We need transformative change in Aboriginal health

Overcoming the soft bigotry of low expectations

Change is complex and invariably poorly managed and understood in Aboriginal affairs, including Aboriginal health. At worst, it is a competition between recycled ideas that have gained or lost currency with changes in the dominance of political ideologies. At best, it is developmental change, a slow and marginal improvement on what we are currently doing.

Comparison of the 1989 National Aboriginal Health Strategy (NAHS) Working Party report and the 1994 evaluation of the implementation of the NAHS with the current National Aboriginal and Torres Strait Islander Health Plan (2013–2023) (http://www.health.gov.au/natsihp) shows that we continue to seek change in the same key areas. Holistic approaches rich in evidence-based thinking, emphasis on community control of health services, inter-sectoral collaboration and improved monitoring and accountability are themes that have repeatedly been highlighted in almost the same way despite the passage of almost a quarter of a century. So what is wrong with this?

Let’s start with the sustainability of public interest in, and commitment to, Aboriginal health and the consequential lack of willingness of our political leaders to live up to their promises. Politicians regularly overpromised and underdelivered in Aboriginal affairs. Former Disability Discrimination Commissioner Graeme Innes describes the “soft bigotry of low expectations”1 as a barrier that people living with disability confront in health care. Sarra has similarly highlighted the impact of low expectations on Aboriginal education outcomes.2 I think the same “soft bigotry” applies to public expectations of Aboriginal health.

It is true that incrementally, slowly, too slowly, things are changing in some areas. Infant mortality in the Aboriginal and Torres Strait Islander population is declining,3 and we have seen significant decreases in avoidable deaths in some jurisdictions4 and improvement in access to medications.5 Aboriginal health is better today than it was in 1971 when the first Aboriginal Medical Service was established, but we need to ask ourselves whether the incremental gains, given elapsed time and effort invested, are sufficient? Where is the tectonic shift that will propel change in Aboriginal health forward at a much more rapid rate? Where is the new strategy that will deliver the Closing the Gap targets on time?

Prime Minister Malcolm Turnbull has said of the Closing the Gap campaign that “we cannot sugar-coat the enormity of the job that remains”6 and has called for innovative and new approaches. Leader of the Opposition Bill Shorten has encouraged us to listen to the “whispering at the bottom of our hearts”7 because it speaks honestly to the unease arising from the knowledge that we can and must do better.

Incremental change is insufficient if our aspirations for Aboriginal and Torres Strait Islander health and the results we deliver are to better align. We need to eschew the soft bigotry of low expectations, of slow incremental change, and embrace a more transformative change agenda.

We need change that not only develops new knowledge but, importantly, puts what we already know into practice efficiently and equitably. The research, for example, supporting the importance of access to high quality, consistent, comprehensive primary health care is extensive,8 but we have largely taken a patchwork approach to coverage in Aboriginal health.

It is still too much the case that Aboriginal and Torres Strait Islander peoples are confronted by a system in which the core services necessary to underscore a successful healthy journey across life are inconsistently available and of varying quality.9 Not all can access prenatal, infant, early childhood, adolescent, adult life and later life services as individuals or as cohorts when, and at a level, they require.10 In this issue, Ah Chee and colleagues provide an example of how transformative change can be implemented through an innovative model based on intervention before Aboriginal children reach school age.11

We need to shift from a program of low expectations to an approach that reinvents organisations and transforms structures, systems, technologies and processes to provide change that transforms the culture of organisations, professions and the workforce and the relationships across societal silos; change that reshapes public policy, financing and accountabilities. We need transformation not incremental change and it will be complex and risky. Tolerating incremental change costs lives, money and economic and social capital.

If we continue to rely on the slow and incremental, we will continue to bear these unacceptable costs. Without transformative change, we are doomed to be haunted by the whispers at the bottom of our hearts.

Are Indigenous mortality gaps closing: how to tell, and when?

Lags between policy and outcomes mean it is important to have good metrics and the right expectations about timelines

It is well known that the health of Australia’s Aboriginal and Torres Strait Islander people is considerably poorer than that of their non-Indigenous counterparts.1 Strategies, policies, programs and funding over many years have been targeted toward improving the health of Indigenous Australians and closing the gap in health status between Indigenous and non-Indigenous Australians. In this article, we review trends in key mortality rates for both populations and two complementary indices of the gap between them, both of which are essential to understanding progress or otherwise in closing the mortality gaps. Importantly, we also discuss the time required until the impact of policy changes can be assessed.

Measures of “the gap”

An understanding of changes in mortality over time requires: (i) graphing the non-Indigenous and Indigenous rates to see whether they are declining, remaining stable or increasing; (ii) showing trends in the rate difference (obtained by subtracting the non-Indigenous rate from the Indigenous rate) to indicate movement in the absolute size of the difference and the magnitude of improvement required for the gap to close; and (iii) showing trends in the rate ratio (obtained by dividing the Indigenous rate by the non-Indigenous rate) to indicate whether the relative rate of improvement in Indigenous mortality is faster than for non-Indigenous mortality — the fundamental requirement for the “gap” to finally close.

Are the gaps closing?

Analysis of data from the Aboriginal and Torres Strait Islander Health Performance Framework 2014 report shows that the overall difference in death rates between Indigenous and non-Indigenous Australians during 2008 to 2012 was 389 deaths per 100 000, with a rate ratio of 1.7.2 The Box shows rate differences and rate ratios for mortality from all causes, child mortality and infant mortality among Indigenous and non-Indigenous Australians from 1998 to 2012.

There have been significant declines in the all-cause mortality rate for both Indigenous and non-Indigenous Australians from 1998 to 2012 (of 13.2 and 7.5 deaths per 100 000 per year respectively; both P < 0.001). The rate difference also declined significantly, by 5.8 deaths per 100 000 per year (P = 0.004). The rate ratio, however, did not decline significantly (P = 0.62), with Indigenous rates remaining about 70% higher than non-Indigenous rates throughout the period.

For cardiovascular disease, there have been significant declines in the mortality rate for both Indigenous and non-Indigenous Australians (of 12.3 and 7.7 deaths per 100 000 per year respectively; both P < 0.001). The rate difference also declined significantly, by 4.6 deaths per 100 000 per year (P < 0.001), but the rate ratio, although showing a slight downward trend, did not decline significantly (P = 0.64).

