Monstrous: Aussie experts on ‘edited’ bubs

A Chinese researcher has engaged in a monstrous game of Russian roulette if he really has made the world’s first genetically edited babies, Australian experts say.

A chorus of international condemnation has erupted after He Jiankui said he’d altered the DNA of twin girls, born earlier this month, to make them resistant to the virus that causes AIDS.

Australian geneticists and bioethicists are sceptical and say he has offered no proof that he permanently altered the twins’ genetic codes.

But if he is telling the truth, they say it’s a premature and dangerous leap with unknown consequences for future generations.

They accuse him of unethical conduct that flies in the face of a consensus ban on fiddling with the genes of embryos that will result in live births.

That ban exists because any changes that are made are passed on to future generations and not enough is known about the effects of that.

They also say the researcher from China’s Southern University of Science and Technology has shown complete disregard for the welfare of the babies at the heart of his experiment.

Limited use of genetic editing in adults – solely for the purposes of treating serious diseases – has shown that it can have unintended consequences.

Professor Julian Savulescu, a bioethicist with Victoria’s Murdoch Children’s Research Institute says that if He’s claims are proven, he’s engaged in “monstrous” conduct.

“These healthy babies are being used as genetic guinea pigs. This is genetic Russian roulette,” he says.

“Gene editing itself is experimental and is still associated with off-target mutations, capable of causing genetic problems early and later in life, including the development of cancer.”

Associate Professor Darren Saunders is a gene technology and cancer specialist in the School of Medical Sciences at the University of NSW.

He shares Prof Savulescu’s concerns and worries that He’s claims could set back the study of gene editing by decades.

“Most scientists think that the safety concerns around gene-editing in humans are still too big to outweigh any potential benefit,” he said.

But he said it was possible the world had just seen “a huge leap towards editing the human book of life”.

“Some might even suggest this is a step towards eugenics,” he said, referring to a movement that advocates improving the genetic composition of the human race.

He claims to have altered embryos for seven couples during fertility treatments, using CRISPR-Cas9 technology, allowing him to cut-and-paste DNA with the aim of specific outcomes, in this case HIV resistance.

He says one pregnancy has resulted so far, the two girls born earlier this month.

But the Chinese university where he worked until February says it didn’t know what He was doing, and has launched an investigation calling his work a “serious violation of academic ethics and standards”.

More: Q&A about gene-edited babies

2018 AMSA National Convention: Welcome to Perth-fect engagement

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

In early July this year, the Australian Medical Students’ Association held our 59th National Convention in Perth. As the world’s largest student-run conference, it hosted more than1000 medical student delegates from across Australia and New Zealand. It was a week of innovative academic and social programs, enhanced by intervarsity competitions, field trips, and workshops. A team of over 100 student volunteers from universities in Western Australia worked for two years to make this huge undertaking possible.

As always, the National Convention was an opportunity for students to showcase their talents, ranging from research with poster presentations and 3 Minute Thesis, Sports Day competitions, debating (won by Monash University), and the Emergency Medical Challenge (won by University of Western Australia).

The academic program was full of motivational Australian and international plenary speakers showcasing contemporary health issues.

The program opened with Burns Specialist, Prof Fiona Wood, speaking to students about harnessing the power of science and technology to strive towards excellence in health care. We were fortunate to be joined by former AMA Presidents, A/Prof Rosanna Capolingua, who spoke on navigating leadership in the medical community, and Dr Michael Gannon, who reflected on his experiences within both AMSA and the AMA, and the advocacy that both groups drive forward. Dr Nikki Stamp spoke on paying attention to detail while not becoming overwhelmed by the minutiae.

There was the opportunity to hear from doctors about working in every context imaginable, from Dr Jeff Ayton’s experiences in Antarctica, Dr Nick Coatsworth travelling from Congo to Darwin with Medecins Sans Frontieres, and A/Prof Gordon Cable’s work in aerospace medicine.

There was also an array of fantastic speakers bringing their expertise from outside the medical world. Steven Bradbury’s recollections of his remarkable Olympic victory included messages that are applicable to all of our daily lives; memory athlete, Daniel Kilov, shared the techniques that make his work possible; and social advocate, Yasmin Abdel-Magied, spoke on challenging stereotypes through personal interactions and navigating a hyper politicised world.

Students left with increased clinical understanding, having battled it out against the hosts of the ‘IM Reasoning’ podcast run by Dr Nic Szecket and Dr Art Nahill in an interactive case reasoning session; heard from Prof Nick Talley on negotiating OSCEs and clinical examination; and participated in workshops on everything from reading ECGs to performing rhomboid skin flaps.

From doctors’ mental health to social issues and innovative medical practice, students learnt about the prominent issues of today’s medical landscape, as well as seeing the endless pathways and opportunities medicine can lead to. Perth Convention 2018 aspired for delegates to discover parts of life and medicine they never knew about before, engage in important issues, meet incredible, like-minded people, and be inspired to leave a lasting positive impression on the field of medicine in Australia.

Indigenous health, an AMA priority

The Federal Government needs to broaden its thinking when it comes to addressing the healthcare needs of Aboriginal and Torres Strait Islanders, because the current situation is unacceptable, according to AMA President Dr Michael Gannon.

Addressing the Australian Indigenous Doctors’ Association (AIDA) conference in the Hunter Valley in September, Dr Gannon said Indigenous doctors were vital to the health of Indigenous Australians.

“The AMA has said time and again that it is simply unacceptable that Australia cannot manage the health care of the first peoples, who make up just three per cent of our population,” Dr Gannon said.

“When it comes to Indigenous health, the Federal Government needs to broaden its thinking.

“For too long now, people working in Indigenous health have called for action to address the social issues that affect the health of Aboriginal and Torres Strait Islander people.

“Education, housing, employment, sanitation, clean water, and transport – these all affect health too.

“This is clearly recognised in the Government’s own National Aboriginal and Torres Strait Health Plan 2013-2023, yet we continue to see insufficient action on addressing social determinants.

“One message is clear – the evidence of what needs to be done is with us. There is a huge volume of research, frameworks, strategies, action plans and the like sitting with governments – and yet we are not seeing these being properly resourced and funded. We do not need more paper documents. We need action.

“The AMA recognises that Indigenous doctors are critical to improving health outcomes for their Aboriginal and Torres Strait Islander patients.

“Aboriginal and Torres Strait Islander doctors have a unique ability to align their clinical and cultural expertise to improve access to services, and provide culturally appropriate care for Indigenous patients.

“But there are too few Aboriginal and Torres Strait Islander doctors and medical students in Australia.”

AIDA used its conference to celebrate the organisation’s 20^th anniversary and had a conference theme of Family – Unity – Success.

Dr Gannon congratulated AIDA on the anniversary, noting that it had “come a long way”.

He said Aboriginal and Torres Strait Islander people face adversity in many aspects of their lives.

