History and humanities

W Ian Cameron Chief Executive Officer, New South Wales Rural Doctors Network, Level 3, 133 King Street, Newcastle, NSW 2300. icameronAT.nswrdn.com.au To the Editor: Bourke is a small rural town in far northwest New South Wales with a population of about 3500. The Bourke Shire Council has recently published a fascinating small book entitled 100 lives of Bourke, which uses Bourke cemetery as a “window to the past”.1 Included in the 100 vignettes based on headstones in the cemetery is one for Dr George Faithfull, Bourke’s third doctor. Dr Faithfull was born in Calcutta, India. He started medical studies in Edinburgh, Scotland, but did not complete them. He travelled to Australia, arriving in Victoria, and worked his way north (Dr Don Faithfull, grandson of George, personal communication). By 1885, he was working as a chemist in Bourke.2 In view of his experience as a “medical man” and his previous medical studies, he later became registered as a medical practitioner under Clause 3 of Act 70, The Medical Practitioners Further Amendment Act of 1900, where it was stated that: It shall be lawful for the Medical Board or its Doctors to place upon a separate register the name of any person who has passed through a course of study as Medical Practitioner in NSW during five years before the passing of this Act. Dr Faithfull was a doctor in Bourke and Goodooga from 1900 to 1908. He must have been one of the very first doctors to have gained what is now termed in NSW “conditional registration in an area of need”. To have become conditionally registered while practising as a chemist in Bourke, he must also be an early example of rural-based distance learning — a cornerstone of our new regionalised general practice training. Dr George Faithfull and his wife, Mary Faithfull (née Whitfield). (Photo, Dr Don Faithfull.) It is sobering to think that the changes made over the last few years by medical boards, and the streamlining of processes outlined in MedicarePlus, had precursors over a hundred years ago. Doctors and their families were not exempt from the morbidity and mortality of the time. Three of Dr Faithfull’s 11 children died young and are buried in Bourke cemetery. Another Bourke doctor, Dr Sides, had three children die in infancy, and Dr Dey lost a six-month-old son. In 1901, a locum doctor died of heat stroke. More recently, in 1992, Bourke cemetery became the final resting place for another overseas-trained doctor, Professor Fred Hollows, who achieved international recognition for his work in ophthalmology in disadvantaged populations, particularly Indigenous Australians.

W Ian Cameron

Re: “The Medical Journal of Australia — prospere, procede et regna”, the editorial by Martin B Van Der Weyden in the 1 July 2004 issue of the Journal (Med J Aust 2004; 181: 3-4) cites incorrect references. These should read: 7 Bhasale AL, Miller GC, Reid SE, Britt H. Analysing potential harm in general practice: an incident-monitoring study. Med J Aust 1998; 169: 73-76. 8 Kuhse H, Singer P, Baume P, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. 12 Armstrong R, Van Der Weyden MB. Indigenous health: tell us your story [editorial]. Med J Aust 2004; 180: 492. 14 Stelfox HF, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101-106. 18 Laporte RE, Marler E, Akazawa S, et al. The death of the biomedical journal. BMJ 1995; 310: 1387-1390. This error only affected the printed version of the article. The web version was correct when published and has not been changed.

Martin B Van Der Weyden MD, FRACP, FRCPA

On July 4, exactly 90 years ago, The Medical Journal of Australia began its life “as the official organ of the British Medical Association in Australia”. Its purpose was clear — “to record the progress of scientific medicine, and to assist in rendering the practice of medicine in all its branches of the greatest benefit to the people of Australia”.1 In that first issue, the president of the Victorian branch of the British Medical Association warmly welcomed the Journal, noting that it symbolised “the intimate union of all the branches of the British Medical Association in Australia”, and that it would “continue every week to indicate and advocate the common aims, interests, and ideals of the profession”. He closed by wishing that the Journal prospere, procede et regna2 — “proceed prosperously and reign”! This bridging between the readers and the profession is the stuff of the Journal. The following 90 years have seen the formation of the Australian Medical Association in 1962,3 and, with the advent of the AMA Gazette in 1968, the disappearance of Federal and Branch news in the Journal. In the late 1980s, after nearly 60 years of living the Australian dream of being an owner/occupier, the Journal’s publisher — the Australasian Medical Publishing Company (AMPCo) — sold its Sydney premises to finance the AMA’s move to Canberra. This was the culmination of the Journal’s Sturm und Drang decade, with the destabilising turnover of editors — six in all — and tensions caused by AMPCo’s financial difficulties. However, after 90 years, the Journal’s purpose remains clear — to “be the recognised forum for information and commentary on all aspects of health care in Australia” through “original peer-reviewed clinical research of the highest standard”, “high level continuing medical education”, and “commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia”.4 In this 90th anniversary issue, Gregory (page 9) surveys the “clinical research of the highest standard” published by the Journal during this time.5 Its ongoing commitment to “commentary and informed debate on standards of clinical practice” is exemplified by the Quality in Australian Health Care Study6 and the study of adverse events in Australian general practice,7 both of which played a part in the lead-up to establishing the Australian Council for Safety and Quality in Health Care. The Journal’s role as a forum for “ethics, social, legal and other issues” is reflected in our reports on end-of-life decisions,8,9 the health of asylum seekers in detention,10,11 and in our commitment to Indigenous health.12 Finally, pragmatic links to the world of medical research and to specialist and general practice were pursued through networking and the Journal’s Content Review Committee. A cursory review of the Journal’s progress over the past 90 years will readily identify broad changes which have come to pass. There has been a noticeable decline in the number of clinical studies, case reports and the more leisurely reviews, with a concomitant increase in studies of healthcare interventions and health system performance, as well as those on adverse lifestyles, substance misuse, mental illness and, more recently, consumer concerns. With the rise of evidence-based medicine came a barrage of evidence-based guidelines and further delineation of levels of evidence. The design and reporting of research itself adopted more rigorous formats, such as controlled trials, systematic reviews and structured abstracts. Significantly, the number of authors per article continues to multiply,13 and the international trend now is for authorship to involve a team of doctors, other healthcare professionals and scientists. Correspondingly, the number of Journal editors has also increased as the number of submissions continues to rise.13 In 2003 we received a record 917 submissions, compared with 856 in 2001 and 741 in 1999. On the downside, the blurring of the boundaries between commerce and research has spawned a culture of suspicion, particularly for research supported by pharmaceutical companies.14 It is interesting to note that all Journal articles are now accompanied by an item noticeably absent a decade ago — the competing interests statement. The Journal’s policy of safeguarding the integrity of research by exploring potential conflicts of interest of contributors and reviewers is detailed by Chew.15 What does the future hold? Just as Gutenberg’s printing press saw the demise of the monastic monopoly of manuscript production, electronic technology has changed both the essence of publishing itself, and ease of access to the latest research. The Medical Journal of Australia, like most other medical journals, simultaneously releases the electronic (eMJA) with the print Journal, and uses rapid online publication for selected articles. Future electronic developments are also anticipated. There are those who promote the notion that peer review and editing are things of the past.16 They believe science should simply be posted on the Internet, thus letting the world judge its quality. However, an editor’s first responsibility is to the readers, and they have signalled that they are too busy to separate the wheat from the chaff.17 They prefer that to be the function of quality filters — the editors, peer reviewers and editorial staff who ensure the clarity, brevity and non-exclusive language of the final product. This bridging between the readers and the profession is the stuff of the Journal. Despite enthusiastic predictions of its demise,18 the printed Journal will live on for some time. There is something reassuring about knowing where a journal’s contents will be revealed, its portability from bed to breakfast table, and the feel of something physical, that binds readers to the paper Journal.19 In any event, whatever changes the future may bring, as long as the Journal continues to add value to its core content of original articles, editorials, reviews and informed debate on contemporaneous healthcare issues in Australia, The Medical Journal of Australia will most certainly prospere, procede et regna.

