more_vertIn their interesting study, Bette Liu and colleagues1 found no association between happiness and mortality. The risk of death was 36% higher in women who were unhappy than in those who were happy most of the time. Excess risk, however, disappeared after adjustment for background characteristics. Happy women were older, had a lower level of education, and consumed alcohol more frequently than did unhappy women, which increased the risk of death in happy women more than in unhappy women. Conversely, happy women were more physically active during their leisure time, less likely to be obese or a smoker, less likely to reside in deprived areas, and less likely to have a medical condition than were unhappy women, which reduced the risk of death in happy women more than in unhappy women.
Preference: Education
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[Comment] Addressing global health disparities among Indigenous peoples
In countries around the world, Indigenous peoples face great social disadvantages and poor health compared with the general population.1,2 In The Lancet, Ian Anderson and colleagues3 have documented significant disparities among 28 Indigenous populations from 23 countries compared with benchmark populations for several variables, including life expectancy at birth, maternal and infant mortality, and frequency of low birthweight and high birthweight infants. They also showed differences for Indigenous peoples in measures related to nutrition (eg, child malnutrition, childhood obesity, and adult obesity), and in key social indicators, including educational attainment and economic status.
Nation’s health only partly on track
Australia is making progress in reducing rates of smoking and dangerous drinking but is losing the battle to rein in weight gain, high blood pressure, and salt and sugar consumption, according to a national snapshot of health trends.
Australia’s Health Tracker, produced by the Australian Health Policy Collaboration with the support of 50 public health organisations, shows that the nation is making good progress toward reducing drinking and smoking, with the proportion of adults drinking at risky levels trending down toward 18 per cent and the country on track to cut the number of adults who strike up on a daily basis down to 10.6 per cent by 2025.
But adults and children are continuing to put on weight, eating too much sugar (and salt) and not doing enough exercise, according to the tracker.
It shows that more than 63 per cent of adults are overweight or obese, along with more than a quarter of children, and almost a half of adults and 70 per cent of children are eating too much sugar.
The tracker found that people are not doing enough exercise, particularly in light of their energy-rich diets – just 55 per cent of adults and less than 10 per cent of teens meet physical activity recommendations.
These readings underline concerns that not enough is being done to reduce the incidence of chronic disease by changing behaviour and encouraging healthier lifestyles.
According to the authors of the Health Tracker, 50 per cent of Australians have a chronic disease, and they estimate that almost a third of such illnesses could be prevented by eliminating smoking, losing weight, cutting down on drinking, taking exercise and reducing blood pressure.
“Chronic disease is the biggest health challenge of the twenty-first century,” the authors said. “Australia lags well behind comparable countries in tackling the risk factors for preventable chronic diseases.”
But, they said, “much of Australia’s chronic disease burden is preventable or capable of significant amelioration”, and urged that there be “population-level interventions that target risk factors shared by many population groups and communities”.
There have been concerns that preventive health has been undermined in recent years by Federal Government policies and cutbacks, including the abolition of the Australian Preventive Health Agency, reducing spending on public health education campaigns, funding cuts for community organisations and programs undertaking preventive health activities and reduced policy emphasis on public health initiatives.
But both the Coalition and Labor have committed to trialling new models of chronic care in the primary health sector centred on general practice as the ‘home’ of health care and involving remuneration based not only on fee-for-service but also incorporating regular payments tied to the management of individual patients with complex and chronic illnesses.
But Public Health Association of Australia Chief Executive Officer Michael Moore said action was now needed.
“A lot of promises were made before the election to fight chronic disease,” Mr Moore said. “This research is the first of its kind, and should be taken as not only a warning, but as a call to action. What we need to see is action from the elected Government.”
Australia’s Health Tracker can be viewed at: https://www.vu.edu.au/sites/default/files/AHPC/pdfs/australias-health-tr…
Adrian Rollins
Watchdog stays hand on codeine
The medicines watchdog has held off on making a final determination on its controversial proposal to axe over-the-counter sales of the common painkiller codeine.
Therapeutic Goods Administration has revealed that at its March scheduling meeting it deferred finalising its position on the re-classification of codeine following an interim decision late last year to make the painkiller a prescription-only medicine.
The delay follows an outpouring of concern by patients and consumer groups worried that taking codeine off the shelves would make it much harder for people to manage chronic pain and force some to pursue unsafe alternatives.
Following an interim proposal in October last year to end over-the-counter (OTC) access to the drug and reclassify it as a schedule 4 poison, the TGA received 127 submissions, including 113 opposing the move and just 14 in support.