“There is arguably no greater indicator of disadvantage than the appalling state of Indigenous health,” he said.

“Aboriginal and Torres Strait Islander people are needlessly sicker, and are dying much younger than their non-Indigenous peers.

“What is even more disturbing is that many of these health problems and deaths stem from preventable causes.

“The battle to gain meaningful and lasting improvements has been long and hard, and it continues.

“I am proud to be President of an organisation that has for decades highlighted the deficiencies in Indigenous health services and advocated for improvements.

“While there has been some success in reducing childhood mortality and smoking rates, the high levels of chronic disease among Indigenous people continue to be of considerable concern.

“For the AMA, Aboriginal and Torres Strait Islander health is a key priority. It is core business.

“It is a responsibility of the entire medical profession to ensure that Aboriginal and Torres Strait Islander people have the best possible health.

“It is the responsibility of doctors to ensure that patients – all patients – are able to live their lives to the fullest.”

This year, the AMA’s Report Card on Indigenous Health – to be released in November – will focus on ear health and hearing loss.

Aboriginal and Torres Strait Islander people in Australia suffer from some of the highest levels of ear disease in the world, and experience hearing problems at up to 10 times the rate of non-Indigenous people across nearly all age groups.

Hearing loss has health and social implications, particularly in relation to educational difficulties, low self-esteem, and contact with the criminal justice system.

The report card will be a catalyst for Government action to improve ear health among Aboriginal and Torres Strait Islander people.

Dr Gannon told the conference that at every opportunity, the AMA highlights the issues of housing, clean water, transport, food security, access to allied medical services, and other social determinants that contribute to chronic disease and act as barriers to treatment and prevention.

And he said the AMA will continue advocating for an increase in the number of Indigenous doctors in Australia.

“The AMA has been a persistent, sustained, and powerful voice on Indigenous health for decades,” he said.

CHRIS JOHNSON

PIC: Dr Jeff McMullen, Dr Michael Gannon, Charles Davison, and Karl Briscoe

President’s speech highlights AMA’s influential voice

BY AMA SECRETARY GENERAL ANNE TRIMMER

You might not have caught the speech given by the AMA President Dr Michael Gannon to the National Press Club in Canberra in August. It was a good speech, well-delivered, and touched on many of the major policy and advocacy debates currently being prosecuted by the AMA.

The President’s comments on the strength of the AMA brought to mind the frequently-stated truism that the AMA represents all doctors but that not all choose to pay the membership subscription. In his speech, Dr Gannon reflected on the AMA’s positioning on major community health and social issues.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

We are completely independent of governments.

We rely near totally on member subscription income to survive. I can promise you, as a Board member, it is often a concern.

But unlike many other lobby groups, inside and outside the health industry, this gives us a total legitimacy to speak honestly, robustly, and without fear or favour in line with our mission – to lead Australia’s doctors, to promote the health of all Australians.

We have strong public support and respect as the peak medical organisation.

The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

People want and expect us to have a view, an opinion. Sometimes a second opinion.

The media demand that we have an opinion. And not just on bread and butter health issues. But also on social issues that have an impact on health.

Our view is never knee-jerk.

We consult our members and the broader medical profession. Often we encourage feedback from other health professionals – the ones who provide quality health care with us in teams.

We attract public feedback whether we like it or not. I can promise you that social media has taken this to a whole new level.”

These reflections accurately represent the contribution of the AMA to public debate on health issues, and on broader social issues that impact on the health of the community. The AMA’s Constitution spells out that the role of the AMA is to represent the interests of its members, and also to promote the well-being of patients, taking an active part in the promotion of programs for the benefit of the community and to participate in the resolution of major social and community interests.

The AMA draws its legitimacy as a powerful voice in public debate through its representation of medical practitioners across the broad sweep of the profession from medical students to retired doctors, and across all specialties and places of work. The development of medico-political policy within the AMA is robust, through the specialist councils and committees of Federal Council and then to debate within Federal Council itself. The President and Vice President are the public faces of the AMA but behind them is a substantial process that ensures a representative voice for the medical profession.

Drink and drugs, a time bomb for baby boomers

In both the UK and Australia, risky drinking is declining, except among people aged 50 years and older, new research has found.

Researchers at Flinders University and South London and Maudsley NHS Foundation Trust in England, published their findings in the BMJ, inAugust this year.

The authors believe that Western countries are sitting on a time bomb of health and social issues arising from drug and alcohol overuse among baby boomers, including a worrying trend for episodic heavy drinking in this age group.

“Alcohol is the most common substance of misuse among baby boomers which presents the most concern because of the larger number of users and wide range of negative consequences,” said Professor Ann Roche, Director of the National Centre for Education and Training on Addiction at Flinders University.

The research also found that this generational trend is not restricted to alcohol.

“Some of the pharmaceutical drugs such as opioids also have severe consequences associated with their use,” Professor Roche said.

In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs.

However, people over 50 also have higher rates than younger age groups for both past year and lifetime illicit drug misuse (notably cannabis).

The authors are keen to highlight that this older age group’s alcohol and drug use presents specific issues that are not common in younger demographics.

“Ageing reduces the body’s capacity to metabolise, distribute and excrete alcohol and drugs, and older people are also more likely to have pre-existing physical or psychological conditions or take medicines that may negatively interact with alcohol and drugs,” Prof Roche said.

“There is also a reduction in lean body mass, resulting in higher alcohol-drug blood concentrations,” she said.

The authors of the research are calling for a coordinated international approach to manage this rapidly growing problem, including treatment programs adapted for older people with substance misuse rather than those aimed at all age groups.

“There remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment,” they state in the BMJ editorial.

Dr Rao and Professor Roche said the growing influence of baby boomer substance misuse will continue to present challenges for healthcare service delivery for older people.

The study also notes that it is an additional concern the increasing proportion of women drinking in later life, particularly those whose alcohol consumption is triggered by life events such as retirement, bereavement, a change in home situation, infrequent contact with family and friends, and social isolation.

The AMA questioned the priorities of the recently released National Drug Strategy 2017-2026, noting whilst alcohol in Australia is associated with 5,000 deaths and more than 150,000 hospitalisations each year, the Strategy puts it as a lower priority than ice.

AMA President Dr Michael Gannon said he believes support and treatment services are severely under-resourced, even though the costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

The broader community impacts of those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted, Dr Gannon said.

The AMA’s Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement can be read at position-statement/harmful-substance-use-dependence-and-behavioural-addiction-addiction-2017.

MEREDITH HORNE

What are we training medical students for?

When young people go to medical school they are called medical students. They know that they are to learn about medicine. Everything about medical school is about learning about medicine. In fact, every waking moment is about learning about medicine.

We learn about anatomy, physiology, statistics, how to read a research paper, how to do a research project, we learn about diseases, pathology, histology, how to examine patients. We learn the right questions to ask in the right way to get the information that is needed.

