Salvaging a prison needle and syringe program trial in Australia requires leadership and respect for evidence

Many countries, including Australia, support needle and syringe programs … but not for prisons

People who inject drugs (PWID) are grossly overrepresented in Australian prisons. Up to 58% of prisoners nationally report lifetime injecting histories.1 The prevalence of blood-borne viruses (BBVs) — commonly transmitted through sharing injecting equipment — is also substantial in prison,1 with high rates of intraprison hepatitis C (HCV) transmission reported.2 However, unlike in the community, PWID in Australian prisons cannot access sterile needles and syringes. Incarcerating PWID in prison environments where drugs are widely available, BBV prevalence is disproportionately high and access to sterile injecting equipment is prohibited breaches basic human rights and international law that ascribes prisoners’ rights to health care standards equivalent to those in the community.3

Prison needle and syringe programs (PNSPs) are endorsed by Australian health and medical peak bodies, including the Australian Medical Association, Australasian Society for HIV Medicine and the Royal Australasian College of Physicians, as well as global bodies like the World Health Organization, UNAIDS and the United Nations Office on Drugs and Crime. Advocacy success resulting in PNSP implementation has been well characterised;4 however, only eight countries currently maintain PNSPs. This leaves 74 countries — including Australia — that support community needle and syringe programs but not PNSPs, in the belief that they implicitly condone illicit behaviour and present particular challenges if applied to correctional settings.

Australian policy and practice targeting BBV prevention in prisons has been inconsistent and largely piecemeal. Despite all four National Hepatitis C Strategies acknowledging people in custodial settings as a priority population, endorsement of effective prevention approaches has varied. The Third National Strategy (2010–2013),5 approved by the Commonwealth and all jurisdictional health ministers, made a strong commitment “for state and territory governments to identify opportunities for trialling [needle and syringe programs] in Australian custodial settings”. In the current, Fourth Strategy (2014–2017),6 however, there is no reference to PNSPs, with only endorsement of substantially less efficacious prevention (eg, bleach provision) or drug demand reduction (eg, drug treatment) approaches.

This lack of an evidence-based BBV prevention policy has supported a reliance on haphazard and largely ineffective interventions in Australian prisons. Despite Australian drug policies being underpinned by harm minimisation approaches that include supply, demand and harm reduction, only costly and ineffective interdiction-based supply reduction approaches and, to a lesser extent, treatment-based demand reduction, have been implemented substantively in prisons.7 Pragmatic regulation to reduce drug-related harm is also found in South Australian, Queensland and Victorian prisons, with lesser penalties for possession of drugs perceived as less harmful (eg, cannabis).8 This approach demonstrates that public health benefits can occur through security regulations and within corrections legislative regimens that prioritise security over prisoner health and human rights. However, there remains an overriding belief in Australian correctional systems that PNSPs are incompatible with security; a contention not borne out by international experience.

While limited progress towards a PNSP trial in Australia is disappointing in a country that once led the world in drug harm reduction policy and practice, one jurisdictional government has consistently demonstrated political leadership on the issue. Successive Australian Capital Territory chief ministers, Jon Stanhope and Katy Gallagher, steadfastly supported trialling a PNSP at the Alexander Maconochie Centre (AMC) — a prison commissioned in 2009 on human rights principles in accordance with the Human Rights Act 2004 (ACT). The 2011 evaluation of drug policies and services at the AMC9 recommended a trial PNSP, while the subsequent government-commissioned report recommended suitable PNSP models and consultation processes based on international experience.10 Key stakeholders, including prison officers and the Community and Public Sector Union (CPSU), were closely involved with each step of this process.

In April, an end to the long-running enterprise bargaining agreement (EBA) stalemate between the ACT Government and the CPSU that centred on a PNSP trial was announced. In his press release,11 the ACT Minister for Justice Shane Rattenbury maintained the “Government’s commitment to implementing an NSP”, but emphasised “the need for this to be developed with input from ACT Corrective Services staff … [to] recognise the genuine concerns”. A Deed of Agreement enabling the EBA states that majority staff support is needed for any PNSP trial to proceed. Given the CPSU’s historical resistance to PNSPs, this requirement may doom any prospect of an AMC PNSP trial.

CPSU resistance nationally has mostly centred on workplace health and safety concerns and encouraging drug use in custody. These concerns are not supported by over 20 years of PNSP operations in 13 countries. Research and evaluation evidence shows no increase in drug use or availability following PNSP implementation and no reports of needles and syringes provided by PNSPs being used as weapons, or safety problems associated with syringe disposal. Evaluations have also noted PNSPs reduce BBV transmission risk, facilitate entry into drug treatment programs, coexist with drug interdiction strategies and contribute to workplace safety.4

The Deed of Agreement states that PNSP negotiations with the CPSU must be conducted in good faith. The discordance between PNSP experiences and the current CPSU position makes it crucial that AMC staff have opportunities to review and openly discuss evidence supporting the benefits of PNSPs for prisoners, staff and the community as part of good faith negotiations. Guidelines and recommendations for engaging effectively with prison staff have been documented internationally, alongside prominent examples of shifts in attitude towards PNSPs by staff before and after PNSP implementations.4 The potential for honest negotiations to deliver such attitudinal shifts in the ACT also exists, given the significant number of AMC prison officers interviewed in the 2011 evaluation who privately supported a trial PNSP, but feared peer and CPSU recriminations if they were to openly express this support.9

With ongoing policy inertia on prison BBV prevention in other Australian jurisdictions, the ACT can show genuine leadership by becoming the first Australian jurisdiction to introduce a PNSP. The recently tabled House of Representatives report on HCV in Australia12 specifically notes that outcomes of a PNSP in the ACT will inform broader Australian debate. While it is hoped that AMC staff might depart from the CPSU’s historical resistance to PNSPs, the ACT Government must show the leadership lacking in other jurisdictions by allowing evidence and expert advice, rather than unions, guide public health policy.

Improving health equity in Australia: practical advice for those ready to act

A personal checklist for the time-poor clinician

In these times of health reform mired in complexity and politics, I found myself recently wondering where physicians with a particular concern about health inequities for rural and remote Australia, especially public health physicians like me dealing daily with their distribution and determinants, might turn for guidance.