In response, the watchdog said it would hold off on making a final determination until at least March, and any implementation would not occur before 2017.
In a submission to the TGA during its first round of consultations, the AMA did not come to a definitive position on the proposal.
While accepting that codeine dependence was “a real concern” and acknowledging the serious side effects caused by excessive consumption, the AMA voiced reservations that re-scheduling the drug would necessarily solve these problems.
It said there could be an argument to restrict access to higher dose and compound codeine preparations, and noted inconsistencies in current regulations that allowed over-the-counter sales of Panadeine Extra, while Panadeine Forte (one tablet of which is equivalent to two Panadeine Extra pills) was only available by prescription.
“Up-scheduling in isolation is unlikely to address the problems of misuse,” the AMA said, arguing that any such move needed to be accompanied by better education about safe and effective pain management options.
But in its interim decision, the TGA indicated it was persuaded by concerns about the potential harm caused by inappropriate use of codeine and the availability of effective alternatives, paracetamol and ibuprofen.
The TGA said OTC codeine was intended to help manage acute, self-limiting pain, but instead people were using it to help treat chronic pain, potentially creating dependence and toxicity.
In addition, it said, at least 10 per cent of the population were “ultra-rapid metabolisers” of the drug, making codeine potentially deadly at even normal doses.
Its concerns have been echoed by Professor Stephan Schug, Director of Pain Medicine at Royal Perth Hospital, who said codeine was a poor painkiller, had become a drug of dependence for many who were taking it at dangerous levels, and was not as effective as other, safer, alternatives.
Professor Schug said he had seen patients who were taking up to 80 tablets of codeine combined with paracetamol or ibuprofen a day, raising the risk of fatal paracetamol and ibuprofen toxicity.
“Dependence on opioid analgesics is a significant concern in Australia, and OTC codeine contributes to this by providing unmonitored access to a drug which in the body is metabolised to morphine,” Professor Schug said.
He said the number of overdose deaths related to codeine had jumped from 3.5 to 8.7 per million between 2000 and 2009.
Professor Schug said scheduling codeine would not reduce access to effective pain relief. He said adding low doses of codeine to paracetamol and ibuprofen did little to enhance their effectiveness, while combining paracetamol and ibuprofen instead provided significantly better and safer pain relief.
“As a practising clinician, I can tell you that under the current arrangements, the easy and widespread availability of these codeine-containing medicines is not limited or monitored at all well,” he said.
The AMA has repeated its call for a national Electronic Recording and Reporting of Controlled Drugs system to provide doctors and pharmacist with real-time information on the prescription of medicines prone to misuse and harm.
The peak medical association has also suggested that pharmacies be required to record codeine sales in the same way as they do for pseudoephedrine.
The AMA warned that making codeine prescription only would also likely increase Medicare and PBS costs for the Government.
Adrian Rollins
News
AMA award winners presented at national conference
At the recent AMA National Conference the following awards were presented: AMA President’s Award in recognition of outstanding contributions to the care of their fellow Australians — Dr Paul Bauert, who for 30 years has fought for better care for Indigenous Australians and, more recently, children in immigration detention, and Vietnam War veteran Dr Graeme Killer, who has devoted his life to improve the care of current and retired Defence Force personnel; Doctor in Training of the Year Award for outstanding leadership, advocacy, and accomplishments of a doctor in training — Dr Ruth Mitchell, a neurosurgery trainee currently in her second year of her PhD at the University of Melbourne, and a neurosurgery registrar at the Royal Melbourne Hospital, and chair of the Royal Australasian College of Surgeons’ Trainee Association; Woman in Medicine Award, presented to a woman who has made a major contribution to the medical profession by showing ongoing commitment to quality care, or through her contribution to medical research, public health projects or improving the availability and accessibility of medical education and medical training for women — Associate Professor Diana Egerton-Warburton, in recognition of her exceptional contribution to the development of emergency medicine, and her passion for public health; Excellence in Healthcare Award recognises ongoing commitment to quality health and medical care, policy, and research, and is awarded to an individual or individuals who have made a significant contribution to improving health or healthcare in Australia — Associate Professor John Boffa and Ms Donna Ah Chee, who have made an enormous contribution to reducing harms of alcohol and improving early childhood outcomes for Aboriginal children.
