more_vertIn January, 2016, in Beijing, Randall Rader, a former Chief Justice of the US Court of Appeals for the Federal Circuit, gave a speech to a private gathering of Chinese Government officials. He had been invited to set out his assessment of China’s progress towards the creation of an effective legal system. “The law is the foundation of all prosperity”, he argued. By prosperity he didn’t mean only wealth. He included all aspects of a society that underpin its peaceful order and good functioning, including health.
Preference: Government and politics
[World Report] Somalia calls for greater coordination in health assistance
Somalia’s health minister says more coordinated efforts between the government and external actors could go a long way to improving the health of the population. Sharmila Devi reports.
[Correspondence] The Institute of Fiscal Studies’ verdict on a sugary drink tax
On Feb 8, 2016, the influential Institute for Fiscal Studies (IFS) released its annual Green Budget—a report aimed at informing the government’s March budget.1 For the first time, their budget report discusses a sugary drink tax and concludes that “the efficacy of [a sugary drink tax] will depend on what products [consumers] switch to and how firms change their prices”. The IFS warns that a sugary drink tax could lead to consumers switching to chocolate or that prices of diet drinks could rise thereby weakening the tax’s impact on health.
[Editorial] Creating a healthier environment for the Chinese population
On March 16, the Chinese Government officially approved its 13th Five-Year Plan—the country’s economic and social development blueprint for 2016–20. Notably, environmental protection—for the first time—has been highlighted as a key priority, along with a more moderate annual economic growth at just above 6·5%. As binding targets, water consumption, energy consumption, and carbon dioxide emissions will be cut by 23%, 15%, and 18%, respectively by 2020. In terms of air pollution, the plan particularly requires a minimum of 80% of days “with good air quality” assessed by fine particulate matter (PM2·5) by 2020.
[Perspectives] Soumya Swaminathan: re-energising tuberculosis research in India
Paediatrician and clinical scientist Soumya Swaminathan is best known for her groundbreaking research on tuberculosis (TB). Last year, much to her surprise, she was appointed Director General of the Indian Council of Medical Research (ICMR) and Secretary of the Department of Health Research (Ministry of Health and Family Welfare) of the Government of India. Swaminathan is only the second woman to lead the ICMR, which was established in 1911, and the only woman to currently head any government science agency in India.
Australia’s internship crisis: a national process
By Matt Lennon, Vice President, Australian Medical Students’ Association
You’re 23. You’re in your final year of medical school and you’re very worried. It’s now December, and you’re waiting to hear back on your very last chance to obtain an internship in Australia.
It’s been a difficult six year slog that you moved countries to undertake; you’re now $300,000 in debt and, if you don’t obtain this internship, you will never graduate as a fully licenced doctor.
This, sadly, is the reality for many final year medical students around Australia. By the end of 2015, 40 students had contacted AMSA because they had not received an internship. It is the greatest weakness of the current system that we cannot know for sure what has happened to those students since then.
As it stands, there is no public data that tells us how many of them never found a last minute offer in Australia, or what the outcomes have been for those who missed out. This makes workforce planning for internships incredibly difficult. Worst of all, it makes it difficult for these young doctors to make a plan for their lives.
The issue stems from the radical increases in medical student numbers and medical school starting back in the late 1990s. Since 2005, the number of medical graduates around the country have doubled. Despite losing local graduates, Australia still imports more than 2000 overseas trained doctors annually – more than any other developed country – and many of these are only on temporary visas, brought in to plug gaps created by the poor planning decisions of the past. Retaining Australian-trained doctors who are graduating today will help to address the shortages of the future.
An imbalance between supply and demand has made it increasingly difficult for students to secure internships – and as a result, students may seek to maximise their chances by applying to a variety of agencies at great financial, logistical and emotional cost. In 2011, 41 per cent of applicants for 2012 internships applied to more than one jurisdiction.
Agencies are then hampered by applicants who have received multiple offers but may fail to reject unwanted offers in a timely manner, if at all. In 2011, there were twice as many applicants who accepted multiple internships than there were in 2010.
Because of this complexity, State health departments have to meet over several months to manually work out which graduates have one or more offers. This usually lasts from July to September, during which time the rounds of offers for internships are slowly going out. It is this period that is really crucial for medical students who are likely to miss out. They are making decisions around moving overseas and doing further study that will direct the rest of their working lives.
Establishing a National Internship Application Process would solve this. It would mean that, rather than taking several months, all internships in Australia would be sorted out in a single day, and a job that is best done by a computer would not consume hundreds of government staff hours.
