The full page ads last week in some capital city papers may have heralded ‘peace in our time’ in the dispute between Medibank Private and Calvary Health, but the big insurer’s approach to safety and quality in our hospitals is still in question by hospitals, doctors, and patients.
While Medibank and Calvary may have finally signed a contract, the detail of the belated agreement remains top secret.
Calvary CEO, Mark Doran, told Adelaide radio that Medibank Private had agreed to engage with the Australian Commission on Safety and Quality in Health Care on what they believe are preventable events, and that they will act on the call for an independent clinical review process. But that’s about all we get to know at this stage.
AMA Vice President Dr Stephen Parnis said that Medibank’s ‘trust us, we’ll do the right thing by you’ response is not good enough.
“I’m a doctor and I don’t say that sort of thing to patients anymore,” Dr Parnis said.
“I’ve got to give them the specifics. And I think Calvary and Medibank Private need to do the same here.
“We’d like to understand exactly what the arrangements are with regard to that long list of 165 complications, which Medibank was erroneously calling mistakes, to understand what is going on with those as a result of this new agreement.
“The concern, of course, is that if you’re insured it’s the detail that tells you what you’re covered for and what you’re not covered for.
“The treating doctors need to understand what their patients will be covered for so that they can treat them in the appropriate setting.
“Up to now it’s been hardball by Medibank.
“The AMA rarely intervenes in these sorts of disputes but, because it has such wide-reaching implications for the health system, both private and public, we have regarded this as essential that, one, it gets sorted out, and, two, that it is done in a transparent way.
“It is positive that the Commission for Safety and Quality in Health Care is now involved.
“The Commission does things the right way when these complications are being assessed to try and reduce risk, rather than what was happening with Medibank saying these are not complications, they’re mistakes, and if they occur we’re not funding them or we’re dramatically reducing our funding.
“So we need more detail here because it doesn’t just affect Calvary and it doesn’t just affect Medibank Private. Every other player in the health system is watching on here.
“If this sets a good precedent, wonderful. If it doesn’t, then it’s going to have repercussions for everyone.”
The recent Obesity Series published in The Lancet considered the bigger picture of environmental factors. The authors of the Series emphasised and proposed important obesity prevention measures, including changing the environment, stimulating the expression of healthy food preferences, and establishing smart food policies.1,2 Some individual factors play an essential part in the development of obesity and therefore should also be a target for obesity prevention. For example, it is well established that alterations in fetal growth increase the risk for developing obesity and its metabolic consequences later in life.
The AMA this week hosted more than 60 leaders from across all medical specialties in Canberra to discuss the medical profession’s participation in the Governments’ Medicare Benefits Schedule (MBS) review, and the recent behaviour of Medibank Private in negotiations with hospitals. Welcoming delegates to the meeting, AMA President, Professor Brian Owler, said it was important that the medical profession was informed and united in its approach to the MBS review.
The AMA has cautiously welcomed the review, led by Sydney University Medical School Dean Professor Bruce Robinson, and supports having a schedule that allows patients access to modern medical procedures, and reflects the modern-day treatments that are provided in our health system.
But Professor Owler has voiced concern that the Government might use the review mostly to remove items from the MBS as part of a cost-cutting exercise, rather than ensuring the schedule is up-to-date and reflects advances in care and medical practice.
“We need to make sure that the Government continues to work with clinicians, that this is a clinician-led process that is based on evidence, and that the process is held in conjunction with the colleges and specialist societies where the knowledge base and expertise lies,” Professor Owler said.
He added that the AMA will continue to work with the Government in the review, and will work with the specialists and colleges in ensuring the best outcome from the review – provided it is not just about cutting costs and provided that doctors maintain access to health care for their patients.
Despite the near-universal acceptance of the benefits of vaccination, some people still worry about risks associated with their use. Luckily, scientists are vigilant about identifying possible risks, so they can be addressed before problems emerge.
Still, people sometimes forget that science is the process by which we arrive at solutions. And they worry about incremental scientific steps that often expose weakness in these solutions.
A recent study published in the journal PLOS Biology, for instance, was presented by some media as claiming that certain vaccines make viruses more dangerous. The research showed chickens treated with its vaccine are more likely to spread a highly virulent strain of Marek’s disease virus, a condition that affects poultry.
The reason was simple: the vaccine used in the study targets Marek’s disease, not the virus that causes it. These types of vaccines are known as “leaky vaccines” because they don’t affect the ability of the virus to reproduce and spread to others; they simply prevent the virus from causing disease.