For cancer, there was a significant decline in the mortality rate for non-Indigenous Australians (of 1.3 deaths per 100 000 per year; P = 0.009) but a significant increase in the Indigenous mortality rate (of 2.1 deaths per 100 000 per year; P < 0.001). The rate difference therefore widened significantly by 3.4 deaths per 100 000 per year (P < 0.001). The rate ratio also increased significantly (by 0.02 per year; P < 0.001).

For child mortality, there was a significant decrease in the mortality rate for both Indigenous and non-Indigenous children (of 5.5 and 2.1 deaths per 100 000 per year respectively; both P < 0.001), a significant decrease in the rate difference (by 3.4 deaths per 100 000 per year; P < 0.001) and a small but significant decrease in the rate ratio (by 0.02 per year; P = 0.03).

Most childhood deaths (around 80%) occur in the first year of life.1 Between 1998 and 2012, Indigenous infant mortality rates declined more quickly than non-Indigenous rates (0.7 and 0.1 deaths per 1000 live births per year respectively; both P < 0.001), and so the gap is closing. In 2012 Indigenous infant mortality was 5.0 per 1000 live births, compared with 3.3 for non-Indigenous infant mortality, a gap of 1.7 deaths per 1000 live births. The rate ratio in 2012 was 1.5.

The rate difference and rate ratio provide different but complimentary perspectives on changes in the gap over time. When the Indigenous rate is much higher, a larger (in absolute terms) reduction in the Indigenous rate is required to achieve the same proportionate reduction as an equivalent relative change in the non-Indigenous rate. This means that the rate difference can decline while the rate ratio remains relatively constant, as with cardiovascular disease.

Should the gaps be closing yet?

A wide range of strategies, policies and programs aimed at improving Indigenous health have been implemented over many years, from the establishment of Aboriginal health units in several states in the late 1960s and the initiation of the first Aboriginal Medical Service in Redfern in 1971, to the development of a National Aboriginal Health Strategy in the late 1980s, the establishment of the Healthy for Life program in the mid-2000s, through to the Closing the Gap targets on life expectancy and childhood mortality set by the Council of Australian Government (COAG) in 2008, and beyond. With any policy, however, there is a lead time between when the policy is announced and when it is fully implemented through programs and interventions on the ground. Significant lead and lag times can occur between:

the policy announcement and the full implementation of the program;
program implementation and improvements in health;
improvements in health and the consequent reduction in mortality; and
when a death occurs and the data become available.

An analysis of the expected length of time required to implement programs designed to promote maternal and child health, the resultant improvements in birth outcomes and infant and child health, the consequent reduction in child mortality and the availability of data to confirm this reduction estimated there would be a lag of about 10 years between implementation of a program and the ability to measure its effects.3 A number of intermediate measures that are available in shorter time frames can be used to indicate whether or not infant and child health are improving. These include the take up of antenatal care programs, the prevalence of smoking and alcohol use during pregnancy, breastfeeding and vaccination rates, the incidence of low birth weight, pre-term births and infant and childhood disease, and neonatal and infant mortality.3

The mortality outcomes shown in this article are at least in part the result of policies and programs implemented many years ago. It is likely that the added effect of the COAG child and maternal health initiatives announced in 2008 will not show up in mortality data until around 2018, which will be available for reporting in 2020.

Similarly, it is likely that the additional effects of the COAG smoking initiatives announced in 2008 might be assessed from changes in smoking rates from 2014 onwards, measured in national survey data collected in the financial year 2017–18, with consequent reductions in smoking-related cardiovascular and respiratory mortality from 2018 onwards, reported from 2020 onwards. The much longer lag times for lung cancer could mean that the first effects of the COAG smoking initiatives on cancer mortality may not be seen until 2030.

Implications

Australian governments have made major commitments to tackling critical areas in Indigenous health to close the health gap between Indigenous and non-Indigenous Australians. While changes to these indicators cannot be attributed to the policy context alone, ongoing monitoring of relevant indicators and the size of the gap, and assessment of whether it is changing over time, is required to further inform policy and program direction.

The different perspectives of the rate ratio and the rate difference provide useful information regarding whether the gap is closing. The rate ratio assesses the relative rates of improvement for Indigenous and non-Indigenous populations, while the rate difference provides information about the size of the task to be achieved. Both measures, set in the context of the observed rates, provide information on the closing or widening of the health gap. For all measures apart from cancer, the rate differences are declining significantly, but for the gaps to ultimately close, improvements in Indigenous rates need to occur significantly faster than in the non-Indigenous population, as is happening for infant mortality and, to a much lesser degree, for child mortality.

The changes in mortality rates we describe reflect, at least in part, the cumulative effects of many years of policies and programs aimed at improving Indigenous health, and were occurring before the effects of the Closing the Gap initiatives had sufficient time to appear in currently available data. At this stage it is too early to see whether the health gaps are closing because of the added effect of the Closing the Gap programs. Lags between policy decisions, the implementation of programs and policies aimed at reducing the gap, the effects on risk factors and health-related outcomes, and the availability of data to monitor these outcomes mean that the additional impact on mortality of the Closing the Gap agenda and related initiatives will not be able to be assessed until 2018 onwards.

Box –
Rate differences (per 100 000 population) and rate ratios for Indigenous and non-Indigenous mortality from all causes, child mortality and infant mortality, 1998–2012

Towards an integrated model for child and family services in central Australia

An innovative model for the delivery of child and family services

The Central Australian Aboriginal Congress is a large Aboriginal community-controlled health service based in Alice Springs in the Northern Territory. Since the 1970s, Congress has developed a comprehensive model of primary health care delivering evidence-based services on a foundation of cultural appropriateness.

In recent years, the community-elected Congress Board has focused on improving the developmental outcomes of Aboriginal children. This has led to the development of an innovative model for the delivery of child and family services, based on the belief that the best way to “close the gap” is to make sure it is not created in the first place.

Early childhood development

It is well established that social and environmental influences in early childhood shape health and wellbeing outcomes across the life course. Adverse childhood experiences are correlated with a wide range of physical health problems and with increased levels of depression, suicide attempts, sexually transmitted infections, smoking and alcoholism.1

The pathways for these effects are complex; however, we know that during the first few years of life, the interactions between genetics, environment and experience have a dramatic impact on brain development. During this critical period, children need stimulation and positive relationships with caregivers to develop the neural systems crucial for adult functioning.2

This evidence indicates that we should not wait to intervene until a child is ready for school at around 5 years of age. By this stage, children have passed many developmental gateways for language acquisition, self-regulation and cognitive function, and their developmental trajectories are set. Of course, developmentally challenged children must be provided with appropriate services during their school years and later in life, but such interventions require increasing amounts of resources (Box 1)3 and produce diminishing returns as the child gets older.4

Governments and policy makers have now widely recognised the importance of investing in the early years.5 The Organisation for Economic Co-operation and Development has advised that investing in early childhood is the most important measure that Australia can take to grow the economy and be competitive in the future.6

Successful programs

There are well evidenced programs for young children and their families that significantly improve health, educational and social outcomes throughout the life course, and which are highly cost-effective compared with later interventions (or with doing nothing, which is the most expensive option).

