Drug testing - the decision is political

Published in Australian Medicine 18 February 2019 https://bit.ly/2GAgAUL

Preventing heart disease - a continuing story

Published in Australian Medicine 21 December 2018 https://bit.ly/2C9G6eV

Doctors notching wins in a war that can't be won

It is incumbent upon us to promote the desirability of alternative solutions to conflict

At the recent Armistice Day centenary commemorations, I had the privilege of attending a splendid rendition of the concert An Australian War Requiem in Sydney’s Town Hall.

The requiem to the nation’s fallen soldiers in World War I is in three tableaux; the first concerns the horror of war, the second focuses on sons and mothers, and the third — and most dramatic — is a reflection on loss.

The event led me to reflect on the far-reaching role ­doctors have played throughout history in times of war, and continue to play when it comes to human horrors.

Our role is multifaceted and spans the breadth of war.

Our first contribution, of course, is to do our best to heal those who are physically and mentally injured by war, and to understand, as best we can, the awful circumstances they have endured.

One such doctor was New Zealand ENT surgeon Sir Harold Gillies. Working on the Great War’s Western Front, he witnessed attempts to repair the ravages of facial injuries and, as a result, became a pioneer in plastic surgery.¹

A plaque honours Sir Harold Gillies. Photo: Simon Harriyott/Wikimedia Commons. https://bit.ly/2TBAgLu

He opened a hospital in the UK after the Battle of the Somme in 1916, where he treated thousands of cases of jaw and facial mutilation.

In World War II, Australian surgeon Sir Ernest Edward ‘Weary’ Dunlop was renowned for his leadership while being held prisoner by the Japanese.

He was hailed by other POWs in the prison camps and jungle hospitals on the Burma-Thailand railway for being “a lighthouse of sanity in a universe of madness and suffering”.²

Kanchanaburi war cemetery, where thousands of Allied POWs who died on the notorious Thailand to Burma death railway are buried.

Our second contribution comes in the aftermath of war when we look at the reasons for negative behaviour in affected servicemen and women and try to assist them if they emerge shell-shocked or, in modern parlance, with PTSD.

Research suggests that even medieval soldiers suffered from the psychological impact of war despite their training from a young age and being surrounded by death.

In 15th-century France, people believed that warfare caused a kind of madness and soldiers who went “berserk” were celebrated. However, non-combatants who were traumatised by war were pitied or ridiculed.³

Today PTSD remains a major therapeutic challenge, and not only for war veterans. A Google search of the phrase ‘Australian doctors treating PTSD’ yields a vast number of entries concerning psychiatric treatment, medication, lifestyle and other treatments.

Finally, we are bound to share our medical insight into the real cost of war with our communities.

Doctors in the US recently engaged in the modern-day version of this duty of care when, just a few days before the Armistice Day centenary, they took to Twitter to reveal the day-to-day horror of the country’s gun crime.⁴

Fuelled by the US gun lobby’s call for doctors to “stay in their lane” on the country’s gun control debate, dozens of emergency care medics posted photos of themselves working while covered in patients’ blood as a visual reminder of the human cost of America’s shooting epidemic.

Away from the front-line, numerous doctors have also been honoured for championing a reduction in the engines of war.

SA palliative care physician Professor Ian Maddocks was president of the Medical Association for Prevention of War when it received an Australian Peace Medal, and vice-president of the International Physicians for the Prevention of Nuclear War when it received the Nobel Peace Prize in 1985.⁵

And, more recently, Professor Tilman Ruff, an infectious disease and public health doctor from the University of Melbourne, was chair of the International Campaign to Abolish Nuclear Weapons — the recipient of the 2017 Nobel Peace Prize.⁶

It is important for doctors, who see the damage, to make clear to our communities and their political representatives the absolute desirability of finding alternative solutions to conflict.

But the reality is that in a world of scarce resources, war will likely remain part of the human condition, and will not, unfortunately, be going away. We must therefore remain ready to meet its challenges.

Requiescat in pace.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy and School of Public Health, University of Sydney. 

