more_vertPrisoners and detainees worldwide have higher burdens of HIV, viral hepatitis, and tuberculosis than the communities from which they come. This disease burden among prisoners has been recognised since the early years of these inter-related pandemics.1 Yet the health needs of prisoners receive little attention from researchers or advocates working to improve responses for these diseases, and scant funding for prevention or treatment interventions. This Lancet Series on HIV and related infections in prisoners1–6 shows that the reasons for this neglect include the very factors that make prisoners and detainees vulnerable to infection and unable to get treatment: unjust and inappropriate laws; underfunded and overcrowded prisons with large numbers of individuals in lengthy pre-trial detention; policing practices that lead to imprisonment with compulsory drug detention centres that provide no evidence-based treatment for substance use disorders and inadequate health care; and discriminatory criminal justice systems.
Preference: Law
558
Prevention key to contain costs
The nation is “going backwards” in tackling its obesity problem and facing a blowout in health care costs unless it ramps up its health prevention efforts, AMA President Dr Michael Gannon has warned.
Reiterating the AMA’s support for a sugar tax as part of a range of measures to promote healthier eating, Dr Gannon said it was not about “demonising” particular foods like Coca Cola or McDonald’s but a much broader approach to help people make more informed choices and help them live more active lives.
The AMA President said that a sugar tax, on its own, would not “fix the problem”.
“Too often…we hear the demonisation of Coca-Cola, we see the demonisation of McDonald’s, when people make bad decisions about the food they put in their mouth every day, the food that they buy from supermarkets, the fact that we all eat so much processed foods,” Dr Gannon told the National Press Club.
“We can’t just have a simple idea that this is the one solution. We need a whole-of-government, whole-of-society approach investing in public health campaigns, thinking about sport and recreation, thinking about how we design our suburbs, looking at traffic-light systems for healthy foods, investing in some really decent public health campaigns so that people…are making informed choices.”
Dr Gannon said the burden of health costs was being largely driven by patients being hospitalised for preventable health problems like obesity, and there needed to be much greater investment in public health campaigns to improve individual wellbeing and hold down the nation’s health bill.
“We are going backwards in addressing obesity, and the effects are felt in almost every area of the health system,” where morbidly obese patients are much more difficult and expensive to treat, he said.
To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.
He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.
“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”
The AMA President told the National Press Club that Australia’s spending on preventive health was woefully inadequate. Just 1.7 per cent of all health spending in 2011-12 went on health prevention, compared with 7 per cent in New Zealand and 6 per cent in Canada.
He said the success of action to curb smoking, including increased taxes, marketing restrictions, no smoking rules and tobacco plain packaging laws, showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.
Adrian Rollins
Assisted dying advocates won’t lie down
The major parties are being challenged to declare their position on assisted dying after the Australian Greens announced plans to introduce national assisted dying legislation during the current term of Parliament.
As a review of the AMA’s policy on euthanasia and physician-assisted suicide reaches its final stages, Greens leader Senator Richard Di Natale has flagged his intention to put proposed Dying with Dignity laws up for debate.
“It’s never easy to talk about death, but our political leaders need to have the courage to take on challenging issues, especially when it concerns the rights of every Australian,” Senator Di Natale said. “The Greens believe that patients with intolerable suffering should have the right to have a say in the timing of their death. As a doctor, I know many patients would be comforted just by knowledge that the right existed, even if they never exercised it.”
While history suggests the Greens will fall well short of the support they need to make their Bill law, there is a growing push to make assisted dying legal.
In Victoria, a cross-party parliamentary committee has recommended that assisted dying be legalised for patients with serious and incurable illnesses, and high-profile television producer Andrew Denton has founded Go Gentle Australia to campaign for the right for patient to choose what happens at the end of their life.
In a nationally televised speech, Mr Denton accused conservative politicians from both the major parties of conspiring to thwart efforts to legalise euthanasia, and called on those with religious or moral objections to assisted dying to accept the right of others to have such a choice.
The presenter has urged the adoption of laws that, subject to strict criteria, would provide legal protection for doctors who assisted patients with terminal illness to die.
He said it would not be “a licence to bump off granny”, and would in practice make legal what was “already happening in Australia without regulation, without support, without transparency or accountability and, from the evidence received, sometimes without consent”.
The Greens Bill follows similar legislation in Canada and California.
In Canada, the Trudeau Government has proposed laws to allow adults with serious and irreversible medical conditions to seek a doctor-assisted death. To do so they must apply in writing, with two witnesses, and the request must be evaluated by two doctors or nurses. Once a request is granted there is a mandatory 15-day waiting period.
California has passed laws that allow people with less than six months to live to seek physician-assisted death, subject to assessment that they are of sound mind.
But in the United Kingdom, the House of Commons last year overwhelmingly rejected a similar proposal.
The issue of assisted dying was debated at length at the recent AMA National Conference, where a panel of medical practitioners and a medico-legal expert argued the merits of the idea.
Though there were sharply divergent views on whether or not doctors should be involved in helping patients to die, there was broad agreement that the medical profession could do better in supporting patients, families and friends at the end of life.
