Forget Sake, let the Koshu pour

Most people, if asked to name a Japanese alcohol, would reply ‘sake’, or perhaps Suntory whiskey or Asahi beer. It comes as a surprise to many to find that Japan is an emerging wine producer.

I have just returned from a conference in Japan, and while there I had the opportunity to sample local, fully domesticated, Japanese wine.

Wine can be labelled Japanese if bottled there. This allows for imported grape juice or must, or even bulk wine, to be called Japanese. One has to look for the fully domesticated label for the true home grown product.

The main regions include Yamanishi, near Mt Fuji, where there are more than 130 genuine wine producers; Nagano/Niigita; and Hokkaido in the north. Hokkaido is the biggest wine producer. Wine production in Hyogo in the Kobe region and Yamagata is a smaller affair, with areas of less than 200 hectares, but the product is superior.

The climate in Japan is extreme. Hot summers with battering typhoons rapidly turn to cold snowy winters courtesy of Mongolia’s frozen steppe. Awesome for skiing, though.

The soil is often acidic and land is scarce. Japan is incredibly mountainous, (another feature that makes it great for skiing) but, combined with the pressure of habitation and competition from other forms of agriculture use, it means Japan is tough going for a vintner.

Persistent wet and cloudy conditions are conducive to the development of mould, and hamper the ripening process.

Interestingly, Japanese authorities allow for sugar to be added during the fermentation process, similar to France’s Chapatal laws. Up to 260 grams per litre can be added. This makes sense when on the Baume scale, which equates sugar levels to expected alcohol when the wine is fully fermented, only reaches to between nine and 11 Baume. By comparison, a serious Barossa Shiraz can be 14 or 15 Baume. Incidentally, the addition of sugar is illegal in Australia.

A high trellised system enables good air flow and some horizontal trellising helps resist typhoon winds.

Japanese vintners sounds like they share some of the maladies and challenges those in the Hunter Valley have to overcome.

Cabernet Sauvignon, Pinot Noir and Merlot dominate the European red varieties, and Chardonnay and Riesling are the mainstays of the whites.

The overwhelming conclusion is that the wines have varietal characteristics.

The Koshu variety, found in 1186 growing in the wild in the middle of Honshu and considered to be Japan’s only true native variety, is the most common used for table wine. The grape is pink in colour, with a thick skin that aids in mould and botrytis resistance. The wine is a pale light yellow colour.

I found delicate white peach and floral notes in some, while in others there were additional grassy aromas. The palate is forward and light, with little acidity.

The four or five I tasted were consistent in this light style, and all were devoid of flaws. Some wine makers are experimenting with barrel fermentation and lees contact for complexity. I thought it was an outstanding match for sashimi of any kind.

Merlot seems to be the most consistent red varietal. A Merlot by Domaine Echigo, from the Niigita region, was outstanding. For $A35, it would match most $A50 Merlot-driven Bordeaux wines. Nice red to purple colour. Restrained red current and spice bouquet, with enough fruit, acid and structure to match lightly seared wagyu.

I had a little wine separation anxiety while in Japan. Certainly, one can pay over the odds in a big hotel for what we consider BBQ wine.

But the bottom line is, “when in Rome…” So, don’t be afraid to try the Japanese wines, but have an open mind, considering it is a fledgling industry.

[Perspectives] Address Malata: advancing nursing and midwifery in Malawi

As a former nurse and midwife, and currently Principal of Kamuzu College of Nursing (KCN), part of the University of Malawi, Address Malata knows the health-care landscape well in her home country. Some half a century after independence from the UK, Malawi is struggling to cope with high maternal and infant mortality, 10% adult population HIV prevalence, and a median life expectancy of under 60 years. “Malawi is a beautiful country, with its stunning lake, peaceful population, with everyone smiling, even when it’s raining”, she says.

Safe and legal medicinal pot just a vote away

Medicinal cannabis should become much more readily available under Federal Government plans to establish a single, national licensing scheme for the production and supply of the drug.

In an initiative cautiously welcomed by medical groups, Health Minister Sussan Ley has introduced legislation amending existing narcotics laws to allow for controlled cultivation of cannabis for medicinal and scientific purposes.

“For Australia, this is the missing piece in a patient’s journey,” Ms Ley said. “Importantly, having a safe, legal and reliable source of products will ensure medical practitioners are now at the centre of the decision-making process on whether medicinal cannabis may be beneficial for their patient”.

There are already provisions in place to allow for the legal production and distribution of medicinal cannabis, which can be prescribed by authorised specialists.

