Maelstrom of money blows over wind farms

The nation’s peak medical research organisation has committed more than $3 million to investigate whether or not wind farms effect human health amid ongoing controversy on the issue.

There have been persistent claims that wind farms are responsible for a range of health problems despite a lack of evidence, and the National Health and Medical Research Council (NHMRC) has commissioned two studies to try to determine if there is a link.

The Sydney-based Woolcock Institute of Medical Research has been awarded $1.94 million to conduct two randomised controlled trials to examine whether inaudible sounds emanating from wind turbines are causing health problems including headaches, dizziness, nausea and sleep disturbances, while a Flinders University researcher has been provided with $1.36 million to compare the relative effects of wind farms and traffic noise on sleep.

The announcement has come less than a year after the NHMRC completed its own exhaustive study, which found that there was “currently no consistent evidence that wind farms cause adverse effects in humans”.

A year earlier, the AMA had come to a similar conclusion. In a Position Statement released in 2014, the AMA found that “available Australian and international evidence does not support the view that the…sound generated by wind farms…causes adverse health effects”.

The-then Chair of the AMA’s Public Health Committee, Professor Geoffrey Dobb, said that although some people living near wind farms may genuinely experience health problems, these were not directly attributable to wind turbines.

Instead, it has been suggested many may be suffering from a ‘nocebo’ effect, and are becoming ill because of anxiety and dislike of wind farms rather than as a result of any sounds emanating from them.

But this has been vociferously rejected by advocates, who insist the health effects are real, and have campaigned hard for more research.

They have influential political backers in Parliament, including senior Nationals MPs and key crossbench senators, and found a receptive audience in former Prime Minister Tony Abbott. Under Mr Abbott’s leadership, the Government appointed a National Wind Farm Commissioner to monitor and investigate complaints about the wind industry, and established an Independent Scientific Committee on Wind Turbines to advise on the potential health and environmental effects of the industry, at a combined cost of more than $2.5 million over four years.

An investigation by Fairfax Media has found that a third of all complaints to the Commissioner have related to wind farms not yet constructed, while the Scientific Committee has held just two brief meetings since it was formed and is yet to provide any advice to Government.

A leading critic of the Government’s policy agenda, including the NHMRC’s research program, Sydney University public health expert Professor Simon Chapman, said internationally there had been at least 25 reviews which found little evidence that wind farms harmed health.

Professor Chapman told the Sydney Morning Herald the health effects that did exist could be put down psycho-social factors like pre-existing antipathy to wind farms and anxiety, and the research was a waste of money.

“It’s really quite disgraceful – it’s money literally poured down the drain,” he told the SMH.

But lead researcher for the Woolcock project, Professor Guy Marks, defended the research, arguing that there existed a “genuine scientific question that needs to be solved”.

“This is a hotly debated area, with many residents convinced that their health is suffering, and other people sure that it’s all a figment of their imagination,” Professor Marks said.

“As far as I am concerned, the science isn’t settled yet [and] it’s important to find out, for the sake of the communities and interests involved,” his co-researcher, Professor Ron Grunstein, said.

But even if the Woolcock and Flinders University studies find that there is no link, few expect it to be the end of the matter.

“Regardless of what we find, there will be passionate advocates that will never be convinced of our conclusion,” Professor Grunstein admitted.

The AMA Position Statement on Wind Farms and Health 2014 can be viewed at: position-statement/wind-farms-and-health-2014

Adrian Rollins

Lead exposure link to violent crime

Australian children who are exposed to higher lead levels are more likely to commit violent crimes later in life, Macquarie University research has found.

The research backs up previous findings that lead exposure increases impulsiveness and crimes of aggression.

Lead author, Professor Mark Taylor, and his team took air samples from six New South Wales suburbs and looked at criminal statistics in the same areas over a period of 30 years.

They found that, after taking into account relevant socio-demographic variables, concentrations of lead in the air accounted for 29.8 per cent of the variance in assault rates 21 years after childhood exposure.

Importantly, the findings were consistent between states – in Victoria, more than 32 per cent of the variance in rates of death by assault 18 years following lead exposure, and in New South Wales the figure was 34 per cent.

In Australia, historically there have been three sources of lead exposure: in paint, petrol, and from mining and smelting emissions.

The researchers found the link between exposure and assault persisted regardless of whether the lead came from smelting or petrol.

Professor Taylor said more specific information was needed to prove that lead exposure caused aggressive behaviour and that, given the findings, lowering lead exposure would be beneficial.

“The results indicate that measures need to be taken to lessen exposure to lead in areas where environmental air levels remains high, so as to avoid any long-term neurodevelopmental consequences,” Professor Taylor said.

The study was published in Environmental Health.

Kirsty Waterford

Primary Health Networks and Aboriginal and Torres Strait Islander health

One of six priorities set by the Australian Government is for Primary Health Networks (PHNs) to focus on the health of Aboriginal and Torres Strait Islander peoples.1 Announced in the 2014–15 federal Budget, PHNs aim to coordinate primary health care provision especially for those at risk of poor health outcomes. There are 31 PHNs across Australia with several formed from consortia of Local Hospital Networks (LHNs). Operational and flexible funding of up to $842 million was committed for PHNs over 3 years from 2015–16.2 It is timely for PHNs to consider how they will improve health care coordination in partnership with Aboriginal and Torres Strait Islander communities in their respective regions.

Efforts to reduce the high hospitalisation rates of Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) people will require PHNs to build formal participatory structures to support best practice service models. Comprehensive primary health care can then be shaped by the needs of the community rather than by ad hoc factors or reactions to financial incentives and health care funding arrangements.3,4 Collaborations with Aboriginal community controlled health services (ACCHSs) within PHN regions have been recommended.5,6

This article outlines how PHNs might support health services to systematically and strategically improve their responsiveness to Aboriginal people within their boundaries according to ten proposals. These best practice models and examples can assist PHNs to adapt their strategic plans to optimally respond to this priority.

1. Collaborate with ACCHSs

ACCHSs are authorities on comprehensive primary health care matters at the local level4,7 and do much more than just cure illness.8 As authentic representational advocates, they can guide PHN responsiveness to Aboriginal health issues and, with more than 150 services across Australia, there are ACCHSs within the regional boundaries of every PHN.

The predecessors of PHNs — the Medicare Locals — were expected to engage with ACCHSs for many Closing the Gap initiatives, such as the Indigenous Chronic Disease Package (ICDP), from 2008.9 Where meaningful partnerships between ACCHSs and Medicare Locals were established in the delivery of these programs, health outcomes for Aboriginal people substantially improved (Box 1).10

2. Establish an Aboriginal and Torres Strait Islander steering committee

PHNs can foster meaningful Aboriginal community engagement by establishing an Aboriginal and Torres Strait Islander steering committee (and Aboriginal representation on the PHN board) with membership led by ACCHSs representatives inclusive of other Aboriginal health service organisations. Similar partnership forums established between the ACCHS, general practice sectors, and state and territory governments have set Aboriginal health priorities at the jurisdictional and regional level for decades.11 The steering committee aims might be modelled on current partnerships between the LHN and ACCHSs (Appendix 1) to develop a strategic plan across the life course.

