more_vertInvestments in health research and development (R&D) are still insufficiently aligned with global public health demands and needs. As little as 1% of all global funding for health R&D is allocated to diseases mostly noted in low-income and middle-income countries, such as malaria and tuberculosis,1 even though these diseases account for more than 12·5% of the global burden of disease.2 The 2014–15 Ebola outbreak exposed the paucity of investment in products and approaches to prevent and minimise the effect of pathogens with epidemic potential.
Preference: Infectious Diseases and Parasitology
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[Seminar] Atopic dermatitis
Atopic dermatitis (also known as atopic eczema) is a chronic inflammatory skin disease that is characterised by intense itching and recurrent eczematous lesions. Although it most often starts in infancy and affects two of ten children, it is also highly prevalent in adults. It is the leading non-fatal health burden attributable to skin diseases, inflicts a substantial psychosocial burden on patients and their relatives, and increases the risk of food allergy, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and mental health disorders.
An up-close view of Indigenous health – good and bad
Professor Owler meets with staff at a remore community health service in the Northern Territory
By AMA President Professor Brian Owler
No running water, overcrowded and non-functional houses, lack of affordable healthy food, no essential services and crippling rates of diabetes, kidney disease and communicable infections – these are just some of the issues that people living in remote Northern Territory communities such as Utopia, Ampilatwatja and Kintore endure every day. On a recent visit to these three communities, I gained a deeper understanding of local health issues and the challenges that doctors and nurses face in delivering health services in remote areas.
In meeting with local Aboriginal leaders and health and medical staff, I found that each community has their own unique challenges; but the overall messages that I heard were strikingly similar. Funding for local health services is inadequate, it is difficult to attract skilled health and medical professionals to work in remote areas, it is logistically challenging to provide health care in remote communities (particularly when patients need to be transported for specialist care), and the level of chronic diseases in these communities are alarming.
Take diabetes, for example. In Kintore, 130 of the community’s approximately 450 residents have non-gestational diabetes – almost a third of its entire population – and in every three houses, one person is on dialysis due to the onset of kidney disease. What is even more concerning is the young age that Aboriginal people are being diagnosed with diabetes. In Utopia, a seven year-old girl was recently diagnosed with type 2 diabetes, and in Ampilatwatja, a 13 year-old girl was diagnosed with the same condition. Among the broader Australian population, or perhaps anywhere in the world, it is unheard of for child so young to be diagnosed with type 2 diabetes, yet it is clearly visible in remote Aboriginal communities.
The lack of water and affordable healthy food in remote communities is strongly linked to the epidemic levels of diabetes among Aboriginal people in these areas. Sugary drinks are more readily available than diet soft drinks, and in some communities they are more accessible than running water. It is unfathomable that in Australia, communities are going without water – a basic human right and a necessity for good health and wellbeing. This is an issue that demands immediate attention and action by all levels of government – without it, the health gap between Indigenous and non-Indigenous Australians will remain wide and intractable.
One important lesson that I did learn while visiting these communities is that it is not all doom and gloom when it comes to Indigenous health. Yes, Aboriginal people in remote areas face great adversity, but they are patient, resilient, strong-willed and are determined to take control of their own health – there are some real positives happening.
At the Purple House, an Aboriginal-controlled dialysis service based in Alice Springs, I was told an inspiring story of Aboriginal people taking action to generate funds for more dialysis sites. Kidney disease is rife across central Australia, with many Aboriginal people developing this condition as a result of poorly controlled diabetes.
The need for dialysis in remote Aboriginal communities is extremely high and for many, treatment means leaving family and country to be treated in Alice Springs. To allow people to be treated on country and near family, Aboriginal artists from across the western desert region grouped together and painted artworks that were auctioned to raise funds. The auction raised more than $1 million, and Purple House was able to expand their dialysis services. They now operate across nine remote communities in the Northern Territory and Western Australia. Purple House also provides a mobile dialysis service via their ‘Purple Truck’, which travels to remote Aboriginal communities.
It is very rare that good news stories such as this are widely publicised, which is disappointing. We need to shed more positive light on Indigenous health, and Indigenous affairs more broadly in Australia.
The POCHE Centre for Indigenous Health and Wellbeing in Alice Springs is also making a positive contribution to the health of Aboriginal people. At the POCHE Centre, I learnt about the research currently being undertaken by PhD candidate Maree Meredith, a young Aboriginal woman from Queensland. Her research project aims to determine the role that art centres play in contributing to positive health outcomes for Aboriginal people across the Anangu Pitjantjatjara Yankunytjatjara (APY) lands. To ensure that this research was in line with cultural protocols and to ensure that appropriate data was collected, Ms Meredith worked with Anangu people to design and deliver a survey in the local language.