But demand significantly outstrips supply, making it difficult and expensive for patients to obtain.

Ms Ley said the legislation would provide “the missing piece in the puzzle” by improving the availability of the drug.

“I am confident [that] creating one single, nationally-consistent cultivation scheme…will not only help speed up the legislative and regulatory process but, ultimately, access to medicinal cannabis products as well,” the Minister said.

The AMA said its supports a nationally-consistent and evidence-based approach to the regulation, supply and use of medicinal cannabis.

In its submission to a Senate committee inquiry on the issue last year, the peak medical group said medicinal cannabis should be regulated in the same way as other therapeutic narcotic products, “in order to ensure it can be standardised and regulated in its pharmaceutical preparations and administration”, reducing potential harm to users.

Medicinal cannabis has been used to reduce the incidence of nausea and vomiting in chemotherapy patients, as an appetite stimulant, and as a treatment for chronic pain.

But AMA President Professor Brian Owler said last year that there needed to be a considered and evidence-based approach to its use.

“There are some conditions where it clearly may be beneficial, and perhaps we don’t need to have an in-depth trial on those sorts of indications. But there are clearly others where the evidence is actually not there,” Professor Owler said. “We need to have proper trials and regulate it as a medication just like any other medication.”

The Royal Australian College of Physicians said that although the move to establish a safe, legal and reliable national supply of the drug was welcome, significant details regarding who would be authorised to prescribe medicinal cannabis, and what appropriate dosages might be, were yet to be resolved.

“It still needs to be determined which type of medical specialist will be authorised to prescribe the drug,” College President Professor Nicholas Talley said. “And we also have reservations that there is still no standard dose of cannabis, and that dosage can vary according to condition.”

Ms Ley expects the legislation to have bipartisan support and to be passed in this session of Parliament.

Adrian Rollins

[Comment] Stillbirths in sub-Saharan Africa: unspoken grief

As Joy Lawn and colleagues’ paper1 in the Lancet Ending preventable stillbirths Series shows, Africa faces the highest burden of stillbirths. The high rates of stillbirth result from poor maternal health and inadequate antenatal and post-partum care.2 Thus stillbirth is a public health as well as a development problem on the continent, as in other low-income regions. Yet the grief endured by parents who have had a stillbirth in these settings remains untold. Stillbirth in low-income countries leaves the mother with many challenges, such as ill health, grief, sadness, and coping with community perceptions.

[Comment] Stillbirths: ending an epidemic of grief

Not all global health issues are truly global, but the neglected epidemic of stillbirths is one such urgent concern. The Lancet’s first Series on stillbirths was published in 2011.1 Thanks to tenacious efforts by the authors of that Series, led by Joy Lawn, together with the impetus of a wider maternal and child health community, stillbirths have been recognised as an essential part of the post-2015 sustainable development agenda, expressed through a new Global Strategy for Women’s, Children’s and Adolescents’ Health which was launched at the UN General Assembly in 2015.

[Correspondence] Faith-based health care

The Lancet should be commended for the recent Series on faith-based health care, which is timely and welcomed. The authors offer a balanced viewpoint, neither missionary nor reactionary secularist. However, it is important to understand that faith can be an important determinant of health and affects culture, law, and health policy. The authors are quite right in highlighting that there is a dearth of research on the topic, with more known about involvement by Christians than by other religions, such as Islam.

AMA in the News – 2 February 2016

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Timing of Medicare cuts announcement criticised, The Age, 29 December 2015
Doctors have criticised the Turnbull government for using the Christmas-New Year holiday period to reveal the first tranche of items to be dropped from the government-subsidised Medicare Benefits Schedule. AMA President Professor Brian Owler said the proposed cuts would make the common tonsillectomy procedure marginally more expensive due to fewer individual parts of the operation being funded by Medicare.

Take care morning after the big night, Adelaide Advertiser, 1 January 2016
Health and safety experts are urging people to be careful embracing life the morning after a big night. AMA President Professor Brian Owler urged people to take it easy with water sports and even sunbaking over summer if they have consumed alcohol.

Anti-vax nuts try to cheat jab laws, The Sunday Telegraph, 3 January 2016
Anti-vaxers are trying to manipulate the new “no jab no pay” laws in a bid to gain taxpayer-funded rebates available only to those who vaccinate their children. AMA President Professor Brian Owler said the attempt is hurting only the child involved.

Threats to handouts prompts jab boosts, The Sunday Telegraph, 17 January 2016
Doctors have noticed a significant boost in the number of parents bringing their children in for vaccinations as the new “No Jab, No Play” laws start to bite. AMA President Professor Brian Owler said the laws were already having a beneficial effect on immunisation numbers.