3. Establish formal agreements to support the strategic plan

PHNs should aim for partnerships to reorient health services from reactionary care to comprehensive primary health care. For example, in remote Western Australia, a partnership agreement between an ACCHS and state government health services was associated with a reversal of the increasing trend in hospital emergency department attendances among other substantial health improvements in only 6 years (Box 2).12

Partnership agreements between PHNs, ACCHSs and other agencies should support Aboriginal leadership, quality care, accountability and patient-centredness, and should be formalised from non-binding memoranda of understanding to binding contracts (Box 1 and Box 2) to support a long term vision for core activity that is flexible to local priorities.

4. Support health services to assess their systems of care

There are now health system assessment tools specifically adapted to optimise the primary health care of Indigenous Australians based on the Chronic Care Model.13 Over 200 Aboriginal primary health care services have used such tools (Appendix 2). Many ACCHSs self-audit their performance using clinical audit tools for chronic disease, maternal and child health and other health priorities, and undertake generic health systems assessment as part of continuous quality improvement (CQI).14

Health system assessment and audits of actual practice against best practice standards should be used to guide PHN (and LHN where there is conjoint responsibility) priorities to systematically enhance quality care within all primary care services in PHN boundaries. Barriers to and enablers for systems improvement, and gaps in health service responsiveness to Aboriginal health needs, will be clearer. These include improving systems for follow-up of patients, use of electronic registers and recalls, Aboriginal community engagement and leadership, the commitment of workforce and management, service infrastructure, and staff training and support.14,15

5. Embed quality assurance activity within primary health care services

A commitment to CQI is a key strategy for disease prevention (Appendix 3) and the prevention of avoidable hospitalisations (Appendix 4), and should be a universal feature of primary health care services providing care to Aboriginal and Torres Strait Islander peoples.15

A national Aboriginal and Torres Strait Islander CQI framework supported by the Australian Government will shortly be released to guide jurisdictions to assess and deliver better quality primary health care.16 PHNs should endorse and adapt this framework to coordinate efforts and develop CQI implementation plans. For example, most state and territory affiliates of the National Aboriginal Community Controlled Health Organisation provide support to ACCHSs for CQI activities; and in some jurisdictions (Queensland and the Northern Territory), CQI support programs are well developed.14

PHNs will need to engage with existing programs to identify strategies for and barriers to CQI. Supporting CQI within the network boundary will require regional facilitators, trained staff, the coordinated use of shared electronic medical records and use of local information management systems by all providers (including locums and visiting services), regular monitoring of CQI indicators, performance reporting, and agreements on data use, ownership and reporting.14

6. Expand primary health care performance reporting

All primary health care services within each PHN delivering care to Aboriginal people (and especially in receipt of financial grants or incentives specific to Indigenous Australians) should be required to undertake CQI, and to participate in regional or centralised performance reporting which can be disaggregated by Aboriginality. Primary health care performance should be a core responsibility of quality, safety and risk subcommittees of both PHNs and LHNs.3 Aggregated CQI data at PHN levels can identify health service gaps and areas that need to be improved.16

The Australian Government reporting framework for PHNs will include national, local and organisational performance indicators.17 National indicators for PHNs will include primary and community health indicators such as potentially preventable hospitalisations (these will be sourced from existing datasets such as the National Hospital Morbidity Database) not unlike what is currently reported for LHNs. Potentially preventable hospitalisations are an indirect measure of whether people are receiving adequate primary health care. The disproportionately high rate of illness affecting Aboriginal people and their poorer access to primary health care explains higher potentially preventable hospitalisation rates independent of age, sex and remoteness (Appendix 4). Age-standardised potentially preventable hospitalisation rates within PHN boundaries should be disaggregated by Aboriginality and incorporated as a performance indicator within PHN strategic plans.

The selection of local and organisational performance indicators by PHNs should be guided by the Aboriginal steering committee. Benchmarking PHN progress using Aboriginal and Torres Strait Islander national key performance indicators18 should be considered. National key performance indicators serve as both a CQI tool and performance measure in the provision of primary health care to Indigenous Australians. For example, ACCHSs are required to report on 19 key performance indicators through a standardised portal supported by the Australian Government.7 Organisational performance reporting of PHN activity should quantify the allocation of funds towards Aboriginal programs and contractors and identify whether these are ACCHSs or other services.

7. Align and endorse PHN and LHN strategic plans

Commitment to region-specific Aboriginal primary health care strategic plans should be the goal for both PHN and LHN boards so that actions are informed by both and integrated to avoid cross purposes.3 These linkages might be streamlined in regions where PHNs have been established by LHNs. However, it is unclear how many LHNs have established Aboriginal health subcommittees or effective and formalised Aboriginal community engagement mechanisms to facilitate endorsement of strategic plans.

All PHNs are expected to complete baseline needs assessment and strategies to respond to service gaps.19 If these submissions pertain to the Aboriginal and Torres Strait Islander population, they should be accompanied by evidence of endorsement by the Aboriginal representative bodies in their region.

8. Strengthen the primary health care service model

Many visiting health providers can overburden Aboriginal people in remote communities with overlapping and poorly explained services.20 A core priority for PHNs is to review the coordination of care and improve clinical pathways in all geographic regions. PHNs will need to review the efficiency of current services including generalist and specialist outreach if they are to avoid duplication, foster local or residential health services,21 and sustain local CQI systems.

Specialist outreach should complement local health services through a bottom-up approach integrated with primary health care. Specialist outreach services operating independently of existing primary health care services will need review. Service reforms might mean building hub-and-spoke models involving ACCHSs, supporting regional Aboriginal health networks (Box 1), using telehealth adapted for Aboriginal and Torres Strait Islander settings, renegotiating clinical pathways, empowering local outreach coordinators of hospitals to support primary health care models, substituting workforce tasks through nurse and Aboriginal and Torres Strait Islander health practitioners, rural generalists and physician assistants,22 and reorienting health services towards primary health care (Box 2, Appendix 5).

9. Enhance cultural competence of primary health care services

Strategies to merely increase the awareness of non-Indigenous health staff to Aboriginal cultural protocols are often recommended to reduce Aboriginal health disparities, but may not lead to cultural competence.23 Some staff still struggle with how to make services culturally responsive beyond the posting of Aboriginal artwork.20 The ICDP invested in cultural awareness training of over 6000 general practice staff but change in practice was not universally embraced.8,15

Enhancing the cultural competence of health services within PHN boundaries will require strategies best managed by the Aboriginal steering committee and may include subcontracting ACCHSs and expanding their outreach role, person-centred and family-oriented care, fostering a culturally identified workforce that reflects the patient population and health needs, staff training in cultural safety, performance measures for cultural competence, and future planning.

