MJA • Volume 186 Number 12 • 18 June 2007 609

LETTERS

Physician migration and the Millennium Development Goals for maternal health: the untold story

659 Onyebuchi A Arah

Potential impact of AUSFTA on Australia’s blood supply660 Albert Farrugia

“Failure to thrive” or failure to use the right growth chart?660 Barbara Radcliffe, Jan E Payne, Helen Porteous, Simone G Johnston

“Meth mouth”661 Anne-Marie L Laslett, John N Crofts

Men’s health661 Kenneth W Sleeman

662 Ann T Gregory

Evaluating medicines: let’s use all the evidence662 Mira L Harrison-Woolrych

Research misconduct: can Australia learn from the UK’s stuttering system?662 Peter T Wilmshurst

Antenatal care implications of population-based trends in Down syndrome birth rates

663 Caroline M De Costa, Cait Calcutt

The difficulty with data: greater accuracy required for policy making663 Susan Downes, Sally M Roach

SNAPSHOT

654 Waterlily sign

Maneesh Khanna, Sandeep Chauhan, Usha Dalal, Sarabmeet S Lehl

610 IN THIS ISSUE

658 IN OTHER JOURNALS

MJA Rapid Online Publication: published 4 June 2007.

From the Editor’s DeskTHE RAISON D’ÊTRE OF ROYAL COLLEGESRecent bureaucratic attempts to modernise postgraduate medical training in the United Kingdom witnessed thousands of doctors marching in protest. The vehicle for change was Modernising Medical Careers — a program implemented by the Department of Health, with the active involvement of the Royal Colleges. It aimed to alter both the curriculum content and the time required for specialist postgraduate training, and its development was overseen by a statutory body accountable not to the medical profession, but to politicians.

The immediate catalyst for the mass demonstrations was the resounding failure of a computerised system to process job applications of some 30000 doctors for 22000 positions. But there were deeper concerns: misgivings about training opportunities and job security. More problematic, perhaps, was disillusionment with the State takeover of postgraduate medical training, jeopardising the very raison d’être of the Royal Colleges.

In the wake of the protests, the Royal Colleges and the British Medical Association (BMA) were widely criticised, as only 10% of trainees felt adequately represented by the Royal Colleges, and 6% by the BMA. Indeed the aftermath saw the resignation of the BMA chairperson There were also calls for the Colleges to be more resolute:

They need to raise their game and make clear they are independent bodies with their own ideas and principles — which may from time to time differ from the government’s . . .*

Given the future explosion of Australian medical graduates, and current workforce shortages, we may well witness similar tensions. There are already government calls to streamline and shorten our postgraduate medical training!

It is imperative that our Colleges remain steadfast and resist political pressure to solve medical manpower problems created by governments. After all, the raison d’être of the Royal Colleges is to be the independent voice of the profession and the vehicle for quality vocational training.

Martin B Van Der Weyden

*Hawkes N. The royal colleges must up their game —or die. BMJ 2007; 334: 724.

LETTERS

The Medical Journal of AustraliaISSN: 0025-729X 18 June 2007 18612 659-664©The Medical Journal of Australia2007 www.mja.com.auLetters

Physician migration and the Millennium Development Goals for maternal health: the untold storyOnyebuchi A Arah

TO THE EDITOR: In 2000, the UnitedNations Millennium Summit produced anagenda for reducing global poverty. Itlisted eight Millennium DevelopmentGoals (MDGs) and was signed by 189countries. Improving maternal health(with the aim of reducing the maternalmortality ratio by three-quarters between1990 and 2015) is the fifth and perhapsthe core health-related MDG if we con-sider the centrality of mothers in socialdevelopment and health.1,2 Globally, thenumber of maternal deaths remains highat 529 000 per annum.2 Ensuring mater-nal survival demands functional healthcare systems with skilled health careworkers. However, migration of healthcare workers (mostly to wealthier English-speaking countries) is a major threat toachieving the MDGs.3-5 Here, I estimatethe associations between maternal health

and physician migration and humanresources for health.

I used recently updated physicianmigration3 and global health workforcedata4 to look at correlations between physi-cian migration and two core maternal healthindicators — the maternal mortality ratio,and the percentage of births attended byskilled personnel.1,2 I also explored the asso-ciations between these maternal health indi-cators and human health care resources.Migration was measured as the number ofphysician émigrés working in Australia, theUnited Kingdom, Canada, and the UnitedStates during 1999–2002, per 1000 popula-tion of their source countries.5 Physicianmigration density values for all four coun-tries combined, and for each country indi-vidually, were determined (Box). Humanhealth care resources included current den-sities of health care workers remaining inthe source countries (Box).

I calculated the Pearson’s correlation coef-ficients between these variables and the twocore maternal MDG indicators.

The Box shows that countries with bettermaternal health are likely to have higherphysician migration and more human

resources for health care. For example,higher migration to Australia is seen fromcountries with lower maternal mortality(r = −0.29; P = 0.011) and more birthsattended by skilled staff (r =0.25; P=0.037).

