2015: a year of action on many fronts

It has certainly been a year of pressing issues for the Council of Salaried Doctors. Some we’ve been directly involved in, others we’ve observed with interest. There are too many issues to cover in detail, but here are the highlights:

Bullying and harassment in the medical workplace

You can’t be precious when you work in a medical workplace. People say things in the heat of what is frequently a tense health care moment that may shock those from other environments. At other times, staff need firm direction, even performance management. Australian workplace law recognises that “reasonable management action” is not harassment.

The key thing for us is to recognise when things can go too far, or when there is deliberate sexual or other harassment of a staff member. That is not acceptable, and we must speak out about it. The AMA, along with its associated body, the Australian Salaried Medical Officers Federation, is developing a Position Statement on sexual harassment in the medical workplace to give doctors a framework for appropriate behaviour and responses to harassment.

End of Life/ palliative care

Demand for palliative care is increasing as our population ages. Patients and their families are seeking access to services to provide relevant care to people who are actually dying from their chronic and complex conditions.

Gaps remain, as our health system is not always able to offer the care that is sought. In an ideal world, governments would work together to provide the necessary funding, as well as a strong legal framework within which patient-centred palliative care can be conducted with dignity and certainty. We intend to keep this important issue in our sights.

Employment issues

Once again, the medical workforce has faced challenges to its structures and ability to cope, particularly related to teaching, research and substitution.

The China-Australia Free Trade Agreement may allow Australian health care providers to set up private clinics in China, but its effect on pharmaceuticals and other areas of health care in Australia are, as yet, undetermined.

Activity-based funding has created a situation where funding models may not adequately compensate hospitals in certain areas, leaving salaried doctors to do more work with fewer resources.

The appearance of hospitalists has been considered by the Committee and the Industrial Coordination Meeting (ICM). There aren’t many yet, but numbers are likely to increase, so we are monitoring the situation, and there will be an update of our Position Statement. We don’t want the hospitalist role to usurp that of either Visiting Medical Officers or Doctors in Training.

Safety of doctors in the workplace

The AMA has highlighted evidence that doctors are at greater risk of stress-related problems than the general population. This is why doctors’ health services are vital to both the profession and the public good.

Doctors need physically safe workplaces. They need to be sure that they are safe from hostile patients. Sound policy and proper funding are vital to this. The AMA is reviewing its Position Statement on Personal Safety and Privacy for Doctors, and the Committee is providing valuable input.

The Australian Border Force Act (ABF Act)

The ABF Act threatens two years’ jail for health workers who speak out against conditions in immigration detention centres. Despite this, more than 400 Royal Children’s Hospital Melbourne staff have refused to discharge patients who face being returned to detention, and have demanded that all children be released from detention. The ABF Act is an outrage to medical independence, clinical judgment and the industrial wellbeing of those involved in treating asylum seekers. We will continue to make representations to the Government on this issue.

Alterations to salary packaging arrangements

The Government announced in its 2015-16 Budget that it would introduce a cap of $5000 for salary sacrificed meal entertainment allowances from April 2016. A consultation process saw more than 64 submissions received, AMA included. This change affects salaried doctors more than any other group of doctors. We are greatly concerned about its potential effect on the ability of hospitals to attract and retain staff, especially struggling rural hospitals. Let’s hope the Government recognises the value to hospitals of this small incentive, though to date senators appear unmoved on the issue.

Medicare Benefits Schedule Review

On 22 April, the Government announced a review of the more than 5500 items on the MBS. What this will mean for rights of private practice (RoPP) in public hospitals is not clear yet, but various governments have in the past targeted RoPP with outrageous and unsubstantiated claims of impropriety. Let’s hope we’re not facing another witch hunt, and that the benefits of RoPP will not be overlooked.

This is the final report from the Committee for the year, so I bid you farewell until next year. Enjoy a well-earned break as we prepare for another, doubtless hectic, year ahead. Best wishes for the Festive Season.

Correction

In the article “Abortion law in Australia: it’s time for national consistency and decriminalisation”, published in the 2 November 2015 issue of the Journal (Med J Aust 2015; 203: 349-350), there was an error in the second sentence of the third paragraph. It should read: “Fetal abnormality is specifically discussed in the legislation of Western Australia, South Australia and the Northern Territory, and covered by the decriminalisation of abortion in Victoria, Tasmania and the ACT …” The corrected article is available at https://mja.com.au/doi/10.5694/mja15.00543.

Deadly attacks raise fears of breakdown in rules of war

Governments and armed groups are being pressured to ensure the safety of patients and health workers in conflict zones amid a spate of high-profile attacks that have left dozens dead and injured.

The World Medical Association, the International Committee of the Red Cross, the World Health Organisation and several other peak health groups have jointly called on national governments and non-state combatants to adhere to international laws regarding the neutrality of medical staff and health facilities, and ensuring this commitment is reflected in armed forces training and rules of engagement.

The call follows the shelling of a Red Cross/red Crescent hospital in Yemen on Sunday, and the release of the initial results of a Medecins Sans Frontieres investigation into the deadly bombing of its hospital in Kunduz which found that there was no fighting occurring in or around the facility at the time of the attack, and that all armed groups, including the Afghan Army and the US Defence Department, had been given the accurate GPS coordinates of the hospital.

MSF said when the hour-long attack began soon after 2am on 3 October, 140 of its staff were at the hospital – including on 80 on duty – and they were treating 105 patients.

The humanitarian charity said at least 30 people were killed in the bombing raid, including 10 patients, 13 staff and seven whose remains were burnt beyond recognition. One MSF staff member and two patients are still missing and presumed dead.

Describing the attack in chilling detail, the charity reported that the intensive care unit, which was full at the time, was the first part of the hospital to be bombed. Several patients burned alive in their beds, a doctor had his leg blown off and a nurse had his arm virtually severed. One MSF staffer was decapitated by shrapnel, and several people were shot from the air as they attempted to flee the burning building.