Warning over autism doctor shopping, The Australian, 19 January 2016
GPs should be given stronger guidance about how to diagnose autism. AMA President Brian Owler said that having consistent guidelines would make things easier for doctors during diagnosis, but added that the emphasis should remain on assessing children early.

Doctors warn of busy emergency facilities, Australian Financial Review, 28 January 2016
The AMA Public Hospital Report Card found the performance of the public hospital system has stagnated, and even declined in some areas. AMA President Professor Brian Owler placed the blame for the declining public hospital performance firmly on the Federal Government’s reduced rate of health funding which would lead to a funding “black hole” in 2017.

Hospitals faced with funding ‘black hole’, Sydney Morning Herald, 28 January 2016
The Federal Government is under pressure to reform taxes following a report card on public hospitals that shows the most urgent patients are waiting longer at emergency departments. AMA President Professor Brian Owler said hospitals would be insufficiently funded to meet the rising demands from 2017, when the states and territories were facing a “black hole”.

State looks sick, Herald Sun, 29 January 2016
Victorian emergency patients are paying the price for a “funding crisis” in the nation’s public hospitals, and doctors warn the worst is yet to come. The AMA warned that a further $57 billion of Commonwealth funding was expected to be lost from hospital coffers over seven years starting next year, by indexing funding growth to CPI and population expansion.

Radio

Professor Brian Owler, 774 ABC Melbourne, 29 December 2015
AMA President Professor Brian Owler discussed recent cuts to the Medicare Benefits Scheme. Professor Owler said it was clearly a cost saving exercise by the Federal Government.

Professor Brian Owler, Radio National, 29 December 2015
AMA President Professor Brian Owler talked about new cuts to the MBS. Professor Owler said the AMA has supported the Medicare Benefits Schedule review from the outset, on the basis there were no cuts to access to patient services.

Dr Stephen Parnis, 4BC Brisbane, 7 January 2016
AMA Vice President Dr Stephen Parnis dismissed claims that pap smears would cost women $30. Dr Parnis said cuts to Medicare have resulted in reports of overpriced pap smears.

Dr Stephen Parnis, Tipple J Sydney, 25 January 2016
AMA Vice President Dr Stephen Parnis discussed the use of so-called “hangover clinics”. Dr Parnis said the treatments they offered were a placebo, and he questioned whether their operations were ethical.

Professor Brian Owler, Radio National, 28 January 2016
AMA President Professor Brian Owler discussed the latest AMA Public Hospital Report Card which revealed a public hospital funding ‘black hole’ as Commonwealth funding cuts hit the States and Territories.

Professor Brian Owler, 2GB Sydney, 28 January 2016
AMA President Professor Brian Owler talked about a report from the AMA showing emergency department waiting times has worsened for the first time in seven years.

Professor Brian Owler, 774 ABC Melbourne, 28 January 2016
AMA President Professor Brian Owler talked about the AMA Public Hospital Report Card and said longer waits for elective surgery and emergency rooms often resulted in more health problems.

Television

Professor Brian Owler, ABC News 24, 28 December 2015
AMA President Professor Brian Owler talked about Health Minister Sussan Ley’s proposed removal of 23 items from the Medicare Benefits Schedule.

Dr Stephen Parnis, ABC News 24, 1 January 2016
AMA Vice President Dr Stephen Parnis talked about how parents who refused to vaccinate their children would be stripped of childcare benefits by the Federal Government under new laws. Dr Parnis said public health was a major government responsibility, and vaccination rates were not as high as health experts would like them to be.

Professor Brian Owler, The Today Show, 14 January 2016
AMA President Professor Brian Owler discussed the importance of safe work environments for emergency workers after a police officer was allegedly shot by a patient with a history of ice addiction at a Sydney hospital.

Professor Brian Owler, Channel 7 Melbourne, 26 January 2016
Medibank says it is passing savings onto its members, but there are concerns more affordable premiums might mean cuts in benefits. AMA President Professor Brian Owler said doctors did not want to see people taking out cheaper premiums and policies and then realising that their private health insurance was not worth it.

Professor Brian Owler, The Today Show, 28 January 2016
The AMA Public Hospital Report Card 2016 showed that, against key measures, the performance of public hospitals is virtually stagnant, and even declining in key areas. AMA President Brian Owler said unless the Government looked at the way it funded public hospitals, people were likely to wait longer in emergency departments and for elective surgery.