Marek’s disease vaccines use a non-disease-causing virus to infect cells. This preventive infection stops tumour formation and death when those cells are infected by the Marek’s disease virus.
But the virus can replicate and still produce more virus particle, which can infect other chickens. All Marek’s disease vaccines, since their introduction in the 1970s, have been leaky; they allow chickens to carry and spread the virus without getting the disease.
‘Imperfect-vaccine hypothesis’
The effect of leaky vaccines on how disease spreads is explained by the “imperfect-vaccine hypothesis”. It holds that, without vaccination, a very virulent virus can get into a population and kill infected hosts (people or animals) very quickly – before they have a chance to spread it. This means that the virus will die out very quickly too, as all potential hosts will be dead or immune to it.
A leaky vaccine can prevent the very virulent virus from killing the host, but doesn’t stop that host from spreading the virus to others. This means that a very virulent virus can survive for long periods in the vaccinated hosts. And it can continue to spread in this time, making it less likely to die out.
The PLOS Biology study showed chickens vaccinated against Marek’s disease were more likely to spread the disease to other chickens, than unvaccinated chickens were. The unvaccinated chickens all died in less than ten days – before they could spread the virus.
The vaccinated chickens, on the other hand, were protected from the disease so were able to spread the virus to other (unvaccinated) chickens for weeks and weeks. And they made those chickens immune to the virus in the process.
One of the reasons the researchers looked at Marek’s disease in chickens is because it has been getting progressively deadlier. Originally, the disease occurred mainly in older chickens and caused paralysis. But an acute form of the disease emerged in the 1950s and has since become the dominant form. This rather virulent version can kill up to 100% of unvaccinated birds.
Leaky but not sinking
But what does all this mean for the future of vaccination?
Well, the first thing to note is that in this study the vaccinated chickens always had the best outcome. In one experiment, only three out of 50 unvaccinated chickens survived the disease, while vaccination protected the majority of chickens (46 out of 50 survived).
The authors also noted that vaccination has been very effective in preventing deaths in chickens due to Marek’s disease. They said their study didn’t indicate whether vaccination played any role in the development of the serious form of Marek’s disease.
Vaccines prevent disease, even if they’re leaky. But it’s important to note there are currently no vaccines against viruses that infect humans that are leaky. Current human vaccines mimic the body’s own response to viruses.
But yet-to-be-developed vaccines for diseases such as HIV, Ebola or malaria, where humans have been unable to mount an effective natural defence, are likely to be leaky. And even imperfect vaccines for these illnesses would be an enormous step forward.
The possible effect of “leaky vaccines” on how viruses spread is an interesting new observation. But there are a number of other ways by which viruses can change in response to vaccination.
An arms race
One response of viruses to vaccines involves the evolution of viral proteins that allow them to escape the vaccine. This is known as “epitope evolution” and it’s the reason flu vaccines change each year.
Even if a vaccine is effective in preventing a particular strain of virus, other strains may take its place. This was a concern when the human papillomavirus (HPV) vaccine was introduced nearly ten years ago. But researchers have investigated whether any HPV types not in the vaccine have become more common since the vaccine was introduced and there’s no evidence this is happening.
The interaction between viruses and their targets can change over time. In the case of Marek’s disease, the infection has become progressively deadlier. Increased use of broiler chickens, lack of genetic diversity in flocks and high-density rearing may all have played a role in the changes seen in the disease.
The benefits of vaccination far outweigh its risks. And it is research like this that helps medical researchers actively identify possible dangers so we can safely continue to avoid the diseases that terrified our parents’ generation.
Health groups remain concerned the massive Trans-Pacific Partnership trade deal will push up the cost of medicine and hamper public health initiatives despite indications United States negotiators are prepared to give ground on controversial intellectual property protections.
While the future of the controversial trade pact is clouded following the failure of officials from 12 nations to seal an agreement in Hawaii last month, reports have emerged that the US is willing to back down on demands that data used to produce biologic medicines be subject to a 12-year exclusivity clause.
The clause would delay the competition pharmaceutical companies would face from cheaper generics, adding billions of dollars to their bottom line.
On the eve of the Hawaii talks, Trade Minister Andrew Robb told Fairfax Media he was pushing for the data exclusivity period to be slashed to five years, and it is understood the United States’ chief negotiator, US Trade Representative Michael Froman, was considering a counter-proposal for a base period of five years, followed by a three-year extension contingent on “certain circumstances”.
The secretive nature of the talks has meant that most observers have had to rely on information gained by websites like Wikileaks for information about the direction of negotiations on the deal which, if concluded, will encompass about 40 per cent of the global economy.
