Talking About The Smokes: summary and key findings

Transforming the evidence to guide Aboriginal and Torres Strait Islander tobacco control

The baseline cross-sectional results from the Talking About The Smokes project outlined in this supplement (and summarised in the Box) provide the most detailed national evidence yet to guide practice and policy to reduce the harm caused by tobacco smoking among Aboriginal and Torres Strait Islander peoples. The national prevalence of daily smoking in the Aboriginal and Torres Strait Islander population is falling, but at 42% is still 2.6 times that of other Australians.1 Research evidence to guide Aboriginal and Torres Strait Islander tobacco control has been constrained by the uncertainties of generalising from small local research projects or from the large body of research in other populations. There have been competing hypotheses about whether Aboriginal and Torres Strait Islander smoking and quitting behaviour is similar to or different from other populations. These new results suggest many similarities with other populations.

We found the proportion of Aboriginal and Torres Strait Islander daily smokers who want to quit, have made a quit attempt in the past year, live in smoke-free homes and work in smoke-free workplaces is similar to that of the general population. Similar proportions also demonstrate knowledge of the most harmful health effects of smoking and hold negative personal attitudes towards smoking.

But there are also differences. Fewer Aboriginal and Torres Strait Islander daily smokers than other Australians have ever made a quit attempt or sustained a quit attempt for at least a month, and a lower proportion agree that social norms disapprove of smoking. Even though similar proportions agree that nicotine replacement therapy and stop-smoking medicines help smokers to quit, fewer have used these. In contrast, a higher proportion recalled being advised to quit by a health professional in the past year.

There are also differences in smoking and quitting behaviour and beliefs within the Aboriginal and Torres Strait Islander population, although the socioeconomic gradients were not consistent. For example, more employed people than those who were not employed wanted to quit, had ever tried to quit, had sustained a quit attempt for at least a month, knew about the harms of smoking, had a smoke-free home, had been advised to quit and had used nicotine replacement therapy or stop-smoking medicines. But there were no differences by employment status in quit attempts in the past year, recall of exposure to health information or in many of the attitudes towards smoking.

Using this new information, health staff working directly with Aboriginal and Torres Strait Islander smokers can be encouraged to do more, knowing that most of the smokers they see will want to quit, already know that smoking and passive smoking are harmful, and are likely to live in a smoke-free home and have a history of recent quit attempts. They can be confident that their messages will be understood and welcomed, then focus on the more difficult task of helping people to successfully sustain their quit attempts.

Those working in clinics can build on their existing good work in ensuring that most Aboriginal and Torres Strait Islander smokers regularly receive brief advice about smoking cessation. They can encourage more smokers to use evidence-based measures to prevent relapse during their next quit attempt, such as stop-smoking medicines, the telephone Quitline, and quit-smoking courses, clinics and groups.

Those working in health promotion will need to continue to reinforce and enhance social norms about being smoke-free, to encourage quit attempts and to support smokers trying to sustain quit attempts. There is a need for continued mainstream and national social marketing campaigns, especially those that build on the particular salience of Aboriginal and Torres Strait Islander smokers’ concerns about the harmful effects of their smoking on others. Local and Aboriginal and Torres Strait Islander campaigns also appear to be useful.

There are also messages for public health professionals, policymakers, funders and managers. They can justify investing health resources in tobacco control, not only because smoking causes 20% of Aboriginal and Torres Strait Islander deaths,2 but also because improvement is clearly possible. Our findings support maintaining an ongoing commitment to a comprehensive approach to Aboriginal and Torres Strait Islander tobacco control, rather than relying excessively on any single strategy or element. Those working directly with Aboriginal and Torres Strait Islander smokers should be made aware of this new evidence and aided in reorienting their practice to accommodate it. One of the specific challenges will be how to efficiently fund targeted social marketing activity, without wasting social marketing resources through too much fragmentation.3

Most recent national policy attention has concentrated on the large increase in dedicated funding initiated by the previous federal government through the Tackling Indigenous Smoking program, followed by the announced cuts to this funding and the review of the program in 2014. The information in this supplement is useful to guide the evolution of the program, but also reminds us that this is only part of the story. Aboriginal and Torres Strait Islander smoking is also being tackled through mainstream tobacco control activities (advertising campaigns, pack warnings and plain packaging, and smoke-free regulation) and activities already incorporated into routine health care (brief advice and individual cessation support).

