Deadly attacks raise fears of breakdown in rules of war

Picture credit: IgorGolovniov / Shutterstock.com

Governments and armed groups are being pressured to ensure the safety of patients and health workers in conflict zones amid a spate of high-profile attacks that have left dozens dead and injured.

The World Medical Association, the International Committee of the Red Cross, the World Health Organisation and several other peak health groups have jointly called on national governments and non-state combatants to adhere to international laws regarding the neutrality of medical staff and health facilities, and ensuring this commitment is reflected in armed forces training and rules of engagement.

The call follows an admission by the US military that a deadly attack on a Medecins Sans Frontieres (MSF) hospital in Kunduz in which 30 people were killed – including 13 staff and 10 patients – was a tragic mistake.

“This was a tragic and avoidable accident caused primarily by human error,” the US’s top commander in Afghanistan, General John Campbell, said, adding that the error was “compounded by systems and procedural failures”.

Though the location of the MSF hospital was widely known, a series of technical and operational errors led the crew of the US gunship that launched the devastating attack to mistake the hospital for the headquarters of the Afghan security service, which had been briefly seized by the Taliban.

The strike co-ordinates for the security building took the aircraft to an open field, so the aircrew decided to launch the attack on the nearest building that matched the description they had been given, which turned out to be the MSF hospital. The aircrew, and the operational command in Kabul, did not check the co-ordinates of the planned target against a “no-strikes” list.

MSF International President Dr Joanne Liu said the incident showed the deadly consequences of any ambiguity about how international humanitarian law applied to medical work in war.

“We need a clear commitment that the act of providing medical care will never make us a target. We need to know whether the rules of law still apply,” Dr Liu said.

The Kunduz attack has added to the urgency for action to be taken to ensure the safety of medical staff and hospitals in combat zones.

The International Committee of the Red Cross (ICRC), through its Health Care in Danger project, recorded 2398 attacks on health workers, facilities and ambulances in just 11 countries between January 2012 and the end of last year.

Policy and Political Affairs Officer for the ICRC’s Australian mission, Natalya Wells, said such attacks were not new, and were virtually a daily occurrence.

Ms Wells often health workers were caught in the cross-fire, particularly as a result of indiscriminate attacks in urban areas.

But she said that on occasion they were also being deliberately targeted, underlining the need for all combatants to respect the Geneva Conventions.
Ms Wells said that through the Health Care in Danger project, the ICRC was working with governments, armed forces and non-state combatants to improve awareness of, and respect for, laws and conventions around the protection of patients, health workers and medical facilities, particularly in conflict zones.

As part of the effort, governments attending the 32^nd International Conference of the Red Cross and Red Crescent between 8 and 10 December were expected to back a resolution reaffirming their commitment to international humanitarian law and a prohibition on attacks on the wounded and sick as well as health care workers, hospitals and ambulances.

In addition, Ms Wells said the ICRC had held meetings with 30 non-state combatant groups from four continents about international humanitarian law and the rules of armed conflict.

The discussions have included incorporating knowledge of these conventions into their training, backed by sanctions for any breaches.

Promisingly, Ms Wells said that so far “one or two” non-state armed groups, though not signatories to the Geneva Conventions, have discussed creating a similar code of conduct for their forces.

Adrian Rollins

Flight into danger

Picture: Dr Jenny Stedmon on deplotyment with the Red Cross to the Philippines following Typhoon Haiyan

It was not getting in to Ebola-struck Sierra Leone that most worried Red Cross medico Jenny Stedmon – it was getting out again.

“I flew in on an Air France flight, and the day after I arrived they stopped flying. All borders were shut,” she recalls. “It was a very volatile situation.”

Dr Stedmon, an emergency physician and anaesthetist, was a member of one of the first medical teams deployed by the Red Cross to Sierra Leone as the scale of the west African outbreak – which would eventually claim more than 11,000 lives – started to become clear in mid-2014.

The Brisbane-based anaesthetist, who has worked as a volunteer for the Red Cross for more than 20 years, was among the first medical specialists the humanitarian organisation contacted as it organised its initial response to the unfolding crisis.

A week after getting the call Dr Stedmon, leaving behind a worried husband, found herself immersed in a medical emergency the like of which she had not encountered before through deployments as far afield as Thailand, Yemen, Sudan, East Timor, Nepal and the Philippines.

Before each deployment, the Red Cross sends their volunteers oodles of information, and ensures they have the supplies and equipment they will need when they arrive.

But because nothing like the Ebola outbreak had been encountered before, Dr Stedmon admits all were going in “a little blind”.

The mission was to set up an Ebola treatment centre on the grounds of one of Sierra Leone’s main hospitals to help cope with the flood of cases arriving on a daily basis.

“Everyone was on a learning curve,” Dr Stedmon remembers. “I had never put on personal protective equipment in my life. There was a lot of fear.”

The Red Cross team learned what they could from World Health Organisation workers who had already been in-country for some time, and did what they could.

As an anaesthetist, Dr Stedmon usually works as part of the surgical team. But in emergency situations such as this, people just pitched in where they could provide the greatest help.

In battling Ebola, she found most of her time spent delivering medicines, water and food to the sick: “This was really basic health care delivery”.

After a month working in such a physically and emotionally demanding environment, Dr Stedmon and her colleagues were due to be rotated out.

But getting out of a country isolated by the international community was always going to be a challenge, and so it proved.

Eventually, she was driven across Sierra Leone to the border with Guinea where a waiting canoe carried her and her suitcase across the river. It was a white-knuckle ride, with the humanitarian worker more than a little alarmed by the strong possibility she might drown.

