[Comment] First Liberal budget good for Canadian science, but what about global health?

The Canadian federal election last October brought new leadership to government, and with it an expectation that Prime Minister Justin Trudeau’s Liberal Party would be kinder to Canadian researchers.1 After almost 10 years of Conservative Party rule, during which previous Prime Minister Stephen Harper made few friends among scientists, it was with eager anticipation that Canadians awaited the new budget on March 22, 2016.2

Get back to the BEACH, Govt told

AMA President Professor Brian Owler has urged the Federal Government to reverse its decision to axe funding for one of the most extensive and sustained studies of general practice in the world, arguing the move is “completely at odds” with its stated primary care focus.

In a decision that has shocked and dismayed medical practitioners and researchers, the long-running Bettering the Evaluation and Care of Health (BEACH) program, which began tracking the activities of Australian GPs in 1998, is being wound up after the Federal Department of Health announced it would not be renewing funding for the research after the current contract expires on 30 June.

Professor Owler has written to Health Minister Sussan Ley urging her to reconsider the move, which he said was particularly ill-considered given major changes planned for primary care.

“Research into general practice and primary care attracts very little funding support in comparison to other parts of the health system,” the AMA President said. “The reality is that we need more of this type of research, not less.”

The Government’s decision to axe its funding for BEACH has come less than two week after Ms Ley unveiled the Health Care Homes initiative to give GPs a central role in improving the care of patients with chronic and complex disease. Simultaneously, the Government is trialling its My Health Record e-health record system and is persisting with a four-year freeze on Medicare rebates.

Professor Owler said the Commonwealth had contributed just $4.6 million of the $26 million that had been used to fund the BEACH program over the years.

“This is a very small investment that has delivered significant policy outcomes and, with all the changes planned for general practice and primary care, I think there is a very strong case to extend funding for the program,” he said.

The wealth of data on general practice that the program had collected had proven invaluable in driving evidence-based policy development, Professor Owler said, and warned that there was “no credible source of information and analysis that is capable of filling the gap that will be left when the program ceases”.

The program’s director, Professor Helena Britt of Sydney University’s Family Medicine Research Centre, said the Government’s decision to cease its contribution had come at a time when the program was already facing a funding crunch caused by a downturn in contributions from other sources including non-government organisations and pharmaceutical companies.

“BEACH has always struggled to gain sufficient funds each year,” Professor Britt said. “However, this notification comes when we also have a large shortfall in funding coming from other organisations…due to the closure of many government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits resulting from changes to the PBS.

“We therefore have no choice but to close the BEACH program.”

Professor Britt said she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

Professor Britt said the BEACH data, which is drawn from an annual sample of GPs providing detailed information on everything from the hours they work to the diseases and other conditions they treat, was a unique resource, and the program’s closure would “leave Australia with no valid reliable and independent source of data about activities in general practice”.

“BEACH has been the only continuous national study of general practice in the world which relies on random samples of GPs, links management actions to the exact problem being managed, and provides extensive measurement of prevalence of diseases, multi-morbidity and adverse medication events,” a statement issued by the Family Medicine Research Centre said.

The data from the latest BEACH survey, which began in April last year and closed at the end of March this year, is being collated and Professor Britt said she hoped to issue a report on the results, possibly in mid-June.

Asked about the possibility of funding coming from other sources, Professor Britt said it was “early days”.

One of the biggest concerns is what will happen to the rich store of data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said the data was used by a huge range of researchers and organisations, and her group was looking at ways to ensure people would continue to have access to it.

“We would be happy to find a place with a senior analyst who could take request to analyse the data for specific purposes,” she said. “We would like to be able to keep that access up there for at least a little while.”

Adrian Rollins

BEACH washed up

Attempts to gauge the effect of big changes to chronic disease management and primary care being planned by the Federal Government have been dealt a blow by revelations one of the most extensive and sustained studies of general practice in the world is facing shutdown.

The long-running Bettering the Evaluation and Care of Health (BEACH) program, which began tracking the activities of Australian GPs in 1998, is being wound up after the Federal Department of Health announced it would not be renewing funding for the research after the current contract expires on 30 June.

The program’s director, Professor Helena Britt of Sydney University’s Family Medicine Research Centre, said the Department’s decision had come at a time when the program was already facing a funding crunch caused by a downturn in contributions from other sources including non-government organisations and pharmaceutical companies.

“We therefore have no choice but to close the BEACH program.”

