[00:00:00] Dr Sanjaya Senanayake: Hi, this is Dr. Sanjaya. Do you know much about pill testing, and have you ever heard of pandemia research? In the latest episode of Behind the Curtain, I chat to Dr. David Caldicott about his nation leading work in pill testing, the motivation that drives him and how he balances this with his day job, the fast-paced hustle and bustle of emergency medicine.

Let's jump into our chat.

Hello. Today on our podcast, we have a very exciting guest.

[00:00:46] David Caldicott: Stop it.

[00:00:47] Dr Sanjaya Senanayake: Yes. No, no. Okay. We don't.

[00:00:50] David Caldicott: Mundane. I'm mundane.

[00:00:52] Dr Sanjaya Senanayake: Now, as you can tell, this should be a very interesting interview. We have with us David Caldicott.

[00:00:58] David Caldicott: Hello. How are you?

[00:00:59] Dr Sanjaya Senanayake: I'm doing very well.

[00:01:01] David Caldicott: You look well.

[00:01:02] Dr Sanjaya Senanayake: Oh, thank you. You do too.

[00:01:03] David Caldicott: Yeah, I mean, I know that you didn't think that this was happening, but for somebody who's rushed across campus to do this interview, you look fantastic.

[00:01:11] Dr Sanjaya Senanayake: Oh, look, thank you very much. Yeah, look, I always try to maintain my composure.

[00:01:15] David Caldicott: Yeah and fitness, you look fit.

[00:01:18] Dr Sanjaya Senanayake: Looks can be deceiving. Now enough about me though, regarding you and your career, it sounds like you started life off in Ireland?

[00:01:28] David Caldicott: Uh, look, no, in fact, I have a sort of a Borne Identity background. I'm an academic brat. So my father is or was a professor of French.

He's retired and we travelled around on his coattails. So, I was born in Scotland. Where he was at the University of Glasgow.

[00:01:48] David Caldicott: And looking forward to getting my Scottish passport as and when they become independent. We moved to Canada and lived in Canada for 10 years. And I'm a Canadian citizen as a consequence of that.

Moved back to Ireland, went to school in Ireland. Did my first university degree in Ireland. And then did my medicine in London at St. Mary's Imperial College. Following a catastrophic, a sort of a tectonic failed relationship, I moved to Australia because it was the furthest place I could find.

And that's my connection to Australia. That's how I found myself here.

[00:02:25] Dr Sanjaya Senanayake: Yes. I mean, there are a lot of Europeans I speak to who would love to visit Australia, but then they say: oh, it's so far away.

[00:02:32] David Caldicott: Yeah. Oh, it's miles away. In fact, if you take a knitting needle and if you had a beach ball of the planet and punched it through orthogonal to the surface of Ireland, it would come out in Australia. It's the furthest place you can get.

[00:02:45] Dr Sanjaya Senanayake: Exactly.

[00:02:46] David Caldicott: Exactly.

[00:02:47] Dr Sanjaya Senanayake: And look, you've told us where you did medicine. And you told us how you got to Australia. How did you end up doing emergency medicine?

[00:02:57] David Caldicott: Oh, look, I never intended to do emergency medicine, mate.

I was going to be a Virologist. So my first degree was a microbiology degree and I was advised by Irene Hillary, who was the boss of the Virus Reference Lab in Ireland at the time, that I could either do a PhD and see how I went or I could just do a medical degree. Medicine was the easy cop out portrayed by the scientists, just do the medicine and you'll always have a job and then you could do virology.

So I cast around and there was a very good, this was at the time when HIV was just sort of breaking out, and there was a very good centre in Imperial College, the Jeffries Unit at St. Mary's. I thought, well, I'll go to St. Mary's and inveigle myself there, and while I was doing my undergraduate studies, I was involved in writing and some acting, and I was asked to provide the casualties for a course that was just emerging in the UK called ATLS, or as we know in Australia, EMST, and then I discovered there was this strange, I'd never heard of it, this strange subset of medicine where the extremes of life presented themselves and people screamed and abused each other and there was blood and faeces and I was sold.

And they pinched me from a career in virology to emergency and I never looked back.

[00:04:36] Dr Sanjaya Senanayake: Oh, wonderful. Yes. It sounds a bit like a Euro Cup final. And so it would have been an emerging sub-speciality at that time.

[00:04:51] David Caldicott: Oh, Australia was always ahead of the UK. So you had a college long before us.

So there was no emergency college in the UK at that stage. We were still frequently called casualty, and the way into doing casualty was either through physician or surgical training. And I did mine through surgical training.

