional funding for research infrastructure which currently continues. Other public issues laden with controversy included an attempt to regulate university education in terms of “competency skills”, and principles guiding relative funding of universities. Mobilising public opinion was the key to successfully resisting some of the Dawkins changes. By 1990, the University of Melbourne had moved into strategic planning and adopted objectives and principles in its own reform agenda. Seeking excellence in its teaching, research and public contributions ran counter to the prevailing political preoccupation with equity and equality. We were regularly under attack. One issue in Victoria during this time was the proposed replacement of most external assessments of secondary education by what were termed “common assessment tasks” — work done independently by students (Figure 4) — to be used in university selection. This was led by left-wing teacher groups, outraged by talk of striving for excellence in education. We threatened to introduce our own entrance examination. I led much of the public debate, supported by a group of school principals, which finally achieved rational compromise. Changes at the University of Melbourne were widespread. We concentrated on the quality of teaching, of supervision of research training and of academic management. Finally, a School of Graduate Studies was established to provide a collegial environment for graduate students, comparable in many ways to what I had experienced in Oxford. Getting a common commitment across the University to take pride in the quality of our work was the key to success. When Peter Baldwin (Dawkins’ successor as Minister for Higher Education) introduced “quality” as a major issue for the federal government, we came up “smelling of roses” in the first review.9 Life after Vice-ChancellorshipExpecting to move into a placid retirement at the age of 65, I was asked by the Premier of Victoria, Jeff Kennett, to lead a review of illicit drug policy at the end of 1995. Deaths from heroin overdose and open trafficking in the streets were both escalating. I headed a group of outstanding individuals with widely varied expertise. The challenge was the need to see drug dependency as a health problem to be handled through education and treatment rather than moralistic preaching and the law. While strong legal sanctions for the trafficking industry were appropriate, education was critical in prevention. Finally, when our 70-odd recommendations were unanimous, I addressed the first ever public joint sitting of both houses of the Victorian Parliament. We thought most of our recommendations would be adopted, but after a state election, with very strong lobbying by conservative politicians and the media, political support waned. National trials of new forms of treatment were implemented. A proposal for a multi-state heroin treatment trial was supported by the Kennett government, but subsequently stopped by Prime Minister Howard. Limited reform, with improvement of services, was achieved and, subsequently, a national policy was adopted for diverting arrested drug users to counselling rather than to courts in the first instance. A repeat review of illicit drug policies, including proposals for heroin injecting facilities, was undertaken in 1999–2000 after election of the Victorian Bracks government, but public and political reaction was a virtual rerun of 1996. National contributions to the drug debate were made through chairing the Capital Cities Lord Mayors’ Drug Advisory Committee 1997–99, and as keynote speaker in the NSW Parliamentary Summit which preceded the establishment of the Kings Cross heroin injecting facility. The College of Physicians was supportive of the changes sought.10 Challenges continue. These now mostly centre on improving support for and management of research in bodies I have chaired and seeking to bring the benefits of medical research to the community through commercialisation or other appropriate public means. Perhaps the most fulfilling have been the great growth and achievements of Cochlear Ltd as a public company and the creation of the new Melbourne Museum in its controversial new modern building. The host of challenges which have come my way over the years have presented many opportunities to contribute to the development of medicine, of education and of the community. Bringing about change has frequently involved conflict, but change would not have been achieved if popularity was what drove me. It has been a real privilege to work with outstanding colleagues at every stage and to have had such a variety of interesting and often exciting challenges — they still come! 1 James Mackenzie. © Royal College of General Practitioners Archives. 2 The London Hospital, circa 1950s–1960s. © The London Hospital. 3 Transmission of AIDS by blood transfusion hit the headlines in 1983 and 1984. The AIDS Task Force was seen as the bulwark of defence for the community. Illustration by J Spooner, reproduced with permission from The Age, Melbourne. 4 The "Common Assessment Task" was seen by its advocates as largely taking the place of external examinations in Year 12 for selection into universities. Illustration by P Nicholson, reproduced with permission from The Age, Melbourne.

