more_vertA survey from the All-China Women’s Federation in 2013 reported that a quarter of Chinese women are victims of domestic abuse at some point in their lives, and the real number is likely to be much higher. Although anyone can be a victim of domestic abuse, women experience the overwhelming majority of attacks, and almost 90% of reported cases in China involve women experiencing abuse from their husbands. Until now, Chinese law has included no specific protection against violence in the home. Domestic violence was only accepted as grounds for divorce in 2001, and was deemed a private matter, with no legal definition and poor police protection.
Preference: Law
558
Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change
How can we respond more effectively?
The current “ice (crystal methamphetamine) epidemic” has thrown into relief long-standing dilemmas for front-line practitioners dealing with the burden of care associated with drug and alcohol misuse in the face of legal complexity and insufficient support from the health system and other government agencies. Despite increasing investment in border protection and law enforcement, the Australian Crime Commission has been reporting growth in the importation, manufacture and supply of crystalline methamphetamine of increasing purity, leading to the establishment of the National Ice Taskforce.1 Concurrently, medical and public health bodies (including the Australian Medical Association, Public Health Association of Australia, and South Australian Network of Drug and Alcohol Services) are reporting under-resourcing of measures to reduce drug demand and to provide early intervention, treatment and rehabilitation in the community.2 The issues for clinicians are not new, and the views of the medical profession need to be strongly heard, so as to achieve rational, health-based policies in response to the ice epidemic and other drug problems, and to manage the problems associated with drug and alcohol misuse, particularly mental health issues.
Historically, in the first half of the 20th century, the predominant concern in Australia was with alcohol and alcoholism; then, the 1960s and 1970s saw an increase in public awareness of illicit drug problems. In 1985, then Prime Minister Hawke called a drug summit which instigated what is now known as the National Drug Strategy. The strategy addressed misuse of legal and illegal drugs, and upheld the principle of harm minimisation, subsequently seen in Australia’s response to the HIV/AIDS and hepatitis C “epidemics”.
However, legal and clinical responses have had different goals: while the legal system has aimed to restrict access to drugs and alcohol to prevent misuse and deter criminal behaviours, clinicians have aimed to prevent and manage the effects of drug misuse and associated secondary physical and mental health issues (including suicide risk and blood-borne virus transmission). As a result, law and medicine have often been in conflict in the sphere of drug policy.
The bottom line is that in the domain of clinical practice, associated legal complexities — especially when those affected are, or could be, “criminalised” — can complicate the implementation of effective management. In such circumstances, medical practitioners must try to negotiate complex interfaces between treatment, legislation, criminal justice and social disadvantage. It is among the socially marginalised — such as the homeless, prisoners and people with mental health disorders — that these interfaces are most notable.
In 1998, a comprehensive mental health survey of homeless people in Sydney night shelters found that while 36% had a drug misuse disorder, 75% had one or more mental health disorders and one in two had a physical health problem.3 Mortality was three to four times higher than that for the general population.4 In 2012, while 70% of surveyed Australian prisoners had used illicit drugs in the past year and 54% were drinking alcohol heavily before offending, 46% had received a mental health diagnosis in the previous 12 months and 21% were taking a prescribed psychotropic medication.5 Indigenous and female inmates were most likely to be affected by such health problems.5 The prison population also had high rates of blood-borne virus exposure.6
In 2013, the National Mental Health Commission reported that almost 340 000 Australians were both experiencing mental illness and misusing drugs, and up to 70% of patients who presented for a mental health or substance use problem were experiencing both concurrently. It highlighted that “People living with this mix of difficulties are discriminated against and are often judged and marginalised from services and the community”.7
Law enforcement agencies, including the courts, are common points for identifying users of crystal methamphetamine and other illicit drugs and for referring these people to treatment. This includes pre-arrest and arrest stages, and court- and sentence-based orders (all states have court-supervised treatment programs for users of illicit drugs). The focus is on illicit drugs, not alcohol. Only two states have treatment units for short-term involuntary “care and control” of severely substance-dependent people whose survival is at risk. Mental Health Acts deliberately exclude the effects of drugs and alcohol from the definitions of mental illness. A person manifesting features of a mental illness that are attributable to substance misuse can be held only for a temporary period as a “disordered” patient. Once discharged from care, primary health care workers may be faced with treating such patients in an environment that has scarce on-the-ground drug and alcohol services.
