The Best Australian Science Writing 2012 (12 page)

Perhaps we needed a final burst of medical reductionism at the beginning of the 21st century to sharpen our critical thinking about the way forward into an increasingly complex future in healthcare. EBM advocates have expanded definitions of the ‘E' to address their critics' complaints: ‘E' includes, now, many other forms of evidence besides RCTs, including qualitative studies, and these days EBM has abdicated absolute authority and modestly aims to serve the patient and the clinician. Perhaps it could be said that EBM in its new, revised form is helping dismantle the infant GORD epidemic like the Ouroboros, the snake swallowing its tail – what began it also ends it.

But critics remain scathing, declaring that brand EBM is intellectually dishonest in its attempts to appropriate the much
greater enterprise of understanding and improving health. It was a masculinist project, they argue. It's had its moment, left its legacy. This is the era of complexity, of personalised, patientcentred medicine, critics maintain, and brand EBM is dead.

Meanwhile, the diagnosis of GORD in unsettled babies in the first months of life is waning, although it's still surprisingly common. Now, more and more breastfeeding mothers of unsettled infants see their GPs about their complicated elimination diets, which are interspersed with food challenges. They pore anxiously over food diaries, explaining which foods have passed through their milk and upset their babies. Or they detail the various formulas they've tried. Food-allergy babies are waking frequently at night, crying excessively, crying in a piercing shriek, arching their backs, turning red in the face, flexing the knees up to the tummy, vomiting, refusing to feed.

Once again, parents are frantic. Conscientious GPs read articles about food allergies written by other specialists. It's dramatically increased in incidence over the past two decades in older children; it's a lifelong illness; it requires constrained diets and swallowed steroids; it may result in oesophageal strictures if untreated. But we are making the same old mistake of extrapolating back, diagnosing food allergies in irritable babies and prescribing PPIs in addition, just to be on the safe side.

Using the tools generated by brand EBM, we can say with confidence that the incidence of cow's milk allergy is increasing, and is a cause of unsettledness in babies. But the evidence that food allergies more generally cause unsettledness in babies in the first few months of life is unconvincing. This diagnosis appears to be another reductionist solution offered to distraught parents by concerned health practitioners in the absence of an accessible, multidisciplinary, primary care approach.

Because health systems with strong primary care are more efficient, have lower rates of hospitalisation, fewer health
inequalities and better health outcomes, the Australian government has promised to make primary care its central plank in health system reform. The Department of Health and Ageing closed down the PHCRED Research Capacity Building Initiative at the end of 2011, channelling funds into a small number of Centres of Research Excellence in primary care, so that teams of mostly postdoctoral researchers can focus on multidisciplinary collaboration, the translation of research into practice, and policy, according to priority themes. But some senior figures fear that the funding pool for primary care research is contracting with the closure of the PHCRED Research Building Capacity Initiative, and that it will be even more difficult for researchers like me, who are just starting out. Certainly everyone in primary care research agrees that if there is to be any seriously effective health system reform, primary care research desperately needs more funding.

* * * * *

In the absence of an easily accessible, multi-disciplinary, primary care approach, it is more likely that the mother of that crying baby next door may cease breastfeeding prematurely, that she may require treatment for postnatal depression, that the baby may be abused in a moment of terrible and frantic overwhelm, that the baby may require treatment once it reaches school age for long-term psychological and behavioural problems.

Recently two internationally prominent gastroenterologists published a paper proposing that acid-suppression medications predispose babies to food allergies. They cite research showing that a less acidic environment in the stomach prevents breakdown of complex proteins, at the same time as the medications increase the permeability of the gut. Absorption of undigested proteins sensitises the immune system. They argue that the dramatic rise
in prevalence of food allergies over the past two decades fits with the exponential increase in the use of PPIs in this time.

So, worse still, it seems quite possible that an epidemic of an imaginary disease in unsettled babies has created, through unnecessary medication, the misery of lifelong food allergies for some. This is a high price to pay for crying out.

A referenced version of this article can be found at .

Doctors

Babies

Earthquakes: When the world moves

Emma Young

When the ground began to shudder, Gavin Corica didn't worry about it – at least not at first. ‘It's not uncommon in Kalgoorlie to feel the ground vibrate because of the mining activity,' says the physiotherapist, who until recently had a practice in the West Australian town. ‘But then I thought that the morning was an unusual time for a blast – and then the ground started to shake sideways.'

A few seconds after that, it felt as though someone was driving a truck through the front of the building, he says. ‘I could hear all these sounds, like massive 3-tonne boulders falling and crashing on the ground, and the lights went out. That's when I, and the patient I was with, looked at each other and pretty much ran for the doorway.'

It was 8.17am on 20 April 2010, and an earthquake measuring magnitude 5.0 on the Richter scale was ripping apart the earth 10km southwest of Kalgoorlie. People reported feeling the earthquake up to 200km away, and, like Gavin's building, many others within a 10km radius were badly damaged.

