Breaking bread delivers big health rewards

There has been a significant decline in serious birth defects following the mandatory fortification of bread with folic acid and iodine.

Signalling a major public health success, the Australian Institute of Health and Welfare has found that the rate of neural tube defects has plunged by almost 75 per cent in babies born to Indigenous mothers, and are down by 55 per cent among babies born to teenage mothers, following the mandatory fortification of bread with folic acid and iodine.

Since 2009, millers have been required to add folic acid and iodine to flour following evidence that deficiencies in the diet of mothers was helping prevent neural tubes in foetuses from closing, causing serious birth defects such as spina bifida.

Research has shown that folic acid taken at recommended levels for at least one month before and three months after conception can prevent most neural tube defects.

The AIHW reported that since mandatory folic acid fortification was introduced, the overall incidence of neural tube defects has declined by 14.4 per cent, including major declines among teenagers and the Indigenous community.

It also found that the addition of iodine to bread had addressed the emergence of mild iodine deficiency in the general population.

AIHW spokesperson said these were “promising” results, but said further data collection was required to ensure these findings were accurate and sustained.

The full report is at: http://www.aihw.gov.au/food-and-nutrition/folic-acid-and-iodine/

Adrian Rollins

Kimberley suicide rate highest in the world

There needs to be more innovative approaches to preventing suicide in Indigenous populations, experts say, with suicide rates in the Kimberley region among the highest in the world.

A report in the Medical Journal of Australia found that there were 125 suicides in the region between 2005 and 2014. 102 of those were Indigenous people.

“As the Kimberley Indigenous population was 13 918 at the 2011 census, this equates to an age adjusted suicide rate of 74 per 100 000 per year in this population,” the authors wrote.

Most of those people were male and less than 30 years old. 70% were not known by the district’s mental health service.

There were 476 Indigenous people who presented with deliberate self-harm or suicidal intention in 2014.

Related: Coping with patient suicide

The authors wrote that collective trauma and ongoing socio-economic deprivation were the drivers of high self-harm and suicide rates.

In an article in MJA InSight, Suicide prevention researcher and director of humanitarian projects at the Institute of Social Justice and Human Rights, Mr Gerry Georgatos said that a Royal Commission was needed into this “catastrophic humanitarian crisis”.

“A royal commission can shift the national consciousness, educate the nation as to the underlying issues while also smashing myths and stereotypes. [This] has the strongest prospect of galvanising the ways forward,” he said.

One of the authors of the MJA paper, Dr Murray Chapman, told MJA InSight that local communities need to be able to develop their own services based on their needs.

“It’s about empowerment and capacity building in communities – as opposed to imposing on the communities,” he said.

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Burma inspires proud Kamilaroi man

Darren Hartnett’s father had always urged him to go into medicine, but it was not until the critical care nurse travelled to Burma as part of a medical team that he decided to take up the challenge.

Mr Hartnett went to Burma in 2010 as part of the Operation Open Heart Team organised through Sydney Adventist Hospital, when he was struck by the thought: “We are making a difference here; why am I not making a difference back at home?”

The question was given added potency when he learned not long after his grandfather died that he learned of his Aboriginal heritage.

“My grandfather never spoke about it because of the hurt involved – he was separated from his family when he was young and sent to work for a farmer. He did not have a choice,” Mr Hartnett said. “It was one of those taboo subjects that was never spoken of when he was alive.”

Now into the third year of a medical degree at Newcastle University, Mr Hartnett, who has spent much of his career as a nurse working in intensive care and coronary care at a major Sydney hospital, is considering working the New England area in critical care or as a rural GP – roles he hopes will involve helping Indigenous patients.

“I have always thought I would end up in critical care, but recently I have done placements with rural GPs and I have found it very rewarding,” he said.

“Knowing that within the next few years I can be out in the community assisting our own Indigenous population makes me proud of the fact that I am a Kamilaroi man.”

He is already contributing to the Indigenous community through his work for the Miroma Bunbilla Pre Medicine entry program, where he is helping aspiring Indigenous doctors.

His path ahead has been made easier by the fact he has been awarded the AMA Indigenous Peoples’ Medical Scholarship for 2016.