The process would not mean that all states would have to align priority systems or methods of application. Rather, in its simplest form, it would be an alignment of the computer systems and portals used by each of the states to detect and prevent any double offers.
States and territories would be relieved of an unnecessary duplication of services, and it would be impossible for applicants to accept multiple places.
There would also be ancillary benefits: collation of internship data would be centralised and more readily accessible and, in light of national registration standards for medical practitioners, the Commonwealth may find benefit in being more closely involved in the internship allocation process.
Most important of all, streamlining the process, aligning dates and providing solid data on those that have missed out from day one would give governments time to ensure spots are created for the remainder.
For many this is a story about bureaucracy and numbers. But for medical students the internship is an indispensable part of our training without which we will never become doctors. For us it is a story about aspirations and a future.
Patients pay for hobbled hospitals
Since the Commonwealth’s unilateral changes to public hospital funding announced in the 2014-15 Budget, the AMA has highlighted the impact of dramatically reduced funding on an already underperforming public hospital system.
In May 2014, the Australian Government walked away from the National health Reform Agreement, abandoning its promise to make public hospital funding sustainable and contribute an equal share towards growth in public hospital costs.
From July 2017, the Commonwealth will instead limit its contribution to public hospital costs based on a formula of the Consumer Price Index (CPI) and population growth only. This represents the lowest Commonwealth contribution to public hospital funding since the Second World War.
According to Treasury, the indexation change will reduce Commonwealth funding to the states and territories by $57 billion between 2017-18 to 2024-25.
The CPI measures changes in prices faced by households only, and is not an appropriate measure of increases in hospital costs. Increasing funding on the basis of population growth does not address cost increases associated with changing demographics, or the costs of new health technologies.
The Finance and Economics Committee resolved last year that the Commonwealth’s contribution to public hospital funding must be sufficient to address real increases in actual costs of the goods and services used by hospitals, and provide for demographic change – not only for population growth, but also for changes associated with ageing and health needs.
The Government’s ongoing justification for its extreme health savings measures, including cuts to public hospital funding, has been that Australia’s health spending is unsustainable.
This is simply not substantiated by the evidence.
The Government’s own figures show that health spending grew by 3.1 per cent in 2013-14. This is almost 2 percentage points lower than the average growth over the last decade (5 per cent). The previous year (2012-13) growth was even slower – just 1.1 per cent, which was the lowest annual increase since Government began reporting on health spending in the mid-1980s.
Clearly, total health spending is not out of control. The health sector is doing more than its share to ensure health expenditure is sustainable.
There have now been two years where growth in health expenditure has been well below the long-term average annual growth of 5 per cent over the last decade.
As part of this slowdown, growth in Commonwealth funding for public hospitals in 2013-14 was just 0.9 per cent, well below inflation and virtually stagnant. This is off the back of a 2.2 per cent reduction in Commonwealth funding of public hospitals in 2012-13.
This austerity has come at a cost, and has been reflected in the performance of our public hospitals. The AMA’s Public Hospital Report Card 2016 shows that, against key measures, the performance of our public hospitals is virtually stagnant or, in many cases, declining. This is the direct effect on patient care of reduced growth in hospital funding and capacity.
The most recent data shows waiting times are largely static, with only very minor improvement. Emergency Department (ED) waiting times have worsened. The percentage of ED patients treated in four hours has not changed, and is well below target. Elective surgery waiting times and treatment targets are largely unchanged. Bed number ratios have also deteriorated.
The Commonwealth’s funding cuts are already having a real impact as a result of almost $2 billion being sliced from programs to reduce emergency department and elective surgery waiting times.
But the most acute impact will be felt from July next year, when the new funding arrangements take effect.
Without sufficient funding to increase capacity, public hospitals will never meet the performance targets set by governments, and patients will wait longer for treatment, putting lives at risk.
Despite these warnings, we have yet to see a solution to the serious and rapidly approaching crisis in public hospital funding.
This is a crisis that has been created by political and budgetary decisions. It is one that will require political leadership to resolve.
– Brian Owler
An up-close view of Indigenous health – good and bad
Professor Owler meets with staff at a remore community health service in the Northern Territory
By AMA President Professor Brian Owler
No running water, overcrowded and non-functional houses, lack of affordable healthy food, no essential services and crippling rates of diabetes, kidney disease and communicable infections – these are just some of the issues that people living in remote Northern Territory communities such as Utopia, Ampilatwatja and Kintore endure every day. On a recent visit to these three communities, I gained a deeper understanding of local health issues and the challenges that doctors and nurses face in delivering health services in remote areas.