Congress has taken particular interest in two preventive programs that have been successfully implemented in disadvantaged communities overseas. These are the Nurse–Family Partnership (NFP) and the Abecedarian approach to educational day care. Both programs work with caregivers and children before developmental problems arise, providing children with the stimulation, quality relationships and access to the services they need for healthy development.

The NFP is a program of nurse home visitation which begins during pregnancy and continues until the child’s second birthday. Pioneered in the work of Olds and colleagues,7 trained nurses use a structured program to address personal and child health, quality of caregiving for the infant, maternal life course development and social support. Special attention is given to establishing a safe, nurturing and enriched parent–infant relationship. Over many years of working with low income, socially disadvantaged families in the United States, the NFP has achieved improvements in women’s prenatal health8 and reductions in child abuse and neglect, maternal use of welfare, substance misuse, and contact with the criminal justice system.9 Children who participated in the program showed long term benefits, such as reduced antisocial behaviour and substance misuse during young adulthood.10

The Abecedarian approach provides a centre-based preventive program for children who are at high risk of developmental delay. It has three main elements — learning games, conversational reading and enriched caregiving — with a priority on language acquisition. The approach has been rigorously evaluated, and longitudinal studies that followed children into adulthood found that participants did better at school; gained more years of education; had better employment outcomes;4 showed reduced rates of smoking, drug use and teen pregnancies and led a more active lifestyle.11 There is also evidence of a significantly lower prevalence of risk factors for cardiovascular and metabolic disease for participants (particularly men) when they reach their mid-30s.12 These effects work against the social gradient, with children from more disadvantaged environments benefitting the most,13 which makes the approach a potentially powerful contributor to social equity.

The situation in central Australia

While the cultures and histories of Aboriginal communities in central Australia make them unique, they share many characteristics with communities in which these programs have been effective.

In particular, many Aboriginal children in and around Alice Springs grow up in an environment marked by poverty, substance misuse and lack of responsive care, with low levels of formal education and school attendance coupled with economic marginalisation and social exclusion.

This is reflected in figures from the Australian Early Development Census (AEDC), which show that by the time they start school, 43% of Indigenous children in the Alice Springs region are vulnerable on two or more of five developmental domains. This is six times the rate for non-Indigenous children (7%) (NT AEDC Manager, Early Childhood Education and Care, NT Department of Education, personal communication, 1 April 2016).

Responding to the developmental needs of Aboriginal children

The Congress integrated model for child and family services is the culmination of its efforts to develop an innovative service response to these challenges based on the best available evidence (Box 2).The key elements of the model include nurse home visitation through the Australian Nursing Family Partnership Program (ANFPP); the Preschool Readiness Program (PRP); the Healthy Kids Clinic; family support services, such as Targeted Family Support and Intensive Family Support; and the Child Health Outreach Program. Congress also runs a childcare centre.

As part of this model, Congress has delivered two short-term programs drawing on the Abecedarian approach. The first was an intensive intervention run through the PRP in 2011 and 2012.14 In the second, Congress is collaborating with the University of Melbourne to assess the impact of a limited implementation of the Abecedarian approach with children attending the Congress childcare centre.

The importance of integration

The Congress model is founded on a long term population health approach that is expected to deliver results in health and wellbeing across the life course. Integration of services under a single provider is the key to achieving this potentially transformative change, enabling children and families to be referred seamlessly to the services that best meet their needs. Such integration is now recognised as a crucial reform needed to increase the cost-effectiveness of services and improve access and outcomes for children and their families.15

The advantages of the Congress integrated model are that:

it supports a consistent approach to screening, allowing children and families to be referred to the programs that best meet their needs;
it allows internal efficiencies between programs to enhance services, thus making a better use of available resources;
it is built on the existing relationships that Congress has with Aboriginal families in Alice Springs through the delivery of culturally appropriate primary health care;
it allows a common evidence-based approach, modified to meet the cultural and social needs of our clients;
it may provide secondary gains for other health programs (eg, working with client families on healthy lifestyles or addiction problems); and
it encourages partnerships with researchers to evaluate progress and with other service providers for follow-up of clients.

Promising early results

This integrated model for child and family services may take many years to show all its benefits. Nevertheless, the early signs are promising.

While maintaining engagement with any disadvantaged population is a challenge, the ANFPP shows a high level of client acceptance, largely due to the inclusion of Aboriginal community workers alongside the nurses. This is reflected in good retention rates: the attrition rate before the child reaches 1 year of age is 44.1%, lower than in the overseas implementations where it is 49.5%. Moreover, a preliminary analysis shows an infant mortality rate of 8.3 per 1000 live births for the 240 infants whose mothers have been on the Congress program, which compares favourably with the NT rate of 13.7 infant deaths per 1000 live births. While these small numbers must be interpreted with caution, they are consistent with the reductions in infant mortality demonstrated in randomised control trials in the US.16

The PRP, which incorporated the Abecedarian approach, also showed positive results even with a limited program delivery. This included developmental gains in expressive language and social skills,17 higher preschool attendance rates and improvements in confidence and school readiness.15

While the data from the collaboration between Congress and the University of Melbourne to implement the Abecedarian approach at the Congress childcare centre are not yet available for publication, an early analysis suggests that they will also show significant benefits in children’s language acquisition and attention.

Conclusions

The integrated model implemented by Congress is already yielding some important lessons on addressing early childhood development in Aboriginal Australia.

First, there is a need for an evidence-based approach adapted to local social and cultural conditions. This requires fidelity to the original program design allied with the local knowledge that Aboriginal community-controlled health services such as Congress have built up over the years. We contrast this approach of responsible innovation with reckless innovation, which ignores what has already been achieved and proceeds on the basis of little or no evidence.

Second, there are the benefits of integrated solutions before school age being provided through the primary health care sector where possible. It is this sector which, through its delivery of antenatal and perinatal care, establishes supportive relationships with mothers, families and children in the period from conception to 3 years of age. Thereafter, the education sector should continue to take responsibility for preschool and primary education.