We endlessly learn about rare diseases, treatment protocols and how to do various procedures and operations. Our whole lives are consumed with medical information.

But is this all that there is to medical school?

Of what value is all the medical knowledge in the world if the person holding that knowledge is miserable and unwell themselves, struggling to work and struggling to cope with people?

Students graduate at the age of 24 (at least) after the most intensive periods of their lives where literally every moment is dedicated to learning as much information as possible.

It has even been said that medical school is a prolonged period of adolescence where life skills are not learned, but one simply has to learn what other people tell you.

There is no time to notice anything else about life. Finances, relationships, property, politics, community engagement……sleep….. everything comes a distant seventh to medical school and learning. Life itself is an afterthought, something that one attends to only if one has to.

Our medical students are not taught about how to conduct or engage themselves in an empowered way in day to day life. They are taught how to recall information, pattern recognise and survive ward rounds.

But how to be in all aspects of life determines how well we are in life, not how much we know about facts.

Our statistics tell us how unwell our medical students and doctors are.

Medical students and junior doctors are not taught how to take care of their own health and well-being, and in fact the very nature of the setup of medical training encourages and fosters them to ignore their own health and well-being.

Our high rates of mental ill health, suicide and physical ill health are a painful reflection of these low standards of self-care in medicine.

Medical students are not taught how to take care of finances.
They are not taught how to be empowered and to run a business.
They are not taught the basic skills of marketing and business administration that people in engineering or even beauty school are taught, even though finally after a prolonged period of education and working they will be working in businesses in the community.
They are not taught how to have relationships with people that are equal, loving and caring that go beyond the arrangement of role of doctor and patient.
They are not taught about the importance of caring for their physical bodies, and indeed much of medical culture in fact promotes the stressing of the human body and mind, asking it to go beyond its limits without care for how it needs to be literally cared for.
They are not taught how to take care of their mental health, with instead judgement and criticism, condemnation and the drive for unattainable perfection being the daily ingrained forms of communication in medicine, none of these building self-esteem or self-worth.

The health and well-being of us doctors is poor. We are not happy; over 50% of us are burnt out. Our suicide rates are at least 2 times higher than the general public, with some studies pointing to 5.7 times higher, and these are only the suicides that we know of. We have higher rates of anxiety and high psychological distress than the general public.

The pressures on us doctors are very real and put simply, in the health care profession we are barely surviving, and most certainly not thriving.

We know medical facts, but we do not know how to take care of ourselves and keep ourselves well in life.

Doctors are disempowered as people and do not consider themselves as human beings with equal human rights, and instead in the role of ‘doctor’ in training learn to simply accept and put up with the circumstances that they find themselves in.

They agree to working arrangements that would not be accepted anywhere else in the corporate world, with many of them seeing bullying as so normal that they don’t even realise that they are being bullied, or that they are engaging in bullying.

Working relationships in hospitals are toxic between doctors and between doctors and other health care professionals. And let’s not even begin with the relationships that doctors have with administration!! This is accepted as ‘normal’ and something to ‘survive’.

Toxic relationships build bad teams and are bad for our mental health and well-being. This has a knock on effect on patient care.

We know that there are multiple determinants of health and well-being. We need to address all of these in our lives to build health and well-being

How are we in relationships? Are we loving and caring?
How are we with food? Is it for indulgence and coping with life, or nourishing the body?
How do we take care of our bodies?
How are we with our finances?
How are we with taking care of ourselves, valuing and empowering ourselves?
How are we with sleep?
How are we with our self-talk, our emotional and mental health?
Do we know how to be who we truly are in all aspects of life? Or are we boxing ourselves in, acting in different ‘roles’ in different circumstances?

As health care professionals we need to be the ones to lead the way in the health and well-being stakes to inspire our patients.

Instead at present as a whole we are more anxious, stressed and suicidal than the general public. Something is wrong here.

There are many reasons that our doctors are not thriving.

Rather than focussing on developing doctors who are simply minimally ‘resilient’ to the current stresses and strains, I propose that as part of our care and responsibility for those we train, that we prepare people to be well in life as a whole, in both medical school and in doctor training in hospitals.

If we don’t prepare our students to be well, then we are leaving them vulnerable with an incomplete education in the world. And thus far the statistics are speaking for themselves.

We need to prepare our students to be well. And we need to design our systems to support our doctors to be healthy and well and not simply ask them to put up with systems the way that they are when they are not honouring of dignity, decency or respect of general human rights.

Care for people is the foundation of health care. To move forward as an institution that leads the way in health care we need to place care for all people firmly at the foundation of our training and our work ethos, beginning with our medical students.

As part of that care, it is important for us to design programs that not only teach students about the nitty-gritties of medical knowledge and information but arm them with the tools to thrive and to live well in all areas of life; how to take care of themselves, value themselves and empower themselves in all areas of life.

Our educational processes and health care systems themselves need to empower our doctors and our students.

Only then will we have a profession that is healthy, well and able to consistently care for others in all avenues of life.

Dr Maxine Szramka (pictured above) is a Sydney-based consultant rheumatologist. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

Political message in National Press Club speech

AMA President Dr Michael Gannon has called on all sides of politics to take some of the politicking out of health, for the good of the nation.

Addressing the National Press Club of Australia, Dr Gannon said some health issues needed bipartisan support and all politicians should acknowledge that.

“Some of the structural pillars of our health system – public hospitals, private health, the balance between the two systems, primary care, the need to invest in health prevention – Let’s make these bipartisan,” he said.

“Let’s take the point scoring out of them. Both sides should publicly commit to supporting and funding these foundations. The public – our patients – expect no less.”

During the nationally televised address, broadcast live as he delivered it on August 23, Dr Gannon warned political leaders that the next election was anyone’s to win and so they should pay close attention to health policy.

“Last year we had a very close election, and health policy was a major factor in the closeness of the result,” he said.

“The Coalition very nearly ended up in Opposition because of its poor health policies. Labor ran a very effective Mediscare campaign.

“As I have noted, the Government appears to have learnt its lesson on health, and is now more engaged and consultative – with the AMA and other health groups.

“The next election is due in two years. There could possibly be one earlier. A lot earlier.

“As we head to the next election, I ask that we try to take some of the ideology and hard-nosed politicking out of health.”

In a wide-ranging speech, the AMA President outlined the organisation’s priorities, while also explaining the ground it has covered in helping to deliver good outcomes for both patients and doctors.

The AMA’s priorities extend to Indigenous health, medical training and workforce, the Pharmaceutical Benefits Scheme, and the many public health issues facing the Australian community – most notably tobacco, immunisation, obesity, and alcohol abuse.

“I have called for the establishment of a no-fault compensation scheme for the very small number of individuals injured by vaccines,” Dr Gannon said.