Three issues in current drug and alcohol policies stand out for resolution: substance misuse problems must be recognised as inherently “people” problems, not solely problems of pharmacology; legislation centred on drug law enforcement must be shifted to a public health framework based on reducing harm from misuse of all drugs; and management of drug and alcohol misuse needs to become a mainstream task for all health services. Accordingly, the nascent Primary Health Networks should be resourced to respond to region-specific drug and alcohol problems, and to work in partnership with specialist drug and alcohol services. To enable this, the speciality of addiction medicine should be recognised by the federal government. Finally, with increasing recognition of the co-occurrence of mental health and substance misuse problems, the historical separation between mental health and drugs and alcohol needs to be re-thought, and new approaches devised.
[Correspondence] Economists, universal health coverage, and non-communicable diseases
We welcome the declaration in support of universal health coverage (UHC) by Lawrence Summers1 on behalf of 267 economists from 44 countries. We are astounded, however, by the complete absence of tackling non-communicable diseases (NCDs) from this call for action. This is especially surprising given the strong focus on NCDs in the Lancet Commission on Investing in Health, chaired by Summers,2 and the cost-effectiveness of many NCD interventions that can be adapted and simplified for inclusion in suitable packages.
[World Report] France passes wide-ranging health reforms
After some turbulent months of protests by doctors and opposition by MPs, France has a new health law, bringing in a raft of new measures. Barbara Casassus reports from Paris.
Talcum powder and cancer link fears after Johnson & Johnson court case
The family of an American woman has been awarded US$72m by Johnson & Johnson after she claimed using talcum powder caused her ovarian cancer. Jacqueline Fox died last year at the age of 62 after a three year battle with cancer.
In an audio deposition in the courtroom, she recounted using Johnson & Johnson products containing talcum powder for 35 years, using them for ‘feminine hygiene’ and applying to her genital area.
The jury came to the verdict after five hours of deliberations. The case is the first among more than 1000 nationally to result in a monetary reward.
Related: MJA – Preventing breast and ovarian cancers in high-risk BRCA1 and BRCA2 mutation carriers
However the link between talcum powder and ovarian cancer has long been disputed by Johnson & Johnson, which said in a statement: “We have no higher responsibility than the health and safety of consumers and we are disappointed with the outcome of the trial. We sympathise with the plaintiff’s family but firmly believe the safety of cosmetic talc is supported by decades of scientific evidence.”
According to Paul Pharoah, Professor of Cancer Epidemiology at the University of Cambridge, the decision of the court is flawed.
“First, the evidence of a causal association between genital talc use and ovarian cancer risk is weak. Second, even if the association were true, the strength of the association is too small to be able to say on the balance of probabilities that any cancer arising in a woman who used talc had been caused by the talc.”
He said the results of studies had been inconclusive and prone to bias however one recent multi-study collaborative analysis of over 8,000 cases and 9,000 controls found that perineal talc use was associated with a 20% increase in the risk of ovarian cancer.
Related: MJA – Reassessing rare cancers
Professor Pharoah said it’s important for people to remember the size of the possible risk: “A 20 year old woman in the UK has a risk of getting ovarian cancer at some point in her life of 18 in a thousand; a 20% increase in this risk would raise this to 22 in a thousand (assuming that the association were real). A woman with a fault in the BRCA1 gene has a lifetime risk of ovarian cancer of about 400 in a thousand.”
Professor Bernard Stewart, a world authority on environmental cancer risks who advises both the International Agency for Research on Cancer and Cancer Council Australia told Fairfax Media that it’s fair enough if women want to stop using talc.
“The evidence is enough to justify anxiety in an individual woman, and if an individual woman wants to stop using talc in this way I have absolutely no criticism of that”.
However he also says the evidence isn’t strong enough for anyone to worry about usage in the past.
Latest news:
Patchy vaccination coverage leaves some at risk
Vaccination rates in some areas are so low that they are vulnerable to the spread of potentially dangerous diseases such as measles and whopping cough.
A report detailing child vaccination rates nationwide has found that although almost 91 per cent of children were fully vaccinated in 2014-15, in more than 100 postcodes less than 85 per cent were fully immunised, including just 73.3 per cent in the Brunswick Heads area on the New South Wales north coast.
The National Health Performance Authority report indicates that the country has a considerable way to go to achieve the target set by the Commonwealth, State and Territory chief health and medical officers for 95 per cent of all children to be fully vaccinated, though there were some encouraging signs of progress.
The NHPA found immunisation rates among one-year-old Indigenous children increased significantly in 14 per cent of geographical areas, and there was a big 8 percentage point jump in the rate outback South Australia.
The report also revealed improvements in Surfer’s Paradise, and the eastern suburbs of Sydney.
The findings were released against the backdrop of concerted efforts nationwide to boost immunisation rates, most notably through the Federal Government’s No Jab, No Pay laws, which deny family tax supplements and childcare benefits and rebates to parents who refuse to have their children vaccinated.
