[Comment] The Vatican–Mario Negri–Lancet Commission on the value of life

When, in April, 2017, the Mario Negri Institute for Pharmacological Research and The Lancet invited international experts from diverse intellectual backgrounds to a meeting in Rome hosted by Cardinal Gianfranco Ravasi, President of the Pontifical Council for Culture, it was to discuss nothing less than the Future of Humanity through the Lens of Medical Science.1 The declared purpose of this ambitious conference was to contribute to healing the schism between science and religion, and to explore the ways in which these two intellectual powers could find solutions to the unprecedented emergencies that humanity faces.

Sugar tax might be the sweetener to change behaviour

The sugar tax concept has divided opinion in Australia, and both major political parties have rejected the idea of introducing the tax.

However, sales of soft drinks within a Melbourne hospital dropped by more than a quarter during an Australian-first trial of a sugar tax, monitored by researchers at Deakin University’s Global Obesity Centre.

The trial, carried out at a convenience store in The Alfred over 17 weeks, increased the cost of sugary drinks by 20 per cent.

The results, recently published in the Journal of the Academy of Nutrition and Dietetics, showed sales of the sugary drinks dropped by 27.6 per cent by the final week of the trial, while sales of water increased by almost the same amount.

The team behind the research believe there had, up until their trial, been limited real-world evidence of how an increase to the price of sugar sweetened beverages would change purchasing behaviour in Australia.

Lead researcher Miranda Blake, Associate Research Fellow at the Global Obesity Centre in Deakin’s School of Health and Social Development, said that the trial shows that an increase to the cost of sugary drinks can have a significant impact on lowering consumption.

“Sugary drinks are considered a good target for price manipulation because of their association with increased risk of health issues like obesity and dental decay, their minimal nutritional benefits and the apparent responsiveness of purchases to price changes,” Ms Blake said.

“Voluntary changes by retailers, which make healthy choices relatively more attractive and affordable, may be particularly appealing to retail outlets in community health promotion settings like hospitals, healthcare centres and sports and recreation facilities.”

Project supervisor Dr Kathryn Backholer, a Senior Research Fellow at the Deakin centre, said researchers interviewed customers and staff to get their perspective on the price increase, as part of the trial.

“About a third of the customers surveyed said the price difference had changed their purchasing decision, or would have changed it. Nearly two thirds of those surveyed said they agreed with intervention,” Dr Backholer said.

The World Health Organization (WHO) last year said that a tax of 20 per cent or more results in the drop of soft drink sales, which they say would also cut healthcare costs if it succeeded in improving health outcomes.

The Grattan Institute has suggested a tax of 40 cents per 100 grams of sugar, and calculated that obesity costs Australians $5.3 billion a year. The savings they have projected would mean an extra $500 million for the Budget.

And a study led by researchers from the Australian National University, performed in Thailand, suggested that thousands of cases of type 2 diabetes could be prevented every year by cutting out sugary drinks.

The AMA believes a sugar tax sends a message to parents of children and other consumers that there is a problem with these drinks. While acknowledging a sugar tax is not a magic bullet, it is time start sending the message that highly sugared carbonated drinks are a part of the problem with a growing obesity epidemic.

MEREDITH HORNE

Indigenous health, an AMA priority

The Federal Government needs to broaden its thinking when it comes to addressing the healthcare needs of Aboriginal and Torres Strait Islanders, because the current situation is unacceptable, according to AMA President Dr Michael Gannon.

Addressing the Australian Indigenous Doctors’ Association (AIDA) conference in the Hunter Valley in September, Dr Gannon said Indigenous doctors were vital to the health of Indigenous Australians.

“The AMA has said time and again that it is simply unacceptable that Australia cannot manage the health care of the first peoples, who make up just three per cent of our population,” Dr Gannon said.

“When it comes to Indigenous health, the Federal Government needs to broaden its thinking.

“For too long now, people working in Indigenous health have called for action to address the social issues that affect the health of Aboriginal and Torres Strait Islander people.

“Education, housing, employment, sanitation, clean water, and transport – these all affect health too.

“This is clearly recognised in the Government’s own National Aboriginal and Torres Strait Health Plan 2013-2023, yet we continue to see insufficient action on addressing social determinants.