Martin B Van Der Weyden MD, FRACP, FRCPA

According to data from the Institute for Scientific Information (ISI), the most-cited MJA article is Cade’s ground-breaking report on the effect of lithium in mania (1949; 888 citations), followed by Marshall et al’s reports on the role of Helicobacter pylori in gastroduodenal disease (1985; 766 and 523 citations, respectively). Others in the “top 10” span decades and disciplines; all have a common grounding in Australian data of global relevance. For the year 1995, shortly after the 80th anniversary of The Medical Journal of Australia (MJA), researchers from the Australian National University used citation analysis to determine Australia’s contribution to new knowledge in medical and health sciences. They found that Australians contributed 2.5% of all publications in the Science Citation Index — 18 390 publications, which had been cited over 88 000 times.1,2 In 2003, the MJA used citation data provided by Thomson ISI (www.isinet.com) to identify the “top 10” articles published in the MJA — that is, the articles which had been cited most often. Data comprised citations within journal articles covered by the database of the Institute for Scientific Information (ISI) for the years 1945–2002; thus, articles published before 1945 could be cited. The MJA top 10 articles span more than 60 years (Box 1). They have in common a grounding in Australian data, but a global relevance. In addition, all provide evidence of the importance of basic as well as clinical research, and of that endangered species the physician–scientist. 1 The MJA’s top 10 articles, by citation analysis Number 1 (888 citations) Cade JFJ. Lithium salts in the treatment of psychotic excitement. Med J Aust 1949; 2: 349-352. Number 2 (766 citations) Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch’s postulates for pyloric campylobacter. Med J Aust 1985; 142: 436-439. Number 3 (523 citations) Marshall BJ, McGechie DB, Rogers PA, Glancy RJ. Pyloric campylobacter infection and gastroduodenal disease. Med J Aust 1985; 142: 439-444. Number 4 (299 citations) Derrick EH. “Q” fever, a new fever entity: clinical features, diagnosis and laboratory investigation. Med J Aust 1937; 2: 281-299. Number 5 (267 citations) Swan C, Tostevin AL, Moore B, Mayo H, Barham Black GH. Congenital defects in infants following infectious diseases during pregnancy. Med J Aust 1943; 2: 201-210. Number 6 (203 citations) George LL, Borody TJ, Andrews P, Devine M, Moore-Jones D, Walton M, Brandl S. Cure of duodenal ulcer after eradication of Helicobacter pylori. Med J Aust 1990; 153: 145-149. Number 7 (170 citations) Trautner EM, Morris R, Noack CH, Gershon S. The excretion and retention of ingested lithium and its effect on the ionic balance of man. Med J Aust 1955; 2: 280-291. Number 8 (169 citations) Bower C, Stanley FJ. Dietary folate as a risk factor for neural-tube defects: evidence from a case–control study in Western Australia. Med J Aust 1989; 150: 613-619. Number 9 (167 citations) Wilson RMcL, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Number 10 (166 citations) Borody TJ, Cole P, Noonan S, Morgan A, Lenne J, Hyland L, Brandl S, Borody EG, George LL. Recurrence of duodenal ulcer and Campylobacter pylori infection after eradication. Med J Aust 1989; 151: 431-435. Simple cation holds promise as psychotropic agentJohn Cade (1912–1980), the author of our most-cited article, once described himself self-deprecatingly as “an unknown psychiatrist, working alone in a small chronic [sic] hospital with no research training, primitive techniques and negligible equipment”.3 Born in Murtoa, a small country town in Victoria, Cade seemed destined to enter psychiatry. His father was a psychiatrist, and as a child Cade lived in the grounds of various “lunatic asylums”. He entered psychiatry in 1936, shortly after graduating in medicine (with honours in all subjects), but spent much of the Second World War as a prisoner of war in Changi, Singapore, returning to Australia as a 40 kg “walking skeleton”.4,5 Cade’s interests included all the sciences, and his “enquiring mind” stayed with him throughout life. The coauthor of his first article (published in 1940), detailing the serological response to influenza virus infection, was none other than Frank Macfarlane Burnet.6 While Cade was investigating potential anticonvulsant agents in guinea-pigs, he came to suspect that the cation lithium had a sedative effect which might be useful in treating mania. He demonstrated this sedative effect in guinea-pigs, and then took lithium himself, before extending his study to patients.3 In his MJA article, Cade reported the Results of a study of the effect of lithium salts in 10 patients with mania (as well as six with schizophrenia and three with “melancholia”). Lithium had a clear effect in mania. He published no further research on lithium, but did search for other cations with psychotropic activity.3 In commenting on his research career, he said: “My own research efforts have been sporadic over many years. Most have ended in blind alleys. Some have been successful. All have been fun. In the process I have learned a greater deal . . . , and en passant something of the causes and effective treatment of manic–depressive illness.”7 Cade’s findings were not immediately accepted in the rest of the world (and not until the 1970s in the United States), so it is not surprising that further notable research on lithium was also conducted in Australia. Ranked seventh in the MJA top 10, The excretion and retention of ingested lithium and its effect on the ionic balance of man was published in 1955. The authors included Trautner, a physiologist at the University of Melbourne, and Noack, a psychiatrist at Melbourne’s Mont Park Hospital. Their research, conducted on themselves and on patients with mania, showed that lithium is retained during the acute phase of mania, necessitating higher doses. These can be reduced as the mania resolves. They also showed that intercurrent illness increases the risk of lithium toxicity. Spiral bacterium linked with gastritis and peptic ulcerToday, we know that Helicobacter pylori colonises the stomach and infects about half the world’s population.8 Further, it has infected people since the dawn of human history, and its geographic variation is being used to map the earliest human migrations, including the arrival of Europe’s first neolithic farmers.9 However, as recently as two decades ago, notwithstanding reports suggesting otherwise (“dispersed over 100 years, in journals of different languages and subspecialities”10), the prevailing dogma was that the human stomach was sterile, and that bacteria could not survive in gastric acid.10 Gastroenterologist Barry Marshall and pathologist Robin Warren first described the association of a campylobacter-like organism with gastritis in two letters to the editor of The Lancet.11,12 Marshall and colleagues later published two articles — in the 15 April 1985 issue of the MJA — providing evidence of a causal relationship. These articles rank second and third in the MJA top 10. 2 Illustrations from Marshall et al’s two “top 10” MJA articles A. Numerous Helicobacter pylori organisms in a gastric biopsy specimen from Barry Marshall, taken 10 days after he ingested a pure culture of the organism (Warthin–Starry silver stain; original magnification x 900). B. Heavy growth of H. pylori from an antral biopsy specimen from a patient with duodenal ulcer. (Larger white colonies are commensal flora of the mouth.) In the first MJA article, the researchers successfully fulfilled Koch’s third postulate by demonstrating that H. pylori (then known as pyloric campylobacter) could colonise histologically normal mucosa. After trying to infect animal models without success, Marshall used himself as a “guinea-pig”. About 5 days after drinking a pure culture of H. pylori (109 organisms), he became ill, with early-morning nausea, vomiting of acid-free gastric juice, and “putrid” breath. Although the illness resolved spontaneously after 14 days, culture and histological examination on the 10th day showed severe acute gastritis with many H. pylori organisms (Box 2A). The experiment allowed Marshall and colleagues to link H. pylori to epidemic gastritis with hypochlorhydria. In the second MJA article, Marshall and colleagues proposed that pyloric campylobacter infection was responsible for damage to the duodenal epithelium, as well as the gastric antral mucosa, based on gastroduodenal biopsy and culture findings from over 100 patients referred to their dyspepsia research clinic (Box 2B). Looking back on these discoveries, Marshall later wrote that early reports of an association between peptic ulcer and H. pylori were met with extreme scepticism by many doctors, who were convinced that psychic stress, cigarette smoking and hyperacidity were the causes of peptic ulcer. Reports of the first therapy ever shown to heal gastritis received “a cool reception at gastroenterological meetings”.10 Compared with Cade’s era, communication among the world’s scientific community had accelerated greatly, and, in 1991, the first convincing study of cure of duodenal ulcer through eradication of H. pylori was published in the United States. However, this was preceded by another pair of notable articles on the same topic in the MJA, from the Centre for Digestive Diseases in Sydney. In 1989, the study by Borody and colleagues, which ranks tenth in the MJA top 10, showed that “triple chemotherapy” with bismuth, tetracyline and metronidazole could lead to long-term eradication of H. pylori in most patients with duodenal ulcer or non-ulcer dyspepsia. Further, they suggested that this eradication could reduce recurrence of, or even cure, duodenal ulcer. The group subsequently reported such cure in their 1990 MJA article, which ranks sixth in the top 10. H. pylori infection is now recognised as the major cause of peptic ulcer disease and an important risk factor for gastric malignancy. For discovering its role in peptic ulcer disease, Marshall was awarded the 1995 Albert Lasker Clinical Research Award.13 Mystery abattoir fever confirmed as new disease 3 Edward Derrick, who first described Q fever In 1961, Derrick became director of the Queensland Institute of Medical Research. (Illustration courtesy of the Brisbane Courier-Mail.) In 1935, unexplained fevers in abattoir workers in Queensland were referred for investigation to Edward Holbrook Derrick, newly appointed director of the state’s Laboratory of Microbiology and Pathology14 (Box 3). He was unable to identify a cause but found that “abattoir’s fever” had a distinctive natural history. The clinical resemblance to murine typhus led him to inoculate patients’ blood into guinea-pigs, which became febrile. The agent could be transmitted serially from one to another, and, after recovery, the guinea-pigs remained resistant to infection. These findings were reported in the MJA in 1937, in an article that ranks fourth in the top 10. Thirty years later, Macfarlane Burnet wrote that “these findings provided a rather cumbersome, but perfectly adequate means of establishing that abbatoir’s fever was a specific entity definable immunologically, and also of allowing laboratory diagnosis in a doubtful clinical case”.15 Although Derrick described the disease and named it “Q” fever, it was Macfarlane Burnet who showed it was caused by a rickettsial agent, as described in his article, coauthored with Mavis Freeman, which followed Derrick’s in the same issue of the MJA.16 The causative organism is now known as Coxiella burnetii. Derrick (1898–1976) received international recognition for discovering not only Q fever, but also the form of leptospirosis caused by Leptospira pomona.17 When Derrick was made a Fellow of the Australian Postgraduate Federation, Macfarlane Burnet stated that “to have defined and elucidated the aetiology of two worldwide infectious diseases is something no other living scientist can claim.”17 German measles in pregnancy may damage the fetusIn 1941, the teratogenic effects of rubella (German measles) were uncovered by the Australian ophthalmologist Norman Gregg.18 At that time, it was generally believed that birth defects were inherited, and that the placenta was an absolute barrier to infectious diseases. Gregg’s suggestion that maternal rubella played a causal role in congenital cataract was considered revolutionary, and several years passed before overseas medical journals commented on the idea.19 However, in Australia only a year later, Charles Spencer Swan was appointed by the National Health and Medical Research Council to investigate the possible relationship.19 On 7 October 1942, a circular sent to all South Australian general practitioners informed them of Gregg’s findings and asked them to complete a form for all children born to women who had an acute exanthem during pregnancy. From these data, covering the years 1939–1943, Swan and colleagues identified 49 infants whose mothers had been exposed to rubella during pregnancy; 31 had congenital malformations, including cataract, deaf-mutism, heart disease, microcephaly and mental retardation. In all but two of the 31 cases, rubella had been contracted in the first 3 months of pregnancy. Further, Swan and colleagues suggested that the type of congenital malformation depends on the stage of pregnancy at which the mother acquired rubella. Their MJA report ranks fifth in the top 10. The rubella virus itself was not identified for about another 20 years. Although Gregg’s landmark article on congenital cataract and maternal rubella was formally published in the Transactions of the Ophthalmological Society of Australia,18 he had presented his observations at the annual meeting of the society in October 1941. A description of the proceedings was published with permission in the MJA in December 1941,20 before the formal article appeared. In defence of the rapid publication, the MJA stated: “The series [of cases] is so striking and the sight of the children is so seriously affected that the facts must be made known without undue delay to the general body of the medical profession.”20 Folic acid in pregnancy can prevent spina bifidaFiona Stanley graduated in medicine from the University of Western Australia and trained in epidemiology at the London School of Hygiene and Tropical Medicine and the National Institutes of Health in the United States. In 1977, she returned to Perth for family reasons and, although a researcher at heart, became Senior Medical Officer in Child Health.21 Yet, this chance worked in both her and our favour, as it allowed her to establish, with colleagues, the Western Australian Congenital Malformations Registry. The registry provided the data for her landmark MJA article, coauthored with Carol Bower, which showed that dietary intake of folate in early pregnancy protects against the occurrence of isolated neural-tube defects in infants. It ranks eighth in the MJA top 10. 4 Fiona Stanley Since her discovery of the role of folate in preventing neural-tube defects, Stanley continues to investigate the epidemiology of childhood and maternal illness. In 1990, a year after her top 10 MJA article was published, Stanley became founding director of the Telethon Institute for Child Health Research in Perth. She continues to explore the promise of epidemiology and other scientific disciplines in tracking trends and preventing major childhood and maternal illnesses.22 Stanley (Box 4) was Australian of the Year in 2003. Healthcare can harm patientsThe Quality in Australian Health Care Study (QAHCS) arose from the Tito Review of Professional Indemnity Arrangements for Health Care Professionals, established by the Australian government in 1991. The review was to examine the adequacy of compensation and funding arrangements for healthcare misadventures in Australia, but lacked the data to answer the fundamental questions: How many adverse patient outcomes arise from healthcare services? How severe are they? What impact do they have on those services? A consortium of the University of Newcastle, the University of Adelaide and Sydney’s Royal North Shore Hospital was awarded the contract to provide these data, led by intensive care physician Ross Wilson. The QAHCS, based on the Harvard Medical Practice Study, was set up to measure preventability rather than negligence. Nevertheless, it provided a national measurement of the safety of healthcare, a measurement many other countries still lack. The most-cited report from the QAHCS was published in the MJA in 1995 and ranks ninth in the top 10. It found that 16.6% of hospital admissions in Australia in 1992 were associated with an “adverse event” to patients, that those events meant patients were injured by their healthcare, and that the injury had caused them some disability. About half the adverse events were considered preventable. In 1999, also in the MJA, the consortium reported further on the preventability of these events.23 “The spirit of the researcher”The MJA’s 10 most-cited articles are testimony to the power of clinical research to revise our understanding of disease and treatment methods, and to enhance prevention of disease and adverse events. Despite the refinements in clinical research methods over the decades, which will continue to evolve, these top 10 articles and the pioneering spirit of their authors should inspire new generations of doctors to make the most of any opportunities or insights that come their way. Derrick, in his address to the inaugural meeting of the Queensland Branch of the Australian Society for Medical Research in 1969, quoted the American physiologist Walter Cannon: Phenomena, no matter how mysterious they may appear to be, have a natural explanation and will yield their secrets to the persistent, ingenious, and cautious efforts of the investigator.24 Cade, in his presidential address to the Seventh Annual Congress of the Australian and New Zealand College of Psychiatrists in 1970, said: Almost everyone can and should do research, both because almost everyone has a unique observational opportunity at some time . . . and also because the intellectual discipline and technical training that it imposes is an essential prerequisite to expertise in a professional field.7 Derrick was said to have had a feeling for the historical context in which his research was done, an awareness of the stepwise progress of knowledge to which all, “however ill-equipped”, might hope to add. He was said to be fond of quoting the wisdom of Descartes: The last should commence where the preceding had left off, and thus by joining together the lives and labours of many, we should collectively proceed much further than anyone in particular would succeed in doing.17