I acknowledge that, like most health sys-tem and global health analyses, these corre-lations are based on an ecological (cross-country) design which does not lend itself tocausal inference. These findings are there-fore descriptive and require further explora-tion. Furthermore, the two maternal healthindicators used here (which are the corematernal health MDG indicators used by theUnited Nations) could be viewed as indica-tors of health system and population healthprogress. Although physicians and otherhealth care workers play major roles inmaternal survival, especially in pregnancy,they cannot be seen as the only require-ments for better maternal health. Physicians’roles can also be substituted by other healthcare workers in many situations in resource-poor settings.

However, less-poor source countries oftenhave higher capacities than poor nations toturn out skilled workers who subsequentlymigrate. Contrary to conventional wisdom,

Correlations between source countries’ core maternal Millennium Development Goal indicators and (A) physician migration to Australia, the United Kingdom, Canada and the United States and (B) human health care resources*

Maternal Millennium Development Goal indicators in source countries

(A) Physician migration to Australia, the UK, Canada and the US

No. of source

countries†

Mean physician migration density‡

(SD)

Maternal mortality

ratio¶ P

Births attended by skilled

health care staff** P

Total migration 141 0.094 (0.224) −0.45 < 0.001 0.34 < 0.001

Migration to Australia 75 0.007 (0.040) −0.29 0.011 0.25 0.037

Migration to the UK 117 0.017 (0.072) −0.27 0.003 0.17 0.072

Migration to Canada 116 0.008 (0.027) −0.47 < 0.001 0.45 < 0.001

Migration to the US 124 0.061 (0.158) −0.55 < 0.001 0.43 < 0.001

(B) Human health care resourcesMean density of health

care workers§ (SD)

Physicians 141 1.655 (1.426) −0.84 < 0.001 0.67 < 0.001

Nurses 141 3.636 (3.544) −0.81 < 0.001 0.72 < 0.001

Public and environmental health care workers 64 0.114 (0.169) −0.56 < 0.001 0.54 < 0.001

Health management and support workers 71 1.488 (2.222) −0.73 < 0.001 0.51 < 0.001

* Data are those available for 1999–2002, and each variable was transformed into its natural logarithmic form for analysis.† Top 10 source countries losing physicians (per 1000 population) to the four destinations combined (in decreasing order): Ireland, Saint Lucia, Lebanon, New Zealand, Jamaica, Iceland, Malta, Dominican Republic, Israel, and Cook Islands. Top 10 source countries for Australia: New Zealand, Ireland, Singapore, Fiji, Malta, Sri Lanka, South Africa, Slovakia, Bahrain, and Hungary. Top 10 source countries for the UK: Ireland, Malta, Barbados, Jamaica, New Zealand, Sri Lanka, Libya, Greece, Iraq, and Iceland. Top 10 source countries for Canada: Ireland, Jamaica, Kuwait, Lebanon, South Africa, New Zealand, Barbados, Bahrain, Saudi Arabia, and Iceland. Top 10 source countries for the US: Saint Lucia, Lebanon, Ireland, Iceland, Dominican Republic, Jamaica, Cook Islands, Israel, Belize, and the Philippines.‡ Number of source country’s physicians working in Australia, the UK, Canada and the US per 1000 source country’s population (based on average year-2000 population).§ Number of health care workers remaining in home/source country per 1000 population.¶ Correlations between the number of maternal deaths per 100 000 live births and (A) physician migration density and (B) human health care resources.** Correlations between the percentage of births attended by skilled health care staff and (A) physician migration density and (B) human health care resources. ◆

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Australia, the UK, Canada, and the US drawsubstantially more migrant physicians fromcountries with higher health care workercapacities. Many countries may be losingphysicians just when they should be reapingthe benefits of their improving fortune.Given the patchy progress towards achiev-ing the MDGs,1 health care worker short-ages may impede many countries’ progressin improving health standards if migrationrates exceed workforce replacement in theface of changing but increasingly complexhealth care needs.1,2,4

Physician migration must be taken seri-ously if the global target of reducing mater-nal mortality by three-quarters between1990 and 2015 is to be realised and sus-tained. Australia and other Western coun-tries must partner with source countries todevelop strong political commitment andscaled-up investments in human resourcesfor health.

Onyebuchi A Arah, Assistant ProfessorDepartment of Social Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.o.a.arah@amc.uva.nl

1 World Bank. Global monitoring report 2006.Millennium Development Goals: strengtheningmutual accountability, aid, trade, and govern-ance. Washington, DC: The World Bank, 2006.http://web.worldbank.org/WBSITE/EXTER-NA L/ EX T DEC / EX T GL O BAL M O NIT O R/EXTGLOBALMONITOR2006/0 ,,content -MDK:20810084~menuPK:2199415~pagePK:64218950~piPK:64218883~theSitePK:2186432,00.html (accessed Apr 2007).