The announcement has been met with shock and dismay by medical practitioners and researchers. Professor Britt said she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

BEACH’s shutdown comes at a particularly uncertain time for general practice as the Government moves to implement its Health Care Homes model of chronic care while simultaneously trialling its My Health Record e-health record and persisting with a four-year freeze on Medicare rebates.

Asked about the possibility of funding coming from other sources, Professor Britt said it was “early days”.

One of the biggest concerns is what will happen to the rich store of data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said the data was used by a huge range of researchers and organisations, and her group was looking at ways to ensure people would continue to have access to it.

Adrian Rollins

[Editorial] Bangladesh’s rural water scandal

Arsenic occurs naturally underground in parts of Bangladesh, and its contamination of rural water supplies first came to public attention more than two decades ago. Since then, the Bangladesh Government supported by donor agencies (including UNICEF and the World Bank) have collaborated to mitigate a growing water contamination crisis, with a focus on the installation of thousands of deep tube wells that source water from below shallower levels where traces of arsenic are often found.

Education tax cap scrapped

The Federal Government has reportedly scrapped plans to axe or cap tax deductions for work-related self-education expenses just days after the AMA warned it would campaign against the idea in the lead-up to the Federal election.

The Australian Financial Review has reported the Government has dumped the idea of trading away work-related tax deductions to help fund business tax cuts in next month’s Budget, and will instead leave tax deductions alone.

The policy change came after the AMA said discussions had been held about resurrecting the Scrap the Cap alliance of more than 70 professional and educational organisations to campaign against any change to tax deductions for self-education expenses.

There had been suggestions the Government was considering imposing a standard deduction for work-related expenses, which AMA Vice President Dr Stephen Parnis said would “effectively be a cap by another name”.

In 2013, the former Labor Government announced plans for a $2000 cap on tax deductions for work-related self-education expenses, a measure that would have disadvantaged thousands of workers who have to undertake continuing education as a condition of their employment.

The proposal provoked outrage among doctors and other professionals, and the AMA was among 70 organisations that formed the Scrap the Cap Coalition to fight the change.

The Abbott Government won plaudits when it dumped the idea soon after winning the 2013 Federal election, but there were fears Prime Minister Malcolm Turnbull would reinstate the measure to help narrow the Budget deficit.

In December, the Government revealed its financial position had worsened since last year’s Budget and the deficit was on track to reach $37.4 billion in 2015-16 with no prospect of a return to surplus in the next four years.

Since then, commodity prices have tumbled lower and economic conditions have remained soft, fuelling concerns the Commonwealth’s finances have become even worse.

The Government has talked down earlier suggestions of tax cuts, and is searching hard for savings, including by trying to push more of the responsibility for health and education funding onto consumers and the states.

But Dr Parnis said earlier this week that deductions for self-education expenses should be off the savings list.

He said doctors had to continually update their skills and knowledge throughout their careers, at their own expense, and scrapping the tax break would have created a “huge disincentive”, particularly for junior doctors considering undertaking specialist training.

According to the AFR report, the Government has backed away from changes to work-related tax deductions for political and administrative reasons.

It was thought scrapping deductions, claimed mainly by middle-income earners, to pay for business tax cuts would be highly unpopular, while the impracticality of abolishing all deductions meant the Government would be left to tinker with individual measures, which would not deliver sufficient savings to be worth the political trouble they would cause.

Adrian Rollins

National talks on remote area nurse safety

Improvements in the security of remote area nurses have been put off to a future meeting of Federal, State and Territory health ministers.

In a statement issued following a meeting with remote health service operators and representatives, Rural Health Minister Fiona Nash said there had been “a number of worthy, original and thoughtful ideas” which the she would carefully consider and raise with her State and Territory counterparts “over the coming weeks”.

The meeting was convened in the wake of the fatal attack on Gayle Woodford, 56, who was working as a nurse in the remote Fregon community in the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of north-west South Australia. A 34-year-old man, Dudley Davey, has been charged with her murder.

The murder has ignited a campaign for improved security for nurses working in remote areas, including calls for the abolition of single-nurse posts and new rules requiring health workers attending call-outs and emergencies to operate in pairs. As at 8 April, almost 130,000 people had signed a petition calling for the changes.

The sector also faces the threat of a mass walkout of staff. A survey of 800 regional nurses cited by the Adelaide Advertiser indicates 42 would quit if single nurse posts are retained.