The results of an AMA member survey on the issue were discussed at an AMA Federal Council meeting last month, along with issues raised at the National Conference forum and a separate consultation on current AMA policy conducted through the pages of Australian Medicine.
Doctors, nurses and other health professionals working in acute care settings can learn more about caring for patients approaching death and their families through Flinders University’s End-of-Life Essentials package. The free online resource includes three learning modules looking at managing end-of-life issues in hospitals, recognising dying, and communication and decision-making.
The modules can be accessed at: www.caresearch.com.au/EndofLifeEssentials
Adrian Rollins
[Correspondence] Weighing up dietary patterns
The Seminar by George Bray and colleagues (May 7, p 1947)1 summarises current guidelines and findings concerning weight loss—an important clinical issue. However, we believe their recommendations are based on flawed interpretations of the evidence they refer to.
[Editorial] Torture and ill treatment in Syria’s prisons
What began as a peaceful protest for democratic reform in Syria in March, 2011, has morphed into a cataclysmic and enduring war against the civilian population. The latest violations against international law in the conflict include a suspected chlorine gas attack on the town of Saraqeb, Idlib province, on Aug 2 and the continued bombing of civilians in the city of Aleppo. Now a new report by Amnesty International released on Aug 18 details a further concern—torture, disease, and death in Syria’s prisons.
Private insurers being brought to account
The AMA’s activities over several years to shed light on the egregious behaviour of certain private health insurers is now bearing fruit.
The Australian Competition and Consumer Commission (ACCC), the Commonwealth Ombudsman and the Federal Government are now taking action to curb unacceptable practices and shift the focus onto consumer needs, informed by AMA advice and submissions.
As part of its work in this area, the AMA recently made a submission to the Government’s review of private health insurance policy. Our submission called for the Government to abolish ‘junk’ policies; prevent insurers from arbitrarily introducing exclusions in policies and benefit payment schedules without prior advice; and prohibit insurers from encouraging consumers to purchase a product, or downgrade their cover to a level that is inappropriate to their health care needs.
In addition, the AMA’s inaugural AMA Private Health Insurance Report Card issued in February this year sent a clear message that consumers could not take at face value information provided by their health insurer. We warned consumers to avoid ‘junk policies’ – those that provide cover only for treatment in public hospitals – and to ensure they clearly understood the level of benefits paid by their insurer and likely out-of-pocket costs.
In response, the Government has now announced that it will eliminate junk policies as a part of its program of private health insurance reforms.
The Government also intends to create a three-tiered system of policies that will allow consumers to more easily choose a product that is right for them. It will mandate minimum levels of cover for policies, and develop standardised terminology for medical procedures.
These proposals will require detailed consideration to ensure an appropriate balance between private and public health care is maintained. This work will keep the Medical Practice Committee busy this year.
The Government has also responded to our complaints that the operations of third party comparator sites for private health insurance are not transparent; ‘comparisons of best value’ exclude some policies and commissions are kept secret. The Government will require third party comparator sites to publish commissions they receive, similar to the requirements for other financial services.
The Commonwealth Ombudsman is also investigating those insurers who are insisting on seeking ‘pre-approvals’ for plastic and reconstructive procedures. Many of our surgeon members have been affected by this practice in which insurers require private hospitals to get surgeons to fill in and ‘certify’ a form providing clinical details of the procedure and the reasons why it is necessary.
While insurers continue to claim that this process is not compulsory and does not constitute a ‘preapproval’, we understand that patients, hospitals and medical practitioners are being told that if forms are not submitted, benefits will not be paid.
In direct response to AMA concerns, the Department of Health wrote to all insurers in 2015 reminding them that, under law, they must pay benefits for a hospital treatment when an insured member undergoes a procedure for which a Medicare benefit is payable, and which is covered by their health insurance product.
Clearly this advice has been ignored, but the Ombudsman’s investigation will hopefully put a stop to this practice.
Finally, the ACCC is taking legal action against Medibank Private for allegedly misleading consumers – specifically, failing to give notice to members on its decision to limit benefits paid for in-hospital pathology and radiology services.
As mentioned earlier, we raised the issue of arbitrary changes to policies and benefits in our submission to the Government’s private health insurance review last year, but we also brought this to the attention of the ACCC in our 2016 submission concerning insurer activities designed to erode the value of private health insurance cover and maximise insurer profits.
Commenting on its legal action, the ACCC said: “Consumers are entitled to expect that they will be informed in advance of important changes to their private health insurance cover, as these changes can have significant financial consequences”.
The AMA wholeheartedly agrees.
[Perspectives] Master copies
The National Gallery’s Painters’ Paintings exhibition invites you into the homes of eight European artists to gaze at the pictures that once hung on their walls. The acquisitions of Anthony Van Dyck, Joshua Reynolds, Thomas Lawrence, Frederic Leighton, G F Watts, Edgar Degas, Henri Matisse, and Lucian Freud are set out in galleries that are a cross between drawing rooms and personal pantheons. Images of the artists’ homes indicate how they displayed their treasures, and lived and worked within the powerful artistic force field they created.