David G Penington AC

David J Tiller,* Rick McLean,† Bruce C Harris‡ * Head, Department of Renal Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050; and Visiting Professor, School of Rural Health, University of Sydney; † Associate Dean, ‡ Program Coordinator, School of Rural Health, University of Sydney, Dubbo Campus, Dubbo, NSW. dtillerATmed.usyd.edu.au To the Editor: Your column in the 5 September issue of the Journal1 was exquisitely timely. Four days later, a seedling from the original Hippocratic tree from the island of Cos was planted in the grounds of a clinical school of the Medical Faculty of the University of Sydney (Figure) — not in proximity to the jacarandas of Camperdown, but rather to the river red gums near the School of Rural Health in Dubbo! The School of Rural Health is the newest of Sydney University’s clinical schools, having been funded as part of the Regional Health Strategy in 2000. The story of how the Hippocratic seedling came to Dubbo is wonderful. About 18 months ago, two of us (B H and D J T) were discussing what shade trees should be planted around the new clinical school (summer in Dubbo is hot), and the matter of the Hippocratic tree arose. We discovered that it was a European plane tree and made an initial approach to the National Library of Medicine in the United States (who, as stated in your column, had grown a tree from a cutting of the original), but this was unsuccessful. However, Dr John Boulas, a Greek-born Sydney-based urologist colleague was soon to depart for the Olympics in Greece and, as luck would have it, undertook to contact an urologist colleague in Greece who looked after the prostate of the mayor of Cos. This was duly done, and within a couple of months, two seedlings from the original tree arrived at customs in Sydney and spent 3 months in quarantine at the Royal Botanic Gardens. After that time, having been declared free of disease, one was brought to Dubbo to acclimatise. The official planting took place on 9 September and was officiated over by John Anderson, previous Deputy Prime Minister, who played a major role in the Australian Government’s commitment to fund the Regional Health Strategy in 2000, and the new NSW Minister for Health, John Hatzistergos, whose parents came from the island of Cos! To close the loop, both Mr Anderson and Mr Hatzistergos are University of Sydney alumni. The university’s motto (“sidere mens eadem mutato”) means “same learning under different stars”, indicating its links to the universities of Oxford and Cambridge. Perhaps the School of Rural Health motto should be “same learning under the same tree”! In any situation, the links to the history of medicine are firmly established, and medical students will have the opportunity to reflect on the tradition of medicine before their taking of the Hippocratic Oath or its modern equivalent. Wanted: a few more modern-day Hippocrates to teach under the tree. Apply within.