To help make ends meet Mr Hartnett, who has two young children, has had to combine the workload of a full-time student with part-time work as a nurse. He said the $10,000 a year scholarship would make a huge difference in helping his family get through while he completes his studies.

The scholarship was established in 1995 with a contribution from the Commonwealth, and the AMA is looking for further sponsorships to support its commitment to Indigenous health.

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

Nation ‘can’t afford’ barriers to care: King

AMA advocacy was “critical” in convincing Labor to make its $2.4 billion commitment to reinstate Medicare rebate indexation, Shadow Health Minister Catherine King told the AMA National Conference.

Highlighting what she said was a “huge gulf” between the major parties on health policy, Ms King said Labor’s promise to lift formed part of its plan to strengthen primary care, enhance preventive health efforts and reduce health inequality.

The Coalition has seized on figures showing that bulk billing has climbed to record levels to dismiss warnings that the rebate freeze will force many doctors to abandon bulk billing and begin charging patients.

But Ms King said the freeze would eventually result in higher out-of-pocket costs for patients.

“Sooner rather than later we know that the freeze will result in less bulk billing, and more and higher co-payments,” the Labor frontbencher said.

“When one in 20 Australians already skips or delays seeing a GP because of cost, that is not something we can afford to let happen.

“When our population is ageing and chronic disease is growing, we should be investing more in primary care, not less.”

Ms King said similar concerns underpinned Labor’s $971 million plan to scrap increases of between 80 cents and $5 to Pharmaceutical Benefit Scheme co-payments and changes to safety net thresholds.

“Cost is a barrier for access to prescription drugs,” she said. “We know that up to one in eight Australians doesn’t fill their scripts because medicines are already unaffordable for them.”

Ms King admitted that the policies, together with other health measures including an extra $15 million for Indigenous health, more than $25 million for cancer treatment and research and $35 million for palliative care, were expensive.

Labor has said it will fund the measures by axing the Coalition’s $50 billion business tax cut.

Ms King said the decision to fund these health policies had not been easy “given the current fiscal circumstances and competing demands. But in the end, budgets come down to choices and values”.

Adrian Rollins

Greens promise billions for hospitals, Medicare

The Australian Greens have committed to a multi-billion dollar boost to Medicare and hospital funding as part of a drive to increase investment in health.

Greens leader Senator Richard Di Natale told the AMA National Conference that his party would not only match Labor’s $2.4 billion promise to ditch the Medicare rebate freeze but would provide an extra $4 billion to restore Commonwealth funding for public hospitals, including providing 50 per cent of growth funding.

Senator Di Natale said the policies reflected the Greens’ commitment to universal and equitable access to health care, and an end to what he said was the Government’s “shameless exercise in cost shifting”.

Though opinion polls indicate the Greens stand no chance of forming government in their own right, they show that the election contest is finely balanced, opening the possibility the Greens could play a crucial balance of power role in forming the next government – making their views on health policy potentially significant.

In his speech, Senator Di Natale lambasted the Coalition’s cuts to health spending and detailed plans to increase Commonwealth support for hospitals, GPs, allied health workers and health services for Indigenous Australians and other disadvantaged patients.

“We should never be fooled, by those who see health as a cost more than an investment, into believing that cuts to the heart of the health system are a necessity,” he said, arguing that Australia’s spending on health was around the average among developed economies.

Senator Di Natale said that while it was important to ensure health funds were spent effectively, health expenditure would increase.

“As exciting new treatments become available and our country’s demographics change, we will need to spend more on health care to enjoy a better quality of life,” he said. “That, we believe, is a clear and legitimate choice for a wealthy nation to make. Spending more on health care is not unsustainable or irresponsible – it is a key priority and an investment we are luck to make.”

On the highly controversial topic of assisted dying, Senator Di Natale said the Greens believed patients should have “access to voluntary euthanasia and physician care for dying with dignity”.

The Greens leader said policies on Indigenous health, drug and alcohol treatment services and preventive health would be detailed later in the election campaign.

Adrian Rollins

AMA has a responsibility to ‘speak up’: Owler

Former AMA President Professor Brian Owler has lashed the Coalition over its conduct of health policy in the past two years, accusing it of allowing short-term budgetary measures to triumph over long-term policy vision.