Recalling plaudits in a book review in the Journal,1 I retrieved all three editions of the Oxford handbook of public health practice. The first edition in 2001 of the handbook2 was rightly praised for conceptualising public health practice in a fresh and imaginative way. Its second edition appeared in 2006, and was emphatic in admonishing that “people who dislike decisions should not become public health practitioners”.3 The third and current edition implores the reader “to leave the health of the public in a better state than you found it”.4 Each edition has included a chapter on health inequities — those of the first two were written by Anna Donald, the much-revered Australian-born advocate for evidence-based medicine who died before publication of the third edition.5

Framing the practical actions in each edition is the ability to distinguish between the forces beyond the health system that cause inequities and the factors within the health system. Using this distinction, the Box presents a personal checklist for clinicians who are time-poor yet curious, influential yet non-specialist in health inequities and rigorous in their scrutiny of evidence and ready to act when that evidence is sufficient.

Within our sphere of influence, the handbook invites intelligent and effective policies, incentives and regulations to ensure that health professionals and health services are distributed according to need. Another piercingly clear recommendation is to empower underserved groups experiencing unjust outcomes themselves to demand the health services they deserve. This means transparent investment in cost-saving primary health care as a buffer before expensive hospitals which, by default, become the facility of both first and last resort for the underserved when local options are limited by factors beyond individual control.6

Sensitising colleagues in non-health sectors to the relationship between what they do and the detrimental effect on health equity as an agreed outcome for society is argued strongly in each edition of the handbook. As the significantly higher death rates for women living in rural Australia are not explained by their behavioural risk factors,7 a singular policy obsession by governments to promote individualistic clinical preventive services is unlikely to make a difference in the absence of steady and substantive long-term strategies to improve environmental, social and economic conditions for women in the bush. When none of Australia’s 564 local government areas ranked in the lowest decile for socioeconomic advantage are located in either Victoria or the Australian Capital Territory, perhaps the physical location of national institutions developing such policies might be an important modifiable factor.

Action on local inequity needs support. A prototype of system-level standards already exists in the Systems Assessment Tool available as part of every One21seventy audit undertaken by primary health care services seeking to meet the needs of Australia’s most severely disadvantaged group — remote Aboriginal and Torres Strait Islander peoples (http://www.one21seventy.org.au/cqi-information/systems-assessment-tool). Dated 2000, the reference document establishing benchmark ratios for health professionals to community size now needs updating. Whether urban or remote, Primary Health Networks whose boundaries embrace especially disadvantaged populations in low-ranked local government areas need these standards. Armed with contemporary system-level standards to evaluate the quality, composition, interconnection and capacity of primary health care, an evidence-based understanding of local impediments consequent to central policies would follow.

High-impact medical journals could play a pivotal role for time-poor clinicians, publishing trends in key social and economic indicators by region to provide backgrounds for readers who are not expert in public health practice but are eager to join an informed, professional chorus for action on health inequities. As respected channels for credible evidence exchange, such journals might feature annual updates on key health system determinants that we can do something about, including distribution of and support for general practitioners, and the use of pragmatic trackers of health system performance in the critical sector of primary health care (for example, to monitor potentially preventable hospitalisations). Because doctors love to learn, is there a niche for well written primers about macroeconomics, industrial relations reform, social impact investing and community empowerment? Simultaneous publication of companion lay versions might create preconditions beyond medical and policy networks for what the World Bank terms community-based monitoring.8 All of these ideas are entirely compatible with the prescient recommendations for action on health inequities put forward in each edition of the handbook.

Box –
Health equity: a checklist for clinicians

Beyond the health system

Learn something specific about social and economic conditions:
- inequality of income distribution in Australia (Gini coefficient)
- Indigenous history in our neighbourhood
- number of babies born into poverty every year
- environmental indices such as walkability in urban suburbs or completeness of plumbing repairs in remote communities
- rules for unemployment and disability payment schemes
- relative advantage and disadvantage by geographic area (Socio-Economic Indexes for Areas)
Develop a personal position on minimum wage policy.
Examine the relocation of centralised government bureaucracies to regional areas with high unemployment and few private employers in order to create sustainable job opportunities and better inform national policy on geographic inequities.
Interrogate proposed incentives or changes and any policy “thought bubble”, in line with our better selves and as health professionals who have sworn to the Declaration of Geneva.
Trace the money flow in every allocation of resources or funding announcement. Who gets a job out of any new government proposal and for how long? Who stays in a tenured position irrespective of policy result? When and how do the disadvantaged themselves take over?
Challenge every social idea: is this the best we can do?

Within the health system

Check the facts about the adequacy of primary health care capacity in the immediate work surroundings.
Critique proposed models of health service delivery in disadvantaged communities by asking whether we would settle for them if they were the options being planned for our children, parents or partner?
Examine the membership and embedded power relationships of every committee we are asked to join. If it is a committee on Aboriginal health, are most members Aboriginal? If it is about migrant health, does an Anglo-Saxon chair it? If it is about rural health, what are the residential postcodes of everyone around the table?
Ask whether another epidemiological project or descriptive report is really necessary. Do we already know enough? Can we already track improvements were they to occur?
Interrogate the role of applied research: should we ever randomise the disadvantaged to interventions already accessible to the affluent?
Argue a timeline for a change in health outcomes at a population level for a community we care about. Specify the target difference, propose a timeline, be willing to be held to account, and set an example by working diligently to this target in our daily practice.

Bad times for good bacteria: how modern life has damaged our internal ecosystems

Human actions damage ecosystems on a global scale. Our influence is so great we’ve triggered a new geological epoch, called the Anthropocene, simply because of the changes we’ve brought about. But it’s not just the outside environment we’ve changed, we’ve also damaged the ecosystems inside us.

Our activities alter natural processes, such as weather patterns, and the way nutrients, such as nitrogen and phosphorus, move within ecosystems. We cause declines in species diversity, trigger extinctions and introduce weeds and pests.

