ANOTHER BRITISH MEDICAL JOURNAL IS HEAVILY POLITICIZED: "Lancet" meddles in Australian politics!

Though anybody who knows of their absurd "600,000 Iraqi deaths" claim will not be surprised. The BMJ has also of course long been known for its frantic Leftism. This politicization does of course explain the very low intellectual standards in both journals that I have repeatedly noted on FOOD & HEALTH SKEPTIC. With their openly avowed contempt for the truth ("There is no such thing as right and wrong") and their failure to consider ALL the facts of most matters, Leftists corrupt everything they touch

A leading international medical journal has denounced the Prime Minister and urged its Australian readers to vote against him in the election. In an editorial titled "Australia: the politics of fear and neglect", The Lancet said John Howard had jeopardised Australia's enviable reputation in medical science with his suggested ban on HIV-positive migrants. It also censured the Health Minister, Tony Abbott, for saying those who spoke up for indigenous health were "simply establishing politically and morally correct credentials", and criticised the Environment Minister, Malcolm Turnbull, for his stance on climate change. It said Australian politicians were scoring below par on health.

The journal said Australian clinical and health research was "an emblem of excellence" in the Asia-Pacific: "That enviable position is being put at risk by Prime Minister John Howard's indifference to the academic medical community and his profound intolerance to those less secure than himself and his administration."

The latest example was his comment last week that HIV migrants should not be allowed, says the journal, whose editor, Dr Richard Horton, spoke at a conference on global health in Sydney this month. "To any visitor, Australian culture feels progressive and inclusive," The Lancet says. "This attractive exterior belies a strong undercurrent of political conservatism, which Howard is ruthlessly tapping into." The Lancet has a significant readership throughout the world and regularly takes a stand on key medical issues.

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Conservative climate skepticism in South Australia

A SOUTH Australian Liberal senator has signalled a hardline policy on tackling climate change by dismissing man-made pollution as a cause of global warming. In an essay urging scepticism on global warming published on the AdelaideNow website, Senator Cory Bernardi argues science is being distorted and manipulated to present a one-sided view to the public. Senator Bernardi is a confidant of Finance Minister Nick Minchin and Foreign Affairs Minister Alexander Downer and his views are likely to have considerable support at senior levels of the Federal Government. It is understood his essay is intended to signal future government policy aimed at prudent measures on climate change, rather than drastic action.

"I have come to believe we're seeing a distortion of a whole area of science that is being manipulated to present a certain point of view to the global public, that is that the actions of man are the cause of climate change," he writes. ". . . I have examined both sides of this debate and, when the alarmist statements are discounted, the scientific evidence that remains does not support the scenario that is being presented to us. The facts do not fit the theory."

His views are a direct contradiction of a wide body of scientific research, most notably the Intergovernmental Panel on Climate Change's "very high confidence" that human activities have contributed to global warming. Australia Institute executive director Clive Hamilton, writing in The Advertiser Review liftout, argues the Government's greenhouse policy has been determined for a decade by "a cabal of powerful fossil-fuel lobbyists" whose commercial interests would be harmed by cuts in carbon emissions. But Senator Bernardi says the existence of climate change itself is not contested - arguing Earth's climate "has continually evolved and changed". He says it is the extent of man's contribution that is in doubt.

"The more you read into this situation, the more the claims that man-made carbon dioxide emissions are responsible for our warming climate do not add up," he says. "However, to deny man's contribution is to risk the wrath of those looking for a set of circumstances to suit their own agendas. "This is of great significance, since governments of the world are facing intense political pressure to act immediately to reduce human carbon emissions."

Prime Minister John Howard has declared himself a "climate change realist" and is expected to introduce a national emissions trading scheme after receiving a report on the issue by the end of next month.

Opposition Leader Kevin Rudd in Washington yesterday urged the U.S. to ratify the Kyoto protocol, saying climate change was the great moral, environmental and economic challenge facing the world. "On this question, our respective national positions are compromised by our refusal so far to ratify the Kyoto protocol," Mr Rudd said.

Senator Bernardi challenges scientific consensus on man-made carbon emissions causing global warming, saying "there is equally enough evidence to the contrary" and even "scientists on the IPCC concede there is room for doubt". He argues that "populist sentiment" is being exploited politically, particularly "by those that have strong anti-Western and anti-industrialisation agendas". "This populist pressure to immediately reduce carbon emissions, based on increasingly disputed extreme scenarios and without consideration of the true cost to our prosperity should really make us question the wisdom of changes such as those proposed by federal and state Labor," Senator Bernardi says. Labor proposes cutting greenhouse gas emissions by 60 per cent of 2000 levels by 2050 and introducing a national emissions trading scheme by the end of 2010. "As of yet, Labor has neglected to provide any details as to how they will achieve this emissions cut . . . although one thing we know for sure is that nuclear energy is ruled out," Senator Bernardi says.