David J Tiller · Rick McLean · Bruce C Harris

The Helicobacter story illustrates some of the human hallmarks of revolutionary research Not so long ago, peptic ulcer disease played havoc with people’s lives. Its sufferers endured chronic and debilitating pain and ran the risk of a life-threatening gastrointestinal haemorrhage or ulcer perforation. Throughout most of the 20th century, the conventional wisdom was that peptic ulcer disease was caused by gastric juice corroding vulnerable mucosa; the dictum “no acid — no ulcer” ruled the day, and neutralisation of gastric acid was the mainstay of management (Box 1). Fixed in this belief, gastroenterologists and surgeons vigorously argued the relative merits of different medications and surgical procedures in reducing gastric secretion, while research addressed the influence of “associated” factors such as social status, smoking and stress on gastric secretion and mucosal resistance. Marshall and Warren, 1984. Reproduced from Helicobacter pioneers.3 By the turn of the century, all this was relegated to medical history by the groundbreaking research of two Australians, Barry J Marshall and J Robin Warren. They scuttled the prevailing acid-mucosal model by showing that peptic ulcer disease is an infectious disease caused by Helicobacter pylori. For this research, Marshall and Warren who, “with tenacity and a prepared mind, challenged prevailing dogmas”,1 were awarded the 2005 Nobel Prize for Physiology or Medicine. The story of their research journey is well known. But its essentials are worth repeating because they illustrate some of the human hallmarks of revolutionary research. These include: being at the right place at the right time, and seeing what other people had seen but thinking what nobody else thought;2 the role of serendipity; a passion for research that abandons personal safety with self-experimentation; and the inevitable resistance of the medical establishment as research undermines current dogma. Being, seeing and thinkingAs part of the physician training program in the 1980s at Royal Perth Hospital in Western Australia, registrars were encouraged to pursue a research project. In 1981, Marshall found himself in such a position as he commenced a rotation in the hospital’s gastroentero-logy service. His boss, Dr Tom Waters, suggested that he talk to Dr Robin Warren, a pathologist at the hospital, about the mucosal spiral bacteria Warren had observed microscopically in some gastric biopsies. Marshall was intrigued and, on reviewing the endoscopic and clinical details of 25 patients exhibiting these mysterious bacteria, found that they were associated with endoscopic diagnoses of duodenal ulcer (n = 2), gastric ulcer (n = 7), gastritis (n = 12), and erosions and scars (n = 4). But there was no consistent clinical pattern. A literature review revealed that these mucosal organisms had been noted intermittently for at least a hundred years, but there were no clear patholo-gical or clinical patterns.3,4 Marshall and Warren decided to explore the significance of the spiral bacteria by gathering more clinical material and by attempting to culture the organism from gastric mucosa obtained at endoscopy. Marshall and Warren were at the right place: members of the Royal Perth Hospital gastroenterology service were prepared to provide such specimens and members of the hospital’s microbiology department were willing to freely provide people and resources for the culture quest. It also was the right time. Apart from the happy meeting of an enthusiastic registrar unencumbered by dogma and a more senior person who had an observation waiting to be explored, flexible endoscopy had become a widely used clinical procedure and provided the means to obtain fresh specimens for research. The presence of mucosal gram-negative bacteria (initially thought to be a Campylobacter-like organism3) was soon confirmed, but all attempts at their culture were unsuccessful. On taking stock, in late 1981, Marshall discussed his progress with two senior members of the Royal Perth Hospital gastroenterology service, Tom Waters and Chris Sanderson. The latter, in true Australian (laconic) style, advised: “Barry, you should stop buggerising around and do a proper study!”3 And so, a prospective study of 100 patients, with the investigators blinded, was born, and the next characteristic of revolutionary research satisfied: thinking and addressing what other people presumably had not thought about. Marshall believes his relative inexperience helped him think in an original way about the bugs in the biopsies. “If the dogma is incorrect, it’s better to know nothing about it.” (Marshall, personal communication, October 2005.) The 100-patient study aimed to pursue the following questions: is the organism present in the normal stomach? can it be cultured? can its presence be correlated with the type and severity of abnormal gastric histology? how is it related to patients’ symptoms and disease status? Marshall and Warren may not have known it, but their journey to Stockholm had begun. Serendipity plays its partThe attempt to culture the elusive organism proved fruitless until religion entered the saga. The gastric mucosal specimens for culture were treated as routine faecal specimens or throat swabs: if at 48 hours no unusual organisms were seen, the culture plates were discarded. In 1982, the Easter holidays occurred from 9 April (Good Friday) to the end of 12 April (Easter Monday). The busy weekend technicians were preoccupied with an outbreak of methicillin-resistant Staphylococcus aureus in the hospital and presumably did not get around to examining the culture plates on Saturday. On the next working day, Tuesday 13 April, small transparent colonies of H. pylori were present.3 Marshall and Warren now had tangible evidence to advance their research. The first solid dataThe 100-patient study was completed by May 1982 and its outcomes were seminal.3,4 Of the 100 patients who had undergone endoscopy, 65 had gastritis, and there was a strong association between gastritis and the presence of the spiral organism. The latter were found in all patients with duodenal ulcer and 80% of patients with gastric ulcer. In contrast, their presence was rare in patients with non-steroidal drug-related ulcers. The bacteria could be cultured, and were a new genus with features of both Campylobacter and Vibrio species. (They were subsequently shown to be H. pylori, but that is another