Most of the world's earthquakes happen at so-called plate boundaries – parts of the planet where tectonic plates are
pushing against one another – and about 80 per cent occur around the edge of the Pacific Plate (the ‘Rim of Fire'), affecting New Zealand, Japan, the west coast of North and South America and New Guinea.

A 6.3 earthquake with a shallow epicentre struck 10km southeast of Christchurch, on New Zealand's South Island, in February 2011, turning much of the city centre to rubble and killing 181 people, and a huge, magnitude 9.0 quake (possibly the fourth most powerful ever recorded) struck off the coast of Japan in March creating a tsunami that killed an estimated 25,000 people, wiped entire towns off the map, and caused the largest nuclear disaster in history.

Australia doesn't sit on the edge of a tectonic plate. However, the Indo-Australian plate, at the centre of which our continent lies, is being pushed to the northeast at about 7cm per year. It's colliding with the Eurasian, Philippine and Pacific plates, causing stress to build up in the 25km-thick upper crust. This build-up of pressure within the plate can cause earthquakes in Australia.

In fact, Australia has more quakes than other regions that sit in the middle of plates and are considered relatively stable, such as the eastern US. ‘The level of seismicity does seem to be significantly higher here,' says Professor Phil Cummins, an expert on quakes at Geoscience Australia (GA) and the Australian National University's Centre for Natural Hazards. ‘But no one really knows why that is.'

According to recent research by GA, there's been about one earthquake measuring magnitude 2.0 or greater every day in Australia during the past decade. ‘There are likely to be many more smaller earthquakes that we cannot locate because they're not recorded on a sufficient number of seismograph stations,' says Clive Collins, a senior GA seismologist.

Western Australia is a quake hotspot, with more quakes
than all the other states and territories combined. But the GA data shows that Adelaide has the highest risk of any capital. It's suffered more medium-sized quakes in the past 50 years than any other (including one that struck in March 1954, just before the visit of Queen Elizabeth II) – and that's because it's being squeezed sideways.

In regions around plate boundaries, it's possible to predict roughly when quakes are likely to happen, as scientists know where to look for any build-up of stresses. ‘We can't predict with an accuracy that would be valuable for evacuation or early warning,' says Cummins, ‘but we can forecast pretty well that certain parts of the plate boundary might be more likely to experience an earthquake in the next ten to 20 years than others.' But for regions that sit in the middle of a plate, like Australia, quakes can strike anywhere, making prediction practically impossible.

Thankfully, most of our quakes are small, and go unnoticed, except by seismologists. But tremors of the size that terrified the residents of Kalgoorlie last April happen every one to two years, and about every five years there's a potentially devastating quake of magnitude 6.0 or more. The biggest quake ever recorded in Australia was in 1941, at Meeberrie in WA, with an estimated magnitude of 7.2 – but it struck a remote, largely unpopulated area.

At 10.29am on 28 December 1989, Australia wasn't so lucky. Thirteen people were killed and more than 160 injured after a magnitude 5.6 earthquake shook Newcastle, NSW. More than 35,000 homes, 147 schools and 3000 other buildings were damaged.

Rather than being a natural disaster, some scientists have suggested that mining might have been to blame in that case. During the past 200 years, the region around Newcastle has experienced five times more earthquakes of magnitude 5.0 or more than the rest of New South Wales combined, says Dr Christian Klose,
formerly of Columbia University in New York and now senior research scientist at Think GeoHazards, based in that city. ‘And we know that over the last 200 years, we have had mostly deepcore coalmining around Newcastle,' he says.

Some experts think this might be enough to destabilise pre-existing faults in the Earth's crust, and to trigger an earthquake. Certainly, human activity – such as large dams being filled – has been linked to quakes overseas.

In Australia, it's known that there's an increase in seismic activity as dams fill. But Klose's ideas about Newcastle are controversial. The quake happened deep within the Earth's crust, making many scientists think it was more likely to be down to natural events. ‘It's certainly possible that mining activity could cause changes in stress that might trigger earthquakes,' he says, ‘but it's very difficult to prove.'

Natural disasters

Under the surface

Seven billion reasons to be a feminist

Rob Brooks

Seven billion people: I had better write fast. Sometime between my deadline to submit this story and the time it goes live, the estimated world population will exceed seven billion for the first time ever.

As I stare at the population clock, I am paralysed at the sheer speed at which the number of people grows. I am terrified at how our world might support all those lives.

But the biggest challenge of all is how to elevate the lives of more than one billion people already alive who eke a living from less than $1 per day, so that they live a life free of famine and preventable disease.

Since at least 1798, when Thomas Robert Malthus argued that population would soon outstrip agricultural production, pessimists have foretold famine, disease and conflict if population growth isn't reined in.

But some economists and demographers don't see the problem this way. To them, Malthus was a crank who never grasped the ambit of human ingenuity. Industrialisation, slave-powered Caribbean sugar colonies and the New England cod fisheries revolutionised food production in the 19th century. Green revolution supercrops staved off Malthusian misery in the 1960s.