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Pressure for independent inquiry of deadly US hospital attack builds

Pressure is mounting on the United States Government to agree to an independent inquiry into its attack on a hospital in Afghanistan that that left 22 people dead following the activation of a rarely-used international investigative body.

The International Humanitarian Fact-Finding Commission (IHFFC), established under the Geneva Conventions, has written to both the US and Afghanistan governments to offer its services for an independent inquiry following a complaint from medical charity Medicins Sans Frontieres, (MSF) which operated the hospital.

US President Barack Obama has issued a public apology for the bombing, and his Government has initiated its own inquiry. But Mr Obama has been steadfast in resisting calls for arms-length investigation, and is considered unlikely to accept the Commission’s offer.

Neither the US nor Afghanistan are member states of the Commission, which has no power to compel their participation.

“It is for the concerned Governments to decide whether they wish to rely on the IHFFC,” the Commission said. “The IHFFC can only act based on the consent of the concerned State or States”.

President Obama has assured that his Government would conduct a “transparent, thorough and objective” inquiry into the tragedy.

But MSF claims the attack could amount to a war crime and must be investigated independently.

“We have received apologies and condolences, but this is not enough. We are still in the dark about why a well-known hospital full of patients and medical staff was repeatedly bombarded for more than an hour,” said Dr Joanne Liu, MSF International President. “We need to understand what happened and why.”

Dr Liu said her organisation was determined to uncover how the attack had occurred, and to hold those responsible to account.

“If we let this go, as if it was a non-event, we are basically giving a blank cheque to any countries who are at war,” Dr Liu said. “If we don’t safeguard that medical space for us to do our activities, then it is impossible to work in other contexts like Syria, South Sudan, like Yemen.

Twenty-two people, including 12 MSF staff, were killed in the hour-long US airstrike, which was called in as Afghan Army units fought to regain control of the city from Taliban insurgents.

MSF nurse Lajos Zoltan Jecs survived the attack and detailed scenes of carnage at the hospital, which was filled with patients at the time.

“I cannot describe what was inside. There are no words for how terrible it was. In the Intensive Care Unit six patients were burning in their beds,” Mr Jecs said.

He told of how surviving medical staff – many badly shaken and traumatised by the blasts – worked frantically to save patients as well as their own colleagues.

“We did an urgent surgery for one of our doctors. Unfortunately he died there on the office table. We did our best, but it wasn’t enough,” he said. “We saw our colleagues dying. Our pharmacist – I was just talking to him last night and planning the stocks – and then he died there in our office.”

President Obama called Dr Liu to apologise for the attack after the US military admitted responsibility.

The attack occurred despite the fact that MSF had given all warring parties the GPS coordinates of the hospital.

Outrage over the attack was heightened when the US initially appeared to claim it was a necessary and legitimate use of force, before later characterising it as a mistake.

MSF said that “any statement implying that Afghan and US forces knowingly targeted a fully functioning hospital – with more than 180 staff and patients inside – razing it to the ground, would be tantamount to an admission of a war crime,” MSF Australia President Dr Stewart Condon and Executive Director Paul McPhun said. “There can be no justification for this abhorrent attack.”

“Medecins Sans Frontieres reiterates its demand for a full, transparent and independent international investigation to provide answers and accountability to those impacted by this tragic event.”

Adrian Rollins

[Series] Towards universal civil registration and vital statistics systems: the time is now

The health and development challenges of the coming decades cannot be tackled effectively without reliable data for births, deaths, and causes of death, which only a comprehensive civil registration and vital statistics (CRVS) system can deliver. Alternative methods such as surveys, censuses, or surveillance are not adequate substitutes from a statistical perspective, and do not provide individuals with the legal documentation they need to benefit from services and participate fully in a modern society.

Frugal Aussies show US how it’s done

The efficiency and effectiveness of Australia’s health system has been highlighted by figures showing Americans have more chronic illnesses and worse life expectancy than Australians despite spending more than double the amount on care.

Although the United States spent $US9086 per person on health care in 2013, compared with $US4115 in Australia, the average American was likely to live about two years less and be burdened with more chronic diseases, a study by The Commonwealth Fund has found.

