[Editorial] Reforming public and global health in Germany

Germany is not fulfilling its full potential in public and global health, according to a new statement from three of the country’s leading scientific academies. Their report—Public health in Germany: structures, developments and global challenges—was produced by an international working group of scientists who assessed what is needed to better the health of the population from the perspectives of academic public health, global health research, supporting institutions and structures, and the translation of science.

Open speeds on Northern Territory roads: not so fast

Road safety should remain a public health priority not a political issue

Annual road deaths in Australia have decreased from 7.9 to 5.2 per 100 000 population in the period from 2004 to 2013 (Box).1 In contrast to the national figures, the Northern Territory has recorded a mean of 21.8 deaths per 100 000 over the same period.

There are many possible factors contributing to this large discrepancy. Among NT road users, alcohol usage is high and seatbelt usage is low.2 Additionally, NT roads are almost invariably single lane and unseparated, many are unsealed, they are subject to the extremes of weather and are also exposed to wandering livestock and wildlife. Consequently, NT roads have attracted the lowest of Australian Road Assessment Program safety ratings, with over half having one and two stars out of five.3 The NT is unique in many ways and these differences threaten the survival of road accident victims. Road traffic is light and, as a consequence of this, victims may not be found for many hours after an accident. Hospitals and retrieval assets are sparse, resulting in prehospital times of many hours. The “golden hour” of trauma — that window immediately after injury when medical intervention can be life-saving — seldom exists for Territorians in remote areas.

Indigenous Australians comprise nearly 30% of the NT population, and most of these people live in remote areas. The risk of road trauma is magnified in these remote communities, as cultural and linguistic differences are a barrier for driver licensing and training and there is a paucity of public transport, and yet there are frequent cultural demands for short-notice mass transport.4

Changing policy with changing governments

Before 2007, there was no speed limit on most NT highways, and drivers were free to travel at whatever speed they felt comfortable with. In 2007, in response to the high road toll, the NT Government introduced speed limits of 130 km/h on the four main highways and 110 km/h on other rural roads.5 Since then, differing political, professional and public opinions have been discussed frequently in the NT media. These speed limits were reconsidered in 2012, and the NT government made an election promise to conduct a review on the feasibility of reintroducing open speeds.6 The government commissioned reports from road safety experts, but this information remains cabinet-in-confidence. In February 2014, the NT Government reintroduced open speeds for a 200 km section of the Stuart Highway on a trial basis,7 despite voiced concerns from medical, policing and road safety groups. The response from the current NT Government to these concerns is to cite the role of fatigue, to emphasise the roles of alcohol and seatbelts, to deny that speed is a major factor in many crashes and to promote individual driver responsibility.7

Vehicular speed and crash risk

The relationship between speed and a motor vehicle collision goes beyond the kinetic energy released being proportional to the product of mass and velocity squared. Researchers have developed several formulas to describe the multifactorial nature of road accidents, involving multiple variables; however, in each of these models, speed remains a decisive factor. An increase in vehicular speed increases crash risk either exponentially or to a power ratio.8 Modelling has suggested that the greater the difference in speed between two vehicles, the greater the crash risk for both the slower and the faster vehicle.8 The implications of a mix of open speed and speed-restricted vehicles, such as towing vehicles, heavy vehicles and probationary drivers, are obvious. Further, Australian and international case–control studies have shown that reducing posted speed limits by 10 km/h on rural roads decreases crash risk by 20%–25%. Multiple examples of this are included in the National Road Safety Strategy 2011–2020.9

What seems to be lacking in this debate is a dispassionate examination of the available evidence. Allowing individual motorists to drive to conditions seems optimistic and discounts that there will always be a cohort of inexperienced drivers. This policy seems to place blame on individual motorists, overlooking the conditions that increase the risks of fatal crashes. Higher vehicle speeds are promoted by lobby groups as a solution to reducing fatigue. While combating fatigue is important in improving road safety, swapping one risk factor for another is not the solution. Campaigns to combat drink driving and poor rates of seatbelt use are appropriate, but road safety is a package, and a vital element of the package is missing.

The small numbers involved make statistical interpretation difficult. The Australian road deaths database shows a decrease in fatalities of 3.4 per year on those NT roads with speed limits of 110 km/h and above after the abolition of open speeds (mean deaths: 2000–2006, 31.1 per year; 2007–2014, 27.7 per year).10 For every road death in Australia, 23 other people are hospitalised as a result of a road crash,9 which amplifies the potential societal benefit of any reduction in speed limit. Other legislative measures, infrastructure and trauma system improvements are likely to have contributed to this reduction, but attempting to minimise the role of speed in crash risk would seem unwise.