Box 1 –
Rates of return for human capital investment for disadvantaged children

Modified from Heckman and Masterov3

Box 2 –
Central Australian Aboriginal Congress integrated model for child and family services

Description

Primary prevention*

Secondary prevention^†

Child focus

Carer focus

Child focus

Carer focus

Centre based

Most work is done at a centre where a child or families come in to access service

Abecedarian educational day care; immunisations; child health checks; developmental screening

Health advice to parents in clinic (eg, nutrition, brushing teeth, toilet training)

Child-centred play therapy; therapeutic day care; Preschool Readiness Program; antibiotics

Filial therapy; circle of security; parenting advice/programs; parent support groups

Home visitation

Most work is done in the homes of families where staff outreach to children and families

Mobile play groups

Nurse home visitation; families as first teachers (home visiting learning activities)

Child Health Outreach Program; ear mopping

Targeted Family Support; Intensive Family Support; case management models for children at risk; Parents under Pressure

* The primary prevention targets children with no current problems, but who are at risk of developing them — the identified risk is usually based on low socio-economic status or maternal education level. † The secondary prevention targets children with current problems identified early in life when they are most likely to respond to intervention and before the problems get worse — it is determined by screening or referral to services.

Financial toxicity in clinical care today: a “menu without prices”

Out-of-pocket costs are rising rapidly and can influence treatment decisions and health outcomes

Australia delivers health outcomes that rank well internationally, with per capita spending demonstrably less than that of the United States. Of concern, Australia’s out-of-pocket costs for health care are sixth highest among Organisation for Economic Co-operation and Development countries,2 despite universal health insurance. These out-of-pocket expenses accounted for 57% of non-government health expenditure in 2011–12, or over 17% of all health care expenditure.3 Health care costs in Australia continue to rise well above the consumer price index. The net burden of costs are reported by clinicians to influence some decisions that patients make, with the potential for detrimental health outcomes for individuals and for Australia’s health as a whole.

The average equivalised weekly disposable household income in 2013–14 was $998, with a median of $844.4 About half of all households therefore have a weekly net income of less than $844, yet that income has to support out-of-pocket health expenses. There are also limits to what is covered under different aspects of the safety net. Further, many aspects of community-based care are associated with part or all of the cost being borne by the patient, in many cases with no safety net provisions (wound dressings, incontinence pads, community nursing and allied health visits).

In cancer care, patients often face tough decisions as new unsubsidised therapies become available. An ageing population, innovations (some with very marginal benefits) and the risk that some procedures are overused or harmful all contribute to unnecessary financial (and emotional) pressure on patients and their families. Procedures and interventions, at times with marginal health gains, are being promoted actively, frequently with high costs and little meaningful benefit in terms of quality of life or survival. In the context of ongoing outcome disparities based on socio-economic status, our aim must be timely access to world class care for all Australians, regardless of financial circumstances.

In the Australian context, financial disclosure is not only how much a procedure will cost but, crucially, whether there are alternatives that offer similar benefits at less cost to the patient. This may be as important to the patient as the side effects or risks of an intervention. Most starkly, the omission of information from a private clinician regarding options in the public sector reduces informed financial choice and increases the potential for significant financial and health disadvantages.

Failing to inform patients about comparative waiting times in public and private systems falls short of fully informed (financial) consent. Indeed, national data demonstrate that public surgical waiting times for a sample of cancers are very short.5 Publicly available data on waiting times and service quality are critical for supporting informed treatment decisions, especially when out-of-pocket expenses can vary from zero to tens of thousands of dollars for the same procedure.

Value in health care is defined as outcomes relative to cost.6 In considering this from a patient’s perspective, it is imperative to not only question outcomes but to understand the true cost for the whole episode of care — the out-of-pocket expenses, the contribution made by the community through Medicare, and any supplementary private insurance. Informed choice should be based on more than the costs charged by an individual practitioner and those incurred by related pathology, imaging and anaesthetics. Informed choice now needs also to account for the extreme variations in the prices charged by identically credentialed practitioners within Australia undertaking the identical procedure.7

International data suggest that the consequences of high out-of-pocket costs include the potential for poorer compliance with ideal care, including prescribed medications that are necessary for best outcomes.8,9 To make decisions about what is often a long treatment pathway across multiple modalities, patients need a comprehensive and early understanding of the financial impacts of treatment, time away from work and other costs, and the opportunity to seek financial advice and assistance early as needed. Indeed, in one survey, people only sought help when the financial burden was starting to cause significant difficulties.9

Arguably, failure by medical practitioners to disclose all of the financial costs affecting patients’ decisions is a cause of avoidable suffering for tens of thousands of households across Australia each year.10 A new standard for financial disclosure is required — a standard that moves beyond disclosure of the costs of a single procedure to one that accounts for the costs of a full pathway of treatment and all the alternatives open to the patient. The issue of financial toxicity in Australian health care requires open debate supported by population- and individual-level data on rapidly rising out-of-pocket costs, and advocacy that places patients’ outcomes at the centre of any debate about the profession’s increasing demands on patients’ wallets.

Rebate freeze ‘must go’: Gannon

New AMA President Dr Michael Gannon has declared that the Medicare rebate freeze is “unfair…and wrong”, and must be scrapped.

In his first public statement following his election at the AMA National Conference, Dr Gannon reaffirmed the peak medical organisation’s commitment to overturning the freeze, which he warned could force some doctors to abandon bulk billing and begin charging patients up to $25 a visit.

“GPs are at breaking point. They can’t take too many more cuts,” he said. “I would not be surprised if those practices that move away from bulk billing, and decide to invest in the infrastructure required to collect the fees, turn around and collect something like a fee between $15 and $25”.

The Federal Government’s decision to extend the current freeze on Medicare rebates an extra two years to 2020 has provoked outrage among GPs and the broader medical profession. The AMA has mounted a nationwide campaign against the policy, which is also the target of television ads by the Royal Australian College of General Practitioners that warn patients the freeze means “you will pay more”.

Dr Gannon has assumed the presidency in a highly politically-charged environment, with the nation embroiled in one of the longest Federal Election campaigns in decades. Opinion polls have the two major parties locked in a close contest.

THe Western Australian obstetrician has held discussions with Health Minster Sussan Ley, Shadow Minister Catherine King and Greens leader Richard Di Natale, and promised to “pursue a consultative style [to] try and find constructive ways forward”.