Mr Robb said that although the deal was not concluded at Hawaii, “we are definitely on the cusp”.
“While nothing is agreed until everything is agreed, I would say we have taken provisional decisions on more than 90 per cent of issues,” the Minister said.
But he admitted data protection for biologic medicines was among a number of “big outstanding issues” to be resolved: “You’ve got to set a balance somewhere between people getting a return on innovation on investment, and enabling competition to bring prices down for the rest of the community.”
Biologic medicines are derived from biological sources, and though they comprise only a fraction of drugs listed on the PBS, many are extraordinarily expensive, with a course of treatment often costing hundreds of thousands of dollars. In 2013-14, they accounted for a quarter ($2.3 billion) of PBS spending in 2013-14.
While the US may have given ground on access to biologic data, the AMA and other health groups remain concerned that other clauses in the proposed trade deal, including provisions allowing pharmaceutical companies to “evergreen” drug patents and giving investors scope to block governments taking public health measures, could undermine health care.
The AMA Federal Council has called on the Federal Government to reject “any provisions in trade agreements that could reduce Australia’s right to develop health policy and programs according to need”.
The Association said it was concerned that aspects of the proposed TPP could be used to attack key health policies and measures including the PBS and the cost of medicine, food labelling and tobacco control laws, restrictions on alcohol marketing, the operation of public hospitals and the regulation of environmental hazards.
Among the most controversial provisions are investor-state dispute settlement (ISDS) procedures that would enable corporations to mount legal action against government policies and laws they felt harmed the value of their investment or future profits.
Tobacco giant Philip Morris Asia used just such provisions in a 1993 investment agreement between Australia and Hong Kong to challenge Australia’s world-first tobacco plain packaging legislation in the courts and seek compensation, arguing that the policy undermined the value of its investment by ‘expropriating’ its trademarks and branding.
It is understood that Australia is arguing that health and environment policies, as well as the Pharmaceutical Benefits Scheme, be made exempt from ISDS provisions.
In addition, the TPP includes proposals demanding the removal of technical barriers to trade – provisions which companies have used to challenge regulations such as alcohol warning labels, alcohol excise, and front-of-packet food labelling.
There are also concerns market access rules in the TPP may be used to restrict government support for public hospitals and other health services by requiring that there be competitive neutrality between such entities and private health providers.
Medical charity Medecin Sans Frontieres is also apprehensive about the deal.
It said that without major changes in the Hawaii talks, the deal would have a “devastating impact” on global health.
MSF was particularly concerned about provisions it warned would “strengthen, lengthen and create new patent and regulatory monopolies for pharmaceutical products that will raise the price of medicines and reduce the availability of price-lowering generic competition”.
It said some of the most concerning provisions centred on patent evergreening, which would force governments to grant drug companies additional patents for changes they made to their medicines, even if these were of no therapeutic benefit.
On Aug 3, 2015, President Barack Obama and the US Environmental Protection Agency (EPA) jointly announced the Clean Power Plan, a sweeping overhaul of emission guidelines. Coal and natural gas remain the biggest contributors to carbon pollution (a third of all domestic carbon emissions) and with around 1000 ageing fossil-fuel power plants in the USA, the introduction of the first-ever national standards have necessarily made power plants crucial targets.
Launching the ‘Avoid the crash, Avoid the trauma’ campaign at Parliament House in Canberra this week, AMA President, Professor Brian Owler, called on politicians, the car industry, and all road users to join the push for adoption of new technologies such as AEB to make cars safer and save lives.
The AMA and the Australasian New Car Assessment Program (ANCAP) have joined forces to lobby governments and car industry leaders to embrace new technology – starting with Autonomous Emergency Braking (AEB) – and make it standard in all new cars sold in Australia.
AEB is an advanced driver assistance technology that is proven to reduce the number and severity of vehicle crashes and associated trauma. AEB systems use camera and sensor technology to detect the speed and distance of objects in the vehicle’s path, and automatically brake if the driver does not respond.
Professor Brian Owler at the launch
Road safety and public health go hand in hand. Road trauma has an enormous impact on the lives of everyday Australians and our health system, Professor Owler said.
“We must do all we can to eliminate it, and governments have an important role to play, especially in working with the car industry to make cars safer, preferably by making life-saving technology like AEB standard features in all new cars.
4 years have passed since the nuclear power plant accident at Fukushima, Japan, moving the problems there from an acute nuclear disaster to a chronic environmental disaster, with multiple social, psychological, economic, and political consequences. As described by Ohtsuru and colleagues,1 many people continue to experience multiple losses, both tangible and intangible, at the individual, family, and community levels.