[00:05:13] Dr Sanjaya Senanayake: Okay. While you were doing surgical training, did you ever think, oh, maybe I could be a surgeon?

[00:05:18] David Caldicott: Oh God, no, no, no, no. I love the surgery. Absolutely love the surgery, but didn't quite fit into this surgical mould. There's a type of person, and they're lovely people, who do surgery. And that's not me. I love the hand stuff. I love the work of surgery. Particularly in the UK, the cronyism and that sort of sponsorship of people who went to certain schools or the familial connections. I never had any of that and so I was never going to succeed in that space. I think the emergency thing is very much like, or has been traditionally, like the Cantina of Mos Eisley in Tatooine where everybody can go there and it's just erratic. And you're judged on your merits. And it doesn't matter who you're related to, what language you speak, where you're from, if you can walk the walk, then you're permitted.

[00:06:24] Dr Sanjaya Senanayake: Yeah, that sounds great. And just picking up on one of the points that you made, whenever my medical students or junior doctors are uncertain about what they should do, I always tell them, just look to a subspeciality and find the people who have a personality like yours.

[00:06:45] David Caldicott: Yeah, I think you're absolutely right. Victoria Brazil talks about the tribes of medicine. I think there are tribes, they overlap. For example, our tribe and emergency, it overlaps with retrieval with critical care with ICU. In Australia, very much overlaps with the rural GP.

That sort of autonomy, resilience, occasion towards bending rules. There are subspecialties in medicine that will absolutely not tolerate any broach in the rules. That's not us. The other thing I think that's terribly important is do the things that you love. Don't think do the things that you think you ought to or that are expected of you. Until you find that which you love in medicine, keep looking, don't settle.

It's like marriage.

[00:07:36] Dr Sanjaya Senanayake: No, no, no. Exactly. Exactly. That's right. So, and I really like that analogy with the tribes. I'm going to use it in the future. And have you had any yearnings to go back to the virology / microbiology side? I ask as an infectious diseases physician.

[00:07:52] David Caldicott: Yeah, look, I mean, it features greatly in my line of work and I find that very useful.

I'm more recently interested in pandemia and the world of pandemia and disaster medicine. And so from that perspective, I'm fascinated by that. Once I know what I'm dealing with in emergency medicine, I become less interested. Because once you've got a diagnosis, then there is a pathway for treatment.

So that which is unknown, unexpected, and a little bit, you know, potentially dangerous, that's fascinating. And of course, the future of our planet is going to be very much determined by the spread of infectious diseases which are consequent upon the changes in our climate. So it's going to be, maybe not for our generation, but for the next generation, critically important that, you know, what is your disease X and what's next coming down the track?

[00:08:52] Dr Sanjaya Senanayake: Look, I think you've raised a really important point for medicine, the practice of medicine, whether you're in general practice or a hospital based speciality, et cetera, is that at the end of the day, although you're doing a lot of good and helping a lot of people, if you're doing the same thing for 30, 35 years, which nurses often don't do because nurses move to different careers, they're very good at that, getting that variety, but we're in fact limited in some way by our training. You do find that even though you're doing a lot of good, you can get bored. So it is really important to find things within your specialty or outside it to keep you stimulated.

[00:09:31] David Caldicott: Couldn't agree with you more.

There comes a time in medicine where you've actually, genuinely seen most things in your field. I had great bosses, Jane Fothergill and Robin Touquet, when I was starting off on this trip, who advised me of the importance of having a portfolio of things that interest you. Certainly things that are adjacent to your chosen speciality, but something you can drop out of and do something else every now and again.

So, you know, in general, I think things like lecturing, teaching, writing, and then within those sort of subsets, variants on what you enjoy doing. And for me, that's catastrophe and the apocalypse. I enjoy anything that looks like that.

[00:10:22] Dr Sanjaya Senanayake: Yeah, so you enjoy the apocalypse.

[00:10:27] David Caldicott: Yeah, well, somebody's got to prepare for it.

[00:10:29] Dr Sanjaya Senanayake: That's right.

And look, talking about things you enjoy, I can't ignore the little badge you've got.

[00:10:34] David Caldicott: Oh, it's so rude of me. I can't believe. Here, you have one now as well. You're very welcome.

[00:10:42] Dr Sanjaya Senanayake: This is a podcast, but Adjunct Associate Professor David Caldicott has presented me with a Pill Testing Australia badge.

[00:10:49] David Caldicott: Highly limited, highly limited edition.

[00:10:52] Dr Sanjaya Senanayake: Yes, and of course, I will treasure this.

[00:10:55] David Caldicott: Please, wear it everywhere.