“I have called on the other States and Territories to mirror the Western Australian law, which exempts treating doctors from mandatory reporting and stops them getting help.

“We also need to deal with ongoing problems in aged care, palliative care, mental health, euthanasia, and the scope of practice of other health professions.

“In the past 12 months, the AMA has released statements on infant nutrition, female genital mutilation, and addiction.

“In coming months, we will have more to say on cost of living, homelessness, elder abuse, and road safety, to name but a few.

“Then there are the prominent highly political and social issues that have a health dimension, and require an AMA position and AMA comment.

“All these things have health impacts. As the peak health and medical advocacy group in the country, the community expects us to have a view and to make public comment. And we do.

“Not everybody agrees with us. But our positions are based on evidence, in medical science, and our unique knowledge and experience of medicine and human health.

“Health policy is ever-evolving. Health reform never sleeps.”

The address covered, among other things, health economics: “Health should never be considered just an expensive line item in a budget – it is an investment in the welfare, wellbeing, and productivity of the Australian people.”

Public hospital funding: “The idea that a financial disincentive, applied against the hospital, will somehow ‘encourage’ doctors to take better care of patients than they already do is ludicrous.”

Private health: “If we do not get reforms to private health insurance right – and soon – we may see essential parts of health care disappear from the private sector.

The medical workforce: “We do not need more medical school places. The focus needs to be further downstream.

“Unfortunately, we are seeing universities continuing to ignore community need and lobbying for new medical schools or extra places.

“This is a totally arrogant and irresponsible approach, fuelled by a desire for the prestige of a medical school and their bottom line.

“Macquarie University is just the latest case in point.”

And general practice: “General practice is under pressure, yet it continues to deliver great outcomes for patients.

“GPs are delivering high quality care, and remain the most cost effective part of our health system. But they still work long and hard, often under enormous pressure.

“The decision to progressively lift the Medicare freeze on GP services is a step in the right direction.”

On even more controversial topics, Dr Gannon stressed that the AMA is completely independent of governments.

While sometimes it gets accused of being too conservative, he said, it was not surprising to see the reaction to the AMA’s position on some issues – like marriage equality.

“Our Position Statement outlines the health implications of excluding LGBTIQ individuals from the institution of marriage,” he said.

“Things like bullying, harassment, victimisation, depression, fear, exclusion, and discrimination, all impact on physical and mental health.

“I received correspondence from AMA members and the general public. The overwhelming majority applauded the AMA position.

“Those who opposed the AMA stance said that we were being too progressive, and wading into areas of social policy.

“The AMA will from time to time weigh in on social issues. We should call out discrimination and inequity in all forms, especially when their consequences affect people’s health and wellbeing.”

Last year, the AMA released an updated Position Statement on Euthanasia and Physician Assisted Suicide.

It came at a time when a number of States, most notably South Australia and Victoria, were considering voluntary euthanasia legislation.

There was an expectation in some quarters that the AMA would come out with a radical new direction. But it didn’t.

“The AMA maintains its position that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” Dr Gannon said.

“This does not include the discontinuation of treatments that are of no medical benefit to a dying patient. This is not euthanasia.

“Doctors have an ethical duty to care for dying patients so that they can die in comfort and with dignity.”

The AMA also takes Indigenous health very seriously.

Dr Gannon travelled to Darwin last year to launch the AMA’s annual Indigenous Health Report Card, which focused on Rheumatic Heart Disease.

“In simple terms, RHD is a bacterial infection from the throat or the skin that damages heart valves and ultimately causes heart failure,” he said.

“It is a disease that has virtually been expunged from the non-Indigenous community. It is a disease of poverty.

“RHD is perhaps the classic example of a Social Determinant of Health. It proves why investment in clean water, adequate housing, and sanitation is just as important as echocardiography and open heart surgery.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

“The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

“People want and expect us to have a view – an opinion. Sometimes a second opinion.”

Chris Johnson

A transcript of the full address can be found here:
media/dr-gannon-national-press-club-address-0

Art and Medicine

By Dr Jim Chambliss

It is often said that a picture speaks a thousand words.

Contemporary medical technology provides incredibly intricate pictures of external and internal human anatomy.

However, technology does not communicate holistic representations of the social, behavioural and psychosocial impacts associated with illness and the healing process.

Studies have shown that increased reliance on reports from expensive laboratory tests, radiology and specialised diagnostic technology has resulted in inadequacy of physical examination skills; decline in patient empathy, and less effective doctor/patient communication.

Having commenced in May this year and continuing until July 8, continuing professional development workshops which explore and promote the value of art expression in the development of observation skills, human sensitivity and relevant healthcare insights will be presented at the National Gallery of Victoria exhibition of the original works of Vincent van Gogh.

The program will incorporate empirical research to illustrate the way neuropsychological conditions can influence art and creativity. The objectives of the workshops are to:

• advance understanding of the impact of medical, psychological and social issues on the health and wellbeing of all people;

• promote deeper empathy and compassion among a wide variety of professionals;

• enhance visual observation and communication skills; and

• heighten creative thinking.

Over the last 15 years, the observation and discussion of visual art has emerged in medical education, as a significantly effective approach to improving visual observation skills, patient communication and empathy.

Pilot studies of implementing visual art to teach visual diagnostic skills and communication were so greatly effective that now more than 48 of the top medical schools in the USA integrate visual arts into their curriculum and professional development courses are conducted in many of the most prestigious art galleries and hospitals.

The work of Vincent van Gogh profoundly illustrates the revelations of what it means to be uniquely human in light of neurological characteristics, behavioural changes and creative expression through an educated, respectful and empathic perspective.

The exact cause of a possible brain injury, psychological illness and/or epilepsy of van Gogh is unknown.

It is speculated by numerous prominent neurologists that Vincent suffered a brain lesion at birth or in childhood while others opine that it is absinthe consumption that caused seizures.

Two doctors – Felix Rey and Théopile Peyron – diagnosed van Gogh with epilepsy during his lifetime.

Paul-Ferdinand Gachet also treated van Gogh for epilepsy, depression and mania until his death in 1890 at the age of 37.

After the epilepsy diagnosis by Dr Rey, van Gogh stated in a letter to his brother Theo, dated 28 January 1989: “I well knew that one could break one’s arms and legs before, and that then afterwards that could get better but I didn’t know that one could break one’s brain and that afterwards that got better too.”

Vincent did not, by any account, demonstrate artistic genius in his youth. He started painting at the age of 28 in 1881.

In fact, his erratic line quality, compositional skills and sloppiness with paint were judged in his February 1886 examinations at the Royale Academy of Fine Arts, Antwerp to be worthy of demotion to the beginners’ painting class. His original drawings and paintings were copies from others’ art, while his sketches in drawing class showed remarkably different characteristics.