He said there was an opportunity to improve the AMA’s relationship with Ms Ley, and said the AMA should “always try and be constructive when it criticises policy of governments or opposition to come up with alternatives”.

Dr Gannon warned that, “when you criticise Government on any area of policy you need to realise that there might be a cost in that area or in other areas of your agenda”.

But he said the Medicare rebate freeze had to go, and reiterated the AMA’s support for Labor’s policy to end the freeze. Both Labor and the Greens have promised $2.4 billion to reinstate rebate indexation from 1 January next year.

Dr Gannon called for the Coalition to “change tack” on the freeze.

“Unravelling the freeze is so important,” he said, adding that such a move should be the start of a broader discussion about improved support for general practice.

“Successive governments have under-invested in quality general practice. That is the cornerstone of the health system,” he said. “High quality primary care reduces the need for more expensive hospital admissions. Unravelling the freeze is not a solution to the underfunding of general practice. We need to do so much better.”

The AMA President also attacked Commonwealth cuts to public hospital funding.

“I don’t think that there’s room to cut hospital funding; in fact, quite the opposite,” Dr Gannon said.

While the AMA needed to be “responsible” in calling for greater health funding, he lamented that both the Federal and State tiers of government had failed to comprehend the rise in hospital costs stemming from the ageing population and health epidemics like obesity and drug use.

But Dr Gannon said his advocacy would not be limited to general practice and hospital, and the AMA’s “very strong” platform on social issues would continue under his leadership.

He said he was committed to “continuing the AMA’s long history in trying to close the gap between Indigenous and non-Indigenous Australians”, and also made particular mention of mental health and “speaking up for people who can’t speak for themselves”.

Adrian Rollins

The Port Arthur massacre and the National Firearms Agreement: 20 years on, what are the lessons?

Twenty years after the Port Arthur massacre and the National Firearms Agreement (NFA), it is timely to examine how assertive national firearms regulation has prevented firearm mortality and injuries, and gun lobby claims that mental illness underpins much gun violence.

On 28 April 1996, Martin Bryant, a lone gunman using semi-automatic weapons killed 35 people at Port Arthur, Tasmania. In response, the Australian Prime Minister, John Howard, negotiated strict national gun control laws, banning automatic and semi-automatic rifles and shotguns, and introducing uniform stringent firearms licensing, a waiting period, security and storage requirements, sales regulation, and instituting compulsory buybacks of the banned weapons. Licensing required a proven genuine reason, with prohibition or cancellation for violence, apprehended violence or health reasons. The Commonwealth, states and territories implemented the NFA in 1996 and the National Handgun Control Agreement in 2002 with bipartisan support. In their wake, the national firearms stockpile reduced by one-third and public mass shootings have so far ceased. Although total homicides have declined since 1969, stabbings exceed shootings (more lately increasingly [http://www.aic.gov.au/statistics/homicide/weapon.html]), and hanging may later have substituted for gun suicides, rates of total gun deaths, homicides and suicides have at least doubled their rates of decline, suggesting that comprehensive gun control measures were responsible.1,2 A 2010 evaluation found that the reforms were averting at least 200 deaths per year and saving around $500 million annually.3

Community reactions to maintaining public memorial services after 20 years reveal the massacre’s long-term traumatic impacts. The anniversary highlights disparate issues: remembering forgotten (especially Indigenous) massacres; firearm availability; debatable relationships between mental illness, violence, guns and indiscriminate media reporting; and future actions to support rather than erode public health gains.

Following recent mass shootings in the United States, gun lobbyists claim that mentally ill people cause gun violence (http://www.theguardian.com/world/2012/dec/21/nra-full-statement-lapierre-newtown) whereas gun control advocates, including President Barack Obama, have invoked the Australian model.

The relationship of psychosis or serious mental illness and violence has been thoroughly reviewed elsewhere.4–6 Various methodological considerations (eg, institutional versus community samples, definitions of mental illness, temporal relationship of illness and violence) influence conclusions.5 However, from the US Epidemiologic Catchment Area (ECA) Study in 1990 onward, numerous international population studies have confirmed a modest but significant link between mental disorders and community violence (4% 1-year population-attributable risk [PAR] in the ECA study).4 Risks of violence for psychoses are 2–10% PAR compared with the general community, 20% PAR for personality disorders (including antisocial personality disorder), and 25% PAR for substance misuse.4 Odds are higher for homicide; Australian statewide data- and case-linkage studies indicate that people with schizophrenia perpetrated violence five times more often7 but homicide 13 times more often8 than the general community. Some studies show the relationship to be fully mediated by dispositional, situational and disinhibitory factors, including substance misuse;9 others find that substance misuse attenuates, not cancels, the relationship.7,8 Untreated active psychotic symptoms10 and past violence play key roles. Risk for violence in psychosis and schizophrenia may predate active symptoms or result from active illness or treatment. Developmental difficulties, impulsivity and anger, antisocial behaviours, social disadvantage or subculture, and substance use mediate these risks. High risk groups are generally identifiable and most violent acts should be preventable.6

Such studies confirm that most violent individuals do not have mental illness, and that the vast majority of individuals with mental illness are not violent. They are more likely to be victims not perpetrators of violence.11 Media portrayal of violence by people with mental illness reinforces public perception of their dangerousness, further stigmatising and endangering them.4 Almost half of those who die at the hands of US police have some kind of disability.12 Crucially, mental illness is strongly associated with suicide — with PARs ranging from 47% to 74%.4

Individuals who do not have mental illness perpetrate more than 95% of gun homicides.13 Rather than armed civilians reducing crime and homicide, extensive studies show that US gun availability, household gun ownership and diluting gun laws increase firearm homicide14 and suicide.15 In 27 developed countries, gun ownership strongly and independently predicted firearm homicide and suicide, whereas the predictive capacity of mental illness was of borderline significance.16

Although mass murderers who seize media attention often seem to suffer from psychosis, no research clearly verifies that most are psychotic or even suffering from severe mental illness.17 One recent analysis of mass shootings in the US reported that in 11% of cases, prior evidence of concerns about the shooter’s mental health had been brought to medical, legal or educational attention.18 Reports that 43%19 and 56%20 of US mass killers have serious mental illness may be confounded by primary diagnostic reliance on internet, law database and newspaper searches, an apparent dearth of reliable information about psychopathology and authorities’ knowledge of illness, and complications for retrospective analysis of murder–suicide or “suicide by cop”. Of 130 victims of mass gun killings in Australia and New Zealand from 1987 to 2015, 78% were slain by someone without a known history of mental illness, 88% by someone without a history of violent crime, and 56% by someone legally possessing firearms (http://www.gunpolicy.org/documents/5902-alpers-australia-nz-mass-shootings-1987-2015). Thus, the mass killer is frequently until that moment a law-abiding owner of a lawfully held gun.