This is only the beginning of the evidence that will emerge from the Talking About The Smokes project. It was designed primarily as a cohort study, and analyses of the prospective longitudinal data of the 849 recontacted smokers and ex-smokers will enable more definitive causal interpretations. The involvement of Aboriginal and Torres Strait Islander people and the Aboriginal community-controlled health service sector in all aspects of this project will facilitate the translation of the results into improved practices and policies that will reduce the harm caused by smoking in Aboriginal and Torres Strait Islander communities.

Key findings from the baseline survey of the Talking About The Smokes project

We interviewed a nationally representative sample of 2522 Aboriginal and Torres Strait Islander people from 35 locations across Australia, including 1643 smokers (1392 daily smokers), 78 ex-smokers who had quit ≤ 12 months before, 233 ex-smokers who had quit > 12 months before, and 568 never-smokers.

Quitting (doi: 10.5694/mja15.00202, 10.5694/mja15.00199, 10.5694/mja15.00105)

70% of smokers want to quit
69% of daily smokers had ever made a quit attempt
48% of daily smokers had made a quit attempt in the past year
47% of daily smokers who had made a quit attempt in the past 5 years had sustained an attempt for at least 1 month
70% of daily smokers who had made a quit attempt in the past 5 years had strong cravings during their most recent quit attempt, and 72% found it hard to be around smokers

Second–hand smoke (doi: 10.5694/mja14.00876, 10.5694/mja15.00200)

53% of daily smokers reported that smoking was never allowed anywhere inside their home
88% of employed daily smokers reported that smoking was not allowed in any indoor area at their workplace
77% of daily smokers agreed that smoking should be banned everywhere (both indoors and outdoors) at Aboriginal community-controlled health services, 93% agreed it should be banned indoors at other Aboriginal organisations, and 51% agreed it should be banned at outdoor festivals and sporting events

Knowledge of the health effects of smoking and second–hand smoke (doi: 10.5694/mja14.00877)

Most daily smokers reported knowing that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%)
Most daily smokers reported knowing that second-hand smoke is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%)

Personal attitudes towards smoking (doi: 10.5694/mja14.01535)

78% of daily smokers agreed that if they had to do it over again, they would not have started smoking
81% of daily smokers agreed that they spend too much money on cigarettes
32% of daily smokers agreed that smoking is an important part of their life

Social norms about smoking (doi: 10.5694/mja14.01534)

62% of daily smokers agreed that mainstream society disapproves of smoking, and 40% agreed that their local community leaders disapprove of smoking
70% of daily smokers agreed that there are fewer and fewer places where they feel comfortable smoking
90% of daily smokers agreed that being a non-smoker sets a good example to children

Anti-tobacco health information (doi: 10.5694/mja14.01628)

65% of smokers recalled often noticing pack warning labels in the past month
45% of smokers recalled often noticing anti-tobacco advertising or information in the past 6 months, most commonly on television
48% of smokers recalled ever noticing any targeted advertising or information featuring Aboriginal and Torres Strait Islander people or artwork in the past 6 months, with 16% noticing advertising or information featuring local people or artwork

Cessation support (doi: 10.5694/mja15.00293, 10.5694/mja15.00205)

75% of daily smokers who had seen a health professional in the past year had been advised to quit
37% of daily smokers had ever used nicotine replacement therapy or stop-smoking medicines, and 23% had used them in the past year
Among all smokers and ex-smokers who had quit ≤ 12 months before, nicotine patches were most commonly used (24%), followed by varenicline (11%) and nicotine gum (10%)

We also surveyed 645 staff at 31 Aboriginal community-controlled health services, including 374 Aboriginal and Torres Strait Islander staff who had a lower age- and sex-standardised prevalence of smoking compared with a national sample of the Aboriginal and Torres Strait Islander population (doi: 10.5694/mja14.01523).