The Federal Government has been urged to sideline the nation’s peak medical research body and set up a stand-alone scientific committee to investigate the health effects of wind farm noise.
The Senate Select Committee on Wind Turbines, chaired by Democratic Labor Party Senator John Madigan, has recommended the establishment of an Independent Expert Scientific Committee (IESC) on Industrial Sound to research the health effects of wind turbines “and any other industrial projects which emit sound and vibration energy” and develop a national noise standard for wind farms.
The IESC, which along with a National Wind Farm Ombudsman, would be paid for through a levy on wind farm operators, would provide advice to State governments on the health effects of any proposed or existing wind farm, and the Senate committee called for states that did not accept expert advice or adopt the national noise standard to be overruled by the Commonwealth.
The recommendations are in keeping with Government objections to the wind power industry.
Senior Government leaders including Prime Minister Tony Abbott and Treasurer Joe Hockey have made no secret of their distaste for wind farms, and the Government recently insisted on a major cut in the national Renewable Energy Target, as well as directing the Clean Energy Finance Corporation to stop investing in wind energy projects.
The Senate Committee report will add to political tensions around renewable energy policy, which is shaping as a key battleground for the next Federal election after Labor declared it should provide 50 per cent of electricity by 2030.
Across the world countries are ramping up their investment in wind power. China has trebled its capacity since 2010 and wind now supplies enough energy to power 100 million homes. In the United States, more than 100 projects are underway and the US Department of Energy estimates it will provide 20 per cent of electricity by 2030.
The importance of renewable energy technologies was underlined by President Barack Obama who, in a speech in early August, declared power plant operators must cut slash carbon dioxide emissions by 32 per cent from 2005 levels by 2030.
“No challenge poses a greater threat to our future and future generations than a change in climate,” President Obama said.
“This is one of those rare issues, because of its magnitude, because of its scope, that if we don’t get it right, we may not be able to reverse. There is such a thing as being too late.”
The Senate Select Committee, which included cross bench senators David Lleyonhjelm and Bob Day, expressed disappointment at the AMA’s stance on the health effects of wind power. In its Position Statement on the issue, the AMA has said there is a lack of evidence to back claims that the sound generated by wind farms affects human health.
“This is regrettable given the influence that the Association’s views have on the Australian medical community,” the Committee said. “It is hardly surprising if general practitioners turn a blind eye to, or downplay, the complaints of those who claim to be suffering the effects of wind turbines when the peak body’s assessment of the authenticity of these impacts is so dismissive.”
The Committee also cast doubt on the reliability of National Health and Medical Research Council investigations of the issue, after the nation’s peak research body reported a lack of evidence to support claims of the harmful effects of wind turbines.
It proposed the IESC take the lead on conducting research on the issue, dismissing the NHMRC’s efforts in the area as “manifestly inadequate”.
But in a dissenting report, Labor Senator Anne Urquhart shredded the credibility of Sarah Laurie, who the majority senators relied heavily upon for evidence of the adverse health effects of wind farms, as an authority on the issue.
Senator Urquhart pointed out that Ms Laurie had voluntarily given up using the title Doctor following a complaint to the Australian Health Practitioner Regulation Agency in 2013, and that numerous judges and tribunals before which she had appeared had rejected her capacity to provide expert or authoritative evidence.
In a hearing on the Stony Gap Wind Farm last year, Ms Laurie called for investigation of the theory that some people were so exquisitely sensitive to certain frequencies that from Australia they could detect an earthquake in Chile.
The judge hearing the case found that Ms Laurie’s testimony did not “contain evidence of a causal link between contemporary operating wind turbines and the kind of health problems reported by deponents”.
The judge said that Ms Laurie “rejects all studies…which are not consistent with her theories”.
A Canadian Environmental Review Tribunal hearing a case regarding the Dufferin Wind Power Project considered that the evidence presented to it by Ms Laurie “does not indicate that she has conducted a comprehensive review of all literature, nor that she has the expertise to assess the sufficiency of the research methodology in individual research studies”.
Senator Urquhart said that, in contrast to the lack of scientific evidence linking wind farms to adverse health effects, the evidence on the health effects of other forms of power generation were well-established.
While not dismissing the concerns of those who believed their health had been harmed by wind farms, the Labor Senator said many of the symptoms complained about were very common in the general population.
The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.
But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.
We’re all ill now
A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.
Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.
Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.
The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.
The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.
What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.
Fundamental shifts in thinking
Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.
More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.
No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.
The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process.
In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.
Rays of hope
Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.
What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine.
Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.
But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.
A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.
Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.
Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a free public lecture on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.
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