Mass murder is an almost exclusively male phenomenon that is frequently planned in advance as retribution for perceived wrongs,17 to vindicate, and to potentially overcome hopelessness and invisibility with instant fame and omnipotent destruction. Many have maladaptive (eg, paranoid, sadistic, narcissistic, antisocial) personality configurations.17 Martin Bryant’s trial judge, relying on four forensic psychiatrists’ reports, noted Bryant was not suffering from mental illness but a personality disorder with limited intellectual and empathic capacities (http://www.geniac.net/portarthur/sentence.htm).

Also critical to vindictive or alcohol (or other drug) related gun violence are precipitating and background factors — situations such as domestic conflict and violence, school or work grudges, toxic social networks, and isolation.17 Whether media reporting of other mass murders primes potential perpetrators with instructions and the above incentives21 requires further investigation.

Firearm suicide, overshadowed in public debate but contributing 77% of total gun deaths in Australia in 2014 (http://www.gunpolicy.org/firearms/region/australia#number_of_gun_suicides), is of especial concern. In Queensland, the firearm suicide rate among people with a current licence far exceeded that of those with no licence.22 General rural suicide rates are roughly twice city rates. Farmers may need guns, but safe storage and removal of the weapons at vulnerable periods of life are vital to prevent suicide.

So 20 years later, what are the lessons?

The NFA, which reduced firearm deaths, particularly suicides but also homicides and mass shootings, mirrors similar benefits of comprehensive gun control measures elsewhere.23 However, prevention of firearm injury and mortality intersects with other pressing public and mental health challenges such as domestic violence and suicide, and therefore needs multidisciplinary coordinated efforts.

Following recent US gun massacres, there have been calls for better resourcing of mental health services to help identify and respond to those at risk and to regulate firearms access.24 Because people with mental illness are not categorically dangerous, and because sensitivity and specificity problems with screening for violence mean that psychiatrists are no better than laypeople or chance at prediction,4 using strategies such as screening mentally ill populations for violence risk is misguided (not to mention costly, burdensome and infringing rights). However, clinicians have a key role in monitoring and assisting regulation of firearm access, especially for high risk populations (eg, children, adolescents, suicidal people, domestic violence victims and perpetrators, farmers and rural residents, police, and security employees). Their work with legal authorities regarding time-sensitive and situation-specific risks needs further exploration.4 Legal measures include penalising alcohol intake around firearm usage; keeping guns from domestic violence and drink-driving offenders; requiring licensed shooters to surrender guns during periods of vulnerability due to anger, threats and suicidality; and a lower threshold for permanent removal of guns and gun licences. Implications for patient confidentiality, the therapeutic alliance and informed consent, also require examination. As with suicide, responsible media reporting should apply to mass violence.

The national weapons stockpile has now returned to pre-1996 levels (http://www.theconversation.com/if-lawful-firearm-owners-cause-most-gun-deaths-what-can-we-do-48567), highlighting the need to maintain and strengthen the national regulatory regime. Complacency has somewhat eroded the NFA. For example, in New South Wales, the pro-gun lobby succeeded in weakening the regulation of pistol clubs — arguably causing at least one homicide.25 NFA opponents hope to overturn the ban on semi-automatic long arms.

The NFA banned semi-automatic rifles and shotguns, but not semi-automatic handguns (pistols), which are permitted for pistol club members. The logic of stringent restrictions on rapid-fire weapons is equally applicable to handguns, which although currently accounting for few gun deaths, are the concealable weapon of choice for criminals. The medical community has long supported bans for semi-automatic handguns. We need a review, revision and tightening of existing laws and more effective restrictions and controls on possession, import and sales of handguns and other firearms, especially via the internet and by illicit imports.

In the US, the National Rifle Association insists it is not guns that kill but only bad and unhinged people (http://www.theguardian.com/world/2012/dec/21/nra-full-statement-lapierre-newtown). Yet evidence suggests that for some people who are indistinguishable within the general public, including some with interpersonal and personality issues, having easy, legal access to guns is lethal, resulting in avoidable excesses of both domestic and mass killings. Clinicians may offer much to firearm risk management yet must remain ambivalent about targeting those with mental illness for gun intervention if this is not complemented by wider gun control measures.4 The campaign to deflect social concern over firearms availability into a debate about whether people with mental illness histories should access such weapons should be exposed as a calculated appeal to prejudice.

Better Access and equitable access to clinical psychology services: what do we need to know?

Critical data on the delivery, outcomes and out-of-pocket expenses of services are lacking

The Australian Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative aims to improve access to evidence-based mental health care in the community.1 Providing rebates for private services appears to be improving treatment uptake,2 yet the equity of Better Access has been questioned, with a recent study showing that specialised Better Access mental health services were disproportionately concentrated in affluent areas.3 This effect was particularly visible for clinical psychology services, with more than 2.5 times the volume of these services provided in the most, versus least, affluent areas. Within Better Access, clinical psychology services are intended for “the treatment of patients with complex and/or chronic mental health disorders, quite often with comorbid drug and alcohol problems”.4 As these patients are also more likely to experience financial distress and live in socio-economically disadvantaged areas,5 there is a pressing need to identify why clinical psychology services may be particularly vulnerable to inequitable service distribution.