The fatal attack on Ms Woodford is but the latest in a series of incidents and assaults on remote area nurses. A University of South Australia study of 349 such nurses, undertaken in 2008, found almost 29 per cent had experienced physical violence, and 66 per cent had felt concerned for their safety.

The study found that there had been a drop in violence against nurses since 1995, coinciding with a reduction in the number of single nurse posts.

Senator Nash paid tribute to health workers in remote areas and acknowledged that they faced “unique and difficult challenges”, but held back from endorsing any particular course of action to improve security.

Part of the problem she faces is that the ability of Federal and State governments to act to improve health worker safety is constrained because remote area health services are independently run, often by Aboriginal communities.

Senator Nash said she would respect the independence of service operators.

“Whilst the Federal Government funds many of these remote services, they are, in fact, independently run, as they should be,” she said. “I will not break Australia’s long-standing multi-partisan commitment to Indigenous self-determination by telling these health providers how to run their services.

“Remote health services do the work on the ground and they know best, so I will be asking them for their ideas on this important issue.”

Adrian Rollins

The world is turning to flab

Rich countries are facing an epidemic of severe obesity and around one in five worldwide will be obese by the middle of next decade unless there is a major slowdown in the rate at which people are putting on weight, according to a major international study involving data from 19 million adults across 186 countries.

Already, more than 2 per cent of men and 5 per cent of women are severely obese, and researchers have warned that the prevalence is set to increase and current treatments like statins and anti-hypertensive drugs will not be able to fully address the resulting health hazards, leaving bariatric surgery as the last line of defence.

In a result which underlines the extent of the obesity challenge, research by the NCD Risk Factor Collaboration* has found that that between 1975 and 2014, the prevalence of obesity among men more than trebled from 3.2 per cent to 10.8 per cent, while among women it surged from 6.4 to 14.9 per cent.

The study’s authors warned that on current trends, 18 per cent of men and 21 per cent of women will be obese by 2025, meaning there was “virtually zero” chance of reaching the global target of halting the prevalence of obesity at its 2010 level.

Instead, in the next nine years severe obesity will supplant underweight as a bigger public health problem, especially for women.

“The world has transitioned from an era when underweight prevalence was more than double that of obesity, to one in which more people are obese than underweight,” the study, published in The Lancet, said.

But although the world is getting fatter, it is also getting healthier, confounding concerns about the detrimental health effects of being overweight.

Writing in the same edition of The Lancet , British epidemiologist Professor George Davey Smith said that the increased in global body mass index (BMI) identified in the study had coincided with a remorseless rise in average life expectancy from 59 to 71 years.

Professor Davey Smith said this was a paradox, given the “common sense view that large increases in obesity should translate into adverse trends in health”.

Generally, a BMI greater than 25 kilograms per square metre is considered to be overweight, while that above 30 is obese and above 35, severely obese.

As the BMI increases above the “healthy” range, it is associated with a number of health consequences including increased blood pressure, higher blood cholesterol and diabetes.

The fact that increased BMI has not so far been associated with decrease longevity has led Professor Davey Smith to speculate that in wealthier countries access to cholesterol lowering drugs and other medications have dampened the adverse health effects, sustaining improvements in life expectancy despite increasing weight.

But he warned this effect would only be limited – many people would not be able to afford such treatments, and pharmacological interventions can only alleviate some of the health problems associated with being obese, meaning many health effects are likely to emerge in greater number later on as the incidence of obesity increases.

One of the most important aspects of the NCD Risk Factor Collaboration report is the insight it provides into differences in the nature and prevalence of weight problems between countries and regions.

For instance, it shows that the biggest increase in men’s BMI has occurred in high-income English-speaking countries, while for women the largest gain has been in central Latin America.

At the extreme, the greatest prevalence of overweight and obesity was in American Samoa, where the age standardised mean BMI for was 32.2, and for women, 34.8. Other areas where the mean BMI for both men and women exceeded 30 included Polynesia, Micronesia, the Caribbean, and several countries in the Middle East and north Africa, including Kuwait and Egypt.

The researchers found that male and female BMIs were correlated across countries, though women on average had a higher BMI than men in 141 countries.

But, in a sign that the rate of weight gain in a country may slow after a certain point, the researchers found that from 2000 BMI increased more slowly than the preceding 25 years in Oceania and most high income countries.

Alternatively, it sped up in countries where it had been lower. After 2000, the rate of BMI increase steepened in central and eastern Europe, east and southeast Asia, and most countries in Latin America and Caribbean.