For many years, anecdotal evidence has suggested art centres make a significant contribution towards health and wellbeing, but there has been no empirical data. This study aims to provide reliable evidence that art centres improve the health and wellbeing of Aboriginal people in remote communities. This is also a clear example of building the capacity of local Aboriginal people to participate in the local workforce.
Aboriginal people know what they want – they know the best way to improve their health and wellbeing, and this must be acknowledged and supported if we are to truly close the gap.
While in Kintore, I spoke with Aboriginal leaders who mentioned that the local people prefer a traditional social and emotional wellbeing framework to be implemented in their community, rather than a Western one.
The community developed a proposal for Government funding for this initiative, but unfortunately it was not accepted.
Connection to culture is important to the health and wellbeing of Indigenous people, and is known to produce positive health and life outcomes, such as reduced incarceration rates.
Aboriginal people needed to be provided with a reason to stay in the communities where they are connected to their land, culture and families. Recent comments made by certain members of Parliament about subsidising the ‘lifestyle choices’ of Aboriginal people in remote areas are extremely concerning.
Within each of these communities, I was disheartened to see a world-class health system fail the Aboriginal people in remote communities. But, I was truly impressed by the resilience and determination of the local Aboriginal people and the passion, commitment and dedication of doctors, nurses and other health staff who work tirelessly such challenging environments.
I am extremely grateful to Warren Snowden, Member for Lingiari, for making visits to these communities possible, and for accompanying me throughout the trip. I am hopeful that we will see further progress made in improving health and life outcomes for Indigenous people across Australia.
First report of Zika virus infection in a returned traveller from the Solomon Islands
A 33-year-old man returning from the Solomon Islands presented to an emergency department in Brisbane after 4 days of retro-orbital headache, fever, and myalgias, which had started 10 days into his journey. On examination, he was afebrile and had a diffuse erythematous rash. A full blood count revealed mild neutropenia and thrombocytopenia. IgG seroconversion for flavivirus was shown by parallel testing, 15 days apart. Zika virus (ZIKV) RNA was also found in blood, urine and throat samples by polymerase chain reaction (PCR) testing. The patient received supportive medical care and recovered fully.
ZIKV is a mosquito-borne flavivirus, first identified in the Zika forest of Uganda during yellow fever research in 1947; the first evidence for infection in humans was reported in 1952. Serosurveys during the 1950s suggested widespread ZIKV transmission in Africa and South-East Asia.1
ZIKV infection occurs in a geographical distribution, and causes a clinical syndrome similar to mild infection with dengue virus (DENV), also a flavivirus. Infection is characterised by fever, arthralgia, myalgia, headache and rash. Other features include peripheral oedema and non-purulent conjunctivitis. Symptoms abate within 3–12 days. Asymptomatic infection is common. ZIKV infection is not typically associated with blood film abnormalities, in contrast to infection with DENV or Chikungunya virus.2 There is neither a specific treatment for nor a vaccine against ZIKV infection. Management is supportive, and prevention consists of avoiding the primary vector, Aedes spp. mosquitoes, particularly A. aegypti.
Before 2007, only a handful of cases of ZIKV disease in humans had been reported. Since then, two large outbreaks in the Pacific Islands have occurred: the first in Micronesia in 2007, the second in French Polynesia in 2013. In each outbreak, most individuals had only mild symptoms.3
Reports of two imported cases of ZIKV infection in Australia have been published, including in a traveller returning to north Queensland,4,5 but this article is the first report in the scientific literature of ZIKV infection acquired in the Solomon Islands. Given the presence of A. aegypti in this region of Australia, a returning traveller with ZIKV viraemia could infect local mosquitoes, causing a local outbreak.
ZIKV is an emerging infectious disease in the Pacific Islands and beyond. It is now widely reported in Central and South America.6 Concerns about a possible association between ZIKV infection and poor neonatal outcomes resulting from infection during pregnancy, including microcephaly, have led to a surge in international interest in ZIKV.7 Cases will continue to be imported into Australia, including by returning travellers from the Solomon Islands. Clinicians should request ZIKV serology and PCR in travellers returning from the Pacific Islands with a DENV-like illness and negative serological tests for DENV, or with an isolated positive result for DENV IgM. Research is urgently required to understand the dynamics of ZIKV transmission and the association of ZIKV infection with adverse pregnancy outcomes in our own region.