Ann T Gregory MB BS, GradDipPopHealth

Restoring humane values to medicine. A Miles Little reader. Ian Kerridge, Christopher Jordens, Emma-Jane Sayers (editors). Sydney: Desert Pea Press, 2003 (x + 307 pp). ISBN 1 87686 108 8. Miles Little’s distinguished credentials and past experience as a surgeon, poet, philosopher and humanist make him particularly qualified to address the restoration of humane values to medicine. The origin of threats to values in medicine today is addressed in depth and in an analytic and reflective way. His essays are well chosen to accomplish this, but are difficult to read, as the language at times seems purposefully abstruse. Nonetheless, the importance of the topics covered makes the effort worthwhile. The technique of adding commentaries by thoughtful people in the field is helpful in putting Little’s views in perspective and in a contemporary context. One of the unique contributions to the book is Little’s discussion of the ethics of surgery and the analysis of its five moral domains. These follow the progression of the surgeon–patient relationship through the process of surgery and the patient’s response to each stage. As Russell Gruen points out in his associated commentary, they “help us to understand why surgery cannot be practised as a purely technical exercise.” In medicine, which is increasingly technology-dependent, the promotion of humanism in physicians and surgeons must be a strong antidote to the impersonalisation and deprofessionalisation which technology can bring. The other essays address the conflicts and dilemmas facing the practitioner in contemporary medicine. As one reads each essay there is an opportunity to reflect and gain a better understanding of the issues, whether the subject is euthanasia, death, the place of evidence-based medicine and epidemiology, the real issues of consent and whether it can be informed, the impact of resource restraints, or the demand for accounting logic in medicine leading to “ethonomics.” Physicians need to reflect on these issues if they are to bring care, compassion, and integrity to their practices. These essays are particularly useful to those in academic medicine where the teaching of the physician as healer and professional require humanism and reflection if these qualities are to be imparted. Sylvia R CruessAssociate Professor of Medicine McGill University, Montreal, Canada

Sylvia R Cruess

Dorland’s illustrated medical dictionary. 30th ed. Philadelphia: Saunders, 2003 (xxvii + 2190 pp + CD-ROM). ISBN 0 7216 0146 4. When you’re lost for words or in search of medical meanings, you may find what you’re looking for in Dorland’s illustrated medical dictionary. Now in her thirtieth edition, this oracle — in print for over 100 years — must have decided that a double celebration was in order. She has reinvented herself, not only in technicolour, but also by gaining a web presence, as book purchasers are granted full on-line access to the dictionary at www.dorlands.com, as well as given a CD-ROM with the Dorland’s pocket dictionary in personal digital assistant format and a spellchecker. The colouring of Dorland’s is not for show, but to facilitate ease of use. Headings are in red type, with the definition(s) following in black. Tables and appendices, and groupings like the syndromes and systems, are readily located within boxes with red borders and a pale yellow background. The word “illustrated” is more applicable than ever before, with the dictionary’s artwork undergoing a complete revamp. There are now 600 colour photographs and nearly 500 line drawings, all in colour. Dorland’s “designers” (lexicographers), with the aid of 22 consultants from North America, have also reviewed her entire wardrobe of words. Obsolete items have been removed, definitions have been updated and expanded, and new words have been added. In fact, the book has gained nearly a kilo in two editions, now tipping the scales at a little over 4 kg. The weight gain is partly due to the decision that she should embrace hundreds of terms from the increasingly popular fields of complementary and alternative medicine. Also contributing to the increase in size are new, updated and reorganised appendices, for example for cancer staging and symbols (such as the “shorthand” often used in clinical note-taking). Those who remember this old girl with fondness need not be alarmed. She has retained her classic, signature style — an attention to accuracy and clarity and an authoritative tone. And, although her accent is North American, Australians should have little difficulty in understanding her. In her class, Dorland’s illustrated medical dictionary remains a firm favourite with the Medical Journal of Australia editorial team. Or, in other words, the old girl’s still got it. Ann T GregoryDeputy Editor, Medical Journal of Australia Pyrmont, NSW

Ann T Gregory

During the 1950s and 1960s, there was a dramatic explosion in the number of letters to the editor about Indigenous health published in the MJA, reflecting increased reader interest. The letters from Barry Christophers were part of the Federal Council for Aboriginal Advancement’s largely successful campaign for equal civil rights for Aboriginal and Torres Strait Islander people. His letters not only drew attention to discriminatory legislation and policies, but also emphasised the structural (especially economic) determinants of Indigenous ill-health, and the negative impact on Indigenous people of racist medical representations. There was little interest in the health of Aboriginal and Torres Strait Islander peoples in the MJA before 1950. Early research portrayed Aboriginal people as being from an inferior and primitive race, the demise of which was thought to be inevitable. For example, in 1924, a case series of Aboriginal psychiatric patients was introduced by stating that: Contact with civilization, phthisis and other diseases, mixed breeding and general racial decay are the order of the day. In a few years this line of research will be closed for ever. Whatever may be one’s sentimental views on the passing of the primitive peoples, from the scientific or even the utilitarian aspect it will be more than unfortunate if our records are not completed before they vanish.1 Any research on Aboriginal and Torres Strait Islander peoples before the 1960s was not primarily about improving their health. It was about using Indigenous health research to improve understanding of the health problems of white Australians, and about collecting information about Aboriginal people for science before the race became extinct.2 Letters to the editor are the voice of the readers of the MJA. Letters do not have the same academic status as journal articles, but three readership surveys in the 1950s and 1960s showed that the letters pages were the most read section of the MJA.3-5 An editorial marking the 50th anniversary of the MJA in 1964 described the number of letters to the editor as a barometer of the interest of readers in a journal.6 Most letters received by the MJA were published.7 Before 1950, there were only 13 letters about Indigenous Australians published in the MJA. Readers did not write more than a single letter to the editor in response to any MJA publication about Indigenous people until 1952, when an editorial announced that a new university scholarship for an Aboriginal student marked a change from the brutal past of the colonial encounter, and decried the obstacles caused by “the monstrous fiction of racial superiority and inferiority”.8 Writers of editorials had much greater freedom of language and freedom to express opinions than writers of scientific articles. Letter writers had even more freedom, and were often those with the strongest opinions. Four letters were published in response to the editorial: one claimed that it was possible to discuss Aboriginal people’s inferiority (but did not assert a biological basis for this inferiority); the others replied that doctors should treat “aborigines as our equals” and that their problems were due to racism.9-12 A dramatic increase in letters to the editor about Indigenous health began in the 1950s (Box 1). This increase occurred before a large increase in the number of all letters later in the decade. Letters to the editor accounted for a quarter (48/200) of the publications on Indigenous health in the MJA in the 1950s and 1960s, increasing to more than a third in the 1980s and 1990s (76/204 and 108/203).2 Barry Christophers’ letters to the MJA editorBarry Christophers (Box 2) wrote 25 letters to the MJA about Indigenous health between 1956 and 1969. He wrote half the letters to the editor about Indigenous health in this period (and a similar number of letters not about Indigenous health), but he did not write any longer articles about Indigenous health. At the time, Christophers was a general practitioner in the inner-city Melbourne suburb of Richmond, and an activist in the Federal Council for Aboriginal Advancement (FCAA) (in 1964 the name was changed to the Federal Council for the Advancement of Aborigines and Torres Strait Islanders [or FCAATSI]) (Box 3). His letters may not have reflected the views of the majority of MJA readers, but they draw attention to one doctor’s role in events that led to great changes in the relationship between Indigenous and non-Indigenous Australians. In 1957, Christophers drew MJA readers’ attention to claims of starvation in the Warburton Ranges made by Pastor (later Sir) Doug Nicholls and Western Australian members of parliament William Grayden and Stan Lapham.16,17 He often sent similar versions of his MJA letters to various newspapers, but he saw a special role for doctors. He explained to me that he wrote to the MJA because doctors were “important folk in the community” who influenced people’s views and attitudes (Dr Barry Christophers, personal communication). Christophers was always careful to not criticise the work of individual doctors; his targets were governments and bureaucrats, and their discriminatory policies and legislation. He did not choose to either alienate his audience or undermine the authority of the medical voice, which could continue to be used for other activities. In contrast, other writers in the MJA questioned the capacity of non-medically trained activists like Nicholls to speak authoritatively on Indigenous health matters.18 Christophers wrote many letters to the MJA about FCAA and FCAATSI campaigns to highlight and then remove discriminatory legislation and policies affecting Indigenous people. He wrote about the restriction of the movement of Aboriginal people in Western Australia by the “leper line”.19,20 He wrote four letters to the MJA, and many more to newspapers, supporters, bureaucrats and politicians, about the exclusion of Queensland Aboriginal patients with tuberculosis from the generous allowance paid to other TB patients to encourage convalescence and treatment.21 He explained that the exclusion was “understandable”, even if abhorrent, only because it was much higher than the very low wages then being paid to Aboriginal people in northern Australia.22 Christophers was secretary of FCAA’s Equal Wages Committee and, in the MJA and elsewhere, he repeatedly emphasised economic causes (and solutions) for Indigenous people’s suffering and ill-health. While many of his contemporaries blamed Aboriginal behaviour, just as their predecessors had blamed Aboriginal people’s inferior racial characteristics, Christophers focused on deeper structural causes of ill-health. In response to a claim that alcohol restriction needed to continue and citizenship to be opposed, he argued that Aboriginal alcohol abuse was merely a “symptom” of the “disease” of “lack of citizenship, low wages and colour prejudice”.23 In spite of his attention to structural determinants of health, he did not portray Indigenous people as passive victims; their actions were constrained, but not entirely determined, by racist, white institutions; nor did they just drift or follow biological urges, as others had claimed. His concern with the WA “leper line” was due to its interference with the attempts by Aboriginal “liberators” to “assist some of their not so fortunate friends”.20 Aboriginal people could be their own liberators and the liberators of other Aboriginal people, not just a problem to be solved by others. In the Northern Territory, he complained about withholding of blood transfusions from Aboriginal patients, inferior medicine chests required to be kept by employers of Aboriginal labour (compared with those at Royal Flying Doctor Service outposts), and legislation about Aboriginal people dying intestate.24-28 He was concerned that this legislation about the estates of Aboriginal people had been taken directly from the Mental Defectives Act: “The psychological trauma inflicted upon aborigines by regarding them and treating them as mental defectives and bankrupts must be immeasurable”.27 He similarly suggested that writers should avoid certain words, used by earlier conventions to describe Aboriginal people, that might inadvertently cause similar “psychological trauma” because of their negative metaphorical associations, or because he thought they were inaccurate or no longer acceptable.29 Christophers did not just promote positive over negative words and representations of Indigenous people, he investigated the portrayal of power in these representations and their colonial context. But no one questioned the fact that these representations of Indigenous people were created in their absence by non-Indigenous doctors. Enormous social changes since the 1950s in Australia make this omission seem obvious today. No longer can doctors expect to be unchallenged as the only authoritative voice on health matters. No longer can non-Indigenous people remain untroubled about the colonial context of their position when they speak about Indigenous people’s lives — or if they try to speak for Indigenous people. After the 1967 referendumFCAATSI’s 10-year campaign successfully led to 90.77% of voters in the 1967 referendum approving the deletion of the two discriminatory references to Indigenous people in the Constitution (Box 3). FCAATSI folded 10 years later after a decade of internal divisions concentrated on concerns about non-Indigenous control of the organisation.13 In part due to FCAATSI’s successes, attention had turned from equality to special Indigenous rights, like land rights, and Indigenous control of Indigenous lives. In the decades since the referendum, hundreds of Indigenous-controlled organisations, including health services, have been established and become successful. In more recent times, however, a new official and grassroots coalition promoting “reconciliation” between Indigenous and non-Indigenous Australians has emerged with prominent Indigenous and non-Indigenous leaders and members. While clearly lobbying in a different time and for different causes, this present-day coalition or social movement evokes memories of FCAATSI. This reconciliation movement has proved to be extraordinarily popular among both non-Indigenous and Indigenous Australians and very effective in spite of the considerable early and continued scepticism of many Indigenous people.30 With time, many people have forgotten or not heard of the activism and achievements of FCAATSI and its members like Barry Christophers. The dramatic changes in Indigenous lives and health that began in the 1950s and 1960s facilitated greater changes in the following decades. Joe McGinness, a Kungarakan man who lived in Cairns, was the President of FCAA (and FCAATSI) for most of its 20-year history. Christophers nominated him for the position in 1961 when he was first elected, and worked closely with him on many campaigns; they remained friends many years later. Sadly, Joe McGinness died in July last year. 1: Number of letters to the MJA editor about Indigenous health, 1914–1999 2: Barry Christophers in Melbourne, August 2000 Photograph: David P Thomas. 3: The Federal Council for Aboriginal Advancement (FCAA) and the 1967 referendum The first meeting of the FCAA declared its goal as equal civil rights for Aboriginal people (equal living conditions and pay and the removal of discriminatory legislation). In the 1960s, FCAA began to assert the need for different Indigenous rights (like land rights), not just equal civil rights.13,14 Torres Strait Islanders were acknowledged when the organisation changed its name to the Federal Council for the Advancement of Aborigines and Torres Strait Islanders (or FCAATSI) in 1964. Historian Peter Read has asserted that there were two dominant groups in the FCAA in its early years: the unions (and associated leftists, such as Christophers) and the churches. These groups included Aboriginal pastors like Doug Nicholls and Aboriginal unionists like Bert Groves and Joe McGinness, but these men had no special status as Indigenous people. FCAA and FCAATSI were “multi-racial” (or anti-racial) organisations, not Indigenous organisations — all people involved were treated “equally”—although, in practice, they were largely run by non-Indigenous people.13 The emphasis on the equality of Indigenous and non-Indigenous members reflected the organisations’ campaign goals for equal rights for Indigenous Australians. FCAATSI’s greatest public acclaim came with the success of its campaign for the 1967 referendum. The Australian Constitution had stated in Section 51 that the Commonwealth Parliament had the power to make “special laws” for the “people of any race, other than the aboriginal race in any State”. Section 127 stated that “aboriginal natives shall not be counted” in the populations of the states. While the referendum merely removed these two discriminatory references to Aboriginal people in the Constitution, FCAATSI’s campaign for the referendum was part of the larger social movement towards other, more significant equal rights. The referendum is now publicly and fondly (even though legalistically incorrectly) remembered for finally granting equal rights to Aborigines, including “citizenship” and the right to vote, as well as being associated with equal rights to drink alcohol.15