[00:10:56] Dr Sanjaya Senanayake: I'll wear it everywhere, indeed. Tell me about pill testing. Is that one of those areas that have allowed you to sort of enjoy medicine?

[00:11:06] David Caldicott: Very much so. Very much on a number of different levels, I think, as an Irishman, you know, and maybe for yourself as well, there's a sneaking love of disruption and being disruptive in a positive way is fun.

You know, people talk about disruptive in the sense of school and detention, but in fact, disruptive as far as industry is concerned is something that people hire for. Changing drugs policy and the face of drugs policy in a very conservative environment such as Australia, which many Australians may not regard as being very conservative, has been one of the most enjoyable projects that I've been involved in.

Over 25 years it's taken. So, as far as pill testing is concerned, that started when I was working in Adelaide. I treated a young man who, this project is the legacy of that young man who died from an overdose of a drug called paramethoxyamphetamine. And no matter what we did, you know, we spent seven hard long days trying to resuscitate him.

And he died. And as a young registrar, you might even remember what that was like. The hubris is still there. You still think that nobody should die on my watch and just watching somebody die, no matter what we did, was impossible to tolerate. So I went away and thought long and hard and looked around at who else was doing other things and came across this extraordinary endeavour out of The Netherlands in which young people were being told what was in their drugs.

And lo and behold, when they were told it changed their behaviour. I was quite convinced that that was the way forward. And there were many who weren't. It's been fantastic to help the evolution of this project and in fact the manifestation of this project in the ACT. The ACT is my little home now and it is this environment, and perhaps the only environment in Australia, where such a project could have been first realised.

[00:13:28] Dr Sanjaya Senanayake: I was going to ask you about that because you said this happened in Adelaide. I guess you're still a registrar, not a consultant. But would it have been difficult or impossible to start in South Australia or Adelaide?

[00:13:39] David Caldicott: Oh, there are so many elements to how things change. The French have got a fantastic word, which doesn't translate very easily, which is terroir.

The soil in which you grow a grape determines the quality of the wine and the outcomes. And the terroir can be the timing, the atmosphere, the soil itself, and the skills of the grower. It did not seem reasonable to me to not debate these issues, which in retrospect, I understand was quite unusual for Australian doctors. But the medical fraternity in the UK and Ireland is considerably more verbose and opinionated right from junior doctor level.

And so I found myself in thrust into the spotlight on issues of drugs policy. And that's where this battle started 25 years ago.

[00:14:42] Dr Sanjaya Senanayake: I have spoken to one of our previous guests about Canberra, the ACT being a great place to get things done. Because even though it's small, it's the federal capital, you've got all the federal health departments, you've got the ministers nearby, you've also got the territorial legislature and government nearby.

So did you find this helped setting up?

[00:15:07] David Caldicott: Oh, very much so. So at the time, just as a by the way, and I'm sure he won't mind me talking about it, the CHO was Paul Kelly. We plotted this in the Double Shot in Dickson. In the ACT you have access to everybody. Everybody is in each other's kids' class.

So there's a social connection. I met with law enforcement, and some of their kids were in school with my kids. And so it's not just an official discussion. Canberra is very much a community and people talk. This is a cliché, it's a big country town, maybe. You know, it's like a halfway decent European city, actually.

I don't mean to be sort of too patronising, but I've always regarded as Canberra as the most approximate to an international city. There are many cities around Australia that would regard themselves as international cities, but in true internationalism and true adaptation of novel ideas and having a proper discussion about issues, the ability to meet up with our local legislators and federal legislators.

There's lots of people who have got strong ideas. We've got two universities. This is an intellectual town. And that's hard to say for potentially other towns around the country.

[00:16:37] Dr Sanjaya Senanayake: And I always say that whenever you go to a dinner party in Canberra, you're bound to meet some really interesting people, which can't be guaranteed in Sydney, Melbourne, Brisbane.

[00:16:47] David Caldicott: And have that level of conversation. So in Ireland, there's an expectation that everybody should be in some way a renaissance person who can chat about everything. And one of the worst things about medicine, and for anybody, is being stuck at a medical party or a medical function and just talk medicine.

That's the last thing I want to do. I want to talk geopolitics, the future of the planet, poetry, music. I want everything else because I do medicine hard when I do medicine. I want something else. I'm very happy to chat to people intermittently. But in Canberra you can meet those people who you can discuss everything with.

[00:17:27] Dr Sanjaya Senanayake: Yeah, that is true. So I think that's one of the great attractions of Canberra. For people in the health care industry who want to come down. You can get a lot done and meet the right people, not just formally, but socially as well.