Cost as a factor in inequitable access to clinical psychology services

Potential causes proposed for this inequitable service distribution include higher-paid professionals choosing to live in more affluent areas and work closer to home, or patients’ out-of-pocket expenses for these services being prohibitive.3 The differential impact of out-of-pocket expenses on access to specialist health services is widely recognised.6 Such expenses include those associated with attending treatment sessions, with incidental costs (eg, lost income, childcare, travel) averaging $57 per treatment session for face-to-face psychological interventions.7

Copayments, often used as a cost-sharing mechanism to distribute health care burden and encourage more judicious use of health services,8 are another common cost. Within Better Access, copayments are the responsibility of patients and cannot be covered by private health insurance rebates or other schemes, although they may be reduced through Medicare safety net arrangements after a specific threshold of expenses has been reached.9 Although copayments may place a financial burden on patients, they are often essential for supplementing non-remunerated tasks, including administration, professional development and supervision, to ensure sustainable private practice.10,11

Why comorbidity may be more important than copayments

However, there is evidence to suggest that copayments for clinical psychology services cannot fully account for inequitable service provision. Roughly 35% of Better Access clinical psychology services are bulk-billed (no copayment), with this rate similar to that for consultant psychiatry services (36%) and lower than that for services provided by other allied health professionals (43%).12 However, average copayment amounts are lower for clinical psychology services ($32) than for other allied health professionals ($37) or consultant psychiatry services ($82).12 So, while Better Access services are associated with higher out-of-pocket expenses overall — compared with schemes such as Access to Allied Psychological Services (ATAPS), where one in 20 sessions incurs a copayment averaging $13.5913 — these costs are not unique to clinical psychology services. Instead, epidemiological and treatment outcome studies suggest that comorbidity is a more likely contributor to inequitable Better Access clinical psychology service distribution.

Currently, there is no routine data collection on the number of treatment sessions provided by health professionals once Better Access allowances (ten individual and ten group sessions per calendar year) have been exhausted. Yet, several factors suggest that, if clinical psychology services are being used for more complex and comorbid presentations as intended, these services will extend beyond ten individual sessions. Comorbidity between mental disorders can signal more severe and treatment-resistant presentations and is often the norm, rather than the exception, in those with mental illness.14 Current best-practice guidelines for managing comorbid mental and substance use disorders include providing empirically supported treatments for each disorder, either sequentially or concurrently.15 Clinical practice guidelines synthesising high-quality clinical and health economic research literature, such as the guidelines developed by the United Kingdom’s National Institute for Health and Care Excellence,16 highlight that these empirically supported treatments are likely to extend beyond ten individual sessions, even for single disorders treated in isolation (Box). Although there is some debate about whether comparable treatment outcomes can be achieved in fewer sessions,17 it is unlikely that combinations of empirically supported treatments for multiple disorders (even in reduced formats) can be contained to ten individual sessions.

The financial impact of mismatched policy and practice

It is important to consider the financial impact of this mismatch between Better Access allowances and empirically supported treatment guidelines. Any sessions beyond Better Access allowances are not supported by alternative initiatives, such as ATAPS, or the Medicare safety net. Private health insurance rebates may also be less available to this population, as increased mental disorder has been linked to both limited financial resources5 and reduced private health insurance coverage.18 Currently, there is little guidance about how to adapt therapy for people with complex presentations who cannot afford treatment beyond ten individual sessions. The Australian Psychological Society recommends adjusting usual intervention techniques to “ensure an outcome is achieved” within available sessions,19 but it is unclear how this is to be achieved or what impact these modifications will have on the effectiveness of treatment.20 There is also little guidance about how to use combinations of Better Access individual and group sessions to best support people with comorbid disorders.

After exhausting Better Access allowances, people who cannot afford ongoing care may be referred to other services, such as consultant psychiatrists (up to 50 individual consultations subsidised by Medicare per year1) or community mental health services. Yet, limited availability of these services may result in long waiting periods, reflecting the “missing middle” of the mental health system.21 It is also unclear whether referral to consultant psychiatrists or community mental health teams for delivery of psychological interventions reflects the most cost-effective or efficient use of scarce health resources. Extending Better Access clinical psychology allowances from ten to 16 sessions, as has been proposed,21 may help bring health policy more in line with empirical evidence.

However, the reduced provision of Better Access clinical psychology services in less affluent areas may not necessarily reflect poor treatment coverage in these areas. Better Access is only one component of federal mental health investment, representing 9.5% ($907.9 million) of federal government spending on mental health in 2012–13.21 It is complemented by a range of programs (eg, ATAPS) targeting hard-to-reach and disadvantaged populations. Lower Better Access coverage in some areas may not be inequitable if general practitioners are instead referring a comparable proportion of people to alternative schemes. This highlights how complex networks of funding arrangements make it hard to assess the overall equity of services.

Implications for mental health policy

Exploring discrepancies between clinical practice guidelines and reimbursement structures highlights the importance of empirical evidence in the design of health care financing. Although finite resources are a constraint in any health care system, without thoughtful consideration of empirically supported treatments, short-term cost-saving measures may have longer-term financial consequences. For example, capping Better Access sessions may contain costs in the short term but may also result in ineffective treatment, increasing rates of drop-out, relapse or reluctance to engage in treatment.22 This may then result in increased costs such as welfare payments, lost productivity and increased use of other health care services. The most recent estimate of the costs of mental disorders in Australia reaches up to $40 billion each year,21 highlighting the importance of identifying cost-effective methods for reducing this burden.

Rather than capping the number of sessions, more creative approaches to achieving efficiencies in the mental health system, while also potentially enhancing the quality of clinical care, could be explored. An example of this could include replacing the review of GP Mental Health Treatment Plans after six sessions with innovative technologies for tracking clinical trajectories. Recent estimates show that patients seek an average of 4.8 Better Access sessions,23 but it is unclear whether these brief treatment courses reflect successful treatment outcomes or treatment drop-out. This means the six-session review may occur too late to identify people at risk of poor outcomes. Anecdotally, requiring a review after six sessions can also have the unintended effect of setting unrealistic expectations about progress that demotivate patients or create treatment delays that negatively affect momentum of change. An alternative may be replacing the six-session review with the use of standardised assessment measures to monitor trajectories of symptom change, identify at-risk patients, provide clinically useful information to practitioners and generate real-time service use data.24

The importance of measurement for management

There is a critical lack of data on the delivery of mental health services under Better Access,21,25 including limited data on how practitioners adapt therapies to fit session constraints, the impact of these modifications, relapse rates, average out-of-pocket costs (not just copayments), the influence of the Medicare safety net on copayments and how various populations may be differentially affected by all these factors. A full understanding of the effectiveness and equity of Better Access requires information about the number of sessions completed once Better Access allowances have been exhausted, the utility of separating Medicare Benefits Schedule items for individual and group psychological therapy and how people transition through services over time.

With the most recent Australian population survey of mental disorders and service use conducted almost a decade ago,26 it is essential to develop a plan to ensure the collection of timely and meaningful data to inform current mental health reforms. It is also essential to take a multidisciplinary approach to mental health policy, to ensure policies facilitate the delivery of best-practice care to those who need it most.