“One message is clear – the evidence of what needs to be done is with us. There is a huge volume of research, frameworks, strategies, action plans and the like sitting with governments – and yet we are not seeing these being properly resourced and funded. We do not need more paper documents. We need action.

“The AMA recognises that Indigenous doctors are critical to improving health outcomes for their Aboriginal and Torres Strait Islander patients.

“Aboriginal and Torres Strait Islander doctors have a unique ability to align their clinical and cultural expertise to improve access to services, and provide culturally appropriate care for Indigenous patients.

“But there are too few Aboriginal and Torres Strait Islander doctors and medical students in Australia.”

AIDA used its conference to celebrate the organisation’s 20^th anniversary and had a conference theme of Family – Unity – Success.

Dr Gannon congratulated AIDA on the anniversary, noting that it had “come a long way”.

He said Aboriginal and Torres Strait Islander people face adversity in many aspects of their lives.

“There is arguably no greater indicator of disadvantage than the appalling state of Indigenous health,” he said.

“Aboriginal and Torres Strait Islander people are needlessly sicker, and are dying much younger than their non-Indigenous peers.

“What is even more disturbing is that many of these health problems and deaths stem from preventable causes.

“The battle to gain meaningful and lasting improvements has been long and hard, and it continues.

“I am proud to be President of an organisation that has for decades highlighted the deficiencies in Indigenous health services and advocated for improvements.

“While there has been some success in reducing childhood mortality and smoking rates, the high levels of chronic disease among Indigenous people continue to be of considerable concern.

“For the AMA, Aboriginal and Torres Strait Islander health is a key priority. It is core business.

“It is a responsibility of the entire medical profession to ensure that Aboriginal and Torres Strait Islander people have the best possible health.

“It is the responsibility of doctors to ensure that patients – all patients – are able to live their lives to the fullest.”

This year, the AMA’s Report Card on Indigenous Health – to be released in November – will focus on ear health and hearing loss.

Aboriginal and Torres Strait Islander people in Australia suffer from some of the highest levels of ear disease in the world, and experience hearing problems at up to 10 times the rate of non-Indigenous people across nearly all age groups.

Hearing loss has health and social implications, particularly in relation to educational difficulties, low self-esteem, and contact with the criminal justice system.

The report card will be a catalyst for Government action to improve ear health among Aboriginal and Torres Strait Islander people.

Dr Gannon told the conference that at every opportunity, the AMA highlights the issues of housing, clean water, transport, food security, access to allied medical services, and other social determinants that contribute to chronic disease and act as barriers to treatment and prevention.

And he said the AMA will continue advocating for an increase in the number of Indigenous doctors in Australia.

“The AMA has been a persistent, sustained, and powerful voice on Indigenous health for decades,” he said.

CHRIS JOHNSON

PIC: Dr Jeff McMullen, Dr Michael Gannon, Charles Davison, and Karl Briscoe

Remote NT patients at risk due to high staff turnover

Half the staff working in a remote Northern Territory healthcare clinic leave after four months on the job, two-thirds leave remote work altogether every year and any one clinic can see a 128 per cent turnover of staff each year, putting patient health at risk, new research shows.

Released on the 10^th anniversary of the United Nations Declaration on the Rights of Indigenous Peoples, the study raises concerns about how the rights to health of Aboriginal and Torres Strait Islander people living in remote communities are compromised by an unstable remote health workforce.

The study’s chief investigator Professor John Wakerman, Associate Dean Flinders Northern Territory, said there was no one simple solution to this issue.

“The work to date suggests a number of possible strategies. These include increased investment in recruiting and retaining local Aboriginal Health Practitioners and consideration of utilising remote nurse practitioners where there are no doctors to provide higher level care and to stabilise the nursing workforce,” Professor Wakerman said.

“We can also learn from successful strategies used for training and retaining doctors and apply them to nursing and allied health professionals.

“This would entail prioritising remote and rural origin and Aboriginal students in undergraduate courses, early exposure and training in remote areas and developing clear career pathways for these remote area health professionals.”

