Fewer than five in 100 interventional cardiologists are women

A new study has highlighted a critical gender gap in interventional cardiology, the medical field specialising in treating blocked arteries in heart disease.

There are only 19 female interventional cardiologists in all of Australia and New Zealand – just 4.8 per cent of that workforce, a new study by medical researchers, including a UNSW PhD student, has shown.

In light of the findings, the researchers have called for change to increase much-needed diversity in the field – and to improve clinical care and outcomes for women. With cardiovascular disease the main cause of death for both men and women, the study is relevant to a large number of Australians.

The findings, published in the Journal of the American College of Cardiology, are the result of research performed by Women in Interventional Cardiology of Australian and New Zealand (WiiCAN – pronounced ‘we can’).

On top of the severe gender disparity in interventional cardiology, the data also reveal that only 15 per cent of all cardiologists across the two countries are women, that 73 per cent of public hospitals have no female interventional cardiologists at all, and that three Australian States have none either.

One of the lead authors, interventional cardiologist Dr Sonya Burgess, is working at Nepean Hospital in Sydney. She is also completing a doctorate at UNSW Sydney, studying patients with heart attacks and the importance of complete revascularisation of the coronary arteries for these patients. She says there are many barriers for female trainees.

“I started my cardiology training in 2007 in New Zealand, the country that first gave women the vote, yet also a country that now has had more female prime ministers than female interventional cardiologists,” she said.

“The reasons for this are complex, but can be overcome with positive changes.”

The paper discusses factors contributing to this gap, including the importance of role models, the expectations of training and society, the impact of geography, occupational radiation, cardiology’s workplace culture, unconscious gender bias, and strategies for promoting change.

The authors call for more evidence-based solutions to tackle the problem, including systematic approaches to actively address disparity and achieve more visibility, so trainees see female role models in leadership positions, in faculty at conferences and in training hospitals.

“We need leaders who believe the data is important and who value diversity, to allow us to change from a culture of de-facto exclusion to one of active inclusion,” Dr Burgess said.

“It is now well documented that women with heart disease receive less treatment, fewer appropriate medications, and experience higher mortality compared to men.

“At the same time, several studies have reported better clinical outcomes for patients treated by female cardiologists and physicians, notably including improved survival rates for female heart attack patients when treated by a female doctor.”

To help address some of these issues and create a community of women, Dr Burgess co-founded WiiCAN.

Dr Burgess helped found the social network in 2017, when she met the other two co-founders, Dr Sarah Zaman from Monash Medical Centre and Dr Elizabeth Shaw from Hornsby Ku-ring-gai Hospital, at a conference that brought together Australian and New Zealand interventional cardiologists. Their goal is to give a voice to female cardiology trainees, patients and colleagues, so they would not feel isolated in a male-dominated workforce.

First ever multi-drug Ebola trial for the Congo

The Ministry of Health of the Democratic Republic of the Congo (DRC) has announced that a randomised control trial has begun to evaluate the effectiveness and safety of drugs used in the treatment of Ebola patients.

The trial is the first-ever multi drug trial for an Ebola treatment. It will form part of a multi-outbreak, multi-country study that was agreed to by partners under a World Health Organisation (WHO) initiative.

Until now, more than 160 patients have been treated with investigational therapeutics under an ethical framework developed by WHO, in consultation with experts in the field and the DRC, called the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI).

The MEURI protocol was not designed to evaluate the drugs. Now that protocols for trials are in place, patients will be offered treatments under that framework in the facilities where the trial has started. In others, compassionate use will continue up to the time when they join the randomisation. Patients will not be treated noticeably differently from before, though the treatment they receive will be decided by random allocation. The data gathered will become standardised and will be useful for drawing conclusions about the safety and efficacy of the drugs.

“Our country is struck with Ebola outbreaks too often, which also means we have unique expertise in combatting it,” said Dr Olly Ilunga, Minister of Health of the DRC.

“These trials will contribute to building that knowledge, while we continue to respond on every front to bring the current outbreak to an end.”

In October, WHO convened a meeting of international organisations, United Nations partners, countries at risk of Ebola, drug manufacturers and others to agree on a framework to continue trials in the next Ebola outbreak, whenever and wherever that is. Over time, this will lead to an accumulation of evidence that will help to draw robust conclusions across outbreaks about the currently available drugs, and any new ones that may come along.

At the heart of the long-term plan and the current trial is always the goal to ensure that patients with Ebola and their communities are treated with respect and fairness. All patients should be provided with the highest level of care and have access to the most promising medications.

The current trial is coordinated by WHO, and led and sponsored by the DRC’s National Institute for Biomedical Research (INRB), in partnership with the DRC Ministry of Health, the National Institute of Allergy and Infectious Diseases (NIAID) which is part of the United States’ National Institutes of Health, The Alliance for International Medical Action (ALIMA) and other organisations.

