In this latest edition of The Health Wrap, Associate Professor Lesley Russell takes readers on a journey from the National Press Club in Canberra to a tour of the Pacific region and the Democratic Republic of the Congo, with stops for some important new public health reading along the way.
The Health Minister’s Long Term National Health Plan – nothing to see here
This week Health Minister Greg Hunt spoke at the National Press Club. You can read his speech here. The focus of his speech and the reporting afterwards was on mental health.
He announced two new measures – an Intergenerational Health and Mental Health Study and the Children’s Mental Health Strategy.
The plan is a self-congratulatory, short-term and short-sighted piece of government puffery – propaganda even – that reads as if it was written as the PR release for the 2019-20 Budget.
The plan is inherently confused about that difference between health and healthcare and there is little admission of the real needs and the real problems – and consequently and unsurprisingly, no real solutions.
The absence of any mention of the social determinants of health, and the impacts of climate change means that health and wellbeing and addressing health disparities are effectively ignored.
Several issues in the report bear comment:
- Primary care
The report states that the goal is “to make primary care more patient focussed, more accessible, and better able to provide preventive health and management of chronic conditions.” The report refers to how the $448.5 million over three years that was provided in the 2019-20 Budget for what was then described as “a new chronic diseases model to support high need patients” will be spent.
It is described thus:
“Co-designed with the Australian Medical Association, it includes $448.5 million in additional funding to doctors to support more flexible care models, rather than the traditional Medicare fee-for-service model. This will encourage better preventive care and management of chronic issues, initially focusing on Australians older than 70 years of age.”
This is clearly Health Care Homes 2.0, and it’s interesting to see the move away from fee-for-service.
As always, it’s frustrating to see that (apparently) the only group consulted on this was the AMA – where were the other clinical groups (RACGP, nurses, allied health professionals, pharmacists), the community health centres and ACCHOs, and of course the consumers and patients?
- Access and out-of-pocket costs
The cost barriers to accessing healthcare services have to be the biggest problems currently facing Australians, especially those in rural and remote areas and those with lower incomes.
The report reads as if the problems have all been resolved with a website to provide information on specialists’ fees and the division of health insurance policies into gold, silver and bronze categories. And not a mention of dental care needs and costs anywhere!
- Aged care
I’m sure I am not the only person outraged by this statement in the report: “With the Royal Commission into Aged Care Quality and Safety underway, we are delivering better accessibility, quality and safety for senior Australians.”
There is absolutely no acknowledgement here of the horrors that are being unearthed by the Royal Commission and the enormous amount of work that must be done to ensure senior Australians in aged care are protected and well-cared for.
- Spending on the PBS
Hunt also made it clear that he has no intention of meaningful reforms when it comes to private health insurance despite receiving some blunt feedback from a National Press Club director, Mark Kenny, who said his experience of PHI was “it’s a dud”.
Yes, it’s great that new medicines are listed in a timely and affordable fashion (as they have always been), but the fact of the matter is, as the Budget Papers show, spending on the PBS is set to decline over the forward projections (from $12.7 billion in 2018-19 to $10.4 billion in 2022-23).
In the report this is hidden with the claim that “Over the forward estimates, we will invest $40 billion to subsidise life-saving and life-changing medicines.”
Climate change impacts in the region
As we watch Australia’s ham-fisted – and not very successful – efforts to be part of the “regional family” at the Pacific Islands Forum in Tuvalu, it is interesting to read the recent report on The State of Health Security in the Indo-Pacific Region from the Indo-Pacific Centre for Health Security at the Department of Foreign Affairs and Trade.
Who knew such a centre existed? It was set up in 2017 with a five-year tenure to focus on countries in South East Asia and the Pacific that receive assistance from the Australian Government.
“Health security” is narrowly defined as “the avoidance and containment of infectious disease threats with the potential to cause social and economic harms on a national, regional or global scale.” This encompasses both human and animal infections.
After my initial puzzlement that conditions such as obesity and its consequences, hypertension and mental health disorders were not included as causes of social and economic harms in the Indo-Pacific region (does DFAT deal with them elsewhere or are they just ignored?), I scanned the report for what it had to say about climate change.
