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Preference: Infectious Diseases and Parasitology

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[The Lancet Commissions] The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

Sub-Saharan Africa’s health challenges are numerous and wide-ranging. Most sub-Saharan countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world.

[Correspondence] WHO leadership is essential for the elimination of NTDs

The second director of the Department of Control of Neglected Tropical Diseases (NTDs) of WHO retired at the end of September, 2017. He was appointed in 2014 to ensure administrative stability after 9 years of innovative growth of this WHO department, which was established in 2005 after the retirement of the first director.1 Sustaining the momentum for elimination of NTDs requires a timely appointment of a new director to lead an effective Department of NTDs in WHO.

[Comment] Rapid changes in epidemiology of inflammatory bowel disease

The prevalence of inflammatory bowel disease, that is Crohn’s disease and ulcerative colitis, has increased over two to three generations in high-income countries, but in only one generation (the past 25 years) in much of the newly industrialised and “developing” world. In China, for example, these conditions have changed from being rare to common and now account for the use of as much as a quarter of gastroenterological and colorectal surgical hospital beds.1 These diseases are not necessarily less severe initially; in developing countries inflammatory bowel disease has as severe a phenotype, with the same complications, morbidity, and mortality as in established patient populations in high-income countries.

Christmas message from AMA President

It has been a very busy and very successful year for the Federal AMA. Your elected representatives and the hardworking staff in the Secretariat in Canberra have delivered significant achievements in policy, advocacy, political influence, professional standards, doctors’ health, media profile, and public relations.

We have worked tirelessly to ensure that health policy and bureaucratic processes are shaped to provide the best possible professional working environments for Australian doctors and the highest quality care for our patients.

Our priority at all times is to provide value for your membership of the AMA.

As 2017 draws to a close, I would like to provide you with a summary of the work we have undertaken on behalf of you, our valued members.

General Practice and Workplace Policy

  • Our strong advocacy led to a decision to lift the freeze on Medicare patient rebates.
  • AMA coordination of Doctors’ Health Services around the country, with funding support from the Medical Board of Australia.
  • Launched the AMA Safe Hours Audit Report, giving added focus to the issue of doctors’ health and wellbeing.
  • Maintained a strong focus on medical workforce and training places, with the National Medical Training Network significantly increasing its workforce modelling and projection work following sustained advocacy by the AMA.
  • Secured a number of concessions in the proposed redesign of the Practice Incentive Program (PIP), as well as a delay in the introduction of changes.
  • Lobbied at the highest level for a more durable solution to concerns over Pathology collection centre rents, focusing on effective compliance, and achieving a fair balance between the interests of GP members and pathologist members.
  • Led the Reforms to After-hours GP services provided through Medical Deputising Services (MDSs) to ensure that these services are better targeted and there is stronger communication between the MDS and a patient’s usual GP.
  • Successfully lobbied the ACCC to renew the AMA’s existing authorisation that permits GPs to engage in intra-practice price setting, potentially saving GPs thousands of dollars annually in legal and other compliance costs.
  • Ensured a proportionate response from the Government in response to concerns over the security of Medicare card numbers, avoiding more draconian proposals that would have added to the compliance burden on practices, and added a barrier to care for patients.

 

Medical Practice

  • Fundamentally altered the direction of the Medical Indemnity Insurance Review, discussing its importance to medical practice at the highest level, helping to ensure the review is not used as a blunt savings exercise, and saving doctors and their patients millions of dollars in increased premiums.
  • Led a nationally co-ordinated campaign with the State AMAs and other peak bodies to uphold the TGA’s decision to up-schedule Codeine.
  • Campaigned against an inadequate, poorly conceived, and ideological National Maternity Services Framework, which has now been scrapped.
  • Campaigned on the issue of Doctors’ Health and the need for COAG to change mandatory reporting laws, promoting the WA model.
  • Launched the AMA Public Hospital Report Card.
  • Pressed the case for vastly improved Private Health Insurance products through membership of the Private Health Ministerial Advisory Committee (PHMAC), my annual National Press Club Address, an appearance before a Senate Select Committee, and regular and ongoing media and advocacy.
  • Launched the AMA Private Health Insurance Report Card.
  • Successfully convinced the Government to address concerns with the MBS Skin items, and will continue to do so with the MBS Review more broadly.
  • Successfully lobbied for changes to the direction of the Anaesthesia Clinical Committee of the MBS Review.
  • Launched a new AMA Fees List with all the associated benefits of mobility and regular updates.
  • Saw a number of our Aged Care policy recommendations included in a number of Government reviews.
  • Lobbied against the ill-thought-out Revalidation proposal, which resulted in a vastly improved Professional Performance Framework based around enhanced continuing professional development.
  • Successfully held off the latest attempt to have a non-Medical Chair of the Medical Board of Australia appointed.