David P Thomas PhD, FAFPHM

Blood and guts: a short history of medicine. Roy Porter. New York: W W Norton, 2002 (199 pp). ISBN 0 393 03762 2. Roy Porter may have left this earth prematurely, but this most productive of modern scholars had some of his best books still in the publisher’s pipeline and he continues to delight and surprise us. Formerly Professor in the Social History of Medicine at the Wellcome Trust in London, Porter brings the outstanding scholarship of our time to the general reader. His vivid narrative enlightens and invites us to reflect on the large questions that medicine and care of the sick pose for a civilised society. He begins with a history of human disease, what he calls that “war between disease and doctors fought out on the battleground of the flesh” that has “a beginning, a middle and no end”. We are reminded that most disease is of our own making, an unwitting product of our drive to farm, irrigate, domesticate herd animals, live in towns and cities, travel, conquer and colonise. Likewise, our determination to extend our mortal coil demands a price in chronic illness, disability and dementia. Chapters discuss, in turn, doctors, the body, the laboratory, therapies, surgery and the hospital, each exploring its theme with a long historical view from ancient to modern. There is no more lucid guide to Hippocrates, Galen, the Scientific Revolution and the Paris Clinic to be found. The final chapter on medicine in modern society reviews the transition from the private relationship between patient and healer to a healthcare industry that is integral to the machinery of an industrialised society. Yet, for all biomedicine’s achievements, the health of the world’s poor has scarcely improved, while the “worried well” of the West consume a disproportionate amount of the available health dollar. Thus at the beginning of the 21st century, after “a golden age of some generations back, the public climate is not one of optimism but of new-millennial anxiety.” Janet S McCalmanReader in History Johnstone-Need Medical History Unit University of Melbourne, VIC

Janet S McCalman

Robert Warnock, or “Doctor Bob” as he was known to his patients and friends, was an outstanding rural doctor for 3 decades in Far North Queensland. Bob was born in Belfast, Northern Ireland, on 5 March 1927, the youngest son of a rural family doctor. He excelled at school at Campbell College, Belfast, where he was school captain, captain of the first XV football team, and captain of the Northern Ireland schoolboys’ hockey team. He studied medicine at Cambridge University before doing his residency at St George’s Hospital, London. After a stint in the British Army, he migrated to Australia with his first wife, Valerie, and their three children in 1958. After a short period in general practice in rural Victoria, Bob drove 3000 km to Babinda, north Queensland, to take up the role of Medical Superintendent of Babinda Hospital in 1958. In Babinda, he developed a reputation as a compassionate, hardworking, supportive general practitioner. He was highly regarded in the disciplines of obstetrics and anaesthesia. Bob moved to Cardwell in 1974, where he established the town’s first general practice and continued working until his early retirement in 1987 due to ill health. Bob was a very active community member. In Babinda he was a Rotarian, President of the Kindergarten Committee and President of the Bowls Club. He was also involved in cricket, tennis and water sports. In Cardwell he was a member of the Cardwell Country Club, and his enduring commitment to lawn bowls was recognised with the award of the Royal Queensland Bowls Association’s Meritorious Medal in 1996 and a Commonwealth Medal in 2000. In his retirement, Bob enjoyed gardening, spending time with his family, and travelling to the United Kingdom to visit former colleagues. He was also a member of Legacy and Probus. Bob’s dedication to rural medicine was recently acknowledged with the announcement that the new Cardwell community health centre, soon to be officially opened, has been named “Cardwell’s Dr R F Warnock Community Health Centre”. Bob died in Townsville on 4 May 2003, of prostate cancer. He is survived by his second wife, Enora, and children Roberta, Julian, Tim, Rowland and Jason. Timothy Warnock

Timothy Warnock

On 15 January 2004, Jack Elliott died peacefully of cardiac failure after a long and productive life during which he made enormous contributions to the discipline of obstetrics and gynaecology — primarily in Newcastle and the Hunter Valley, but also at a national level. Jack was born in Nowra, NSW, on 12 February 1912. He did his Leaving Certificate in Nowra, but needed to attend Fort Street High School (in Sydney) for a year to matriculate to the University of Sydney. He graduated in pharmacy, science and finally medicine in 1940. He supported himself in those student years by working part-time or full-time, supplemented by playing professional rugby league. He also played district cricket and was awarded a university blue in rugby union. Jack was commissioned as a captain in the Royal Australian Army Medical Corps and served throughout most of World War II, including service in Papua New Guinea. After the war, he resumed his medical career at the Royal Newcastle Hospital, where he embarked on a lifetime involvement in obstetrics and gynaecology. He set up the first specialist unit in the Hunter Valley at the Royal, training generations of residents and registrars, and became the trusted consultant for general practitioners throughout the region, holding appointments at most of the region’s hospitals. Beginning in the 1950s, he implemented a remarkable series of new initiatives in obstetrics and gynaecology, including a dramatically increased role for midwives and rooming-in and demand-feeding for mothers. He embraced the principles of natural childbirth, encouraged fathers to attend antenatal classes — and eventually the labour ward (an idea considered very radical at the time!). He pioneered the use in Australia of magnesium sulfate to treat severe pre-eclampsia, advocated the increased use of caesarean section, and was one of the first to promote the use of vaginal hysterectomy rather than the older Manchester-type repair operation. In the 1960s, Jack was one of the first consultants to develop country hospital clinics and operating sessions. He obtained his membership of the Royal College of Obstetricians and Gynaecologists in 1953 and became heavily involved in the College, serving on the NSW committee and subsequently the Regional Council. He was a member of the inaugural Council of the Royal Australian College of Obstetricians and Gynaecologists in 1979. Jack was an extremely modest man and, sadly, recorded little of his knowledge and wisdom in the literature. But his enduring legacy is the gratitude of thousands of mothers and the babies he delivered and the adoption by his trainees and colleagues of many of the initiatives that he began 50 years ago. Alan D Hewson

Alan D Hewson

Joe Cinque's consolation. A true story of death, grief and the law. Helen Garner. Sydney: Picador, 2004 ($30, 328 pp). ISBN 0 330 36497 9. IN 1997 A YOUNG WOMAN gave her boyfriend a large dose of Rohypnol and heroin. As a result she is now a graduate in law with a special interest in criminology, and he is dead. She was found guilty of manslaughter and sentenced to 10 years’ imprisonment. The usual complex arithmetic surrounding sentencing set her free less than three years after being sentenced. The circumstances of the killing were complex and bizarre and the author has examined them carefully. It occurred in a maelstrom of late-adolescent turmoil, drug taking and disturbed group processes, filled with denial. If you wish to discover the details buy the book — it is very good value. Garner questions the legal processes which can produce such a result, as well as curiosities such as the preventing of the two Crown psychiatrists from examining the defendant. The law is imperfect but getting better. At the beginning of the 19th century there were more than 220 statutes containing the death penalty, and judicial interpretation had expanded the list to more than 350 capital offences. Children were hanged with some frequency, on one occasion 10 in a row. Not until the Criminal Evidence Act of 1898 were accused persons permitted to give evidence in their own defence. Most improvements were made in the teeth of firm legal opposition. One must keep up the pressure and Helen Garner is doing this here. Is such an outcome morally wrong? Morality is a system of approvals: there will be as many moralities as there are groupings in society. There is no empirical way of establishing which is to be preferred. Those who argue that morality must be founded on religious beliefs should remember that until relatively recently the Christian church thought it morally right to burn alive those who did not believe that the Earth was the centre of the universe and was orbited by the sun. The best we can do is to examine every proposition put to us and this thoughtful book does just that. John H T EllardPsychiatrist Balmoral Beach, NSW

John H T Ellard

Three dog night. Peter D Goldsworthy. Melbourne: Penguin, 2003 (340 pp). ISBN 0 6708 9398 6. I THINK UNLESS A JOURNEY is bumpy and uncomfortable you haven’t really travelled far from home. In his latest book, Three dog night, Goldsworthy sure does “good travel” according to my requirements. In this lyrical, and strangely suspenseful, novel we accompany three doctors who travel — literally into the desert, and figuratively into the untidy and impolite world of death and erotica — to a place that unnerves, but surely tantalises, us all. The title refers to the number of dogs you need to sleep with in the desert at night to keep warm. Martin, the protagonist psychiatrist, has a head full of Latin names and is obsessively in love with his impenetrably beautiful but physically flawed wife, Lucy. She is also a psychiatrist and a specialist in pain management. Lucy is a “trophy wife” and Martin is bringing her home to Adelaide (think churches and zoo murders) to show her off. He is particularly keen to introduce her to his oldest friend Felix, a grumpy old surgeon, who years ago turned his back on the Establishment and went bush to work with the Aboriginals, being initiated into the Japalarri people along the way. Felix is dying of hepatitis-related hepatoma that he contracted from a young boy who died as a result of his drunkenness. He is tormented by the boy’s death and seeks penance (or is it pain relief) from his friend’s subsequent agony. He also wants to travel into the desert to find a place to die, a sinkhole that is a special place for his Dreaming. In one last unbearable stretch of friendship he wants company. Martin and Lucy, armed with morphine, oxygen and a disappearing mask of propriety, accompany him on his journey, and nothing is the same again. Goldsworthy, in a book where too much metaphor is barely enough, has written a worthy and enthralling travel manual, peering under masks into the murky realms of the “id” below. Fortunately, he has done so with forgiveness. Christine HampshireGeneral Practitioner Balmain, NSW