As soon as the attack start, MSF made multiple calls to the Afghan Army and US armed forces, both in Kabul and to the Defence Department in Washington DC.

MSF International President Dr Joanne Liu said the internal review confirmed that MSF rules, including its strict ‘no weapons’ policy was in force and respected at the time of the attack, that the charity was in full control of the facility, that there were no armed combatants within the hospital compound, and there was no fighting from or in its vicinity before the airstrikes.

“We were running a hospital treating patients, including wounded combatants from both sides – this was not a ‘Taliban base’,” Dr Liu said.

The MSF President said the incident showed the deadly consequences of any ambiguity about how international humanitarian law applied to medical work in war.

“What we demand is simple: a functioning hospital caring for patients, such as the one in Kunduz, cannot simply lose its protection and be attacked,” Dr Liu said. “The attack…destroyed out ability to treat patients at a time when we were needed the most.

“We need a clear commitment that the act of providing medical care will never make us a target. We need to know whether the rules of law still apply.”

The United States and Afghan governments are yet to announce whether they will consent to an International Humanitarian Fact Finding Commission inquiry into the bombing.

But the Kunduz attack has nonetheless added to the urgency for action to be taken to ensure the safety of medical staff and hospitals in combat zones.

The International Committee of the Red Cross (ICRC), through its Health Care in Danger project, recorded 2398 attacks on health workers, facilities and ambulances in just 11 countries between January 2012 and the end of last year.

Policy and Political Affairs Officer for the ICRC’s Australian mission, Natalya Wells, said such attacks were not new, and were virtually a daily occurrence.

Ms Wells often health workers were caught in the cross-fire, particularly as a result of indiscriminate attacks in urban areas.

But she said that on occasion they were also being deliberately targeted, underlining the need for all combatants to respect the Geneva Conventions.
Ms Wells said that through the Health Care in Danger project, the ICRC was working with governments, armed forces and non-state combatants to improve awareness of, and respect for, laws and conventions around the protection of patients, health workers and medical facilities, particularly in conflict zones.

As part of the effort, governments attending the 32^nd International Conference of the Red Cross and Red Crescent between 8 and 10 December are expected to back a resolution reaffirming their commitment to international humanitarian law and a prohibition on attacks on the wounded and sick as well as health care workers, hospitals and ambulances.

In addition, Ms Wells said the ICRC had held meetings with 30 non-state combatant groups from four continents about international humanitarian law and the rules of armed conflict.

The discussions have included incorporating knowledge of these conventions into their training, backed by sanctions for any breaches.

Promisingly, Ms Wells said that so far “one or two” non-state armed groups, though not signatories to the Geneva Conventions, have discussed creating a similar code of conduct for their forces.

Adrian Rollins

AMA in the News

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

Baby shaking on par with road toll, The Australian, 10 September 2015

New research shows shaking kills as many Australian babies and toddlers as car crashes. AMA President Professor Brian Owler said The Children’s Hospital at Westmead in Sydney was treating a case every month.

AMA urges surgeons to cut bullying, The Age, 11 September 2015

A Sydney senior surgeon whose comments on sexual harassment helped draw attention to widespread bullying in the profession has warned that it will be difficult to fix the problem. AMA President Professor Owler said it would be up to the current generation of surgeons to ‘‘break the cycle’’ of bullying, harassment, and discrimination in the profession.

Calling for review of health fund crisis, The Daily Telegraph, 12 September 2015

Health bodies are demanding a radical review of the private health system as health fund premiums skyrocket, hospital price gouge, and funds slash benefits. AMA President Professor Brian Owler demanded Federal Government intervention as he revealed NIB had removed more than 225 items from its schedule of medical benefits.

Boxer dies after title fight at RSL club, Sydney Morning Herald, 16 September 2015

A 28-year-old Australian boxer has died in a Sydney hospital after being knocked out in an IBF regional title fight. The AMA has released a position statement calling on boxing to be banned from the Olympic Games and the Commonwealth Games.

Medicare review placates AMA by agreeing to stagger changes, The Australian, 17 September 2015

The powerful AMA has won an early concession out of much-anticipated Medicare reforms, with the head of a review taskforce agreeing that recommend changes should be staggered to protect doctor and practice incomes.

‘Junk policies’: the private health cover ripoff, Sydney Morning Herald, 24 September 2015

Fewer than half of all private health insurance policies offer adequate cover for private hospital care, and many patients have no idea what their insurance includes, new figures show. AMA President Professor Brian Owler said policies that insured private patients in only public hospitals were junk policies and should not be allowed.

$20bn addiction to Medicare, Adelaide Advertiser, 28 September 2015

The cost of procedures covered by the Medicare Benefits Schedule has more than doubled to $20 billion a year over the past decade despite much smaller increases to Australia’s population. AMA President Professor Brian Owler said he agreed that Medicare needed to be modernised.

Authorisation to sedate ice addicts welcomed by the AMA, The Age, 28 September 2015

The AMA has welcomed new powers for emergency doctors and nurses to subdue violent ice addicts. AMA president Professor Brian Owler said doctors had already called for all hospitals to have appropriate security to deal with the increasing number of patients affected by ice.

BUPA, nib, Medibank back health review, Australian Financial Review, 29 September 2015

Health Minister Sussan Ley has dismissed the doctors’ lobby’s objections to a review of Medicare, saying the health care system is plagued by ineffective and unnecessary medical procedures and desperately needs reform. AMA President Professor Brian Owler accused Ms Ley of using the review to “cut health funding and health services” and “publicly attack the medical profession”.

Playing doctors and curses, Courier Mail, 29 September 2015

The Turnbull Government has cautioned patients against diagnosing themselves on “Dr Google” and then demanding unnecessary and costly treatments from medicos. AMA president Professor Brian Owler said it was wrong to attack doctors to try to justify cuts to Medicare.