 

Public Health

  • Launched the AMA Indigenous Health Report Card, which this year focused on ear health, and specifically chronic otitis media, in conjunction with the Minister for Indigenous Health, The Hon Ken Wyatt AM.
  • Led the medical community by being the first to release a Position Statement on Marriage Equality, and advocated for the legislative change that eventuated in late 2017.
  • Released the updated AMA Position Statement on Obesity, following a policy session at the AMA National Conference, which brought together representatives from the medical profession, sports sector, food industry, and health economists.
  • Launched the AMA Position Statement on an Australian Centre for Disease Control (CDC), which was welcomed by experts in communicable diseases.
  • Released the AMA Position Statement on Female Genital Mutilation, which provided a platform for the AMA to engage in advocacy on preventing this practice.
  • Released the AMA Position Statement on Infant Feeding and Maternal Health.
  • Released the progressive and widely-supported AMA Position Statement on Harmful substance use, dependence, and behavioural addiction (Addiction).
  • Successfully lobbied against the proposal to drug test welfare recipients, including a strongly worded submission to a Parliamentary Inquiry on the proposal, which resulted in defeat of the proposed measure in the Parliament.
  • Released the AMA Position Statement on Firearms, generating considerable media coverage and interest, in Australia and overseas. Most importantly, it is a factor in Australia maintaining its tough approach to gun control.
  • Released the AMA Position Statement on Blood Borne Viruses (BBVs), which called for needle and syringe programs (NSPs) to be introduced in prisons and other custodial settings to reduce the spread of BBVs. This policy has been promoted by other health organisations and saw the AMA create strong ties within the sector.
  • Ongoing and prominent advocacy for the health and wellbeing of Asylum Seekers and Refugees, including a meeting with the Minister for Immigration and Border Protection, The Hon Peter Dutton MP, and lobbying on behalf of individual patients behind the scenes.
  • AMA lobbying of manufacturers saw a change to the sale of sugar-sweetened beverages in some remote Aboriginal communities, which will improve health outcomes.
  • Promoted the benefits of Immunisation to individuals and the broader community. Our advocacy has contributed to an increase in child and adult vaccination rates.
  • Provided strong advocacy on climate change and health.
  • Consistently advocated for better women’s health services.
  • Lobbied for the establishment of a No-Fault Compensation Scheme for people adversely affected by vaccines.

 We promoted our carefully-constructed Position Statement on Euthanasia and Physician Assisted Suicide during consideration of legislation in Tasmania, Victoria, NSW, and WA.

I would like to thank Dr David Gillespie for his contribution to the Rural Health portfolio, and hope that his legacy will be seen in the success of the new Rural Health Commissioner, a position the AMA lobbied for and supports.

In the New Year, we will release new Position Statements on Mental Health, Road Safety, Nutrition, Organ Donation and Transplantation, and Rural Workforce.

As your President, I have had face-to-face meetings with Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Health Minister Greg Hunt, Shadow Health Minister Catherine King, Greens Leader Dr Richard Di Natale, and a host of Ministers and Shadow Ministers.

We also organised lunch briefings with backbenchers from all Parties to promote AMA policies.

In July, our advocacy was publicly recognised when the Governance Institute rated the AMA as the most ethical and successful lobby group in Australia.

I have met regularly with stakeholders across the health sector, including the Colleges, Associations, and Societies, other health professional groups, and consumer groups.

