[Correspondence] Defending academic and medical independence in Turkey

We write on behalf of 207 health professionals, academics, and researchers, and 25 health and human rights organisations from many countries (appendix). We wish to bring to the attention of The Lancet’s readers alarming events taking place in Turkey, where the state has been waging a campaign of terror and punishment against thousands of health professionals and academics.

Relationships with industry

BY DR CHRIS MOY, CHAIR. AMA ETHICS AND MEDICO LEGAL COMMITTEE

A major priority for the AMA’s Ethics and Medico-Legal Committee (EMLC) will be the review of the Position Statement on Medical Practitioners’ Relationships with Industry 2012. The statement provides guidance for doctors on maintaining ethical relationships with “industry”, including the pharmaceutical industry, medical device and technology industry, other health care product suppliers, health care facilities, medical services such as pathology and radiology, and other health services such as pharmacy and physiotherapy.

The current Statement encompasses the following sections:

medical education;
managing real and potential conflicts of interest;
industry sponsored research involving human participants including post-marketing surveillance studies;
meetings and activities organised independent of industry;
meetings and activities organised by industry;
hospitality and entertainment;
use of professional status to promote industry interests;
remuneration for services;
product samples;
dispensing and related issues; and
relationships involving industry representatives.

Doctors’ primary duty is to look after the best interests of their patients. To do so, doctors must maintain their professional autonomy, clinical independence and integrity, and have the freedom to exercise professional judgement in the care and treatment of patients without undue influence by third parties (such as the pharmaceutical industry or governments).

But what happens when the impetus to change the relationship with industry comes from within the profession itself? For example, the AMA’s current policy on doctors and dispensing states that:

11.1 Practising doctors who also have a financial interest in dispensing and selling pharmaceuticals or who offer their patients’ health-care related or other products are in a prima facie position of conflict of interest.

11.2 Doctors should not dispense pharmaceuticals or other therapeutic products unless there is no reasonable alternative. Where dispensing does occur, it should be undertaken with care and consideration of the patient’s circumstances.

In recent years, we have heard from members who believe this position is too strict and doctors should be able to dispense pharmaceutical products, arguing that it’s more convenient for patients and leads to better compliance. For example, patients may be more likely to fill their prescriptions onsite at the doctor’s office than if they have to go offsite to a pharmacy. In addition, the doctor is there to answer any questions relevant to the prescription which will reduce pharmacy call backs and waiting times.

Historically, the AMA has strongly advocated that doctors do not make money from prescriptions. Allowing doctors to dispense pharmaceuticals or other therapeutic products (other than in exceptional circumstances) would be a fundamental shift in this position – but is that a sufficient reason not to change it?

After all, dispensing pharmaceuticals or other therapeutic products is not in itself unethical so long as it is undertaken in accordance with good medical practice. Unfortunately, however, there can still be a strong perception of a conflict of interest, particularly if doctors are making a profit rather than just recovering costs. So for many doctors – but more importantly our patients and the wider community who are our ultimate judges – this is a line which should not be crossed.

These are the types of issues the EMLC will consider in reviewing this policy and we will endeavour to seek members’ views during the process.

The EMLC will also be developing an overarching policy on managing interests, highlighting the potential for professional and personal interests to intersect, and at times compete, during the course of a doctor’s career. While a real, or perceived, conflict of interest is by no means a moral failing, it is important that doctors are able resolve any potential for conflict in the best interests of patients.

The Position Statement on Medical Practitioners’ Relationships with Industry 2012 is accessible on the AMA’s website at position-statement/medical-practitioners-relationship…. If you would like to suggest any amendments to the current Statement, please forward them to ethics@ama.com.au.

New App set to assist with pain monitoring for dementia patients

A point-of-care assessment app designed to help detect pain in people with dementia has gained approval for use as a medical device in Australia and Europe.

The Electronic Pain Assessment Tool (ePAT) is a mobile application tool, which has evolved from research undertaken by Curtin University over the past four years that aims to assess and monitor pain in people who cannot communicate verbally.

ePAT now has gained regulatory approval for its device and will roll out the app in Australia this year, in Europe next year and then aim to have US regulation by 2019.