Fees for all finished as uni plan gets the third degree, Adelaide Advertiser, 2 October 2015

Tony Abbott and Christopher Pyne’s controversial plan to allow universities to set their own fees has been dumped, in one of the first major policy shifts of the new Turnball Government. AMA president Professor Brian Owler welcomed the decision, and called on the Government to give students more certainty that degrees will not be priced out of reach.

Backing for RCH doctors, The Herald Sun, 12 October 2015

Victoria’s Health Minister Jill Hennessy has led a resounding show of support for the Royal Children’s Hospital’s demands that children be removed from immigration detention centres. AMA President, Professor Brian Owler, urged Mr Turnbull and Immigration Minister Peter Dutton to intervene.

Surgeon’s road safety plea, The Daily Telegraph, 17 October 2015

AMA President Professor Brian Owler said every new car should by law have autonomous emergency braking to stop rear-end car crashes.

Brain-injury teen stranded by beds deficit, Canberra Times, 23 October 2015

A teenage boy with a critical brain injury was blocked access to the Sydney Children’s Hospital for four days because there were not enough beds, his family was told. AMA President Professor Brian Owler said the incident highlighted that there was an issue with capacity in paediatric hospitals, both at Westmead and the Sydney Children’s Hospital.

Doctors resist camp return of asylum pair, The Age, 12 October 2015

Doctors at Melbourne’s Royal Children’s Hospital refused to discharge an asylum seeker and her child because the immigration department would have sent them back to detention at the expense of their health. AMA Vice President Dr Stephen Parnis said the association had a fundamental problem with keeping children in detention, and had been urging governments to look for any alternative to it for years.

Codeine medicines to be prescription-only next year, The Age, 2 October 2015

Common painkillers such as Nurofen Plus and Panadeine could soon require a doctor’s prescription after a shock decision by Australia’s drug regulator. AMA Vice President Dr Stephen Parnis backed the TGA’s judgement.

Radio

Professor Brian Owler, 2UE Sydney, 10 September 2015

AMA President Professor Brian Owler discussed new research which indicated that shaking kills as many Australian babies and toddlers as car crashes. Professor Owler said the Westmead Children’s’ Hospital treated a case every month.

Professor Brian Owler, 2UE Sydney, 28 September 2015

AMA President Professor Brian Owler talked through his concerns about the upcoming Medicare review and the approach that the Government was taking. Professor Owler believed it would lead to a cut to the number of services patients can access.

Professor Brian Owler, Radio National, 1 October 2015

AMA President Professor Brian Owler talked about the Turnbull Government shaking up the Medicare Benefits Schedule, with Health Minister Sussan Ley launching consultations on a review of nearly 6000 taxpayer-subsidised items on the schedule

Dr Stephen Parnis, 774 ABC Melbourne, 2 October 2015

AMA Vice President Dr Stephen Parnis talked about the rules changing around getting codeine from the chemists. Dr Parnis said the TGA, which determines what things need to put on prescription, has had an inquiry about over-the-counter medications which contain codeine.

Dr Brian Morton, ABC Gippsland, 7 October

AMA Chair of General Practice Dr Brian Morton talked about Mental Health Day and said that all employees were allowed to have ten sick days per year. Dr Morton said but it will still depend on the reason and what you will do with the sick days you will take.

Dr Stephen Parnis, 612 ABC Brisbane, 9 October 2015

AMA Vice President Dr Stephen Parnis discussed calls from health academics to ban energy drinks for people younger than 18 years of age. Dr Parnis said stimulants in the products could cause heart rates to reach dangerously high levels, arrhythmias, problems to blood vessels, difficulties sleeping or anxiety.

Dr Stephen Parnis, 3AW Melbourne, 11 October 2015

AMA Vice President Dr Stephen Parnis talked about Royal Children’s Hospital doctors protesting the detention of children in Australian detention centre. Dr Parnis said the AMA is very supportive of getting all children out of immigration detention and says they can’t see any good coming out of the situation.

Dr Brian Morton, Radio National. 21 October 2015

AMA Chair of General Practice Dr Brian Morton talked about the idea of shared doctor appointments. Dr Morton said privacy could be an issue in shared appointments.

Professor Brian Owler, ABC NewsRadio, 23 October 2015

AMA President Professor Brian Owler talked about a new domestic violence campaign being launched by the AMA. Professor Owler said doctors are being encouraged to report domestic violence.

Professor Brian Owler, 2UE Sydney, 23 October 2015

AMA President Professor Brian Owler discussed the Sydney Children’s Hospital turning away a teenage boy with a brain injury because there were not enough beds.

Television

Professor Brian Owler, Sky News Sydney, 27 September 2015

AMA President Professor Brian Owler talked about the Federal Government reviewing the Medicare system. Dr Owler said the AMA were willing to engage with the Federal Government, but says their discussion paper does not allow new procedures to be added.

Professor Brian Owler, Channel 9, 12 October 2015

AMA President Professor Brian Owler speaks to the Today Show about the Royal Children’s Hospital in Melbourne remaining locked in a bitter dispute with the Federal Government over their refusal to discharge asylum seeker children.

Professor Brian Owler, ABC News 24, 23 October 2015

AMA President Professor Brian Owler talked about the AMA launching a new domestic violence campaign, including a video encouraging patients to confide in their GPs. Professor Owler said there were “far too many” cases of domestic violence, affecting both women and children.

Dr Stephen Parnis, ABC News 24, 28 September 2015

AMA Vice President Dr Stephen Parnis discussed a Four Corners investigation that claimed the medical profession was over-servicing patients and ordering wasteful and potentially dangerous scans. Dr Parnis denied that doctors were over-servicing, but said there was a lot the AMA agrees with when it comes to more judicious care.

Domestic violence victims urged: talk to your doctor

Women suffering violence at the hands of their partners are being encouraged to speak with their family doctor amid concerns that many are failing to get the support they need.

AMA President Professor Brian Owler has joined with Australian of the Year Rosie Batty and AMA New South Wales President Dr Saxon Smith in launching the Share your story campaign to encourage victims of domestic violence to speak with their GP.