10. Transition primary health care services to Aboriginal community control

PHNs are to be the health “providers of last resort and their decision to directly provide services should require the approval of the Department of Health”.3 Agreement from local ACCHSs in the region should be required if a PHN opts to directly provide health services to Aboriginal communities rather than make purchasing arrangements with existing Aboriginal services (Box 1). ACCHSs should also be supported to choose their involvement in programs within the PHN boundary.

Coalitions of Aboriginal organisations have advised that future funding on Indigenous health programs be prioritised to ACCHSs being better placed to meet Aboriginal health needs with better returns on investment.24 For example, according to the ICDP evaluation, it was unclear whether Closing the Gap measures (such as financial incentives to general practices) increased the provision of services to Aboriginal people who are “hard to reach” or increased their access to primary health care.9,15 For PHNs, it makes sense to direct Aboriginal health strategies to health services with the desire and potential to provide quality care to Aboriginal patients, which is also more cost-effective.15

The Queensland and Northern Territory governments have commenced processes to transition certain health services in remote areas to Aboriginal community control.25,26 The aim is to reform remote area services from doctor-focused, illness-centred, acute hospital-based primary care services to community-engaged, comprehensive, preventive and responsive systems. Policy frameworks propose staged approaches and capacity building of existing ACCHSs. Strategic plans developed by PHNs should consider transitioning health services and responding to existing transition plans26 to ensure alignment with them.

Conclusion

These proposals offer policy makers and PHNs a framework for health service planning within newly established boundaries, and may inform PHN organisational performance reporting on efforts to close the gap in Aboriginal health disparity.

Australians report that our health system is not sufficiently patient focused. Primary care is reactive and episodic, funding structures support providers and not patients, and there is little accountability for health outcomes.4 Through existing and better targeted additional investments, PHNs can offer Aboriginal and Torres Strait Islander people some hope towards reforming access to and quality of primary health care in their localities, but only if programs and systems can better fit in with community needs. To close the gap, PHNs need to support Aboriginal communities towards greater participation in primary health care, ultimately through the expression of community control.

Box 1 –
Example: collaboration between Medicare Locals and Aboriginal community controlled health services

In 2008, to close the gap in Aboriginal health disparity, the Indigenous Chronic Disease Package funded the Care Coordination and Supplementary Services (CCSS) program. The program supports Aboriginal and Torres Strait Islander patients with complex care needs, by coordinating clinical care and providing supplementary funding for allied health, specialists, transport services and medical aids. Implementation required collaborations between Aboriginal and mainstream health services. In South-East Queensland, the Metro North Brisbane Medicare Local (MNBML) was funded to deliver the CCSS program on behalf of four other Medicare Locals in South-East Queensland. A consortium of ACCHSs — the Institute for Urban Indigenous Health (IUIH) — was subcontracted by the MNBML to implement the program in 2013–14. IUIH employed a manager to oversee the program delivered by 20.5 full-time equivalent care coordinators.

The IUIH reported that subcontracting delivered significantly more services to significantly more Indigenous Australians with complex chronic conditions than any other part of the country: “In 2013–14 IUIH and members [ACCHSs] delivered over 57 000 episodes of care via the CCSS Program. The delivery of intensive case management and access to a comprehensive range of specialist and allied health services and medical aides for this population has avoided costly hospital admissions for Government and significantly improved the health and wellbeing of some of our most vulnerable and unwell patients.”10

Box 2 –
Example: a partnership to reorient acute care to comprehensive primary health care

Clinic services in the very remote Fitzroy Valley in Western Australia are delivered by state government health services (Fitzroy Crossing Hospital and the Kimberley Population Health Unit for community health services). Non-clinical health services are delivered by the Aboriginal community controlled health service (Nindilingarri Cultural Health Services) to a population of 3500 (80% Aboriginal). These services comprise healthy lifestyle programs designed around Aboriginal culture. A formal agreement between the agencies was negotiated in 2006 to form a single governance structure to allocate funding, share an e-health record, and coordinate health promotion, cultural safety, acute inpatient care, primary care and specialist care, and population-based screening. Commonwealth funding supported the development of a shared e-health record for quality improvement and additional staff (through the Healthy for Life and Indigenous Chronic Disease programs), and provided Medicare rebates to patients for primary care services delivered at the hospital clinic (an exemption from section 19(2) of the National Health Insurance Act 1973). Medicare billings were reinvested to support this reorientation under the guidance of the partners.

This reorientation enhanced health promotion programs and was associated with a reversal of the increasing trend in emergency department attendances. In the primary care clinic, there was a substantial increase in the number of patients seen, the number of health checks, the detection of risk factors, the proportion of patients with diabetes having care plans, transport provision, cultural security and follow-up attendances in only 6 years.12

Australia’s health: being accountable for prevention

Stronger policy and a comprehensive approach to prevention is a good investment

The global action plan of the World Health Organization (WHO) for preventing and controlling non-communicable diseases1 aims to substantially reduce the burden of premature mortality caused by cancer, diabetes, cardiovascular disease and chronic lung disease by 2025, through action on nine targets measured by 25 indicators of performance.1 As a member state of the WHO, Australia is committed to the global action plan. However, we argue that the Australian government devotes insufficient attention to health policy, funding and program implementation for effective prevention. In this article, we review Australia’s progress against national non-communicable disease (NCD) targets set in 2009, and suggest that a more comprehensive approach is required.

NCDs are responsible for nine out of ten deaths in Australia, and often reduce people’s quality of life and ability to function. Tackling the growing personal, social and national economic impact of NCDs (also referred to as chronic diseases) is imperative, particularly in a country with an ageing population. Some population groups, such as Indigenous Australians and socio-economically disadvantaged people, are affected more than others.

