more_vertTo mark the 40th anniversary of the Alma-Ata Declaration, The Lancet will dedicate the issue of Oct 20, 2018, to primary care and related themes. While we welcome submissions on all aspects of primary care at all times, and across all Lancet titles, this call for papers is particularly aimed at researchers in primary care settings.
Preference: Statistics, epidemiology and research design
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[Comment] Offline: Apostasy against the public health elites
“Epidemiology is built on a history of convincing experiments…We need to get better at using randomised controlled trials as knowledge translation in the public health field”, wrote Anne Cockcroft last year. Who could disagree? The centrality of randomised evidence is firmly established for evaluating interventions and their application in clinical medicine. The same is true in public health. But any clinician or public health practitioner knows that there is more to evidence than the results of a precious randomised trial.
[Comment] Amending the EU Withdrawal Bill: a safeguard for health
Detailed analyses of the health consequences of Brexit have focused on its negative effects on the UK’s National Health Service, food security, international cooperation to combat threats to health, medicines regulation, and medical research.1 Faced with this depressing picture, it is natural to seek any glimmer of hope. Could there be any opportunities to improve health? The answer, invariably, is that leaving the European Union (EU) could allow the UK to go beyond existing European policies to strengthen protection in public health—eg, by introducing traffic light labelling on food or implementing stricter environmental standards.
[Department of Error] Department of Error
Watts N, Amann M, Ayeb-Karlsson S, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet 2018; 391: 581–630—In this Review (published online first on Oct 30, 2017), Jonathan Chambers, Ian Hamilton, Robert Lowe, and Steve Pye’s affiliation has been corrected to UCL Energy Institute, London, UK; Fereidoon Owfi and Mahnaz Rabbaniha’s affiliation has been corrected to Iranian Fisheries Science Research Institute, AREEO, Tehran, Iran; Meisam Tabatabaei’s affiliation has been corrected to Biofuel Research Team, Agricultural Biotechnology Research Institute of Iran, AREEO, Karaj, Iran; and Ali Mohammad Latifi’s affiliation has been corrected to Applied Biotechnology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
Additional research funding for rare cancers
The Federal Government has announced a $69 million boost to help medical researchers in their fight against rare cancers and rare diseases.
The funding is aimed at assisting patients who often have few options and poor life expectancy.
Health Minister Greg Hunt said the Government was committed to investing in research to find the answers to these challenges.
“This is a significant boost on the $13 million that was originally flagged when we called for applications and reflects the incredibly high calibre of medical research that is happening right here in Australia,” Mr Hunt said.
The new funding includes more than $26 million for 19 research projects as part of the landmark Medical Research Future Fund’s Rare Cancers, Rare Diseases and Unmet Needs Clinical Trials Program.
These projects will undertake clinical trials for devastating conditions like acute lymphoblastic leukaemia in infants, aplastic anaemia, multiple sclerosis and Huntington’s disease.
Researchers at the University of New South Wales will test a vaccine to target glioblastoma, a lethal brain cancer and the most frequent cause of cancer deaths in children and young people.
Another clinical trial at the University of Queensland will evaluate the benefits of medicinal cannabis for people with advanced cancer, and define the role of the drug for patients with cancer in palliative care.
Monash University is researching a new preventive treatment for graft versus host disease following a bone marrow transplant which could halve instances of the life-threatening complication, while a trial by the University of Western Australia to simultaneously compare a range of cystic fibrosis treatments may lead to improved care for this complex disease.
Other trials will explore the effectiveness and safety of aspirin compared to heparin to treat blood clots and test a new triple therapy regimen to target rare viral-driven brain lymphomas.
Prior to this announcement, rare and less common cancers received 12 per cent of the cancer research dollar, despite accounting for over 50 per cent of cancer deaths.
Details of the rare cancer projects that have received funding can be found here: www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt008.htm
MEREDITH HORNE
New test to help seniors keep independence
A major study has been released by Aged Care Minister Ken Wyatt designed to uncover frailty and spark simple interventions to help older Australians maintain their independence.
It comes with a new online test to help detect the signs of frailty while action can be taken.
The Frailty in Community Dwelling Older People – Using Frailty Screening as the Canary in the Coal Mine is a landmark report, which surveyed 3000 Australians aged over 65 and found six per cent were frail and 38 per cent were considered pre-frail.
Women were found to be more likely to be frail than men.