Professor Owler said doctors were at the domestic violence frontline, and saw the consequences of the physical and emotional abuse of women and children as part of their daily work.

“I remember when I started as a neurosurgeon at the Children’s Hospital at Westmead, I was shocked – and in fact still am shocked – , at the number of cases that we deal with, the proportion of our work that is taken up with severe head injuries, devastating consequences of domestic violence,” the AMA President said. “Some of them die in hospital; the vast majority end up with severe disability and are in need of lifelong care”.

Ms Batty said the nation needed to do more to protect children from family violence.

“How does a child recover from the trauma of injury, psychological abuse, sexual abuse? How do they lead a life as adults when they are permanently affected by the trauma of being impacted by violence in their families?” she said. “The children are the future, and we are not doing a good enough job.

Ms Batty said that doctors had a big role in helping women in need.

Professor Owler said familiarity with the family doctor often made them the first port of call for those suffering abuse at home, even more so than specialist care.

“Everyone knows where to go if they want to see a doctor, but that’s not always the case with domestic violence services,” he said. “Domestic violence services are certainly there and ready to help, but they can be less visible than doctors in the community.”

The Share your story campaign is complemented by a program to assist family doctors in identifying and supporting patients suffering domestic violence. Earlier this year the AMA joined with the Law Council of Australia in producing a guide for doctors in how to broach the issue of domestic violence with their patients, both victims and perpetrators, as well as canvassing legal obligations and detailing support services.

The AMA President said that the ability to provide support and find appropriate help was “a vital role that doctors, nurses, care workers play, both in helping to identify, but also in trying to support victims – whether they’re women or children or anyone else, that are victims of this scourge in our community”.

At the launch, Professor Owler sought to draw particular attention to the plight of children, who he said often suffered lifelong effects of domestic violence.

“We see large numbers of children that present through our hospitals that unfortunately are victims of domestic violence, and they have a range of injuries, including head injuries, eye injuries and fractures, [that can] have a devastating impact on the rest of their lives,” the AMA President said.

He said non-accidental head injury, usually resulting in bleeding on the brain, was “very common” among children growing up in abusive households, and could lead to severe disability or other life-long impediments such as epilepsy and poor emotional control.

“The other side of this is…that we have children that are just exposed to domestic violence or abuse, and that can have significant consequences as well, particularly from psychological perspectives.”

Between 2008 and 2010, 29 children were killed by a parent or step-parent, and Professor Owler said abuse by a parent or step-parent was the third most common cause of injury in children, after car accidents and accidental drowning.

Adrian Rollins

Australasian Doctors’ Health Conference 2015

By Dr Kym Jenkins, Conference convenor and Medical Director, Victorian Doctors’ Health Program

Doctors’ health, and the health of the medical profession more generally, has never been more in the news.

Through both the general media, and specialised medical publications, we have been hearing all too frequently of toxic workplaces, bullying and harassment. Stories of individual doctors who have “stuffed up”, or who are struggling, seem to make good headlines.

The Australasian Doctors’ Health Conference 2015 (adhc2015), held 22 -24 October, with its theme of “Pathways and Progress”, sought to address and redress these issues.

The conference focussed on extending the debate beyond what is wrong with our profession and just delineating the health issues we face, to a demonstration of what can be done to improve things and an examination of how individuals and organisations have overcome adversity to improve health outcomes.

The Australasian Doctors’ Health Conference is biennial event, and is an initiative of the Australasian Doctors’ Health Network. This year, the Victorian Doctors’ Health Program was proud to host the conference, and I was privileged to be its convenor.

The selection of invited speakers reflected both the breadth and depth of issues regarding wellbeing currently facing the medical profession.

Associate Professor Jan Mckenzie, a consultant psychiatrist and Associate Dean at the University of Otago, gave a moving description of how the Christchurch earthquake affected the lives of students, teachers and administrators at the University of Otago medical school.

Somehow, in the midst of the devastation, and despite the lack of electricity, a functioning IT system or functional buildings, the teaching continued. Although Jan and her colleagues live in homes that still await rebuilding, they not only support their students but have managed to produce a study with case-controlled data on the educational outcomes for Christchurch students, which has helped identify factors that have led to better outcomes.

Professor Carmelle Pesiah, Professor at the University of New South Wales, provided an entertaining (and, for some, shocking) insight into doctor aging. Professor Pesiah delivered some very strong messages and salutary warnings for us all as we get older. She emphasised that there is not just one formula for successfully aging and negotiating the approach to retirement. Aging with a little disgrace may increasingly be the norm.

Dr Hilton Koppe, a general practitioner and medical educator from Lennox Head explored what makes a career in medicine fulfilling. Dr Koppe was an innovative and engaging teacher, and his presentation encouraged people to challenge their perceptions.

On day two of the Conference, Sydney-based psychiatrist and addiction specialist Associate Professor Stephen Jurd spoke on the Doctors Recovery Movement. In a very inspirational presentation, Professor Jurd disavowed those present of any doubt that addiction is an illness. He highlighted the challenges for doctors overcoming addictions, demonstrated the power of recovery and is himself living embodiment of how much our profession will lose if we do not support for medical professionals in their recovery.

The system of mandatory reporting of impairment in doctors was the focus of a presentation from public health physician and health lawyer Dr Marie Bismark, who informed her presentation with data she has obtained from the Australian Health Practitioners Regulation Agency.

The program of free papers, seminars and workshops throughout the two days likewise stimulated much debate, discussion and sharing of initiatives to make ourselves and our workplaces healthier.

The academic program concluded with a “Hypothetical” in which former Alfred Hospital General Counsel Bill O’Shea quizzed and challenged a team of experts about the multiple issues raised in a (not so) hypothetical case of a doctor found using propofol in the workplace.

The need to consider and look of after the individual doctor was apparent, as were the effects on the doctor’s colleagues and the workplace, and the issues of mandatory reporting.