Christine Hampshire

The secret cure Sue Woolfe. Melbourne: Picador, 2004 (444 pp) ISBN 0 3304 2124 7 Sue Woolfe, author of the widely enjoyed book Leaning towards infinity, dedicates this, her latest novel, “To a brother I never knew”. The dedication sets the tone of the book. In a fictitious Australian town, the central character, Owen, who has spent most of his life confined to his home and is completely mute, allows himself a month in the real world, posing as a hospital maintenance worker. From afar he falls in love with Eva, an exuberantly dressed but painfully shy laboratory assistant. Most of the book is a record of his outrageously voyeuristic attempts to spy on Eva and her scientist lover Gunther, whom he tries to discredit in order to replace him in Eva’s affections. These “spying” passages could make some readers uncomfortable, as it is difficult to know how much Woolfe expects us to suspend our disbelief. However, it is worth pushing through this to enjoy the book’s main themes. Each character in the story, however peripheral, harbours a secret — and, in some way, everyone is mute. This obvious metaphor forms a good canvas for Woolfe’s exploration of Asperger syndrome and, of course, that substance whose secrets have galvanised scientists since its discovery over 50 years ago — DNA. Why do people do science? The characters in this book have compelling reasons for their obsessive (and, in Eva’s case, illegal) pursuit of a cause and a cure for Asperger syndrome and, while you might have to suspend your disbelief a little more to swallow Woolfe’s conclusion, it is wonderful to believe that secrets can be known and silences broken. Ruth M ArmstrongDeputy EditorMedical Journal of Australia, Pyrmont, NSW

Ruth M Armstrong

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

Ian Maddocks

Reading doctors’ writing: race, politics and power in Indigenous health research 1870-1969 David P Thomas. Canberra: Aboriginal Studies, 2004 (xvi + 209 pp). ISBN 0 85575 458 3. This is an apt title for this book. Race, politics and power in Indigenous health research have, not surprisingly, mirrored race, politics and power in Indigenous affairs generally. In order to tackle these subjects, Thomas has provided an interesting history of the development of medical associations and medical journals in Australia. The notion of Aboriginal people as primitive and a dying race who needed to be studied before they became extinct permeated much of the early research — “smoothing the pillow of a dying race”. But it was not simply a matter of Aboriginal people needing to be studied while the opportunity was still there. It was also an issue of the health of Aboriginal people potentially impacting on the health of non-Aboriginal people, and of the potential to learn things of value to the non-Aboriginal population by studying the health of Aboriginal people. This was all caught up with power relationships between Aboriginal people as research subjects and non-Aboriginal people as researchers and administrators. The concept of Aboriginal people being research subjects because they were considered to be more “primitive” was pervasive, and this belief led to a variety of wider paternalistic and repressive policies. In 1961 Sir Paul Hasluck, then Federal Minister for Territories, felt obliged to write that “I myself am not disposed to direct that wards can be sampled like a herd of cattle[.] Personal willingness of native people to assist is essential.” This statement is an interesting reflection on the tenor of the times. The sad part of all of this is that, with few exceptions, little research appears to have been done in that period with the explicit aim of helping to improve the health of Aboriginal and Torres Strait Islanders. Most researchers reflected the prevailing mood, but there were occasional exceptions, continuing the tradition of individual doctors arguing for a wholly different viewpoint against the mainstream, and perhaps with more than a little effect. There is much in this book for those with an interest in doctors’ role over a 100-year period in one of the major unresolved issues in Australian public health. Ian T RingEpidemiologist Health Information Centre Queensland Health, Brisbane, QLD

Ian T Ring

Former Director General of Public Health and a loyal and long-serving member of the New South Wales medical fraternity, Cyril Joseph Cummins spent more than 30 years committed to improving public health and health services. Cyril was born in Sydney on 10 November 1914. He attended Marist Brothers High School, Darlinghurst, where he excelled academically and at sport, completing his studies at the age of 16. Too young for university, he began a cadetship in journalism, but later enrolled in medicine at the University of Sydney to pursue his interest in health issues. After graduation in 1937, Cyril began his residency at St Vincent’s Hospital, where he later became Medical Superintendent. It was there that he met Eileen, a nurse, whom he later married. In 1939, Cyril joined the Royal Australian Air Force and rose to the rank of Wing Commander in charge of the No. 3 RAAF Hospital. While holding an administrative position in New Guinea during the war, he was often called upon to give anaesthesia during busy surgical periods. After the war, he worked for 3 years in a specialist practice in occupational health and was also a consultant in industrial medicine to the Department of Post-War Reconstruction before completing a Diploma of Public Health at the University of Sydney. In 1950, Cyril became Director of Industrial Hygiene at the Department of Public Health, where he was later promoted to the positions of Deputy Director of Public Health and Director General of Public Health. Cyril was passionate about his work and had a tremendous ability to organise and influence committees. His keen interest in mental health led him to take on the position of Director General of State Psychiatric Services in 1961, in addition to his role as Director General of Public Health. Cyril also held appointments in a number of healthcare organisations, including the World Health Organization, the Nurses Registration Board and the Board of Health, and acted as Commissioner under the Venereal Diseases Act. Cyril produced more than 25 publications spanning a range of health-related issues, including mental health, aged care and infectious diseases. His article outlining the history of the Colonial Medical Service in NSW has been recognised as a valuable public resource and is now available on the NSW Health website (www.health.nsw.gov.au/history/med_admin). Cyril retired at the age of 60 to spend time with his family and to follow his great interest in horse-racing. Sadly, Eileen died in 1992, and some 6 years later Cyril moved to the Central Coast to be nearer his daughter and grandchildren. He died peacefully in his Woy Woy home on 19 July 2003. Kimberley Moore

Kimberley Moore

Psychiatry and the specialised field of eating disorders lost one of its most respected practitioners at the end of 2003 with the death of Pierre (“Peter”) Beumont. Peter was a world-renowned psychiatrist, an innovative educator, a brilliant scientist and author, and a larger-than-life role model to his colleagues. He was one of the foremost authorities in the field of eating disorders, identifying early in his research that anorexia was a psychological disorder, not an endocrinological one. He was the first scientist to classify anorexia nervosa into clearly identifiable subtypes. This work still forms the basis for the classification of eating disorders today. Peter was born in South Africa in 1937. He was educated there and in the United Kingdom. He lectured at Merton College, Oxford, before returning to South Africa in 1971 to become Acting Head of Psychiatry at Groote Schuur Hospital and the University of Cape Town. During this time he was adviser on medical matters to Mrs Helen Suzman, the sole Member of Parliament for the anti-apartheid Progressive Party. He settled in Australia in 1975 when he took up the position of Professor and Head of Psychological Medicine at the University of Sydney. He is credited with creating a strong and integrated department with eclectic interests and excellence in teaching, research, clinical work and work in the community. Peter was a gifted teacher, and generations of medical students benefited from his encyclopaedic knowledge of psychiatry and medicine, as well as philosophy, religious studies, ancient and modern history, the arts, and his special love — Egyptology. In 1975, he founded New South Wales’ first specialist unit for anorexia nervosa, at the Royal Prince Alfred Hospital, and remained as its Director until illness forced him to retire. He was a tireless campaigner for better treatment facilities for patients with eating disorders and a devoted clinician who provided exemplary care for his patients. He also trained many of the specialists who now practise in this area. Peter was awarded the Gaskell Gold Medal and Prize by the Royal College of Psychiatrists (in 1975) and the Max Planck Prize by the Humboldt Foundation (in 1995) for his work in psychosomatic medicine. In 2001, he was made a Member of the Order of Australia. Peter is survived by his wife Daphne, his three daughters and their extended families. Stephen W Touyz

Stephen W Touyz

Ross Webster served Australian medicine for 55 years — 20 as a rural general practitioner, 15 as Professor of Community Medicine, and 15 with the Medical Indemnity Protection Society. Son of Reginald Webster, the first Victorian public hospital pathologist, Ross was born on 5 January 1924 in Melbourne. He studied medicine at the University of Melbourne, graduating in 1947. After graduation, Ross served in the Occupation Force in Japan as a member of the Royal Australian Army Medical Corps. Returning to Australia in 1950, he did postgraduate training in Melbourne, then moved to Horsham, in north-west Victoria, to join a multidisciplinary clinic and to be Honorary Medical Superintendent of the Wimmera Base Hospital. He served 6 years on the Horsham City Council, including one year as Mayor. After his wife Marjory’s death in 1972, and with three children to care for, Ross opted for regular hours of work at the Cancer Institute in Melbourne. In 1975, he was appointed Foundation Professor of Community Medicine at the University of Melbourne. In 1985, he married Jill, who was at the time Director of Nursing Education at the Cancer Institute. Ross was a tireless worker for the University community. He chaired the University’s Board of Social Studies, the Academic Committee and the Social Biology Resources Centre. He also chaired accreditation committees for nursing courses and the Victorian Health Advisory Council. He served on the Health Services Review Council and on the Federal Administrative Appeals Tribunal. Ross was an active and dedicated member of the Australian Medical Association (AMA), being a Councillor of the Victorian Branch for 33 years, President in 1977 and Chairman for 14 years. He is the only recipient of AMA Victoria’s Medal of Merit. He chaired the AMA Federal Council and Assembly for 6 years and was elected a Fellow of the AMA in 1979. Ross was Chairman of the Australian Medical Agency, the Victorian Medical Insurance Agency, the AMA Friendly Society, AMA Financial Services and the AMA Health Fund. From 1983 to 1988, he was Chairman of the Australasian Medical Publishing Company, publisher of the Medical Journal of Australia. Although he retired from the University in 1989, Ross did not stop working. In 1990, he became a part-time Director of Medical Services at Werribee and Broken Hill hospitals. He was also Foundation Chairman of the Medical Indemnity Protection Society (1988–1998), and continued to manage legal claims until his retirement in 2002. Ross was a man of great integrity. He was intolerant of questionable corporate behaviour and conflicts of interest, and had no time for specious arguments “justifying” such behaviour. He was friend, mentor and, above all, exemplar to many doctors. He died on 26 November 2003, of multiple myeloma. The profession and the community at large celebrate his lifetime of achievement and service. Paul Nisselle

Paul Nisselle

The art of living ... the art of medicine. The wit and wisdom of life and medicine: a physician’s perspective. Edward C Rosenow. Victoria, BC: Trafford Publishing, 2003 (140 pp). ISBN 1 4120 9262 1. Edward Rosenow III is an experienced physician who is seeking to pass on his skills in how best to relate to patients as well as to other professional staff. The book can be dipped into and enjoyed in small portions or it can be consumed in more substantial quantities. However you approach it, this book has something to offer most people. Written in a pithy and humorous style, with many quotations, it is easy to read. At the same time the author has some important messages that he is offering to the younger physician in particular. The very full curriculum provided for medical students today allows little time to deal with the more qualitative aspects of how to balance the pressures of a professional career with one's needs as a whole person and one's responsibilities to family and community. The value of role models and mentoring in supporting, and gently nurturing, the inherent skill of the young physician certainly strikes a chord with my own views. The author is quite concerned about the public image of the physician and is aware that there has been a decline in the level of trust of physicians generally. It is no surprise that the longest chapter in the book is called "Qualities of the respected person", in which he works his way through many qualities, such as trustworthiness, humility, communication skills, collegiality and professionalism. The more serious section of the book deals with how to avoid stress, "burnout", and depression, suggesting a range of practical and cognitive strategies. The chapter on end-of-life issues clearly demonstrates his compassion and sensitivity, and provides poignant reminders of the importance of the good physician’s role and obligations at this time. This slim volume is certainly value for money and will empower the reader to focus attention on the human elements of our work that have become endangered in the modern world. Chris MileshkinDirector of Clinical Services St Vincent’s Mental Health Services Melbourne, VIC