There have been anecdotal reports of surge in vaccinations before the commencement of the school year as the new rules loomed, but public health expert Julie Leask warned the causes of low vaccination rates were complex, and it was too early to assess the effectiveness of the No Jab, No Pay laws.
In her Human Factors blog (https://julieleask.wordpress.com/), Ms Leask, a social scientist at Sydney University’s School of Public Health, said a significant percentage of the 84,571 children reported as not fully vaccinated were in fact up-to-date but there were errors in recording their status on the Australian Childhood Immunisation Register.
In other instances, parents were unaware of vaccination requirements, or encountered problems in arranging for the immunisation of their children.
Ms Leask said that without further research, it was impossible to know how many children were being denied immunisation because their parents objected to it.
She said there were encouraging accounts of some parents who were previously objectors arranging for their children to be vaccinated – including some who were “angry and resentful, feeling coerced into making the decision because they cannot afford to miss the payments”.
But Ms Leask aired concerns about the implementation of the No Jab, No Pay laws.
She said Primary Health Networks and providers including GPs, nurses and Aboriginal health workers were being forced to work “very hard to implement a complex policy in a very short timeframe,” with often inadequate resources.
Providers were in many cases being overwhelmed by demand and had not been provided with additional assistance, and were being denied access to the ACIR and so could not update patient details.
The importance of high rates of vaccination have been underlined by warnings that the world remains “significantly off-track” targets to eliminate measles, and that communities with immunisation rates below 90 per cent were at risk of fast-spreading outbreaks.
The Gavi Vaccine Alliance said that although the number of deaths from malaria worldwide had fallen substantially in the past decade, the disease still claimed 114,900 lives in 2014 – most of them children younger than five years.
Gavi said it had developed a new approach to support periodic, data-driven measles and rubella campaigns in addition to action to tackle outbreaks.
“Measles is a key indicator of the strength of a country’s immunisation systems and, all too often, it ends up being the canary in the coalmine,” Gavi Chief Executive Dr Seth Berkley said. “Where we see measles outbreaks, we can be almost certain that coverage of other vaccines is also low.”
Adrian Rollins
AMA in the News – 23 February 2016
Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.
Print/Online
AMA attacks health insurers’ clawback, Adelaide Advertiser, 5 February 2015
Private health insurance customers could finally see a slowdown in the rate of premium rises, amid criticism of insurers for scaling back members’ entitlements. AMA President Professor Brian Owler accused some insurers of scaling back members’ coverage.
Sticking up for all children, Northern Territory News, 8 February 2016
The AMA wants all children who fall behind on their vaccination program to be allowed to catch up for free, calling for further Federal Government funding to boost immunisation rates. AMA President Professor Brian Owler said Government claims that health spending was unsustainable were not backed by evidence.
Medicare plan risks privacy, Adelaide Advertiser, 12 February 2016
A private company would know whether a patient had an abortion, herpes or was getting mental health treatment if the Government proceeds with a plan to privatise Medicare and medicine payments. The AMA is calling on the Government to change the system so a patient’s Medicare rebate could be assigned directly to the doctor.
Anti-vax nuts crack at last, The Sunday Telegraph, 14 Februay 2016
Almost 260 extra children are being immunised every week as even the most hardened anti-vaccine fanatics change their view. AMA President Professor Brian Owler said people are starting to realise the anti-vaccination lobby does not hold weight, and some of the policies are starting to take effect.
Indigenous health vital, The Herald Sun, 18 February 2016
AMA President Professor Brian Owler, in Alice Springs visiting health groups and clinics, said the Closing the Gap report, released last week, indicated that health had fallen off the radar.
Bulk-billing on the rise despite mooted cuts, The Australian, 19 February 2016
Bulk billing rates have continued to rise despite health groups warning patients will be left out-of-pocket because of a Federal Government freeze on Medicare rebates. AMA President Professor Brian Owler said the plan to remove the bulk billing incentive from pathology services was a sign the co-payment had risen from the grave.
Radio
Professor Brian Owler, 666 ABC Canberra, 8 February 2015
AMA President Professor Brian Owler discussed the AMA’s Pre-Budget Submission. Professor Owler criticised the Federal Government for telling basic ‘untruths’ about health spending.
Dr Brian Morton, 2GB Sydney, 9 February 2016
AMA Chair of General Practice Dr Brian Morton discussed homeopathy. Dr Morton said he was concerned that people who chose homoeopathy might put their health at risk.
Professor Brian Owler, ABC News Radio, 11 February 2015
AMA President Professor Brian Owler talked about health spending and the MBS Review.