The ghosts of Budgets past

While listening to the Secretary of the Department of Health in the Health Budget lock-up in Canberra on Tuesday night, I was more than a little surprised that the sales pitch to Australia’s health leaders was that the centrepiece of the 2015 Health Budget was the Review of the Medicare Benefits Schedule (MBS) – a measure that had been announced some months earlier with supposedly no Budget revenue implications.

I was even more surprised when the Secretary inferred that the MBS Review would deliver further considerable savings to the Government. Health Minister, Susan Ley, has since clarified that this was not the Government’s intention.

It is not purely about a savings measure, it is about making sure that we have a modern MBS that actually reflects modern medical practice, and it actually maintains access for patient services.

Nevertheless, given the damage caused to the Government from last year’s Budget co-payment proposals and public hospital funding cuts – misguided measures that brought misery to the Government for the best part of a year – the general expectation was that the Government would play some strong suits in health policy.

That was not the case. Instead, we saw a range of modest (but welcome) announcements that remain completely overshadowed by the lingering negative effects of the Medicare patient rebate freeze and public hospital funding cuts – the ghosts of Budgets past.

The Budget unfortunately does not go anywhere near addressing the concerns of the AMA from last year’s Budget.

There is no indication that the public hospital cuts are going to be restored. Nor is there any indication about the required changes for the indexation freeze that we are seeing for GP and specialist patient rebates.

People need to remember that the indexation freeze is a freeze for the patient’s rebate. It is not about the doctor’s income. It is actually about the patient’s rebate and their access to services. There is no indication that those freezes are going to be lifted any earlier than 2018.

There have also been cuts of nearly $150 million taken out of general practice from changes to the child health checks, apparently because of ‘duplication’. It is very unclear where the so-called duplication occurs. Such a change would have been better dealt with as part of the MBS Review, rather than as a hastily conceived Budget saving measure.

There is also a lack of clarity around some of the announced cuts. There was a mystery package of $1.7 billion in cuts that was claimed to cover child health assessments, a number of dental programs, and ‘flexible funds’ for NGOs in the health sector. A big number, but little detail. The end result is a number of small organisations that do very good work looking after vulnerable people left wondering about their funding and their future.

The focus should have been on positives.

The AMA welcomed a range of other measures, including:

e-health changes, including the myHealth Record, particularly the opt-out component;
mental health plan;
support for the National Critical Care and Trauma Response Centre;
funding for Aboriginal Community Controlled health organisations;
organ donation programs; and
the Ice Action strategy.

The AMA has been invited by the Minister for briefing and clarification of issues such as Indigenous health program funding, after hours care, and preventive health.

Public and preventive health programs under cloud

The future of important public and preventive health and support programs for Alzheimer’s, palliative care, alcohol and addiction, rural and Indigenous health are under a cloud after the Federal Government announced almost $1 billion of cuts from health programs.

In a decision that has thrown doubts over the funding of organisations including Alzheimer’s Australia, Palliative Care Australia and the Foundation for Alcohol Research and Education, the Government said it would achieve savings of $962.8 million over the next five years by “rationalising and streamlining funding across a range of Health programs”, including so-called Health Department Flexible Funds, dental workforce programs, preventive health research, GP Super Clinics and several other sources.

AMA President Associate Professor Brian Owler the lack of detail around the savings was concerning.

“There is a lot of uncertainty in Canberra and around the country at the moment as to whether those important programs, those important organisations, such as Palliative Care Australia, Alzheimer’s Australia, the Foundation for Alcohol Research and Education, and many other non-government organisations, are going to be continued to be funded,” A/Professor Owler said. “Rather than announcing that these cuts of almost $1 billion are going to be made to those flexible funds, and leaving it up in the air for these organisations, we need to see certainty around where those cuts are going to be made, how they are going to be applied, so that these organisations can not only plan for their future but also continue their very important work.”

In addition, the Government has tagged the Health Department for an extra $113.1 million of savings in the next five years as part of its Smaller Government initiative.

It said this would be achieved by measures including consolidating the Therapeutic Goods Administration’s corporate and legal services into the Health Department, axing the National Lead Clinicians Group, replacing IT contractors by recruiting full-time staff and “ceasing activities that mirror the work of specialist agencies”, such as the Independent Hospital Pricing Authority, the National Blood Authority, and the Australian Institute of Health and Welfare.