Professor Brian Owler and Dr Stephen Parnis, Channel 9, 28 January 2016
The AMA released its new Public Hospital Report Card and the figures revealed that scores of patients were not being treated within recommended times. Doctors fear the situation is only going to get worse.

Professor Brian Owler, ABC News 24, 28 January 2016
The AMA has warned that public hospitals are facing a funding crisis. AMA President Professor Brian Owler said hospitals faced a crisis due to the funding fight between Federal and State governments.

Anti-vax dodge dismissed by Commonwealth

The Federal Government has confirmed that a form being circulated by anti-vaccination campaigners attempting to circumvent new ‘No Jab, No Pay’ laws has no legal standing, backing AMA advice that doctors are under no obligation to sign it.

Social Services Minister Christian Porter has written to AMA President Brian Owler confirming that medical practitioners were under no obligation to sign the form, which asks doctors to acknowledge the ‘involuntary consent’ of a parent to the vaccination of their children, and which is deemed to be ineffective in any case.

“I am able to advise you that under the No Jab, No Pay Act, immunisation providers are not obligated to sign such declarations,” Mr Porter wrote. “This statutory declaration is not relevant evidence for the purposes of family assistance payments, [so that] even if such a form were signed by a doctor…it would not in any circumstances make the relevant parent eligible for payments that would otherwise be suspended.”

The form has been circulated by anti-vaccination campaigners following Federal Government welfare changes aimed at denying certain welfare payments to parents who refuse to vaccinate their child.

Under the No Jab, No Pay laws, from 1 January this year parents of children whose vaccination is not up-to-date are no longer eligible for the Family Tax Benefit Part A end-of-year supplement, or for Child Care Benefit and Child Care Rebate payments. The only exemption will be for children who cannot be vaccinated for medical reasons.

The new laws were introduced amid mounting concern that vaccination rates in some areas were slipping to dangerously low levels, increasing the risk of a sustained outbreak of potentially deadly diseases such as measles.

The Australian Childhood Immunisation Register shows there has been a sharp increase in the proportion of parents registering a conscientious objection to the vaccination of their child, from just 0.23 per cent in late 1999 to 1.77 per cent by the end of 2014.

In all, around a fifth of all young children who are not fully immunised are that way because of the conscientious objection of their parents.

The form being circulated by anti-vaccination groups, headed “Acknowledgement of involuntary consent to vaccination”, is intended to circumvent the No Jab, No Pay laws and allow conscientious objectors to receive Government benefits without allowing the vaccination of their children.

But Mr Porter said the aim of the new laws was to boost immunisation rates “by providing a level of encouragement and incentive for families to more thoroughly inform themselves about the importance of immunising their children”.

The Minster said the Government recognised the right of parents to decide not to vaccinate their children, but the new laws meant there would be consequences.

“An individual is not prohibited in any way from maintaining their vaccination objection; it is simply the case they will not receive some of their family assistance,” he said. “This is a relatively small financial cost, particularly when compared to the cost that the spread of crippling, debilitating and deadly diseases has on our health system and community.”

“It is the Government’s view that when an individual decides not to vaccinate their child, they are putting their child and the community at risk of infectious diseases.”

Last month, the AMA’s senior legal adviser John Alati advised that, where there was no medical reason for vaccination exemption, the doctor’s job was to outline the relevant facts about immunisation and to provide vaccination where consent was given. Where it was withheld, “the doctor should not perform the procedure as it might constitute trespass to the person”.

His advice was backed by Mr Porter, who said that “the appropriate path for a doctor or medical profession who may be requested to sign [the form being circulated by anti-vaccination campaigners] is simply to vaccinate where there is consent, and decline where consent is absent”.

Adrian Rollins

Conclaves and concurrent expert evidence: a positive development in Australian legal practice?

Many medical practitioners are called up to provide expert evidence in court. Some medical practitioners do so frequently, such as in personal injury litigation, including claims asserting medical negligence.

Traditional expert evidence sees testimony given sequentially by expert witnesses for one side and then the other, with the experts being examined and cross examined by the legal representatives for each side. The change to pre-hearing meetings of experts (conclaves) being convened to prepare joint reports to identify areas of agreement and disagreement, followed by concurrent expert evidence at trial, appears to have been driven by judicial preference, with the underlying rationale being the desirability of facilitating the “just, quick and cheap resolution of the real issues in proceedings”: s 56 of the Civil Procedure Act 2005 (NSW) and, for some matters, Supreme Court Practice Notes (SC CL 5 and SC CL 7).