The hypothetical demonstrated the need to take a systems view when a doctor is impaired in the workplace, and to bring together the multiple agencies involved: in this case, the general practitioner, addiction specialist, hospital administration, the Doctors’ Health Program, representatives from the doctor’s own specialist college, and the provision of support services for the colleagues – including a registrar and a medical student – traumatised after finding the doctor unconscious and apparently intoxicated.

Healthy doctors and a healthy profession – a personal reflection

By Dr Kym Jenkins, Conference convenor and Medical Director, Victorian Doctors’ Health Program

The Australasian Doctors’ Health Conference 2015 left me with three take-home messages regarding the health of doctors and the wellbeing of the medical profession. These were:

1. the importance of diversity within the medical profession. That for the medical profession to be healthy, we need not only doctors with different personality styles, but doctors from diverse cultural backgrounds and ethnicities, whatever their sexuality and gender;

2. the importance of being something or doing something other than being a doctor: what we do when we’re not practising medicine not only refreshes and rejuvenates us, but enriches us as human beings and, as a consequence, enriches us as doctors; and

3. the importance of a sense of connection. Isolation is not good for doctor health. Connections to our workplace, to our craft group, to our colleagues, to a learned College or a professional group, or to an individual such as a mentor, are all protective factors for keeping us healthy.

adhc2015 fulfilled its ambition in help make discussion about the need to keep ourselves and our profession healthy well and truly open. In 2015, taking an interest in doctor health is no longer seen as a frivolous or non-essential activity. There is an increasing body of work in this area and much more is still needed.

The next Australasian Doctors Health conference will be in in Sydney in 2017.

Hospitals, health workers increasingly targeted as conventions break down

A wave of deadly attacks on hospitals and health workers in Middle East conflicts has fuelled fears that basic conventions against targeting medical and humanitarian services in war zones are breaking down.

United Nations Secretary General Ban Ki-moon has denounced what calls “the brazen and brutal erosion of respect for international humanitarian law.”

“These violations have become so routine there is a risk people will think that the deliberate bombing of civilians, the targeting of humanitarian and health care workers, and attacks on schools, hospitals and places of worship are an inevitable result of conflict,” he said.

Mr Bann called for action to be taken against those responsible.

“International humanitarian law is being flouted on a global scale,” Ban said. “The international community is failing to hold perpetrators to account.”

A senior Medical charity Medicins Sans Frontieres (MSF) official has warned that the concept of international humanitarian law may be “dead” after a hospital operated by the organisation was destroyed in a bombing attack by Saudi-led forces operating in Yemen – the second such attack in less than a month.

MSF said that on 26 October its hospital in Haydan was destroyed by air strikes carried out by the Saudi Arabia-led coalition fighting against Houthi forces in the war-torn Middle East country. Multiple casualties were only avoided by the rapid evacuation of patients and medical staff.

The attack came just weeks after United States forces bombed an MSF hospital in north-east Afghanistan, killing 22 people including 12 medical staff.

And the charity has reported that at least 35 patients and medical workers have been killed, and 72 wounded, following an escalation of air bombing raids in northern Syria.

It said 12 hospitals have been hit in the Idlib, Aleppo and Hama governorates in the past month, causing six to close and destroying four ambulances.

Head of MSF operations in Syria, Sylvain Groulx, said calls for an immediate halt to such attacks had so far fallen on deaf ears.

“After more than four years of war, I remain flabbergasted at how international humanitarian law can be so easily flouted by all parties to this conflict,” Mr Groulx said. “We can only wonder whether this concept is dead.”

Pressure is mounting on the United States Government to agree to an independent inquiry into its attack on the MSF hospital in the Afghan city of Kunduz.

The International Humanitarian Fact-Finding Commission (IHFFC), established under the Geneva Conventions, has written to both the US and Afghanistan governments to offer its services for an independent inquiry following a complaint from MSF.

US President Barack Obama has issued a public apology for the bombing, and his Government has initiated its own inquiry. But Mr Obama has been steadfast in resisting calls for arms-length investigation, and is considered unlikely to accept the Commission’s offer.

Neither the US nor Afghanistan are member states of the Commission, which has no power to compel their participation.

“It is for the concerned Governments to decide whether they wish to rely on the IHFFC,” the Commission said. “The IHFFC can only act based on the consent of the concerned State or States”.

President Obama has assured that his Government would conduct a “transparent, thorough and objective” inquiry into the tragedy.

But MSF claims the attack could amount to a war crime and must be investigated independently.

“We have received apologies and condolences, but this is not enough. We are still in the dark about why a well-known hospital full of patients and medical staff was repeatedly bombarded for more than an hour,” said Dr Joanne Liu, MSF International President. “We need to understand what happened and why.”

Dr Liu said her organisation was determined to uncover how the attack had occurred, and to hold those responsible to account.

“If we let this go, as if it was a non-event, we are basically giving a blank cheque to any countries who are at war,” Dr Liu said. “If we don’t safeguard that medical space for us to do our activities, then it is impossible to work in other contexts like Syria, South Sudan, like Yemen.

Saudi authorities have denied responsibility for the Yemen hospital attack, though it has been reported that Saudi Arabia’s ambassador to the UN has blamed MSF for providing incorrect GPS coordinates to the Saudi-led coalition – a claim the charity denies.

MSF said it provided Saudi-led armed forces with details of the hospital’s location on multiple occasions, including just two days before the strike that destroyed the facility.

President Obama called Dr Liu to apologise for the attack after the US military admitted responsibility.

The Kunduz hospital attack occurred despite the fact that MSF had given all warring parties the GPS coordinates of the hospital.

Outrage over the attack was heightened when the US initially appeared to claim it was a necessary and legitimate use of force, before later characterising it as a mistake.

MSF said that “any statement implying that Afghan and US forces knowingly targeted a fully functioning hospital – with more than 180 staff and patients inside – razing it to the ground, would be tantamount to an admission of a war crime,” MSF Australia President Dr Stewart Condon and Executive Director Paul McPhun said. “There can be no justification for this abhorrent attack.”