Adrian Rollins

Child protection Australia 2013–14

This report contains comprehensive information on state and territory child protection and support services in 2013-14, and the characteristics of Australian children within the child protection system. This report shows that: – around 143,000 children, a rate of 27.2 per 1,000 children, received child protection services (investigation, care and protection order and/or in out-of-home care); – three-quarters (73%) of these children had previously been the subject of an investigation, care and protection order and/or out-of-home care placement; – Aboriginal and Torres Strait Islander children were 7 times as likely as non-Indigenous children to be receiving child protection services.

Statin-associated myotoxicity in an incarcerated Indigenous youth — the perfect storm

Clinical record

A previously healthy 18-year-old dark-skinned Indigenous man was incarcerated in a juvenile detention centre in New South Wales for 3.5 years from 2010 to 2013. Juvenile detention limits outdoor activity and, consequently, exposure to sunlight. Young people are confined indoors for schooling and other programs, with additional periods of cell lockdowns to accommodate detainee movements and staff handovers. Periods outdoors involve bursts of strenuous physical activity, mostly team sports or swimming. Further, detention centre policy requires young people to wear T-shirts and hats, and to use sun protection factor 30+ sunscreen when outdoors.

On entering custody, the patient’s weight was 65 kg, with a healthy body mass index (BMI) of 21 kg/m2 (reference interval [RI], 18.5–24.9 kg/m2). Full blood count, urea, electrolyte and creatinine levels and liver function test results were normal, and a blood-borne virus screen returned a negative result. He had a strong family history of type 2 diabetes in his mother and maternal grandmother, and, reportedly, of hypercholesterolaemia and early cardiovascular death in his father and paternal grandfather.

Seven months after incarceration, the man developed auditory and visual hallucinations and was noted to be withdrawn and depressed, with long periods spent resting in his cell owing to fatigue. He was commenced on the antipsychotic quetiapine 150 mg at night and the antidepressant fluoxetine 20 mg in the morning. At commencement of these medications, his weight was 89 kg (BMI, 29 kg/m2). Baseline pathology tests were not repeated at this time.

Six months after commencement of psychotropic medications, his weight had increased a further 25 kg to 114 kg and he was morbidly obese (BMI, 36 kg/m2), with phenotypes of metabolic syndrome including central obesity (waist circumference, 108 cm [RI, < 94 cm]), hyperlipidaemia (total cholesterol, 7.8 mmol/L [RI, < 5.5 mmol/L]; low-density lipoprotein cholesterol, 4.9 mmol/L [RI, < 4.0 mmol/L]; high-density lipoprotein cholesterol, 0.8 mmol/L [RI, > 1.0 mmol/L]), elevated triglyceride level (2.28 mmol/L [RI, < 2.0 mmol/L]), and fatty liver disease (γ-glutamyl transferase, 83 U/L [RI, 0–60 U/L]; alkaline phosphatase, 208 U/L [RI, 30–110 U/L]; alanine transaminase, 72 U/L [RI, 0–55 U/L]; aspartate transaminase, 46 U/L [RI, 0–45 U/L]) (Figure). Blood pressure and thyroid-stimulating hormone levels were within normal limits. With concerns about his obesity and metabolic derangements, quetiapine was ceased. He received counselling for dietary restriction (portion control, low saturated fat diet, reduction of energy-dense snacks) and, in particular, was encouraged to avoid the additional bread, butter and sugary drinks that are available to supplement meals. Increased physical activity was encouraged. An off-label trial of metformin was commenced, given the evidence for weight benefits in antipsychotic recipients,1 and increased to 1 g twice daily over the following 4 weeks.

Three months later, the patient’s fasting lipid levels remained similarly elevated despite lifestyle changes, and he agreed to trial atorvastatin 10 mg daily. He was also permitted to take recreational leave from the centre and commenced thrice-weekly training with the local football club.

Three weeks after commencing atorvastatin, the patient complained of worsening fatigue but denied having muscle tenderness, myalgia or cramping. Creatine kinase (CK) levels were normal at atorvastatin commencement, but had risen to 350 U/L (RI, < 170 U/L). Atorvastatin dosage was reduced to 5 mg in the morning, metformin was continued and fluoxetine was ceased.