The Northern Territory needs a stronger road safety package

Trauma is too often considered an accident when it should be considered a preventable disease. We understand the causes and effects and we know, to an extent, how to prevent this trauma from occurring. Every crash is multifactorial, and alcohol and seatbelt use should remain a focus of a strong road safety package. However, allowing unlimited speed on major highways sends the wrong message to the NT population, especially when they are already three times more likely to die on the roads than people living in other parts of Australia, and at a rate that is equivalent to that in many low- and middle-income countries.11 The available evidence in the literature suggests that the piecemeal reintroduction of open speeds on the highways of the NT will eventually result in an increased number of fatalities and serious injuries. The NT Government should strengthen its road safety package and tailor it to the unique needs of its population, not abandon components due to popular demand. A comment from scientist Richard Feynman on the interplay between science and politics resonates here:

For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled.

Comparison of annual road deaths per 100 000 population in the Northern Territory with the national total, 2004–2013*

* Data from: Bureau of Infrastructure, Transport and Regional Economics. Road deaths Australia: 2013 statistical summary.1

[Comment] Capacity for science in sub-Saharan Africa

During the past decade there has been an increase in funding for research capacity building in Africa. Two major European programmes are at a turning point: the Wellcome Trust’s African Institutions Initiative is about to end, while their new initiative, DELTAS Africa,1 will be launched later this year. The European Union’s Seventh Framework Programme (FP7) is ending, superseded by Horizon 2020,2 with the transition of some research areas that are important to Africa into the expanded second phase of the European and Developing Countries Clinical Trials Partnership.

[Correspondence] Causes of child death: comparison of MCEE and GBD 2013 estimates

Child cause of death (COD) estimates for 2013 produced by the Maternal and Child Epidemiology Estimation group (MCEE, formerly the Child Health Epidemiology Reference Group or CHERG) and the WHO were published (online on Sept 30, 2014) in The Lancet.1 Estimates of child COD from the Global Burden of Disease (GBD) Study were later published in The Lancet (online on Dec 17, 2014).2 The GBD authors compared our previously published estimates for 20103 with their new estimates for 2010 providing both differing causes and numbers of deaths than they published previously.

[Correspondence] Causes of child death: comparison of MCEE and GBD 2013 estimates – Authors’ reply

Information about causes of childhood mortality is an important input to global health policy making. Two sets of estimates are available from the Global Burden of Disease Study (GBD) 20131 and the Maternal and Child Epidemiology Estimation group (MCEE, formerly known as the Child Health Epidemiology Reference Group [CHERG]). Liu and colleagues2 make a comparison between estimates for 2013 from the two studies and speculate reasons for the differences.

Australia good, but can do better, on heart disease and stroke

Australia has one of the lowest mortality rates from cardiovascular disease in the developed world, but the nation has been told it needs to consider taxes on sugar-rich and unhealthy foods to combat rising obesity and diabetes.

Australia’s cardiovascular disease (CVD) mortality rate fell to 208 per 100,000 people in 2011, 30 per cent below the average among Organisation for Economic Co-operation and Development member countries of 299 per 100,000, and the potential years of life lost to circulatory diseases dipped to 372 per 100,000, 36 per cent below the OECD average of 581 per 100,000.

In a report released overnight, the OECD attributed the nation’s success in driving down deaths from heart attacks and stroke to accessible, high quality health care and effective public health policies, particularly in reducing smoking.

The Organisation said comprehensive tobacco control measures, including a hefty excise, mass media campaigns, advertising and smoking bans and, most recently, tobacco plain packaging laws, had helped drive the smoking rate down to 12.8 per cent last year, one of the lowest in the OECD and well below the average of 20.9 per cent among member countries in 2012.

But the OECD warned the nation needed to overcome several challenges if it was to cement and build upon its success in reducing CVD mortality.

It cautioned that Australia’s high obesity rate – 28.3 per cent, almost double the OECD average of 18 per cent – threatened to drive up the incidence of CVD unless it was addressed, and noted that the nation’s spending on preventive health measures had slipped to just 1.8 per cent of total health expenditure, well below the OECD average of 2.9 per cent.

In its first Budget, the Abbott Government abolished the Australian National Preventive Health Agency and absorbed its functions with the Health Department, heightening concerns of a loss of national focus and leadership on preventive health measures.