Once across, she was taken to an airfield at “a little place in the middle of nowhere”. Her fellow travellers included a health worker who was the sole survivor of a team massacred by frightened villagers who believed they were spreading Ebola rather than trying to fight it.

The experience caused Dr Stedmon to reflect that, “You never know where the danger is going to come from.”

Though danger is an inescapable part of working in areas afflicted by war or disaster, Dr Stedmon has never been directly attacked.

“I have been lucky so far,” she said. “I have never actively been involved in a violent act [and] I have never been impeded in my work.”

But she has had some good friends who have not been so lucky.

One of her best friends, New Zealand nurse Sheryl Thayer, was among six Red Cross workers assassinated by gunmen in a brutal attack on a field hospital near Grozny in Chechnya in 1996.

Another friend was seriously injured when a land mine blew up the Red Cross vehicle she was riding in near Fallujah in Iraq.

The Red Cross itself takes the safety and security of its staff and volunteers very seriously, Dr Stedmon said.

During her deployment in 2004 to the Yemen civil war, for example, the organisation took care to make sure the field hospital she worked at was away from the front lines, and even though there was “a lot of shooting going on, none [was] near us”.

Similarly, during the Sudan civil war, Dr Stedmon worked at a field hospital set up right on the border with Kenya, and patients were flown in by plane for care for everything from snake and hyena bites to landmine injuries and gunshot wounds.

Through all these deployments, Dr Stedmon has generally found local people and combatants, from whatever side, have respected the Red Cross’s neutrality.

But she is worried that a shift in attitude seems to be underway that could render Red Cross work ever more hazardous.

“I would never say it’s not dangerous…but I get the feeling there is erosion of respect and knowledge of the symbol [going on],” Dr Stedmon said. “Most people are reasonable, but there appears an increasing number of situations where there is no respect.

“It’s probably getting more dangerous to work for the Red Cross than when I started. That is my gut feeling.”

It is why Dr Stedmon is so passionate in her support for the ICRC’s Health care in Danger project, which aims to highlight attacks on health workers and educate combatants about the need to respect Red Cross neutrality.

“The time has come for the medical profession to stand up and say it’s not acceptable. We should be able to treat people in safety.”

What it is like to volunteer for the Red Cross

Training:

Three-day basic training course;

Week-long medical course drawing on expertise in areas like war surgery and emergency medicine.

Pre-deployment:

Detailed briefing notes; vaccinations; medical kits

Deployment:

Duration – typically three months, though in intense disaster response situations one month.

Equipment and supplies – apart from personal belongings, everything else supplied.

Support – extensive network of experienced in-country staff look after travel, accommodation, logistics

Costs – Red Cross covers air fares, food and shelter, and provides a per diem

Work absence – Dr Stedman has the support of her employer, Redlands Hospital, and takes unpaid leave for duration of deployment (gives them some scope to employ a locum if needed).

Post-deployment: extensive debriefing

Adrian Rollins

News briefs

Loneliness can be a killer

A new study from the United States’ National Institutes of Health shows that loneliness can increase the risk of premature death in older adults by as much as 14%, Forbes reports. “The research team found that perceived social isolation—the ‘feeling of loneliness’—was strongly linked to two critical physiological responses in a group of 141 older adults: compromised immune systems and increased cellular inflammation. Both outcomes are thought to hinge on how loneliness affects the expression of genes through a phenomenon the researchers call conserved transcriptional response to adversity, or CTRA. The longer someone experiences loneliness, the greater the influence of CTRA on the expression of genes related to white blood cells (aka, leukocytes, the cells involved in protecting us against infections) and inflammation. A lessened ability to fight infections along with a slow erosion of cellular health leaves the body open to a host of external and internal problems, some of which worsen over time with few distinct symptoms.” The researchers said the results were specific to “perceived social isolation” and were unrelated to stress and depression.

Fifth retraction for former Baker IDI heart researcher

Retraction Watch reports that JAMA has issued a second retraction for former Baker IDI Heart and Diabetes Institute researcher Anna Ahimastos. In September, JAMA announced that Ahimastos had “fabricated [records] for trial participants that did not exist” in a trial for a blood pressure drug. That trial was retracted, along with a subanalysis. The second paper — Effect of perindopril on large artery stiffness and aortic root diameter in patients with Marfan syndrome: a randomized controlled trial — has been retracted at the request of Ahimastos’ coauthors because it included data from the first discredited paper. The retraction is the fifth for Ahimastos, who has admitted to fabricating data for studies published in the Journal of Hypertension and Annals of Internal Medicine. Three more are expected.

WHO partly to blame for Ebola deaths

An independent group of public health researchers, published in The Lancet, has called for big changes to the World Health Organization in the wake of the 11 000 deaths from Ebola, Wired reports. Suerie Moon from Harvard, a co-author of the report, said: “Ebola was really a wake-up call. If we don’t get together to make reforms after something as devastating as Ebola, you really have to wonder when we will.” According to Wired “in the early days of the Ebola outbreak, WHO’s response was so lackadaisical it [messed] up even the chlorine — the disinfectant doctors got was expired”. The researchers called for a new WHO centre “dedicated to emergency outbreak response, and an independent commission that will hold the agency accountable for its actions”. WHO has since convened another group of independent experts to assess its response to the Ebola outbreak.