All this comes with costs, caused by the increasing unpredictability of both physical and biological systems. Our infrastructure and agriculture rely on a consistent climate, but that’s now becoming increasingly unreliable. And it’s not just the outside world that’s unpredictable; it may come as a surprise to some that we have internal ecosystems, and that these have also been damaged.

Shrinking population

Every adult is made up of 100 million, million human cells (that’s a one followed by 14 zeroes). But the human body is also home to ten times this number of bacterial cells, which, collectively, are called the microbiota. Biologists have only been exploring this internal ecosystem for a decade or so, but surprising and important results are already emerging.

Bad times for good bacteria: how modern life has damaged our internal ecosystems - Featured Image

Humans damage ecosystems on an epic scale. Global Water Forum/Flickr, CC BY

Because the laboratory where I work is interested in how humans affect evolutionary processes, it was natural for us to ask how much humans might affect microbial ecosystems. The answer turns out to be quite a lot.

Possibly the most direct and personal effects are on our own microbiota. And these changes come with consequences for health and well-being. Exactly the same processes we see in external ecosystems – loss of diversity, extinction, and introduction of invasive species – are happening to our own microbiota. And damaged ecosystems don’t function as well as they should.

Scientists have tried to “go back in time” and ask what the original human microbiota might have looked like. There are three ways of doing this: biologists can look at the microbiota of our nearest relatives, the great apes; we can examine DNA from fossils; or we can look at the microbiota of modern-day humans who still have a hunter-gatherer lifestyle.

All these approaches tell the same story. Modern humans have a lower diversity of microbiota than our ancestors, and there’s been a consistent decline in this diversity across ancient and recent human history.

There are a number of reasons for the decline. The widespread use of fire from 350,000 years ago increased the calories we could obtain from food. This probably decreased our need for a big gut, and a smaller gut means less room for microbes.

The invention of agriculture between 8,000 and 10,000 years ago changed our diet, and with it, our microbiota. The end result was the extinction of some components of the microbiota in farming populations. Even today, hunter-gatherers and subsistence societies have many bacterial species in their gut that are never found in the guts of people from westernised societies.

One of the last hunter-gatherer societies in the world, the Yanomami people of South America, have a highly diverse and stable microbiota, and don’t suffer from diseases common in the developed world. christian caron/Flickr, CC BY-ND

Modern onslaught

Changes in microbiota have been tracked using bacteria preserved on the teeth of skeletons, and this showed falls in diversity linked to dietary changes, as well as a shift to microbial species associated with disease.

The changes are particularly apparent after the Industrial Revolution, when processed flour and sugar became widely available. And diet continues to have a major influence on our microbiota.

But the greatest disruption probably happened after the 1950s. This time period corresponds to a number of changes that directly affect the composition of the human microbiota. One involves the opportunity for microbiota to colonise newborns and infants. Normally, babies obtain some microbiota from their mother during childbirth, but caesarean births interrupt this opportunity. Bottle feeding, increased sanitation, and eating processed, sterile foods also limit opportunities to acquire microbiota.

Modern medicine has been very successful at controlling bacterial diseases with antibiotics. Unfortunately, antibiotics cause considerable collateral damage to innocent and beneficial bacteria. After antibiotic therapy, the microbiota may never return to their original abundance, and genetic diversity is reduced in those bacteria that remain.

Antibiotics can also damage beneficial bacteria. Photo: Shutterstock

Collectively, these changes mean that our microbial ecosystems have become degraded, much like natural ecosystems globally. The microbiota are less functional and resilient than they should be. And it turns out they have essential roles in developing our immune systems, and in regulating metabolism. So it shouldn’t be surprising that altered microbiota are now being associated with many diseases of the modern world.

These diseases include obesity, allergic reactions, chronic inflammatory conditions and autoimmune disorders. More recently, it’s also been suggested that psychological conditions, such as depression and anxiety, are linked to the bacteria that live inside us.

In some cases, the parallels with more conventional ecosystems are clear. Clostridium difficile is a bacterium that can grow out of control in our gut, like an invasive weed. And, like a weed invading degraded land, it often spreads rapidly after other bacteria have been eliminated from the gut by antibiotics. The most effective cure is similar to bush regeneration; donating microbiota from healthy volunteers (a “poo transplant”) helps restore a healthy ecosystem.

But, for many diseases associated with our microbiota, there are no immediate cures. Like most ecosystems, our gut bacteria are complex and dynamic. The challenge now is to understand this system and how to acquire and maintain a healthy microbiota, so that in the future, a microbiota check-up might be a routine part of a visit to the doctor.

In such a future, hunter-gatherers such as the Yanomami of the Amazon may turn out to be the custodians of valuable species that are extinct in the microbiota of the developed world.

This article was originally published on The Conversation. Read the original article.

Giant trade deal will not drive up cost of meds: Govt

Australians will be shielded from any increase in the cost of government-subsidised medicines under the terms of a massive trade deal covering 40 per cent of the global economy, Trade Minister Andrew Robb has promised.

Negotiators from 12 nations including Australia, the United States, Japan, Canada, Vietnam and Mexico concluded talks on the controversial Trans Pacific Partnership agreement after the US agreed to an Australian compromise to protect the Pharmaceutical Benefits Scheme in the face of demands for an extension of data protection for biologic medicines.

AMA officials and other health campaigners had raised concerns that intellectual property provisions proposed during the course of negotiations would have forced up the price of prescription medicines, costing consumers and the Government billions of dollars, and possibly allowed corporations to block public health measures such as anti-smoking laws.

But Trade and Investment Minster Andrew Robb said the final deal recognised Australia’s existing medicines regime and included carve-outs to protect health and environmental policy from action taken under investor-state dispute settlement (ISDS) provisions.

“Importantly, the TPP will not require any changes to Australia’s intellectual property laws or policies, whether in copyright, pharmaceutical patents or enforcement,” Mr Robb said. “Australia’s five years of data protection for biological medicines will remain unchanged. The TPP will not increase the price of medicines in Australia.”

The US had been pushing for at least eight years of data exclusivity for developers of biologic medicines, which are derived from biological sources such as human cells, blood, proteins and antibodies, and are used to treat diseases including cancer and rheumatoid arthritis.