Chris Mileshkin

Trevor (“Jim”) Dinning was born in Adelaide on 16 February 1919 and died on 22 September 2003 after a long illness terminating in renal failure. He was the chief architect of neurosurgical services in South Australia and the creator of a very successful research foundation. After graduating in medicine from the University of Adelaide in 1942, Jim served as an army medical officer in several units, including the North Australian Observer Unit, charged with detecting Japanese landings. However, he developed pulmonary tuberculosis and was incapacitated for some 2 years. After his recovery, he took an appointment as lecturer in anatomy at the University of Adelaide. He decided to make a career in neurosurgery, and in 1951 he went to Guy’s Hospital in London to undergo specialist training. From the outset he had the qualities of a good neurosurgeon: an unhurried and meticulous operative technique and a total commitment to the welfare of patients. Jim returned to Australia in 1953 to take up an appointment, initially as Honorary Assistant Neurosurgeon, at the Royal Adelaide Hospital (RAH), where he remained for the next 30 years under various titles. From 1953 to 1971 he was also Chief of Neurosurgery in what is now the Women’s and Children’s Hospital. In 1971 he became full-time Director of Neurosurgery at the RAH. In both hospitals he established modern neurosurgical units, with rigorous attention to quality control and case audits. The development of an integrated state-wide neurosurgical service was very largely Jim’s achievement. He gave special attention to the needs of Australians living in rural areas and was ahead of his time in planning how to manage head injuries in remote locations. On a national level, Jim was a major force in creating neurosurgical training systems in Australia, beginning around 1970, when he was president of the Neurosurgical Society of Australasia. He helped to place promising trainees in overseas units with good research facilities, where they learned skills that have since helped to make Adelaide a leading centre for head-injury research. In 1964 he created what is now the Neurosurgical Research Foundation. As NRF President, Jim initiated fundraising for an academic chair in neuroscience. His vision was realised in 1992 with the establishment of a chair of neurosurgery research at the University of Adelaide. Jim was liked and trusted by his colleagues, and admired as a superb diagnostician, teacher and scholar. He was warm and compassionate towards his patients, and had a long and fulfilling life with his wife Beatrice and his four children. After official retirement, he continued to treat patients with intractable pain at the Memorial Hospital. His other retirement activities included bee keeping and sheep breeding. The many memorials to Jim’s achievements include the RAH’s Dinning Neuroscience Library, the Neurosurgical Research Foundation, and the legacy of his practice and teaching, which are now part of the fabric of Australian neurosurgery. Donald Simpson

Donald Simpson

Walter Monz was born in Boonah, in south-east Queensland, on 8 July 1914. He was educated at Brisbane Boys Grammar School, where he won a prestigious science prize. After completing the first year of the basic sciences course at the University of Queensland, he proceeded to the University of Sydney, where he graduated MB BS with Honours in 1939. (There was no medical school in Brisbane at the time.) Walter worked at the Brisbane General Hospital (now the Royal Brisbane Hospital) from 1940 to 1942, when he joined the Royal Australian Army Medical Corps. He was based on Thursday Island, where he worked at the 106th Australian Casualty Clearing Station of the Australian Imperial Force. He was also the Medical Officer to the Japanese prisoner-of-war camp on Thursday Island. Following demobilisation in 1945, Walter became a general practitioner in Goomeri, in south-east Queensland. In 1950, he set up a solo general practice in the Brisbane suburb of Yeronga, where he remained for the next 50 years, until severe osteoporosis forced him to retire in 2000. Walter was a Foundation Member of the Thoracic Society of Queensland (1945) and the Royal Australian College of General Practitioners (RACGP) (1958). He was also a life-long member of the Queensland Branch of the British Medical Association (later a branch of the Australian Medical Association). Walter was a skilled photographer and had a great interest and expertise in the area of audiovisual aids as an integral part of the Continuing Medical Education program. In 1968, he was elected Chairman of the Audio-Visual Aids Sub-Committee of the Medical Education Standing Committee of the Queensland Faculty of the RACGP. He was subsequently elected to the Queensland Faculty Board, and remained a Board member until 1986. Walter was a quiet, gentle, unassuming, and very private person. He died on 29 January 2003, aged 88 years, after a fall. He is survived by his daughters Pamela and Deirdre. Walter made generous bequests to the Queensland Faculty of the RACGP and St Andrew’s Lutheran Church on Wickham Terrace, Brisbane, with which his family had a long association. John A Comerford

John A Comerford

Walter James (“Bill”) Skinner died of melanomatosis on 12 July 2003, aged 88, after a long illness. Born on 3 April 1915, he was educated at Waverley College, Sydney, and studied medicine at the University of Sydney, graduating in 1940. After working as a Resident Medical Officer at St Vincent’s Hospital, Sydney, Bill enlisted in 1941 in the 2nd Australian Imperial Force. He served as a Medical Officer in the Middle East with an artillery regiment and later had various postings in the Papua New Guinea campaigns. In 1942 he married Dorothy Magee, a St Vincent’s nurse. After the war, Bill worked in country general practice in various places, including Taree, NSW, and southern Queensland. In 1955, he bought a practice in Windsor, NSW, and also the famous, historic “Doctor’s House” in Windsor’s Thompson Square. Bill practised in the Hawkesbury area for some 36 years. He was a foundation member of the Nepean–Hawkesbury Local Association of the British Medical Association (NSW) Branch, and a long-serving Secretary of the Honorary Medical Board of the Hawkesbury District Hospital. For most of his years as an Honorary Medical Officer there were no resident medical staff, so Bill and his colleagues were responsible for all emergency and in-patient care. For many years he performed most of the anaesthetics for his colleagues’ patients as well as having a very large obstetric practice. Bill’s high principles and ethics, and his loyalty to the Anglican Church, to his profession, and to his colleagues and many patients made him a highly respected member of the community. He had hoped, in retirement, to have time for his great love — cricket. His idea of a perfect day was to be in the members’ stand watching a good game of cricket and having a leisurely lunch of a bottle of beer with two cold Sargent’s meat pies. Bill is survived by his children Elizabeth, Mary and Stephen.

John J G Bain MB BS, FAMA, JP

compassion n. Pity inclining one to help or be merciful. (The Concise Oxford Dictionary). Doctors resigning and demoralised by forces ranging from heavy workloads to indemnity woes . . . A society conditioned to instant gratification, soaring expectations of modern medicine and technology, often fuelled by media hype (Ooi, page 639; Daniels, page 637) and increasingly cynical about doctors’ true priorities . . . A lucky country that’s materially better off than ever before . . . The latter observation comes from one of our foremost playwrights David Williamson (page 594), yet, as sociologist Hugh Mackay comments, we are “. . . neglecting the most vulnerable people in our society — the aged, the frail, the sick, the disadvantaged, the bewildered”.1 Meanwhile, internationally, the rift between rich and poor nations grows, and the lack of compassion of nations who “have” toward those who “have not” is seen as one of the antecedents to current international insecurity. Is compassion in its death throes two millennia after one man in Jerusalem advocated loving others as oneself, and another in Mecca described “a person’s true wealth [as] the good he or she does in the world”? A flock of white coats hovers above a young man in a hospital bed. The consultant tells the patient that he needs an urgent back operation and the flock moves on. It disperses after the ward round, and its most junior member returns to write up the young man’s medication chart. She is about to dash to her next task when the patient calls out, “Will the operation make me walk again?” The resident hesitates. “That’s unlikely, but it will stop things getting worse.” The patient nods and turns his head away. The resident hesitates again then leaves as her beeper goes off. Fifteen years later, I still wish I’d stayed to ask this man if he wanted to say or ask more. It would have cost me little, despite feeling ill-equipped to handle his pain and the eternal call of ward duties. It might have made no difference to him, but surely we are each responsible for becoming the change we wish to see. M Chew, Deputy Editor A qualified “no” is the answer to this question from contributors to the 2003 Christmas issue of the Journal. Perspectives by emergency physicians O’Reilly et al (page 649) and Fulde (page 651), who make space in their hearts and lives for homeless people visiting their emergency departments, and by Sutton (page 591) and Taylor (page 617), who have worked in developing nations, indicate that many doctors are still motivated by compassion. Furthermore, a recent forum on globalisation, aid and foreign policies, and their impact on health brought together diverse Australian and international experts (Zwi and Reid, page 573) and showed that many of us want to engage in compassionate “big picture” action. Yet all acknowledge the difficulties of practising compassion in an environment that does not seem conducive to it. Bleeding hearts?Certainly not. There are sound, even pragmatic, reasons for healthcare workers to act compassionately. Firstly, it benefits patients. While the benefits of a compassionate approach may be difficult to measure, a systematic review suggests that patients have less pain and recover faster if their doctors show empathy and reassurance.2 Furthermore, homeless patients presenting to a Canadian emergency department, and randomly allocated to receive “compassionate” care (a chat and a snack with a volunteer) re-presented less frequently than those receiving standard care.3 Secondly, doctors are well placed to join informed debate about sociopolitical issues that may impact on health. This is also crucial if our profession is to regain the trust of a sceptical community. The Royal Australasian College of Physicians (RACP) gives its rationale for taking physicians’ views on health and social policy to Canberra: “What doctors must do is show the community that medicine and consumers have overwhelmingly common imperatives and that doctors stand with the community before self interest. . . . lack of trust [that doctors act from concern for their patients] . . . most seriously threatens medicine’s continuance as a profession bound up in ethical values rather than commercial ones”.4 Thirdly, a modicum of compassion would not go astray in medical workforce planning. Part of the remedy for our workforce crises lies in regarding it as “more than a numbers game and . . . [with more] explicit attention to working conditions, incentives and rewards”.5 While compassion might begin at home, a global perspective is also vital. At the inescapable altar of evidence, even certain humanitarian medical interventions (such as vaccination, providing food and safe water) have gained sanction for efficacy, although alternative types of evidence and outcome measures should also be pursued.6 Smith’s editorial in this issue (page 571) argues that the impact of climate change on the health and economies of all in our global village offers rich countries ample incentive to act now for a win–win solution. Ultimately, however, to provide or enable healthcare of any ilk is a moral endeavour7 — we do so because we value human life. How do we regain compassion?Paradoxically, we believe that self-care (as opposed to self-centredness) is one of the keys. Reciprocity (or “getting something back”) is a motivation for altruism,5 and contributors to this issue of the Journal highlight their need for personal and external supports to prevent distress and the erosion of compassion (Smart, page 587; Edwards, page 647). Like it or not, role models are integral to medical training, and medical students and young doctors value attributes such as compassion in their role models, as eminent neurologist Lance attests (page 620). Yet good role models are not plentiful in our hospitals,8 and all of us need both to be and to emulate such models (see Box). Indeed, the World Health Organization has outlined the social accountability of medical schools, which have an obligation to direct their education, research and services toward the community’s priority health concerns.9 Medical schools must be responsive to, and proactive about, societal needs. Our initial and ongoing education should also seek to actively instil a recognition of the social determinants of health, and the place of humane values and ethics.10 The imposition of mechanistic guidelines, audits and regulations on clinical practice, with increasing commercialisation, have contributed not only to de-professionalism, but also to compassion fatigue. Our practice and research should embrace and refine such outcome measures as quality of life and the doctor–patient relationship. Compassionate action may also mean becoming advocates and agents of change for a variety of public health issues, such as more equitable healthcare access. We can do so as individuals by enthusing colleagues, engaging with others in the community and petitioning parliamentarians. We can do so as members of professional bodies (eg, the Australian Medical Association stance on Indigenous health [www.ama.com.au/web.nsf/doc/WEEN-5N5UHZ] and the joint statement by the RACP and the Royal Australian and New Zealand College of Psychiatrists on the health of children in immigration detention centres [www.racp.edu.au/hpu/policy/asylumseekers/detention.htm]). We can do so by supporting national and international coalitions of health, development, social justice and human rights, rather than coalitions of conflict or commercial interests. Examples of the former include Healthy Skepticism (Mansfield, page 644), the Medical Association for Prevention of War (www.mapw.org.au/about.html), and Médecins Sans Frontières. Surely medical involvement in some of these fields represents the ultimate preventive healthcare! . . . and what about a compassionate society?Hugh Mackay also observed in his commentary, “Who could have predicted that, at the turn of the century, Australia would become a less tolerant, less hospitable and less compassionate society?”1 This issue of the Journal celebrates the survival of compassion in medicine, in the face of bewildering societal changes. But we need much more. We need our policymakers to develop evidence-based, targeted strategies against health inequities. We need continued leadership and advocacy from our professional bodies. Above all, we need political leaders who champion compassion and unity rather than fear and division. If you want others to be happy, practise compassion. If you want to be happy, practise compassion — The Dalai Lama.