Professor Brian Owler, ABC South East NSW, 15 February 2016
AMA President Professor Brian Owler discussed hydrocephalus. Professor Owler said shunt registry for hydrocephalus could be used as a quality assurance tool in order to decrease blockages and infections which affect morbidity and increase costs to the health system.
Television
Professor Brian Owler, ABC News 24, 28 December 2015
Landmark legislation will be introduced into Parliament to legalise medicinal cannabis. AMA President Professor Brian Owler said medicinal cannabis should be regulated in the same way as other narcotics.
Professor Brian Owler, CNN, 16 February 2016
AMA President Professor Brian Owler slammed Government policy on asylum seekers. Professor Owler said doctors who work with asylum seeker children face an incredible ethical dilemma, because they cannot allow children to be discharged into an unsafe environment.
Professor Brian Owler, SBS Sydney, 17 February 2016
Prime Minister Malcolm Turnbull said there would be no change to Australia’s border protection policies despite an offer from New Zealand Prime Minister John Key to take in children headed for offshore detention. AMA President Professor Brian Owler said this was a complex issue, but the issue facing the AMA is to ensure the health care of asylum seekers and getting children out of detention.
Govt funding goes begging because of bungling
The Health Department has been accused of bungling a multi-million dollar program intended to boost GP training in rural areas.
AMA President Professor Brian Owler has taken the Department to task over revelations that fewer than 50 Rural and Regional Teaching Infrastructure Grants have been awarded, despite funding for double that number.
In its 2014-15 Annual Report, the Department advised that just 10 of 100 grants provided for by the Government in that year had been approved. Professor Owler said that since then a further 38 had been awarded, and negotiations on another “20 or so” were underway.
But the AMA President said this still fell well short of expected targets. In its 2014-15 Budget, the Government committed $52.5 million over three years to fund at least 175 grants worth up to $300,000 each.
There are ongoing concerns about the difficulty of recruiting and retaining doctors to practise in country areas, and the grant program was established to help rural clinics to expand their facilities to accommodate medical students and supervising GPs.
Professor Owler said the program’s underperformance was particularly disappointing given the Government’s crackdown on spending in most areas of health.
“Many health services and programs and organisations are struggling as the Government puts the Budget bottom line ahead of improving health outcomes,” he said. “So it’s a surprise to find an area of health where funding targets are not being met or, to put it another way, precious allocated health funding is not being spent.”
The AMA President said the implementation of the program had been flawed – it took the Department four months to invite applications, and set a deadline during the 2014-15 Christmas-New Year holiday period.
“Give the Department’s extensive experience with infrastructure grants, this should have been a straightforward exercise. Clearly it has bungled the process,” Professor Owler said. “This ineptitude has wasted a rare opportunity to enable more medical students and GP registrars to experience and develop an interest in rural practice, and give patients better access to health services in their community.”
He said that what made it all the more galling was that this had occurred at a time when the Government was slashing GP funding.
The episode also showed the destructive effect of health spending cuts.
Professor Owler said the financial uncertainty created by Government policies such as the Medicare rebate freeze and the MBS Review had made general practices increasingly risk averse.
In order to qualify, practices have to commit to matching the grant provided by the Government, and the AMA President said many were reluctant to make the investment in the current environment.
He said it was unsurprising that, given the lacklustre response, the Government was reconsidering its approach to infrastructure grant funding.
Adrian Rollins
Department giving GPs the PIPs
The Health Department is threatening to axe incentive payments to medical practices that fail to upload shared health summaries to the My Health Record system despite the fact that it is still under development.
In a move condemned by AMA Council of General Practice Chair Dr Brian Morton, the Department has advised general practices that unless shared health summaries for 0.5 per cent of their standardised whole patient equivalent are uploaded in May, they will no longer be eligible for payments under the e-health Practice Incentives Program (ePIP).
A Department spokeswoman told Pulse+IT magazine the eligibility requirement could be met by a single GP in the practice, and added that a tiered performance-based approach linked to levels of system use would be introduced from August, “subject to the outcome of consultations with the general practice community”.
But Dr Morton condemned the Department’s move, which he said was premature and had been undertaken without adequate consultation.
“It’s going to be an appalling cock-up because they haven’t listened to the profession, they’ve not listened to the stakeholders, and they’re not giving us enough time,” he told Medical Observer.
The Department is implementing the new eligibility requirements even though a trial of My Health Record’s opt-out arrangements is not due to commence until mid-July, and numerous privacy issues have yet to be resolved.
“They should be holding off until the pilots have been run and the opt-out has actually happened,” Dr Morton said.