Australian law currently provides for a five-year period of data exclusivity, and the extra years were potentially worth billions to pharmaceutical companies by delaying the entrance of lower-cost rivals the while adding hundreds of millions to the cost of the PBS.

The issue threatened to derail the deal, but US negotiators accepted an Australian counter-proposal to accept the five-year protection period where it exists while giving countries the option to opt for eight years if they so choose.

Prime Minister Malcolm Turnbull hailed the signing of the trade a “very big win”.

Public health campaigner Professor Mike Daube said the provision in the deal preventing tobacco companies from suing countries for anti-tobacco laws was “a quite remarkable and historic development”.

“It’s a huge achievement for public health, and possibly the biggest international setback for the tobacco industry that we have ever seen,” he said. “Tobacco has rightly been singled out as the pariah industry.”

There had been fears that tobacco and alcohol producers would use ISDS provisions to try and prevent governments from implementing public health measures – tobacco companies are already using ISDS provisions in Australia’s trade agreement with Hong Kong to challenge the legality of tobacco plain packaging laws.

The Government has expressed confidence that the finalised deal will prevent this, but intellectual property law expert Professor Matthew Rimmer sounded a more cautious note.

“Drug companies, junk food and soda companies, and alcohol manufacturers could still challenge government policy and regulation,” Professor Rimmer told Fairfax Media. “There is concern that the general defences for public health policy are limited.”

A major gripe of critics has been the secrecy surrounding the negotiations, which Professor Rimmer said had not served public health policy well.

Among those concerned about the health implications of the completed TPP is medical charity Medicins Sans Frontieres, which warned it would limit the access of people in developing countries to vital drugs.

The charity said millions relied on the ability of pharmaceutical companies in places like India to manufacture drugs coming off patent for a fraction of the cost of name brand producers, and the precedent set by the trade deal would impede this.

“The big losers in the TPP are patients and treatment providers in developing countries,” US Manager of MSF’s Access campaign Judit Rius Sanjuan told Fairfax Media. “Although the text has improved over the initial demands, the TPP will still go down in history as the worst trade agreement for access to medicines in developing countries, which will be forced to change their laws to incorporate abusive intellectual property protections for pharmaceutical companies.”

Adrian Rollins

Unconventional natural gas development and human health: thoughts from the United States

Many countries are exploring the feasibility of unconventional gas development (UGD) as a component of their national energy policy. Broadly, UGD refers to natural gas produced from atypical reservoir types, including coal seam gas (CSG) and shale gas, which require extraction techniques different from those used for conventional production. The development of unconventional natural gas has been a game changer for the United States by significantly increasing domestic supply and lowering gas prices. However, there is a downside that must be considered, including potential harms to the environment, human and animal health and the world’s climate.

Australia is not exempt from controversy over UGD. Since the mid 1990s, billions have been spent on CSG wells, liquefied natural gas plants and export facilities, primarily in Queensland, New South Wales and Victoria. Although CSG is a major industry in Australia, a focus on shale gas extraction, predominantly in Western Australia, South Australia and the Northern Territory, is underway to determine whether the geological properties are sufficient to support commercial production. Australia has large shale gas formations similar in size to the Marcellus and Barnett formations in the US.

The geology and extraction processes for CSG and shale gas differ in that coal seams are typically shallower than gas trapped in shale. Hydraulic fracturing is a well-stimulation method whereby highly pressurised fluid (consisting of water, sand and chemicals) is injected into a wellbore to open cracks in rock formations of low permeability. This technique is often used to release gas from coal seams and, when combined with directional drilling, to extract oil and gas from shale formations. Extracting gas from shale requires millions of litres of water per well; less water is required to extract CSG. However, the potential for harm to health and the environment is real and common to all forms of UGD.

Australia could learn much from the US experience. We acknowledge concerns from Australia1 and argue that if UGD (particularly from shale) continues to expand, the health and environmental impacts must be adequately addressed. Specifically, UGD policies should be informed by empirical evidence based on actual experience rather than theoretical solutions and the assurance of best practices.2

Hazards, risks and exposure pathways

A significant part of the UGD controversy focuses on the hundreds of toxic chemicals used in the hydraulic fracturing process. Fracturing fluids contain organic and inorganic chemicals known to be health damaging.3 Hazardous compounds have been identified in wastewaters produced by the process, including salts, chlorides, heavy metals (eg, cadmium, lead and arsenic), volatile organics (eg, benzene, toluene, ethylbenzene and xylene) and, depending on the geochemistry of the target reservoir, naturally occurring radioactive materials (eg, radium 226 and radon).4,5 Recent evidence from Pennsylvania suggested a positive association and upward trend with indoor radon concentrations and shale gas development.6

Human exposure to toxic chemicals and other pollutants associated with UGD can occur throughout the life cycle of UGD. These include surface leaks, spills, releases from holding tanks, venting, well-casing failure and accidents during transportation of fluids.7 Air pollutants such as volatile organic compounds, aromatic hydrocarbons, diesel particulate matter and tropospheric ozone can come into contact with human populations from atmospheric dispersion of UGD air emissions. As with air, risks to water quality can occur over the full life cycle of UGD, and surface water and aquifer contamination has been linked to UGD on numerous occasions.8–12

Potential exposure to endocrine-disrupting chemicals (EDCs) is an increasing concern in the context of UGD, primarily because these chemicals, even at low levels of exposure, interfere with the body’s endocrine system and multiple other physiological systems to produce adverse developmental, reproductive, neurological and immune effects.13 EDCs present a unique hazard particularly during fetal and early childhood growth and development, when organ and neural systems are forming.14 The epigenetic effects of EDCs must be better understood. Unfortunately, epigenetic research has been hampered in the US by an incomplete listing of chemicals used in hydraulic fracturing.

There are other health, environmental and social concerns associated with UGD, including its contribution to methane emissions and climate change;15,16 depletion of water supplies (of particular importance to Australia, as it is considered to be the world’s driest inhabited continent); the management (storage, treatment, and disposal) of wastewater produced; noise pollution;17 social justice and community concerns;18 seismic activity;19 and ecosystem disruption and habitat loss.20 Of the more than 480 peer-reviewed journal articles pertaining to these impacts (as of May 2015), more than 75% were published since 1 January 2013; the overwhelming majority of these focus on UGD and the impact on the environment in the US.21 The rapid growth in UGD activities has occurred without health and epidemiological studies designed to assess the short- and long-term impacts of UGD.