2 World Health Organization. The world healthreport 2005: make every mother and child count.Geneva: WHO, 2005. http://www.who.int/whr/2005/en/ (accessed Apr 2007).

3 Mullan F. The metrics of the physician braindrain. N Engl J Med 2005; 353: 1810-1818.

4 World Health Organization. The world healthreport 2006: working together for health.Geneva: WHO, 2006. http://www.who.int/whr/2006/en/ (accessed Apr 2007).

5 Arah OA, Ogbu UC, Okeke CE. Too poor toleave, too rich to stay? Developmental and globalhealth correlates of physician migration to theUnited States, Canada, Australia, and the UnitedKingdom. Am J Public Health 2007. In press. ❏

Potential impact of AUSFTA on Australia’s blood supplyAlbert Farrugia

TO THE EDITOR: In reference to the letterby Kennedy et al, reporting two patients whotested positive to human T-lymphotropicvirus I/II (HTLV-I/HTLV-II) antibodies afteradministration of the intravenous immu-noglobulin, Octagam (Octapharma Australia,Sydney, NSW),1 the Therapeutic GoodsAdministration (TGA) would submit that:• This product was accepted for review bythe TGA at a time when plasma productssourced from overseas had to demonstratesuperiority over the local product. Thisrequirement was fulfilled by Octagam ongrounds that included pathogen safetyissues.• HTLV-I and HTLV-II are entirely cell-associated viruses and are thus irrelevant tothe safety of plasma derivatives. They are ina group of pathogens for which risks,implied by epidemiological factors, apply tocellular but not to plasma products. Anothercommon example is malaria. The Australianplasma pool includes donations from indi-viduals who are at risk of transmittingmalaria, so their cells are not used but theirplasma is used for fractionation. This situa-tion is well understood and managed byregulators, none of whose standards interna-tionally include the need to test plasmadonors for HTLV-I/HTLV-II infection. As thebulk of Australia’s fractionation pool isderived as a by-product of whole blood,blood is tested for HTLV-I/HTLV-II in thiscountry, but it is not a mandatory require-ment in Australia or anywhere else.• The exclusion of antibody from theplasma pool, as occurs for HTLV-I/HTLV-IIin Australia, may actually lead to the loss ofpotentially protective antibodies, which maywell have a therapeutic effect in protectingpatients from HTLV-I/HTLV-II infection.2

Such considerations apply, for example, inthe requirements of the Food and DrugAdministration in the United States forsource plasma for fractionation. Therequirements take care to allow the inclu-sion of antibody-positive units for someviruses that would be excluded from bloodtransfusion.• The incident referred to by Kennedy et alwas appropriately reported to the TGA’sAdverse Drug Reactions Unit, which con-cluded that this was not an adverse event.• A Northern Territory Government docu-ment on HTLV reports: “In Central Australiathe prevalence of HTLV-I is estimated to be

up to 14%, compared to 4.7% in the North-ern Territory cattle country . . .”3 The resid-ual risk of transmission of HTLV-I/HTLV-IIinfection, while low,4 clearly varies acrossthe potential donor population, and com-parisons that are irrelevant in relation to thesafety of specific products would appear tobe unwise.• It is recommended that practitionersseeking to assess causality in putative infec-tious disease transmission by plasma prod-ucts follow rigorous scientific processes,such as those recommended by the Germanregulatory authority.5

Albert Farrugia, Head of Blood and TissuesOffice of Devices, Blood and Tissues, Therapeutic Goods Administration, Canberra, ACT.albert.farrugia@health.gov.au

1 Kennedy GA, Cummings J, Durrant ST. Potentialimpact of AUSFTA on Australia's blood supply [let-ter]. Med J Aust 2007; 186: 427.

2 Kariya N, Hayashi K, Hoshino H, et al. Protection ofrabbits against HTLV-II infection with a syntheticpeptide corresponding to HTLV-II neutralizationregion. Arch Virol 1996; 141: 471-480.

3 Northern Territory Government. Centre for DiseaseControl. HTLV-I. http://www.nt.gov.au/health//cdc/fact_sheets/HTLV1.rtf (accessed May 2007).

4 Seed CR, Kiely P, Keller AJ. Residual risk of transfu-sion transmitted human immunodeficiency virus,hepatitis B virus, hepatitis C virus and human Tlymphotrophic virus. Intern Med J 2005; 35: 592-598.

5 Schosser R, Keller-Stanislawski B, Nübling CM,Löwer J. Causality assessment of suspected virustransmission by human plasma products. Transfu-sion 2001; 41: 1020-1029. ❏

“Failure to thrive” or failure to use the right growth chart?Barbara Radcliffe, Jan E Payne, Helen Porteous and Simone G Johnston

TO THE EDITOR: Growth charts areimportant tools in assessing the physicaldevelopment of infants and children.Understanding and comparing the deriva-tion and applicability of the new WorldHea lth Organization Chi ld GrowthStandards1 and the Centers for Disease Con-trol and Prevention (CDC) growth charts2 isessential.