Mr Wyatt said he believed the simple FRAIL five-point online test was an important start to people have the opportunity to detect frailty before it hits, allowing them to take action to live better lives, remain in their own homes for longer and avoid potential hospitalisation.
The Minister encouraged older Australians to do the test and follow up with their GP as necessary.
“People classed as frail are more at risk from fall injuries, deteriorating health and premature death,” Mr Wyatt said.
“Importantly, the study recommends that with the right support at the right time, frailty can be halted or even reversed by consulting with health professionals for safe, simple, inexpensive, practical interventions.”
The study was produced by aged care provider Benetas, a large not-for-profit aged care provider based in Victoria and part of Anglicare Australia.
The aim was to validate and implement a simple self-completed tool that can accurately identify frailty. Older people who are at risk of increased dependency and/or mortality can then be identified and provided with appropriate services to keep them well.
The study found 56 per cent of elderly Australians were considered to be robust, with 41 per cent of women classed as pre-frail compared to 34 per cent of men.
Authors of the report believe frailty is generally considered to be a consequence of ageing but not all elderly people are frail.
Frailty describes any person, regardless of age, who is at heightened risk to illness or injury from relatively minor external stresses.
Frailty should be considered a syndrome rather than a disease in itself and can be defined by a number of components — unintentional weight loss, self-reported fatigue, diminished physical activity, and measured impairment (comparative to age-standardised norms) of gait speed.
The study also recommends that, with the right support at the right time, frailty can be halted or even reversed by consulting with health professionals for safe, simple, inexpensive, practical interventions.
These positive changes to decrease frailty risks include taking steps to modifying diet to include more proteins as well as taking vitamin D supplements. Increasing activity, including light resistance exercises and walking, as well as evaluating prescription medication intake, in consultation with your GP, were also recommended by the authors.
Benetas project leader Stephen Burgess said frailty was the “canary in the coal mine” which could help detect a rapid health decline before it happened.
“Frailty, including pre-frailty, is an invisible condition. Many who are frail appear to function reasonably well in the community. As a result, individuals and family members are often unaware frailty is present,” he said.
The FRAIL test is available through the Positive Ageing Resource Centre website. (www.parc.net.au). At the conclusion of the brief questionnaire, users can print off a personal summary to present to their health professional.
The PARC website is funded by an Aged Care Service Improvement and Healthy Ageing Grant from the Federal Department of Health http://www.health.gov.au/ and is developed by researchers from Monash University’s School of Primary Health Care http://www.med.monash.edu.au/sphc/ and Benetas.
MEREDITH HORNE
AMA shines in Australia Day Honours
Former Australian Medical Association President Dr Mukesh Haikerwal has been awarded the highest honour in this year’s Australia Day awards by being named a Companion of the Order of Australia (AC).
He is accompanied by the current Editor-in-Chief of the Medical Journal of Australia, Laureate Professor Nick Talley, as well as longstanding member Professor Jeffrey Rosenfeld – who both also received the AC.
The trio top a long and impressive list of AMA members to receive Australia Day Honours this year.
AMA Federal Councillor, Associate Professor Julian Rait, received the Medal of the Order (OAM).
A host of other members honoured in the awards are listed below.
AMA President Dr Michael Gannon said the accolades were all well-deserved and made he made special mention of those receiving the highest Australia Day Honours.
“They have dedicated their lives and careers to helping others through their various roles as clinicians, researchers, teachers, authors, administrators, or government advisers – and importantly as leaders in their local communities,” Dr Gannon said.
“On behalf of the AMA, I pay tribute to all the doctors and other health professionals who were honoured today for their passion for their profession and their dedication to their patients and their communities.
“The great thing about the Honours is that they acknowledge achievement at the international, national, and local level, and they recognise excellence across all avenues of human endeavour.
“Doctors from many diverse backgrounds have been recognised and honoured again this year.
“There are pioneering surgeons and researchers, legends across many specialties, public health advocates, researchers, administrators, teachers, and GPs and family doctors who have devoted their lives to serving their local communities.
“The AMA congratulates all the doctors and other health advocates whose work has been acknowledged.
“We are, of course, especially proud of AMA members who are among the 75 people honoured in the medicine category.”
Dr Haikerwal, who was awarded the Officer in the Order of Australia (AO) in 2011, said this further honour was “truly mind-blowing” and another life-changing moment.
“To be honoured on Australia Day at the highest level in the Order of Australia is beyond imagination, beyond my wildest dreams and extremely humbling,” Dr Haikerwal said.