The regulatory approval follows a peer-reviewed study confirming the validity and reliability of ePAT in people with moderate to severe dementia that was accepted for publication in Journal of Alzheimer’s Disease (JAD) in July this year.

Curtin University’s Professor Jeff Hughes, the co-inventor of the app said: “Our vision to ensure no person who cannot speak will suffer in silence with pain is closer to being a reality.”

The ePAT app works by taking a 10-second video of the patient’s face and analysing it in real time for micro-expressions that indicate the presence of pain.

It combines this with information also captured through the app on non-facial pain cues, such as vocalisations, behaviours and movements, to calculate a pain severity score.

Both residents and care staff stand to benefit, Professor Hughes said.

“For people with dementia, it’s a more reliable way for their pain to be assessed and hence a reduced likelihood that it will go undetected or unmanaged.

“It offers residential aged care staff looking after people with dementia a simple reproducible means of assessing and monitoring pain.

“This should result in better pain management and a reduction in pain related behavioural problems, in turn decreasing the need for psychotropic medications,” Professor Hughes said.

The Australian Institute of Health and Welfare data shows 342,800 Australians were estimated to have dementia in 2015. Based on projections of population ageing and growth, the number of people with dementia will reach almost 400,000 by 2020, and around 900,000 by 2050.

MEREDITH HORNE

Publically funded contraception set for challenge by the Trump administration

With the politics in the United States still playing out on the Affordable Care Act, the White House has reportedly moved forward with a plan to cut a provision that was introduced to protect women’s reproductive rights.

The Affordable Care Act expanded contraception coverage to about 55 million women with private insurance coverage.

The Trump administration is expected to amend the Federal regulation that requires employers to provide health-insurance plans that offer preventive care and counselling – which the US Department of Health and Human Services has interpreted to include contraception – at no cost.

The expected Presidential executive order will allow any business or organisation to request an exemption on religious or moral grounds.

The Obama administration issued regulations allowing religious employers to opt out of offering contraceptive coverage. However affected employees were then covered directly by their insurers.

Gretchen Borchelt, Vice President for Reproductive Rights and Health at the National Women’s Law Center, has said that hundreds of thousands of women could lose access to their birth control “if this broad-based, appalling, and discriminatory rule is made final”.

Many family planning advocates are concerned that this policy shift will see a result to an increase in abortion rates across the US. Recent research by the Guttmacher Institute suggests that improved contraceptive use, resulting in fewer unintended pregnancies, likely played a larger role than new state abortion restrictions in the decline between 2011 and 2014.

The American Congress of Obstetricians and Gynaecologists has issued a statement that denounces any plan to roll back contraception coverage, saying that any move to decrease access to these services would have a damaging effect on public health.

“Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives.

“Since the Affordable Care Act increased access to contraceptives, our Nation has achieved a 30 year low in its unintended pregnancy rate, including among teens.

“Unintended pregnancies can have serious health consequences for women and lead to poor neonatal outcomes,” the statement reads.

MEREDITH HORNE

Report warns blindness set to rise

A new study published in Lancet Global Health warns the number of blind people across the world is set to triple within the next four decades.

The research predicts cases will rise from 36 million to 115 million by 2050, if treatment is not improved by better funding.

A growing ageing population is behind the rising numbers.

Some of the highest rates of blindness and vision impairment are in South Asia and sub-Saharan Africa.

Although the percentage of the world’s population with visual impairments is actually falling, according to the study, the global population is growing and so the number of people with sight problems will soar in the coming decades.

Analysis of data from 188 countries suggests there are more than 200 million people with moderate to severe vision impairment.

That figure is expected to rise to more than 550 million by 2050.

“Even mild visual impairment can significantly impact a person’s life,” said lead author Professor Rupert Bourne, from Anglia Ruskin University in Cambridge.

“For example, reducing their independence…as it often means people are barred from driving.”