Arguments for and against the standarduse of the new WHO growth charts arebeing discussed on the basis of differences instudy designs used and growth patternsfound.3,4 The WHO charts show the growthof breastfed infants on the basis of data fromabout 8500 children from widely differentethnic backgrounds and cultural settings(Brazil, Ghana, India, Norway, Oman and

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the United States); these children were fromselected populations in which no health,environmental or economic constraints ongrowth existed.1 In contrast, the CDC chartsrepresent the combined growth pattern ofartificial-formula-fed and breastfed infantsin the United States, where about 50% ofinfants are never breastfed and only around33% are breastfed for 3 months or longer.2

Is it possible to misdiagnose breastfedinfants who are growing normally as failingto thrive if the CDC growth charts are used?The simplest common definitions used forfailure to thrive are a drop below the 3rd or5th percentile for weight, or when growthdeviates from an established growth curvefor 3 consecutive months.5 By the CDCgrowth charts, the normal growth patterndescribed by the WHO Child GrowthStandards for a 15th percentile, breastfed,female infant at 18 months would meet allthree definitions of failure to thrive. Theclinical response to this perceived failure tothrive may be to provide additional energyin the form of energy-dense foods or supple-ments (eg, artificial formula). This would atbest be unnecessary, and at worst mightcontribute to the development of over-weight and obesity.

So, where to from here? We recommendthat all health professionals who use growthcharts be cognisant of which chart they areusing and its application, especially forbreastfed infants. There is also a need forAustralian national and state governmentsto debate which growth charts should beused and in what contexts. Finally, irrespec-tive of the choice of growth charts, it mustbe recognised by practitioners and the gen-eral public that these charts are guides only,and should be used as part of a holisticapproach to infant growth assessment andmanagement.

Barbara Radcliffe, Nutritionist1

Jan E Payne, Lecturer2

Helen Porteous, Nutritionist2

Simone G Johnston, Nutritionist2

1 Southern Brisbane and Logan Breastfeeding Promotion and Training Coalition, Brisbane, QLD.

2 School of Public Health, Queensland University of Technology, Brisbane, QLD.

j.payne@qut.edu.au

1 World Health Organization. The WHO ChildGro wth S ta nd a rds . h t tp : / / www.wh o . i nt /childgrowth/en/index.html (accessed Apr 2007).

2 Centers for Disease Control and Prevention.National Center for Health Statistics. NationalHealth and Nutrition Examination Survey. WHOChild Growth Standards. http://www.cdc.gov/growthcharts/who_standards.htm (accessed Apr2007).

3 de Onis M, Garza C, Onyango AW, Borghi E.Comparison of the WHO child growth standardsand the CDC 2000 growth charts. J Nutr 2007 137:144-148.

4 Binns C, Lee M. Will the new WHO growth refer-ences do more harm than good? [letter]. Lancet2006; 368: 1868-1869.

5 Olsen EM. Failure to thrive: still a problem of defini-tion. Clin Pediatr (Phila) 2006 Jan-Feb; 45: 1-6. ❏

“Meth mouth”Anne-Marie L Laslett and John N Crofts

TO THE EDITOR: Single case reports of“meth mouth”, similar to that recently pub-lished in the Journal,1 exaggerate the dentalproblems surrounding the use of metham-phetamines. Evidence that methampheta-mines cause grinding and wear of teeth,2

xerostomia,3 and cravings for sweet drinks isweak. The drug use reported by Shetty wasintravenous or intranasal, not oral. Whilesystemic effects may contribute to dentalproblems, local oral effects associated withacidity of methamphetamines would beminimal with intravenous or intranasal druguse.

A more plausible explanation for dentaldisease may be the years of neglect, traumaand poor diet experienced by many peoplewho use drugs.4 Many drug users beginusing as early as 14 years of age and con-sume multiple illegal psychoactive and legalantipsychotic and antidepressant medica-tions associated with xerostomia. A compre-hensive drug-use history is required beforedental problems are attributed to one drug.

Advising treating dentists to avoid the useof analgesics is misinformed and potentiallyleaves patients in severe pain unnecessarily.People affected by methamphetamines areunlikely to seek dental or medical treatment.A more likely scenario is presentationbecause of pain between methamphetaminebinges, or presentation when they are takingstock of their health problems. At suchtimes, they are unlikely to be affected bymethamphetamines, which generally haveshort half-lives. At these times, non-steroidal anti-inflammatory drugs, nitrousoxides, narcotics (including codeine) orincreases in methadone dose may be neededto manage pain. Analgesic depressants arenot contraindicated unless other illicit orlicit depressants are being used concur-rently, as depressants work on differentreceptors and areas of the brain thanamphetamine-type stimulants. Careful dis-cussion with the patient and the patient’s

general practitioner or alcohol and drugspecialist is critical in balancing the need forpain relief with the potential for drug inter-actions and even overdose, if the patient istaking other depressants (legal or other-wise).