[Comment] Finding a balance: Canada’s law on medical assistance in dying
On June 17, 2016, the Parliament of Canada passed Bill C-14, a new law governing medical assistance in dying.1 The law permits physicians, and in some cases nurse practitioners, to provide an assisted death for competent adult patients who make a voluntary request, who have been informed of means available to alleviate their suffering, and who have a “grievous and irremediable” condition, as defined in the legislation. Canada’s new law must be understood in the context of competing moral and legal claims at play in a highly charged policy debate.
[Editorial] Reassessing blood donation by men who have sex with men
Following the Pulse nightclub shootings in Orlando, FL, USA, on June 12, 2016, many gay men were barred from donating blood in aid of the surviving victims because of the deferral policy of the US Food and Drug Administration (FDA). The policy is aimed at reducing the risk of HIV transmission through blood products, but in the wake of the shooting was criticised by lawmakers and activists as antiquated and discriminatory. Now, as the USA faces a severe blood shortage, the FDA is reconsidering its stance.
Doctors challenge Border Force gag laws
Image: paintings%20/%20Shutterstock.com“>paintings / Shutterstock.com
Controversial Federal Government laws to suppress information regarding the operation of immigration detention centres are being challenged by a group doctors who claim they are being used to intimidate health workers.
The group Doctors for Refugees and the Fitzroy Legal Service have jointly launched action in the High Court challenging the constitutionality of secrecy provisions in the Australian Border Force Act which threaten up to two years imprisonment for workers who disclose conditions in detention centres.
In a Statement of Claim filed with the High Court on 27 July, Doctors for Refugees said it was bringing the action to “advocate for the public’s right to know what their Government is doing in their name, and to support the public health imperative of transparency to mitigate harm occurring in detention centres on and offshore”.
The action asks for the High Court to rule on whether the public disclosure of information regarding the operation of detention centres, including conditions, health care, mandatory detention and offshore detention, are protected by the freedom of political communication implied in the Constitution, and whether the ABF Act invalidly prohibits such communications.
The Act, which was introduced last year, includes provisions which make it a criminal offence for those contracted to provide services to the Department of Immigration and Border Protection to record or disclose information obtained in the course of their work. The penalty is up to two years’ imprisonment. The legislation was passed with support from Labor.
The Act was introduced amid widespread concern regarding conditions in detention centres, including reports of widespread sexual abuse and significant physical illness and mental health problems, particularly among children.
The Moss review substantiated allegations of sexual abuse at the Nauru Detention Centre, and operator Transfield Services reported 67 claims of child abuse, 33 allegations of sexual assault or rape, and five alleged instances of sexual favours traded for contraband.
Soon after being elected, the Coalition Government abolished an independent panel of medical experts that was overseeing health care in detention centres, and has so far ignored AMA calls to replace it with a group of health experts empowered to investigate and report on detention centre conditions directly to Parliament.
Doctors have protested that the secrecy provisions in the ABF Act conflict with their ethical duties and their obligations under the Medical Board of Australia’s Code of Conduct, most particularly their paramount obligation to the health of their patients.
These concerns have been magnified by a number of cases in which, it is claimed, authorities have sought to intervene in or override clinical advice on the transfer of detainees in need of medical attention, including the death of Omid Masoumali, who was medically evacuated to Australia from Nauru more than 24 hours after setting himself alight.
Suspicion that the Government has sought to interfere in the clinical decisions of doctors has been heightened by documents obtained by The Australian under Freedom of Information laws showing Immigration officials devised a strategy to prevent detainees from being evacuated to Australia for medical treatment because of a “propensity of those transferred to Australia to join legal action which prevents their subsequent return to PNG or Nauru”.
The Government has denied that the intention of the law is to prevent doctors from speaking up on behalf of their patients, and Immigration Minister Peter Dutton has indicated he thinks it unlikely that health practitioners would be prosecuted under the Act.
But it has since been revealed that Dr Peter Young, who oversaw the mental health care of detainees for three years, was the subject of Australian Federal Police investigation, including access to his electronic communications.
At its most recent Naiotnal Conference, the AMA passed an urgency motion asking the Federal Council to “look into the matter” of AFP surveillance of doctors.
In its Statement of Claim, Doctors for Refugees said the Government’s assurances had “not altered the perception that the ostensible intent of the ABF Act is to silence doctors, teachers, social workers and others working in detention centres”.
“Regardless of whether prosecutors exercise a discretion to charge health practitioners working with refugees and asylum [seekers], the law remains in place,” the Statement said. “Practitioners speaking out are subject to a Sword of Damocles, unsure when or if they might be investigated or charged for adhering to their ethical (and moral) obligations.”
Doctors for Refugees said that even if the High Court found that the ABF Act’s secrecy provisions served a legitimate purpose, it would also have to decide whether the constraint they imposed on political communication was “proportionate”.
“The ultimate question is whether the secrecy provisions…undermine the proper functioning of our democracy and the right of electors to be informed accurately, openly and truthfully about matters of national political importance,” the group said.
Adrian Rollins