Naegleria warning in WA

In the wake of an episode of the ABC’s Australian Story program, the Western Australian Health Department has issued an official warning about the lethal amoeba, Naegleria fowleri, and the subsequent risk of Amoebic meningitis, Outbreak News Today reports. Australian Story told of the Keough family whose son Lincoln who died of the illness after playing in infested water from a garden hose. N. fowleri can be found in any fresh water body or poorly treated water. It thrives in warm water temperatures, between 28oC and 40oC. Amoebic meningitis only occurs if water containing active amoeba goes up the nose and then to the brain. The warning recommended swimming only in saltwater or chlorinated pools.

New president for RCPA

Dr Michael Harrison has been confirmed as the new president of the Royal College of Pathologists of Australia. Dr Harrison, who has been vice-president for the past 4 years, replaces Associate Professor Peter Stewart in the role. He has been a consultant pathologist with Sullivan Nicolaides Pathology for 30 years, first in their clinical chemistry and microbiology division and then as CEO and Managing Partner for the past 12 years.

The flabby country

Children are continuing to pack on the pounds even though the pace of weight gain among adults appears to be slowing, underlining concerns that a combination of poor diet and inactivity is putting millions at heightened risk of heart disease, diabetes and other serious lifestyle-related health problems.

There has been a small but notable slowing in weight gain among adults – particularly women – since the global financial crisis struck in 2007-08. The proportion considered overweight or obese increased by just 0.6 of a percentage point to 63.4 per cent in the last three years after jumping more than 6.5 percentage points in the previous 15 years.

But Australian Bureau of Statistics figures show that children are putting on weight much more rapidly. The proportion who are overweight or obese leapt 1.7 percentage points in the last three years.

Overall, the country continues to have a severe weight problem.

Last financial year, more than 63 per cent of adults were overweight or obese, including more than 70 per cent of men, while more than a quarter of all children (27.4 per cent) are carrying too much weight.

The results mean Australia retains the unenviable status of having some of the highest rates of overweight and obesity in the world. By comparison, the World Health Organisation calculates that 39 per cent of adults worldwide are overweight, and 13 per cent obese.

The nation’s waistline has continued to bulge against a background of poor eating and exercise habits.

The ABS found that although half of all adults, and 70 per cent of children, eat two or more serves of fruit a day, Australians are not getting enough vegetables in their diet – just 7 per cent of adults and 5.4 per cent of children meet dietary guidelines for the consumption of vegetables.

Just as concerning, a large proportion of Australians are not getting enough exercise. While 55 per cent of adults reported doing at least two-and-a-half hours of moderate physical activity or 75 minutes of vigorous exercise each week, 30 per cent did not manage to do even this much, and almost 15 per cent said they did none.

AMA Vice President Dr Stephen Parnis said the findings showed much more needed to be done on health prevention.

“The message from this survey is clear – Australians have to get moving,” Dr Parnis said.

He said while it was heartening that rates of smoking and risky drinking were declining, the incidence of preventable disease highlighted the need to do more.

The ABS, which surveyed 19,000 people for its report, found that just 14.5 per cent of adults smoke on a daily basis – down from 16 per cent in 2011-12 – while the proportion who drink excessively has slipped to 17.4 per cent, a 2 percentage point decline over the same period.

Dr Parnis said the results showed the effectiveness of Australia’s tobacco control measures, including its plain packaging laws, but warned that alcohol continued to “wreak havoc” on families and communities.

“We cannot be complacent about alcohol because one in four men and one in 10 women are still exceeding the lifetime risk guidelines [for consumption],” he said.

The effects of excessive drinking, poor diet and relative inactivity are showing up in persistent rates of lifestyle-related illnesses identified in the ABS report, National Health Survey: 2014-15.

It found that rates of diabetes and heart disease (both affecting about 1.2 million people) are continuing to grow, while 2.6 million have hypertension and 1.6 million suffer from high cholesterol.

Dr Parnis said that, amidst the flurry of reviews of Medicare, primary care and private health insurance, the ABS report showed the “urgent need” for greater attention on preventive health measures.

“Investing in prevention pays big dividends. It keeps people healthy and away from costly hospital care,” he said. “We need to do more to make Australians more aware of their diets, their exercise regime, and the serious health risks of smoking and excessive or irresponsible alcohol consumption.”

Adrian Rollins

Empowering clinicians to address the global challenge of trauma: an example from Myanmar

Investment in clinicians and in hospitals can trigger wholesale change in thinking about health systems

Runner-up — Medical practitioner category

No one had thought to resuscitate him; shocked, hypoxic and drowsy as he was. This Myanmar Delta fisherman had been left alone with his obstructed airway and bleeding, bilateral compound femoral fractures. Hours earlier, he’d fallen from his boat and under the blades of the outboard motor. Dragged out of the water by his comrades, he didn’t receive any first aid and the local clinic care was woefully inadequate. Even at the national trauma hospital in Yangon, the fisherman lay unattended and neglected in the emergency receiving area.

He didn’t receive essential trauma care until we arrived: a team of doctors training to be Myanmar’s first emergency specialists and me, as their tutor. He needed simple airway support, oxygen, intravenous fluids for shock, pressure and immobilisation for his fractures, antibiotics and some pain relief. Not complicated, not expensive, but perhaps too late.

Fast forward 2 years, for that was in 2013, and I’m impressed by the rapid response to another trauma patient. She’s been hit by a car and has severe facial injuries and a tense, swollen abdomen. This time I’m an observer at the Myanmar hospital, visiting my former students who are now leading the care. The team have assembled around the patient in the dedicated resuscitation space of the newly renovated emergency department. She receives simple but effective interventions that stabilise her until the surgeons, called urgently to assist, can take her to theatre.