“For me to be in a position in my life and career to receive such an honour has only been made possible due to the unflinching support and unremitting encouragement of my closest circle, the people who have been with me through every step of endeavour, adversity, achievement, and success.”
CHRIS JOHNSON
AMA MEMBERS IN RECEIPT OF HONOURS
COMPANION (AC) IN THE GENERAL DIVISION
Dr Mukesh Chandra HAIKERWAL AO
Altona North Vic 3025
For eminent service to medical governance, administration, and technology, and to medicine, through leadership roles with a range of organisations, to education and the not-for-profit sector, and to the community of western Melbourne.
Professor Jeffrey Victor ROSENFELD AM
Caulfield North, Vic
For eminent service to medicine, particularly to the discipline of neurosurgery, as an academic and clinician, to medical research and professional organisations, and to the health and welfare of current and former defence force members.
Professor Nicholas Joseph TALLEY
Black Hill, NSW
For eminent service to medical research, and to education in the field of gastroenterology and epidemiology, as an academic, author and administrator at the national and international level, and to health and scientific associations.
OFFICER (AO) IN THE GENERAL DIVISION
Emeritus Professor David John AMES
East Kew, Vic
For distinguished service to psychiatry, particularly in the area of dementia and the mental health of older persons, as an academic, author and practitioner, and as an adviser to professional bodies.
Dr Peggy BROWN
Sanctuary Cove, Qld
For distinguished service to medical administration in the area of mental health through leadership roles at the state and national level, to the discipline of psychiatry, to education, and to health care standards.
Professor Creswell John EASTMAN AM
St Leonards, NSW
For distinguished service to medicine, particularly to the discipline of pathology, through leadership roles, to medical education, and as a contributor to international public health projects.
Professor Suzanne Marie GARLAND
Docklands, Vic
For distinguished service to medicine in the field of clinical microbiology, particularly to infectious diseases in reproductive and neonatal health as a physician, administrator, researcher and author, and to professional medical organisations.
Dr Paul John HEMMING
Queenscliff, Vic
For distinguished service to higher education administration, to medicine through contributions to a range of professional medical associations, and to the community of central Victoria, particularly as a general practitioner.
Professor Anthony David HOLMES
Melbourne, Vic
For distinguished service to medicine, particularly to reconstructive and craniofacial surgery, as a leader, clinician and educator, and to professional medical associations.
Dr Diana Elaine O’HALLORAN
Glenorie, NSW
For distinguished service to medicine in the field of general practice through policy development, health system reform and the establishment of new models of service and care.
MEMBER (AM) IN THE GENERAL DIVISION
Dr Michael Charles BELLEMORE
Croydon, NSW
For significant service to medicine in the field of paediatric orthopaedics as a surgeon, to medical education, and to professional medical societies.
Dr Colin Ross CHILVERS
Launceston, Tas
For significant service to medicine in the field of anaesthesia as a clinician, to medical education in Tasmania, and to professional societies.
Associate Professor Peter HAERTSCH OAM
Breakfast Point, NSW
For significant service to medicine in the field of plastic and reconstructive surgery as a clinician and administrator, and to medical education.
Professor Ian Godfrey HAMMOND
Subiaco, WA
For significant service to medicine in the field of gynaecological oncology as a clinician, to cancer support and palliative care, and to professional groups.
Dr Philip Haywood HOUSE
WA
For significant service to medicine as an ophthalmologist, to eye surgery foundations, and to the international community of Timor Leste.
Adjunct Professor John William KELLY
Vic
For significant service to medicine through the management and treatment of melanoma, as a clinician and administrator, and to education.
Dr Marcus Welby SKINNER
West Hobart, Tas
For significant service to medicine in the field of anaesthesiology and perioperative medicine as a clinician, and to professional societies.
Professor Mark Peter UMSTAD
South Yarra, Vic
For significant service to medicine in the field of obstetrics, particularly complex pregnancies, as a clinician, consultant and academic.
Professor Barbara S WORKMAN
East Hawthorn, Vic
For significant service to geriatric and rehabilitation medicine, as a clinician and academic, and to the provision of aged care services.
MEDAL (OAM) IN THE GENERAL DIVISION
Professor William Robert ADAM PSM
Vic
For service to medical education, particularly to rural health.
Dr Marjorie Winifred CROSS
Bungendore, NSW
For service to medicine, particularly to doctors in rural areas.