The results suggest that public health campaigns and other polices aimed at curbing weight gain and encouraging healthier diets and more physical exercise are so far having little effect, spurring policymakers to consider different measures.

Though not canvassed in the study, one idea gaining support intnationally is for governments to impose a tax on sugary foods.

The United Kingdom will levy a tax on sugary drinks from next year, similar to one already in place in Mexico, and the World Health Organisdaiton has backed the policy as a way to curb the rapid increase in cases of diabetes in the world.

While overweight and obesity has become a major public health problem, particularly in wealthier countries, inadequate nourishment remains a health scourge in much of the world.

The NCD Risk Factor Collaboration report shows that millions continue to suffer serious health problems from being underweight, and warned that “the global focus on the obesity epidemic has largely overshadowed the persistence of underweight in some countries”.

As in other respects, global inequality in terms of weight have increased in the past 40 years, and while much of the world is getting fatter, in many areas under-nutrition remains prevalent.

The study found that more than 20 per cent of men in India, Bangladesh, Timor Leste, Afghanistan, Eritrea, and Ethiopia are underweight, as are a quarter or more of women in Bangladesh and India.

* The study drew on 1698 population-based data sources involving body mass index measurements taken from 9.9 million men and 9.3 million women in 186 countries between 1975 and 2014.

Adrian Rollins

Shingles vaccine to cost unless you are 70

A vaccine to prevent the painful and potential deadly shingles infection will be available to 70-year-olds free of charge from November this year.

But those in their 50s, 60s, and 80s will continue to have to fork out $200 or more for a dose of the Zostavax vaccine if they want to be protected from the viral infection.

The Federal Government has allocated $100 million over four years to provide the vaccine free through the National Immunisation Program (NIP), and expects around 240,000 people to be immunised each year.

It is also funding as five-year catch up program during which Australians aged between 71 and 79 years are eligible to receive Zostavax through the NIP. Altogether, the Government expects around 1.4 million will be administered the vaccine through this initiative.

But other vulnerable groups, particularly those in their 60s, will have to make their own arrangements if they want to be protected from the infection, the risk and severity of which increases markedly with age.

Shingles is caused by the reactivation of the varicella-zoster virus that causes chicken pox in children. Following initial infection, the virus lies dormant in nerve roots near the spinal cord, and can reactivate at any time.

The infection often appears as a painful rash or blisters on the skin, and the associated pain can be excruciating.

In addition to the rash, in 50 per cent of cases shingles can lead to post-herpetic neuralgia, a chronic and debilitating form of neuropathic pain that can persist months or even years after the rash has healed.

Drug company bioCSL said that more than 97 per cent of Australians had developed antibodies to the varicella-zoster virus by the time they were 30 years of age, indicating almost universal potential to develop shingles among the adult population – though medical experts warn there is no way to predict who might develop shingles, or when.

Zostavax is approved for the prevention of shingles in those aged 50 years or older, and for the over 60s is also indicated as a protection against post-herpetic neuralgia and as a treatment to reduce acute and chronic zoster-associated pain.

But even though shingles is recognised as a risk for those 50 years and older, the medicines watchdog has resisted calls for Zostavax to be subsidised for those aged 50 to 69 years because of the vaccine’s limited longevity and doubts about the cost effectiveness of the measure.

Research indicates the vaccine is only effective for around 10 to 12 years, meaning that a typical 50-year-old receiving it would need at least two, and possibly three or more boosters to maintain protection.

Even though prevalence increases with age, from around 2 infection per 1000-person years in the under 50s to 5 per 100 person-years among those in their 50s, to 7 per 1000 among those in their 60s, and 10 per 1000 in 70-year-olds, an evaluation by the US Centers for Disease Control and Prevention found that Zostavax was not cost effective for those in their 50s.

It calculated that for every 1000 people receiving the vaccine at age 50, only 25 shingles cases and one case of shingles-related pain would be prevented.

Australia’s Therapeutic Goods Administration has done significant work evaluating the veracity of drug company claims about the longevity and effectiveness of the vaccine, and in 2014 advised against subsidising Zostavax for 60-year-olds because of “unacceptable assumptions” in the economic case for the proposal.

Adrian Rollins

Govt might try cap on for size, AMA warns

The AMA has warned the Federal Government it could face a damaging campaign during the forthcoming Federal election if it revives plans for a cap on deductions for work related education expenses in its hunt for Budget savings.