Judicial comment on concurrent expert evidence seems almost universally favourable.1 For example, in Halverson v Dobler [2006] NSWSC 1307, a medical negligence case, after hearing concurrent evidence from medical experts including four cardiologists (one by satellite from the United States) and five general practitioners, the trial judge observed:

This process proved both highly productive and efficient and has been of great benefit to me in resolving this case. The discussion was sustained at a high level of objectivity by all participants, each of whom displayed a genuine endeavour to assist the court to resolve the problems. The fact that ultimately they disagreed on critical issues was not due to anything other than a genuine difference of opinion about the appropriate conclusion to be drawn from the known facts.

Concurrent expert evidence is currently most well developed in the civil disputes arena, where courts are required to determine private disputes, usually with financial outcomes. The State Coroner’s Court of New South Wales has accepted concurrent evidence for some time, and some examples have begun to appear in criminal trials. Concurrent evidence is being increasingly adopted in medical negligence trials.

Practical considerations

In preparation for the conclave, the parties are required to agree on matters such as which experts should attend, the questions to be answered, and the materials to be placed before the experts. While the conclave may be held with or without legal representatives, in practice it is rare for legal representatives to be present.

Perhaps predictably with a new process, especially one existing in the context of disputes that have resulted in litigation, disagreements have arisen regarding logistical matters and more substantive issues, such as which experts should meet and in what groupings. Although there may be delays and expense associated with resolving such disagreements in the early adoption phase, a body of case law is now developing which will guide parties into the future.

In most cases, the courts have expressed preference for the experts to decide between themselves matters which could be labelled procedural in nature, such as the format of the meetings and secretarial support. The courts have had somewhat more input in relation to which experts should be present and in what groupings — mostly on a pragmatic basis by reference to areas of comment,2 subject to suitable expertise.3 If lawyers cannot agree on the form of questions to be asked, the courts will also intervene.

Expert witness immunity and conclaves

Expert witnesses in Australia appear to remain immune from civil suit in respect of what is said or done in court, and in preparatory steps, as stated by the High Court in D’Orta Ekenaike v Victoria Legal Aid [2005] HCA 12. The application of the expert witness immunity rule to expert witnesses participating in conclaves of experts was affirmed by the NSW Court of Appeal in Young v Hones [2014] NSWCA 337.

There is perhaps some potential for expert witness immunity to be revisited in a matter presently before the High Court for hearing in 2016, Attwells v Jackson Lalic Lawyers Pty Limited. It was revisited in the United Kingdom in Jones v Kaney [2011] UKSC 13, where a majority of the Supreme Court held that a retained expert witness was not entitled to the benefit of immunity from actions brought by his or her own clients for professional negligence. However, even if the High Court does not modify the current immunity law, where an expert purports to give expert evidence beyond his or her area of competence, he or she may be vulnerable to disciplinary proceedings.4

Advantages and disadvantages

The use of conclaves and concurrent expert evidence has the potential to advance the objective of the just, quick and cheap resolution of the real issues in the proceedings before a court. Further, the efficient and effective management of expert evidence has an important role to play in enabling the parties to engage meaningfully in alternate dispute resolution as evidence emerges before a final hearing.

Despite these advantages, there has been anecdotal concern expressed that fairness and integrity in the trial process might be compromised by widespread adoption and implementation of the concurrent expert evidence process. For example, unless experts are required to give reasons for their conclusions, the interests of open and transparent justice may be compromised. Most commonly expressed concerns include fears that experts will simplify their analysis of complex evidence to enable lawyers and judges to understand it and to meet time constraints, and that dominant experts will overshadow others such that not all opinions will be fully heard and taken into account.5

However, it should be noted that conclaves lack transparency unless experts are required to give reasons for their conclusions.

The balance of opinions from judges, lawyers and expert witnesses favours conclaves and concurrent evidence as a positive development in Australian legal practice, at least for civil disputes. While only positives seem to flow from concurrent evidence at trial, it is arguably too soon to tell whether the relative lack of transparency at the conclave stage will give rise to difficulties in the coronial, disciplinary and criminal arenas.

[Correspondence] Policy misperceptions and support for gun control legislation

Firearms kill more than 30 000 Americans annually.1 Although federal law requires licensed gun dealers to undertake background checks on people who purchase guns, private sales at gun shows and online are exempt from these checks. Universal background checks for gun purchases could substantially reduce the number of gun-related deaths in the USA.2,3 Despite strong public support for universal background checks (92% of 1446 people polled in one survey),4 Congress has failed to act. Some researchers have argued that this disconnect between public opinion and legislation is attributable to a gap in engagement between supporters and opponents of stronger gun control.