Increased symptoms of epilepsy and exposure to seizure triggers (absinthe and sleep deprivation) ran parallel with van Gogh’s most innovative artistic techniques and inspirations following his move to Paris in 1886 to 1888.

These symptoms increased, accompanied by breathtaking innovation following his move to Arles, France in 1888 and his further decline in mental and physical health.

In Paris he was exposed to the works of many of the most famous impressionistic and post impressionistic painters, but so much of his new techniques and imagery were distinctly innovative in detail without traceable influences from others.

While in Paris his work transitioned from drab, sombre and realistic images to the vibrant colours and bold lines.

His ebb-and-flow of creative activity and episodes of seizures, depression and mania were at their most intense in the last two years of his life when he produced the greatest number of paintings.

His works are among the most emotionally and monetarily valued of all time. Vincent’s painting of Dr Gachet (1890) in a melancholy pose with digitalis flowers – used in the treatment of epilepsy at that time – sold for $US82.5 million in May, 1990, which at the time set a new record price for a painting bought at auction.

Healthcare professionals and art historians have written from many perspectives of other medical and/or psychological conditions that impacted van Gogh’s art and life with theories involving bipolar disorder, migraines, Meniere’s decease, syphilis, schizophrenia, alcoholism, emotional trauma and the layman concept of ‘madness’.

What was missing as a basis to best resolve disputes over which mental or medical condition(s) had significant impact on his life was a comprehensive foundation of how epilepsy or mental illness can influence art and possibly enhance creativity based on insights from a large group of contemporary artists.

Following a brain injury and acquired epilepsy I gained personal insight into what may have affected the brain, mind and creativity of van Gogh and others who experience neurological and/or psychological conditions.

The experience opened my eyes to the medical, cognitive, behavioural and social aspects of two of the most complex and widely misunderstood human conditions.

Despite having no prior experience or recognisable talent, I discovered that my brain injury/epilepsy had sparked a creative mindset that resulted in a passion for producing award-winning visual art.

I enrolled in art classes and began to recognise common topics, styles and characteristics in the art of contemporary and famous artists who are speculated or known to have had epilepsy, such as Vincent van Gogh, Lewis Carroll, Edward Lear and Giorgio de Chirico.

Curiosity for solving the complex puzzle of how epilepsy could influence art led me to pursue a Masters in Visual Art which included a full course exclusively about Vincent van Gogh.

I subsequently obtained the world’s first dual PhD combining Visual Arts, Medicine and Art Curation at the University of Melbourne.

The PhD Creative Sparks: Epilepsy and enhanced creativity in visual arts (2014) was based on the visual, written and verbal insights from more than 100 contemporary artists with epilepsy and provided:

• objective and subjective proof that epilepsy can sometimes enhance creativity – supported by brain imaging illustrating how that can occur;

• a comprehensive inventory of the signature traits of neurological and psychological conditions that have significant interpretive value in healthcare practice and consideration in art history;

• the largest collection of images of the visual narratives from people with epilepsy;

• comparative data to distinguish epilepsy from other medical and mental conditions; and

• the Creative Sparks Art Collection and Website – artandepilepsy.com.

Interest in these research discoveries and art exhibitions provided opportunities for me to deliver presentations at national and international universities, hospitals and conferences. Melbourne University Medical School sponsored an innovative series of workshops through which to teach neurology and empathy by an intriguing new approach.

Jim Chambliss has a dual PhD in Creative Arts and Medicine and has explored the ways epilepsy and other health conditions can influence art and enhance creativity.

Information about his Art and Medicine Workshops involving Vincent van Gogh can be obtained by visiting artforinsight.com or artandepliepsy.com

Why sexual advances towards a patient are never OK, even if ‘consensual’

In a recent independent review, I recommended chaperones no longer be used as an interim protective measure to keep patients safe while allegations of sexual misconduct by a doctor are investigated.

The review was commissioned by the Medical Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA), following media reports that a Melbourne neurologist was facing criminal charges for sexually assaulting a patient.

Dr Andrew Churchyard was allowed to keep practising after the alleged sex abuse. But this was subject to a condition on his registration that an approved chaperone be present for all consultations with male patients.

The Medical Board of Australia and AHPRA have accepted my recommendations that the current system of using chaperones is outdated and paternalistic. In future cases where a doctor is accused of sexual misconduct, and interim protection is considered necessary, restrictions may be imposed after an assessment of the allegations by a specialist board committee.

They will include prohibitions on contact with patients of a specified gender, prohibitions on any patient contact, or suspension from practice.

Sadly, cases of sexual misconduct are likely to continue. It’s important patients know the warning signs and where to seek help if they suspect their doctor is behaving inappropriately.

Ethical boundaries

The Hippocratic Oath states that in their professional lives, doctors will:

abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman.

The oath frames sexual contact with patients as a type of intentional harm that is forbidden. Much has changed in medical practice since the days of the ancient Greeks, but Hippocrates’ clear-eyed prohibition on sexual contact with patients, and categorisation of such conduct as a form of abuse, remains apt.

It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact.

International studies indicate that the prevalence of sexual boundary violations by health practitioners may be as high as 6 to 7%. A Canadian survey of 8,000 members of the public in 1992 found that 4.1% of respondents (4.7% of women, 1.3% of men) reported touching of a private body part by their doctor “for what seemed to be sexual reasons”.

During my review, I heard first-hand accounts of the harm sexual contact from their doctor causes patients. The harrowing stories from abused patients and their families confirm what the literature says.

Patients who are sexually exploited by their doctor suffer from major depressive disorders, suicidal and self-destructive behaviour, and relationship problems. They experience feelings of shame, guilt, isolation, poor self-esteem and denial. They may also delay seeking medical help.

Their trust in their doctor, and in the consultation room as a safe place to share problems and seek advice, is shattered.

Consensual relationships?

The impact on patients who have been indecently assaulted – by being subjected to unnecessary and inappropriate clinical examinations – has much in common with the effects of sexual abuse on victims in other, non-clinical contexts.

But patients who engage in “consensual” sexual relations with their doctor also suffer harm. Issues of vulnerability, transference and breach of trust are well recognised for current patients. Yet even former patients may be harmed by entering a sexual relationship with their former doctor.

Critics of a “zero tolerance” approach to doctor-patient contact suggest notions of vulnerable patients being exploited by their doctor are old-fashioned. They argue that a mature, consenting adult should be free to enter a consensual sexual relationship with their doctor, once the doctor-patient relationship has ended. Such views are misguided.

It is one thing to accept that a doctor may later become romantically involved with a patient after fleeting professional contact. But if the doctor-patient relationship has endured for some time, and has involved confidential disclosures and advice, any subsequent sexual relationship risks harm to the patient, and damaging professional consequences for the doctor.

Warning signs

It may be very difficult to discern whether an examination of the genitalia is warranted. For all the rhetoric about empowered patients, when we are unwell and consulting a doctor (especially someone new) for diagnosis and treatment, it can feel awkward to ask whether it is really necessary to disrobe for a full examination.