As ministers come under mounting pressure to identify cuts and savings to improve the bottom line for the 3 May Budget, the AMA has called on Treasurer Scott Morrison to reaffirm the Government’s commitment to supporting the continuing education requirements of professionals, including doctors.

AMA Vice President Dr Stephen Parnis said there had been worrying reports the Government could be considering resurrecting unpopular measures, including imposing a ‘standard deduction’ for work-related expenses.

“This would effectively be a cap by another name,” Dr Parnis said.

The proposal provoked outrage among doctors and other professionals, and the AMA was among 70 organisations that formed the Scrap the Cap Coalition to fight the change.

The Abbott Government won plaudits when it dumped the idea soon after winning the 2013 Federal election, but there are now fears Prime Minister Malcolm Turnbull may reinstate the measure to help narrow the Budget deficit.

In December, the Government revealed its financial position had worsened since last year’s Budget, the deficit was on track to reach $37.4 billion in 2015-16, and warned there would be no return to surplus in the next four years.

Since then, commodity prices have tumbled lower and economic conditions have remained soft, fuelling concerns the Commonwealth’s finances have become even worse.

Dr Parnis said a parliamentary inquiry into tax deductibility added to concerns that deductions for self-education expenses could be in the Government’s sights.

“We are urging the Government to resist any moves to put in place, directly or indirectly, a cap on deductions for legitimate work-related self-education expenses in the Budget or in any new tax policies,” he said, pointing out it would have a severe impact on doctors and other professionals who must continually update their skills and knowledge throughout their careers, at their own expense.

“Doctors must learn new about new technologies, surgical techniques, treatments, and pharmaceuticals if they are to provide the best possible care to save lives and improve quality of life for their patients,” Dr Parnis said. “Doctors can spend many thousands of dollars each year undertaking mandatory courses and professional development to equip them with essential skills in caring for patients.”

The AMA Vice President said doctors in rural and remote areas would be hardest hit, because they were forced to travel to attend training courses and seminars.

He warned it would create a “huge disincentive” for junior doctors to pursue specialist education, potentially creating or adding to shortages of specialists in the future.

If the Government does include the measure in next month’s Budget, it is likely to meet with powerful opposition.

Already, discussions have been held about reconvening the Scrap the Cap alliance and mount a vigorous campaign during the forthcoming Federal election if the Government does move to impose some form of education expenses cap.

Adrian Rollins

Military should get annual check up

Australian Defence Force personnel would undergo annual mental health checks under plans backed by the AMA to tackle rates of depression, post-traumatic stress disorder and suicidal thoughts in the military.

A parliamentary committee inquiring into the mental health of soldiers, sailors and air force personnel found that although in the short term they were no more prone to mental health problems than the broader community, the nature of their work meant the types of problems they experience are not the same.

The 2010 ADF Mental Health Prevalence and Wellbeing Study found that 22 per cent of Defence personnel experienced a mental disorder in the previous 12 months, roughly similar to that found in a sample of general members of the community, while almost 7 per cent who suffered multiple problems.

But although, in the short term, the prevalence of problems was approximately the same, over their lifetime, ADF personnel were found to be more at risk of mental health problems.

Military personnel were found to be less prone to alcohol abuse, but they were more likely to suffer depression, and to think about and plan suicide. The most common mental health problem, however, was anxiety, particularly post-traumatic stress disorder.

AMA President Professor Brian Owler said this reflected the particular characteristics of their work, including experiences during deployment overseas and long absences from family and support networks.

Professor Owler said a recommendation from the Foreign Affairs, Defence and Trade References Committee for annual mental health screening was a welcome proposal.

“Annual screening would help ensure that mental health problems are identified at a much earlier stage, would support early intervention, and lead to much better mental health outcomes for affected personnel,” the AMA President said.

He also endorsed the Committee’s call for a unique identifier number for veterans linked to their service and medical records.

In 2013, the Federal Government gave in-principle support to a similar idea put forward by the Joint Standing Committee on Foreign Affairs, Defence and Trade, but Professor Owler said there appeared to have been little progress made on it since.

“A unique or universal identifier could help improve health outcomes for these patients,” Professor Owler said.

The AMA President said it would support the transition of personnel out of Defence Force-funded health services into those provided by the Department of Veterans’ Affairs or the mainstream health system, and would enable tracking of the health of former ADF personnel over time, which was critical to research.

He said there was strong support for the idea among veterans’ groups, and called on the Government and bureaucracy to fast-track the initiative.

Adrian Rollins