[Obituary] Judith Lumley

Influential public health researcher who focused on perinatal epidemiology and maternity services. Born in Cardiff, UK, on Feb 15, 1941, she died from complications of Alzheimer’s disease in Melbourne, VIC, Australia, on Oct 25, 2018, aged 77 years.

[Health Policy] Implementation research: new imperatives and opportunities in global health

Implementation research is important in global health because it addresses the challenges of the know–do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices.

[Department of Error] Department of Error

Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries Lancet 2018; https://doi.org/10.1016/S0140-6736(18)31668-4—In figure 2 of this Article (published Online First on Sept 5, 2018), the y axis should read “deaths in 100 000s”. The affiliation for Prof Salomon should read “Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA”.

[Perspectives] Reimagining addiction

The Narcotic Farm was established in 1935 in Lexington, KT, USA, by the US Department of Public Health with two aims. First, it was to create a new way of dealing with addiction as an issue of health rather than criminal justice, by offering treatment and rehabilitation instead of punishment and retribution. Second, it aimed to bring together researchers to study addiction in its Addiction Research Center, and to find a cure. “Narco”, as it was commonly known, was a noble idea, designed to support men and women convicted of drug-related offences alongside those who made a voluntary decision to commit to treatment.

The gap isn’t closing

The nation is failing in its efforts to close the health and life expectancy gap between Indigenous and non-Indigenous Australians.

The AMA Indigenous Health Report Card 2018, launched in Brisbane on November 22, scrutinises the 10-year-old Closing the Gap Strategy and concludes that it is unravelling.

The strategy must now be rebuilt, not refreshed, said AMA President Dr Tony Bartone.

One of the strategy’s main targets was to close the life expectancy gap by 2031, but Dr Bartone said it was obvious Australia is not on track to meet that goal.

“Ten years on, progress is limited, mixed, and disappointing,” he said.

“If anything, the gap is widening as Aboriginal and Torres Strait Islander health gains are outpaced by improvement in non-Indigenous health outcomes.

“The strategy has all but unravelled, and efforts underway now to refresh the strategy run the risk of simply perpetuating the current implementation failures.

“The strategy needs to be rebuilt from the ground up, not simply refreshed without adequate funding and commitment from all governments to a national approach.”

Political leadership and increased funding are lacking on the issue, Dr Bartone said.

A refocussing of effort and priorities is needed.

“It is time to address the myth that it is some form of special treatment to provide additional health funding to address additional health needs in the Aboriginal and Torres Strait Islander population,” he said.

“Government spends proportionally more on the health of older Australians when compared to young Australians, simply because elderly people’s health needs are proportionally greater.

“The same principle should be applied when assessing what equitable Indigenous health spending is, relative to non-Indigenous health expenditure.”

The Australian Institute of Health and Welfare estimates that the Aboriginal and Torres Strait Islander burden of disease is 2.3 times greater than the non-Indigenous burden, meaning that the Indigenous population has 2.3 times the health needs of the non-Indigenous population.

This means that for every $1 spent on health care for a non-Indigenous person, $2.30 should be spent on care for an Indigenous person.

But this is not the case, Dr Bartone said. For every $1 spent by the Commonwealth on primary health care, including Medicare, for a non-Indigenous person, only 90 cents is spent on an Indigenous person – a 61 per cent shortfall.

For the Pharmaceutical Benefits Scheme, the gap is even greater – 63 cents for every dollar, or a 73 per cent shortfall from the equitable spend.

“Spending less per capita on those with worse health, and particularly on their primary health care services, is dysfunctional national policy,” he said.

“It leads to us spending six times more on hospital care for Indigenous Australians than we do on prevention-oriented care from GPs and other doctors.”

The Report Card outlines six areas where the Closing the Gap Strategy can be rebuilt.

These include: equitable, needs-based expenditure; implementing health and mental health plans; filling primary health care service gaps; environmental health and housing; addressing social determinants; and placing Aboriginal health in Aboriginal hands.

“We need those leaders, those health leaders in those various communities, to come together with the peak bodies, with the Aboriginal controlled community health organisations, and all the other people as stakeholders in this space to come together to work collaboratively and with common purpose,” Dr Bartone said.

“We will not close the gap until we provide equitable levels of health funding. We need our political leaders and commentators to tackle the irresponsible equating of equitable expenditure with ‘special treatment’ that has hindered efforts to secure the level of funding needed to close the health and life expectancy gap.”

National Aboriginal Community Controlled Health Organisation (NACCHO) welcomed the release of the Report Card and joined the AMA in calling for the Closing the Gap Strategy to be rebuilt from the ground up.

NACCHO Chairwoman Donnella Mills called for the immediate adoption of the Report Card’s recommendations.

“We congratulate the AMA on their work to support closing the gap and endorse the recommendations in the Report,” she said.

“The Report highlights research which indicates the mortality gaps between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians are widening, not narrowing.

“Urgent and systematic action is needed to reverse these failures and to have any prospect of meeting the Council of Australian Governments’ goal to Close the Gap in life expectancy by 2031.”