As your President, I have been active on the international stage, representing Australia’s doctors at meetings in Zambia, Britain, Japan, and the United States.

The highlight of the international calendar was the annual General Assembly of the World Medical Association. Outcomes from that meeting included high level discussions on End-of-life care, numerous ethical issues, Doctors’ health, and an editorial revision of the Declaration of Geneva.

But our focus remains at home, and your AMA has been very active in promoting our Mission: Leading Australia’s Doctors – Promoting Australia’s Health.

We have had great successes. We have earned and maintained the respect of our politicians, the bureaucracy, and the health sector. We have won the support of the public as we have fought for a better health system for all Australians.

We have worked hard to add even greater value to your AMA membership.

May I take this opportunity to wish you, your families, and loved ones a safe, happy, and joyous Christmas, and a relaxing and rewarding holiday season. I hope you all get some quality private and leisure time – you deserve it.

Dr Michael Gannon
Federal AMA President

Unacceptable kidney transplant rate for Indigenous Australians

AMA President Dr Michael Gannon has called for urgent attention in addressing the gap between Indigenous and non-Indigenous Australians accessing kidney transplants.

Figures just released show that Indigenous patients are 10 times less likely than non-Indigenous patients to be added to the waiting list for a kidney donation transplant.

About 13 per cent of patients receiving dialysis treatment in Australia are Indigenous. Only 241 of 10,551 patients with a functioning kidney transplant are Indigenous.

Some renal experts have pointed to a racially-based bias, suggesting some non-Indigenous doctors favour non-Indigenous dialysis patients.

Other specialists in the field insist the gap is not fuelled by racism.

During an interview with the ABC, Dr Gannon said these figures were unacceptable and more needed to be done to ensure Indigenous Australians received transplants when needed.

“I’m shocked by those figures. A ten-fold gap is entirely unacceptable,” Dr Gannon said.

“The topic of racism in our health system is an uncomfortable one for doctors, nurses, but it has to be one of the possible reasons for this kind of disparity.

“If there’s reasons why Aboriginal and Torres Strait Islanders are not being transplant-listed, they need to be investigated, but the problems need to be fixed.”

Dr Paul Lawton, a specialist at the Menzies School of Health Research, told the ABC that while Australian kidney specialists were well meaning, there was a “structural racism” that had led to low transplant rates for Indigenous patients.

“Currently, our system is structured so that us non-Indigenous, often male, middle-aged white kidney specialists offer kidney transplants to people like ourselves,” Dr Lawton said.

“It both makes me sad and angry that in Australia in the 21st century, we see such great disparities in access to good quality care.”

Indigenous Health Minister Ken Wyatt said he was disheartened with the figures and wanted to focus on building a heightened awareness of the issue over the next year.

According to Kidney Health Australia, about 30 of 800 kidney transplants performed each year are received by Indigenous Australians.

This under-representation can be attributed to a variety of reasons such as comorbidities, delays in listing and significant tissue matching issues. Importantly, the outcomes from transplantation are considerable poorer than among non-indigenous people.

To improve access to transplantation by Aboriginal and Torres Strait Islander renal patients, there needs to be a better understanding of how to address the barriers. There also needs to be improved support services for patients.

Kidneys for transplantation are largely from deceased donors. There are very few living kidney donors in Aboriginal and Torres Strait Islander communities, due to burden of disease and likelihood of comorbidities evident. Increasing live donations or listing more people on the waiting list is very unlikely to see improvements, given the burden of disease experienced and current barriers in the system.

The reasons for poor access to transplantation experienced by Aboriginal and Torres Strait Islander Australians are complex and can be attributed to:

• The greater burden of comorbid illness amongst Aboriginal and Torres Strait Islander dialysis patients leading to fewer patients being judge medically suitable;

• The shortage of living and deceased donors from within Aboriginal and Torres Strait Islander communities;

• The length of time on the waiting list and matching system;

• The challenges in delivering appropriate health services to people living in remote areas who might also have low health literacy and not speak English as a first language;

• The dislocation that follows from moving to transplant centres in distant capital cities; and

• The high complication rate, particularly in terms of early infectious complications leading to poor transplant outcomes, including substantially higher death and graft loss rates.