Associate Professor Mark Andrew DAVIES
Maroubra, NSW
For service to medicine, particularly to neurosurgery.
Dr David William GREEN
Coombabah, Qld
For service to emergency medicine, and to professional organisations.
Dr Barry Peter HICKEY
Ascot, Qld
For service to thoracic medicine.
Dr Fred Nickolas NASSER
Strathfield, NSW
For service to medicine in the field of cardiology, and to the community.
Dr Ralph Leslie PETERS
New Norfolk, Tas
For service to medicine, and to the community of the Derwent Valley.
Associate Professor Julian Lockhart RAIT
Camberwell, Vic
For service to ophthalmology, and to the development of overseas aid.
Mr James Mohan SAVUNDRA
South Perth, WA
For service to medicine in the fields of plastic and reconstructive surgery.
Dr Chin Huat TAN
Glendalough, WA
For service to the Chinese community of Western Australia.
Dr Karen Susan WAYNE
Toorak, Vic
For service to the community of Victoria through a range of organisations.
Dr Anthony Paul WELDON
Melbourne, Vic
For service to the community, and to paediatric medicine.
PUBLIC SERVICE MEDAL (PSM)
Dr Sharon KELLY
Yeronga, Qld
For outstanding public service to the health sector in Queensland.
Professor Maria CROTTY
Kent Town, SA
For outstanding public service in the rehabilitation sector in South Australia.
The sugar wars: be careful to define the enemy and choose your weapons
BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR, PUBLIC HEALTH, UNIVERSITY OF SYDNEY
The statistics do not support the view that there are big differences in sugar consumption between the fact and the thin. We need to define our enemy clearly in the battle against obesity and stop beating up individual consumers.
The Sydney Morning Herald has announced a war on sugar. Its rationale is that we need to combat obesity with all its attendant ills. Good thinking. Sugar may appear to be easy pickings. Beware.
It is vital that sugar consumption by individuals not be cast as the behaviour that we must attack (willpower, my friends, willpower) with all our might to solve the problem of obesity. That will be a waste of energy – no pun intended – and leave the real changes essential for reversing our current trend to a fatter, less healthy community untouched.
Just how critical is sugar to obesity? A study of 132, 479 individuals in the UK, published in the International Journal of Epidemiology* in 2016, analysed their consumption of macronutrients – fat, protein, carbohydrate and sugar – and compared how much energy in the diet of obese versus non-obese individuals came from these food categories. This group was assembled for the UK Biobank genetic study and the current study made use of the comprehensive health data collected on all participants.
Anderson and Pell, the lead authors of the study from the University of Glasgow, made the point that in this study: “Dietary intake was self-reported outside the clinic, which may encourage more truthful reporting, and was collected using a 24 hour recall questionnaire which produce more accurate results than a food frequency questionnaire (the usual approach adopted in large-scale studies).” Their general conclusion was: “66.3 per cent of men and 51.8 per cent of women were overweight/obese.”
Anderson et al wrote: “Compared with [those participants with] normal BMI, obese participants had 11.5 per cent higher total energy intake and 14.6 per cent, 13.8 per cent, 9.5 per cent and 4.7 per cent higher intake from fat, protein, starch and sugar, respectively.” So while the fat folk were consuming more energy than the thin, the excess due to sugar intake between the two groups was quite small. “There is only a weak correlation between absolute energy derived from sugar and from fat. Therefore, targeting high sugar consumers will not necessarily target high consumers of fat and overall energy.”
They concluded that: “Fat is the largest contributor to overall energy. The proportion of energy from fat in the diet, but not sugar, is higher among overweight/obese individuals. Focusing public health messages on sugar may mislead on the need to reduce fat and overall energy consumption.”
Do these observations mean that we should not include sugar as needing attention in our approach to obesity? Not at all. Many drinks and processed foods are overloaded with sugar and that should change. But it cannot be said to be the main game in obesity, like tobacco is in lung cancer.
Unlike tobacco – a single and inessential commodity – there is no case to ban sugar completely. A sugar tax would make all sugar-containing foods and drinks more expensive and hence less accessible to less affluent consumers who may at present depend on these sugar-laden commodities. It passes the penalty for consuming foods with high sugar content onto the consumer and so a tax would needs careful calibration using the criterion of equity. Also, Anderson et al warn of the tendency to substitute one source of energy for another and if the substitute for less sugar is more fat, then we are no further ahead.
