more_vertFrom Malawi to the UK and back again and from Kenya to the UK and now, once again, to Malawi. There is, Professor Nyovani Madise admits, no grand scheme in her geographically oscillating career path; each move has been made in response to a particular need or opportunity. But the pattern has proved beneficial. Working in the UK has broadened her horizons and offered opportunities for her main field of research: the social determinants of sexual and reproductive health and rights (SRHR) in low-income and middle-income countries (LMICs).
Preference: Statistics, epidemiology and research design
1138
[Correspondence] Medical research in war-torn Syria: medical students’ perspective
The ongoing war in Syria has caused substantial damage to the country’s infrastructure, affecting almost all aspects of life.1 The consequences of this tragedy have further handicapped the underdeveloped research environment in Syria.
Code Green
BY DR TESSA KENNEDY, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING
When we talk about sustainability in health we are usually talking about spending and workforce. But what of the physical environment?
Existing AMA policy acknowledges that: “Human health is ultimately dependent on the health of the planet and its ecosystem. Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.”
Yet the health sector itself contributes around seven per cent of all greenhouse gas emissions. Our own resource rich settings create an enormous amount of plastic and other waste which take a direct toll on patient health and our environment. The way we run our hospitals is also increasingly unsustainable from an environmental perspective.
Health facilities and workers should promote a holistic approach to health, including its social and environmental determinants. We are increasingly acknowledging this: hospitals are non-smoking areas, because tobacco is a significant risk to health. There have been efforts to improve food options and exclude sugar sweetened beverages from hospital canteens because obesity is a significant risk to health.
Yet every time I place a cannula, suture a chest drain, resuscitate a baby, I generate a large amount of disposable, non biodegradeable waste, including plastics and instruments that have barely touched a patient. When I wash my hands tens of times a day, paper towels are co-mingled with nonrecyclable rubbish. Many of us will drive to work because of lack of public transport options to suburban hospitals, especially when working shifts, and a lack of showering and changing facilities required to encourage active self-transport options like cycling or jogging.
Disposable coffee cups, choice of volatile anaesthetic gases, computers and lights left on overnight – there are many environment degrading and wasteful practices that would take little effort to change.
Nonetheless, I’m sure like me, many of you have felt like the threat of climate change is more of an existential one than of direct relevance to your every day. Even with good intentions it just feels too big, too far beyond our reach to change. Like any efforts we make are just a drop in a warming ocean.
But what if we could see the impact of our actions in the community we treat? To measure the impact of our efforts to change in terms of patient outcomes and cost savings that could be reinvested in our insatiable health budget? It would be a lot easier to stay motivated.
Luckily, we not only have a fantastic opportunity of many low hanging fruit to improve sustainability due to the current lack of priority it is afforded, but a proven model of how to go about achieving change from the UK NHS Sustainable Development Unit. This dedicated unit has coordinated research, policy and action to improve the sustainability of health care. They succeeded in cutting NHS greenhouse gas emissions by 11 per cent between 2007 and 2017, despite an 18 per cent increase in health service activity.
If we are sincere in acknowledging climate change and environmental degradation as one of the most significant threats to human health in our time, we must acknowledge our part in addressing it in how we work. As Associate Professor Forbes McGain of the University of Sydney and Doctors for the Environment Australia has said: “The [Australian] health-care system can’t become low carbon and low waste without leadership, incentives and direction.”
Being aware of the environmental impact of our work practices and changing our individual actions are a great way to bring the issue front of mind and help start a conversation with others. But to achieve sizeable change we need to issue a triage category upgrade for environmental sustainability, and we need the whole system to respond.
So, bring your Keep Cup. But also ask the coffee shop whether they would give discounts to everyone who brings one. Choose the instruments that go back to the sterilizer, not into the sharps bin. But also question whether the marginal cost saving of procuring single use plastic items offsets the clinical waste disposal and other environmental costs. Factor environmental impact into your choices and practices at work every day, and write to your chief executive to ask them to do the same. Improve patient outcomes locally, globally, and save money doing so – it’s a no-brainer.
The science is clear – we’ve been issued a Code Green. And if we are serious about safeguarding human health, we must respond.
Is oral health the unspoken determinant?
BY AMA PRESIDENT DR TONY BARTONE
According to the Australian Institute of Health and Welfare’s (AIHW) report Australia’s Health 2012, most people will experience oral health issues at some point in their life. In fact, oral diseases are recurrently among the most frequently reported health problems by Australians.
Considered a disease of affluence up until the late 20th century, poor oral health outcomes have now become an indicator of disadvantage, highlighting a lack of access to preventative services. Insufficient access to, high cost of, or long waiting periods for dental services; and low oral care education, have all been associated with patients not seeking dental care when it is needed. Of course, non-fluoridised water supplies also has a role in explaining the prevalence.