The poorer outcomes among those who receive transplants are due to higher rates of rejection, less well-matched kidneys, higher rates of infection and infection-related deaths. There are downsides to transplantation.

Prior to transplantation, these include a requirement for significant work up tests and assessments which require visits to major centres. After transplantation there is the prospect of a post-operative stay and side effects away from home and supports. The number of medications usually increases, and there is an increased risk of infections and cancers

CHRIS JOHNSON AND LUKE TOY

 

Helsinki for holidays if you are safety conscious

The newly released 2018 Travel Risk Map reveals threat levels across the globe in three categories – medical, security and road safety.

Produced by security specialists International SOS, the charted risks across the three categories shows that Finland is the safest place on the planet.

Also listed as ‘low’ threats for medical concern are Norway, Sweden as well as much of western Europe, the US, Canada and Australia.

International SOS say that their Medical Risk Ratings are determined by their assessment of a range of health risks and mitigating factors including: infectious diseases, environmental factors, medical evacuation data, the standard of available local emergency medical and dental care, access to quality pharmaceutical supplies, and cultural, language or administrative barriers.

Group Medical Director of Health Intelligence for International SOS Dr Doug Quarry said that there is an increased understanding of preventative agendas in medical and travel risk mitigation, however organisations need to do more to strategically support their travelling staff.

“A staggering 91 per cent of organisations have potentially not included their travel risk program in their overall business sustainability program and 90 per cent are seemingly ignoring the impact a wellbeing policy could have on their travelling workforce,” Dr Quarry said.

The Scandinavian countries also perform well for road safety, possessing a ‘very low’ risk of a road traffic accident. Countries that Australians visit in significant numbers that have a ‘high’ road risk include Thailand and South Africa.

Unfortunately the number of Australians who died while travelling overseas rose past 1600 last financial year according to the Australian Government’s Department of Foreign Affairs and Trade (DFAT).

DFAT updates their travel advice to countries continuously and urges any Australian travelling overseas to register on the DFAT’s Smart Traveller website. This will allow the government to immediately alert Australians of any changes to the situation and know where Australians were if an evacuation was necessary.

Travel insurance remains an area of concern for Australian consular officials. Travellers without travel insurance are personally liable for covering any medical and associated costs they incur. The Australian Government won’t pay for your medical treatment overseas or medical evacuation to Australia or a third country.

The latest survey results undertaken by DFAT that looks at how Australians use travel insurance reveals Australians are not adequately using travel insurance, especially when it came to cruises. Half (48 per cent) of recent cruise goers who took out insurance were exposed to the risk of being unknowingly uninsured. This was a combination of those (38 per cent) who took out a general travel insurance policy that may not have adequately covered them for a cruise, and / or those (30 per cent) who were not certain that their travel insurance covered them for all countries their cruise liner visited.

The Australian Government provides regularly updated travel advice to all Australians at http://smartraveller.gov.au/Pages/default.aspx.

MEREDITH HORNE

AMA PHN member survey

In response to the recommendations of the Hovarth Review into Medicare Locals (the Hovarth Review), the Government established 31 Primary Health Networks (PHNs) across Australia, commencing in July 2015. These replaced Medicare Locals (MLs) that were established by the previous Labor Government.

The fundamental purpose of PHNs is similar to that of their predecessors “to facilitate improvements in the primary health system, promote coordination and pursue integrated health care.” However, GPs are expected to play a more central role in PHNs than they did in MLs. PHNs are also expected to focus more on improving the linkages between primary and hospital care.[1][2]

In 2013, leading up to the Hovarth Review, the AMA conducted a survey of GP members to gauge their views on the performance of MLs. More than 1,200 GPs participated in that survey, with members particularly critical of  their engagement with GPs and the extent to which many had failed to help improve patient access to primary care services. This survey formed the basis of AMA submission to the Hovarth Review, which recommended significant reforms including a more central role for GPs.

The AMA recently conducted a similar survey to provide members with the opportunity to give us their views on the performance of PHNs to date. Participants were provided with a number of statements and, were asked to select the options (strongly agree, mostly agree, neither agree or disagree, mostly disagree, or strongly disagree) that best reflect their opinion.