[Correspondence] Changing oral vaccine to inactivated polio vaccine might increase mortality
We, the undersigned, write as physicians and scientists committed to optimising the beneficial effects of vaccines to reduce infant mortality worldwide. In settings with high childhood mortality, live vaccines such as oral polio vaccine (OPV), BCG vaccine, and measles vaccine might have heterologous (non-specific) effects that reduce mortality from diseases other than poliomyelitis, tuberculosis, and measles, respectively, whereas inactivated vaccines might increase all-cause mortality.1 The importance of these effects is controversial.
[Editorial] Unite to end tuberculosis
March 24 marks World TB Day. This year, the theme is “Unite to end tuberculosis”. WHO calls on governments, civil society, and the private sector to unite to end the tuberculosis epidemic—a much needed approach to tackle this deadliest of diseases. Although 43 million lives were saved through effective diagnosis and treatment between 2000 and 2014, more than 9 million cases of tuberculosis and 1·5 million deaths (0·4 million deaths in HIV-positive individuals) occur annually.
[Comment] NextGen HIV prevention: new possibilities and questions
In less than a decade, HIV prevention has evolved from a reliance on education, behavioural interventions, and use of condoms to focusing on the optimum use of antiretrovirals to suppress infectiousness and for primary prophylaxis. Landmark studies have shown the efficacy of the early initiation of treatment for people infected with HIV,1 and the use of oral pre-exposure prophylaxis (PrEP) for those at highest risk to decrease HIV transmission.2 Despite PrEP being shown to be efficacious in most trials in which it was assessed, the paramount importance of consistent use of preventive medication was shown when oral and topical tenofovir-based regimens did not show efficacy in three studies involving young African women, primarily because of suboptimum adherence.
A nation in pain
Australians are world champion pill poppers, quadrupling their use of common opioid-based painkillers such as codeine, morphine, and oxycodone in the last decade, an international study has found.
Researchers from the independent body responsible for implementing the United Nations international drug control conventions, the International Narcotics Control Board, found that the use of opioid painkillers in Australia rose from 22 million doses annually in 2001 to 106 million doses annually in 2013.
Though there has been a worldwide trend toward greater reliance on painkillers, Australia is one of a handful of regions that accounted for the vast bulk of increase in their use.
The INCB study, which examined the consumption of the painkillers, and the prevalence of disorders that needed them, in 214 countries, found that overall opioid painkiller use had doubled since 2001. But Australia, North America, Western and Central Europe and New Zealand accounting for more than 95 per cent of global opioid use.
While researchers speculated the higher usage in developed countries could be due to increased pain management for cancer in aging populations and other chronic illnesses, low-income and developing countries, which have higher rates of the diseases for which opioid medications are needed, had little access to the drugs, and there was no significant increase in their use.
Co-author of the study, Professor Richard Mattick, from the University of New South Wales’ National Drug and Alcohol Research Centre, said that there were a number of factors that made it difficult for patients in in developing countries to get painkillers, particularly cost, but also including a lack of training among medical professionals and fear of dependence.
Professor Mattick told The Guardian that because there was no recognised level of appropriate prescribing and dosage for opioids, it was hard to tell if their use in Australia was excessive or inappropriate.
“You can’t have benefits without some harms; it’s just nonsense to think otherwise,” Professor Mattick said.
“So, while it’s correct to bring attention to harms, I think we have some work to do to understand this situation accurately, and to get a comprehensive national picture of what is driving this use.”
The study was published in the Lancet.
Kirsty Waterford
[Comment] Pharmacogenetics of lithium response: close to clinical practice?
The beliefs that genes are the root of diseases and that genomics has the potential to help us screen, diagnose, predict, and treat disease are particularly compelling in cancer research.1,2 However, human genomic research focusing on mental disorders and other complex illnesses is at a fairly early stage, with no best approach yet identified to study complex diseases such as bipolar disorder. Genes associated with risk for bipolar disorder have been searched with candidate gene and genome-wide association approaches.
Health on the Hill – briefs
Dying with dignity
Laws legalising euthanasia in the ACT and the Northern Territory would be reinstated under a Bill introduced to the Senate with the support of a group of MPs drawn from across the major parties.
In a rare display of cross-party action, Labor MPs including Alannah Mactiernan, Katy Gallagher and Nova Peris have joined with Liberal MP Sharman Stone and Australian Greens leader Richard Di Natale in backing legislation which would restore to the ACT and the NT the right to legislate around euthanasia.