Many NCDs share common, preventable risk factors such as smoking, harmful alcohol use, poor nutrition and physical inactivity. They contribute to biomedical risk factors such as obesity, hypertension and high cholesterol levels. Modifiable risk factors account for a substantial proportion of the burden of disease in Australia, with, for example, high body mass and physical inactivity explaining 60% of the health loss associated with type 2 diabetes.2 Seventy per cent of mortality from cardiovascular disease in Australia has been attributed to high blood pressure, high cholesterol levels and physical inactivity.3

Preventive health efforts

Effective prevention can improve health and reduce pressure on clinical services. Australia has had some outstanding successes in areas such as smoking, road trauma and heart disease. However, we lack a sustained, comprehensive and strategic approach to prevention, together with adequate funding, coordination and monitoring. In the 2013–14 financial year, spending on public health (which includes prevention activities) was only 1.53% of total recurrent health spending, and this proportion is declining.4 This places Australia out of step with similar countries. The Organisation for Economic Co-operation and Development reported in 2011 that Australia’s spending on prevention and public health as a share of total recurrent health spending was 2.0%, much less than in New Zealand (6.4%), Finland (6.1%) and Canada (5.9%).5

Health goals and targets can provide important foci for action. The National Preventative Health Taskforce was established in 2008 to develop a National Preventative Health Strategy (NPHS). The NPHS focused on obesity, tobacco and alcohol, and set a number of targets for prevention. Also in 2009, the Council of Australian Governments (COAG) National Partnership Agreement on Preventive Health (NPAPH) set a number of complementary targets.

In addition to targets, the NPHS outlined actions, including 32 alcohol-specific actions and 27 obesity-specific actions. A review of progress against the alcohol-specific actions in 2013 by the Foundation for Alcohol Research and Education found that four actions had been completed, 18 were progressing, and no progress had been made against ten actions.6 With respect to the obesity actions, a similar recent analysis by the Obesity Policy Coalition found that of these three had been completed, 17 were progressing and no progress had been made against seven (Jane Martin, Obesity Policy Coalition, personal communication).

The recommendations of the NPHS included establishing the Australian National Preventive Health Agency, which was set up in 2011, but abolished in June 2014. The NPAPH was also abolished in 2014, which resulted in the removal of $374 million of funding to the states. In the context of substantial policy change, and disinvestment in prevention, it is timely to review the progress made against the NPHS and NPAPH goals. This review is shown in the Box.

What needs to change?

With the exception of tobacco control, the data suggest there is little or no progress being made in preventing and controlling risk factors for chronic diseases in Australia.

Failure to make progress in relation to poor nutrition, physical inactivity and harmful alcohol use is linked to a failure of implementation. Expert advice about these risk factors has been sought and obtained by many governments, but implementation of expert recommendations has often been lacking.

Despite government concern about the sustainability of the health system, Australia is not currently investing significantly in disease prevention. Assessment of progress against national goals and targets from 2009 suggests that Australia is failing to take adequate steps to reduce these modifiable risk factors, although some progress is being made with Indigenous child health.

Our country is a global leader in tobacco control, and this has generated considerable benefits for the population, health system, and economy. A comprehensive approach, including taxation to make tobacco products more expensive, media campaigns, regulation of tobacco products and targeted interventions for vulnerable groups has contributed to the reduction in smoking. Sustained bi-partisan commitment has been important to our success in tobacco control.

The reduction in the prevalence of smoking in Australia has occurred in the face of considerable opposition from tobacco companies. Progressive undermining of evidence-based policy by unhealthy commodity industries,13 and weakening of public health approaches to chronic disease prevention is common in Australia and other countries.14

Comprehensive and courageous approaches to other risk factors, such as poor nutrition, physical inactivity and alcohol would significantly benefit the health of Australians. Evidence-based interventions, including taxation, media campaigns, regulation of unhealthy products and targeted interventions could reduce the chronic disease burden in this country,15 and hence the pressure on our health system. Often, these are also the most cost-effective interventions, and a number are cost-saving. Improving diet and nutrition presents a different set of challenges than do single-risk-factor problems such as smoking or excessive salt intake. However, it is important that diet and nutrition are tackled, given that most Australian adults are overweight or obese, and (unlike England and the United States) rates have continued to rise in Australia.16 All interventions, and their impact on NCDs and risk factors, should be rigorously evaluated.

Continuity and progressive change towards improved health are important. Taking on the problems of tobacco and the road toll has involved many governments implementing a range of actions over decades. Many of the states and territories are active in the area of preventive health, and the federal government is currently developing a National Strategic Framework for Chronic Conditions. The COAG Community Care and Population Health Principal Committee may provide a forum where a preventive health agenda can again be taken forward.

Conclusion

Australia invests less in prevention than do other comparable countries, and our investment is declining. The burden of NCDs is high; more than seven million Australians are living with a chronic condition, and we are failing to meet most of the national targets set by COAG and the NPHS in 2009.

NCDs have a high personal, social and national economic impact. If we seek to achieve significant reductions in the burden of chronic disease in Australia, sustained, comprehensive and courageous approaches are required.

Box –
Preventive health targets and progress in Australia since 2009

Target and source

Target year

Progress against target

Results

Halt and reverse the rise in overweight and obesity (NPHT)

2020

Not on track

71% of Australian men and 56% of women are overweight.7 One in four adults are obese, and 27% of children are overweight or obese. Australia is not on track to meet either COAG or NPHT targets for overweight and obesity7

Increase the proportion of children and adults meeting national guidelines for healthy body weight by 3% within 10 years (COAG)

2019

Not on track

Increase the proportion of children and adults meeting national guidelines for healthy eating and physical activity by 15% within 6 years (COAG)

2015

Healthy eating not on track; physical activity on track

In 2014–15, only 5.1% of adults and children ate enough fruit and vegetables7 — the COAG target for adults is 21.2%55% of adults met the physical activity recommendations in 2014–15.7 The COAG physical activity target for adults for 2015 is on track

Reduce the prevalence of daily smoking among adult Australians aged 18 + years from 17.4% in 2007 to 10% or lower (NPHT)

2020

On track

Progress with regard to smoking has been very encouraging. Between 1993 and 2013, the proportion of daily smokers aged 18 years or older halved from 26.1% to 13.3%8

Reduce the proportion of Australians who drink at short-term risky or high-risk levels to 14%, and the proportion of Australians who drink at long-term risky or high-risk levels to 7% (NPHT)

2020

Unlikely to be met

19.1% of Australians drank at long-term risky levels in 2013.9 A recent study showed increases in medium- and high-risk drinking among adults from 2001 to 2011–12,10 consistent with very high levels of alcohol-related hospital emergency department presentations.11 Of concern are high levels of risky drinking among people aged 15–18 years and increasing risky drinking levels among young women

Close the gap in life expectancy within a generation (COAG)

2031

Not on track

Limited progress. The current rate of progress will have to gather considerable pace if the target is to be met12

Halve the gap in mortality rates for Indigenous children under five within a decade (COAG)

2018

On track

Long-term progress. Between 1998 and 2013, the Indigenous child death rate declined by 31%, and in the same period, there has been a 35% narrowing of the gap in child death rates between Indigenous and non-Indigenous children12

COAG = Council of Australian Governments. NPHT = National Preventative Health Taskforce.

Time to raise the minimum purchasing age for tobacco in Australia

Increasing the minimum purchasing age may be the most straightforward way towards a tobacco-free generation

Australia is often described as a global leader in tobacco control. While this is true, it has taken two generations to reduce current smoking rates to around 15% of the population, and there is still a long way to go, especially in disadvantaged communities.