The need for empirical studies

As the pace of UGD increases globally, well designed peer-reviewed studies on its health impacts are needed. Health impact assessments, environmental epidemiological studies and ecological studies to assess the burden of disease in populations, as well as descriptive trend studies, are important means to empirically document the impact of UGD on health and wellbeing. Baseline and trend morbidity and mortality data need to be collected and analysed before and during UGD activity in order to assess changes in population health over time. Unfortunately, in the US, few health impact assessment studies have been conducted before or even during UGD activities, and there have been even fewer well designed epidemiologic studies.

Although adverse health effects may appear fairly quickly after exposure in some individuals, specific diseases may take more time to develop (eg, cancers; harm to the reproductive, endocrine and nervous systems; and delayed developmental effects). A higher incidence of asthma, cancers, heart disease and the effects of endocrine disruption on the developing fetus as well as infants and children only become evident over time, and confounding factors must be taken into account. Certainly, the potential for harm will vary by proximity to operations; type, pathways, duration and route(s) of exposure; and the safety culture of the operators. Comparison populations are necessary to assess the association of the hypothesised risk factors to disease development.

The limited evidence from the US should serve as a warning to those intent on expanding gas extraction in the absence of epidemiological studies. For example, an association study analysing randomised survey data suggested higher reported health symptoms per person among residents living closer to natural gas wells.22 Another study demonstrated a greater prevalence of some adverse birth outcomes, including congenital heart defects for neonates born to mothers living in areas of higher-density UGD.23 Yet the current evidence leaves many questions unanswered. This neither implies nor excludes that there is little or no harm from UGD activities. There have been numerous reports of clinical signs and symptoms in the US, including its impacts on the respiratory system (sinus problems, coughing, throat soreness or irritation), the integumentary system (rashes or skin irritation), the neurological system (headaches, dizziness) and the gastrointestinal system (nausea or abdominal pain).24 A causal connection to UGD has not yet been established by analytic research, but reported symptoms have been consistent across geographical space and are compatible with human exposure to contaminants associated with UGD. Self-reported survey data and other qualitative research already exist.25 These can help generate hypotheses and serve as the basis for more rigorous, analytic epidemiological investigations, which are needed to assess short- and long-term impacts of UGD on health.

Concluding thoughts and policy considerations

Ultimately, in any nation, federal and local governments will have to assess the potential costs and benefits of UGD. As well as the various concerns outlined above, this consideration must also take into account production potential based on reserve estimates and capital expenditures required to develop unconventional natural gas. This is particularly important for Australia, which will need to invest heavily in transmission infrastructure and export facilities.

Regardless of what governmental bodies decide, preventive public health measures should be put in place before expanding the development of unconventional natural gas. To assess trends and changes in morbidity and mortality, baseline data should be collected in areas where UGD is planned. There should be a system to track the risk of exposure to environmental agents and the incidence and prevalence of diseases. This could take the form of a health registry or roster, health response line, community reporting systems, or an environmental public health tracking system similar to that developed by the US Centers for Disease Control and Prevention (http://www.cdc.gov/nceh/tracking).

As Australia considers expanding UGD, particularly the extraction of shale gas, it should not necessarily follow the lead of the US. In the US, regulatory actions have generally been weak or ineffective and little attention has been paid to monitoring adverse harms to humans and animals. There must be full transparency in measuring, regulating and monitoring the impacts of the process; studies must be done to measure the potential short- and long-term harm to the environment as well as to animal and human health. To date, few epidemiological or ecological studies of the effect of UGD have been conducted in Australia. Without these data, it is difficult to assess its health impacts.

Many countries have decided to exercise caution as they debate the pros and cons of UGD. New York State recently banned high-volume hydraulic fracturing (and, effectively, shale gas development) based on a recommendation by the state Department of Health after a comprehensive review of the scientific literature.26 France and Bulgaria have banned the practice, and Scotland and Wales recently imposed moratoria. In Germany, the government has upheld a de-facto moratorium on shale gas development amid environmental and public health concerns, but is currently considering a nationwide law that would effectively delay shale gas development for at least 5 years.

As in US, UGD bans in Canada have been mixed. Large-scale UGD has been ongoing in parts of Western Canada (Alberta), whereas more densely populated parts of the country (Nova Scotia, Newfoundland, Quebec, New Brunswick) have imposed indefinite bans or moratoria on high-volume hydraulic fracturing. Other countries, however, are intent on moving forward despite the lack of more evidence of environmental and public health safety. China joined the US and Canada as only the third country in the world to produce shale gas on a commercial scale. Because of its dependency on Russian natural gas, Poland was especially keen on development and initial estimates from the Polish Geological Institute predicted enough shale gas resources to supply the country for 35–65 years.27 However, foreign investors have since pulled out of the country because of regulatory delays, public opposition and test flow results not high enough for commercial production. Australia has been somewhat divided on the issue and although there is significant interest in the expansion of CSG operations and shale gas exploration, some jurisdictions have implemented moratoria, including Tasmania and Victoria.

There is a strong rationale for precautionary measures.28 In the absence of scientific consensus, policymakers face two possible risks: either failing to develop unconventional natural gas when the harms are manageable, or developing it when the harms are substantial. Given recent evidence from the US, we believe there is strong support for minimising the risk of the latter. Based on the US experience, there have been significant impacts to the environment and health under current lax “best practices” and equally lax regulations. Australia would do well to consider the emerging evidence from the US as it debates the feasibility of the expansion of UGD.

Rural v metro: geographical differences in sports injury hospital admissions across Victoria

Injury prevention is one of the Australian National Health Priority Areas.1 Injuries requiring medical attention place considerable demands on the health care system and are increasingly being recognised as a significant public health problem.2 Recent statewide data from Victoria show that the public health burden of sports injury, as a particular context for hospitalised injury, has increased significantly in recent times.3,4 Understanding whether sports injury rates vary by geographic regions in Vic would inform better health service delivery to redress identified health inequalities across regions and aid targeting of preventive programs.