[Perspectives] Tom Potokar—helping burns climb up the international agenda
Tom Potokar was inspired to be a doctor after watching a Médecins Sans Frontières (MSF) documentary on Vietnamese boat people in the 1970s. Today, he is a consultant in burn injuries at Morriston Hospital in Swansea, Wales, and Director of Interburns (International Network for Training, Education and Research in Burns), a non-profit agency aiming to improve burns care and prevention in low-income countries, where most global burn injuries occur. According to Richard Nnabuko, President of the Pan African Burn Society, Enugu, Nigeria, “Tom has a passion for the burn victims of the low and middle-income countries of Africa and southeast Asia and for training dedicated men and women from these areas.”
[Perspectives] Action against body shaming
Fatphobia is one of the last acceptable prejudices in public spaces. Fat people endure outright abuse, not-so-covert photography/filming, and assumptions about their intelligence and education. Although workplace equal opportunities policies technically outlaw discrimination based on difference, there are many ways to express prejudice other than abuse or obvious criticism.
[Comment] Offline: The pleasures of being an academic
The case against modern university life has never been stronger. In his new book, Les Back, a Professor of Sociology at Goldsmiths, University of London, describes the predicaments of surviving within today’s “neoliberal university”. Academic Diary (Goldsmiths Press, 2016) is his report from the frontlines of higher education in Britain. He uses the terms of the academic year to uncover the vicious cruelties and small beauties of university life. He anatomises the audit culture, its individualised quantification of performance and value, together with its professionalisation, overspecialisation, managerialism, overproduction, selfishness, hollow vanity, and even racism.
On assisted dying
The AMA National Conference hosted a special policy session on the highly contentious issue of assisted dying as part of an on-going AMA policy review.
The session, moderated by ABC presenter Tony Jones, brought together a panel of doctors, ethicists and lawyers with a range of views on whether doctors should be involved in assisted dying.
The debate began with an account of the death of an elderly patient who had had a breathing tube removed without anaesthetic because the treating doctor was fearful that if they administered a drug they might be charged with causing their death.
The scenario prompted discussion of the degree to which doctors were uncertain about the law around assisted dying and the so-called double effect doctrine.
Professor of Ethics at the University of Queensland, Malcolm Parker, said it was “widely understood the doctor knowledge of the law in all sorts of areas is not particularly good,” and many doctors were worried that if the treatment they provided had the effect of causing death, “they will get into trouble”.
Avant Head of Advocacy, Georgie Haysom, said the issue hinged around intent: “If you intend to cause someone’s death, that is murder”.
Dr Karen Hitchcock, who works in acute and general medicine at Melbourne’s Alfred Hospital and last year wrote a Quarterly Essay on caring for the elderly, said there needed to be much greater education around the double effects doctrine, under which the death of a patient is a side effect of treatment.
“Double effect is the bedrock of medicine, which is to treat symptoms,” Dr Hitchcock said. “We never treat life, we treat symptoms. So hastening death is not an issue. [Doctors] do not set out to kill; alleviating symptoms is the aim.”
Associate Professor Mark Yates, a geriatrician at Ballarat Health Services, said the double effects doctrine “is used on a day-today basis”, and rather than changing its position on assisted dying, the AMA should devote its efforts to promoting good palliative care.
But Emeritus Professor Bob Douglas from the Australian National University said the double effects doctrine was “a nonsense”, and was causing serious concern for both doctors and the broader community.
Professor Douglas agreed that there needed to be greater investment in palliative care and advance care planning, but said patients should have the choice of assisted dying.
“From the perspective of a patient, my concern is that when I get to the point of incurable illness and inevitable death, I don’t want to put all my relatives through the pain and suffering of an unnecessarily elongated process,” he said.
Professor Douglas said laws similar to those enacted in the US state of Oregon, which allow terminally ill adults to obtain and use prescriptions from their physicians for self-administered, lethal doses of medications, would “give a lot of people comfort”.
Dr Hitchcock said, however, that Oregon-style laws were unnecessary and could actually be harmful, by making the elderly and disabled feel pressured into seeking assisted dying, such as because of the fear of being a burden to their relatives.
“Every patient [already] has a right to choose to have treatment withdrawn,” she said. “The main reason people request physician-assisted suicide is because of feelings of uselessness and hopelessness. If we give people the choice, it will influence them.”
Dr Hitchcock disputed claims that Oregon-style laws put doctors at arms’ length from killing their patients, arguing it was “ridiculous” to pretend that writing a prescription for a lethal dose of medicine was not an act.