A total of 399 GPs participated in the survey, which represents a much smaller sample size than the 2013 survey. Nonetheless, it does provide a snapshot of the views of those members who participated in the survey and the results should be used to provide helpful guidance on areas where PHNs need to increase their focus.  

The survey results are summarised as follows:

Understanding of the role and functions of PHNs:

  • 61.5 per cent of respondents indicated that they have a reasonable understanding of the role and functions of PHNs (comparative data is not available for MLs).
  •  Information about activities and services:
  • 47.9 per cent of GPs surveyed believe they have not been kept informed about the work their PHN is undertaking and the services it supports (48.9 per cent for MLs).
  • GPs access to information and events of relevance:
  • 51.4 per cent indicated that they have not been provided with information and access to events of relevance to day to day practice (57.8 per cent for MLs).
  • PHN engagement with local GPs:
  • 62.6 per cent indicated that their PHN had failed to engage and listen to them about the design of health services needed in the local area (68.8 per cent for MLs).
  • Practice staff access to useful and effective education and resources:
  • 46.3 per cent of GPs surveyed indicated that their practice staff have not been provided with access to useful and effective education and resources (comparative data is not available for MLs).
  • Valuing GP contribution:
  • 52.8 per cent believed that their PHN does not value or recognise the inputs of local GPs (60.8 per cent for MLs).
  • Timing of meetings and information sessions:
  • 46.1 per cent indicated that their PHN was holding meetings and information sessions at times that were not easily attended (52.4 per cent for MLs).
  • Supporting targeted programs for disadvantaged groups:
  • 50.6 per cent indicated that their PHN has not been supporting well targeted programs that could help patients, particularly those who are disadvantaged (comparative data is not available for MLs).
  • Facilitating services that complement existing general practice:
  • 52.8 per cent indicated their PHN is not focused on facilitating services that complement existing general practice services s (comparative data is not available for MLs).
  • Practice support for MyHealth Record:
  • 57.4 per cent indicated that their PHN had not provided effective support for practices to implement the MyHealth Record (56.6 per cent for MLs re PCEHR).
  • Access to psychological services:
  • 48.0 per cent indicated that their PHN had failed to improve patients’ access to psychological services (48.9 per cent for MLs regarding improved Access to Allied Psychological Services (ATAPS)).
  • Accessible mental health services for ATSI patients:
  • 35.5 per cent of GPs surveyed indicated that their PHN had not facilitated appropriately funded and accessible services to meet the mental health care of Aboriginal and Torres Strait Islander (ATSI) patients (comparative data is not available for MLs).
  • Delivery of mental health and suicide prevention services and supports to ATSI patients:
  • 43.3 per cent of GPs surveyed indicated that their PHN had not been able to improve the delivery of mental health and suicide prevention services and support to ATSI patients (comparative data is not available for MLs).
  • Access to services for patients requiring mental health care, but who are not eligible for National Disability Insurance Scheme (NDIS) packages:
  • 52.7 per cent indicated that their PHN had been ineffective in facilitating for the needs of patients requiring mental health care, but who are not eligible for NDIS packages (comparative data is not available for MLs).
  • Psycho-social supports for patients with mental health problems:
  • 55.9 per cent indicated that their PHN had been unable to ensure effective and timely psycho-social supports to patients with mental health problems (comparative data is not available for MLs).
  • Overall PHN performance:
  • 58.0 per cent indicated that their PHN had not improved local access to care for patients (73.0 per cent for MLs).
  • Overall delivery of primary care:
  • 62.6 per cent indicated that their PHN had not improved the capacity to deliver better quality healthcare overall (71.6 per cent for MLs).

PHNs have an important role to play in improving the integration of health services within primary health care, enhancing the interface between primary care and hospitals, and ensuring health services are tailored to the needs of local communities. They have the potential to have a strong impact on aged care services, mental health outcomes, chronic disease management, Indigenous health services, and services for the disadvantaged.  