In meeting with local Aboriginal leaders and health and medical staff, I found that each community has their own unique challenges; but the overall messages that I heard were strikingly similar. Funding for local health services is inadequate, it is difficult to attract skilled health and medical professionals to work in remote areas, it is logistically challenging to provide health care in remote communities (particularly when patients need to be transported for specialist care), and the level of chronic diseases in these communities are alarming.
Take diabetes, for example. In Kintore, 130 of the community’s approximately 450 residents have non-gestational diabetes – almost a third of its entire population – and in every three houses, one person is on dialysis due to the onset of kidney disease. What is even more concerning is the young age that Aboriginal people are being diagnosed with diabetes. In Utopia, a seven year-old girl was recently diagnosed with type 2 diabetes, and in Ampilatwatja, a 13 year-old girl was diagnosed with the same condition. Among the broader Australian population, or perhaps anywhere in the world, it is unheard of for child so young to be diagnosed with type 2 diabetes, yet it is clearly visible in remote Aboriginal communities.
The lack of water and affordable healthy food in remote communities is strongly linked to the epidemic levels of diabetes among Aboriginal people in these areas. Sugary drinks are more readily available than diet soft drinks, and in some communities they are more accessible than running water. It is unfathomable that in Australia, communities are going without water – a basic human right and a necessity for good health and wellbeing. This is an issue that demands immediate attention and action by all levels of government – without it, the health gap between Indigenous and non-Indigenous Australians will remain wide and intractable.
One important lesson that I did learn while visiting these communities is that it is not all doom and gloom when it comes to Indigenous health. Yes, Aboriginal people in remote areas face great adversity, but they are patient, resilient, strong-willed and are determined to take control of their own health – there are some real positives happening.
At the Purple House, an Aboriginal-controlled dialysis service based in Alice Springs, I was told an inspiring story of Aboriginal people taking action to generate funds for more dialysis sites. Kidney disease is rife across central Australia, with many Aboriginal people developing this condition as a result of poorly controlled diabetes.
The need for dialysis in remote Aboriginal communities is extremely high and for many, treatment means leaving family and country to be treated in Alice Springs. To allow people to be treated on country and near family, Aboriginal artists from across the western desert region grouped together and painted artworks that were auctioned to raise funds. The auction raised more than $1 million, and Purple House was able to expand their dialysis services. They now operate across nine remote communities in the Northern Territory and Western Australia. Purple House also provides a mobile dialysis service via their ‘Purple Truck’, which travels to remote Aboriginal communities.
It is very rare that good news stories such as this are widely publicised, which is disappointing. We need to shed more positive light on Indigenous health, and Indigenous affairs more broadly in Australia.
The POCHE Centre for Indigenous Health and Wellbeing in Alice Springs is also making a positive contribution to the health of Aboriginal people. At the POCHE Centre, I learnt about the research currently being undertaken by PhD candidate Maree Meredith, a young Aboriginal woman from Queensland. Her research project aims to determine the role that art centres play in contributing to positive health outcomes for Aboriginal people across the Anangu Pitjantjatjara Yankunytjatjara (APY) lands. To ensure that this research was in line with cultural protocols and to ensure that appropriate data was collected, Ms Meredith worked with Anangu people to design and deliver a survey in the local language.
For many years, anecdotal evidence has suggested art centres make a significant contribution towards health and wellbeing, but there has been no empirical data. This study aims to provide reliable evidence that art centres improve the health and wellbeing of Aboriginal people in remote communities. This is also a clear example of building the capacity of local Aboriginal people to participate in the local workforce.
Aboriginal people know what they want – they know the best way to improve their health and wellbeing, and this must be acknowledged and supported if we are to truly close the gap.
While in Kintore, I spoke with Aboriginal leaders who mentioned that the local people prefer a traditional social and emotional wellbeing framework to be implemented in their community, rather than a Western one.
The community developed a proposal for Government funding for this initiative, but unfortunately it was not accepted.
Connection to culture is important to the health and wellbeing of Indigenous people, and is known to produce positive health and life outcomes, such as reduced incarceration rates.
Aboriginal people needed to be provided with a reason to stay in the communities where they are connected to their land, culture and families. Recent comments made by certain members of Parliament about subsidising the ‘lifestyle choices’ of Aboriginal people in remote areas are extremely concerning.