Lead author of the report, Dr Deborah Russell of Monash University, said there was considerable anecdotal evidence about the difficulties remote communities faced attracting and retaining suitably skilled health staff and their increasing reliance on agency nurses.

“This is a landmark study that actually measures turnover from the perspective of a particular remote health service,” Dr Russell said.

“It shows extreme fragility of the remote workforce, confirming that there is a heavy reliance on agency nurses to provide primary health care in Northern Territory remote communities.

“Lack of continuity of care has serious implications for both patient health and staff safety in remote communities across Australia.”

“Constantly having to recruit and orient new staff is also a serious drain on resources and can make it very difficult for these health services to participate in quality improvement.”

The study was a collaboration between Flinders University, Monash University, Macquarie University, the University of Adelaide, the University of Sydney and the NT Department of Health. It is part of a larger program of research investigating the impact and cost of short-term health staffing in remote communities to determine whether fly-in, fly-out is the cure or the curse.

The study looked at data provided by the NT Government payroll and account system from 2013 to 2015 covering 53 remote clinics.

While the study looked specifically at NT health services, the authors say that extremely high turnover and heavy reliance on short-term agency nurses for supply has important implications for remote health services anywhere in Australia.

“There’s good evidence that primary health care is critically important for achieving equitable population health outcomes,” said Dr Russell.

A chronic lack of continuity of care sees people less likely to access primary health care in a timely way and to disengage from their health care altogether.

“And, ultimately, that results in poorer health outcomes.”

The paper Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015 published in Human Resources for Health is available at: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0229-9

CHRIS JOHNSON

[Perspectives] Betty Kirkwood: trailblazer in global health epidemiology

After 38 years at the London School of Hygiene & Tropical Medicine (LSHTM), Betty Kirkwood is still in love with her academic home. “It’s the mission—shared by everyone from cleaners to refectory staff to academic staff—to improve health worldwide that brings a unique atmosphere to the school”, she says. Kirkwood is head of LSHTM’s Maternal and Child Health Intervention Research Group, and has been Professor of Epidemiology and International Health at LSHTM since 1995.

SIDS and serotonin link confirmed

A new Australian study has confirmed abnormalities in serotonin, a common brain chemical, are linked to sudden infant death syndrome (SIDS).

SIDS is the leading cause of infant death (between the ages of one month and one year) in Australia and most of the developed world.

University of Adelaide’s Medical School conducted the Australian first study, investigating 41 cases of SIDS deaths, and found there were striking abnormalities in chemical serotonin within the brain. The study has been published in the Journal of Neuropathology & Experimental Neurology.

Dr Fiona Bright, the primary researcher, said the study was significant because it confirmed abnormalities in serotonin in the brain are most definitely linked to cases of SIDS.

“Our research suggests that alterations in these neurochemicals may contribute to brainstem dysfunction during a critical postnatal developmental period,” she said.

“As a result, this could lead to an inability of a SIDS infant to appropriately respond to life-threatening events, such as lack of oxygen supply during sleep.”

Her work builds on research conducted in the United States at the Boston Children’s Hospital and Harvard Medical School, where Dr Bright was based for 18 months during her combined studies.

The Sudden Infant Death Research Foundation Inc., now known as Red Nose, estimates that annually, 3,200 Australian families experience the sudden and unexpected death of a baby or child. They have been quick to welcome the results of a University of Adelaide study.

Risk reduction still remains the key preventer of SIDs. This includes evidence-based safe sleeping public health program. Since risk reduction campaigns began in 1989, the rate of SIDS in Australia has decreased by 80 per cent. Red Nose believes that an estimated 9,450 lives have been saved.

Dr Bright’s research also reinforces that risk factors are central to managing SIDS.

“Notably, the SIDS cases we studied were all linked to at least one major risk factor for SIDS, with more than half of the infants found in an adverse sleeping position and having had an illness one month prior to death,” Dr Bright says.

“Ultimately, we hope that this work will lead to improved prevention strategies, helping to save baby’s lives and the emotional trauma experienced by many families.”

For information on how to sleep baby safely to reduce the risk of sudden unexpected death in infancy, including SIDS and fatal sleeping accidents, visit https://rednose.com.au/section/safe-sleeping.