Tasmania’s tobacco-free generation

One innovative idea on the road towards minimising smoking rates is currently before the Parliament of Tasmania. Put simply, passage of the Public Health Amendment (Tobacco-free Generation) Bill 20141 would ensure that people born after 1999 could not lawfully purchase tobacco at retail outlets within Tasmania in their lifetimes.2

The Tobacco-free Generation Bill was introduced into the Legislative Council by independent member Ivan Dean, whose father was a chain smoker and who suffered terribly before dying from lung cancer.2 The Bill is currently being considered by a Parliamentary Committee, and public submissions can be viewed online.3

The Tobacco-free Generation Bill defines a member of the tobacco-free generation as “a person born on or after 1 January 2000”.1 Although the Bill does not prohibit smoking by a member of the tobacco-free generation, it does create a new offence for retailing tobacco within Tasmania to such a person, with a first-time penalty of up to $7700.1 By contrast, there would be no offence for retailing tobacco to adults born before 2000. As time passes, the legislation would create two distinct classes: adults who, by virtue of being born before the year 2000, would be entitled to continue to purchase tobacco during their lives; and adults of the tobacco-free generation, born after 31 December 1999, who would be forever unable to purchase tobacco lawfully in Tasmania.

The Bill would create an offence for a member of the tobacco-free generation to use a false proof of age to purchase tobacco, with a fine of up to $540. However, it would not penalise friends or family members from purchasing tobacco that was subsequently consumed by a member of the tobacco-free generation, provided that the tobacco was given, rather than sold, to that person.1,2

In its submission to the Committee, the Tasmanian Government raised concerns that the Bill would encourage interstate and internet purchases of tobacco by smokers who were members of the tobacco-free generation, thereby undermining the goals of the Bill. It pointed to the Tasmanian Population Health Survey as evidence that current policies were reducing smoking rates effectively.4

Predictably, the Bill has been opposed by tobacco manufacturers. One submission by a retailer on Flinders Island suggests that Imperial Tobacco systematically urged retailers to lobby the Legislative Council against the Bill.5

Seizing the opportunity for leadership in tobacco control in Tasmania

Tobacco is more than just the “risky product” that tobacco companies claim it to be. If today’s smokers do not quit, a majority will die prematurely from tobacco-related diseases. A study by Banks and colleagues published in 2015 suggests that about two-thirds of deaths among current smokers are caused by smoking.6 The authors followed more than 200 000 smokers aged over 45 years, for 4 years, showing that even ten cigarettes daily doubles a person’s risk of dying prematurely. As Tasmania’s popular former Premier, Jim Bacon, said in 2004, when he quit politics following a diagnosis of lung cancer: “The message from me to everyone is please don’t be a fool like me, don’t keep smoking, try and give it up and if you are young and you haven’t started, don’t start”.7

The idea of legislating for a tobacco-free generation is one of a growing number of tobacco endgame scenarios promoted by tobacco control advocates.8 While it is plausible that the Bill could discourage smoking initiation by members of the tobacco-free generation, it is possible that the Bill might also inadvertently create a permanent “outlaw class” of adults addicted to tobacco but unable to purchase it lawfully within Tasmania. Achieving acceptance about why two adults of different ages should be treated differently in terms of their right to access tobacco is one of the challenges the Bill faces.

If the Tobacco-free Generation Bill does not succeed, the opportunity remains for Tasmania to show national leadership by raising the minimum purchase age for tobacco to at least 21 years. A higher minimum purchase age would make it more difficult for youth to access tobacco at the ages when they are most vulnerable to smoking initiation.

The case for raising the minimum purchasing age for tobacco

The case for a higher minimum purchasing age is supported by four key factors. According to the National Drug Strategy Household Survey (NDSHS), in 2013 Tasmania’s daily smoking rate for people aged 14 years and above was 16.1%. This is second only to the Northern Territory (21.3%) and well above the national average of 12.8%.9 The same survey found that 31.6% of Tasmanians aged 18–24 years were daily smokers — more than twice the Australian average of 13.4% for this age category.9 In its submission to the Parliamentary Committee, the Tasmanian Government quoted the Tasmanian Population Health Survey 2013, which estimated a 19.7% smoking rate for 18–24-year-olds, and a 15% smoking rate overall.4 The Tasmanian Department of Health and Human Services has acknowledged that due to its methodology, the Tasmanian survey significantly under-represented males and younger age groups.10 NDSHS estimates suggest that smoking rates remain alarmingly high in young adults and that innovative strategies are needed to ensure that Tasmania does not fall further behind the mainland states.

Second, a higher minimum purchasing age for tobacco could help to reduce high smoking rates among young pregnant women. In 2013, the average rate of smoking while pregnant was 12% nationally,11 but was 15% in Tasmania and in excess of 33% among pregnant Tasmanian women aged under 20 years.12

Third, a higher minimum purchasing age for tobacco could go a long way towards encouraging the creation of a tobacco-free generation, since few people begin smoking for the first time after their mid-20s. A 2013 study of smoking initiation rates in New Zealand confirmed that while initiation after age 24 is rare, the highest initiation rates occur among those aged 15–21 years. Over a 4-year period, the rate of smoking initiation for those aged 15–17, 18 and 19, and 20–24 years was 14.2%, 7.0% and 3.1%, respectively.13

Finally, in the United States, at least 30 cities and counties, including New York City, have set 21 years as the minimum purchasing age for tobacco products.14 Four states have raised the minimum purchase age to 19 years,14 and in June 2015, Hawaii raised it to 21 years for both tobacco products and e-cigarettes.15 If linked to a proof-of-age swipe card or so-called smoker’s licence, the right to purchase tobacco could be verified instantaneously.16

In its recent report, an expert committee of the US Institute of Medicine concluded that raising the minimum purchasing age for tobacco would delay initiation by adolescents, with the largest proportion of reductions being among teenagers aged 15–17 years.14 Based on modelling, the Committee concluded that while raising the minimum purchase age to 19 years would likely yield only a modest reduction in smoking initiation by 18-year-olds, raising it to 21 years would substantially reduce smoking prevalence and smoking-related mortality, given the numerous life transitions that young adults experience between 18 and 20 years. The Committee concluded that increasing the minimum purchasing age would also improve fetal, maternal and infant health outcomes by reducing the likelihood of maternal or paternal smoking.14