During my review, one patient recalled seeing a specialist about his severe migraines. He thought a full body examination was unusual, but said: “How was I meant to know what was normal?”

Ideally, patients will know that it’s always ok to ask why an examination or procedure is necessary, to request to have a support person present, and to raise any concerns with a practice manager after a consultation.

Patients concerned that their doctor may have acted improperly can contact support services such as CASA House in Victoria, which provides information and counselling to victims of sexual assault.

Patients should be alert to signs that their doctor’s interest is more than professional. Scheduling appointments for the end of the day, asking personal questions unrelated to the presenting problem, and providing their mobile number may all be warning signs.

Doctors should always be willing to question their own motives and, if in doubt, to seek advice from a professional mentor.

Sexual advances or sexual assault by doctors causes significant harm. A strict “zero tolerance” approach protects patients and doctors.

Ron Paterson, Professor of Health Law and Policy, University of Auckland

This article was originally published on The Conversation. Read the original article.

The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline

There are currently more than 65 million people who have been forcibly displaced worldwide, including 21.3 million people with formal refugee status, over half of whom are aged under 18 years.1 More than 15 000 refugees have resettled in Australia in the 2015–16 financial year, which includes a proportion of the 12 000 refugees from Syria and Iraq recently added to Australia’s humanitarian intake.2 In addition, around 30 000 asylum seekers who arrived by plane or boat are currently in Australia awaiting visa outcomes.3

People from refugee-like backgrounds are likely to have experienced disruption of basic services, poverty, food insecurity, poor living conditions and prolonged uncertainty; they may have experienced significant human rights violations, trauma or torture. These circumstances place them at increased risk of complex physical and mental health conditions. They face numerous barriers to accessing health care after arrival in Australia, such as language, financial stress, competing priorities in the settlement period, and difficulties understanding and navigating the health care system.4–6 Most people require the assistance of an interpreter for clinical consultations.7 Offering a full health assessment to newly arrived refugees and asylum seekers is a positive step towards healthy settlement, and helps manage health inequity through the provision of catch-up immunisation and the identification and management of infectious and other health conditions.

These guidelines update the Australasian Society of Infectious Diseases (ASID) guidelines for the diagnosis, management and prevention of infectious diseases in recently arrived refugees8 published in 2009 and previously summarised in the MJA.9 When these recommendations were first published, more than 60% of humanitarian entrants arriving in Australia were from sub-Saharan Africa10 and had a high prevalence of malaria, schistosomiasis and hepatitis B virus (HBV) infection.11–15 The initial guidelines were primarily intended to help specialists and general practitioners to diagnose, manage and prevent infectious diseases. Since then, there have been changes in refugee-source countries — with more arrivals from the Middle East and Asia and fewer from sub-Saharan Africa16,17 — and an increased number of asylum seekers arriving by boat,18 alongside complex and changing asylum seeker policies and changes in health service provision for these populations. In this context, we reviewed the 2009 recommendations to ensure relevance for a broad range of health professionals and to include advice on equitable access to health care, regardless of Medicare or visa status. The revised guidelines are intended for health care providers caring for people from refugee-like backgrounds, including GPs, refugee health nurses, refugee health specialists, infectious diseases physicians and other medical specialists.

This article summarises the full guidelines, which contain detailed literature reviews, recommendations on diagnosis and management along with explanations, supporting evidence and links to other resources. The full version is available at http://www.asid.net.au/documents/item/1225.

Methods

The guideline development process is summarised in Box 1. The two key organisations developing these guidelines are ASID and the Refugee Health Network of Australia. ASID is Australia’s peak body representing infectious diseases physicians, medical microbiologists and other experts in the fields of the prevention, diagnosis and treatment of human and animal infections. The Refugee Health Network is a multidisciplinary network of health professionals across Australia with expertise in refugee health.20

We defined clinical questions using the PIPOH framework (population, intervention, professionals, outcomes and health care setting).21 The chapter authors and the Expert Advisory Group developed recommendations based on reviews of available evidence, using systematic reviews where possible. Australian prevalence data also informed screening recommendations; for example, the low reported prevalence of chlamydia (0.8–2.0%) infections and absence of gonorrhoea infections in refugee cohorts in Australia13,22–24 (and in other developed countries25–27) informed the new recommendation for risk-based sexually transmitted infection (STI) screening.

Despite the intention to assign levels of evidence to each recommendation, there was limited published high level evidence in most areas, and virtually all recommendations are based on expert consensus. Consensus was not reached regarding the recommendations relating to human immunodeficiency virus (HIV) and STIs.

The term “refugee-like” is used to describe people who are refugees under the United Nations Refugee Convention,28 those who hold a humanitarian visa, people from refugee-like backgrounds who have entered under other migration streams, and people seeking asylum in Australia. “Refugee-like” acknowledges that people may have had refugee experience in their countries of origin or transit, but do not have formal refugee status.

Current pre-departure screening

All permanent migrants to Australia have a pre-migration immigration medical examination 3–12 months before departure,29 which includes a full medical history and examination. Investigations depend on age, risk factors and visa type,30 and include:

a chest x-ray for current or previous tuberculosis ([TB]; age ≥ 11 years);
screening for latent TB infection with an interferon-γ release assay or tuberculin skin test (for children aged 2–10 years, if they hold humanitarian visas, come from high prevalence countries or have had prior household contact);
HIV serology (age ≥ 15 years, unaccompanied minors);
hepatitis B surface antigen (HBsAg) testing (pregnant women, unaccompanied minors, onshore protection visas, health care workers);
hepatitis C virus (HCV) antibody testing (onshore protection visas, health care workers); and
syphilis serology (age ≥ 15 years, humanitarian visas, onshore protection visas).

Humanitarian entrants are also offered a voluntary pre-departure health check depending on departure location and visa subtype.31 The pre-departure health check includes a rapid diagnostic test and treatment for malaria in endemic areas; empirical treatment for helminth infections with a single dose of albendazole; measles, mumps and rubella vaccination; and yellow fever and polio vaccination where relevant. The current cohort of refugees arriving from Syria will have extended screening incorporating the immigration medical examination and pre-departure health check, with additional mental health review and immunisations.

People seeking asylum who arrived by boat have generally had a health assessment on arrival in immigration detention — although clinical experience suggests that investigations and detention health care varies, especially for children. However, asylum seekers who arrived by plane will not have had a pre-departure immigration medical examination.

General recommendations

Our overarching recommendation is to offer all people from refugee-like backgrounds, including children, a comprehensive health assessment and management plan, ideally within 1 month of arrival in Australia. This assessment can be offered at any time after arrival if the initial contact with a GP or clinic is delayed, and should also be offered to asylum seekers after release from detention. Humanitarian entrants who have been in Australia for less than 12 months are eligible for a GP Medicare-rebatable health assessment. Such assessments may take place in a primary care setting or in a multidisciplinary refugee health clinic. Documented overseas screening and immunisations, and clinical assessment should also guide diagnostic testing.