“What we are proposing is that instead of [a palliative care team], doctors can give a patient a prescription to go ahead and kill themselves,” she said. “We are talking about replacing the palliative care team with a script.”
But Professor Douglas countered that just knowing assisted dying was an option could bring people enormous comfort, and experience showed that far from all who acquired a prescription for lethal medication went on to use it.
Figures published by the Oregon Public Health Division show that from the time the laws were introduced in 1997 and the end of 2013, 1173 had obtained prescriptions and 752 had used them. During 2013, 122 people were provided a prescription, and 71 had killed themselves.
AMA President Dr Michael Gannon, who initiated the policy review as Chair of the AMA Ethics and Medico-legal Committee, said the National Conference session would, along with 3500 responses to an AMA member survey, be used to help inform the AMA Federal Council’s deliberations on the issue.
Adrian Rollins
AMA Awards
President’s Award
Dr Paul Bauert OAM and Dr Graeme Killer AO
Two doctors, one a passionate advocate for the disadvantaged and the other a pioneering force in the care of military veterans, have been recognised with the prestigious AMA President’s Award for their outstanding contributions to the care of their fellow Australians.
Dr Paul Bauert, the Director of Paediatrics at Royal Darwin Hospital, has fought for better care for Indigenous Australians for more than 30 years. More recently, he has taken up the battle for children in immigration detention.
Dr Bauert arrived in Darwin in 1977 as an intern, intending to stay for a year or two. In his words: “I’m still here, still passionate about children’s health and what makes good health and good healthcare possible for all children and their families. I believe I may well have the best job on the planet.”
Dr Graeme Killer, a Vietnam veteran, spent 23 years in the RAAF before becoming principal medial adviser to the Department of Veterans’ Affairs. Over the next 25 years, he pioneered major improvements in the care of veterans, including the Coordinated Veterans’ Care project.
Dr Killer has overseen a series of ground-breaking research studies into the health of veterans, including Gulf War veterans, atomic blast veterans, submariners, and the F-111 Deseal and Reseal program. He was also instrumental in turning around the veterans’ health care system from earlier prejudicial attitudes towards psychological suffering.
Dr Bauert and Dr Killer were presented with their awards by outgoing AMA President, Professor Brian Owler, at the AMA National Conference Gala Dinner.
Excellence in Healthcare Award
The Excellence in Healthcare Award this year recognised a 20-year partnership devoted to advancing Aboriginal health in the Northern Territory.
Associate Professor John Boffa and Central Australian Aboriginal Congress CEO Donna Ah Chee were presented with the Award for their contribution to reducing harms of alcohol and improving early childhood outcomes for Aboriginal children.
Associate Professor Boffa has worked in Aboriginal primary care services for more than 25 years, and moved to the Northern Territory after graduating in medicine from Monash University.
As a GP and the Chief Medical Officer of Public Health at the Central Australian Aboriginal Congress, he has devoted his career to changing alcohol use patterns in Indigenous communities, with campaigns such as ‘Beat the Grog’ and ‘Thirsty Thursday’.
Ms Ah Chee grew up on the far north coast of New South Wales and moved to Alice Springs in 1987. With a firm belief that education is the key pathway to wellbeing and health, she is committed to eradicating the educational disadvantage afflicting Indigenous people.
Between them, the pair have initiated major and highly significant reforms in not only addressing alcohol and other drugs, but in collaborating and overcoming many cross-cultural sensitivities in working in Aboriginal health care.
Their service model on alcohol and drug treatment resulted in a major alcohol treatment service being funded within an Aboriginal community controlled health service.
AMA Woman in Medicine Award
An emergency physician whose pioneering work has led to significant reductions in staph infections in patients is the AMA Woman in Medicine Award recipient for 2016.
Associate Professor Diana Egerton-Warburton has made a major contribution to emergency medicine and public health through her work as Director of Emergency Research and Innovation at Monash Medical Centre Emergency Department, and as Adjunct Senior Lecturer at Monash University.
Her just say no to the just-in-case cannula has yielded real change in practice and has cut staff infections in patients, while her Enough is Enough: Emergency Department Clinicians Action on Reducing Alcohol Harm project developed a phone app that allows clinicians to identify hazardous drinkers and offer them a brief intervention and referral if required.
Associate Professor Egerton-Warburton has been passionate about tackling alcohol harm, from violence against medical staff in hospitals to domestic violence and street brawls.
She championed the first bi-annual meeting on public health and emergency medicine in Australia and established the Australasian College of Emergency Medicine’s alcohol harm in emergency departments program.