Box –
Number of sessions for psychological interventions recommended by NICE clinical guidelines for mental disorders16

CBT = cognitive behavioural therapy. NICE = National Institute for Health and Care Excellence. * These figures do not include initial assessment sessions, which are typically required to confirm and refine diagnosis.4 † Signifies the current cut-off of Better Access sessions. ‡ Some sessions longer than 60 minutes recommended. § Recommended in conjunction with pharmacotherapy for moderate to severe presentations.

Ebola outbreak in West Africa: considerations for strengthening Australia’s international health emergency response

It is time for a common vision and strategy for deploying Australian expertise to international public health emergencies

An effective response to health emergencies such as the Ebola virus disease outbreak in West Africa relies on global capacity to rapidly surge the supply of skilled workers, particularly when they are limited in affected countries and increasingly depleted during the emergency. Before the Ebola outbreak, health professionals in West Africa were already scarce; for example, in Liberia the doctor-to-population ratio was 1:70 000, compared with 1:300 in Australia.1,2 In addition to clinicians, an effective response to a large outbreak of Ebola virus disease in resource-limited settings requires international technical support across a range of public health and other disciplines, including infection prevention and control, epidemiology, laboratory diagnostics, communication, mental health, anthropology, social mobilisation, logistics, security and coordination.

Early in the Ebola virus disease outbreak in West Africa, many international non-government organisations (NGOs) and several governments established treatment centres and sent public health professionals to provide clinical care and augment control efforts. Timely public health interventions in Ebola-affected rural communities achieved crucial reductions (about 94%) in Ebola transmission.3 The Centers for Disease Control and Prevention (CDC) in the United States is a case study in how governments can deploy significant public health staff to countries affected by health emergencies. At time of writing, the CDC had effected 2206 staff deployments since July 2014 to support the public health response in Ebola-affected countries across a wide range of areas including surveillance, contact tracing, database management, laboratory testing, logistics, communication and health education.4 Most CDC public health staff were deployed into roles with a low risk of Ebola virus infection (ie, non-patient care roles) and none have become infected. In assessing the CDC’s exemplary response, it is important to note its pre-existing Global Health Strategy that clearly articulates the CDC’s vision, rationale, role, strategy, funding, partnerships, staff and areas of expertise for working in international public health, including in health emergencies such as Ebola virus disease.5

In contrast, nearly 6 months into the outbreak — when almost 5000 deaths had already been recorded — the Australian Government was being criticised by public health experts for its lack of substantive assistance to Ebola-affected countries.6 The Public Health Association of Australia called on the government to help strengthen the medical and public health capacity in the region by deploying an Australian Medical Assistance Team (AUSMAT), and by supporting Australians who wanted to volunteer their services through the World Health Organization or international NGOs by encouraging their employers to provide special leave and continuation of entitlements.6 Ultimately, the Australian Government declined to deploy AUSMAT resources, stating it would not consider sending people to Ebola-affected countries until it could get assurances from developed countries closer to West Africa that Australians would be able to be evacuated for treatment in the event they became infected.7 Instead, the Australian Government chose to fund a private contractor to staff a single treatment centre built by British army engineers in Sierra Leone. To date, anecdotal reports suggest no public health professionals have been deployed to Ebola-affected countries by the Australian Government, although the risk of infection is low.

The current and all previous Australian governments have not clearly articulated a vision for providing public health support during an international health emergency. AUSMATs are multidisciplinary health teams of doctors, nurses, paramedics, firefighters (logisticians) and allied health staff such as environmental health workers, radiographers and pharmacists8 who provide timely acute medical relief immediately after disasters in Australia and overseas. Staff of state and territory governments can be members of AUSMATs, and these agencies are reimbursed by the federal government for the salaries of staff who deploy through this mechanism. AUSMATs have a relatively small number of public health professionals on a roster largely drawn from staff of state and territory health authorities, but this list includes only a limited number with relevant outbreak response skills. While AUSMATs have a proven track record in providing emergency medical care in post-disaster settings, they are not currently designed to support the public health response required for a large outbreak.

The decision not to use AUSMAT assets and the lack of federal support for other Australian health professionals who wanted to volunteer to help contain the Ebola outbreak transferred the pressure to institute human resource policies (ie, special leave and continuation of entitlements) to state and territory health authorities. Without the type of financial arrangements that the AUSMATs afford state and territory health authorities, and with a general lack of jurisdiction-funded strategies for their staff engaging in emergency responses overseas, the environment for staff deploying independently was not always supportive.

Despite the challenges, many public health professionals from state and territory health authorities and academic institutions in Australia deployed as volunteers for NGOs or United Nations agencies, including about 15% of the Australian National University Master of Applied Epidemiology (MAE) program’s alumni since 1991 (Martyn Kirk, MAE Program Director, Australian National University, personal communication). Still, only one current Australian MAE participant was deployed, with Médecins Sans Frontières (as of January 2015), compared with 97 from a similar program in the US (the CDC’s Epidemic Intelligence Service), highlighting the missed opportunity for Australia’s next generation of outbreak control experts to get invaluable field experience while providing much needed support.

Now that the Ebola virus disease outbreak is over, Australia needs to examine how well it performed in assisting the WHO to respond to this significant threat to global health, as it was declared by the International Health Regulations Emergency Committee in August 2014.9 We believe it is time for the Australian Government, in consultation with state and territory health authorities and public health training institutions, to establish a common vision and strategy for deploying Australian expertise to international public health emergencies, including Ebola virus disease outbreaks. If AUSMATs (currently the only funded mechanism) are Australia’s preferred approach to responding to international health emergencies, their capacity to support a major public health response should be expanded by including more professionals in relevant disciplines. To maximise the impact of public health professionals deployed through AUSMAT arrangements, personnel should be made available at the beginning of future health emergencies. In addition, formalising support arrangements with members of the Australian Response MAE (ARM) Network10 (created by academic institutions in response to gaps in the coordination of Australia’s public health surge capacity) may be a way for the government to effectively mobilise skilled public health professionals for deployment overseas in response to disease outbreaks. Consideration should also be given to expanding the AUSMAT roster of public health professionals and integrating structures like the ARM Network into the response framework.

The Australian Government missed an important opportunity to contribute timely, valuable technical assistance to Ebola-affected countries; support that was essential to stopping the outbreak at its source at a time when it was needed most. In the end, many Australians stepped up as volunteers in the fight to extinguish this global threat to public health. Australian federal authorities should reflect on this experience and consider it an opportunity to strengthen Australia’s response to future health emergencies and demonstrate leadership on the global stage.