Serial changes in the patient’s CK levels are shown in the Figure. Five weeks after atorvastatin commencement, lipid levels had improved but CK levels continued to rise and all medications were ceased. There were concerns regarding rhabdomyolysis, but urinalysis results, estimated glomerular filtration rate and renal function remained normal. His physical symptoms remained unchanged. The patient was encouraged to rest and drink plenty of water. He continued to play competition football. CK levels continued to rise, peaking at 3042 U/L.

Serum 25-hydroxyvitamin D levels were found to be low, and he was treated with cholecalciferol (vitamin D3) 1000 IU daily, increasing temporarily to 4000 IU daily after endocrinologist consultation. Serial CK and 25-hydroxyvitamin D levels showed slow improvement initially, with substantial improvements contemporaneous with aggressive vitamin D supplementation (Figure). The patient continued with lifestyle strategies and (in concert with cessation of psychotropic medications) lost 10 kg in weight, but lipid levels remained elevated. Fluoxetine was recommenced by the treating psychiatrist at 20 months because of concerns regarding the patient’s mood.

At the conclusion of his sentence, the patient was released from custody and referred to the local Aboriginal Medical Service for continuing management of his hypercholesterolaemia, myositis, and metabolic and mental health problems.

Indigenous Australians have a reduced life expectancy of up to 20 years compared with non-Indigenous Australians and, by 40 years of age, are 10 times more likely to suffer premature cardiac-related death.2 In recognition of this, the Indigenous Chronic Disease Package (through Closing the Gap initiatives) encourages the use of statins, recommending treatment at lower lipid thresholds.3

There is evidence that Indigenous populations may be at higher risk of statin-related myopathy owing to a higher risk of vitamin D deficiency,4 higher rates of human T-cell lymphotropic virus type 1 infections causing polymyositis5 and, possibly, genetic susceptibility to statin-associated myotoxic effects (the SLCO1B1 gene prevalent in other indigenous populations6). Other risk factors predisposing our patient to statin-related myopathy were his age, strenuous exercise, mild hepatic dysfunction and concomitant use of fluoxetine (a CYP3A4 inhibitor).4,7,8 As CK elevation persisted after atorvastatin cessation, the differential diagnosis was necrotising autoimmune myopathy, previously described in indigenous patients with persistent myopathy.9 The recommencement of fluoxetine at 20 months may also have perpetuated the elevated CK level.

Almost 12 000 people are incarcerated in NSW, with a quarter being Indigenous Australians and at greatest risk of vitamin D deficiency.10 This is the first report of statin-related myopathy in an Indigenous adolescent or an incarcerated person. It is worth noting by other clinicians who work with Indigenous and incarcerated groups that the risk factors for this patient’s “perfect storm” were not unusual — metabolic syndrome, vitamin D deficiency, and use of statins in the context of mental illness and concomitant psychotropic medication use.1,2

This report highlights the need for monitoring of vitamin D levels and supplementation (with an argument for easier access to injectable vitamin D in this group), with pre-statin counselling, particularly for those at high risk of statin-related myopathy — Indigenous Australians, youths, females, and those serving lengthy custodial sentences.

This case also highlights the detrimental effects of antipsychotics on weight and metabolic risk. An international declaration supporting young people with psychosis11 has delineated the obligations of health care providers to prevent weight gain and metabolic complications that contribute to the 25-year shortfall in life expectancy in people with severe mental illness.

In addition to these learning points, there are the obvious problems of the unmet health needs and human tragedy in this vulnerable patient group: a baseline high metabolic risk associated with Aboriginality and family medical history, the constraints of incarceration exacerbating the risk of vitamin D deficiency, and a doubling of weight resulting in rapid-onset obesity secondary to antipsychotic use. Co-prescription of lifestyle interventions at the time of commencing antipsychotic therapy is essential. In addition, metformin has proven efficacy in abrogating weight gain following antipsychotic commencement, with its use encouraged in patients who make clinically significant weight gains.1

Lessons from practice

Indigenous Australians, young people and those serving lengthy custodial sentences are at risk of low vitamin D levels and statin-associated myopathy.
Aggressive vitamin D supplementation may be required to normalise levels before commencing statin therapy.
For all people receiving antipsychotics, lifestyle intervention should be co-prescribed, and weight gain should be monitored and actively prevented.
Metformin has proven benefit for weight loss in patients who significantly gain weight on antipsychotic treatment.