The Federal Government is urging consideration of nuclear energy as a low-emission alternative for electricity generation. Dr Hamilton argues "there is compelling evidence" that the Government has both quarantined Australia from global efforts to tackle climate change and "actively set out to sabotage the Kyoto protocol".

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Double jeopardy: It is only sensible that the law keep pace with technology

IN the grand tradition of English law, a person convicted of a crime has the right to appeal against their conviction. It's a one-sided game, because the prosecution does not enjoy the same right. For more than 800 years, a principle known as "double jeopardy" has applied. It means that a person cannot be tried twice for the same crime, even when fresh, compelling evidence emerges. It is time to balance the ledger.

Advances in technology, particularly DNA technology, mean that many so-called cold cases are now being solved as new evidence becomes available. It is common sense that if powerful evidence of guilt exists, it should be put before a court. Of course, there must be limits. New trials should not be ordered simply because a witnesses decided to change their story, or because police failed to properly gather all available evidence. There must be some certainty. It would be intolerable for a person to be tried and re-tried for the same offence. This is why double jeopardy laws were enacted, to stop a person from being subjected to repeated or vexatious prosecution by the state.

The Council of Australian Governments, which this week agreed to reform the double jeopardy principle, has come up with a good compromise. The principle would remain but exceptions would be made where there is fresh, compelling evidence, such as new DNA evidence. Exceptions to double jeopardy would apply only in the most serious criminaloffences such as murder, manslaughter, aggravated rape and armed robbery.

The Director of Public Prosecutions' consent would be required and there would have to be a good reason why the evidence was not presented at the original trial. The NSW Government was the first to abolish the double jeopardy principle, saying there should be retrials of serious cases carrying a sentence of 20 years or more if fresh evidence emerged. The reform needs to be extended across the nation, so that criminals cannot move out of NSW. The public has indicated a desire for change. One case in particular comes to mind: Greg Domaszewicz, was acquitted of Jaidyn Leskie's murder or manslaughter in 1998. An inquest later found Mr Domaszewicz had contributed to the toddler's death and thrown his body in a dam. For 800 years, lawyers have lived by the maxim: it is better that 10 guilty men go free than one innocent person is convicted. Yes, but if new evidence is found, justice must have every chance to take its course.

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A deeply corrupt State public hospital system

Two contradictory pieces of advice about cancer treatment for Maryanne Smith* led Maryanne and her husband, Michael*, to question a doctor's competence. In the beginning, all they wanted was a straight answer. But as the Sydney South West Area Health Service obfuscated and the shutters came down on a bureaucracy used to getting its own way, it turned into so much more.

Almost 2« years after their initial complaint, Maryanne Smith is gravely ill and only one thing is clear: NSW has learnt little from the bitter and heartbreaking patient safety scandal at Camden and Campbelltown hospitals. A Herald investigation has found that the internal inquiry into the Smiths' complaints against Concord Hospital was conducted with little regard for fairness, key doctors were not interviewed and the results were heavily censored. A specialist who supported the Smiths was investigated in an attempt to silence him and the doctor alleged to have given the contradictory advice continues to practise.

The dispute shines a light into the often murky dealings of the state's health system. It leads along a trail of relentless and expensive legal action against doctors and through a complaints handling system that in some hospitals still seeks to silence rather than openly discuss problems. In this world, there is no resolution for anyone: not patients, and not doctors or other health professionals.

There are an estimated 8000 deaths in Australia each year as a result of medical errors, more than the annual road toll of about 1600. Hidden beneath innocuous labels such as "complications", "misadventure" and "sequela", these deaths and injuries have become an accepted part of health care, experts argue. "Harm caused by health care ranges from the mundane to the catastrophic, from a small skin tear on the arm of a frail, elderly patient being helped into bed, to quadraplegia or death," say Merrilyn Walton and colleagues Bill Runciman and Alan Merry, the authors of the recently released Safety and Ethics in Healthcare. "These problems were, for many years, viewed as part of the price to be paid for the great benefits of modern health care."

Walton, an associate professor of medical ethics at the University of Sydney who was NSW's first health care complaints commissioner, is incensed that governments have not moved faster to prevent the rising toll of serious harm and deaths from medical errors. "I am talking about system errors that are getting repeated and repeated - at some stage the governments in this country are going to have to be brave and deal with this," she says. "We have acknowledged there are a high number of adverse events, but we haven't gone the step further . that means confronting some hierarchies around the design of the system to force change."

In addition, violations of basic standards of care are tolerated daily, she warns. "Routine violations happen, for instance, around handwashing . a system that tolerates routine violations is a dysfunctional system and yet it happens regularly in every hospital because there are no consequences."