These are stories of trauma and clinical care. In Myanmar, injuries, primarily from road traffic accidents, remain the leading cause of morbidity and the second highest cause of death. Like other low-income countries, the burden of trauma falls heavily on the young and productive. In Myanmar, and elsewhere, death and disability from trauma have long been unacknowledged by local and global health authorities whose focus is on Millennium Development Goals priorities.

Clinical care of injured patients in low-income countries is substandard or absent. Health systems are weak and underfunded. Crowded, dirty hospitals are perceived as places of death and infection; people don’t trust them to provide emergency care. For donors and funders, hospitals are unsustainable drains on limited resources. An Australian Government aid official told me recently that hospitals are “expensive luxuries” that are not on any global health agenda.

Yet, my experience in Myanmar suggests that investment in clinicians and in hospitals, as critical places of care, can trigger wholesale change in thinking about health systems and health advocacy. Further, given future Sustainable Development Goals targets that aim to reduce death from road traffic accidents, much more attention to clinical care, hospitals and clinicians will be required.

What has been behind the transformation taking place in Myanmar? The examples given above are of life-saving improvements in emergency care, but it’s more than that. In Myanmar, the program that is reducing death and disability from trauma — and any other acute and urgent condition — has expanded from training staff to hospital renovation, introducing acute care systems (such as pre-hospital care and triage), changing legislation and educating the public. Where and how were the seeds sown for this type of change?

One starting point, and perhaps a symbol of the importance of empowering clinicians, is the Primary Trauma Care (PTC) course. Introduced in Yangon in 2009 in the aftermath of Cyclone Nargis, PTC is a 2-day course that aims to train front-line staff with the skills, knowledge and attitude for preventing death and disability in the seriously injured patient. Designed specifically for underdeveloped and low-resource areas, PTC exists under the auspices of a non-for-profit Foundation based in Oxford, United Kingdom (http://www.primarytraumacare.org). It’s free, adaptable to any context and empowers local clinicians to teach the PTC principles in their own environments. First launched in Fiji in 1997, the course is now being taught in over 70 countries and is thriving in parts of Africa, the Middle East and Central America. In the Pacific region (where I’ve also taught), PTC is known as a “gospel message”; it is bringing new vision, new language and new actions to previously limited clinical environments.

After our inaugural PTC course in Myanmar, a young orthopaedic doctor went back to his rural district hospital and mobilised his colleagues and hospital administrators. He sourced funding to renovate and equip a room in the old hospital “receiving area” to provide a safe and effective environment to care for emergency trauma victims. He taught his staff the PTC principles and practised teamwork through simulated trauma scenarios. Six years later, this doctor is now a leader of emergency medicine in the country. He’s meeting government authorities to discuss the national roll-out of acute and trauma care standards, participating in workshops to introduce a coordinated pre-hospital system, making plans for road safety and injury prevention campaigns, and providing good quality clinical care in his well designed, functional emergency department. This doctor was part of our team who tried to save the life of the Myanmar Delta fisherman.

The work to establish these clinical and health system improvements in Myanmar has been substantial, and not just about a short trauma skills course. Supported mostly through a network of volunteers from Australia and Hong Kong, Myanmar doctors and nurses have been trained and empowered to provide better clinical care in superior clinical environments and become national leaders in acute health care.

These Myanmar clinicians already had the vision and drive for change. The PTC course has been a catalyst to realise their desire for improvement. It is a tool that starts with the clinical, then inspires broader thinking about environments and systems of care, and then even the health status of the population. This “clinical to public health” cascade has brought about substantial health improvements in other national contexts. For trauma, the front-line clinicians dealing with injuries agitated for seatbelts, speed limits and helmets.

Investment in clinicians and their hospitals is a priority in order to achieve the right balance between clinical medicine and public health for an effective response to the global challenge of trauma.

Clinicians have often been the “outsiders” in the global health discourse. In low-income countries, they are exhausted and overwhelmed by the service provision needs of their communities. Working their guts out day after day, they often view public health authorities with suspicion. Likewise, the authorities perceive clinicians as somehow less worthy, excluding them from funding sources and health improvement programs. This is a false and harmful division. Public health needs clinical service in order to provide an effective health system and prevent unnecessary death and disability. People need hospitals that they can trust to deliver safe and effective clinical care in order to inculcate confidence in their health system for times of increased need. As the Myanmar example shows, given support, a network and a few simple tools (like the PTC), clinicians can address the global challenge of trauma and become the strongest advocates for public health and health systems improvements.

Upstream or downstream?

The river analogy helps describe the health continuum from prevention to treatment

Winner — Medical student category

When I first looked at a map of Alice Springs, the ephemeral Todd River was marked as a deceptive blue snake, winding its way through the centre of town. For the local Arrernte people, the river is known as Lhere Mparntwe. In my head, I pictured a desert oasis, brown-skinned children gleaming with sun and water, screaming with glee as they plunged from rope swings into the cool river water. During my first week in Alice, somebody told me that it’s only after you have seen the river flow three times that you can be considered a local. The rest of the time it is just a dusty creek bed, filled with the soft rusty sand that has now found its way into almost every item that I own.