Creatine kinase (CK) and other markers according to time and medications.

The AMA a persistent and powerful voice on Indigenous health

By Professor Ian Ring, Professorial Fellow at the Australian Health Services Research Institute, University of Wollongong. Professor Ring has worked with the AMA on Indigenous health issues for more than 20 years.

Nothing exemplifies quite so clearly the AMA’s concern with issues far broader than simply representing the interests of doctors as does its role in Aboriginal health.

That interest is broad in scope, genuine and effective, and dates at least from Dr Brendan Nelson’s term as AMA President in the mid-1990s.

Almost every President since has shared Dr Nelson’s deep, personal and organisational concern and involvement in Aboriginal health, and that involvement is the specific reason I, and no doubt others, joined the AMA many years ago.

That involvement has taken a variety of forms – lobbying, promoting public awareness through the media, preparing and disseminating annual Report Cards on a wide variety of relevant topics, and active engagement with Indigenous organisations and leaders.

Promoting public awareness of issues regarding Aboriginal health has been central to the AMA’s role and purpose, and has taken many forms.

For example, Keith Woollard and I travelled to New Zealand during his term as President (1996-98), notionally to learn more about international experience in improving Indigenous health, but with a secondary aim of drawing the attention of the Australian media. Both aims were achieved. There was substantial Australian press coverage and, equally, we learnt a lot about the linkage of health services with community, cultural, social and economic programs.

Lobbying has taken many forms.

During the late 1990s, when the lack of progress in Aboriginal and Torres Strait Islander health was seen as an international disgrace and symptomatic of a national failure to come to grips with the issues concerning Australia’s Indigenous peoples, the AMA arranged to bring together political, public service and health leaders in an effort to bring about a more effective focus on Indigenous health.

It organised meetings with the-then Prime Minister John Howard and several of his ministers, including Senator Amanda Vanstone, Michael Wooldridge, Tony Abbott and John Herron and Commonwealth Department secretaries. It also met with Aboriginal leaders and organisations, notably the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors Association (AIDA) and other leaders of the medical profession.

The AMA’s role became more institutionalised during Dr Kerryn Phelp’s term with the formation of the AMA Indigenous Taskforce, whose membership was drawn from NACCHO, AIDA, the Indigenous branch of RACGP, Aboriginal health leaders, AMSA , AMA council members and other AMA members with an active involvement in Aboriginal health.

Since its inception, the Taskforce has produced annual Indigenous Health Report Cards highlighting issues including infant health, inequality, incarceration, low birth weight, workforce requirements and Indigenous primary health care.

Under the leadership of the current President Associate Professor Brian Owler, the AMA is an active participant in the Close the Gap campaign and lobbies effectively on matters of key importance to Indigenous health, such as patient co-payments.

This is in keeping with the AMA’s well-established role as a persistent, sustained and powerful voice on Indigenous health for at least the past two decades.

During that time, much has changed for the better, particularly as a result of the Close the Gap campaign – although recent cutbacks to funding are a significant concern.

For the future, the development of the Implementation Plan for the National Aboriginal and Torres Strait Island Health Plan will be a priority, including ensuring that it is guided by the voice of Aboriginal people and effectively addresses issues of culture and racism, as well as the practical issues of service models, building service capacity and ensuring an adequate workforce and funding.

Health at the core of closing the gap

AMA President Associate Professor Brian Owler has warned that governments need to increase their investment in health in order to close the yawning gap in life expectancy and wellbeing between Indigenous people and other Australians.

In a veiled swipe at the Federal Government’s policy focus on school attendance and employment in Indigenous communities, A/Professor Owler told a major international conference on the social determinants of health that too often the importance of wellbeing was overlooked.