The new laws would roll back a Private Member’s Bill, introduced by Liberal MP Kevin Andrews in 1996, that nullified NT euthanasia legislation and stripped the ACT of the power to legislate for euthanasia.
The issue is politically divisive, and the Labor caucus last month decided to allow ALP MPs a conscience vote on the matter.
The push to allow for euthanasia has gathered momentum in recent months and has the backing of several high-profile advocates including broadcaster Andrew Denton.
But even if the legislation is passed by the Senate, there are doubts it will attract sufficient support in the Lower House to become law.
Indecent disclosure
Health care providers are set to come under scrutiny over the adequacy of their information disclosure as the consumer watchdog vows to crack down on confusing and misleading conduct.
Australian Competition and Consumer Commission Chair Rod Sims said the agency had “important investigations underway” into the disclosure practices of health care providers amid concerns some were in breach of Australian Consumer Law.
Flushed with success after forcing Canberra’s Calvary Private Hospital to provide patients with more information about potential out-of-pocket costs, Mr Sims said the ACCC would focus on shortcomings in disclosure to consumers.
He said the Commission’s scathing report on the behaviour of the private health insurance industry, released last year, would provide a springboard for greater scrutiny regarding the provision of incomplete information that was not only confusing but potentially misleading.
Research boost
Research to develop an AIDS vaccine and reduce the incidence of over-diagnosis are among 96 projects sharing $130 million of funding in the latest round of grants from the nation’s peak medical research organisation.
Health Minister Sussan Ley said the money was part of $850 million that will be disbursed by the National Health and Medical Research Council to fund a wide range of projects.
There has been criticism that scientists starting their research career have often been unfairly overlooked in the race for funding, but NHMRC Chief Executive Officer Professor Anne Kelso said grants were awarded to a mix of both “outstanding new talent and experienced and internationally recognised researchers”.
TPP
Drug companies may effectively hold at least an eight-year monopoly on the supply of expensive biologic medicines under the terms of the controversial Trans Pacific Partnership trade deal, activists have warned.
Trade watchers have seized on remarks made by Australia’s Special Trade Envoy, Andrew Robb, during a visit to Washington DC late last month to claim the Government was looking at using administrative delays and other bureaucratic processes to effectively extend monopoly protection for biologic medicine manufacturers to eight years – three years longer than stipulated under the treaty.
The Washing-based Politico news service reported assurances from Mr Robb, who was visiting the US capital to help rally US Congress support for the TPP, that the trade agreement would effectively provide at least eight years market protection for biologic makers, as possibly as long as 17 years.
During negotiations for the TPP, Australia and other countries resisted US demands for at least 12 years of data protection for biologic manufacturers, and there was eventual agreement on a “five-plus” approach guaranteeing makers a minimum of five years’ monopoly on supply.
Though Mr Robb told Politico Australia would not be “a party to anything that would imply that we’ve changed our position”, he emphasised the importance of providing drug companies similar protection to that they received in the US: “We’ve got a very burgeoning biologics sector in Australia, [and] if they weren’t getting the protection that they could get in the United States, they wouldn’t be setting up in Australia”.
Health advocates warn this would effectively mean at least eight years before cheaper generic versions of expensive biologic medicines – gene and cellular-based therapies that are being developed to treat diseases long-considered intractable, such as cancer, HIV/AIDS, rheumatoid arthritis, diabetes, hepatitis B and multiple sclerosis – would become available.
Get moving
Teenage girls are being urged to ‘make your move’ following findings that they are, on average, only half as physically active as their male counterparts.
Health Minister Sussan Ley has launched the #girlsmakeyourmove campaign to encourage young women to play sport and engage in other activities amid concerns many are heading for a life of poor health.
Ms Ley said research showed almost 60 per cent of girls aged between 15 and 17 years undertook little or no exercise, compared with a third of boys in the same age group.
The Minister said such sedentary habits, particularly during the formative teenage years, could lead to a lifetime of chronic disease.
“[This campaign] aims to tackle this sliding door moment in a young woman’s life when they actually are laying down the foundation for the rest of their lives,” Ms Ley said. “Physical activity in the teenage years lays down the muscle and bone you need for the rest of your life.”
Many girls get put off playing sport or engaging in physical activity because of a lack of confidence, fear of being judged or a bad experience, and the campaign uses television ads and social media to feature girls enjoying playing sport and being active.