[00:17:40] David Caldicott: Yeah, my father's an academic, and he mocked me roundly for sort of going out to the sticks until he discovered it.

[00:17:47] Dr Sanjaya Senanayake: Did he do it in French?

[00:17:48] David Caldicott: He would do occasionally, except it backfired because now my children are in a French school. So my children are having an international education in Canberra. It's a public school and they speak better French than I did at their age, me having lived in France for several years.

So those opportunities exist here. You know, we can live vicariously through the opportunities that are created by the diplomatic services and politicians. So those opportunities are for everybody who lives here.

[00:18:24] Dr Sanjaya Senanayake: And David, now, going back to pill testing.

[00:18:27] David Caldicott: Yes.

[00:18:28] Dr Sanjaya Senanayake: So, how, it's been around for a few years now. Is it being more accepted nationally and are we seeing good results coming out of it?

[00:18:38] David Caldicott: Yeah, sure. So we started doing pill testing in the ACT in 2018. That was at music festivals. The success of that and the independent evaluation of that was such that the government was persuadable to countenance a fixed site. So the vast majority of people…

[00:18:58] Dr Sanjaya Senanayake: Federal or the ACT?

[00:18:59] David Caldicott: ACT Government. So the vast majority of people don't use their drugs at festivals, they just use them during the year. So using just festivals for testing drugs is a missed opportunity.

So in 2022 we opened CanTEST and this year we've had our funding renewed. As a consequence of the successes that we've been able to build on here, we've been able to encourage other jurisdictions like Queensland to take it on. We provided the first festival testing this Easter. It's a festival in Queensland called Rabbits Eat Lettuce. And as you might have heard, Victoria has just announced that they're going to drop four million into a project in Victoria this summer, which is fantastic news.

All the time, you know, people coming to us for advice and providing some information about how we do it. This is something that's been going on since the 90s around the world, but our argument has always been that to get this off the ground in Australia, we would probably have to design and provide an Australian service that didn't scare the horses in Australia.

Australians have been told an awful lot about illicit drugs. Much of it is untrue. And so to provide a counter narrative, we have to be very careful about the sort of service that we provide and be very clear that this is not about encouraging drug use, but to allow kids to come home safely to their parents.

[00:20:39] Dr Sanjaya Senanayake: I guess if a couple of your KPIs were to save lives with the pill testing program, CanTEST, and get it accepted more widely in Australia, it looks like you've certainly achieved that with Queensland and Victoria coming on board. And have you saved lives? Can you say that you've saved lives or is it hard to do that?

[00:21:00] David Caldicott: You know as well as I do, it's very hard. It's not as cut and dried as it is with an individual who you might give an antibiotic to. So the purpose of drug checking, as it's called internationally, or pill testing, as the local population seems to like calling it, is to, as you say, stop people being harmed.

I'm certain that we've been able to do that. The level of harm that some of these drugs can cause would suggest to me that we might have saved some lives but we certainly reduced the hospital burden. So we're very clear in our evaluations that we can change people's behaviour. So without the service that we have, people just eat what they've got without knowing what it is.

With the service we provide, we can change the behaviour of about three quarters of people. There are some people who we just can't change their behaviour because that's what they're inclined to do. So, what we can do is provide information where people are going to use less of what they thought they were going to use.

They are not going to mix their drugs. They are not going to drink alcohol and then use their drugs. So, the alcohol consumption changing their risk assessments. I think we can change behaviour in such a way that it stops people requiring health care services and certainly stops drug overdoses.

And some of those overdoses would have resulted in deaths. The other side of the coin of drug checking is that we become one of the most sensitive indicators of what's on the market. Not that which is vicariously tested by customs, but what do people want, what are people pursuing and what are they consuming.

And so we are sampling at the point of consumption, which no other methodology does in Australia, which I think is why so many other jurisdictions are interested. You've probably heard about fentanyl, haven't you, outside of the medical context? So the problem of fentanyl in the United States is dark.

It's horrible. There are more people dying from fentanyl overdose than from firearms injuries in the United States at the moment. And that's saying something. And so we've been on the lookout for fentanyl in a very significant and concentrated way and not really found any in Australia.

But what we have found are another character, another dark character in this story called the Nitizines. And we were, of course, some of the first to have discovered them in Australia through our testing service. It would be exactly the same as you finding the next COVID super early and being able to get the message out super early through your public health networks.

We can do exactly the same thing. The sad thing is to date is that we don't have the fantastic federal resources for infectious diseases that exist in Australia but hopefully as this type of service rolls out elsewhere, we'll be able to compare and track the spread of drugs across Australia and provide the necessary warnings as they come out.