He said it also limited people’s educational and economic opportunities.

The worst affected areas for visual impairment are in South and East Asia. Parts of sub-Saharan Africa also have particularly high rates.

The study calls for better investment in treatments, such as cataract surgery, and ensuring people have access to appropriate vision-correcting glasses.

Professor Rupert Bourne said that interventions provide some of the largest returns on investment in eye health.

“They are some of the most easily implemented interventions in developing regions because they are cheap, require little infrastructure and countries recover their costs as people enter back into the workforce,” he said.

In Australia, the CEO of the Fred Hollows Foundation, Brian Doolan, spoke to the research, saying that more needs to be done for social development, targeted public health agreements and accessible eye health facilities.

“The strategies being used around the world have been shown to work, all we need is to get them to the right scale to address the growing global need,” Mr Doolan said.

According to Mr Doolan, the leading cause of blindness worldwide is poverty, followed by gender.

The report also indicates Aboriginal and Torres Strait Islander people are still three times more likely to be blind than other Australians. Most blindness in Australia is due to readily preventable or treatable causes of vision loss, including cataract, diabetes, refractive error and trachoma.

The AMA continues to call on the Federal Government to correct the under-funding of Aboriginal and Torres Strait Islander health services, including programs to limit preventable blindness.

MEREDITH HORNE

[Comment] Building virtual communities of practice for health

Advances in medical research and innovation mean little if they do not reach the patients who need them. Too often, specialised medical knowledge remains within the walls of academic and tertiary care centres in capitals and major cities, inaccessible to much of the world’s population due to geographical distance and economic disparity. To “ensure healthy lives and promote well-being for all at all ages”, UN Sustainable Development Goal 3, a more efficient and equitable way to disseminate new scientific knowledge and evidence-based expertise is needed.

[Articles] Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care.

Processed meats need a closer look

OPINION
By Dr Alphonse Roex and Dr Heleen Roex-Haitjema

In October 2015, the authoritative International Agency for Research on Cancer (IARC) confirmed that processed meat causes cancer and red meat is a probable carcinogen (Table 1.^1,2).

IARC Carcinogenic Classification Groups

Likelihood to cause cancer in humans

Type of meat

Examples

Causes cancer

Processed meats

Bacon, ham, sausages, hot dogs, hamburgers, ground beef, mince, corned beef, beef jerky, canned meat, offal and blood

Probably causes cancer

Red meats

Meat from mammals: pork, veal, beef, bull meat, sheep, lamb, horse meat and,

Meat from hunting: wild boars, deer, pigeons, partridges, quail and pheasants

Table 1. Based on the IARC’s data on the carcinogenicity of processed meat and red meat.^1,2

The IARC assessed more than 700 epidemiological studies regarding red meat and more than 400 provided data on processed meat. The IARC estimates that worldwide the consumption of diets high in processed meat results in approximately 34,000 deaths annually and diets high in red meat in 50,000 avoidable cancer deaths per year. Eating an extra portion of 50 grams of processed meat daily increases the relative risk of colorectal cancer by 18 per cent.

The strength of evidence that processed meat is a carcinogen is comparable with tobacco smoking and asbestos.^3,4

Diets high in animal protein show a 75 per cent increase in total mortality, a 500 per cent increase in diabetes, a 400 per cent increase in cancer risk, and produce significantly higher levels of IGF1, a potent cancer-promoting hormone.⁵

Chronic diseases are responsible for considerable human suffering and contribute heavily to the burden of disease nationally. Australia’s ever increasing total healthcare expenditure has in 2016 for the first time surpassed 10 per cent of its Gross Domestic Product. It is estimated that 55-60 per cent of this total is spent on chronic disease management.

Nearly two years have passed since the World Health Organisation’s report on the categorisation of processed animal products as carcinogenic. The time has come that we doctors take the initiative to inform our citizens and create systems, processes and policies to protect our patients and communities from further harm from such known carcinogens. We were finally moved to show united leadership 60 years ago in regards to smoking. Ultimately, after roughly 7000 scientific publications showing the relationship between smoking and lung cancer, healthcare providers became advocates for the best available medical evidence trumping the lures of a treasured habit for many of their patients (and indeed, fellow colleagues).