However, more recently, it is the modifiable risk factors like poor nutrition, smoking, substance use, stress, and poor oral hygiene that are considered to have the greatest impacts on periodontal diseases.
Dental conditions frequently rank in the top 10 potentially preventable acute condition hospital admissions for Aboriginal and Torres Strait Islander people and were the third leading cause of all preventable hospitalisations in 2013-14, with 63,000 admissions.
Like most other health conditions, Aboriginal and Torres Strait Islander people have poorer oral health outcomes. While Indigenous people currently have most of the same oral health risk factors as non-Indigenous people, they are less likely to have the same access to preventative measures, leading to marked disparities in oral health between Indigenous people and other Australians.
While the majority of oral health concerns are often considered inconsequential, such as avoiding certain foods, or cosmetic with people embarrassed about their physical appearance, there is a significant body of evidence which suggests that oral health may be the undiscussed determinant of health.
More than two decades ago, population-based studies identified possible links between oral health status and chronic diseases such as cardiovascular disease (CVD), diabetes, respiratory diseases, stroke, and kidney diseases, as well as pre-term low birthweight. And the relationship appears to lie with inflammation.
It is clear more research is needed to determine the exact links (if any), between periodontal disease and chronic disease condition, however, the growing body of evidence links poor oral health to major chronic illnesses.
The Government has made numerous financial commitments to improving access to dental services, however, oral health data will continue to demonstrate that without equitable access to dental services, Australians, and particularly Aboriginal and Torres Strait Islander people, will continue to suffer poorer oral health outcomes, and potentially poorer health outcomes, as a result.
The AMA supports improved Doctor/Dentist collaborations if such partnerships could lead to increased early identification of both chronic disease and oral health conditions, particularly for Aboriginal and Torres Strait Islander peoples, for whom oral health services are less frequently accessed.
Dental Health Week is 6-12 August 2018.
Aged care building as an election battleground
Opposition Leader Bill Shorten recently used an appearance on ABC’s Q&A program to declare aged care is in a fundamental state of crisis and that he aims to make it a central national issue.
Mr Shorten said if the aged care system was not adequately funded at the national level, it was simply being set up to fail.
“It is a problem. It is a crisis,” he said.
“We need to sit down as a nation. Forget the politics, take off your Liberal hat or your Labor hat when you walk in the door, and start talking about how we properly fund aged care.”
The Government maintains that the latest Budget has seen a considerable boost in the overall spend for aged care, increasing from $18 billion a year to $23 billion over four years.
However, the Opposition believes that the Government has cut $2 billion from aged care by moving money from residential care and reallocating it to home care.
Speaking in Adelaide following the Q&A program, Mr Shorten said that there were many things to do to help improve aged care, and he has not ruled out a Royal Commission.
“We’ve got to make sure that aged care staff are valued, paid properly and properly trained. Two, we’ve got to make sure that the promises being made to vulnerable people in their care are being delivered on. Three, we’ve actually got to do a lot more to challenge the scourge of dementia,” he said.
In April, the AMA launched its Position Statement on Resourcing Aged Care 2018 to outline the workforce and funding measures that the AMA believes are required to achieve a high quality, efficient aged care system that enables equitable access to health care for older people.
AMA President Dr Tony Bartone said Australia’s ageing population will require an increasing amount of medical support due to significant growth in the prevalence of chronic and complex medical disorders and associated increase in life expectancy.
The AMA has called for more Government funding and support to allow ongoing access to medical and health care at home, so people can remain in their home for as long as is appropriate.
The AMA also believes there needs to be improved access for older people in residential aged care facilities (RACFs) to doctors through enhanced Medical Benefits Schedule (MBS) funding, and research into improved models to facilitate medical care in RACFs. Currently, inadequate MBS funding is a barrier for GPs to attend residents of aged care facilities, as they do not compensate for the significant non-face-to-face time (travel, finding residents and staff, etc) that comes with caring for RACF residents.
The AMA also believes that more nurses are needed in full time employment in aged care, and a minimum nurse to resident ratio should be included in the Aged Care Quality Standards.
Dr Bartone said AMA members have reported cases where nurses are being replaced by junior personal care attendants, and some residential aged care facilities do not have any nurses on staff after hours.
“It is unacceptable that some residents, who have high care needs, cannot access nursing care after hours without being transferred to a hospital Emergency Department,” he said.
The House of Representatives is currently conducting an Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia. At the time of publication, more than 100 submissions had been received.