The OECD has also echoed warnings from the AMA about the dangers of deterring patients from seeing their doctor by imposing out-of-pocket costs.

AMA President Professor Brian Owler said the Government’s four-year freeze on Medicare rebates would create a patient co-payment “by stealth” by forcing doctors to reduce bulk billing and charge out-of-pocket (OOP) expenses.

The OECD said that Australian patients already faced higher than average out-of-pocket costs, and cautioned that “higher OOP costs will lead to a lower use of primary care services, particularly among the poor”.

Nonetheless, the Organisation said access to primary care in Australia was “generally good”, and the nation’s heavy use of cholesterol-lowering drugs – the highest in the OECD – showed there was ready access to medication.

The observation came two days after research was published estimating that 60,000 patients stopped taking cholesterol-lowering statins after the ABC television program Catalyst questioned their safety.

The OECD said Australians with CVD had access to good quality acute care. The 30-day case-fatality rate for acute myocardial infarction patients was 4.4 per cent, one of the lowest rates in the OECD, while case-fatality for stroke patients was around the OECD average and the proportion of stroke patients treated in dedicated facilities was higher than many other comparable countries.

The OECD said the country needed to curb the rise in obesity if it was to make further inroads into CVD fatality rates, and suggested it consider measures adopted in other countries, such as taxes on unhealthy or sugar-rich food and drinks and the development of nationally-co-ordinated health promotion programs.

Adrian Rollins

Curb the drinks to cut the violence

Australian of the Year Rosie Batty has backed calls for a crackdown on sales of alcohol, including an end to 24-hour trading and a buyback of liquor licenses, as part of efforts to stamp out family violence.

Echoing the AMA’s call last year for governments nationwide to take strong action to curb alcohol-related violence, Ms Batty has urged national leaders including Prime Minister Tony Abbott and Opposition leader Bill Shorten to adopt a set of proposals developed by the Foundation for Alcohol Research and Education (FARE) to reduce the saturation of alcohol in the community.

“There is not, and can never be, an acceptable level of family violence,” Ms Batty said. “Prevention must be our ultimate goal, and we must do everything in our power to stop it.”

Ms Batty’s plea has underlined the outcomes of the National Alcohol Summit organised by the AMA last October that called for a consistent national approach to the supply and availability of alcohol, including statutory regulation of alcohol marketing and a review of taxation and pricing arrangements.

AMA President Professor Brian Owler, who convened and led the Summit, said at the time that alcohol misuse was one of the country’s major health issues, with estimates that the damage it caused through violence, traffic accidents, domestic assaults, poor health, absenteeism and premature death, cost the community up to $36 billion a year.

“Alcohol-related harm pervades society. It is a problem that deserves a nationally consistent response and strategy,” Professor Owler said.

In recognition of the fact that often family doctors are the first port of call for victims of domestic violence, the AMA, in conjunction with the Law Council of Australia, last month released a toolkit providing guidance and resources for GPs in helping patients who have been attacked by their partners.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at: article/ama-family-violence-resource

The plan to prevent alcohol-related family violence developed by FARE, launched by Ms Batty on 17 June, calls for those applying for liquor licenses to be subject to more stringent approval process, a restriction on trading hours, a liquor licensing freeze or buybacks in saturated areas, an end to 24 hour licences and an extra levy on alcohol to help pay for the costs incurred by governments in responding to family violence.

FARE said alcohol was a factor in 65 per cent of family violence incidents reported to police and almost half of child abuse cases. In addition, more than a third of those who murdered their partner had been drinking prior to the attack.

Chief Executive Michael Thorn said a tough problem called for tough solutions.

“Alcohol’s involvement in family violence is undeniable,” Mr Thorn said. “Governments must acknowledge the vast research and the irrefutable evidence that clearly links the availability of alcohol with family violence, and act accordingly. In practice, that means putting public interests ahead of the alcohol industry and being prepared to say no to liquor licence applications that put people at greater risk of harm.”

The FARE plan echoes the recommendations of last year’s AMA Summit in emphasising measures aimed at preventing alcohol-related harm while simultaneously urging ongoing funding for vital alcohol support and treatment services.

Professor Owler said that although individuals and communities had a role to play, governments – particularly the Commonwealth – needed to be far more active in tackling the issue.

“Too many times we hear that it’s all about personal responsibility. It’s rubbish,” Professor Owler said. “Personal responsibility is important, but we can’t rely on the personal choices of others for our own safety and health. Governments can influence behaviour through deterrents but, most importantly and more effectively, through shaping individual and societal attitudes to alcohol.”