“Medecins Sans Frontieres reiterates its demand for a full, transparent and independent international investigation to provide answers and accountability to those impacted by this tragic event.”

Adrian Rollins

Australian-made cannabis no free-for-all

Access to cannabis for medicinal purposes will be tightly controlled and subject to rigorous scientific assessment even as the country moves to legalise and license its cultivation.

Health Minister Sussan Ley has confirmed that medical cannabis will only be available by prescription, and its use will be subject to approval by the Therapeutic Goods Administration.

Advocates have welcomed Federal Government plans to introduce legislation allowing the controlled cultivation of cannabis for medical and scientific purposes by the end of the year.

But Ms Ley cautioned that although the new laws, which have the support of Labor, would legalise and regulate the production of medicinal cannabis, any potential application would need to be approved by the medicines watchdog based on evidence as to safety and efficacy.

“It’s important we maintain the same high safety standards for medicinal cannabis products that we apply to any other medicine,” the Health Minister said. “I’m sure Australians would be concerned if we allowed medicinal cannabis products to be subject to lower safety standards than common prescription painkillers or cholesterol medications.”

The AMA has argued that cannabis should be regulated in the same ways as other therapeutic narcotics, and be subject to rigorous testing to assess its clinical safety and effectiveness for various conditions.

AMA President Professor Brian Owler said last year that the efficacy of medicinal cannabis for treating symptoms of multiple sclerosis was well established, but other applications should be subject to the same rigorous assessment process as applied to other medicines.

“The way that we regulate medicines in this country for clinical indications is through the TGA, and I think we need to keep using those mechanisms…to regulate the availability of cannabis – not crude cannabis that can be grown at home, but the pharmaceutical preparations that are actually already available, and even looking at putting those on the PBS for particular indications,” the AMA President said.

The Health Minister said medicinal cannabis would not be made available over the counter, except through a doctor’s prescription or as a result of evidence gained through clinical trials.

“At the end of the day, cannabis is classified as an illegal drug in Australia for recreational use and we have no plans to change that,” Ms Ley said. “In many cases the long-term evidence is not yet complete about the ongoing use of various medicinal cannabis products, and it’s therefore important we maintain the role of medical professionals to monitor and authorise its use.”

The Government has proposed the Health Department operate a national licensing scheme to allow the controlled cultivation of cannabis, providing what Ms Ley said was the critical “missing piece” in enabling a sustainable domestic supply of safe medicinal cannabis for Australian patients.

While there are already systems in place to license the manufacture and supply of medicinal cannabis products, local production is currently illegal, and patients and carers trying to obtain them have been forced to try illegal suppliers or to overcome numerous barriers to access on international markets.

“Allowing the cultivation of legal medicinal cannabis crops in Australia under strict controls strikes the right balance between patient access, community protection and our international obligations,” Ms Ley.

The Government will consult with Labor, the Australian Greens, crossbench senators and the states and territories before introducing a final version of the proposed legislation to Parliament by the end of the year.

Ms Ley said the proposed Commonwealth licensing scheme would set out universal obligations and a common legislative framework for states looking to allow medicinal cannabis cultivation.

“It’s imperative we have a clear national licensing system to ensure we maintain the integrity of crops for medicinal or scientific purposes,” she said. “It allows us to closely manage the supply of medicinal cannabis products from farm to pharmacy. We also want to make sure that this approval and monitoring process for cultivation isn’t fragmented across different jurisdictions and provides regulatory consistency.”

But the Greens, though welcoming the Government’s move, argued that it did not go far enough.

Greens leader Dr Richard Di Natale said the proposed legislation did nothing to remove the “bureaucratic barriers” he argues will prevent it from being prescribed like other medicines.

Adrian Rollins

Freedom of choice a weighty problem

Governments will have little choice but to tighten food and marketing regulations and possibly increase taxes on unhealthy products if the nation’s waistline continues to bulge, the AMA has warned.

The peak medical representative organisation told a Senate inquiry into so-called “nanny state” laws that unless Australians improved their diets and increased physical activity, rates of overweight and obesity would continue to climb and the consequent social and economic costs could force governments to act.

While not calling for a sugar tax, the AMA warned that simply giving people information for them to make informed choices may not, by itself, be enough.

“If people continue to make poor choices, and the number of adults who are overweight or obese continues to increase, Government will have little choice but to regulate,” it said, suggesting this might extend to include “restricting…advertising, increasing price, and reducing access, to products known to have a negative impact on health”.

Its views were echoed by ACT Chief Health Officer Dr Paul Kelly, who told The Canberra Times that although he did not advocate a sugar tax, government needed to be “part of the solution” to obesity.

“Just telling people [about healthy food choices], and asking them to make their own decision, is insufficient,” Dr Kelly said. “We know that the majority of the work we do in the hospital system is related to chronic diseases, many of which, if not caused by, are at least made worse by people being overweight or obese. And that’s a real cost to the whole community.”

The AMA made its warning in a submission to the Senate inquiry being led by Liberal Democratic Party Senator David Leyonhjelm, who objects to what he sees as unwarranted Government constraints on freedom of choice, and has taken particular aim at public health measures such as tobacco controls, alcohol restrictions and bicycle helmet laws.

“It’s not the government’s business, unless you are likely to harm another person. Harming yourself is your business, but it’s not the government’s business,” Senator Leyonhjelm said. “So bicycle helmets, for example, it’s not a threat to other people if you don’t wear a helmet; you’re not going to bang your bare head into someone else.”

Poor choices can hurt many

But the AMA argued this was a narrow view that ignored the society-wide consequences of individual choices.

The Association said that often people failed to appreciate the effect of their choices on those around them.

“All too often it is family members and governments who are left to provide support and care for poor individual decision-making,” the AMA said. “More tragically, sometimes innocent victims have to bear the consequences. As doctors, we see too many innocent victims, victims of road traffic accidents caused by drunk or speeding drivers, victims of alcohol and drug-induced violence.”