The authors say that 10 per cent of admissions to acute hospitals are associated with an adverse event. In NSW, where government figures put the annual admission rate to acute care hospitals at 1.3 million a year, that means up to 130,000 patients are being harmed or experience near misses each year.

The Smiths are waiting to hear whether the Independent Commission Against Corruption will investigate their concerns. The director-general of NSW Health, Robyn Kruk, referred the case to the watchdog just weeks before last month's state election. Since then, there has been a familiar refrain from bureaucrats and politicians: "I cannot comment on a matter that is before ICAC."

The poor advice Maryanne Smith received may not have been a medical error that resulted in death, but even small mistakes can lead to prolonged suffering, delayed treatment, more pain and unnecessary confusion.

NSW Health is fighting a war on several fronts, some official, others under the radar. Camouflaged in carefully written policies and the weasel words of bureaucratise, the state's health officials and the revolving door of ministers have sought to convince a sceptical public the NSW health system is safe. After surviving the horror years of multiple investigations into 19 patient deaths at Camden and Campbelltown hospitals, two other state-run hospitals have been called to the NSW Coroner's Court this month to explain themselves. The court is separately investigating the deaths 18-year-old Jehan Nassif, who died from meningococcal disease at Bankstown hospital last year, and Vanessa Anderson, 16, who died at Royal North Shore Hospital in November 2005, three days after being admitted for a head injury. She was treated by overtired and junior staff, after the hospital had been warned about a potential staffing crisis.

The inadequacies of our mental health system were also laid bare this week with the news that in 2001 a teenager was discharged from a psychiatric unit without treatment or medication after a suicide attempt, and then became a quadriplegic after another suicide attempt days later. He is suing the Sydney South West Area Health Service for negligence.

Add to that a steady stream of specialists leaving the public health system citing flagrant breaches of patient safety as a factor and one thing becomes abundantly clear: it is only a very thin veneer of safety and accountability that cloaks our public hospitals.

Maryanne Smith had a slow-growing tumour and was referred to a doctor then on staff at Concord Hospital in June 2003. She was advised, as a matter of urgency, to pursue a particular form of treatment. "I cannot overemphasise to you just how strongly [the doctor] advocated that I agree to submit to an urgent . treatment," Smith wrote in her first letter of complaint to Concord Hospital on November 28, 2004. "In contrast, none of my former specialists . ever spoke to me in terms of such urgency."

Alarmed at the doctor's approach, she returned to her regular doctor, who reassured her that her condition did not yet need to be treated with urgency. By April 2004 the cancer had progressed and she was again referred to the doctor at Concord. This time he gave her advice that she says contradicted his earlier recommendations. "This time he stated very definitively that [treatment] would in no way reduce the bulk of my tumours. Both my husband and myself left this second appointment somewhat confused and distressed." Again, her cancer specialists were perplexed by this advice and she was referred to a second specialist at Concord. That second specialist told her the therapy would help reduce the bulk of her tumours. After careful consideration and much angst, she had the treatment.

The doctor in question has denied many times that he gave Smith conflicting advice. When the couple complained about the inconsistencies in his advice and attitude, they were assured by senior health bureaucrats his performance had not been called into question. Yet information they obtained under freedom of information laws tells a different story. It shows multiple concerns have been raised about the doctor's performance - and that his own colleagues had complained about his clinical and professional behaviour, some as far back as 1998.

Four months after her initial complaint, the area health service wrote to Smith, rejecting her allegations and giving the doctor's interpretation of the two consultations. The cover-up had begun. Infuriated, she wrote a second letter of complaint in August 2005. She believes the doctor falsified his notes from their meeting, and one of the findings from one of the three investigations into this issue showed the doctor had not taken contemporaneous notes at his consultations, in contravention of NSW Health and hospital policy.

Beyond the doctor's treatment of Smith, there were other serious problems relating to his performance, a senior staff specialist told the Herald. "I had innumerable clinicians complain to me about what he was doing," the specialist says. The most serious complaints relate to allegations that patients had received radiotherapy unnecessarily because the doctor had mistakenly interpreted bone scans as showing the presence of cancer. The specialist wrote his first letter to a senior hospital bureaucrat in April 1998, warning that the doctor's performance had "reached a dangerous level, impacting on patient care". "I personally had to intervene to stop one such patient being treated with high-dose radiation unnecessarily," the specialist says. On another occasion, the doctor prematurely and wrongly stopped a patient's therapy, he says.

In October 2005 the doctor again denied Smith's allegations in a letter to South West Area Health Service obtained under FoI laws. "I have not 'lied' to any person or intentionally misled them. I . can only reiterate my recollection of the consultations with the support of my letters to her referring physician," he writes. "I regret [Smith] has the perception I closed the door to discussion about possible . treatment. This was not my intention."