For more information on the AMA National Alcohol Summit, visit: ausmed/end-cheap-grog-and-saturation-marketing-alcohol-summit-tells-govt

The National Alcohol Summit communique can be viewed at: media/ama-national-alcohol-summit-communique

Adrian Rollins

Flawed broadcast prompts thousands dump vital drug

Almost 3000 people are at heightened risk of a fatal heart attack or stroke as the result of the broadcast of a controversial television program questioning the safety of prescribed cholesterol-lowering medications.

A University of Sydney study published in the Medical Journal of Australia has estimated that around 60,000 people stopped taking prescribed statins immediately after the ABC’s Catalyst science program in October 2013 called into question the link between cholesterol and heart disease and included claims that statins were toxic.

The Sydney University researchers found that in the weeks after the two-part program was broadcast, the number of statins being dispensed dropped by 2.6 per cent – and by more than 6 per cent among patients not taking other medications – and that the effect was sustained.

The researchers warned that the “significant and sustained” decline in statins dispensing following the Catalyst broadcast meant it was likely that 60,897 people had stopped taking their medication, potentially causing preventable – and possibly fatal – major vascular events in up to 2900 people.

“The prevalence of statin use in Australia, and the established efficacy of these drugs, means that a large number of people are affected, and may suffer unnecessary consequences,” they warned.

Claims made in the Catalyst program about the usefulness and safety of statins are at odds with established medical advice and were met with a storm of criticism from health experts.

The ABC subsequently withdrew the program after an internal review judged that it had breached standards on impartiality.

But there are signs that the show has had a long-lasting effect on perceptions regarding the safety of statins. The Sydney University researchers said that, as at mid-2014, there was no sign of a rebound in the dispensing of statins after the sudden drop following the Catalyst broadcast.

The phenomenon has underlined the need for the media to be very careful about the way they report health issues.

The number of statins dispensed dipped sharply in 2012 following publication of a story about the risk of diabetes and dementia associated with statins use, and a 2007 news broadcast associating osteonecrosis of the jaw with bisphosphonate use provoked a 30,000 plunge in prescriptions.

NPS MedicineWise, which advises on the safe and effective use of drugs, has urged patients who have stopped taking their statins after watching the Catalyst program to immediately see their doctor.

Chief Executive Dr Lynn Weekes said that although all medicines carried risks as well as benefits, “we also know it’s very clear that people at high risk of a heart attack or stroke benefit substantially from statins”.

“It is worrying…that such a large number of people have stopped taking their prescribed statins,” Dr Weekes said. “Someone prescribed a statin is likely to be at higher risk of stroke or heart attack. For these medicines to reduce that risk, they need to be taken every day, and for the long term.”

Adrian Rollins

Patients to be hit by pill price hike

Changes to pharmacist dispensing fees negotiated by the Federal Government will force the cost of the nation’s most commonly prescribed medicines up, leaving hundreds of thousands of patients out of pocket.

The Federal Government claims patients will get vital medicines more cheaply and much quicker following changes to the way pharmaceuticals are supplied under deals with industry it claims will save taxpayers $6.6 billion over the next five years.

But Health Department officials admitted at a Senate Estimates hearing earlier this month that the introduction of a new $3.49 pharmacist handling fee to replace the existing 15 per cent mark up arrangement would push up prices.

The Herald Sun said the change would add between $2 and $3 to the cost of nine of the 10 most commonly prescribed medicines, costing some patients an extra $18 a month.

The revelation tarnishes earlier claims by Health Minister Sussan Ley said patients could save more than $100 a year under agreements the Commonwealth has struck with the pharmaceutical industry, while efforts to accelerate the listing of new medicines on the Pharmaceutical Benefits Scheme were beginning to pay off.

Ms Ley has signed a five-year deal with the Generic Medicines Industry Association to slash the cost of generic pharmaceuticals, including halving the price of common medicines for cholesterol, heart conditions and depression, potentially saving taxpayers about $3 billion over five years.

According to the Government, the changes mean that from October next year the cost of the widely-used cholesterol drug Atorvastatin could drop from $14.60 to $10.68, while the heart medicine Clopidogrel would fall from $14.01 to $10.38 and the depression treatment Venlafaxine would cost $11.65 instead of $16.52.