The power of the sugar industry – cane, corn and beet – is immense and it is far from squeaky clean when it comes to promoting a healthy diet. It is at the level of production and marketing that our attention needs to focus in creating a healthier approach to sugar.
Encouraging individuals to lobby for less sugar in processed foods and drinks will not be easy but that is what is needed. Blood will be spilt as that battle plays out. But it is to this battle – and not by beating up individuals to reduce their individual consumption of sugar (desirable but neither necessary nor sufficient) – that our efforts should be applied for sustainable community-wide gains.
An international comparison of cost-effective ways of reducing obesity by McKinsey and Co, a consultancy, nominated reducing portion size as the best approach among about 30 useful options. Given the nearly 12 per cent difference in total energy intake between the obese and non-obese participants in the Anderson study, reducing the size of meals we eat by 10 per cent (and we would need the cooperation of restaurants, processed meal manufacturers and others) would seem a wise recommendation.
(* Professor Leeder is also editor of the International Journal of Epidemiology.)
AMA fully supports Physician’s Pledge update
BY DR CHRIS MOY, CHAIR, AMA ETHICS AND MEDICO LEGAL COMMITTEE
As a member of the World Medical Association (WMA), the AMA takes great pride in highlighting the achievements of the WMA as a world leader in the development and promotion of global ethical standards for the medical profession.
While the WMA adopts a wide range of global policy statements on ethical issues related to medical professionalism, human rights, patient care, medical research and public health, it also actively counteracts violations of its ethical standards.
As examples, the WMA consistently condemns governments and others who threaten to compromise professional autonomy and clinical independence, as well as those who undermine the role of medical neutrality and fail to protect healthcare workers in areas of armed conflict.
One of the oldest, and most defining, of the WMA’s ethical statements is the Declaration of Geneva, often considered a modern version of the Hippocratic Oath. Established in 1947, the WMA (of which the Federal Council of the British Medical Association in Australia was a founding member) was particularly concerned with the global state of medical ethics and decided to take on the responsibility of developing ethical guidelines for the world’s doctors.
The WMA believed that developing an international oath, or pledge, to be recited upon graduating medical school, would impress upon newly qualified doctors the fundamental ethics of medicine and raise the standard of professional conduct.
Attempting to seek international consensus on a pledge that was relevant to, and representative of, doctors from a wide range of cultural, religious, racial, political and linguistically diverse backgrounds, was challenging, but in 1948 the 2nd WMA General Assembly officially adopted the Declaration of Geneva to serve that role.
Over the years, the Declaration has undergone only minor amendments, the exception being its most recent iteration. In October 2017, the 68th WMA General Assembly in Chicago adopted the 7th revision of the Declaration, a culmination of a two-year consultation with more than 100 member National Medical Associations, as well as the public.
According to the Chair of the WMA Declaration of Geneva Workgroup, Dr Ramin Walter Parsa-Parsi of the German Medical Association, when reviewing the document, the workgroup considered modern developments in medicine and medical ethics, as well as contemporary WMA policies and international literature.
The Declaration has changed in subtle, but significant, ways. It is now more patient-centred. For the first time, it refers to patient autonomy and dignity and recognises the importance of ‘well-being’ to patient care. Further, the whole document has been reformatted to emphasise obligations to patients first followed by obligations to colleagues and society.
The updated Declaration better reflects the modern notion of collegiality, while doctors should respect their teachers, it now recognises they should respect their colleagues and students as well. Particularly relevant to the Australian context, the Declaration acknowledges the essential role that physician ‘well-being’ (and not just health) has on a doctor’s ability to provide a high standard of patient care.
In addition, it now refers to sharing medical knowledge for the benefit of the individual patient and wider health care, recognising the duty not just to the individual but the broader health system and society.
The WMA advocates that the Declaration of Geneva, now formally referred to as the Physician’s Pledge, be taken up on a global scale. The AMA has formally adopted the updated Declaration of Geneva. It is our hope as well that the Declaration will unite doctors throughout the world by affirming the highest standards of ethical conduct in the profession’s service to humanity.
The WMA Declaration of Geneva can be accessed at https://www.wma.net/policies-post/wma-declaration-of-geneva/.
[Obituary] Fotis Kafatos
Biologist, science administrator, and founding President of the European Research Council. He was born in Heraklion, Crete, Greece, on April 16, 1940, and died there on Nov 18, 2017, aged 77 years.