Practitioners can contact a 24-hour druginformation line for health professionals forinformation of this kind in most Australianstates and territories (Box).

Anne-Marie L Laslett, Research Fellow, Epidemiology and Research DepartmentJohn N Crofts, DirectorTurning Point Alcohol and Drug Centre, Melbourne, VIC.annel@turningpoint.org.au

1 Shetty K. “Meth mouth”. Med J Aust 2006; 185: 292. 2 McGrath C, Chan B. Oral health sensations associ-

ated with illicit drug abuse. Br Dent J 2005; 198:159-162.

3 Saini T, Edwards PC, Kimmes NS, et al. Etiology ofxerostomia and dental caries among methamphet-amine abusers. Oral Health Prev Dent 2005; 3: 189-195.

4 Robinson PG, Acquah S, Gibson B. Drug users: oralhealth-related attitudes and behaviours. Br Dent J2005; 198: 219-224. ❏

Men’s healthKenneth W Sleeman

TO THE EDITOR: Perusing your long-needed issue on men’s health,1 I was struckby the absence of any mention of obstructivesleep apnoea.

As an anaesthetist in private practice, I seethree or four middle-aged men with previ-ously undiagnosed obstructive sleep apnoeaeach week. Usually, I also see at least oneman who has had the diagnosis confirmed,

Drug information contact numbers

Service Contact number

DACAS (VIC) 1800 812 804

DACAS (TAS) 1800 630 093

DACAS (NT) 1800 111 092

DASAS (NSW) 1800 023 687 or(02) 9361 8006

ADIS (SA) 1300 131 340*

CAS (WA) 1800 688 847 or(08) 9442 5042

ADIS = Alcohol and Drug Information Service. CAS = Clinical Advisory Service. DACAS = Drug and Alcohol Clinical Advisory Service. DASAS = Drug and Alcohol Specialist Advisory Service. * Clinicians should ask to be put through to the duty doctor service. ◆

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but has not persisted with treatment becausehis wife has become used to his snoring orhas moved to another bedroom.

Advising the undiagnosed men of theimportance of a sleep test, I refer them backto their general practitioner for follow-up,and suggest a couple of respiratory physi-cians who could perform the test. On asomewhat random follow-up, I have beendisappointed with the results, as the follow-ing comments were reported back aftermen’s GP consultations:• “Most blokes over 50 snore”;• “Your wife will get used to it”; and• “Surgery doesn’t work”.

Men who have been diagnosed buthaven’t persisted with treatment (togetherwith their wives) are often totally unaware ofthe health risks; they believe that they areonly managing the unacceptable noise oftheir snore!

I would have thought that some of thearticles in the issue would have mentionedthe contribution of obstructive sleep apnoeato hypertension, atrial fibrillation, erectiledysfunction and sleep disturbances, withresulting poor performance during the day,particularly in the workplace.

This is an extremely important healthissue (and not only in men) that appears tobe sadly neglected, still.

Kenneth W Sleeman, AnaesthetistVictorian Anaesthetic Group, Melbourne, VIC.kenslee@bigpond.net.au

1 Men’s health issue. Med J Aust 2006; 185: 409-472.❏

Ann T Gregory

IN REPLY: We thank Sleeman for his astutecomment. In the men’s health issue,1 ourintention was to highlight several majorareas relevant to men’s health rather thanattempt comprehensive coverage of thefield. Sleep apnoea was indeed one of thepotential topics we identified when weplanned the issue. We anticipated that sleepapnoea would be discussed within some ofthe key contributions to the issue. Althoughthis did not eventuate, we acknowledge theimportance of sleep apnoea in general medi-cal practice, and plan to revisit the topic infuture issues of the Journal.

Ann T Gregory, Deputy Editor, and Editor of MJA Men’s Health IssueThe Medical Journal of Australia, Sydney, NSW.medjaust@ampco.com.au

1 Men’s health issue. Med J Aust 2006; 185: 409-472. ❏

Evaluating medicines: let’s use all the evidenceMira L Harrison-Woolrych

TO THE EDITOR: With the proposed for-mation of the Australia New Zealand Thera-peutic Products Authority (ANZTPA), therecent viewpoint article1 and accompanyingeditorial2 on systems of evaluating medi-cines were timely. Both reports providedinteresting comments on existing systemsand proposals for improving these in thefuture. However, I would like to commenton some omissions and errors in thesearticles.

In their viewpoint article, Kelman et alstated that “there are as yet no overseasexamples of ‘routine’ medicines monitor-ing”.1 This is not correct. The New ZealandIntensive Medicines Monitoring Programme(IMMP) has been undertaking routine mon-itoring of selected medicines since 1977.The IMMP collects nationwide prescriptiondata to form cohorts of patients who aresubsequently monitored for adverse events.3

These patient cohorts provide accuratedenominator populations, which, as notedby Kelman et al,1 is important for riskquantification by measurement of incidence.