Health care providers should adhere to the principles of person-centred care when completing post-arrival assessments.32,33 These include: respect for the patient’s values, preferences and needs; coordination and integration of care with the patient’s family and other health care providers; optimising communication and education, provision of interpreters where required (the Doctors Priority Line for the federal government-funded Translating and Interpreting Service is 1300 131 450) and use of visual and written aids and teach-back techniques to support health literacy.34 It is important to explain that a health assessment is voluntary and results will not affect visa status or asylum claims.

Specific recommendations

Recommendations are divided into two sections: infectious and non-infectious conditions. Box 2 provides a checklist of all recommended tests, and Box 3 sets out details of country-specific recommendations. A brief overview is provided below. For more detailed recommendations regarding management, follow-up and considerations for children and in pregnancy, see the full guidelines.

Infectious conditions

TB:

Offer latent TB infection testing with the intention to offer preventive treatment and follow-up.
Offer screening for latent TB infection to all people aged ≤ 35 years.
Children aged 2–10 years may have been screened for latent TB infection as part of their pre-departure screening.
Screening and preventive treatment for latent TB infection in people > 35 years will depend on individual risk factors and jurisdictional requirements in the particular state or territory.
Use either a tuberculin skin test or interferon-γ release assay (blood) to screen for latent TB infection.
A tuberculin skin test is preferred over interferon-γ release assay for children < 5 years of age.
Refer patients with positive tuberculin skin test or interferon-γ release assay results to specialist tuberculosis services for assessment and exclusion of active TB and consideration of treatment for latent TB infection.
Refer any individuals with suspected active TB to specialist services, regardless of screening test results.

Malaria:

Investigations for malaria should be performed for anyone who has travelled from or through an endemic malaria area (Box 3), within 3 months of arrival if asymptomatic, or any time in the first 12 months if there is fever (regardless of pre-departure malaria testing or treatment).
Test with both thick and thin blood films and an antigen-based rapid diagnostic test.
All people with malaria should be treated by, or in consultation with, a specialist infectious diseases service.

HIV:

Offer HIV testing to all people aged ≥ 15 years and all unaccompanied or separated minors, as prior negative tests do not exclude the possibility of subsequent acquisition of HIV (note that consensus was not reached regarding this recommendation).

HBV:

Offer testing for HBV infection to all, unless it has been completed as part of the immigration medical examination.
A complete HBV assessment includes HBsAg, HB surface antibody and HB core antibody testing.
If the HBsAg test result is positive, further assessment and follow-up with clinical assessment, abdominal ultrasound and blood tests are required.

HCV:

Offer testing for HCV to people if they have:
- risk factors for HCV;
- lived in a country with a high prevalence (> 3%) of HCV (Box 3); or
- an uncertain history of travel or risk factors.
Initial testing is with an HCV antibody test. If the result is positive, request an HCV RNA test.
If the HCV RNA test result is positive, refer to a doctor accredited to treat HCV for further assessment.

Schistosomiasis:

Offer blood testing for Schistosoma serology if people have lived in or travelled through endemic countries (Box 3).
If serology is negative, no follow-up is required.
If serology is positive or equivocal:
- treat with praziquantel in two doses of 20 mg/kg, 4 hours apart, orally; and
- perform stool microscopy for ova, urine dipstick for haematuria, and end-urine microscopy for ova if there is haematuria.
If ova are seen in urine or stool, evaluate further for end-organ disease.

Strongyloidiasis:

Offer blood testing for Strongyloides stercoralis serology to all.
If serology is positive or equivocal:
- check for eosinophilia and perform stool microscopy for ova, cysts and parasites; and
- treat with ivermectin 200 μg/kg (weight ≥ 15 kg), on days 1 and 14 and repeat eosinophil count and stool sample if abnormal.
Refer pregnant women or children < 15 kg for specialist management.

Intestinal parasites:

Check full blood examination for eosinophilia.
If pre-departure albendazole therapy is documented:
- if there are no eosinophilia and no symptoms, no investigation or treatment is required; and
- if there is eosinophilia, perform stool microscopy for ova, cysts and parasites, followed by directed treatment.
If no documented pre-departure albendazole therapy, depending on local resources and practices, there are two acceptable options:
- empirical single dose albendazole therapy (age > 6 months, weight < 10 kg, dose 200 mg; weight ≥ 10 kg, dose 400 mg; avoid in pregnancy, class D drug); or
- perform stool microscopy for ova, cysts and parasites, followed by directed treatment.

Helicobacter pylori:

Routine screening for H. pylori infection is not recommended.
Screen with either stool antigen or breath test in adults from high risk groups (family history of gastric cancer, symptoms and signs of peptic ulcer disease, or dyspepsia).
Children with chronic abdominal pain or anorexia should have other common causes of their symptoms considered in addition to H. pylori infection.
Treat all those with a positive test (see the full guidelines for details, tables 1.5 and 9.1).

STIs:

Offer an STI screen to people with a risk factor for acquiring an STI or on request. Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current evidence.
A complete STI screen includes a self-collected vaginal swab or first pass urine nucleic acid amplification test and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and HBV.
Syphilis serology should be offered to unaccompanied and separated children < 15 years.

Skin conditions:

The skin should be examined as part of the initial physical examination.
Differential diagnoses will depend on the area of origin (see table 11.1 in full guidelines for details).

Immunisation:

Provide catch-up immunisation so that people of refugee background are immunised equivalent to an Australian-born person of the same age.
In the absence of written immunisation documentation, full catch-up immunisation is recommended.
Varicella serology is recommended for people aged ≥ 14 years if there is no history of natural infection.
Rubella serology should be completed in women of childbearing age.

Non-infectious conditions

Anaemia and other nutritional problems:

Offer full blood examination screening for anaemia and other blood conditions to all.
Offer screening for iron deficiency with serum ferritin to children, women of childbearing age, and men who have risk factors.
Check vitamin D status as part of initial health screening in people with one or more risk factors for low vitamin D.
People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, paired with advice about sun exposure.
Consider screening for vitamin B₁₂ deficiency in people with history of restricted food access, especially those from Bhutan, Afghanistan, Iran and the Horn of Africa.

Chronic non-communicable diseases in adults:

Offer screening for non-communicable diseases in line with the Royal Australian College of General Practitioners Red Book35 recommendations, including assessment for:
- smoking, nutrition, alcohol and physical activity;
- obesity, diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease and lipid disorders; and
- breast, bowel and cervical cancer.
Assess diabetes and cardiovascular disease risk earlier for those from regions with a higher prevalence of non-communicable diseases, or those with an increased body mass index or waist circumference.