Mabel Chew FRACGP, FAChPM · Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP, FRCPA

Medical officers (MOs) employed by the Armed Services are, in a sense, both doctors and warriors. The concept of being both a doctor and a warrior is quite difficult for many to grasp. How can someone who has elected to dedicate his or her life to healing be part of an organisation that may enter into armed conflict? How can healing and harming go hand in hand? Nevertheless, they do. The idea of sending MOs to war is not new, as where there is war there is medical work to be done. Indeed, thousands of MOs around the world have shown a willingness to put their own needs aside to achieve a greater good. Furthermore, many advances in medical science that can benefit us all (eg, transfusion, ambulance services, and various surgical techniques) were first realised or developed in the theatre of war. MOs have played a vital role in Australia’s military history. Many have been decorated for their bravery and medical work on the front line, including Major General Sir Neville Howse in the Boer War (awarded Australia’s first Victoria Cross), Sir Edward “Weary” Dunlop in WWII, and, more recently, Captain Carol Vaughan-Evans, who was awarded the Medal of Gallantry for working during a massacre at Kibeho refugee camp in Rwanda in 1995. Others have made the ultimate sacrifice, dying in the service of their country — among them a personal hero of mine, Lieutenant (Dr) George Merz (who was killed by hostile Arabs in 1915, after working tirelessly as both an MO and pilot on many dangerous missions in WWI) and Major Susan Felsche (who died in a plane crash in 1993 while serving with the United Nations [UN] mission in the Western Sahara). Australian MOs continue to serve in wars, peacekeeping missions and humanitarian activities. Since the September 11 attacks on the United States, they have been busier than ever, providing medical support to the Coalition Against Terrorism in Afghanistan, triage and aeromedical evacuation in the wake of the Bali bombings, and a range of medical services in the war against Iraq and the subsequent mission to rebuild Iraq’s infrastructure. Most recently, our medical personnel were again at the front line, supporting the Regional Assistance Mission in the Solomon Islands and providing humanitarian assistance to the people of that country. These awards and activities are high-profile aspects of what it is to be a military MO in the Australian Defence Force (ADF). But there is much more to the job. Here, I will try to separate the myths from the reality of what it really means to be a military MO in Australia. I will outline what is expected of us at home and on operations, draw a picture of the many and varied experiences of service life and try to explain how the inevitable problems that can develop are dealt with. Jack of all trades and moreWhen not on deployment, the military MOs of all three services (Navy, Army and Air Force) are really “jacks of all trades”. They help to ensure that fit, healthy service personnel stay that way. They combine the roles of general practitioners, sports medicine physicians, preventive health experts and occupational health consultants. Some military MOs are involved in specialist areas of medicine, either at unit level or as part of the ADF’s three health centres of excellence — the Navy’s Submarine and Underwater Medicine Unit in Sydney, the Australian Army Malaria Institute in Brisbane, and the Air Force’s Institute of Aviation Medicine in Adelaide. On deployment, an MO’s main purpose becomes keeping people fit enough to carry out their job in extreme circumstances. This includes ensuring that only physically fit people are deployed, preventing casualties, and returning people who become ill to health as soon as possible. It involves providing operational health support, which reflects three concepts: first response (first aid); the “golden hour” for resuscitation (ie, the first hour after injury, when treatment has the greatest chance of increasing survival); the “three hour rule” (for initial wound surgery). Basically, if casualties can survive the first hour, then they have a high probability of surviving three hours,1 which should be time enough for them to be swiftly evacuated (by air, land and/or sea) to a place where they can receive an appropriate, adequate level of care. Based on these three principles, health support is organised into five levels of care: Level 1 (basic first aid), Level 2 (resuscitation), Level 3 (initial wound surgery), and Levels 4 and 5 (more specialised healthcare and rehabilitation provided in major civilian teaching hospitals). Surgical and intensive-care capabilities at our Level 3 facilities in the field are provided by members of the ADF’s Specialist Reserve, who include general surgeons, orthopaedic surgeons, anaesthetists and intensivists. Such reservists are often the unsung heroes who form the basis of our deployed health support. To supply effective support to the ADF personnel involved in the high-risk occupation of waging war, military MOs must be skilled not only in disaster and trauma medicine but also in the detection and management of injury caused by nuclear, biological or chemical attacks. Furthermore, in most of the missions we have been on in recent years, providing humanitarian aid has been an additional priority. However, more than anything, military medicine plays a major role in upholding the morale of a fighting force — an efficient, well equipped healthcare system allows members of the military to do their job in the knowledge that, if injured, they will be well looked after. Unique stressorsAll doctors know that medicine can be a stressful occupation, and military medicine is no exception. However, there are a number of stressors that are unique to this environment. Personal and professional stressorsFirst and foremost, there are the oddities of military life — the discipline, the bureaucracy, the uniforms and the haircuts. This lifestyle doesn’t suit everybody. Then, the ADF is a kind of “extended family”. The people who are your patients are also the friends you eat lunch with, see at the gym or socialise with at the mess. On deployments this is even more of a problem, as you are also living with your patients, who may have difficulty relating to you other than in your role as doctor. Relationships with family and friends can be challenging, as military MOs are often away from home — on courses or deployments or filling in for other people on courses and deployments. Being on very short standby for deployment can make it difficult to plan your life. The unexpected does happen, bringing with it a range of experiences (Box 1). 1: All in a day’s work One Monday morning in April 1999, I was called at 08:30 and told to be at the airport by 13:00 to be deployed to an island off the coast of Malaysia to investigate a fatal F-111 accident. It was an incredibly demanding mission, as the accident location was in a small swamp on a small island in the South China Sea. Aircraft wreckage poses many dangers, and the weather was hot and humid. It took several days to retrieve the bodies of the air crew, and both of the casualties were known to me personally. This took a toll on my physical and mental wellbeing, and I was physically ill before heading out to the site of a morning. But, as the only medical person on the team, I had many responsibilities in addition to my role as an accident investigator. As well as retrieving the bodies, I provided healthcare (including mental health support) to other team members and kept up their spirits. I counselled one of the spouses who visited the site. I liaised with Malaysian military personnel and police to bring the bodies ashore. When we reached Kuala Lumpur, I assisted with the autopsies. When we arrived back in Australia, I had to interview both spouses. Lastly, I organised psychological follow-up for my non-medical team members and, importantly, for myself. Gaining appropriate clinical expertise and opportunities for professional development can also be a challenge. Young medicos may be directed towards senior administrative roles early in their career; the opportunity to specialise may be limited to a few specific fields. All military MOs must have a broad range of skills, but often may have only limited scope to practise and maintain these skills when not deployed. On operations, many of the stresses of military medicine are magnified and others enter into the equation. Living conditions can be less than ideal. Working with unfamiliar cultures that may have different standards of care can lead to difficulties and conflict. Long working hours are often unavoidable, and fatigue takes its toll. War protocolThe Laws of Armed Conflict are the protocols that govern our actions in war. They protect our role as medical personnel and non-combatants, allowing us to do what we do best — tend to the sick and wounded. They also define our use of weapons. Many may shudder at pictures of personnel wearing the Red Cross while carrying guns; however, the Laws of Armed Conflict allow medical personnel to carry weapons to protect themselves and their patients. The Laws also state that it is our responsibility, as MOs, to treat everyone — friend or foe — using medical criteria to prioritise care. This can create a moral dilemma for the treating doctor, who may know that this same person, now a patient, committed almost inhuman atrocities in front of our personnel, as happened in Rwanda. Extreme operation: RwandaMuch of what I have described I have personally experienced in the most extreme operation I have been involved with to date — Australia’s commitment to the UN Assistance Mission in Rwanda.2 After the genocide in that country in April 1994, Australia sent two contingents of 300 peacekeepers to Rwanda from August 1994 to August 1995. As our mission was primarily a medical one — to provide health support to the UN troops and civilian personnel — nearly a third of our deployed personnel were health personnel. Although we were organised primarily to treat fit and healthy UN troops, we were now in a country whose health infrastructure had been largely destroyed in the genocide. Most Rwandan health professionals had either been killed or had fled the country. Consequently about 75% of our efforts were directed towards what was to have been, supposedly, our secondary mission — the humanitarian role. Despite the best efforts of our military training, there was no way we could have been adequately prepared for the influx and range of illnesses and injuries among civilians that we had to try to treat, as best we could, with limited and inconstant resources. We were able to save the life of a young mother who had lost both her legs as well as a pregnancy after stepping on a mine. However, we couldn’t help a young boy from a remote village who presented with a massive tumour of the head and neck. He was one of many we could neither diagnose nor treat. All we could do was advise his mother to take him home to die. So overwhelmed were we by the broad range of exotic medical and surgical conditions that confronted us that the MOs in my contingent had T-shirts made up with a logo that expressed our predicament precisely: instead of “Médecins Sans Frontières”, like our NGO colleagues, we sometimes felt like “Médecins Sans L’Idée” (Doctors Without A Clue) (Box 2). 2: T-shirt logo aptly expressing how overwhelmed we felt during the Rwandan crisis Rather than “Doctors Without Borders” (like our NGO colleagues) we sometimes felt like “Doctors Without A Clue”. It was difficult to come to terms with the harsh reality of trying to manage with extremely limited resources. Further, since our mission was primarily to support the UN troops, we had to give them priority. It felt, at times, as if we had to “play God”, a circumstance that did not sit comfortably with many of us. The fact that many of our Rwandan patients were HIV positive or had full-blown AIDS added to the danger and stress of our working environment. However, all of these challenges would have to be considered less distressing than my contingent’s involvement with the April 1995 massacre at the Kibeho refugee camp and dealing with the aftermath. The members of our medical team who witnessed the massacre felt the terrible frustration of seeing death and destruction before their eyes and of not being allowed to lift a finger to stop it. Even without the massacre, conditions at the camp were extreme — when food was in short supply there, I witnessed people picking corn out of human faeces that was scattered throughout the camp so they that could re-cook it. We worked among the filth and squalor, while talk of a sniper in the camp after the massacre persisted. Practising medicine while wearing a flak jacket, helmet and two pairs of gloves can be quite an experience, let me tell you. Thankfully, our experience at Kibeho ended on a positive note, as we were eventually able to convince the refugees to leave the camp and return home. Support strategiesYou will not be surprised to learn that these stresses do take their toll (Box 3). Military MOs are not immune to developing mental and physical problems, but we are perhaps more likely to ignore such problems in ourselves. On a deployment, we are the primary caregivers, preventive health experts, and often the mental health providers as well, to all personnel, including the health team (and, of course, oneself!). The MO may be the sole doctor at a site of deployment. I know of some who have become so preoccupied with their patients, their duty to fellow team members and their wider responsibilities that they have developed serious medical conditions that they themselves have not always recognised. 3: Post-traumatic stress disorder All personnel involved in war activities are at risk of developing post-traumatic stress disorder. A study of returned personnel from my contingent in Rwanda (of whom 27% were medical personnel) revealed that most subjects had been exposed to potentially traumatic events, such as seeing or handling dead bodies and fearing exposure to a contagious disease, toxic agent or injury.3 Six years after deployment, one in five were still experiencing significant levels of distress, with symptoms of post-traumatic stress disorder and a measurable impact on general psychological wellbeing. However, compared with infantry (who made up 30% of the sample), medical personnel reported lower levels of post-traumatic stress related symptoms and alcohol use — despite no differences between the groups in their levels of traumatic exposure, either in Rwanda or over their lifetimes. A questionnaire completed by 16 nursing officers who served in a different contingent in Rwanda revealed that it was not only traumatic experiences that were perceived as negative aspects of deployment. Other things, such as changing guidelines, having to accept some decisions made by non-medical personnel, the difficulty of interactions with other care organisations, and the lack of usual routine, were also a source of frustration.4 However, on a positive note, nearly all participants in the study felt the experience had changed their lives for the better. However, support strategies exist for helping us through the tough times — our overall military training, medical screening before departure, training with personnel from other services before deployment to develop group cohesiveness, and a willingness to support each other. A strong sense of purpose and an appreciation of the big picture — “we’re here to help, and we’re doing a good job” — and, at times, good old-fashioned MASH-style black humour, are also useful. DevelopmentsThe military has learnt from its experience, and our high operational tempo of recent years has been accompanied by more attention to support for military members on deployment. There is now more focus on adequate preparation for deployment, with appropriate training and medical and psychological screening. Research on personnel returning from deployments has led to improved mental health strategies before, during and after deployment. Personnel are being educated about the support available and encouraged to seek support. To better prepare medical personnel for the clinical aspects of deployment, military health units have entered into strategic alliances with major civilian hospitals in order to expose our personnel to a broader range of clinical experience. A new MO career structure has been developed that incorporates the need for ongoing professional development and specialisation in relevant areas of medicine. We are also exploring the use of technologies such as telemedicine in providing more and enhanced clinical support to deployed MOs. ReflectionsMilitary medicine is a challenging occupation. Although it can be stressful, especially when on deployment, it can certainly provide a fulfilling career for a doctor within an organisation that appears, at first glance, to espouse the philosophical opposite to the profession of medicine. Speaking for myself, my military career has also given me some incredible life experiences, such as flying at the speed of sound in fighter aircraft and travelling on duty to countries all over the world. In addition, I have learnt a lot about myself — my limitations and weaknesses as well as my strengths. Although the very nature of the job means that the health needs of MOs are often considered secondary to the needs of others, this situation can be, and is being, addressed. I look forward to seeing further development in support strategies for military MOs and to my next opportunity to practise medicine on the front line!