A survey of Australian secondary school students’ use of tobacco found that in 2014, nearly 18% of 16–17-year-old smokers purchased their last cigarette from a commercial source.17 This finding underscores the need for rigorous enforcement of existing laws to further reduce the retail availability of tobacco to underage youth. However, the fact that current underage smokers mostly obtain their tobacco from non-commercial sources does not demonstrate that current age restrictions have no impact on youth smoking rates, nor that a higher minimum age would be similarly ineffective. Rigorously enforced age restrictions reduce tobacco purchase attempts and youth smoking rates,14,18,19 although their impact is likely to be strengthened when integrated within a comprehensive set of tobacco control policies that maintain high retail prices and de-normalise tobacco use.14,20 These features would likely boost the impact of youth access laws by reducing or interrupting sources of social supply, inhibiting initiation and leading to decreased tobacco use rather than mere substitution of purchased tobacco with tobacco from social sources.20

Summary

The time has come for Australian state governments to seriously consider raising the minimum purchasing age for tobacco. If the Tasmanian Parliament fails to support the Tobacco-free Generation Bill, as seems likely, a higher minimum purchasing age could reinforce efforts to reduce smoking initiation and help to address the significant health inequalities that Tasmanians experience relative to the mainland states. Simple amendments to the provisions in the Public Health Act 1997 (Tas) that govern underage smoking could raise the minimum purchasing age and encourage the creation of a tobacco-free generation. In late December 2015, the Tasmanian Government released a 5-year strategic plan for health that includes raising the minimum legal smoking age to 21 or 25 as an option for consideration.21 This is welcome news. Rigorous monitoring and enforcement of legislative amendments to raise the minimum purchase age for tobacco would strengthen social norms against youth smoking, and generate data that could inform tobacco control policies in other states.

Closing the million patient gap of uncontrolled asthma

Australia’s burden of asthma requires structural reform in health care delivery

Asthma control is the principal aim of asthma management. Uncontrolled asthma impairs quality of life, increases exacerbation frequency, heightens risk of death, and is four times more costly to treat than controlled asthma. Therefore, results from a web-based Australian asthma survey are disappointing and disquieting.1

One-quarter of respondents did not regularly use asthma preventers, despite having uncontrolled asthma. Another 20% of respondents had uncontrolled symptoms even while regularly using preventers. If these figures are truly representative of the nation’s 2.3 million people with asthma, they suggest that about one million Australians have uncontrolled asthma. This is despite the fact that asthma guidelines have been available for 26 years.2,3 Fundamental reforms to providing asthma care are therefore needed. A new National Asthma Strategy is on its way, and may provide a platform for structural changes.4

The first therapeutic gap highlighted by the web-based survey was the lack of regular preventer use by many patients, despite having uncontrolled symptoms.1 These patients seemed to favour immediate symptom relief over long term disease control.1 Ironically, the present dispensing system reinforces such behaviour. Relievers are readily available over the counter, but preventers require prescriptions, necessitating additional effort, time and expense.

The logical solution to this problem is to re-design access to asthma medications. Preventers must be made more accessible. It is encouraging that the possibility of dispensing low-dose inhaled corticosteroids without prescription is now under discussion.4

A less palatable but arguably more important measure would be to detect and attempt to reduce the high volume dispensing of relievers without adequate concomitant preventers, because this pattern of medication use is implicated in asthma deaths.5 Such a move would require electronic coordination across pharmacies, with the ability to trigger referral for asthma review.6

These proposals would increase the rate of preventer dispensing, but they cannot guarantee adherence. One reliable way to improve preventer use would be to launch and promote a combined short-acting reliever and steroid preventer in a single device. This would ensure that every dose of reliever was accompanied by a corresponding dose of preventer. There is now evidence that as-needed use of an inhaled corticosteroid combined with a short-acting β-agonist improves symptoms in mild persistent asthma.7 There is less support for this approach in moderate to severe asthma, but an inhaled corticosteroid combined with a long-acting β-agonist may be used instead in such patients, for prevention and relief.8

The second therapeutic gap identified by the survey relates to patients who claim to take regular preventers, but whose asthma remains uncontrolled. The drivers for this situation are complex. Important contributing factors to this problem probably include limited understanding of the disease, incorrect inhaler technique, ongoing smoking and insufficient attention to other asthma triggers, such as aero-allergens, occupational exposures and non-specific irritants.3 These problems are challenging to solve within general practice consultations, and rebates may need to be adjusted so they are based on realistic consultation times. An alternative approach also under consideration is to fund asthma educators and organise the appropriate credentials for them.4 Finally, more patients could be encouraged to schedule regular reviews; for example, by discounting medication costs for those who do.

Even with optimal asthma management in primary care, a small proportion of patients will continue to have uncontrolled asthma, some of whom may be insensitive to corticosteroid-based therapies.3,9 These patients need to be reviewed by respiratory specialists, and automated prompts to activate referrals should be built into asthma review programs.

For the most challenging patients, evaluation at a dedicated “difficult asthma” centre provides additional benefits for outpatient respiratory consultations.10 Many of these patients will have truly severe asthma, but there are also high rates of misdiagnosis, comorbidities and psychosocial factors. According to results from a recent uncontrolled study, dealing with these issues through comprehensive multidisciplinary assessment can improve quality of life and use of health care services, and can also define the patient subgroups most likely to respond to the expensive biological agents now entering clinical practice.11

In the United Kingdom, there are at least 11 specialised centres for treating difficult asthma that operate along similar lines.11 In Australia, this concept is less well developed, and services with interest in difficult asthma vary widely in the scope of their protocols and the extent of multidisciplinary support. Agreement is needed on which patients warrant extensive assessment, and how such patients should be evaluated. Resources could then be channelled to match demand.

We suggest radical steps to curb excessive reliance on relievers, enhance preventer adherence, encourage asthma review, and provide specialised evaluation for the most complex patients. The ultimate challenge is to fully integrate all these measures for maximal impact. Technological solutions are necessary for unhindered data sharing and seamless clinical transition across all levels of asthma care.6

Asthma management in Australia has come a long way, but innovative strategies are needed to bridge the remaining gaps.

New recommendations for Hepatitis C treatment

New recommendations have been released for the management of hepatitis C virus (HCV) infection in a consensus statement.

The statement was drawn up by Gastroenterological Society of Australia, the Australasian Society of Infectious Diseases, the Australasian Hepatology Association, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Hepatitis Australia and the Royal Australian College of General Practitioners.

A summary, published in the Medical Journal of Australia, says that the recommendations for Hepatitis C treatment were drawn up in the wake of the new direct-acting antiviral therapies that were added to the Pharmaceutical Benefits Scheme earlier this month.

“The introduction of DAA therapies for HCV that are highly effective and well tolerated is a major medical advance,” said Professor Alexander Thompson, director of gastroenterology at St Vincent’s Hospital in Melbourne.

“All Australians living with HCV should now be considered for antiviral therapy.”