“Health is the cornerstone on which education and economics are built,” the AMA President said. “If you can’t go to school because you or your family are sick, truancy officers won’t work. If you can’t hear because of otitis media, you won’t learn. If you miss training opportunities because of depression or ill health, you won’t progress to employment. You can’t hold down a job if you keep having sick days.”

His remarks to a British Medical Association symposium on the role of physicians in addressing the social determinants of health came a month after Prime Minister Tony Abbott admitted that the nation had fallen behind on meeting most of its Closing the Gap targets.

While there has been some improvement in the life expectancy of Aboriginal and Torres Strait Islander people, Indigenous men still on average 10.6 years earlier than other Australian males, and the gap for women is 9.5 years.

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said the fact that chronic and non-communicable diseases and other preventable occurrences such as suicide, trauma and injury accounted for a major proportion of the gap in life expectancy underlined the need for greater investment in health care, particularly Aboriginal community controlled health services.

“While those with chronic disease need to be cared for, prevention, particularly in the early part of life, is the key if we are going to see a generational change in health outcomes,” A/Professor Owler said.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

“There have been many examples of governments trying to address the social determinants of health – but often they have failed,” he said, referring to policies including building inappropriate housing and taking children from their families.

The AMA President said any attempt to improve Indigenous health needed to acknowledge the fundamental importance for Aboriginal and Torres Strait Islander people of their connection with the land, and understand that in many Aboriginal languages health was a concept of social and emotional wellbeing rather than a physical attribute.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

“Constitutional recognition is a vital step towards making Aboriginal and Torres Strait Islander people feel historically and integrally part of the modern Australian nation,” A/Professor Owler said. “Recognising Indigenous people in the Constitution will improve their self-esteem, their wellbeing, and their physical and mental health.”

Prime Minister Tony Abbott has taken a personal interest in Indigenous affairs, concentrating responsibility for many Indigenous policy areas within the Department of Prime Minister and Cabinet and overseeing the development of the Indigenous Advancement Strategy.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

“What is missing from the core of the IAS is a focus on health,” the AMA President said. “Health underpins many of these outcomes. We need to get the balance right and we, the AMA, need to ensure that health is seen as a foundation to these outcomes.”

He said that “spending on health is an investment. Investing in health must underpin our future policies to Close the Gap, and to address what is, for Australia, a prominent blight on our nation”.

Adrian Rollins

New strains force late start for flu vaccination program

Doctors and patients will for the first time have access to single-dose vaccines covering the four most common flu viruses amid concerns a mutated strain that wreaked havoc in the northern hemisphere could take hold in Australia.

The Therapeutic Goods Administration has approved nine vaccines, including, for the first time, three quadrivalent formulations, as preparations advance for the roll-out of National Seasonal Influenza Immunisation Program from 20 April.

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

Drug company Sanofi Pasteur, which manufactures two of the quadrivalent vaccines, said they were well tolerated and provided additional protection because they covered both B strains of the influenza virus as well as the two A strains – compared with trivalent vaccines that covered both A strains but only one B strain.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

“The double-strain change has resulted in manufacturing delays due to the time it takes to develop, test and distribute the reagents needed to make the vaccine,” a Health Department spokesperson said. “The commencement of the program is being delayed to ensure sufficient supplies of influenza vaccine are available from at least two suppliers in order to mitigate the risk of administration of bioCSL’s Fluvax to children under five years of age.”

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

The TGA has repeated its advice that Fluvax is not registered for use on children younger than five years, and that it should only be used on children between five and nine years following “careful consideration of potential benefits and risks in the individual child”.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

In a stroke of good fortune, the delay in the vaccination program has coincided with a relatively quiet start to the flu season, with reports that influenza activity has so far been weaker than that experienced at the same time last year.

The Health Department and the TGA said that, despite the delay, they do not expect any flu vaccine shortages, and the Government has committed $4.5 million over the next five years to provide free flu vaccination for Indigenous children aged between six months and five years.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

The network, which has been operating for more than a decade, collates information from more than 200 GPs and medical practices across the nation to provide health authorities with an early warning of developing outbreaks. Its information is used in conjunction with data from hospitals.

Adrian Rollins

Health at the core of closing the gap

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

Adrian Rollins

New strains force late start for flu vaccination program

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

Adrian Rollins