Analysis of International Classification of Diseases-coded hospitalisation data routinely collected from all Victorian public and private hospitals admissions over the financial years 2003–04 to 2011–12 was undertaken. The cases selected had a principal diagnosis of injury and an activity code indicating sport. They were classified according to the Local Government Area (LGA; 31 metropolitan, 49 rural/regional) of the patients’ usual residence. Population-adjusted sports injury hospital admission rates were based on annual LGA populations; trends were analysed by negative binomial regression.

The overall annual number of sports injury-related hospital admissions increased by 34% (n = 8092 to n = 11 359). The regression model found a corresponding 15% increase in the annual population-adjusted sports injury-related hospital admissions rate from 166.0 to 205.0¹ per 100 000 population. For every year, the population-adjusted rate of sports injury hospital admissions was higher for people residing in rural/regional LGAs than in metropolitan LGAs (Box, Appendix).

Sports injuries requiring hospital treatment can have a significant impact on individuals and for the health services providing the treatment, particularly in rural/regional communities. Our data demonstrate geographical differences in population-adjusted sports injury hospital admissions rates that have persisted over time. This epidemiological study is the first step to understanding how the burden of sports injuries varies by region in Victoria.

Our findings are likely to be an underestimation of the geographical variations in sports injury health care burden. Only a small proportion of people who sustain a sports injury are admitted to hospital; however, research has shown that a substantial number of sports injuries receive some form of health care treatment.5 The higher rate of sports injury hospital admissions for people residing in rural/regional areas could be due to a number of factors that are different for people residing in metropolitan areas: hospital administrative practices, health care accessibility, level/nature of sports injury risk, or sports participation levels.

In conclusion, these findings have implications for strategic planning around availability of trained staff in rural/regional health services to meet the demands for sports injuries requiring hospital treatment. There is a need for further research that links location of the injury occurrence to the LGA of treating health service and the LGA of residence to explain these geographical variations in sports injury burden more accurately.

Box –
Rate of sports injury hospital admissions per 100 000 resident population in metropolitan v rural/regional LGAs

LGA = Local Government Area.

RACGP unveils new GP funding model vision

The Royal Australian College of General Practitioners has launched a new GP funding model vision on the first day of its annual conference.

RACGP President Dr Frank R Jones unveiled the vision this morning, saying it was developed in consultation with over 1000 GPs, stakeholders and community groups.

Titled Vision for general practice and a sustainable health system, the document introduces the concept of the ‘medical home’ for patients.

It would require a patient to register with a GP so their medical management can be tailored for them.

Related: Empowering General Practice

The intention of the model is to improve integration of care for patients and reduce the use of inappropriate services including emergency department use and avoidable admissions.

“There has been a lack of support for chronic disease management, integration of care, prevention, continuity of care, and population health,” Dr Jones said.

“This has led to fragmentation of care, which results in the duplication of patient services and testing, unnecessary care, loss of a coordination, and poorer health outcomes for patients. The consequences are unnecessary hospital presentations and admissions, costing our health system more than $3 billion per year.”

The vision includes a comprehensiveness payment to GPs and general practice teams and coordination support payments to help bridge the gap between hospitals and primary healthcare.

Read the full vision on the RACGP website.

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Pattern of malignant mesothelioma incidence and occupational exposure to asbestos in Western Australia

Western Australia has one of the highest rates of malignant mesothelioma (MM) in the world.1 Early cases of MM were predominantly caused by the crocidolite mining operations at Wittenoom.1–3 During the 1950s, Australia had the highest per capita asbestos consumption in the world,2 mostly to manufacture asbestos cement, and there was an increasing number of MM cases in workers using these asbestos products. Production declined rapidly in the 1980s, and all production and importation of asbestos were prohibited from 31 December 2003.

The aim of our study was to describe the pattern of MM incidence in WA in relation to occupational exposure to asbestos.

All incident cases of MM are recorded in the WA Cancer Registry and reviewed by an expert committee (pathologist, respiratory physician, occupational physician, epidemiologist and cancer registrar) to verify the diagnosis. All available exposure information — including medical (often collected for workers’ compensation purposes) and employment records — was examined to determine the most significant occupational exposure likely to be responsible for the disease. The number of cases for each occupational group was expressed as a proportion of all cases for each decade.

There were 1263 confirmed cases of MM between 1962 and 2009 (97% male) in persons who had experienced occupational exposure to asbestos, and a further 75 cases (53% in males) where no exposure could be identified (Box). The total number of cases increased from 57 in the 1960s and 1970s combined, to 211 in the 1980s, 475 in the 1990s, and 595 in the 2000s. The proportions of cases resulting from crocidolite production and transport were highest in the 1960s and 1970s, as were cases in rail workers and plumbers. The proportions linked to asbestos exposure in waterside workers, the armed forces, laggers and insulators, and those working in shipbuilding, asbestos cement production, automotive brake work and non-asbestos mining peaked in the 1990s; the proportions in building and construction workers, electricians, boilermakers and welders, and power station workers were greatest in the 2000s. Overall, the largest proportions of cases were in construction and Wittenoom workers. The proportion of cases with no identifiable exposure was less than previously reported4 and did not differ significantly between decades.

In conclusion, the numbers and proportions of MM cases attributed to occupational asbestos exposure in WA reflect the patterns of asbestos use in the respective occupations more than 30 years ago. Since 1980, an increasing proportion of MM cases has not been linked with occupational exposure to asbestos.5 Occupational exposure nevertheless clearly remains the major cause, and appears likely to be so for many more years. Despite the exponential rise in the risk of MM following exposure to asbestos, decline in the working population at risk and removal of asbestos from construction and industrial equipment suggest that the MM epidemic in WA will be finite.