As the Federal Government looks to use the Medicare Benefits Schedule Review to cut health spending, the Commonwealth Fund report shows Australia gets good value for its health dollar, achieving high life expectancy and low rates of infant mortality despite one of the smallest outlays among its rich-world peers.

The investigation found the US spent 17.1 per cent of its national output on health care in 2013 – far more than any of the other 12 high-income countries included in the survey. The next biggest spender was France, where the health bill amounted to 11.6 per cent of gross domestic product.

By comparison, Australia’s health care was a bargain. Its total expenditure was the second-lowest among the 13 countries examined – just 9.4 per cent. This was on a par with Norway and only slightly more than the smallest spending nation, Great Britain (8.8 per cent).

Despite this, Australians can expect to live longer than the average American, and in better health. US life expectancy was 78.8 years in 2013, the lowest among the 13 countries examined and considerably less than the 80.1 years for Australian men and 84.3 years for women recorded at the time.

Not only did Americans live shorter, on average, but they were also sicker. The Commonwealth Fund’s 2014 International Health Policy Survey found that 68 per cent of Americans aged 65 years or older had at least two chronic illnesses, compared with 54 per cent of Australians in the same age group. Just 13 per cent had no chronic conditions, compared with 32 per cent of older Britons.

America’s big spending ways are being driven by the adoption of advanced technology and higher service charges rather than because they are constantly rushing to the doctor.

The Commonwealth Fund found that in the US almost 107 MRI exams are conducted for every 1000 people, compared with a rich world average of 50.6 per 1000 and just 27.6 per 1000 in Australia. Similarly, Americans are more than twice as likely to have a CT or PET scan as an Australian.

Not only were they having more scans, they were paying higher prices for them.

Americans also paid the highest prices for medical procedures and prescription drugs. Data from the International Federation of Health Plans indicates that in 2013 bypass surgery in Australia cost an average of around $US42,130, compared with $US74,345 in America, and drugs in Australia were around 50 per cent less expensive.

Not surprisingly, given the relative expense of seeing a doctor in the US (average out-of-pocket costs were $US1074, second only behind Switzerland), Americans were relatively reluctant to seek care. On average, in 2013 they saw a doctor just four times a year, compared with an average 7.1 times among Australians, and the number of hospital discharges per 1000 people in the US was 126 – well below Australia (173 per 1000).

The consequences of America’s heavy health spending are far-reaching, the Commonwealth Fund concluded, not only driving people into bankruptcy and government budgets into deeper deficit, but holding down wages as health insurance eats further into salary packages.

It added that the imbalance in Government spending caused by America’s burgeoning health bill may actually be making the situation even worse.

The Commonwealth Fund warned that American governments were spending so much on health care it was crowding out other areas of expenditure that could actually improve health, particularly social programs and support.

“In the US, health care spending substantially outweighs spending on social services,” the Fund said. “This imbalance may contribute to the country’s poor health outcomes. A growing body of evidence suggests that social services play an important role in shaping health trajectories and mitigating health disparities.”

It suggested one way to redress the imbalance could be through funding arrangements in which providers are rewarded for health outcomes could make it sensible for insurers, hospitals and others to invest in social services and other interventions.

The Commonwealth Fund study can be viewed at: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

Adrian Rollins

 

[Series] Are well functioning civil registration and vital statistics systems associated with better health outcomes?

In this Series paper, we examine whether well functioning civil registration and vital statistics (CRVS) systems are associated with improved population health outcomes. We present a conceptual model connecting CRVS to wellbeing, and describe an ecological association between CRVS and health outcomes. The conceptual model posits that the legal identity that civil registration provides to individuals is key to access entitlements and services. Vital statistics produced by CRVS systems provide essential information for public health policy and prevention.

Mental health system crisis deepens as Govt dithers

The mental health system is descending deeper into crisis and instability as the Federal Government delays its response to the National Mental Commission’s report, a Senate inquiry has said.