The Association said that millions were alive today because of public health initiatives such as vaccination programs, road safety laws, smoking restrictions and air and water standards that initially encountered resistance, but which are now widely accepted and supported as reducing the risk to individuals and enhancing the common good.

For example, smoking is a leading cause of preventable deaths, and dealing with its health and economic consequences costs the country billions of dollars each year. For this reason, the community accepts and expects measures to control tobacco marketing and use.

Similarly, compulsory bicycle helmets laws introduced in the early 1990s have been found to have greatly reduced the risk of head injury for cyclists, to the benefit of individuals, their families and the community.

Sydney University philosopher Professor Paul Griffiths and Sydney Law School Professor Roger Magnusson said Senator Leyonhjelm’s critique of public health measures missed the mark.

“Australia’s health legislation is a poor candidate for Libertarian criticism,” they wrote in The Age. “Accurate information about the risks and harms posed by consumer products increases freedom by helping people understand their options.”

In its submission, the AMA rejected the view that these and similar regulations were an unwarranted intrusion on individual liberty.

It said that even with such public health measures in place, “people in Australia are largely able to do as they wish, even when it is likely to cause harm to themselves or others – some people continue to smoke or consumer excessive amounts of alcohol”.

But the AMA asserted governments had a responsibility to protect people from harm caused by others, and to regulate behaviour to improve individual health and promote the greater good.

“Government does have a role to play in making this country a safer and healthier society,” it argued, “…in regulating and modifying the behaviour of individuals so that the rest of us can be confident that we won’t be affected by the poor decisions of others, such as being run off the road by a drunk driver.”

“We need all those who have a responsibility for prevention, including governments at all levels, to live up to their responsibilities for public health and prevention.”

Adrian Rollins

Presentations with alcohol-related serious injury to a major Sydney trauma hospital after 2014 changes to liquor laws

A number of recent studies have reviewed aspects of the complex questions associated with alcohol consumption, particularly with the misuse of alcohol.1–4 The impact of alcohol on emergency services has also been examined.5–10 It was found that drinking a single glass of wine doubled the risk of presentation to an emergency department; after three glasses, there was a 5-fold increase.11 The same study found that, after 10 standard drinks, the risk of needing to attend an emergency department was increased 10-fold for men and 14-fold for women.

There have been few well designed studies of alcohol-related injuries, and they often rely on emergency department data. Although of some value, such data have significant limitations if not collected prospectively and their acquisition appropriately resourced.12

On 24 February 2014, the New South Wales Government introduced changes to liquor regulations in the central district of the City of Sydney, the so-called “party precinct”. These legislative changes were enacted in response to community outrage after a series of adverse events reported in the media, particularly the deaths of two young men associated with alcohol-fuelled violence.

Many of the changes were based on successful strategies in the nearby Australian city of Newcastle, which had experienced similar alcohol-related serious injury problems.7,8 Some of the core changes are listed in Box 1. Several other, possibly key, initiatives were introduced in Sydney during the first year of the changed regulations. These included:

visibly increased police presence and monitoring;
introduction of identity document scanning on entry into some venues; and
sharing of information by venues to prevent intoxicated persons who have been refused entry at one site from gaining access to another.

In addition to the legislative changes, volunteer nocturnal patrols, usually under the auspices of non-government organisations, also commenced activities in the precinct.

Some of the initiatives were controversial in both the medical literature and the broader media.7–9,13 Our study was undertaken to assess the impact of these measures on alcohol-related serious injury, and also to determine the possible impact on emergency services in the relevant catchment area. Our study is timely in view of the review process currently being undertaken by the Australian Government on the impact of the lockout laws.14

Methods

To determine whether the strategy adopted to reduce alcohol-related injury in central Sydney has been successful, we undertook a 2-year retrospective analysis of alcohol-associated serious presentations to the emergency department of St Vincent’s Hospital, a major teaching hospital in the heart of the area where the changes were instituted. We analysed patient data stored on the hospital’s emergency department patient information computer system (EDIS).

Patient records for two periods were analysed: the 12 months preceding the introduction of the new alcohol laws (24 February 2013 – 23 February 2014; period 1) and the 12 months after their introduction (24 February 2014 – 23 February 2015; period 2). To avoid any bias, the researchers were blinded to which year was being analysed. One of the authors (G F) was assigned as the sole assessor who identified cases of alcohol-related serious injury.

Our search was restricted to persons with injuries classified under Australasian triage categories 1 and 2, as our attention was focused on the seriously or critically injured (Box 2). De-identified, routinely obtained demographic data included time and day of the week of the relevant injury. Other key data fields that were extracted and analysed were presenting symptoms and triage assessment.

In order to identify patients injured by serious assault, but also those suffering other serious injuries and major traumas associated with alcohol (such as vehicular and pedestrian injuries, or falls from a height), the presenting symptoms, triage assessment and diagnosis of all patients who presented as a result of serious trauma during the periods of analysis were examined for any reference to alcohol. All patients identified in this manner were included in this study.

The Fisher exact test was used to compare categorical outcome data, with statistical significance defined as P < 0.05. Confidence intervals (95%) for proportions were calculated with the standard assumption of normally distributed logarithms of the relative risk. There were no missing data for the analysed variables. Data analysis was performed with Stata 13 (StataCorp).

Ethics

Ethics approval was obtained for the study from the St Vincent’s Hospital Human Research Ethics Committee (ref. HREC/LNR/15/SVHA/62).

Results

During the 2-year study period, there were 13 110 Australasian triage category 1 and 2 presentations to the St Vincent’s Hospital emergency department: 6467 patients during period 1 and 6643 during period 2.

Of these presentations, 564 (4.3%) were identified as alcohol-related serious injuries: 318 during period 1 (4.9% of presentations during this period) and 246 during period 2 (3.7%). This decrease was statistically significant (P < 0.05), and occurred gradually during period 2 (Box 3).