The American Medical Association in the USA has led the way by calling on hospitals there to improve the health of patients, staff and visitors by (1) providing a variety of healthful food, including plant-based meals that are low in fat, sodium and added sugars, (2) eliminating processed meats from menus and (3) providing and promoting healthful beverages.^6,7^,8

Springmann et al. estimated the effects of consuming less – or no – animal products on global population health should a transition to a more plant-based diet be made leading up to 2050. Conclusions reached were a reduction in premature deaths, abundant economic benefits and reduced greenhouse gas emissions. Table 2.⁹

Healthier diets compared to present omnivorous diet	Characteristics diets	Human health benefits: millions of premature deaths avoided	Economic valuation: value-of-statistical life approach. Trillion of AUD saved per year
Healthy Global Diet (WHO)	Less meat and sugar; More vegetables and fruit	5.1	27.6
Vegetarian	Minimal animal products: dairy and eggs only	7.3	36.8
Vegan	No animal products: plant-based only	8.1	39.4

Table 2. Human lives and money saved in 2050 if the world population would adapt more healthful diets. Based on publication M Springmann et al.⁹

We understand that our AMA is aware of the issue and we are engaging with its Public Health team.

The time for compassionate action and leadership on this important issue by the Australian medical profession has arrived. All medical administrators, procurement officers, caterers and doctors (in association with registered dietitians) should then feel encouraged, empowered and supported to play a role in implementing the elimination of processed meats in medical institutions.

Views expressed in the above Opinion piece are those of the authors and do not reflect official policy of the AMA.

The authors’ credentials are listed below:

Dr Alphonse Roex MD PhD, FRANZCOG

Senior Consultant Obstetrics and Gynaecology The Lyell McEwin Hospital South Australia
Senior Lecturer, The University of Adelaide
Medical degree: Utrecht University, the Netherlands
Specialist degree and PhD: Free University Amsterdam, The Netherlands
Member PCRM (Physicians Committee for Responsible Medicine (Washington DC USA)
International presenter on Nutrition and Health

Dr Heleen Roex-Haitjema, Paediatrician (not practising)
Certificate in Plant-Based Nutrition, Cornell University, New York
Certified Food for Life Instructor, The Physicians Committee for Responsible Medicine, Washington DC
Medical degree: Utrecht University, The Netherlands
Specialist degree: Free University Amsterdam, The Netherlands.
Member PCRM (Physicians Committee for Responsible Medicine (Washington DC USA)
International presenter on Nutrition and Health.

References

Bouvard V, Loomis D, Guyton KZ et al. on behalf of the IARC Monograph Working Group. Carcinogenicity of consumption of red and processed meat. Lancet Oncology 2015.
http://publications.iarc.fr/Book-And-Report-Series/Iarc-Monographs-On-The-Evaluation-Of-Carcinogenic-Risks-To-Humans. Volume 114 (2015).
IARC Monographs on the Evaluation of Carcinogenic Risks to humans. Volume 83 (2004) Tobacco Smoke and Involuntary Smoking.
IARC Monographs on the Evaluation of Carcinogenic Risks to humans. Volume 100C. (2012) Asbestos.
Levine ME et al. Low Protein Intake is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population. Cell Metabolism 2014;19:407-17.
https://janeunchained.com/2017/06/23/ama-comes-out-against-serving-processed-meats-in-hospitals/
http://www.pcrm.org/nbBlog/american-medical-association-passes-healthy-food-resolutions
https://wire.ama-assn.org/ama-news/ama-backs-comprehensive-approach-targ…
Springmann M. et al. Analysis and valuation of the health and climate change co-benefits of dietary change PNAS doi:10.1073/pnas. 2016; 1523119113.