Recommendations in the consensus statement include:

All individuals with a risk factor for HCV infection should be tested.
Annual HCV serological testing is recommended for seronegative individuals with risk factors for HCV transmission.
People with confirmed HCV infection should be tested for HCV genotype (Gt).
All concomitant medications should be reviewed before starting treatment, using the University of Liverpool’s Hepatitis Drug Interactions website.
The use of any DAA regimen during pregnancy is not recommended.
People who are not cured by a first-line interferon-free treatment regimen should be referred to a specialist centre.
All people with decompensated liver disease, extra-hepatic manifestations of HCV, HCV–HIV or HCV–HBV co-infection, renal impairment or acute HCV infection, as well as people who have had a liver transplant should be referred for management by a specialist who is experienced in the relevant areas.
All people living with HCV infection should have a liver fibrosis assessment before treatment to evaluate for the presence of cirrhosis.
People with no cirrhosis can be treated by general practitioners working in consultation with specialists.

Read the full recommendations on the Gastroenterological Society of Australia’s website.

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Alcohol and tax — time for real reform

Alcohol tax reform would reduce harm and costs — and could fund major prevention and treatment programs

Australia’s first comprehensive report on drugs was entitled Drug problems in Australia — an intoxicated society? This 1977 report from the Senate Standing Committee on Social Welfare noted that alcohol “now constitutes a problem of epidemic proportions”. The Committee concluded that, given the extent of the problem, “any failure by governments or individuals to acknowledge that a major problem — and potential national disaster — is upon us would constitute gross irresponsibility”.1

Many of the report’s recommendations are as valid now as they were four decades ago, particularly in relation to alcohol advertising (including the “appeal to sportsmen and sportswomen throughout Australia not to lend their names and prestige to the promotion of alcoholic beverages”), effective controls on availability of alcohol, and use of pricing mechanisms to reduce alcohol use and harm.

It has become increasingly clear that in dealing with harm from alcohol, price matters. There is now an overwhelming consensus from leading Australian and international health authorities and researchers that alcohol taxation is one of the most effective policy interventions to reduce problems related to alcohol.2 The World Health Organization has identified alcohol tax increases as a “best buy” intervention in reducing harmful alcohol use.3 Even small increases in the price of alcohol can have a significant impact on consumption and harm at the population level. However, alcohol taxation and other pricing strategies have been underused in Australia as a component of the comprehensive approach required to reduce harm from alcohol.

At a time when tax reform is high on the political agenda, there is near-universal agreement that the current approach to alcohol taxation in Australia is complex and that change is long overdue. The Henry Tax Review described the alcohol tax system as “incoherent” and the Wine Equalisation Tax (WET) in particular as “not well suited to reducing social harm”.4 Others have described the system less flatteringly. Some 16 different excise categories apply, depending on the type and volume of alcohol and container size. Taxes on spirit products are at the upper end of the scale; draught beer taxes are at the lower end. Wine is treated differently; the WET is based on the wholesale price of wine, not its alcohol content. The WET is why cask wine can be promoted and sold for as little as 18 cents per standard drink, or $1.80 per litre — cheaper than many bottled waters — contributing only 5 cents per standard drink in tax. The system is further complicated by producer rebates and concessions, some of which are no longer appropriate, such as the WET rebate. The WET is effectively a subsidy, propping up the production of low-value wines.

Health groups are in broad agreement about the key principles that should guide tax reform if the alcohol tax system is to play a more effective role in reducing harm and promoting a lower-risk drinking culture. Approaches to alcohol tax and price should reflect that alcohol is no ordinary commodity and is associated with substantial health and social costs. A volumetric approach that applies to all alcohol products should be central to reform, with tax increasing for products with higher alcohol volumes.5 A tiered system that includes stepped increases in tax rates would provide economic incentives for the production and consumption of lower-strength alcohol products and help ensure that the prices of some other products do not drop substantially.6

A minimum floor price set at an appropriate level would support and complement a volumetric approach, in particular by targeting the heaviest drinkers who consume the most. A minimum price would restrict the ability of alcohol retailers to heavily discount products, thus undermining the tax strategy, and has been strongly supported by groups concerned about alcohol-related problems in Aboriginal communities.7

Other important principles include: there should be an overall increase in alcohol tax collected; the real price of alcohol should increase over time; and changes to the tax system should not decrease the price of alcohol products, other than for low-alcohol products.

In contrast to the consensus among health groups, the alcohol industry is deeply divided on the best approach to alcohol taxation. Arising from the existing variation in excise levels between product categories, the commercial interests of the wine, beer and spirits industries do not necessarily align in relation to tax reform. There is even division within specific industry groups; for example, between premium wine producers and high-volume, low-value wine producers. In its submission responding to the government’s March 2015 Tax discussion paper, the Winemakers’ Federation of Australia (WFA) noted that “Consultation with industry has confirmed mixed views on the optimal tax platform for the Australian wine sector … As such, WFA does not hold a position on the preferred structure for wine tax”.8 WFA did, however, affirm that the industry agreed on its opposition to both increasing the level of wine tax revenue and reforms driven by social policy objectives. The divisions between and within industry groups are expected to add to the challenges for government in navigating the range of interests and objectives associated with alcohol tax reform.

Alcohol consumption patterns in Australia are very different now to those in earlier decades, when beer was king, Australian-owned companies dominated and hotels were the drinking venues of choice. Now, beer is in decline (in 2013–14, beer contributed 41.3% of the total alcohol available for consumption, wine 37.5%, spirits 12.6% and ready-to-drink pre-mixed beverages 6.3%),9 most of the major alcohol companies are overseas-owned, and some 80% of alcohol is sold from retail outlets, primarily chain stores.

There are some encouraging trends, particularly among adolescents10 — but alcohol remains pre-eminent as a cause of preventable social and community harm. While the tragedies arising from city-centre violence and road crashes attract regular media coverage, there is also increasing community understanding of alcohol’s many hidden and longer-term harms: from domestic violence to cancers, from fetal alcohol spectrum disorder to damage to the developing brains of young drinkers.

As ever in public health, there are no simple, short-term solutions. As is so often the case when profitable products are involved, there is strong, well funded and often misleading resistance to effective action. There is, however, good evidence to support implementation of a comprehensive approach — with carefully implemented tax reform at the forefront.6

One additional reform to the alcohol tax system could bring profound benefits to the community. Around the country, alcohol treatment and support services are stretched, funding for prevention is barely visible, and the latest Australian Institute of Health and Welfare expenditure report shows that in the 2013–14 financial year, all public health attracted $2.22 billion — an almost derisory 1.5% of total health funding.11

The federal government derives over $8 billion annually from the taxes and excise duties levied on alcohol.5 In addition to health and social harm, the annual costs of alcohol to the economy are estimated at upwards of $15 billion.12 Further, the government’s annual revenue includes more than $200 million from underage drinkers and almost $2 billion from drinkers under the age of 25 years.13

Historically, Treasuries are not keen on hypothecated taxes, but there are good precedents,14 notably for tobacco where, in the days of state tobacco licence fees, tax increases were successfully used to fund public education and to replace tobacco sponsorship of sport, as well as to provide governments with additional revenue for their general programs.