In public health, there is the concept of “upstream” and “downstream” factors. The analogy of the river is used to describe how pre-existing social, cultural, financial, environmental and historical factors ultimately go on to influence health outcomes in a profound way.1

The children’s ward at Alice Springs Hospital is busy. The nurses exasperatedly chase a young boy down the corridor. This pint-sized patient is surprisingly speedy as he makes his naked bid for freedom. A happy little boy and exceptionally cute, this child has quickly become a favourite of mine. It’s close to a month since he was first admitted for ongoing weight loss on a background of acute gastroenteritis. He has had chronic diarrhoea since he’s been here, his stool best described as a microbiological zoo. His small body has been bombarded with every antibacterial, antifungal and antiparasitic agent we have. His poor gut is so damaged from his numerous recurrent infections that it’s essentially no more than a slippery dip. It’s difficult for him to absorb any nutrients from his food, and we desperately need him to gain weight so his body and brain can grow.

In the treatment room Bananas in Pyjamas is playing. The room is crowded. In between the paediatrician, two nurses, the surgical registrar, mum and a writhing, screaming patient, there are bubbles. So many bubbles. The young surgical trainee gingerly examines the numerous boils that cover the little girl’s legs and groin. They will require an operation to drain them. She too has been with us for a week already. Her kidneys are struggling, after her body mounted an autoimmune reaction to the streptococcal infection from the boils. We closely monitor her weight and blood pressure until her kidneys are out of the woods.

The diabetes educator and paediatrician discuss a 13-year-old girl, who has just been diagnosed with type 2 diabetes mellitus. Already she weighs over 100 kg. Her case being outside the realm of conventional paediatric practice, the paediatrician is seeking advice on the best management plan for this patient. The girl’s mother, in her 30s, already suffers from retinopathy from her diabetes. One of the challenges of managing type 2 diabetes in an adolescent is the general lack of evidence to inform practice. It’s simply too new a phenomenon. The evidence to inform the management of type 2 diabetes in an Indigenous child is virtually non-existent.

At the hospital, we are so far downstream that we are practically out to sea. Essentially, we patch the kids up, keep them from dying, and make an attempt at educating the child’s parents about what has happened and why. It is grossly inadequate when almost everything that we see is preventable.

How is it then, in a wealthy nation like Australia which boasts a universal health system that is arguably one of the best in the world, that the life expectancy of Indigenous Australians is still (at a conservative estimate) 10–17 years less than their non-Indigenous counterparts? Why do the babies of Aboriginal mothers die at more than twice the rate of non-Aboriginal mothers? Why are so many remote communities still plagued by poor hygiene, overcrowding and dysfunctional living conditions, condemning their inhabitants to lifelong chronic disease? To me, it’s incomprehensible.

The instinct of many is to blame the individual. I know that I am often tempted to do so, especially when you see children who are suffering. However, blaming or inducing guilt is counterproductive. It does not help anyone. If anything, it alienates and denigrates. It is simply not correct to suggest that a person engages in certain behaviours by “choice”, and choice alone. It is too simplistic. To do so ignores the fact that every individual is a member of a community and is shaped by that community, his or her environment, education, and a personal and collective history.

To date, many health promotion programs have made a grossly inaccurate assumption that health education will automatically translate to behaviour change. It’s the same flawed logic that tells me I should floss daily and do at least 30 minutes of moderate-to-vigorous physical activity each day. Does knowledge alone empower me to change my behaviour? Sometimes it can, but only when the environment allows. Can I prevent my children from getting scabies when 15 people live in my home, multiple people share mattresses and I don’t have running water in the house, let alone a washing machine? Unlikely.

There is no strategic plan or coordination between services to promote hygiene improvement in remote communities.2 The social determinants of health have been ignored or, at the very least, addressed in a piecemeal manner. Public servants in air-conditioned offices write hygiene promotion strategies that fail to address the functional state of housing infrastructure and the unique environmental conditions of remote communities. Obesity and micronutrient deficiency in remote communities is a direct result of food insecurity caused by low incomes and the high price of fresh, nutritious food. This is unlikely to ever be overcome as long as local stores (often the sole providers of food in remote communities) continue to be viewed as a small business, rather than an essential service such as health or education.3 The past and continuing erosion of Indigenous culture and language serves only to perpetuate the vicious cycle of poverty and poor health.4

Government departments are often only as far apart as a different floor in the same building, yet the level of communication and collaboration between departments would suggest there is in fact a chasm between them. Multisector collaboration and high-level engagement and partnership with Indigenous peoples are the only hope we have to “close the gap”.

Good health is not made in hospitals. Good health is made by the food we eat, the water we drink, by feeling safe, secure, loved and connected. It is the roof over our heads, our sense of purpose in the world. Education is not just power, but health too. It is health, not illness that I am passionate about. I need to be further upstream. Maybe I need to see the Todd River flow.

–

The Todd River, Alice Springs. Photo taken in March 2015.

News briefs

Sonic “tractor beam” could have medical uses

The tractor beam, a Star Trek staple, could be about to happen, and there could be medical applications, report The Japan Times and The Guardian. Researchers from the University of Bristol in the UK, and Spain’s Public University of Navarre say they have developed a tractor beam that “uses high-amplitude sound waves [at a frequency of 40 kilohertz] to levitate, move and rotate small objects without making contact with them”. The waves took the form of “tweezers to lift an object, a vortex to hold a levitating object in place and a cage to surround an object and hold it in place”. “Sound cannot travel through the void of space, but it can do it through water or human tissue. This potentially enables the manipulation of clots, kidney stones, drug capsules, microsurgical instruments or cells inside our body without any incision,” one of the lead researchers said.