Malignant mesothelioma cases over 5 decades in Western Australia, according to occupational group

Occupational group	1960–1979		1980–1989		1990–1999		2000–2009		Total
Occupational group	No.	%	No.	%	No.	%	No.	%	No.	%

Wittenoom workers	31	54.4%	70	33.2%	83	17.5%	82	13.8%	266	19.9%
Rail workers	8	14.0%	14	6.6%	36	7.6%	51	8.6%	109	8.2%
Plumbers	2	3.5%	6	2.8%	14	2.9%	20	3.4%	42	3.1%
Asbestos transport	2	3.5%	6	2.8%	12	2.5%	8	1.3%	28	2.1%
Non-ABA Wittenoom workers	0	—	10	5.1%	9	1.9%	12	2.0%	31	2.3%
Other asbestos work	0	—	1	0.5%	1	0.2%	0	—	2	0.1%
Waterside workers	2	3.5%	15	7.1%	34	7.2%	19	3.2%	70	5.2%
Armed forces	0	—	6	2.8%	29	6.1%	27	4.5%	62	4.6%
Laggers and insulators	1	1.8%	8	3.8%	21	4.4%	16	2.7%	46	3.4%
Ship building	0	—	7	3.3%	17	3.6%	11	1.8%	35	2.6%
Asbestos cement production	1	1.8%	2	0.9%	16	3.4%	14	2.4%	33	2.5%
Automotive (brakes)	0	—	2	0.9%	11	2.3%	13	2.2%	26	1.9%
Non-asbestos mining	0	—	0	—	2	0.4%	2	0.3%	4	0.3%
Building and construction workers	2	3.5%	28	13.3%	84	17.6%	175	29.4%	289	21.7%
Other occupations*	2	3.5%	11	5.2%	34	7.2%	51	8.6%	98	7.3%
Electricians	0	—	2	0.9%	6	1.3%	28	4.7%	36	2.7%
Boilermakers and welders	1	1.8%	6	2.8%	16	3.4%	26	4.4%	49	3.7%
Power station workers	0	—	1	0.5%	8	1.7%	11	1.8%	20	1.5%
Pipe fitters	1	1.8%	2	0.9%	3	0.6%	11	1.8%	17	1.3%
No identifiable source of asbestos exposure	4	7.0%	14	6.6%	39	8.2%	18	3.1%	75	5.6%
Total	57	100.0%	211	100.0%	475	100.0%	595	100.0%	1338	100.0%

ABA = Australian Blue Asbestos company. Occupations that are not covered by the presented list of occupational groups. The bold* cells mark the decades with the highest proportion of malignant mesothelioma cases for each occupational group.

Suburbs with higher diabetes rates have more access to takeaway food, alcohol

When looking at rising type 2 diabetes rates, we need to also look the availability of fresh food in the local geographical area, experts say.

In a perspective published in today’s Medical Journal of Australia, research has found that people living in western Sydney have a higher access to takeaway and alcohol shops than those living in Sydney’s north shore.

There are also much higher rates of Type 2 diabetes rates in western Sydney, particularly around the suburbs of Mount Druitt and Blacktown.

Dr Thomas Astell-Burt, Director of Public Health Sciences at Western Sydney University, and Dr Xiaoqi Feng, Senior Lecturer in Epidemiology at the University of Wollongong calculated the number of greengrocers, supermarkets, takeaway shops and alcohol outlets within 15–20 minutes’ walk from a person’s home.

“About 28% (868/3148) of neighbourhoods in the west had at least [a 3:1] ratio of takeaway shops to greengrocers and supermarkets, in comparison to 20% (546/2744) in the north,” they report.

“The equivalent results for alcohol outlets were 12% (365/3148) in the west and 5% (131/2744) in the north.”

They said in Sydney’s west, the availability of fresh produce within a reasonable walking distance was limited.

These preliminary findings are from the Mapping food Environments in Australian Localities (MEAL) Project, which was initiated in 2014 to explore geographical inequities in food environment in metropolitan Sydney.

The researchers say the findings indicate that more needs to be done to help people struggling with Type 2 diabetes.

“We have to invest in multisectoral change for which the health benefits may only be realised in the long term,” they write.

Read the full perspective in the Medical Journal of Australia.

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Geographic inequity in healthy food environment and type 2 diabetes: can we please turn off the tap?

We need fairer policies and investment in change that may only be realised in the long term

The human, financial and wider societal costs of type 2 diabetes mellitus (T2DM) in Australia are high,1 but not inevitable.2 Studies indicate that lifestyle interventions involving weight reduction can reduce T2DM risk.3 Prevention and better management of T2DM can also help to prevent cardiovascular complications.4 So, to paraphrase the title of a recent editorial in the Journal, if we know what to do, what is the problem?5

One problem is that the complexity of sustaining the prevention effort has not been captured well by randomised trials,6,7 which veer towards individual-level (sometimes referred to as “high-risk”) strategies rather than evaluations of structural interventions at the population level.8 General practitioners have a very valuable role to play, but placing the burden of prevention squarely on them will not work.9 The determinants of T2DM risk are intergenerational, relational, multifaceted and inequitably distributed.10 Legions of scientists have engaged with the idea that where we live and work, and where our children grow up and attend school, all have some influence on our life chances — for better and for worse.11 Pollution, green space, sidewalks, vandalism and so on — these “social determinants” accumulate, support, insult, provide resilience, wear us down and conspire in no small way to shape the manifestation of geographic inequities in health that our best efforts appear unable to budge. In fact, there is increasing appreciation that some health interventions actually widen health inequities.12

We recently highlighted the spatial disparity in T2DM risk in the metropolitan area of Sydney, Australia: lower risk in the eastern suburbs and north shore, and much higher risk in the west, particularly around Blacktown and Mount Druitt.13 For members of the health workforce in those communities, this was no revelation. Addressing this inequity has been a core motivation in the development of the Western Sydney Diabetes Prevention and Management Initiative — a consortium led by the Western Sydney Local Health District and the Western Sydney Primary Health Network (formerly the Western Sydney Medicare Local), involving the University of Western Sydney and other local universities, councils, non-governmental organisations and other locally operating institutions. This initiative recognises that, for the most part, people who receive support from the health sector remain exposed to the same quantum of determinants that contributed to their health condition. The health sector has little control over features of our neighbourhoods that we think may have a powerful downstream impact on health across our lives. To use a well-trodden metaphor, the health sector is bailing water from the sink but cannot reach the tap.