The AMA gave evidence at the inquiry in May and the submission can be read here: www.aph.gov.au/DocumentStore.ashx?id=00ae9808-57c3-476f-8533-385e701fa619&subId=563295
The AMA Position Statement on Aged Care Resourcing can be found here: www.ama.com.au/position-statement/aged-care-resourcing-2018
MEREDITH HORNE
Europe’s digital highway changing the future of health care
The European Commission continues to strategically progress digital changes to modernise its healthcare system, with significant funding announced in their June EU Budget.
The budget announcement proposes to create the first ever Digital Europe program and invest €9.2 billion to align the next long-term EU budget 2021-2027 with tackling increasing digital challenges.
Andrus Ansip, the European Commissioner’s Vice-President for the Digital Single Market, said the announcement would ensure the EU budget was fit for the future.
“Digital transformation is taken into account across all proposals, from transport, energy and agriculture to health care and culture. We are proposing more investment in artificial intelligence, supercomputing, cybersecurity, skills and eGovernment – all identified by EU leaders as the key areas for the future competitiveness of the EU,” Mr Ansip said.
The European Commission’s legislative framework is based on new technologies enabling cross-border access of data to create more personalised, accurate and patient-oriented health care in a safe environment.
The framework is designed to overcome three challenges; ageing population and chronic diseases putting pressure on health budgets; unequal healthcare quality; and shortage of health professionals.
Currently EU citizens have the right to access health care in any EU country and to be reimbursed for care abroad by their home country.
The Commission’s digital health goal is to reduce administrative costs, avoid human errors, optimise the use of medical data and increase quality of services by systematically aligning healthcare IT systems and implement systems that support open standards-based data exchange.
The Commission recently established a set of measures to increase the availability of data in the EU, building on previous initiatives to boost the free flow of non-personal data in the Digital Single Market.
Thirteen European countries signed a declaration in April for delivering cross-border access to their genomic information. This is a game changer for European health research and clinical practice: sharing more genomic data will improve understanding and prevention of disease, allowing for more personalised treatments (and targeted drug prescription), in particular for rare diseases, cancer and brain related diseases. The target of the EU is to make one million genomes accessible in the EU by 2022.
The European Commissioner for the Digital Economy and Society, Ms Mariya Gabriel, said the agreement was founded in the understanding modern health relies on digital innovation and cross-border interoperability.
“Secure access to genomic and other health data among Member States is essential for better health and care delivery to European citizens and to ensure that the EU will remain at the forefront of health research.”
MEREDITH HORNE
Big tobacco’s latest scam revealed
A new study from the University of Bath’s Tobacco Control Research Group has exposed evidence that big tobacco is still facilitating tobacco smuggling, while also trying to control a global system aimed at preventing it.
The research draws on leaked documents. It also investigates industry front groups and details elaborate lengths the industry has gone to control to undermine a major international agreement, the Illicit Trade Protocol.
The Protocol aims to protect public health by stopping the tobacco industry from smuggling tobacco, but the University of Bath research shows how tobacco companies are trying to get around it by employing elaborate scam techniques.
Released in June, the research paper was published in the journal Tobacco Control and it calls on governments and international bodies to crack down on the tactics of big tobacco companies.
It requires governments being much more vigilant in ensuring that the systems designed to control tobacco smuggling are free of industry influence.
The study argues that despite the tobacco industry claiming to have changed and to be themselves the victims of counterfeit tobacco (and have lobbied to work with governments to help tackle counterfeit tobacco), it is still facilitating tobacco smuggling.
Approximately two thirds of smuggled cigarettes may still derive from industry, the study states. It highlights how companies have developed their own track and trace system, known as Codentify, and lobbied around the world for it to adopted, while at the same time creating front groups and paying for misleading data and reports.
The University of Bath’s research has revealed:
- Big Tobacco funding (through a front group) the World Customs Organisation’s conference on illicit or smuggled tobacco;
- Philip Morris International (PMI) setting up a $100 million fund for research on illicit tobacco, which funds organisations whose previous reports on tobacco smuggling have already been widely criticised; and
- PMI funding INTERPOL to promote Codentify.
Leaked documents show the four major transnational tobacco companies hatched a joint plan to use front groups and third parties to promote Codentify to governments and have them believe it was independent of industry. It also reveals how these plans were put into action. For example, the study reveals how a supposedly independent company fronted for British American Tobacco (BAT) in a tender for a track and trace system in Kenya.
Professor Anna Gilmore, Director of the Tobacco Control Research Group, explains: “This has to be one of the tobacco industry’s greatest scams. Not only are tobacco companies still involved in tobacco smuggling, but they are positioning themselves to control the very system governments around the world have designed to stop them from smuggling. Their elaborate and underhand effort, implemented over years, involves front groups, third parties, fake news and payments to the regulatory authorities meant to hold them to account.