More correspondence followed - much of it written by Michael Smith as he repeatedly laid out the initial complaints his wife made about her treatment, followed by a growing number of complaints about their treatment by the area health service's bureaucrats. In May last year the Smiths received a four-page letter from Mike Wallace, the chief executive of the newly formed Sydney South West Area Health Service, saying an investigation had been completed and 49 recommendations had been made. Despite repeated requests, Wallace would not release the recommendations or discuss the findings with the couple.

All the area health service would tell the Herald is this: "The chief executive has referred this matter to the Independent Commission Against Corruption . on 24 January 2007. It is therefore inappropriate for the area health service . to comment. In mid-2006 the AHS offered to meet with and mediate with the family through the Health Care Complaints Commission. This offer was not taken up."

A spokeswoman said the doctor whose performance was in question had "fully co-operated with the investigation into the . family's complaint. The investigation found that there was a difference of opinion about the information conveyed by [the doctor] at the two consultations with [Maryanne Smith]."

Cliff Hughes, the chief executive of the NSW Clinical Excellence Commission, is a former senior cardiac surgeon who faced his demons as a young doctor in the public system. He is a strong believer in being up-front with patients about errors, and encourages his colleagues to do the same. And despite the problems in the state's health system, he is determined that patient safety will improve under his watch. "We are at one stage along a very rapidly progressing path - in most of the areas I think NSW is leading the procession down this path," Hughes says.

Eradicating medication errors - one of the most common causes of harm - is high on the list. The introduction of a national in-patient medication chart goes a long way to ironing out common problems and mistakes, he says. Anticoagulants such as warfarin have been tagged as a major problem, mostly because until recently such drugs have usually been dispensed about 9pm, after the prescribing doctor had gone home. Modern lab techniques mean blood test results - vital for deciding whether the drug is needed and in what quantity - are now available much earlier in the day. That means the doctor who ordered the tests in the morning is still on duty when they come back in the afternoon, Hughes says, reducing the potential for communication errors between shifts.

Another project Hughes says will reduce harm to patients is the campaign to reduce the number of unnecessary blood transfusions. "Blood is a good product but it is not entirely safe, there is the risk of both minor and major infections, immune reactions and so on," he says. "The evidence that we have collected indicates that we can reduce the level of blood usage by about 10 per cent or so across the system."

The prevention of hospital-acquired infections, via a handwashing campaign and a project on intravenous lines, as well as a falls-prevention campaign, a program to reduce aspiration pneumonia in stroke patients and a clinical leadership training package are all new, positive steps.

But even Hughes admits that guidelines are not enough. There are still 400 to 500 events in NSW that cause serious harm or death to patients each year, he says. "The real change is the whole of the system wants to measure themselves regularly, that is the big change from pre-Campbelltown days . we have got a whole system, all 108,000 [health system employees], who can report [errors] and when they report, we can take action." He acknowledges some are still reluctant to throw themselves on the mercy of the system - particularly when individuals are wrongly singled out for blame in a system where errors occur mostly as part of a chain of events. "We need to recognise there are always going to be people who are frightened of what has just happened or what nearly happened, who don't quite know what they should do and are worried about retribution."

Is change happening quickly enough? "All of us . where the risks are patients lives or wellbeing, want to move faster," Hughes says. "I don't believe NSW Health is in crisis, but we have recognised the urgency of all of these programs - it can be expensive at times, it can be draining at times, it can require more personnel at times, but we must move forward."

It could have been so different for the Smiths. This dispute could have ended so many times in the past 2« years - if the hospital or the area health service had conducted a proper investigation and if the Smiths had felt their complaints had been dealt with seriously. There were many opportunities to do it right. But what began as a simple complaint about conflicting medical advice became a lesson in dealing with the dysfunctional and bullying bureaucracy of one of the state's largest area health services.

The Smiths are idealists. They believe public servants should serve the public. They are livid at what they see as the misuse of power by senior bureaucrats who backed a doctor whose clinical skills were under a cloud following the persistent complaints from his colleagues, patients and their families.

The NSW Ombudsman and the NSW Medical Board have received complaints from the Smiths, as have the Health Care Complaints Commission, Medicare, NSW Health and the NSW Health Minister. It is unclear how those complaints are progressing.

Since the multiple inquiries into patient deaths at Camden and Campbelltown hospitals, NSW Health has gone some way to addressing medical errors and how they are investigated. Clinical governance units have been established in all health services and the Government is spending $60 million over five years to implement its patient safety and clinical quality program, a spokesman says. "The NSW health system has adopted the 'open disclosure' standard . [that] aims to promote a consistent approach by all hospitals to open communication with patients . following an adverse event." Yet for all the talk about a system of open disclosure of errors, about involving patients more in the process of health care, it seems NSW public hospitals and the bureaucrats who run them have a lot to learn.

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