Mental health:

A trauma informed assessment of emotional wellbeing and mental health is part of post-arrival screening. Being aware of the potential for past trauma and impact on wellbeing is essential, although it is generally not advisable to ask specifically about details in the first visits.
Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children.

Hearing, vision and oral health:

A clinical assessment of hearing, visual acuity and dental health should be part of primary care health screening.

Women’s health:

Offer women standard preventive screening, taking into account individual risk factors for chronic diseases and bowel, breast and cervical cancer.
Consider pregnancy and breastfeeding and offer appropriate life stage advice and education, such as contraceptive advice where needed, to all women, including adolescents.
Practitioners should be aware of clinical problems, terminology and legislation related to female genital mutilation or cutting and forced marriage.

Box 1 –
Guideline development process

An EAG, consisting of refugee health professionals, was formed and it included two ID physicians, an ID and general physician, two GPs, a public health physician, a general paediatrician and a refugee health nurse. An editorial subgroup was also formed.
The EAG determined the list of priority conditions in consultation with refugee health specialists and RACGP Refugee Health Special Interest Group clinicians, incorporating information from consultations with refugee background communities19 and previous ASID refugee health guidelines.
Each condition was assigned to a primary specialist author with paediatrician and primary care or specialist co-authors. Twenty-eight authors from six states and territories were involved in writing the first draft.
The EAG reviewed the first draft to ensure consistency with the framework and the rest of the guidelines. They were then revised by the primary authors.
External expert review authors reviewed the second draft and they were then revised by the primary authors.
The EAG and the refugee health nurse subcommittee reviewed the third draft.
The stakeholders reviewed the fourth draft: ASID, NTAC, RHeaNA, RACGP Refugee Health Special Interest Group, RACP, RACP AChSHM, the Victorian Foundation for the Survivors of Torture, the Multicultural Centre for Women’s Health, the Asylum Seeker Resource Centre, the Ethnic Communities Council of Victoria and community members.
The comments from the stakeholders were returned to the authors for review and the EAG compiled the final version.
ASID, RACP, NTAC and AChSHM endorsed the final version.

AChSHM = Australasian Chapter of Sexual Health Medicine. ASID = Australasian Society for Infectious Diseases. EAG = Expert Advisory Group. GP = general practitioner. ID = infectious diseases. NTAC = National Tuberculosis Advisory Council. RACGP = Royal Australian College of General Practitioners. RACP = Royal Australasian College of Physicians. RHeaNA = Refugee Health Network of Australia. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

Box 2 –
Short checklist of recommendations for post-arrival health assessment of people from refugee-like backgrounds

Offer test to

Test

Comments and target condition

All

Full blood examination

Anaemia, iron deficiency, eosinophilia

Hepatitis B serology (HBsAg, HBsAb, HBcAb)

HBsAg testing introduced overseas in 2016 for Syrian and Iraqi refugee cohort and may have been completed in other groups

Strongyloides stercoralis serology

Strongyloidiasis

HIV serology*

≥ 15 years or unaccompanied or separated minor
Also part of IME for age ≥ 15 years

TST or IGRA

Offer test if intention to treat. All ≤ 35years; if≥ 35 years, depends on risk factors and local jurisdiction. TST preferred for children < 5 yearsTST or IGRA testing introduced in 2016 as part of IME for children 2–10 years (humanitarian entrants, high prevalence countries, prior household contact)
LTBI

Varicella serology

≥ 14 years if no known history of disease
Determine immunisation status

Visual acuity

Vision status, other eye disease

Glaucoma assessment

Africans > 40 years and others > 50 years

Dental review

Caries, periodontal disease, other oral health issues

Hearing review

Hearing impairment

Social and emotional wellbeing and mental health

Mental illness, trauma exposure, protective factors

Developmental delay or learning concerns

Children and adolescents
Developmental issues, disability, trauma exposure

Preventive health as per RACGP35

Non-communicable diseases, consider screening earlier than usual age

Catch-up vaccinations

Vaccine preventable diseases, including hepatitis B

Risk-based

Rubella IgG

Women of childbearing age
Determines immunisation status

Ferritin

Men who have risk factors, women and childrenIron deficiency anaemia

Vitamin D, also check calcium, phosphate, and alkaline phosphatase in children

Risk factors if dark skin or lack of sun exposure
Low vitamin D, rickets

Vitamin B₁₂

Arrival < 6 months, food insecurity, vegan diet or from Bhutan, Afghanistan, Iran or Horn of Africa
Nutritional deficiency, risk for developmental disability in infants

First pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR

Risk factors for STI or on request*

Syphilis serology

Risk factors for STIs, unaccompanied or separated minors. Part of IME in humanitarian entrants aged ≥ 15 years

Helicobacter pylori stool antigen or breath test

Gastritis, peptic ulcer disease, family history of gastric cancer, dyspepsia

Stool microscopy (ova, cysts and parasites)

If no documented pre-departure albendazole or persisting eosinophilia despite albendazoleIntestinal parasites

Country-based (Box 3)

Schistosoma serology

Schistosomiasis

Malaria thick and thin films and rapid diagnostic test

Malaria

HCV Ab, and HCV RNA if HCV Ab positive

HCV, also test if risk factors, regardless of country of origin

HBcAb = hepatitis B core antibody. HBsAb = hepatitis B surface antibody. HBsAg = hepatitis B surface antigen. HCV = hepatitis C virus. HCV Ab = hepatitis C antibody. HIV = human immunodeficiency virus. IGRA = interferon-γ release assay. IME = immigration medical examination. LBTI = latent tuberculosis infection. PCR = polymerase chain reaction. TST = tuberculin skin test. * The panel did not reach consensus on these recommendations. See full guideline at http://www.asid.net.au/documents/item/1225 for details.

Box 3 –
Top 20 countries of origin for refugees and asylum seekers2,3,16 and country-specific recommendations for malaria, schistosomiasis and hepatitis C screening*

Country of birth

Malaria36

Schistosomiasis37

Hepatitis C^†38

Afghanistan

Bangladesh

Yes

Bhutan

Yes

Burma

Yes

China

Congo

Yes

Egypt

Yes

Eritrea

Yes

India

Yes

Iran

Iraq

Yes

Lebanon

Pakistan

Yes

Somalia

Yes

Sri Lanka

Yes

Stateless^‡

Yes

Sudan

Yes

Syria

Yes

Consider

Vietnam

* There are regional variations in the prevalence of these conditions within some countries. We have taken the conservative approach of recommending screening for all people from an endemic country rather than basing the recommendation on exact place of residence. Note that some refugees and asylum seekers may have been exposed during transit through countries not listed here. See full guideline for further details. † People with risk factors for hepatitis C should be tested regardless of country of origin. ‡ “Stateless” in this table refers to people of Rohingyan origin. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.