In a typically forthright speech in his last address to the AMA National Conference as AMA President, Professor Owler said decisions to extend the Medicare rebate freeze, slash public hospital funding and try to impose a GP co-payment had been driven by a focus on savings without regard for their impact on patients and health system.

“As confirmed by [Health Minister Sussan Ley] herself…the health portfolio is not run by the Minister for Health. It is run by Treasury and Finance,” he said.

Professor Owler said the history of the last two years had shown that the Government had a problem when it came to health policy, “but the problems are not the making of the AMA [or] of an outspoken AMA President”.

“The failures of this Government are of their own making – a failure to consult with genuine intent, a failure to listen.”

The former President detailed how the Government set a combative tone for the relationship early on.

“In my first meeting as AMA President, I met with the Health Minister, Peter Dutton, who delivered an ultimatum: ‘As I see it,’ he said, ‘the AMA can either support the Government’s co-payment plans or you can be on the outside’.”

Professor Owler said it was an easy choice: “I was not going to sell out our members, and I certainly wasn’t going to abandon our patients”.

He told the conference how the Government responded after asking the AMA to develop an alternative to its co-payment policy.

“We dutifully did this. We worked hard, we kept it in confidence, and we delivered it to the Minster,” he said. “In return, the Minister ignored the plan and [described it] as a ‘cash grab by greedy doctors’. So much for working closely with Minister Dutton.”

Professor Owler said the Medicare rebate freeze was affecting the viability of medical practices, was punishing patients and was “not sensible policy. It affects the whole system”.

He said it was pleasing that, as a result of intense AMA lobbying, Labor had committed end the freeze, and said it was not too late for the Government to follow suit.

In his speech, Professor Owler took aim at private health insurers, who he said wanted to introduce US-style managed care.

He said the medical profession needed to be “endlessly vigilant” to the threat.

“We must never let private health insurers undermine our health care system, whether it be by interfering with the doctor-patient relationship or by disturbing equity of access in general practice,” he said. “Australians are…relying on you to defend against the actions of insurers, for whom the interests of shareholders come first, and patients are a distant second.”

Professor Owler acknowledged that some AMA members had been made “anxious” by the Association’s statements on asylum seeker policy.

But he said that with the AMA’s influence also came a “responsibility to speak up when governments overstep the mark – that is what happened with Australia’s approach to asylum seekers”.

The former President also highlighted AMA advocacy on Indigenous health and public health, including on family and domestic violence, road safety, alcohol, climate change, immunisation and physical activity.

Adrian Rollins

Holding the Government to account

I was greatly humbled and honoured to be elected as President of the AMA at last month’s National Conference in Canberra.

It is an exciting and challenging time to assume such an important position – in the midst of a close, hard-fought federal election campaign, with health at the top of the agenda. I want to make sure that it stays there.

I am talking to all sides of politics about the issues that matter to you and your patients. Getting rid of the Medicare rebate freeze and increasing funding for public hospitals are top priorities.

The rebate freeze is unfair and it is wrong. We know that it is pushing many practices to breaking point. Some are being forced to introduce patient charges for the first time, others are having to increase their fees. Either way, patients lose out and health suffers.

It is bad policy because it causes people to think twice before seeing their doctor. It will mean more people turning up at hospital – the expensive end of the health system.

Hospitals are already under enough pressure. All levels of government need to realise that an ageing population and epidemics like obesity and drug use are pushing demand up.

We need to break the idea that health is a cost. It is an investment in the future of our community. Without good health, you cannot have a healthy society or, for that matter, a productive economy. Spending on health is not just another budget line to be cut or held down.

I will criticise the Government when they deserve it. I will speak up fearlessly when they produce bad policy.

But I want such criticisms to be the start of the conversation, not the end. I want to engage constructively with all sides of the political debate, and to find better ways forward.

I want to invigorate a conversation on the medical workforce. We need more training positions, not more medical students – and certainly, not more medical schools. The workforce we train should meet the needs of the community it is there to serve. We can do better for rural Australia.

The AMA has a long history of advocating for the sick, the vulnerable and the voiceless. That will continue under my leadership. I have committed myself to continuing the AMA’s work in closing the gap between Indigenous and non-Indigenous health outcomes. I want to do more on mental health. I will hold the Government to account on the health care of asylum seekers.