Two-thirds of the world’s under 50s have herpes

The World Health Organization reports that more than 3.7 billion people under the age of 50 – or 67% of the population – are infected with herpes simplex virus type 1 (HSV-1). “Some 140 million people aged 15-49 years are infected with genital HSV-1 infection, primarily in the Americas, Europe and Western Pacific”, WHO says. “Fewer people in high-income countries are becoming infected with HSV-1 as children, likely due to better hygiene and living conditions, and are instead at risk of contracting it genitally through oral sex after they become sexually active.” WHO estimated that 417 million people aged 15-49 years have HSV-2 infection, which causes genital herpes. Taken together, the estimates reveal that over half a billion people between the ages of 15-49 years have genital infection caused by either HSV-1 or HSV-2.

23andMe is back in business

Two years after it was banned from distributing health information to its customers, controversial health and ancestry information provider 23andMe is back in business, reports Gizmodo Australia. In 2013, the US’s Food and Drug Administration stopped the company from providing private customers with health and ancestry information directly from their sequenced DNA, saying it was “concerned about the public health consequences of inaccurate results from the [23andMe] device … the main purpose of compliance with FDA’s regulatory requirements is to ensure that the tests work”. Now the FDA has given 23andMe the green light to resume distributing health information, albeit in a more limited way. “The new reports will provide details about what’s known as ‘carrier status’. The tests will identify genetic mutations in DNA samples that could lead to the passing of one of 36 diseases — including cystic fibrosis, sickle cell anaemia and Tay-Sachs — on to offspring. In each case, the disease would only be passed on if both parents shared the same mutation and the child inherited both mutated genes.” 23andMe has also hiked prices from USD$99 to USD$199.

Can Google Glass help autistic kids?

Wired reports that researchers at Stanford University in the US are working on software for Google’s wearable computer, Glass, which will help autistic children recognise and understand facial expressions and, through them, emotions. Lead researcher Catalin Voss has previously developed a Glass app which recognises emotions, which is now being turned into heads-up technology for cars. The new app is designed like an interactive game. “Children are asked to, say, find someone who is happy”, the researchers said. “When they look at someone who is smiling, the app recognises this and awards points. You can plot, as they wear the glasses, how they’re improving, where they’re improving. You can look at video to understand why.” The app is now being tested in a clinical trial with 100 children.

“Flakka” worse than ice, says toxicologist

A synthetic drug considered fatal has been detected in Australia and has the potential to be worse that ice, the International Business Times reports. “Flakka” is man-made, “has a similarity to cocaine and can be injected, snorted or smoked”. It can lead to a series of extreme symptoms called “excited delirium”, marked by violent behaviour, paranoia and spikes in body temperature. Reports from the United States suggest flakka, also known as “gravel” has caused several deaths there. “Flakka comes in bulk from China and is sold through gas stations, via the internet and other dealers”. Forensic toxicologist Andrew Leibie said that the drug has become so popular with people that “it will be appearing on the streets, it will be appearing in schools, it will be appearing in workplaces.”

Deadly attacks raise fears of breakdown in rules of war

Governments and armed groups are being pressured to ensure the safety of patients and health workers in conflict zones amid a spate of high-profile attacks that have left dozens dead and injured.

The call follows the shelling of a Red Cross/red Crescent hospital in Yemen on Sunday, and the release of the initial results of a Medecins Sans Frontieres investigation into the deadly bombing of its hospital in Kunduz which found that there was no fighting occurring in or around the facility at the time of the attack, and that all armed groups, including the Afghan Army and the US Defence Department, had been given the accurate GPS coordinates of the hospital.

MSF said when the hour-long attack began soon after 2am on 3 October, 140 of its staff were at the hospital – including on 80 on duty – and they were treating 105 patients.

The humanitarian charity said at least 30 people were killed in the bombing raid, including 10 patients, 13 staff and seven whose remains were burnt beyond recognition. One MSF staff member and two patients are still missing and presumed dead.

Describing the attack in chilling detail, the charity reported that the intensive care unit, which was full at the time, was the first part of the hospital to be bombed. Several patients burned alive in their beds, a doctor had his leg blown off and a nurse had his arm virtually severed. One MSF staffer was decapitated by shrapnel, and several people were shot from the air as they attempted to flee the burning building.

As soon as the attack start, MSF made multiple calls to the Afghan Army and US armed forces, both in Kabul and to the Defence Department in Washington DC.

MSF International President Dr Joanne Liu said the internal review confirmed that MSF rules, including its strict ‘no weapons’ policy was in force and respected at the time of the attack, that the charity was in full control of the facility, that there were no armed combatants within the hospital compound, and there was no fighting from or in its vicinity before the airstrikes.

“We were running a hospital treating patients, including wounded combatants from both sides – this was not a ‘Taliban base’,” Dr Liu said.

The MSF President said the incident showed the deadly consequences of any ambiguity about how international humanitarian law applied to medical work in war.

“What we demand is simple: a functioning hospital caring for patients, such as the one in Kunduz, cannot simply lose its protection and be attacked,” Dr Liu said. “The attack…destroyed out ability to treat patients at a time when we were needed the most.

“We need a clear commitment that the act of providing medical care will never make us a target. We need to know whether the rules of law still apply.”

The United States and Afghan governments are yet to announce whether they will consent to an International Humanitarian Fact Finding Commission inquiry into the bombing.

But the Kunduz attack has nonetheless added to the urgency for action to be taken to ensure the safety of medical staff and hospitals in combat zones.

Policy and Political Affairs Officer for the ICRC’s Australian mission, Natalya Wells, said such attacks were not new, and were virtually a daily occurrence.

Ms Wells often health workers were caught in the cross-fire, particularly as a result of indiscriminate attacks in urban areas.

As part of the effort, governments attending the 32^nd International Conference of the Red Cross and Red Crescent between 8 and 10 December are expected to back a resolution reaffirming their commitment to international humanitarian law and a prohibition on attacks on the wounded and sick as well as health care workers, hospitals and ambulances.