The AMA 2018 Indigenous Health Report Card is on the AMA website.

[Perspectives] Susan Buchbinder: driving HIV prevention efforts worldwide

Susan Buchbinder’s drive to fight the HIV epidemic started, as with many of her colleagues, when she was treating patients during the 1980s. “While some doctors and nurses turned their backs and refused to treat patients with HIV/AIDS in those early days, many of us fought hard to do all we could, when we had so few tools available to us. That same group of colleagues continues to work on HIV to this day, and are some of the leaders in developing new prevention and treatment tools”, says Buchbinder, now Clinical Professor of Medicine, Epidemiology, and Biostatistics at the University of California, San Francisco (UCSF), CA, USA.

[Comment] Twice the benefits with twincretins?

Rising global numbers of patients with obesity and diabetes and a scarcity of approved medical therapeutics with curative potential are major challenges for physicians, biomedical researchers, and health-care systems worldwide. Scientific breakthroughs such as discovering gut hormone-based polyagonists with preclinical efficacy and action profiles similar to gastric bypass surgery suggest that transformative medicines for obesity and type 2 diabetes might be within reach.1 Remaining uncertainties are the inclusion of glucagon receptor agonism as a driving factor in the promotion of energy expenditure and weight loss in some of the leading candidates for unimolecular coagonism targeting obesity and type 2 diabetes, because this action requires substantial buffering by incretin action to prevent detrimental effects on glucose metabolism.

WILLINGNESS GROWS TO END RHD

BY AMA PRESIDENT DR TONY BARTONE

Rheumatic heart disease (RHD) is a preventable illness affecting about 6,000 Australians, with Indigenous children 55 times more likely to die from the disease than their non-Indigenous peers.

The AMA recognises the role RHD contributes to the widening of the life expectancy gap between Indigenous and non-Indigenous Australians. In 2016, we launched a Report Card on Indigenous Health, A call to action to prevent new cases of RHD in Indigenous Australia by 2031 (target year for ‘closing the gap’ in Indigenous life expectancy).

Our Report Card made a strong statement on the devastating impact of RHD and the importance of new, collaborative strategies to control the disease. Its recommendations included calling for Australian Governments to commit to a target to prevent RHD. It also recommended that governments work in partnership with the Indigenous community to fund and implement a strategy to end RHD.

The Report Card also provided an opportunity for a group of leading health, community, and research organisations to form a coalition END RHD. The purpose of the coalition is to advocate for urgent, comprehensive action on this preventable disease of inequality, and to support those living with the disease and prevent new cases arising.

The founding members of END RHD are the AMA, Heart Foundation, RHD Australia (based at the Menzies School of Health Research), the END RHD Centre of Research Excellence (based at Telethon Kids Institute), the National Aboriginal Community Controlled Health Organisation (NACCHO), the Aboriginal Medical Services Alliance Northern Territory (AMSANT), the Aboriginal Health Council of Western Australia (AHCWA), the Aboriginal Health Council of South Australia (AHCSA), the Queensland Aboriginal and Islander Health Council (QAIHC), and the Aboriginal Health and Medical Research Council of NSW (AH&MRC).

To eliminate rheumatic heart disease in Australia, the coalition calls on the Federal Government to:

guarantee that the Aboriginal and Torres Strait Islander leadership drives the development and implementation of RHD prevention strategies;
set targets to end RHD in Australia;
fund a roadmap to end RHD by 2031;
commit to immediate action in communities at high risk of rheumatic heart disease; and
invest in strategic research and technology to prevent and treat acute rheumatic fever and rheumatic heart disease.

In the two years since the Alliance was formed, END RHD has been working with the communities at risk, securing funding and political will to translate research into action and educating Australians to play a role in ending RHD.

I believe the momentum is growing. RHD was discussed at the COAG meetings in August and October 2018. This has been further helped by the recent commitment from Indigenous Health Minister Ken Wyatt, to a Roadmap to end RHD in Australia, which is due to be completed by early 2019.

There is no doubt that funding is a crucial part of the equation to ending RHD. Recent developments include $3.7m being allocated to five Aboriginal medical services for local community-led pilot Acute Rheumatic Fever (ARF) and RHD prevention programs.

A further $950,000 has been granted to the Telethon Kids Institute to work with the Kimberley Aboriginal Medical Services to establish an innovative END RHD community program focussed on environmental health and local workforce development.

On 23^rd October 2018 an advocacy event at Parliament House, co-hosted by END RHD and the Snow Foundation, where the Government was asked for non-partisan commitment to eliminate RHD in Australia. Minister Wyatt and Shadow Assistant Minister for Indigenous Health Warren Snowden both made commitments in public to tackle RHD as a non-partisan issue. It is an important step for political leaders to acknowledge the seriousness of the problem.

Now, with community-driven change and funding to enable the change, we can hopefully start to bring about the end for RHD in Australia.