I congratulate Dr Tony Bartone on his election as AMA Vice President. He is a much valued colleague and friend. I look forward to working closely with him in the next two years to advance the interests of patients and AMA members.

I pay tribute to the tireless work of my predecessor, Professor Brian Owler, and former AMA Vice President Dr Stephen Parnis, in advocating on behalf of patients and our community.

I look forward to the next two years as AMA President with great energy and enthusiasm.

[Series] State humanitarian verticalism versus universal health coverage: a century of French international health assistance revisited

The French contribution to global public health over the past two centuries has been marked by a fundamental tension between two approaches: State-provided universal free health care and what we propose to call State humanitarian verticalism. Both approaches have historical roots in French colonialism and have led to successes and failures that continue until the present day. In this paper, the second in The Lancet’s Series on France, we look at how this tension has evolved. During the French colonial period (1890s to 1950s), the Indigenous Medical Assistance structure was supposed to bring metropolitan France’s model of universal and free public health care to the colonies, and French State imperial humanitarianism crystallised in vertical programmes inspired by Louis Pasteur, while vying with early private humanitarian activism in health represented by Albert Schweitzer.

Rebate freeze ‘must go’: Gannon

New AMA President Dr Michael Gannon has declared that the Medicare rebate freeze is “unfair…and wrong”, and must be scrapped.

In his first public statement following his election at the AMA National Conference, Dr Gannon reaffirmed the peak medical organisation’s commitment to overturning the freeze, which he warned could force some doctors to abandon bulk billing and begin charging patients up to $25 a visit.

“GPs are at breaking point. They can’t take too many more cuts,” he said. “I would not be surprised if those practices that move away from bulk billing, and decide to invest in the infrastructure required to collect the fees, turn around and collect something like a fee between $15 and $25”.

The Federal Government’s decision to extend the current freeze on Medicare rebates an extra two years to 2020 has provoked outrage among GPs and the broader medical profession. The AMA has mounted a nationwide campaign against the policy, which is also the target of television ads by the Royal Australian College of General Practitioners that warn patients the freeze means “you will pay more”.

Dr Gannon has assumed the presidency in a highly politically-charged environment, with the nation embroiled in one of the longest Federal Election campaigns in decades. Opinion polls have the two major parties locked in a close contest.

THe Western Australian obstetrician has held discussions with Health Minster Sussan Ley, Shadow Minister Catherine King and Greens leader Richard Di Natale, and promised to “pursue a consultative style [to] try and find constructive ways forward”.

He said there was an opportunity to improve the AMA’s relationship with Ms Ley, and said the AMA should “always try and be constructive when it criticises policy of governments or opposition to come up with alternatives”.

Dr Gannon warned that, “when you criticise Government on any area of policy you need to realise that there might be a cost in that area or in other areas of your agenda”.

But he said the Medicare rebate freeze had to go, and reiterated the AMA’s support for Labor’s policy to end the freeze. Both Labor and the Greens have promised $2.4 billion to reinstate rebate indexation from 1 January next year.

Dr Gannon called for the Coalition to “change tack” on the freeze.

“Unravelling the freeze is so important,” he said, adding that such a move should be the start of a broader discussion about improved support for general practice.

“Successive governments have under-invested in quality general practice. That is the cornerstone of the health system,” he said. “High quality primary care reduces the need for more expensive hospital admissions. Unravelling the freeze is not a solution to the underfunding of general practice. We need to do so much better.”

The AMA President also attacked Commonwealth cuts to public hospital funding.

“I don’t think that there’s room to cut hospital funding; in fact, quite the opposite,” Dr Gannon said.

While the AMA needed to be “responsible” in calling for greater health funding, he lamented that both the Federal and State tiers of government had failed to comprehend the rise in hospital costs stemming from the ageing population and health epidemics like obesity and drug use.

But Dr Gannon said his advocacy would not be limited to general practice and hospital, and the AMA’s “very strong” platform on social issues would continue under his leadership.

He said he was committed to “continuing the AMA’s long history in trying to close the gap between Indigenous and non-Indigenous Australians”, and also made particular mention of mental health and “speaking up for people who can’t speak for themselves”.

Adrian Rollins