Heart disease and suicide killing more methamphetamine users

A national seven-year study has found that the number of methamphetamine-related deaths in Australia doubled between 2009 and 2015, with heart disease and violent suicide identified as prominent causes of death.

The study, undertaken by the National Drug and Alcohol Research Centre was published in the journal Addiction.

It analysed 1649 cases of methamphetamine-related death retrieved from the National Coronial Information System (NCIS) and found that in a fifth of cases (22 per cent) death was attributed to natural disease in conjunction with methamphetamine toxicity.

The most frequent natural disease was cardiac and/or cardiovascular disease and stroke.

Lead author Professor Shane Darke said the results were indicative of a major public health issue and highlighted a hidden problem.

“To see such large and significant increases in mortality rates over the study period indicates a major methamphetamine problem,” Professor Darke said.

“With so much public attention focused on violence, many users may be unaware that heart disease is a major factor in methamphetamine-related death.

“Without increased awareness of the connection between methamphetamine use and cardiac and/or cardiovascular disease we could expect to see a significant increase in cases of this kind in the coming years.”

Suicide accounted for 18 per cent of methamphetamine-related deaths, with specific characteristics around methods and gender. Studies of suicide in the general population have consistently shown that males predominately use violent means and females self-poisoning.

Professor Darke urged health professionals to be aware of the prominent role of violent suicide and take appropriate steps to monitor methamphetamine users.

“The impulsivity and disinhibition associated with methamphetamine intoxication may be a factor,” he said.

“In this series, suicide by violent means – most prominently hanging – was the main method used by both genders.”

Other findings of the study include: nearly half of cases occurring in rural and regional locations; the most common manner of death (43 per cent) is accidental drug toxicity; and even modest amounts of methamphetamine may provoke cardiac arrhythmia.

The research also noted that there were 245 deaths from traumatic accidents, including 156 where the person was driving a car or motorbike.

The AMA is very concerned about the health impacts crystal methamphetamine has on users, their families, and the health system. The AMA’s Position Statement on methamphetamine can be found on their website here: position-statement/methamphetamine-2015

MEREDITH HORNE

Speak into the microphone please doctor

Patients in the United Kingdom and United States are increasingly taking their smart phones out of their pockets, placing them on doctors’ desks and pressing record during medical consultations.

Even more are secretly recording their visits.

Laws vary according to national and State jurisdictions, but generally in those countries patients have the right to record clinical visits while doctors also have the right to terminate consultations if they don’t want them recorded.

According to a research paper recently published in the American Medical Association’s medical journal JAMA, the growing practice should not necessarily be a concern.

Some health clinics even offer patients recordings of their visits.

“Many clinicians and clinics have concerns about the ownership of recordings and the potential for these to be used as a basis for legal claims or complaints,” the authors noted.

“Administrators and patients are unclear about the law and are concerned that recording clinical encounters might be illegal, especially if done covertly. The law is inconsistent: recording is allowed in certain situations and is illegal in others.”

The research found, however, that for most patients wishing to record consultations, the motivation was reasonable.

“Patients want a recording to listen to again, improve their recall and understanding of medical information, and share the information with family members,” the report says.

“As healthcare continues to make significant strides toward transparency, the next step is to embrace the value of recording clinical encounters.

“The clinician can choose to continue, accepting that the conversation is being recorded, or terminate the visit.

“Using the recording to harm or damage the reputation of the clinician recorded could lead to legal action.”

A survey conducted among the general public in the UK found that 19 of 128 respondents (15 per cent) indicated they had secretly recorded a clinical visit, and 14 of 128 respondents (11 per cent) were aware of someone covertly recording a clinic visit.

A subsequent review identified 33 studies of how patients used recordings of their clinical visits. Across the studies, 72 per cent of patients listened to their recordings and 68 per cent shared them with caregivers.

Patients who recorded their consultations reported greater understanding and recall of medical information.

In parts of the US, clinicians as well as patients report benefits in having sessions recorded. Liability insurers in America even insist that the presence of a recording can protect doctors.

CHRIS JOHNSON