Given the nature of the problem, we examined the high alcohol time (HAT) separately; ie, the weekend, from 6 pm Friday to 6 am Sunday. The proportion of alcohol-related serious injury presentations in triage categories 1 and 2 was much higher during HAT (9.1%) than the rest of the week (3.1%; P < 0.05). There was a significant decrease in the total number of seriously injured patients during HAT after the introduction of the various control measures in 2014: from 140 presentations (10.4%) in the 12 months before the changes to 106 (7.8%) in period 2 (P < 0.05). This was a relative risk reduction of 24.8% (95% CI, 4.3%–40.9%).

Analysis of the numbers of alcohol-related injuries by time of day found a consistent decrease in the number of presentations of seriously injured patients with alcohol-related injuries between 1 am and noon after the introduction of the new regulations. There was, however, a small increase in the number of patients presenting with alcohol-related injuries between 9 pm and midnight, as well as a small spike around 1 pm (Box 4).

These trends were even clearer when analysis was restricted to HAT (Box 5). During this time period, large reductions in serious injuries associated with alcohol-related violence were seen after 1 am.

Discussion

Our analysis has identified some significant positive results that followed the 2014 changes to the liquor laws and associated measures.

The clear decrease in serious injuries related to alcohol took some time to occur (Box 3); the gradual implementation of the policies may have led to a delayed decline in alcohol-related serious injuries. The small increase in alcohol-related injuries between 9 pm and midnight after the changes were introduced may have been related to increased alcohol intake earlier in the evening (“preloading”), before the times when the various bans take effect; the 1 pm spike may reflect lunchtime alcohol consumption.

The new measures were focused on curbing excessive drinking and violent behaviour after midnight, which could also explain some of our findings. Other indicators outside the scope of this study also support the success of the combined measures during their first 12 months of operation. Neurosurgeons at St Vincent’s Hospital reported a decrease in the numbers of patients presenting between 8 pm and 8 am with serious head injuries, which often require immediate surgery, from 26 patients during period 1 to 11 in the 12 months after the changes. Intensive care use also decreased; notably, there was not a single admission associated with alcohol-related violence during the first New Year’s Eve after the changes.16 The NSW Bureau of Crime Statistics reported a 32%–40% drop in assaults across the CBD Entertainment Precinct, and there was no increase in the number of assaults in neighbouring police command areas during the 12 months after the changes.17

There is significant controversy and discussion about which elements of the interventions may have been effective. Because of the non-specific nature of the data recorded, our study could not examine the effects of individual measures. The cost–benefit relationship of changes introduced to reduce alcohol-related serious harm has also been debated, as income, jobs and businesses have been lost as a result of the changes.4,10 This is especially relevant because the NSW Government is reported to be considering widening the regulations to include other geographical areas.

The precise costing of any reduction in the need for hospital care can be difficult,18 but the resources needed to treat critically ill, seriously injured patients, often after regular operating hours, and other associated costs are significant. The burden to both the patient and the community must be considered alongside the morbidity and mortality data.1,19

There are many limitations inherent to this and similar studies.8–10,13 Our methods cannot accurately capture complete data on the intake of alcohol. They rely on voluntary information provided by the patient and enquiries by health care workers; the information is recorded as free text in the EDIS system, without specific details about a number of relevant factors, such as the precise details of the reported injury or accident. The involvement of alcohol in trauma cases is almost certainly underestimated to a considerable extent, as blood alcohol testing may not be routinely undertaken in all unconscious or severely injured patients. Further, it was beyond the scope of our study to correct for potentially relevant demographic or ecological variables during the period of the study, such as population volumes.

Published research on acute alcohol harm relies heavily on information from emergency departments.5,11,20 This approach to data collection is not methodologically designed, and, being retrospective, is especially limited when trying to establish any causal relationships. In response to this, an Australia-wide research and data collection initiative has been established, and this collaboration between researchers, health organisations and the Australasian College of Emergency Medicine should facilitate a formal, more robust approach to data collection (personal communication, Associate Professor Peter G. Miller, School of Psychology, Deakin University, June 2015).

This study found a significant decrease in the number of patients presenting to a major trauma and teaching hospital with critical or seriously injuries related to alcohol use following the 2014 changes to regulations in the inner-city precinct of Sydney, Australia. The reduction was most marked in the period after midnight, which corresponds with the main thrust of the changed regulations.

Box 1 –
Key changes to alcohol laws for the Sydney CBD Entertainment Precinct, 2014

All takeaway alcohol sales stop at 10 pm.
No service of “shots” (alcoholic spirits) after midnight.
1.30 am–3.30 am “lockouts” at hotels, registered clubs, nightclubs and licensed karaoke bars. No entry for patrons, or re-entry for those who exit during the lockout period.
3.00 am “last drinks”. All alcohol service ceases.

CBD = central business district, central Sydney.

Box 2 –
Australasian triage categories relevant to serious or critical injuries15

Category 1

Immediately life-threatening: conditions that are threats to life (or imminent risk of deterioration) and require immediate aggressive intervention.

Category 2

Imminently life-threatening: condition is serious enough or deteriorating so rapidly that there is the potential of threat to life, or organ system failure, if not treated within 10 minutes of arrival in the emergency department; orImportant time-critical treatment: the potential for time-critical treatment (eg, thrombolysis, antidote) to make a significant effect on clinical outcome depends on treatment commencing within a few minutes of the patient’s arrival in the emergency department; orVery severe pain: humane practice mandates the relief of very severe pain or distress within 10 minutes.

Box 3 –
Alcohol-related serious injury presentations to the emergency department of St Vincent’s Hospital, Sydney, by calendar month, before and after changes to alcohol regulations.

*February 2014: 26 cases to 23 February, 5 for 24–28 February; February 2015: cases until 23 February (study end).

Box 4 –
Alcohol-related serious injury presentations to the emergency department of St Vincent’s Hospital, Sydney, by hour of day before and after changes to alcohol regulations

Box 5 –
Alcohol-related serious injury presentations to the emergency department of St Vincent’s Hospital, Sydney, on weekends, by hour of day