The Senate Select Committee on Health has warned that while Health Minster Sussan Ley ponders expert recommendations on how to reform mental health care, the prolonged policy and funding limbo is taking a heavy toll of the system.

“Mental health policy and funding in Australia is in a state of suspended animation while the Government re-reviews, re-consults on, and re-considers the findings of the National Mental Health Commission’s review,” the Committee said in its fourth interim report. “The uncertainty caused by the government’s constantly delayed decision making has caused workforce instability and increasing uncertainty for mental health consumers and carers. This is an unacceptable situation.”

Its call was backed by Mental Health Australia, which said the current mental health system was “fragmented and difficult to navigate”, and urged the Government to take a bold approach to reform.

“The mental health sector is ready to embrace reform, and to assist the Government in a carefully staged reform process,” Chief Executive Officer Frank Quinlan said. “We need to build a system around the individual, and ensure care is provided in the community, preventing illness where possible and providing early assistance when illness does occur.”

Related: MJA – Telling the story of mental health

Ms Ley is examining the recommendations of the Expert Reference Group she appointed to advise on the implementation of the Commission’s reforms, and has said the Government will announce its plans by the end of the year.

But the seven-member Senate Committee, which chaired by Labor Senator Deborah O’Neill and includes three Coalition MPs, has called on Ms Ley to immediately release the Reference Group’s report and guarantee funding for mental health groups and providers for 12 months after the Government announces its reforms.

“Mental health policy has been on hold since the beginning of the Commission’s review in February 2014. In October 2015, ten months after the completion of the Commission’s thorough review, the government has still not responded to the Commission’s recommendations.

“As a result, the mental health sector struggles with ongoing funding uncertainty and indecision about the future direction of mental health policy in Australia,” the Committee report said. “The Committee considers that the Government’s lack of response to the Commission’s findings has caused significant harm.”

The National Mental Health Commission’s report, released in April, identified “fundamental structural shortcomings” in the nation’s health system, and urged a shift in emphasis away from acute care and more on to prevention and early intervention.

It argued this would reduce the severity and duration of mental health issues, ultimately slowing demand for expensive acute hospital care and lowering the incidence of long-term disability.

Ms Ley rejected the Commission’s suggestion that $1 billion be re-directed from hospitals to primary care, but endorsed the need to close service gaps and improve coordination between services.

“We needed to re-think our approach…and change the focus from a service-centred approach to one where services are organised around the needs of the person,” the Minister said.

The Senate Committee said the Government’s reforms should include recognition of the links between housing, employment and mental health, support models of care that promote early intervention, and articulate a clear and comprehensive mental health workforce strategy.

It said the Government needed to provide its response “as a matter of urgency”.

The Senate Committee’s report can be viewed at: http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Health/He…

Adrian Rollins

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Palliative care a growth industry

The ageing population and the increasing prevalence of chronic illness has driven a sharp rise in demand for palliative care in hospitals.

There has been a 52 per cent jump in palliative care-related hospitalisations in the past decade, according to the Australian Institute of Health and Welfare, the majority involving patients with cancer.

The Institute reported that almost 62,000 people were admitted to hospital for palliative care in 2012-13, up from 40,435 in 2003-04, and the overwhelming proportion were, not unexpectedly, were elderly or in late middle age.

Institute spokesman Geoff Neideck said a shift in the pattern of disease afflicting people towards the end of their lives – the growing prevalence of chronic illnesses – contributed to the increased use of palliative care, as did growth in the number of people living into old age.

“As we would expect, palliative care services are accessed more frequently by older people – people aged 75 years and [older] accounted for just over half of all palliative care hospitalisations,” Mr Neideck said.

The report showed that 56 per cent of patients hospitalised for palliative care had cancer, and palliative care was particularly prominent in a treatment of those with certain types of the disease.

For instance, he said, a third of all hospitalisations related to pancreatic cancer were related to palliative care.

The Institute’s report, Palliative care services in Australia 2015, also detailed the sort of medications patients in palliative care were prescribed.

It found more than 51,200 prescriptions were provided to 25,900 patients in 2013-14, 87 per cent of which were subsidised by the Federal Government.