The IMMP uses prescription-event moni-toring (PEM) methods to perform activepostmarketing surveillance of new medi-cines in New Zealand, and has been success-ful in identifying numerous new signals ofadverse drug reactions and in quantifyingrisk.4 The IMMP has developed ways ofenhancing PEM methodology by linkingrecords with national morbidity and mortal-ity databases.3 This methodology wasrecently successfully applied in a study ofthe safety and usage of atypical antipsy-chotic medicines in a nationwide paediatricpopulation.5

In their editorial, Stanley and Meslin com-mented that none of the health care datalinkage systems in England, Scotland, theUnited States or Canada “are nationwide orhave the routine ability to link health carerecords with drug prescription data”.2 Asdescribed above, the IMMP has both theseabilities. It was somewhat surprising that,although discussions regarding pharma-covigilance in the ANZTPA are now wellunderway, current systems in New Zealandwere not mentioned in either of these Jour-nal articles.

I would encourage Australia to developpharmacovigilance systems similar to thoseestablished in New Zealand. Of course,these will need to be adequately funded to

achieve the expected outcomes. The forma-tion of the ANZTPA is a great opportunity toimprove pharmacovigilance in both coun-tries.Competing interests: The IMMP is partly fundedby Medsafe, the regulatory body of the NZ Ministryof Health, and partly by unconditional donationsfrom various sources, including some pharmaceuti-cal companies. Funding providers do not have anyrole in the design, analysis or interpretation of anyof the studies performed by the IMMP.

Mira L Harrison-Woolrych, DirectorDepartment of Preventive and Social Medicine, Intensive Medicines Monitoring Programme, University of Otago, Dunedin, New Zealand.Mira.harrison-woolrych@otago.ac.nz

1 Kelman CW, Pearson SA, Day RO, et al. Evaluatingmedicines: let’s use all the evidence. Med J Aust2007; 186: 249-252.

2 Stanley FJ, Meslin EM. Australia needs a bettersystem for health care evaluation [editorial]. Med JAust 2007; 186: 220-221.

3 Harrison-Woolrych ML, Coulter DM. PEM in NewZealand. In: Mann RD, Andrews EB, editors. Phar-macovigilance. 2nd ed. Chichester, UK: John Wiley& Sons, 2007: 317-332.

4 Clark DWJ, Harrison-Woolrych ML. The role of theNew Zealand Intensive Medicines Monitoring Pro-gramme in identification of previously unrecog-nised signals of adverse drug reactions. CurrentDrug Safety 2006; 1: 169-178.

5 Harrison-Woolrych ML, Garcia-Quiroga J, Ashton J,Herbison P. Safety and usage of atypical antipsy-chotic medicines in children: a post-marketing pro-spective cohort study in New Zealand. Drug Safety2006; 29: 986. ❏

Research misconduct: can Australia learn from the UK’s stuttering system?Peter T Wilmshurst

TO THE EDITOR: In his article on researchmisconduct,1 Marcovitch cited my article oninstitutional corruption in medicine, whichwas published in the BMJ in 2002.2 Hestates:

Readers of the MJA will have to find thepaper version in their libraries, as theelectronic version has been replaced onthe BMJ’s website . . . with the baldstatement that it has been removed forlegal reasons.

In case any of your readers are concernedthat the article has been retracted, I wouldlike to point out that the article wasremoved from the website on 10 June 2004,when Dr Richard Smith was editor of theBMJ. Dr Smith cited my article in his ownarticle on research misconduct in 2006.3 Hewould not have done so if the article hadbeen retracted. Neither would Marcovitch.1

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My article described how some seniorindividuals in British academic medicinehad concealed misconduct for a decade. Thearticle had an editorial footnote stating:“Documentary evidence corroborating thisarticle was made available by Dr Wilmshurstto the BMJ.” It was cleared for publication bythe BMJ’s lawyers. An “Editor’s Choice” col-umn entitled Corruption in medicine accom-panied my article online.4 That column hasalso been removed from the website. Itstated: “The article by Wilmshurst has itsorigins in a seminar he gave to the BMJ in1996. For years he had been informing us ofmisdemeanours. Fear of libel stopped usfrom publishing.”4

Ironically, it was fear of libel actions thatcaused the BMJ to remove the article fromthe website. Soon after publication, the BMJreceived threats of libel actions from aca-demics and their institutions. Dr Smith andI spent considerable time working with law-yers to counter these challenges. None cameto court, but the legal costs for the BMJ’sinsurers mounted. It was pointed out that alibel action must be started within 1 year ofpublication. Because the article was on thewebsite it was constantly being republished.If it was removed from the website therecould be no more threats of litigation after 1year. Therefore, the insurance company thatcovers the BMJ against libel insisted that thearticle be removed from the website.

If readers are unable to get a copy, theycan email me and I will send a PDF version.