In addition, Ms Wells said the ICRC had held meetings with 30 non-state combatant groups from four continents about international humanitarian law and the rules of armed conflict.

The discussions have included incorporating knowledge of these conventions into their training, backed by sanctions for any breaches.

Promisingly, Ms Wells said that so far “one or two” non-state armed groups, though not signatories to the Geneva Conventions, have discussed creating a similar code of conduct for their forces.

Adrian Rollins

News briefs

The BMJ questions e-cigarettes endorsement

The BMJ has questioned the decision by Public Health England — (mission statement: “We protect and improve the nation’s health and wellbeing, and reduce health inequalities”) — to endorse the use of e-cigarettes as an aid to quitting smoking. In a report released at the end of August PHE concluded that e-cigs were “95% less harmful” than conventional cigarettes and described them as a potential “game changer” in tobacco control. In The BMJ Professor Martin McKee and Professor Simon Capewell said the available evidence, including a recent Cochrane review, did not show clearly that e-cigs were as effective as established quitting aids. “We might also expect that the prominently featured ‘95% less harmful’ figure was based on a detailed review of evidence, supplemented by modelling”, wrote McKee and Capewell. “In fact, it comes from a single [sponsored] meeting of 12 people.” The sponsors included a CEO with previous funding from British American Tobacco. One of the 12 was a chief scientific advisor with declared funding from an e-cigarette manufacturer, and Philip Morris International. “None of these links or limitations are discussed in the PHE report”, McKee and Capewell wrote.

Dramatic rise in antibiotic use globally

Nature reports that “antibiotic use is growing steadily worldwide, driven mainly by rising demand in low- and middle-income countries”, citing the latest report from the Center for Disease Dynamics, Economics and Policy. The organisation used a review of data from scientific literature, and national and regional surveillance systems to calculate and map the rate of antibiotic resistance for 12 types of bacteria in 39 countries, and trends in antibiotic use in 69 countries over the past 10 years or longer. “Global antibiotic consumption grew by 30% between 2000 and 2010. This growth is driven mostly by countries such as South Africa and India, where antibiotics are widely available over the counter and sanitation in some areas is poor.” The report also found that the use of antibiotics in livestock is growing worldwide, particularly in China, which used about 15 000 tonnes of antibiotics for this purpose in 2010, and is projected to double its consumption by 2030.

Child mortality under six million for first time

A new World Health Organization report says deaths among children aged 5 years and under worldwide have more than halved over the last 25 years, falling from 12.7 million a year in 1990 to 5.9 million in 2015. “While progress has been substantial, a 53% drop in child mortality is far short of the Millennium Development Goal, where countries agreed to reduce child mortality between 1990 and 2015 by two-thirds.” Around 16 000 children under 5 still die every day, most from diseases that are readily preventable or treatable, says the report. Around 50% of global deaths among the under 5s occur in sub-Saharan Africa, while 30% occur in southern Asia. Approximately 45% of deaths among the under 5s occur in the first 28 days of life. One million infants die on the day they are born, and nearly 2 million during the first week following birth. Leading causes of death in this group include complications during labour, premature birth, pneumonia, sepsis, diarrhea and malaria. Most of the remaining deaths among the under 5s are tied to undernutrition.

Static electricity next frontline in malaria control

Dutch researchers have come up with a way of improving the efficacy of mosquito nets using static electricity, according to a report in The Economist. With the WHO reporting a 60% drop in deaths caused by malaria since 2000, In2Care, a Dutch mosquito-control firm, is finding a way to deliver insecticides embedded in mosquito nets more effectively to the target insect. “Current mosquito nets are woven from fibres impregnated throughout with an insecticide”, The Economist reports. “This permits them to be washed and used for years without loss of potency. But it also means this potency is not as great as it could be, because the insecticide is released only slowly by the fibres. Using static electricity, by contrast, means all of the insecticide is held on the surface of a net’s fibres. Much larger doses can thus be transferred to an insect which blunders into the net. In addition, a wide range of insecticides — and even, possibly, the spores of a fungus harmless to people but lethal to mosquitoes — can be applied to the fibres.”

Photobacterium damselae and Vibrio harveyi hand infection from marine exposure

Clinical record

A 75-year-old man presented to the emergency department at our tertiary teaching hospital on 11 April 2014 with a 3-day history of a rapidly enlarging, painful haemorrhagic blister on his right hand. He had caught sea bream while fishing at a southern Sydney beach 3 days earlier, but did not recall any hand trauma. His past medical history was significant only for hypertension (amlodipine 10 mg daily), hypercholesterolaemia (atorvastatin 10 mg daily) and mild penicillin allergy. At presentation, he was febrile (38.3°C), with a tense, tender, 3 × 3 cm haemorrhagic bullous lesion surrounded by erythema and swelling of the hand and forearm with reduced range of wrist movement (Figure, A). Systemic examination was unremarkable. His white cell count was elevated (14.4 × 10⁹/L; reference interval [RI], 3.5–11 × 10⁹/L) with neutrophilia (10.9 × 10⁹/L; RI, 1.7–7 × 10⁹/L), and his C-reactive protein level was 30 mg/L (RI, <3 mg/L). Fluid was aseptically aspirated from the lesion, inoculated into blood culture bottles and incubated in the automated BacT/ALERT 3D system (bioMérieux). Treatment was commenced with doxycycline 100 mg orally 12-hourly and cefazolin 1 g intravenously every 8 hours.