Many reports in recent decades have recommended additional funding for alcohol prevention and services, both for the community overall and for specific priority groups. A 2015 report commissioned by the Foundation for Alcohol Research and Education concluded that: “By removing the privileged treatment of wine, the government could receive increased revenues in the order of $1 billion each year”.15 Even half of this would enable the establishment of a dedicated National Alcohol Prevention, Treatment and Services Program that could make Australia a world leader in reducing alcohol harm, to match its record in tobacco control.

Such a program would enable the government to provide desperately needed funding for national and local services, to work with and support Aboriginal and other communities in their efforts, and to develop a comprehensive approach to prevention. The funding would enable establishment of a major research-based national public education program, along the lines of the successful 1990s National Tobacco Campaign, as well as better support for enforcing current legislation (including sales to minors), independent controls on alcohol marketing, development of research-based warning label messages, and a range of further national and local activities.

The arguments in favour of alcohol tax reform linked to increased funding for prevention and services are that this will reduce direct and indirect harm, will reduce costs to the health and law enforcement systems and to the community, and will bring special benefits for young people and disadvantaged communities.

The arguments against reform will come from the powerful and massively funded alcohol industry and its allies, which will support the continuation of ineffective policies and oppose anything that might have a serious impact on alcohol use — and hence on alcohol harm.

At a time when there is continuing community and political concern about the impacts of alcohol, broad election policies are being developed and tax reform is under discussion with assurances that “all options are on the table”,16 there is an opportunity for health groups to press for comprehensive policies that include a clear commitment to alcohol tax reform. This will require strong and consistent communication of the substantial evidence base for reforming alcohol tax to improve health, as well as appropriate responses to misinformation likely to come from vested interests.

Failure by governments to act will now, as 40 years ago, “constitute gross irresponsibility”.

[Editorial] Creating a healthier environment for the Chinese population

On March 16, the Chinese Government officially approved its 13th Five-Year Plan—the country’s economic and social development blueprint for 2016–20. Notably, environmental protection—for the first time—has been highlighted as a key priority, along with a more moderate annual economic growth at just above 6·5%. As binding targets, water consumption, energy consumption, and carbon dioxide emissions will be cut by 23%, 15%, and 18%, respectively by 2020. In terms of air pollution, the plan particularly requires a minimum of 80% of days “with good air quality” assessed by fine particulate matter (PM2·5) by 2020.

Rural health – the continuing challenge

Rural health is frequently inferior to city health. This old generalisation covers much contradictory detail, and exceptions abound: according to the Australian Institute of Health and Welfare, the life expectancy of non-Indigenous women in 2002-04 was much the same – 84 – whether they lived in big cities or very remote areas. For men, the difference is a matter of six months or so. And it is not a rigid generalisation: increasingly sophisticated broadband-enabled communications and ever-more efficient transport have reduced the gap between city and country.

Nevertheless, the numbers and the facts suggest that the accumulation of wealth, talent and many other features of contemporary city life confer a small advantage in life expectancy and wellbeing on city-dwellers. This disparity challenges those who hold the value that one of our social duties is to ensure, as far as possible, equality of opportunity to health and health care to all Australians. What should we do?

Two pathways to action present themselves for our consideration.

The first, and the one most easily grasped by the medical profession, concerns access to medical care in the rural setting. Massive technologically-based services can only be provided in large cities, and lesser technology-dependent services need at least strong regional bases.

We are getting better at finding ways to make these technologies available in relation to services such as radiotherapy, relieving the pressure on country women to favour radical breast surgery because they cannot afford the time and separation for chemo and radiotherapy.

But as we concentrate on providing rapid care for people with acute coronary syndrome and stroke (an increasing possibility in cities), the challenge of providing similar care in remote parts of the country may be beyond us at present.

The attitude of some to this problem – that those who live in remote parts of the country do so entirely by choice – is similar to saying that drowning people should be left, as they chose to swim or go boating.

But with telehealth, and many large city medical services increasingly interested in providing networked services to places that lack them, the problem is being partially addressed.

The search for equality of access may well require affirmative funding, and this has been recognised to some extent in fee structures and remuneration.

Equality does not mean paying the same for the care of people in different places: we need to accept that services provided beyond cities will cost more, and ensure that we finance them accordingly.

There are also concerns, raised most recently by Max Kamien, Emeritus Professor of General Practice at the University of Western Australia in Medical Observer, that the relaxation of hiring rules in many rural areas will “open the floodgates” to corporate practices.

While on the surface of it, a boost to the number of doctors working in rural areas would be welcome, this is not the case if they are being employed on short-term contracts to simply churn through large numbers of patients, and leave more challenging and time-consuming cases to existing practices. The focus needs to be on quality of care, not just quantity.

The extent to which the learned colleges have recognised the need for greater action on behalf of their rural members has been variable.

A framework for rural health developed by representatives of all Australian states, territories and the Commonwealth in 2011, recognised the need to be sensitive to the special needs of older people, babies and children, Aboriginal and Torres Strait Islander people, people with chronic disease, refugees and people from culturally and linguistically diverse backgrounds.

The second approach to rural health disparities takes us well beyond the surgery.

Even with networked services, e-health, and affirmative funding, we are faced with residual differences in health status that are attributable to the social and economic context of rural and remote life.

Medicine cannot, for example, diminish the vast distances many country people have to drive, every kilometre increasing their risk of a serious accident. At best, it can be sensitive to distance when arranging care of patients with continuing problems.

Medicine cannot do much to promote high-quality educational opportunity, although the development of regional universities and technical education capacity has been impressive in the past three decades.

Rural clinical schools have done a remarkable job in acquainting future medical practitioners and other health professionals with the challenges and opportunities of rural practice, and the long-term effects of this intervention will be seen in the next 20 years.

Medicine, though, has no influence over agricultural and extractive industry policies, all of which have great significance for employment and economic sustainability in rural communities.

These environmental factors – the social determinants of health – set the health agenda.

Some fall within the sphere of influence of public health, but many are well beyond even its wide reach.

Their importance was reviewed in a paper by Jane Dixon, from the ANU, and Nicky Welch, from Waikato University, in The Australian Journal of Rural Health in 2000. ‘What is it about rural places or the rural experience that contributes to different health outcomes?’ they ask.

The broad-spectrum advocacy of the Rural Doctors Association of Australia and the Rural Health Alliance contribute to the wider political and policy agenda that may help us to answer this question and to make serious progress.

It is vital for medicine to respond to the needs of rural communities as they are, not as they might be in a reimagined ideal world.

My sense is that we are making steady progress. The indicators that we have favour an optimistic view.