Peter T Wilmshurst, CardiologistRoyal Shrewsbury Hospital, Shrewsbury, UK.peter.wilmshurst@rsh.nhs.uk

1 Marcovitch H. Research misconduct: can Australialearn from the UK’s stuttering system? Med J Aust2006; 185: 616-618.

2 Wilmshurst P. Institutional corruption in medicine.BMJ 2002; 325: 1232-1235.

3 Smith R. Research misconduct: the poisoning of thewell. J R Soc Med 2006; 99: 232-237.

4 Smith R. Corruption in medicine [Editor’s choice].BMJ Online 2002; 325 (23 Nov). ❏

Antenatal care implications of population-based trends in Down syndrome birth ratesCaroline M De Costa and Cait Calcutt

TO THE EDITOR: A further reason for thedifferences in antenatal Down syndromescreening rates between urban and ruralwomen, reported by Coory and colleagues,1

is likely to be the relative difficulties many

Queensland women face in accessing abor-tion services. We are aware of severalQueensland public hospitals that provideexcellent antenatal screening services —testing for chromosomal abnormalities aswell as providing the 18–20-week ultra-sound scan for structural abnormalities.However, these hospitals do not offer subse-quent counselling or abortion for womenwho make the difficult decision to terminatea pregnancy at this gestation, instead direct-ing them to the private system. Some ofthese women are undoubtedly among themany Queensland women who travel inter-state for abortions each year.2-5

First-trimester abortion is difficult toaccess for women in rural areas throughoutQueensland. This is probably an importantfactor in women making the decision not tohave early screening and/or chorionic villusbiopsy, and possibly also a factor in doctorsnot offering it. Having to travel several hun-dred kilometres for the test, with the possi-bility of a further journey for an abortion, isbeyond the resources of many rural women.

We are in agreement with Coory et al thata majority of the population would supportequity of access to services and equalchoices for all women in the matter ofantenatal screening for fetal abnormality. Infact, amniocentesis for chromosomal abnor-malities has been available, with little con-troversy, for more than 30 years. If earlyantenatal screening is made available to allwomen, then it is reasonable to expect thatappropriate counselling and access to safe,affordable abortion is also provided.

Caroline M De Costa, Professor of Obstetrics and Gynaecology1

Cait Calcutt, Coordinator2

1 James Cook University, Cairns, QLD.2 Children by Choice, Brisbane, QLD.caroline.decosta@jcu.edu.au

1 Coory M, Roselli T, Carroll H. Antenatal care impli-cations of population-based trends in Down syn-drome birth rates by rurality and antenatal careprovider, Queensland, 1990–2004. Med J Aust 2007;186: 230-234.

2 Nickson C, Smith AM, Shelley JM. Travel under-taken by women accessing private Victorian preg-nancy termination services. Aust N Z J Public Health2006; 30: 329-333.

3 Chan A, Sage LC. Estimating Australia’s abortionrates 1985–2003. Med J Aust 2005; 182: 447-452.

4 Nickson C, Smith AM, Shelley JM. Intention to claima Medicare rebate among women receiving privateVictorian pregnancy termination services. Aust N ZJ Public Health 2004; 28: 120-123.

5 Adelson PL, Frommer MS, Weisberg E. A survey ofwomen seeking termination of pregnancy in NewSouth Wales. Med J Aust 1995; 163: 419-422. ❏

The difficulty with data: greater accuracy required for policy makingSusan Downes and Sally M Roach

TO THE EDITOR: Women of the remoteIndian Ocean Territories (Christmas Islandand the Cocos Islands [see map]) regularlyquestion why their comprehensive obstetricservice, allowing deliveries on the Islands,ceased in 1998. A study in 20051 aimed toprovide answers for these women.

There is one general practitioner on theCocos Islands and two on Christmas Island.Previously, procedural GPs attended to mostdeliveries. Now, pregnant women mustleave the Islands 4 weeks before theirexpected delivery. The financial, physical,emotional, and cultural costs of this aresubstantial.

Reports published in 20022 and 20043

identified community concerns, but resistedrecommendations to resume on-Islandbirthing, because of perceived low birthnumbers and difficulty sustaining the skillsof clinicians. Both studies relied on externalbirthing data, as the Indian Ocean Terri-tories Health Service (IOTHS; administeredby the Department of Transport andRegional Services) had not documentednumbers of deliveries.

The Alberton Report,3 extrapolating fromAustralian Bureau of Statistics (ABS) data,assumed that the population of childrenaged less than 1 year in a census yearequalled the number of deliveries the yearbefore. The ABS has a system to protect theconfidentiality of small isolated popula-tions and purposely does not report thesenumbers.

The Bath Report2 relied on data from theWestern Australian Midwife NotificationSystem (MNS). The MNS reported 136births to Island women from 1995 to 2004,while our study (Western Australian Centrefor Remote and Rural Medicine)1 recorded326 births. Thus, the MNS attributed only

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41% of known births to Island womenduring 1995–2004, and only 23% duringthe period considered by the Bath Report.

We believe that the MNS data shortfalloccurred for two reasons. Firstly, womenfrequently provide their temporary main-land address on the MNS form for practicalreasons. Secondly, one in seven women leav-ing the Islands to deliver their babies chooseto give birth in a state other than WesternAustralia to be closer to family, and thesebirths are not attributed to women from theIslands.