Tracy L Smart BM BS, DipAvMed

Finding a niche and fulfilment in Australia When the MJA contacted me about writing a “perspective”, I was initially delighted, thinking that it would be related to my research in breast cancer testing. When the word “personal” entered the discussion, I hesitated, then agreed — I owe that much to my mother, my teachers, and Priscilla. My migrant background has, in many ways, given me a broad perspective of what a community is, and I have grown up comfortable with seizing the best of different cultures. At 38 years of age, I tend to see life as a series of challenges and opportunities, and I feel very fortunate that, in Australia, I have always had sufficient support to make the most of these. My twin brother Hadi and I were born in Beirut, Lebanon, into a relatively wealthy family, the youngest of six children. I guess one could say we had everything — loving parents, private schools, and a huge apartment in the heart of Beirut. There was never any plan to migrate to another country. When I was about 6 or 7 years old, things started to go wrong with my parents’ health. First, my mother, then in her early thirties, developed renal failure that rapidly deteriorated, necessitating a transfer to Melbourne under the care of a Dr Priscilla Kincaid-Smith, with a view to transplantation. She was supposed to return soon after, but never did. Then, within about 8 months, my father suffered a heart attack and died. I was later to hear from my mother about her wonderful Australian renal physician, who had treated her kindly and broken the news of my father’s death to her while holding her hand. Because of my mother’s very favourable experience with her medical care, she naturally wanted to remain where she had received her transplant, and it was decided that we would join her in Australia. It was to be another 3 years before we were re-united with my mother. It was a painful time, and, while we were looked after by various members of my mother’s family, my oldest sister Sahar (then aged only 13 years) had responsibility for taking care of “the twins”. The cost of care for six children during that time consumed nearly all our resources. When I arrived in Sydney, aged almost 11 years, I thought that this was the most wonderful place in the world (and still do), although I could not speak a word of English. There seemed to be an abundance of everything, plus a backyard with pets! In retrospect, being re-united with my mother was what largely influenced my view of my new country. I found most things easy to learn and, having had a bilingual education (I spoke fluent French and Arabic at the time), English was a relatively easy language for me to learn. By the end of my first year at school, I was communicating well, had made a few friends, and was topping my class in science. At school, and to a much lesser extent at university, there was the inevitable taunting, and the occasional “wog” labelling. It rarely affected me, and in many instances I chose to ignore it. My school teachers were very encouraging, and within a few years had put me on the school debating team. Debating was an extremely arduous task, as I still “thought” in Arabic, yet had to express myself in English. My mother, like many people of non-English-speaking backgrounds, had a strong belief that, armed with education, you could do almost anything. She wanted me to do well enough in the Higher School Certificate (HSC) to gain entry into medicine (and of course would talk of why I should become a renal specialist!). I studied hard and expected to do well in the HSC, but was surprised to come first in my school, and gain entry into medicine at the University of Sydney. It feels as if Sydney University has always been a part of my life, from medical school until the present. During my undergraduate days, and through the three postgraduate degrees I subsequently completed at this university, I rarely encountered discrimination and felt generally happy. Yet, until I commenced the clinical years, I was unsure about whether to continue with medical school, as the non-clinical years gave me little indication as to whether I would enjoy providing care for people. Lidcombe Hospital was a teaching hospital at the time, and a great place to learn the art of clinical care. The tutors were enthusiastic, and we had a particularly inspiring medical tutor who seemed to know more medicine than the textbooks. By the time I completed my medical degree in 1987, I was fairly sure I wanted to be a doctor (but one with little interest in kidneys!). I was also sure that I had found the perfect partner. However, having been brought up in a strict Moslem family, boyfriends were not allowed, let alone Italian–Australian ones. We announced our engagement amidst strong (but short-lived) objections from both his family and mine, and my fiancé, along with my mother and siblings, celebrated my graduation in 1988. I completed my internship and a year of residency at Concord Repatriation General Hospital, a wonderful hospital to work in for general medical rotations, especially for unfortunate souls like me who were undecided about specialising. The internship included a secondment to Auburn Hospital, with its culturally diverse community, where I frequently saw Arabic-speaking patients in the emergency department. They genuinely appreciated being able to communicate with their doctor without a third party, and there were occasions when particularly sick elderly patients would grab my hand to kiss it, a gesture of appreciation in many Arab cultures. During my internship, I got married, and managed to celebrate with two wedding ceremonies, a Moslem one and a Catholic one. Early in 1990, I accepted a position as a breast clinician in one of Sydney’s private breast centres (Sydney-Square Breast Clinic) under the mentorship of Dr Joan Croll, one of Australia’s pioneers of mammography. Being able to help women with breast symptoms, who generally felt very vulnerable, and to spend time discussing management options with them, was very rewarding. I was soon convinced that this was the medicine I wanted to practise long term. Around that time, the methods of breast cancer detection were evolving, and our unit was one of the pilot sites for Australia’s breast-screening initiative, as well as one of the first centres to use ultrasound-guided needle biopsy. There was much to learn and do, and clinicians like me who were responsible for “triple testing” of breast abnormalities (by clinical examination, imaging and biopsy) were called “breast physicians”. Life events 1965 Born in Beirut, Lebanon 1972 Mother is transferred from Beirut to Melbourne for a renal transplant 1973 Father dies of a heart attack 1976 Siblings and I migrate to Australia and are reunited with my mother in Sydney 1988 Graduate in medicine from the University of Sydney Marry in two wedding ceremonies (Moslem and Catholic) 1988–89 Internship and residency at Concord Repatriation Hospital 1996– 2002 Medical Director (and, subsequently, Director), MBF’s Sydney-Square Breast Clinic 1997 Graduate Master of Public Health 1998 First child (Nadine) is born 1999 Graduate Master of Education 2002 Move from private practice to NSW Breast Cancer Institute, and the Royal Hospital for Women Complete PhD thesis: Accuracy of mammography and ultrasound in women with breast symptoms Second child (Laura) is born 2003 Graduate PhD Senior Lecturer, Screening and Test Evaluation Program, School of Public Health, University of Sydney I was 30 years old and had worked in multidisciplinary breast services for several years when I was appointed Medical Director of the Sydney-Square Breast Clinic. Although a little anxious about the responsibility, I was eager to do a good job and ensure that we provided a high standard of care to our patients. It was in this phase of my medical career that I first experienced some discrimination. The team of more than 40 staff was generally supportive, but I was aware that a few of my peers did not consider that I had the appropriate profile for the role. It was difficult to ascertain how much of this was due to my youth, my ethnicity, or perhaps my lack of a high profile, compared with that of my renowned predecessor Joan Croll. This was, however, transient. I remained in that role for 7 years, and during that time I combined clinical work with postgraduate study and research in public health, and developed a research profile for the centre in breast diagnosis, particularly in breast imaging accuracy. My research mentor, Professor Les Irwig, changed my life. Not only did he teach me the skills for conducting research, he provided invaluable advice and tolerated my “I give up” tantrums through an MPH and a PhD in clinical epidemiology. Last year, after a short break to have my second child (the baby having arrived a fortnight after I completed my PhD thesis!), I switched from private practice back to the public hospital system. I currently spend half my time at the New South Wales Breast Cancer Institute, working in services that range from a “benign disease” clinic to a “metastatic breast cancer” clinic. I also consult at the Royal Hospital for Women’s breast centre, seeing women with predominantly symptomatic breast conditions. The rest of my time is spent at the School of Public Health at Sydney University, continuing breast cancer research. Maintaining the balance between clinical and academic work is certainly a challenge, but I think the greatest challenge is spending enough time with my family, and making sure that my Australian children grow up with an appreciation of both the opportunities that surround them and their mixed heritage. We live in a part of Sydney that is greatly enriched by Italian–Australian culture, and my children are able to learn Italian at the local school, celebrate Italian fiestas, and visit Casa d’Italia on a regular basis. I think there is less opportunity for them to discover their Lebanese heritage, and I wonder how I can change that — with my busy life I myself have become increasingly distant from it. In a few weeks’ time, I will sit the Public Health Physicians Fellowship exams. I consider my chances of passing to be slim — breast cancer control is but a tiny fraction of the broad field of public health medicine. However, I am optimistic because of the enormous amount of help I am receiving from the public health medicine community, my colleagues at the Breast Cancer Institute, my husband, and Julia, a fellow candidate for the exams, who has been coordinating our study group. At my PhD graduation earlier this year, my husband and oldest daughter (aged 5 years) celebrated with me. My mother was not there, but I think she would have been proud. She passed away many years ago, aged 54 years, 20 years after her transplant. A few weeks before she passed away, she asked me if I had ever met Priscilla Kincaid-Smith (but the answer was no, and I still haven’t met Priscilla).

Nehmat Houssami MB BS(Hons), PhD, MPH