[00:24:22] Dr Sanjaya Senanayake: And you did mention this, but I'll mention it again. So for people who come to have their pills tested, you also provide counselling around the use of drugs as well. So it potentially can help them change their behaviours and practice more safely.

[00:24:37] David Caldicott: In many ways that's the secret sauce. So we use the identity of people's product as a currency with which to attract people who frequently have never spoken to anybody about their drug use or have been lectured to about their drug use by a giraffe.

Because I believe that's the most sophisticated school education program that we have regarding drugs. We are providing tailor made, generationally appropriate, advice to the highest risk group of people who are out there, which are those people who are committed to using drugs. We are delivering something that hasn't been seen in Australia and largely hasn't been seen for political reasons.

The evidence that this works has been around for a decade and the opposition now is mostly ideology.

[00:25:36] Dr Sanjaya Senanayake: Look, we could talk about this for...

[00:25:38] David Caldicott: We should talk about it! What else do you want to talk about?

[00:25:40] Dr Sanjaya Senanayake: Well, you also mentioned your Masters of Disaster Management. Tell me a bit more about that. What got you interested?

And what do you see its relevance in Australia?

[00:25:51] David Caldicott: I think people who are watching where the wind is blowing probably understand that the experience for our children is likely to be very different than our experience as humans.

[00:26:07] Dr Sanjaya Senanayake: Particularly if the wind is carrying anthrax spores.

[00:26:09] David Caldicott: Yeah, anthrax spores or indeed soot.

[00:26:14] Dr Sanjaya Senanayake: White powder or black powder?

[00:26:16] David Caldicott: Yeah, it's a dangerous world in which our kids are growing into. And we're seeing cliched things that we're not paying much attention to like climate change. The geopolitical instability that comes with that.

I think our children are going to be growing up in a much more unstable world. And I want to be able to do something that can mitigate against the negative experiences that they are inevitably going to have. Two years ago, I presented at the WADM, the World Association of Disaster and Emergency Medicine Conference, on Australia being the sandpit of the apocalypse.

The only people who don't realise how much trouble Australia is in are the Australians. By 2050, we're unlikely to have enough potable water. We're unlikely to be able to control bushfires. And we need to start thinking about that right now. So we need to look at horizons. This is similar again to disease X, to drug X, to disaster X.

That which we can't anticipate is likely to be the thing that bites us on the arse. So I enjoy that anticipation. There's not a lot of good disaster training in Australia just yet. We're looking forward to changing that. So I did my European masters out of the University of Piedmont Oriental.

That's what I've just finished and just written and submitted my thesis late, impossibly late, but it's finished.

[00:27:59] Dr Sanjaya Senanayake: Fantastic. Well, that is a great achievement in itself. And that is interesting, because if you immediately say you've done a Masters of Disaster Management acute mass trauma like a shooting. But certainly, what you're saying, you're looking at more long-term disasters.

[00:28:16] David Caldicott: Very much in your neck of the woods as well mate. Because I know you do infectious disease and public health and that's that sort of overlap. You know, there's no point in just being the guy who defibrillates the person in cardiac arrest. You also have to be the guy who gives the message about not smoking as well. There is now, I think, a growing need among doctors, particularly the next generation of doctors, to embrace that advocacy position.

And I think we've been a bit slack as a profession in that space. And in other countries where doctors are being shot for doing doctory stuff, that becomes more important. Australia's lovely and comfy and everything, but we now need to start talking about the things that will affect Australia in the years to come.

It's kind of like preventive medicine, if you want to have a liveable country, you're going to need to do something to change that.

[00:29:16] Dr Sanjaya Senanayake: David, we will have to get you back. In fact, I think that is an invitation on the podcast.

[00:29:23] David Caldicott: I will so come back. There's so many problems you and I personally need to solve together.

[00:29:26] Dr Sanjaya Senanayake: Exactly, exactly. I look forward to doing it. But, as for now, adieu.

[00:29:32] David Caldicott: Au revoir. Absolute pleasure. Anytime.

[00:29:43] Dr Sanjaya Senanayake: Thank you for listening. I hope you'll join us behind the curtain for our next episode where we'll delve into the story of another of our fantastic health professionals here at Canberra Health Services. If you're interested in starting an exciting career with us, head to our website to join Team CHS. And that website is www.canberrahealthservices.act.gov.au/careers

[00:30:34] Dr Sanjaya Senanayake: I acknowledge the Ngunnawal People as traditional custodians of the ACT, the land I’m recording on, and recognise any other people or families with connection to the lands of the ACT and region.