Both aerobic and anaerobic culture bottles returned positive results within 8 hours of incubation, and direct Gram stain showed gram-negative bacilli. Subculture onto MacConkey agar incubated at 35–37°C in air, Columbia blood agar (5% defibrinated horse blood) incubated at 35–37°C anaerobically and chocolate agar incubated at 35–37°C in 5% supplemental CO₂ showed predominant growth of a slowly oxidase-positive gram-negative rod after overnight incubation on all media, with a second smaller colony type. Subsequent use of matrix-assisted laser desorption ionisation time of flight mass spectrometry (Bruker) identified Photobacterium damselae and Vibrio harveyi with spectral scores of 2.18 and 2.25, respectively (score ≥2 required for species-level identification). Antibiotic susceptibility testing was performed with the CDS method for gram-negative organisms.1 Both organisms were susceptible to doxycycline, ceftriaxone, ciprofloxacin, cefepime and ticarcillin–clavulanic acid. Photobacterium damselae but not V. harveyi was ampicillin susceptible. Considering the potential for necrotising infection in such a case, the patient was referred to a specialist hand surgeon for debridement. The lesion was deroofed and debrided, followed by hand splint immobilisation and regular dressing changes. Treatment was completed uneventfully with 7 days of oral doxycycline 100 mg 12-hourly (Figure, B).

Named after its pathogenicity for damsel fish, P. damselae (formerly V. damsela) is a marine bacterium of the Vibrionaceae family that is pathogenic to a variety of sea life including fish, crustaceans, molluscs and large sea mammals. It has been isolated from ocean and estuarine waters, seaweed and seafood, and its ability to grow at 37°C facilitates colonisation and infection of humans.2 Most reported human infections have occurred in coastal areas of the United States, Australia and Japan in wounds exposed to salt or brackish water and typically associated with fish handling. A number of case reports of P. damselae wound infection have been published, describing severe infections presenting with necrotising fasciitis with a rapidly fatal outcome.3,4 Severe infection occurs in healthy as well as immunocompromised individuals.3,5,6 Virulence is mediated by potent haemolytic toxins such as the phospholipase D damselysin.2

The role of V. harveyi, considered pathogenic only to marine animals, is unclear. This is the second reported case of dual infection with P. damselae and V. harveyi. Both cases resulted from exposure to Australian coastal water in the past 2 years. The first report described a lower limb infection in a German traveller after a boating injury on the west coast of Australia near the Murchison River estuary. On the traveller’s return to Germany, delayed presentation with progressing tibial ulceration prompted surgical debridement, with bacteriological diagnosis made from cultured wound tissue. Treatment with empirical ofloxacin, followed by doxycycline and regular debridement, resulted in a favourable outcome, although complete healing took 14 weeks.7

Vibrio spp are gram-negative rod-shaped bacteria; they inhabit warm surface waters worldwide. They preferentially grow in warm water (>18°C) of low salinity, with increasing rates of growth up to 30°C.8 Of at least 12 Vibrio spp that are pathogenic to humans, V. cholerae, V. parahaemolyticus and V. vulnificus are the most important for their associated scale of human disease and high case fatality rates, particularly in the developing world.9 The US Centers for Disease Control and Prevention have reported a threefold increase in the annual incidence of vibriosis per 100000 population, up from 0.15 in 1996 to 0.42 in 2010, despite public education and other interventional measures.10 Warming of coastal waters, which enhances growth and persistence of Vibrio spp, has been postulated as a contributor to this increase.8,10 An increased incidence of vibriosis in northern European countries during particularly hot summer months in 2006 has been associated with warming of the Baltic Sea surface temperature.11 Researchers have suggested other potential contributing factors, such as changes in precipitation and increased run-off into estuaries potentially lowering salinity, demographic changes with increasing coastal populations and recreational water activities in hotter months, and increasing host susceptibility.8,11 There appears to be sufficient public health concern in the northern hemisphere to call for enhanced surveillance and further research to increase awareness, assess health risks and guide public health action.8–11

This may apply also to the southern hemisphere. Australia’s extensive coastline is more populated within the temperate to tropical zones, regions that are also frequented by international travellers, potentially exposing many to these pathogens. Rapid global travel allows for presentation of such infections in locations very distant to the point of exposure, where vibriosis awareness and clinical experience may be limited.

Advances in diagnostic microbiology will assist with rapid identification of these organisms from appropriate culture material. A history of water exposure is essential to guide laboratory practice. Gram-negative organisms isolated from non-sterile specimens may be overlooked in the laboratory without appropriate history, and infections may therefore go unrecognised and be underreported. Greater awareness of this potentially serious emerging infectious disease is necessary to optimise detection. Improved clinical outcomes will require early targeted antibiotic therapy with doxycycline or ciprofloxacin, along with aggressive surgical management.

Lessons from practice

Soft tissue infection caused by non-cholera Vibrio spp may arise from innocuous marine exposure.
To ensure that potential pathogens are not overlooked, a history of water exposure is essential to guide appropriate microbiology laboratory diagnostic methods, particularly for gram-negative organisms. These methods may include the use of appropriate selective media such as thiosulfate–citrate–bile salts–sucrose agar for non-sterile sites.
Inoculation of aspirated fluid into blood culture bottles may enhance detection of Vibrio spp.
Doxycycline or ciprofloxacin is the treatment of choice, with consideration of early referral for surgical debridement.

Figure

A: Haemorrhagic bullous lesion on the patient’s right hand at presentation caused by Photobacterium damselae infection. B: Lesion resolution 2 weeks after treatment.