The AMA has long flagged serious concerns with the approach the Department is taking to implementing the My Health Record (MyHR) system, which is intended to supersede the flawed Personally Controlled Electronic Health Record.
In a submission to the Health Department last year, the AMA argued that fundamental issues with the design of MyHR had to be resolved before any move to links its use to the ePIP.
It said that until shortcomings of the PCEHR such as incomplete and hidden information and a lack of take-up among consumers were fully addressed, it was premature to try to force doctors to adopt it.
“Until these problems have been rectified MyHR is neither a meaningful or functional tool, and it is unreasonable to expect GPs to actively use it,” the AMA said at the time.
“If the MyHR is easy for practitioners to utilise, the information it contains is reliable, the system and record transparently interoperable, and practitioners can quickly and clearly recognise how it will enhance patient care then they will readily engage with it.
“However, we know that the MyHR is none of these things and using the PIP incentive to try and mandate use of the MyHR will not solve this.”
The AMA said that, rather than a single practice-level ePIP payment, a better way to encourage GPs to use the system was to remunerate them through an MBS item or a Service Incentive Payment (SIP).
Adrian Rollins
Let them out
Picture: paintings / Shutterstock.com
The Federal Government’s refugee policies will come under attack at a forum being organised by the AMA to highlight the enormous harm caused by indefinite detention.
As doctors at Brisbane’s Lady Cilento Children’s Hospital stand steadfast in their refusal to discharge a one-year-old girl who faces being sent back to the immigration detention centre on Nauru, hundreds are expected to attend an AMA forum in Sydney on 21 February condemning the treatmernt of asylum seekers.
AMA President Professor Brian Owler, who will address the forum, is expected to highlight concerns about the standard of health care provided to asylum seekers, particularly those held in offshore facilities, and to call for the immediate release of all children currently being detained.
The forum, which is expected to be attended by leading clinicians, entertainers, commentators, jurists and religious leaders, comes as the Government advances plans to deport 267 asylum seekers, including 72 children, to Nauru after seeing off a High Court challenge to the legality of its offshore detention regime.
In a landmark decision, the High Court rejected the claim by a Bangladeshi woman detained by immigration authorities that the Government’s arrangement with Nauru breached the Constitution.
The nation’s highest court ruled that the Commonwealth’s memorandum of understanding with the Nauruan Government was authorised by section 61 of the Constitution, and its move to hire Transfield to operate the detention centre on the island was “a valid law”.
Releasing an AMA Position Statement on the health care of asylum seekers late last year, Professor Owler said that although the number of children being held in detention had declined dramatically under the Coalition Government, the practise needed to end completely.
“Detention has severe adverse effects on the health of all asylum seekers, but the harms in children are more serious,” Professor Owler said late last year. “Some of the children have spent half their lives in detention, which is inhumane and totally unacceptable.
“These children are suffering extreme physical and mental health issues, including severe anxiety and depression. Many of these conditions will stay with them throughout their lives.”
The forum, which will be held at the Ionic Room, SMC Conference and Function Centre, 66 Goulburn Street, Sydney on Sunday, 21 February from 11am, will also hear from leading child health experts from the Children’s Hospital at Westmead, including Consultant PaediatricianProfessor Elizabeth Elliott; Clinical Professor, Paediatrics and Child Health, Professor David Isaacs; and Paediatric Nurse Alanna Maycock.
Meanwhile, the Government is being frustrated by the action of doctors, nurses and hospital administrators in refusing to discharge children who face being returned to detention.
Since 12 February, doctors at the Lady Cilento Children’s Hospital have refused to release baby Asha, who was evacuated there from Nauru after being badly burnt by boiling water.
A hospital spokesman told the ABC that the child would not be discharged until a “suitable home environment is identified, as is the case with every child who presents at hospital”.
The spokesman said decisions relating to treatment and discharge were made by qualified clinical staff “with the goal of delivering the best outcome”.
The decision is a rebuke to the Government over the quality of care it provides for detainees, particularly those held offshore.
It echoes similar action taken by doctors at Melbourne’s Royal Children’s Hospital late last year.
The AMA said all asylum seekers and refugees should have universal access to basic health care, something that was “clearly not happening.”
The AMA Position Statement on the Health Care of Asylum Seekers and Refugees can be viewed at: position-statement/health-care-asylum-seekers-and-refugees-2011-revised-2015
The details of the AMA forum on asylum seeker health are:
| Date: Sunday, 21st February 2016
Venue: Ionic Room, SMC Conference and Function Centre, 66 Goulburn St, Sydney Time: 11:00am – 1:00pm RSVP: By COB Thursday, 18th February 2016 to amaforum@ama.com.au |
Adrian Rollins