The AMA believes that for PHNs to be successful they must: have a clear purpose, with clearly defined objectives and performance expectations; be GP-led and locally responsive; focus on supporting GPs in caring for patients and working collaboratively with other health care professionals; have strong skills based Boards; be appropriately funded to support their operations, particularly those that support the provision of clinical services; focus on addressing service gaps, not replicating existing services; not be overburdened with excessive paperwork and policy prescription; and be aligned with Local Hospital Networks (LHNs), with a strong emphasis on improving the primary care/hospital interface. [3]

They should focus on the following areas:

  • Population Health – Identifying community health needs and gaps in service delivery; identifying at-risk groups; supporting existing services to address preventive health needs; and coordinating end of life care.
  • Building General Practice Capacity – Supporting general practice infrastructure to deliver quality primary care through IT support; education and training of practices and staff; supporting quality prescribing; training to support the use of e-Health technology and systems; enhancing practices capacity and capabilities to embrace the principles in being a medical home to their patients, and facilitating the provision of evidence-based multidisciplinary team care.
  • Engaging with Local Hospital Networks (LHNs)/Districts – Identifying high risk groups and developing appropriate models of care to address their specific health issues (e.g. those at high risk of readmissions, including non-insulin-dependent diabetes mellitus, congestive cardiac failure, chronic obstructive pulmonary disease, and other chronic diseases); and improving system integration in conjunction with local health networks.[4]

Given that PHNs are still a relatively new feature on primary care landscape, the jury is still out on the performance of PHNs. The AMA believes that they should be given every chance to succeed and intends conducting the same survey in a couple of years’ time to see how much of a difference they are making for GPs and their patients.

Dr Moe Mahat
Manager Policy
AMA General Practice Section

[1]Ducket et al (2015) Leading change in primary care: Boards of PHNs can improve the Australian health care system.

[2] Prof. John Hovarth AO (2014) Review of Medicare Locals: Report to Minister for Health and Minister for Sport.

[3] AMA Position statement Primary Health Networks 2015  position-statement/primary-health-networks

[4] Op Cit.

Terminator says health is collateral damage of fossil fuels

Hollywood actor and former Governor of California, Arnold Schwarzenegger, has used a United Nations gathering in Germany to describe fossil fuels as a public health hazard.

At a sideline event of the 12-day UN climate talks in Bonn in November, Mr Schwarzenegger delivered a well-received speech that issued a challenge to world leaders.

A long-time outspoken environmental activist, the star of such blockbusters as The Terminator, Total Recall, Collateral Damage and Predator, urged governments everywhere to start labeling fossil fuels with a public health warning.

That health warning should state, he said, that their use could cause illness and death.

He praised the World Health Organization (WHO) for delivering on a 164-nation tobacco control deal in 2003 that resulted in health warnings on tobacco products.

But he added that a similar deal could be reached with regards to oil and coal products.

“Wouldn’t it be great now if they could make the same pact with the rest of the world to go and say, ‘let’s label another thing that is killing you – which is fossil fuels’,” he said.

“If you went to a gas station, it says that thing you’re pumping into your car is killing you.

“Pollution kills more than nine million people a year. Over 300,000 people will die over the course of this conference. That’s the population of Bonn.

“This is a massive tragedy. And as depressing and terrifying as it is, we are not talking about it enough,” he said.

WHO Director-General Tedros Adhanom Ghebreyesus called on conference delegates talk about building climate resilient health facilities in their home nations by 2013, which is a stipulation of the Paris Agreement.

He added that more investment was needed in the health sector.

“Climate change strikes at the heart of what it means to be human,” Dr Ghebreyesus said.

“Climate change is not a political argument in Fiji and other island nations. It’s everyday reality – whether that’s in the form of destructive storms, rising sea levels or increased risk of infectious disease.

“These communities need assistance to cope with a world that is changing in front of them.”

The Paris Agreement global climate treaty aims to limit rising temperatures to below 2˚C by reducing greenhouse gas emissions.

Fiji presided over the Bonn conference and was also the beneficiary of an initiative launched by WHO and the UN climate secretariat aiming to triple international financial support for action on climate-related health issues in the developing small island nations.

CHRIS JOHNSON