The good news: climate change, and gender and disability, are seen as “cross cutting themes”.
The bad news: beyond that, and a mention that women, especially those who are pregnant, are especially at risk from the infectious diseases considered – nothing. This is pretty shocking when you consider the impact of climate change on the spread of some of the diseases that are seen as most problematic.
The highest burden of disease in the areas is attributed to respiratory infections and there is growing concern about the prevalence of multi-drug resistant TB. Other major diseases are diarrhoeal diseases, HIV infections and malaria. There is increasing incidence of dengue fever (especially in the Pacific) and measles. High-risk diseases like Nipah virus, Zika virus and highly pathogenic avian influenza are also increasingly being seen.
The ability to prevent, detect and respond to these threats is very variable. In many countries funding for core functions of public health, animal health and environmental health is described as inadequate or unsustainable.
The $500 million that the Prime Minister has committed to the Pacific Islands for the mitigation of the effects of climate change is described as “repurposed” DFAT aid funds.
Can we be sure that funds needed to address the health security issues outlined in this report are not being inappropriately diverted to buy influence in the Pacific?
Meanwhile, the Asia Pacific Parliamentary Forum on Global Health will be held in Fiji next week with the theme of Climate Change and Health. My colleague Melissa Sweet reports that Australia is expected to be a no show at the Forum. There is more information here.
And make sure you read the Croakey report on calls for action to assist Pacific Island climate refugees.
New Ebola treatments offer hope
There was some good news this past week from the US National Institutes of Health on Ebola treatments that will help save lives.
A randomised, controlled trial of four investigational agents began in November 2018 in the Democratic Republic of the Congo as part of the emergency response to an ongoing Ebola outbreak.
The August review by the independent data and safety monitoring board (this meets periodically to review interim safety and efficacy data and to make recommendations to the study team and the sponsors) has recommended that two arms of the study be stopped and future patients assigned to just the remaining two.
This recommendation was based on preliminary data analyses that showed two antibody-based treatments (designated REGN-EB3 and mAb114s) greatly increased survival. When these two treatments were administered within a day of infection, survival rates were around 90 percent.
The scientists involved are now talking about Ebola as “curable”. These findings are expected to be published in the peer-reviewed literature shortly.
As the first Ebola trial to confirm a medical success, it’s a hopeful development. The Ebola virus, which hijacks the immune system and causes massive haemorrhaging, currently proves fatal for nearly 70 percent of patients.
To date the DRC epidemic has infected an estimated 2,800 people and killed more than 1,800.
The economic cost of preventable disease in Australia
I commend to you an excellent systematic review of the Australian evidence of the economic burden of preventable diseases which was commissioned by the Australian Prevention Partnership Centre and recently published in the Australian and New Zealand Journal of Public Health.
The Global Burden of Disease study found that 36 percent of the health burden in Australia in 2016 was attributable to modifiable risk factors. Many of these risk factors are lifestyle‐related, such as tobacco smoking, alcohol consumption, an unhealthy diet, physical inactivity and obesity.
In addition to the substantial health burden, preventable diseases also have a significant economic impact that is incurred by all aspects of the healthcare system and outside the healthcare sector (such as the criminal justice system for alcohol‐related violence and accidents and reduced taxation receipts to governments due to reduced productivity).
The review looked at five specific risk factors (obesity, smoking, excess alcohol consumption, physical inactivity and diet) in eighteen studies and included evidence from the grey literature.
Estimates of the annual productivity loss that could be attributed to individual risk factors were between $840 million and $14.9 billion for obesity; up to $10.5 billion due to tobacco; between $1.1 billion and $6.8 billion for excess alcohol consumption; up to $15.6 billion due to physical inactivity and $561 million for individual dietary risk factors (all monetary values expressed in 2016-17 Australian dollars).