The methods used by the AlbertonReport, the MNS and the Bath Report resultin underestimations of the number of con-finements for Island women by up to 77%.

It is regrettable that this situation has notbeen previously recognised or acknowledged,and that recommendations for the resump-tion of obstetric services by the IOTHS haverepeatedly been based on incomplete data. Ifrecords of the numbers of births for Islandwomen had been collected and considered bythe IOTHS, Island families might again enjoya comprehensive on-Island delivery servicefor low-risk pregnancies.

Competing interests: Susan Downes was paid amodest honorarium by the Department of Trans-port and Regional Services to assist her in under-taking a research study, of which this was oneaspect.

Susan Downes, General Practitioner1

Sally M Roach, Associate Director of Research2

1 Royal Flying Doctor Service of Australia, Fremantle, WA.

2 Western Australian Centre for Remote and Rural Medicine, University of Western Australia, Perth, WA.

semarabali@hotmail.com

1 Downes S, Roach S. Obstetric services in the IndianOcean Territories. Perth: Western Australian Centrefor Remote and Rural Medicine, 2006.

2 Bath R. Indian Ocean Territories Health ServicesDevelopment Project — report to the Common-wealth Department of Transport and Regional Serv-ices. Perth: Department of Health WesternAustralia, 2002.

3 Indian Ocean Territories Health and CommunityServices needs assessment — a combined consult-ative and evidence based approach. Perth: Alber-ton Consulting, 2004. ❏

ISSN 0025-729X

EditorMartin Van Der Weyden, MD, FRACP, FRCPADeputy EditorsBronwyn Gaut, MBBS, DCH, DARuth Armstrong, BMedAnn Gregory, MBBS, GradCertPopHealthTanya Grassi, MBBS(Hons), BSc(Vet)(Hons)Senior Assistant EditorHelen Randall, BSc, DipOTAssistant EditorsElsina Meyer, BScKerrie Lawson, BSc(Hons), PhD, MASMTim Badgery-Parker, BSc(Hons), ELSJosephine Wall, BA, BAppSci, GradDipLibKatherine McLeod, BSc(Hons)Scientific Proof ReadersChristine Binskin, BScSara Thomas, BScRivqa Berger, BSc(Hons)Editorial AdministratorKerrie HardingEditorial AssistantVictoria Reed, PhDProduction ManagerGlenn CarterProduction CoordinatorPeter HumphriesWeb ManagerPeter Hollo, BSc(Hons), BA, LMusAWeb CoordinatorRobert ParisLibrarianJackie Treadaway, BAComm(Info)Consultant BiostatisticianVal Gebski, BA, MStatContent Review CommitteeCraig S Anderson, PhD, FRACPLeon A Bach, PhD, FRACPFlavia M Cicuttini, PhD, FRACPJennifer J Conn, FRACP, MClinEdMarie-Louise B Dick, MPH, FRACGPMark F Harris, MD, FRACGPPaul D R Johnson, PhD, FRACPTom Kotsimbos, MD, FRACPCampbell Thompson, MD, FRACPTim P Usherwood, MD, FRCGPE Haydn Walters, DM, FRACPOwen D Williamson, FRACS, GradDipClinEpiJane Young, PhD, FAFPHMJeffrey D Zajac, PhD, FRACP Australasian Medical Publishing Co Pty LtdAdvertising Manager: Peter ButterfieldMedia Coordinators: Kendall Byron; Julie Chappell

The Medical Journal of Australia (MJA) is published on the 1st and 3rd Monday of each month by the Australasian Medical Publishing Company Proprietary Limited, Level 2, 26-32 Pyrmont Bridge Rd, Pyrmont, NSW 2009. ABN 20 000 005 854. Telephone: (02) 9562 6666. Fax: (02) 9562 6699. E-mail: medjaust@ampco.com.au. The Journal is printed by Webstar Australia, 83 Derby Street, Silverwater, NSW 2128.MJA on the Internet: http://www.mja.com.au/None of the Australasian Medical Publishing Company Proprietary Limited, ABN 20 000 005 854, the Australian Medical Association Limited, or any of its servants and agents will have any liability in any way arising from information or advice that is contained in The Medical Journal of Australia (MJA). The statements or opinions that are expressed in the Journal reflect the views of the authors and do not represent the official policy of the Australian Medical Association unless this is so stated. Although all accepted advertising material is expected to conform to ethical and legal standards, such acceptance does not imply endorsement by the Journal.All literary matter in the Journal is covered by copyright, and must not be reproduced, stored in a retrieval system, or transmitted in any form by electronic or mechanical means, photocopying, or recording, without written permission.

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Hospital separations for cannabis- and methamphetamine-related psychotic episodes in Australiahttp://www.mja.com.au/public/issues/186_07_020407/

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664 MJA • Volume 186 Number 12 • 18 June 2007