What are these spatially manifesting risk factors that promote T2DM and potentially hinder its effective management? Food environment, or perhaps inequity of healthy food environment (eg, ample access to fresh produce) more specifically, is a prime candidate because what we eat is fundamental to our health. Accordingly, the Mapping food Environments in Australian Localities (MEAL) Project was initiated in 2014 to explore geographic inequities in food environment in metropolitan Sydney. Also, members of our MEAL Project team have subsequently joined forces with the Australian Prevention Partnership Centre Liveability Project team to engage in related epidemiological studies across the country.14 Here, we report preliminary findings from the MEAL Project.

Gathering geocoded data from the Yellow Pages (circa 2012), we used a geographic information system to calculate the number of greengrocers, supermarkets, takeaway shops and alcohol outlets within a 1.6 km road network distance from a person’s home. We chose a 1.6 km catchment to reflect a walking distance of about 15–20 minutes, although we acknowledge that there will be some variation in how far people are prepared to walk to purchase food. Australian Bureau of Statistics residential Mesh Blocks, released for the 2011 census and containing between 30 and 60 dwellings each, were used as a proxy for home. We report results comparing selected areas of Sydney’s west (3148 Mesh Blocks) and north shore (2744 Mesh Blocks), where T2DM prevalence was just below 7% and a little above 2%, respectively, according to the National Diabetes Services Scheme Australian Diabetes Map (2013).

The maps in the Box tell a story that is in part surprising, yet also no surprise at all. The first map shows that in these selected areas of western Sydney and the north shore, most neighbourhoods did have access to at least one greengrocer or supermarket. Those neighbourhoods in blue (379 [6%]), however, did not have a greengrocer or supermarket within 1.6 km. It was more common in the west than in the north (261 [8%] v 118 [4%]) for residents to most likely rely on public or private transport to obtain fresh produce.

The second and third maps show the number of takeaway shops or alcohol outlets relative to the number of greengrocers and supermarkets available within 1.6 km. Neighbourhoods where takeaway shops and alcohol outlets outnumbered greengrocers and supermarkets by at least 3:1 are highlighted in red. About 28% (868 of 3148) of neighbourhoods in the west had at least the aforementioned ratio of takeaway shops to greengrocers and supermarkets, in comparison with 20% (546 of 2744) in the north. The equivalent results for alcohol outlets were 12% (365 of 3148) in the west and 5% (131 of 2744) in the north.

Overall, there is by no means a dearth of alcohol or takeaway options if one lives in the affluent north shore. But there are multiple venues for purchasing fresh produce within a reasonable walking distance from home should a person choose to do so. Importantly, much the same can be said in many neighbourhoods in the west of Sydney, even although that area is comparatively less well off. But for many other communities in the west, the availability of fresh produce within a reasonable walking distance is limited. Meanwhile, the provision of takeaway shops and alcohol outlets outnumbers greengrocers and supermarkets in many neighbourhoods in the west. In some of those communities, there is a takeaway shop but no greengrocer or supermarket.

These results are preliminary and subject to limitations, not least in the possible undercount of takeaway shops because many of them are local independent retailers with no need to advertise in the Yellow Pages. But if the real number of takeaway shops is substantially higher, that only serves to deepen our concern. Analysis of smaller catchments (eg, a 400 m road network distance from a person’s home) may also reveal sharper inequities in these indicators. This research is currently underway, and we are also comparing food consumption patterns and health in relation to local food environment.

Nonetheless, there is an important question of what evidence is necessary to fuel effective policies and practices, because large-scale investments in structural change may not guarantee the desired impacts. In the United States and the United Kingdom, studies of takeaway shop bans and introduction of supermarkets to communities that did not previously have one, for example, have revealed little behavioural change in the short term.15–17 On the other hand, life course theory indicates that engrained behaviour is unlikely to change drastically at the flick of a policy switch; we have to invest in multisectoral change for which the health benefits may only be realised in the long term.10

Meanwhile, potentially unintended short-term consequences should also be taken into account, because takeaway shops and alcohol outlets are also places of work for many people. Removing them may not only result in the loss of livelihoods and potential social networks but could also increase car dependency if more attractive, healthier and affordable substitutes are not provided within a reasonable walking distance from home. Rather than just addressing the problem as if it were somehow in a vacuum or laboratory, we also need to be wary of the possibility of shifting these potentially “obesogenic” circumstances from one location to another. To enhance the business case for the multisectoral approach for prevention, we need to have greater confidence in what works locally. This means that the health impact of structural change in the built environment, such as the ongoing developments in western Sydney, needs to be evaluated with as much rigor as possible. To this end, investment in local evidence and in academia–industry partnerships is fundamental so that those evaluations are well developed and resourced from the get-go. The aforementioned studies and other wisdom from overseas, although relevant and to be taken into consideration, are no substitutes for well-crafted experimental and observational studies conducted in our patch.

To conclude, we re-emphasise that geographic inequities demonstrably manifest within cities and the related issues of T2DM and food environment are ones that we ought to pay close attention to in the health sector. In Australia’s largest city, there is a clear spatial mismatch, in which many communities — where access to a car is not guaranteed and public transport options can be thin, where social and economic pressures weigh heavy, and where diet-related health challenges are considerable — have few opportunities to purchase fresh produce close to home. We know not whether land-use zoning, better public transport or other structural changes will provide the upstream silver bullet for preventing the myriad chronic diseases that challenge us collectively as a society. But policies that ensure opportunities to purchase fresh produce that is affordable and available within a reasonable walking distance from home in communities where this is not presently the case would be fairer. We would not build neighbourhoods without roads, clean water and sanitation, so why do we build neighbourhoods without other things that are essential, such as good access to fresh produce? Investment in gathering local evidence driven by multisector initiatives (such as the Western Sydney Diabetes Prevention and Management Initiative) has to be part of the solution. What seems clear is that more of the same and a failure to take action on the status quo are unlikely to stem the flow of bad news for our fellow human beings who are living with and fighting T2DM. It is time we all work together to turn off that tap.

Indicators of food environment within a 1.6 km road network distance of residential Mesh Blocks in selected areas of western Sydney and the north shore