Published in Medical Observer 26 November 2018

https://www.medicalobserver.com.au/views/doctors-notching-wins-war-cant-be-won

David Maddison Lecture 2018

Please follow link below to the David Maddison Lecture 2018:

David Maddison Lecture 2018

Keeping cool in the global warming climate

Published in Australian Medicine 19 November 2018  https://bit.ly/2QZAsSO

It's counter-intuitive but getting healthier should make us worry

Unlike in the past, modern public health programs have led to more poverty, unemployment and a rapid rise in chronic illnesses, says a leading GP

Confronted with challenges in our daily work, reinforced by depressing news about global politics, it is understandable that we feel like hunkering down and concentrating on local distractions, such as family and valuable friendships — not that these ‘distractions’ are uniformly free of challenges, of course.

But what is occurring globally establishes a context within which we all work and there can be value in looking above the parapet, keeping an eye open for a sniper in the distance.

Adjunct Professor Thomas Bollyky, a senior fellow and director of the Global Health Program at the Council on Foreign Relations in Washington DC, has written a challenging essay in the latest issue of council publication Foreign Affairs.  The article is both informative and deeply disturbing. Entitled ‘Health without wealth’, Bollyky addresses “the worrying paradox of modern medical miracles”.

“For the first time in recorded history,” he states “bacteria, viruses and other infectious agents do not cause the majority of deaths or disabilities in any region of the world.” This infamy belongs to chronic illness.

Bollyky takes an historical view of how the vast improvements of the past century in health occurred in the US and Europe as a result of controlling communicable diseases.

These measures included “government-mandated measures — such as milk pasteurisation, laws against overcrowded tenements, and investments in clean water and sewage treatment systems — and better social norms around hygiene, childcare and girls’ education”. Half of the improvement in life expectancy in developing countries between World War II and 1970 was due to these means — and not to antibiotics and immunisation, Bollyky claims.

These public health measures had a strong relationship with prosperity. They occurred because governments invested in water and sewers and public housing. And, in return, a healthier workforce contributed to prosperity.

Big cities, the engines of innovation and achievement, became increasingly affluent because of rising productivity and were able to complete the circle of public health investment leading to societal economic benefit.

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However, modern-day public health programs to address the likes of malaria, HIV and child immunisation have undoubtedly saved lives and increased life expectancy, but have failed to increase prosperity. “The recent hard-won gains threaten to bring a host of new and destabilising problems,” Bollyky writes.

This is because such programs, which are often paid for by outside agencies rather than local governments, have not automatically led to greater productivity, more employment or the expansion of local health services. In fact, the situation has led to more poverty, unemployment and a rapid rise in chronic illnesses as a result of changes to food supply, greater availability of tobacco and housing shortages.

In this setting, chronic disorders have flourished and a new generation of peri-urban slums have developed.

In Australia, we enjoy the ability to treat these conditions and we have succeeded in pushing many of them into the senior years. But think back to the 1950s and ’60s when our therapeutic abilities were much less and where death from an MI or stroke was common among middle-aged men. That is how it is in many less economically developed nations now — a huge loss of productive workforce in middle age.

Bollyky states that deaths from hypertensive heart disease among people under 60 have increased by nearly 50% in sub-Saharan Africa in the past 25 years.

“In 1990, heart disease, cancer and other non-communicable diseases caused about a quarter of deaths and disabilities in poor countries,” he adds. “By 2040, that number is expected to jump as high as 80% in countries that are still quite poor.”

The remedy, Bollyky suggests, is a more comprehensive approach to international aid — ensuring that investments help countries to improve their healthcare systems, make their cities more liveable and “enable their companies to employ more people more productively”.

While our preventive approaches to chronic illness in Australia could do with more money, we can be thankful that we have healthcare that enables us to manage chronic ailments, especially through general practice.

However, in this global era of chronic illness, it would be wise for governments to remember that spending on healthcare and enjoying prosperity are two sides of the same coin.

Professor Stephen Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy and School of Public Health, University of Sydney.

Published in the Medical Observer 18 October 2018 https://bit.ly/2PwaJVK

Paying for Performance

Published in Australian Medicine.  15 October 2018.  https://bit.ly/2qNjEmN