These productivity costs outweigh healthcare costs. For example, a 2008 study that looked at these five risk factors, plus the high psychological distress caused by intimate partner violence, found that the cost of all six risk factors combined was $6.3 billion in healthcare costs, $90.5 million in other costs to government (lost taxation revenue) and $8.1 billion in productivity losses over the lifetime of the 2008 Australian population. These risk factors were also estimated to cause 26,000 deaths and 414,000 DALYS (years of life lost due to premature death).
This same study estimated that just small decreases in the prevalence of these risk factors could deliver substantial savings in healthcare costs and increased in production improvements, along with thousands of deaths and DALYs averted.
Interestingly, it noted that there would be a small increase in non‐healthcare costs to government because of taxation foregone due to decreases in smoking and alcohol consumption. (Surely a government wouldn’t allow this to influence decisions on preventive health?)
The review concludes that:
The significant economic burden associated with preventable disease provides an economic rationale for action to reduce the prevalence of lifestyle‐related risk factors.
New analysis of the economic burden of multiple risk factors concurrently is needed.”
Impact of racism on children’s health
A new statement from the American Academy of Pediatrics looks at the effects of racism on children’s development, starting in the womb, and offers paediatricians mechanisms for dealing with this.
The report states:
Pediatricians and other child health professionals must be prepared to discuss and counsel families of all races on the effects of exposure to racism as victims, bystanders, and perpetrators.
To do this, it is critical for pediatricians to examine their own biases. Pediatricians can advocate for community initiatives and collaborate with government and community-based organisations to help redress biases and inequities in the health, justice, and educational systems.
These strategies may optimise developmental outcomes and reduce exposure to adverse events that dramatically alter the lived experiences, health, and perceived self-value of youth.”
Although this statement has an American perspective, there are many issues that apply to Australia, particularly in efforts to Close the Gap.
Racism is recognised as a significant social determinant of health. It has an impact on children and families who are targeted and also on those who witness it. In a media article about the statement, one of the authors called racism “a socially transmitted disease” that is taught and passed down.
Living with discrimination and racism takes a toll on physical and mental health throughout life, and the problems start before birth.
Studies show that mothers who report experiencing discrimination are more likely to have infants with low birth weight.
The chronic stress that is generated can lead to hormonal changes and inflammation that have been found to forecast chronic diseases of aging, such as coronary disease, stroke and cognitive problems. Experiences of racism have been shown to affect children’s mental health and behaviour.
Many Australian children and adolescents have experiences of racism. In a Victorian study by The Lowitja Institute, 97 percent of Aboriginal and Torres Strait Islander people surveyed experienced racism multiple times.
The good news – tackling hospital noise
“Unnecessary noise is the cruellest absence of care,” said Florence Nightingale.
Anyone who has spent time in hospital, especially in an intensive care ward, knows how noisy all that fancy beeping, pinging, dinging equipment is, especially when the alarms go off.
For device manufacturers, sound is often an afterthought in the design; they are simply focussed on making sure their machines deliver alerts when needed (although studies have shown that as many as 99 percent of alarms are false).
The proliferation of pinging and bleeping can contribute to patient delirium and staff burnout. And because caregivers know that many devices are crying wolf, they might be less responsive or apathetic, a potentially fatal safety issue known as alarm fatigue.
There are (now outdated) international standards for medical device alarm sounds which set forth tones for six critical functions: cardiovascular, drug administration, ventilation, oxygen, temperature and artificial perfusion (the flow of blood and oxygen). You can hear them in this article.
But these sound alerts were never tested and they are difficult to tell apart.
So now a committee is developing (and testing) new standards. The proposed sounds, called auditory icons, are representative of their functions.
So the sounds represent critical organ functions and imitate the lub-dub sound of a heartbeat, or a rattling pill bottle for a drug infusion, or a whistling teakettle for temperature. You can hear them here.
Other researchers are developing a device that transcribes a patient’s physiological condition into songs that sound a bit like chill electronic dance music. The melody is derived from a patient’s vital signs: drums for the heartbeat, guitar for oxygen saturation and piano for blood pressure.
When a patient is stable, the tune is harmonious, but it becomes dissonant when a patient’s status changes for the worse, ideally grabbing a caregiver’s attention.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.