story.) Resistance from the medical establishmentIn January 1983, to stake their individual legitimacy in the evolving H. pylori story, Warren and Marshall submitted two separate research letters outlining their preliminary data to The Lancet. Publication was delayed, as Robin Fox, an editor at The Lancet, wanted to know why there were two separate letters. These were eventually published in June of that year.5 Locally, an abstract outlining preliminary findings of the 100-patient study was not accepted by the Gastroenterological Society of Australia for presentation at its annual conference (Box 2), and difficulties attended the submission of the definitive paper of the 100-patient study to The Lancet in January 1984. Once again, the journal’s Editor-in-Chief, Ian Munro, was challenged — this time because he was not able to find reviewers who would agree on the importance of the paper. Munro sent Marshall a “temporising letter”, after the first round of review advising Marshall the he believed that The Lancet should publish the paper and that he was trying to find reviewers who would agree with him (Marshall, personal communication, October 2005). The paper was published in June 1984.6 An accompanying editorial noted in classical reserved style: “If the authors’ hypothesis of cause and effect should prove valid this work is very important indeed.”7 Self-experimentationAt the end of 1982, Marshall had left Royal Perth Hospital and taken up a senior registrar post in general medicine and gastroenterology at the Fremantle Hospital in Western Australia. Again, he was at the right place with the right people. The staff at the hospital were aware of Marshall’s research at Royal Perth Hospital and encouraged him to continue at Fremantle. These included Ian Hislop, head of gastroenterology, David McGechie, a microbiologist with excellent laboratory facilities, and the pathologist, Ross Glancy. At Fremantle Hospital, Marshall and his colleagues showed that bismuth salts (which had been used to treat gastritis and peptic ulcer disease for many years) killed H. pylori in vitro; and, in clinical studies, that bismuth cleared H. pylori but the infection would recur unless metronidazole was added to the regimen. Yet during this time, Marshall was frustrated with The Lancet’s seeming procrastinations and his own failure to develop an animal model for the disease. Possibly because of these frustrations, he decided to infect himself with H. pylori. He asked Hislop to perform a gastric biopsy on him and then ingested a pure culture of H. pylori (109 organisms). All was well for 5 days, but then he developed halitosis, morning nausea, and recurrent vomiting of acid-free gastric juice. A gastric biopsy on Day 10 showed severe acute gastritis and many H. pylori (Box 3). The symptoms spontaneously resolved after 14 days, but Marshall’s wife, Adrienne, had had enough and demanded that he immediately commence antibiotics or “be evicted from the household to sleep under a bridge”.3 The Medical Journal of Australia connectionAfter the 1984 Lancet paper came out, Marshall received a call from the then MJA editor, Alistair Brass. He congratulated Marshall on the Lancet paper, but suggested that, next time he published, it might be closer to home. In a recent interview with the Journal, Marshall noted that he had always planned to submit his initial work to The Lancet, but has no objections to publishing in Australia: “If it has a local flavour I send it to the MJA.” (Marshall, personal communication, October 2005.) And so it came to pass that the account of his self-experimentation8 and observations on the in-vitro sensitivities of H. pylori and further clinical correlates9 were submitted to this Journal and promptly published. In a citation analysis performed by the MJA to celebrate its 90 years of publication, these two articles ranked second and third among the Journal’s 10 most cited articles.10 Marshall and Warren join four other Australian born Nobel Laureates in Physiology or Medicine: Howard Florey for his discovery of penicillin, MacFarlane Burnet and Peter Doherty for immunology, and John Eccles for neurobiology. Marshall and Warren’s achievement is made more extraordinary by the fact that they performed all their ground-breaking work not in well endowed and cloistered medical research institutes, but in the orderly chaos of hospitals. And their attempts to convince medical orthodoxy were not smooth: as noted by their Nobel Prize citation, they challenged prevailing dogmas with “tenacity and a prepared mind”.1 The Helicobacter story, and the journey to this particular Nobel prize, doubtless benefited from great timing, the right people and places, original thinking, serendipity, tenacity and passion. But the outcome is unarguable: Marshall and Warren have irrevocably changed clinical practice and have alleviated much human suffering. 1 Advertisement from the MJA, 1957 2 Letter from the Gastroenterological Society of Australia* * Reproduced from Helicobacter pioneers.3 3 Silver stain of Marshall’s gastric biopsy on Day 10 after ingesting Helicobacter pylori Epithelial cells have rounded up in shape without intracellular mucin, and have many closely adherent black H. pylori organisms. Reproduced from Helicobacter pioneers.3

Martin B Van Der Weyden MD, FRACP, FRCPA · Ruth M Armstrong BMed · Ann T Gregory MB BS, GradCertPopHealth

During the Australasian Antarctic Expedition of 1911–1914, Douglas Mawson and two companions, Belgrave Ninnis and Xavier Mertz, undertook an ill-fated mapping journey. Ninnis died when he fell down a crevasse, together with the sledge carrying most of their food supplies, and later Mertz became ill and died. Only Mawson returned. In 1969, Cleland and Southcott proposed that Mertz died of vitamin A toxicity and Mawson suffered from the effects of hypervitaminosis A because, with little food left, they were forced to eat their surviving dogs, including the liver. This hypothesis was supported by Shearman in 1978. After re-evaluating this hypothesis, I propose that Mawson and Mertz suffered from the effects of severe food deprivation, not from hypervitaminosis A, and that Mertz died as he was unable to tolerate the change from his usual vegetarian diet to a diet of mainly dog meat. I also suggest that Mertz’s condition was aggravated by the psychological stress of being forced to eat the dogs he had cared for for 18 months.

Denise Carrington-Smith BA(Psych), MSocSc(Archaeology)