MEREDITH HORNE

Sugar tax might be the sweetener to change behavior

The sugar tax concept has divided opinion in Australia, and both major political parties have rejected the idea of introducing the tax.

The trial, carried out at a convenience store in The Alfred over 17 weeks, increased the cost of sugary drinks by 20 per cent.

MEREDITH HORNE

Emergency department use in developed countries

A global study undertaken by George Washington University has evaluated the use of emergency departments in seven developed countries and has identified areas where efficiencies are needed.

The study, conducted with Royal Philips researchers, found that Australia has a low use of emergency departments when compared to Canada, the US, the UK, the Netherlands, Switzerland and Germany.

This finding points to Australia’s strong access to primary care resulting in less frequent use of emergency resources.

The paper, Acute unscheduled care in seven developed nations: a cross-country comparison, compares the similarities and differences across nations with a focus on care delivery and the impact of socio-economic factors.

The research from Philips and the GWU School of Medicine and Health Sciences reveals unsustainable ED use in some developed nations.

Better access to primary care can result in lower ED use.

The findings of the report show Germany (22 per cent) and Australia (22 per cent) as having the lowest ED use, likely resulting from better and faster access to primary care — nearly two-thirds of Australians (58 per cent) and three-quarters of Germans (72 per cent) were able to make same or next day appointments with their primary care physicians (PCPs) compared to less than half of Americans (48 per cent) and Canadians (41 per cent).

“In looking at the way emergency departments are used around the world, we were able to obtain valuable new insights to help improve care delivery,” said Jesse Pines, from GWU.

“Because of research findings presented in this report, all emergency departments, no matter their location, have the opportunity to efficiently improve the way care is delivered in emergency department settings.”

Kevin Barrow, managing director of Philips Australia and New Zealand said the research shows Australia ranked relatively well when it comes to hospital emergency department admissions.

“And (for) the cost of health care for both government and individuals, in comparison to other countries surveyed, reflecting the relative ease of access to primary care in our country,” he said

“However, the findings also identified a need to improve departmental efficiencies and increase activities to minimise the burden on acute care facilities, by continuing to focus on preventive care, chronic disease management and the education of patients on the appropriate care for their health needs.”

Data has been formulated into a list of key areas researchers say impact the way care is delivered in emergency settings, and the broad differences in available treatments across countries.

They include:

• Social determinants (smoking, eating, violence, substance abuse and poverty) have a strong impact on the use of EDs;

• Reduced access to health insurance results in poorer population health; placing a greater strain on emergency departments;

• Sick patients do not make the most efficient decisions about when and where to seek medical care;

• Extensive provider training is mandatory for effective delivery of acute unscheduled care; and

• Quality measures for EDs are immature and not standardised.

“There’s a belief that easy access to primary care can result in lower emergency department use,” said Mark Feinberg of Philips North America.

“However, as a result of this report, it is clear that even if people have easy access to primary care and full healthcare coverage, there is no guarantee the patients will make economically prudent decisions to seek the most appropriate medical care setting.”

The complete report can be accessed at: www.healthsystems.philips.com/acute-unscheduled-care

CHRIS JOHNSON

[Series] Advances in paediatric gastroenterology

Recent developments in paediatric gastrointestinal surgery have focused on minimally invasive surgery, the accumulation of high-quality clinical evidence, and scientific research. The benefits of minimally invasive surgery for common disorders like appendicitis and hypertrophic pyloric stenosis are all supported by good clinical evidence. Although minimally invasive surgery has been extended to neonatal surgery, it is difficult to establish its role for neonatal disorders such as oesophageal atresia and biliary atresia through clinical trials because of the rarity of these disorders.

[Correspondence] Research misconduct and the INTERGROWTH-21st study

We respectfully take issue with the Comment published in February, 2017, by members of The Lancet’s editorial staff stating that WHO’s judgment of misconduct regarding the Oxford INTERGROWTH-21st study was unproven.1–3 We are saddened by the fact that they base their conclusion on limited and biased material and simply dismiss the case as rivalry. As members of the WHO Fetal Growth research group and a former WHO external expert not associated with that trial but with evidence that WHO initially refused to hear, we wish to note the following.