Within each of these communities, I was disheartened to see a world-class health system fail the Aboriginal people in remote communities. But, I was truly impressed by the resilience and determination of the local Aboriginal people and the passion, commitment and dedication of doctors, nurses and other health staff who work tirelessly such challenging environments.
I am extremely grateful to Warren Snowden, Member for Lingiari, for making visits to these communities possible, and for accompanying me throughout the trip. I am hopeful that we will see further progress made in improving health and life outcomes for Indigenous people across Australia.
News briefs
UK experts want ban on tackling in school rugby
More than 70 UK doctors and health experts have written an open letter addressed to government ministers, chief medical officers and children’s commissioners, calling for a ban on tackling in school rugby games, The Guardian reports. “The majority of all injuries occur during contact or collision, such as the tackle and the scrum,” the letter says. “These injuries, which include fractures, ligamentous tears, dislocated shoulders, spinal injuries and head injuries, can have short-term, life-long and life-ending consequences for children.” Rugby is a compulsory part of the UK physical education curriculum from the age of 11 in many boys’ schools, particularly in the independent sector, The Guardian says. The letter’s authors urged schools to move to touch and non-contact versions of the game. “Repeat concussions have been found to have a link to cognitive impairment, and an association with problems such as depression, memory loss and diminished verbal abilities. Children also took longer to recover to normal levels on measures of memory, reaction speed and post-concussive symptoms.” The Rugby Football Union said it took player safety “extremely seriously” and that recent changes meant young players underwent a “gradual and managed” introduction to the contact version of the game.
PLOS ONE paper provokes social media backlash
Retraction Watch reports that a paper on the biomechanics of the hand published in PLOS ONE has provoked a social media backlash for using apparently religious language in the abstract, introduction and conclusion. “In conclusion, our study can improve the understanding of the human hand and confirm that the mechanical architecture is the proper design by the Creator for dexterous performance of numerous functions following the evolutionary remodeling of the ancestral hand for millions of years.” Some commentators on Twitter described the publication of the paper as “an absolute joke” and “a big problem”. A spokesperson for PLOS was quoted by Retraction Watch as saying: “PLOS has just been made aware of this issue and we are looking into it in depth. Our internal editors are reviewing the manuscript and will decide what course of action to take. PLOS’ publishing team is also assessing its processes.” The corresponding author is listed as Cai-Hua Xiong, based at Huazhong University of Science and Technology in China.
Australian health system “underprepared” for heatwaves
A Climate Council report has found Australia’s health system is underprepared to deal with longer, hotter and more intense heatwaves, the ABC reports. “The Climate Council report … found nursing homes and medical centres across the country may not be equipped with necessary back-up energy and water supplies in extreme heat. The council noted several states had upgraded heat and health warning systems since the deadly heatwaves in 2009, but the lack of a streamlined response system was putting lives at risk. The report found heatwaves put pressure on health services, with emergency call-outs jumping almost 50 per cent and heart attacks almost tripling in the heatwaves of January and February 2009. By 2030, Australia’s annual average temperature is predicted to rise by 0.6 to 1.3 per cent, with the globe continuing to heat up to the end of the century, the report said. The report highlights the global problem of heatwaves, pointing to 55 700 deaths during the Russian heatwave in 2010, and 3700 killed in India and Pakistan in May 2015.”
Astronaut Scott Kelly and his twin a boon to science
Commander Scott Kelly has returned to Earth after 340 days on board the International Space Station (ISS) and a raft of scientists and doctors can’t wait to get their hands on him, Forbes reports. Any astronaut coming home is scrutinised, but Cmdr Kelly’s return was particularly anticipated because he has a twin brother. Retired astronaut Mark Kelly has spent the past year on Earth, providing scientists conducting NASA’s Twins Study with the chance to conduct the ultimate “controlled experiment”. Weightlessness can lengthen the spine and body by up to 3%, can cause loss of muscle — most notably in the heart — and bone mass; cause the head to swell; and cause dizziness and fainting on return to Earth. There are also issues of radiation exposure without the shield of the Earth’s atmosphere.
[Editorial] Unite to end tuberculosis
March 24 marks World TB Day. This year, the theme is “Unite to end tuberculosis”. WHO calls on governments, civil society, and the private sector to unite to end the tuberculosis epidemic—a much needed approach to tackle this deadliest of diseases. Although 43 million lives were saved through effective diagnosis and treatment between 2000 and 2014, more than 9 million cases of tuberculosis and 1·5 million deaths (0·4 million deaths in HIV-positive individuals) occur annually.