In addition, she has developed countless resources for emergency departments to facilitate management of pandemic influenza and heatwave health, and has authored more than 30 peer-reviewed publications.
Professor Owler said Associate Professor Egerton-Warburton’s tireless work striving for high standards in emergency departments for patients and her unrelenting passion to improve public health made her a deserving winner of the Award.
AMA Doctor in Training of the Year Award
Trainee neurosurgeon Dr Ruth Mitchell has been named the inaugural AMA Doctor in Training of the Year in recognition of her passion for tackling bullying and sexual harassment in the medical profession.
Dr Mitchell, who was a panellist in the Bullying and Harassment policy session at National Conference, is in her second year of her PhD at the University of Melbourne, and is a neurosurgery registrar at the Royal Melbourne Hospital.
Presenting the award, Professor Owler said Dr Mitchell had played a pivotal role in reducing workplace bullying and harassment in the medical profession and was a tireless advocate for doctors’ wellbeing and high quality care.
MJA/MDA National Prize for Excellence in Medical Research
A study examining the impact of a widely-criticised ABC TV documentary on statin use won the award for best research article published in the Medical Journal of Australia in 2015.
Researchers from the University of Sydney, University of NSW and Australian National University found that tens of thousands of Australians stopped or reduced their use of cholesterol-lowering drugs following the documentary’s airing, with potentially fatal consequences.
In 2013, the science program Catalyst aired a two-part series that described statins as “toxic” and suggested the link between cholesterol and heart disease was a myth.
The researchers found that in the eight months after program was broadcast, there were 504,180 fewer dispensings of statins, affecting more than 60,000 people and potentially leading to as many as 2900 preventable heart attacks and strokes.
AMA/ACOSH National Tobacco Scoreboard Award and Dirty Ashtray
The Commonwealth Government won the AMA/ACOSH National Tobacco Scoreboard Award for doing the most to combat smoking and tobacco use, while the Northern Territory Government won the Dirty Ashtray Award for doing the least.
The Commonwealth was commended for its continuing commitment to tobacco control, including plain packaging and excise increases, but still only received a B grade for its efforts.
The Northern Territory received an E grade for lagging behind all other jurisdictions in banning smoking from pubs, clubs, and dining areas, and for a lack of action on education programs.
State Media Awards
Best Lobby Campaign
AMA NSW won the Best Lobby Campaign award for its long-running campaign to improve clinician engagement in public hospitals.
The campaign started after the Garling Inquiry in 2008, which identified the breakdown of trust between public hospital doctors and their managers as an impediment to good, safe patient care.
It led to a world-first agreement between the NSW Government and doctors, signed in February 2015 by Health Minister Jillian Skinner, AMA NSW and the Australian Salaried Medical Officers’ Federation NSW, to embed clinician engagement in the culture of the public hospital system, and to formally measure how well doctors are engaged in the decision-making processes.
Best Public Health Campaign
AMA NSW also took home the Best Public Health Campaign award for its innovative education campaign on sunscreen use and storage.
The campaign drew on new research which found that many Australians do not realise that sunscreen can lose up to 40 per cent of its effectiveness if exposed to temperatures above 25 degrees Celsius.
The campaign received an unexpected boost with the release of survey results showing that one in three medical students admitted to sunbaking to tan, despite knowing the cancer risk.
Best State Publication
AMA WA won the highly competitive Best State Publication award for its revamped Medicus members’ magazine.
The 80-page publication provides a mix of special features, clinical commentaries, cover articles and opinion pieces to reflect the concerns and interests of WA’s medical community and beyond.
The judges said that with its eye-catching covers, Medicus made an immediate impact on readers.
Most Innovative Use of Website or New Media
AMA WA won the award for its Buildit portal, a mechanism for matching trainee doctors with research projects and supervisors.
The judges described Buildit as taking the DNA of a dating app and applying it to the functional research requirements of doctors in training, allowing for opportunities that may have otherwise been missed.
National Advocacy Award
AMA Victoria won the National Advocacy Award for its courage and tenacity in tackling bullying, discrimination and harassment within the medical profession.
AMA Victoria sought the views and concerns of its members, and made submissions to both the Royal Australasian College of Surgeons’ inquiry and the Victorian Auditor-General’s audit of bullying, harassment and discrimination within state public hospitals.
The judges said that tackling a challenge within your own profession was a particularly difficult task, especially in the glare of public scrutiny, making the AMA Victoria campaign a standout.
Maria Hawthorne