Laxatives were the most commonly-prescribed drug, followed by analgesics and anti-epileptics.

Adrian Rollins

 

Aged care handed back to health

Responsibility for aged care has been returned to the Health portfolio and Minister for Rural Health Senator Fiona Nash has been given oversight of indigenous health among changes made to the allocation of roles by Prime Minister Malcolm Turnbull.

In a move welcomed by the AMA, the Federal Government announced on 30 September that Health Minister Sussan Ley would retain her hold on the Sport portfolio and would take on the additional role as Minister for Aged Care.

Mr Turnbull said that giving Ms Ley responsibility for aged care would ensure that ageing was “front and centre with the health portfolio as our population continues to live longer and healthier lives”.

As part of the change, aged care functions will be transferred from Department of Social Services to the Health Department.

AMA President Professor Brian Owler said aged care had languished in recent times because taking it out of Health had reduced the political focus.

“It is vital that the health needs of older Australians are considered as a key component of the broader health policy debate, and it is fitting that aged care is back with the Health Minister,” Professor Owler said. “Caring for older Australians, whether they live in residential aged care or independently in their own homes, is an integral part of medical practice.”

One of the major issues to be tackled in the area is the dislocation of care for people in nursing homes, as well as adequate support for GP-led primary health teams in providing co-ordinated care to enable the elderly to live at home.

“Most older Australians have longstanding relationships with their GP, who is best placed to determine which services will work best for their patient,” Professor Owler said. “Early medical assessment is critical to ensuring that older Australians receive the appropriate support to maintain their level of independence before their social and health situation deteriorates.

He said including the clinical opinion of a patient’s usual treating doctor in the assessment of their care needs and formulating a care package should be normal practice, not, as is currently the case, an optional extra.

“We also need to see improved processes to allow doctors to manage the provision of straightforward care, such as wound care, for older people still living in their own home,” the AMA President said. “The aged care sector must be able to provide the level and quality of medical, nursing, and allied health services required to meet the needs of our ageing population.”

Professor Owler said the AMA would seek to discuss these issues and other aged care policy priorities “at the earliest opportunity.”

In addition to rural and indigenous health responsibilities, Senator Nash has retained her oversight of drug and alcohol policy and organ donation.

Assistant Health Minister Ken Wyatt will provide support for Ms Ley in aged care.

Adrian Rollins

Health workers in crosshairs as Kurdish conflict flares

There is mounting concern about the welfare of civilians in south-east Turkey amid reports health workers and ambulances have come under attack as a conflict between government forces and Kurdish rebels intensifies.

The World Medical Association has appealed to the Turkish Government to restore basic health services to the region amid reports from the Turkish Medical Association that paramedics have been assaulted and ambulances blocked from aiding the sick and injured in a number of cities including Diyarbakir, Cizre, Varto, Yuksekova, Lice and Silvan.

‘We are receiving alarming reports from the Turkish Medical Association about ambulances not being allowed to tend to those killed and wounded in the fighting in the city, or take them to hospital,” WMA President Dr Xavier Deau said.

“The Government curfew prevented people from going out to buy food and water, and no outside observers are being allowed to visit the city to investigate the situation.

“This lack of basic health care, and the failure to allow health professionals to move freely in the city, is a scandal that must end.

“We urge the Turkish Government to bring a halt to this inhumane
situation and to allow health professionals to care for the sick and
wounded.”

Fighting in the area, which lies close to war-wracked Syria and Iraq, has intensified in the past two months as the central government seeks to contain and eliminate a Kurdish-led insurgency that has claimed more than 40,000 lives since hostilities broke out in 1984.

The fighting has dashed hopes that when the pro-Kurdish Peoples’ Democratic Party won 14 per cent of the vote in a national election in June marked an end to the conflict. Instead, both President Recep Tayyip Erdogan and hardline militants in the separatist PKK movement have been accused of stoking tensions, causing a resumption of hostilities that so far are estimated to have left more than 100 soldiers and police dead, and at least as many rebels.

Adrian Rollins