“Governments, tax and customs authorities around the world appear to have been hoodwinked. It is vital that they wake up and realise how much is at stake. Our simple message is this: no government should implement a track and trace system linked in any shape or form to the tobacco manufacturers. Doing so could allow the tobacco industry’s involvement in smuggling to continue with impunity.”
The report’s co-author Andy Rowell said: “By analysing new leaked documents from the tobacco industry and other contemporary evidence, it’s clear that the masters of deception are up to their old tricks. The evidence suggests the industry is still facilitating tobacco smuggling, whilst trying to control the international system to stop smuggling. But authorities should not let the sly old tobacco fox look after the hen house.”
To access the peer-reviewed paper see: http://tobaccocontrol.bmj.com/lookup/doi/10.1136/tobaccocontrol-2017-054191
CHRIS JOHNSON
Active commuting might not be that hard
More than two in three Australians drive to work, according to the latest 2016 Census data. An active commute, where physical activity forms a significant part of the way people travel to and from work, is far easier than often thought – and it could even be a lifesaver.
One of the main hurdles for the uptake of active commuting could be based in an overestimation of the length of time people believe it would take to walk or ride to work, a recent study suggests.
Associate Professor Melissa Bopp, one of the study’s co-authors from Pennsylvania State University, said: “Often people indicate that the reason they choose to drive is that it’s much quicker than walking or biking when, in reality, that may not be the case.”
When the study’s participants were asked to estimate how long it would take them to bike or walk to a common location in town, they found that the majority of people estimated incorrectly. Ninety-one per cent of study participants incorrectly estimated how long it would take to commute with walking, and 93 per cent mis-estimated how long it would take to bike.
In Australia, rates of walking and cycling remain constant and low – even in smaller centres such as Hobart, Darwin and Canberra. Even in the most ‘cycling-oriented’ places (Darwin and Canberra), only about three per cent of commuters cycle.
The World Health Organisation (WHO) launched in June this year its first Global Action Plan for Physical Activity 2018-2030, to encourage an increased participation in physical activity by people of all ages and abilities across the world.
WHO recommends that adults aged between 18 and 65 should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity. For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent. Muscle-strengthening activities should be done involving major muscle groups on two or more days a week.
Active commuting offers an extremely effective health solution to modern sedantry lifestyles as supported by findings from the University of Glasgow published earlier this year in the British Medical Journal, a study that investigated the health benefits of cycling to work.
The Scottish-based researchers observed the incidences of heart disease, cancer, accidents and death, adjusting the study to consider other factors contributing to their health, such as sex, age, smoking, and time spent sitting down.
Cyclists had a 52 per cent lower risk of dying from heart disease, and a 40 per cent lower risk of dying from cancer. In terms of developing the disease at all, they had a 46 per cent lower risk of getting heart disease and a 45 per cent lower risk of getting cancer.
The commuters who walked to work also enjoyed some benefits, such as a 27 per cent lower risk of heart disease and a 36 per cent lower risk of dying from it. However, they did not have a lower risk of dying from any of the causes.
People who cycled combined with other modes of transport had 24 per cent lower risk of death from all causes, a 32 per cent lower risk of developing cancer and a 36 per cent lower risk of dying from cancer.
The Australian Heart Foundation estimates the cost of being inactive in Australia is $805 million each year, with much of the costs relating to healthcare spending ($640 million). The cost of physical inactivity to households is $124 million each year, due to diseases related to lack of exercise.
World leaders will meet later this year to take action on physical inactivity and other causes of NCDs, and mental disorders, when they take part in the Third United Nations General Assembly High-level Meeting on Non-Communicable Diseases (NCDs), being held on September 27 in New York.
The World Health Organisation’s Global Action Plan for Physical Activity 2018-2030 can be found here: http://www.who.int/ncds/prevention/physical-activity/gappa/
MEREDITH HORNE
[World Report] Alzheimer’s disease research: the future of BACE inhibitors
A series of setbacks at the clinical trial level raises questions about the future of Alzheimer’s disease research, but experts remain confident. Talha Burki reports.
The evolving epidemiology of Clostridium difficile infection in Canadian hospitals during a postepidemic period (2009-2015) [Research]
Background:
The clinical and molecular epidemiology of health care–associated Clostridium difficile infection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care–associated C. difficile infection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain.
Methods:
Adult inpatients with C. difficile infection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends.
Results:
Over a 7-year period, 20 623 adult patients admitted to hospital with health care–associated C. difficile infection were reported to CNISP, and microbiological data were available for 2690 patients. From 2009 to 2015, the national rate of health care–associated C. difficile infection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficile infection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29–2.82). Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care–associated C. difficile infection; for every 10% increase in the proportion of NAP1 strains, the rate of health care–associated C. difficile infection increased by 3.3% (95% CI 1.7%–4.9%).
Interpretation:
Rates of health care–associated C. difficile infection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.