But consumer groups have warned that the decision to pay pharmacists a flat $3.49 fee (indexed to inflation) for dispensing medications instead of receiving a percentage of the price, will push the cost of many cheap medicines up.

The Consumer Health Forum said figures in the agreement showed consumers would “directly contribute” $8.2 billion to pharmacy owner remuneration in the next five years – around 34 per cent of the $23.6 billion to be paid to pharmacies for PBS medicines.

Forum Chief Executive Leanne Wells said that under the current agreement, consumers contributed 29 per cent of total payments.

The agreement includes bigger incentives for pharmacists to offer patients the option of using cheaper generic versions of medicines, backed by a $20 million media campaign.

The Government has already obtained the pharmacy industry’s grudging acceptance of an optional $1 discount on patient co-payments, and it has also negotiated agreement on lower prices for branded drugs for which there is no generic substitute.

In a measure expected to save about $1 billion, the Government will cut the price it is prepared to pay for branded medicines by 5 per cent after they have been listed on the Pharmaceutical Benefits Scheme for five years.

The Commonwealth is also implementing changes to how it calculates the price it pays for medicines when they go off-patent. Currently, the Government determines market price using a weighted average of the price of all brands.

But under the new arrangement, expected to come into effect from October next year, the original ‘premium’ brand will be excluded from the calculation, driving the average price down.

“Removing originator brands from price calculations for everyday medicines could see the price of common generic drugs halve for some patients, whilst also saving taxpayers $2 billion over five years,” Ms Ley said.

The Government also expects to save $610 million over five years by closing loopholes around the way combination drugs – where two separate medicines are combined to create a new patented medication – are subsidised.

As previously flagged, the Commonwealth also expects to save $500 million remove several low-cost over-the-counter medicines such as everyday painkillers from the PBS.

The Minister said Government efforts to speed up the listing of new medicines were also working, pointing out that there had been 652 new and amended listings on the PBS since it was elected in September 2013, compared with 331 listings during the previous three years.

Ms Ley said the chief independent scientific adviser on medicines, the Pharmaceutical Benefits Advisory Committee took an average of just 17 weeks to recommend whether or not a drug should be listed on the PBS – a turnaround that was one of the fastest in the world.

“We understand the importance of ensuring Australians have fast access to affordable medicines when and where they need them, and we are investing heavily to deliver this,” the Minister said.

PBAC’s operations have been reinforced by the appointment of leading cardiovascular disease specialist Professor Andrew Wilson as Chair, and Ms Ley said the Government would soon introduce legislation to expand PBAC’s membership from 18 to 21 in recognition of its increasing workload and the complexity of matters being considered by it.

“Expanding the capacity of the PBAC to deal with complex medicines is another important step to ensure Australians benefit from new medicines sooner,” she said.

And the Government expects Australia patients to get improved access to leading-edge medications with the launch of a website providing a one-stop shop regarding clinical trials happening around the world.

Evidence indicates that almost half of all phase three clinical trials conducted in Australia fell short of their patient recruitment targets, and Ms Ley said the website would make it easier for patients to find out about trials and take part in ground-breaking medical research.

Adrian Rollins

AMA develops GP toolkit to help victims of family violence

AMA President Associate Professor Brian Owler has urged caution in any attempt to make the reporting of family violence mandatory amid an anticipated surge in victims coming forward and seeking help given heightened national awareness of the issue.

Speaking at the launch of a joint AMA/Law Council of Australia toolkit providing guidance and resources for GPs dealing with instances of family violence, A/Professor Owler said that while it was mandatory to report child abuse, governments should be careful about extending this to include adults.

“It’s a complex issue and what you don’t want to do…is set up a system where you might deter people from coming forward and having a conversation with their GP,” the AMA President said. “What you say to the doctor is something that should be kept in confidence, except in very extreme circumstances. We need people to have confidence in actually being able to disclose to their GP that there may be an issue at home and feel safe about doing that.”

The toolkit, prepared by the AMA in consultation with the Law Council of Australia, gives GPs vital information on how to detect and discuss family violence, assess risk, understand legal obligations and provide details of support services and resources for victims and their children.

A/Professor Owler said GPs were often the first port of call for victims of family violence, so it was important that they knew how to discuss the issue and where to access the resources and information needed to help victims and their families.

“There is likely to be more people coming forward…and so it’s important that our GPs are prepared when people do come forward that they have the right resources and the right information to allow and assist them to prescribe the right treatment,” he said.

The pervasiveness of family violence has been underlined by Australian Bureau of Statistics/Australian Institute of Criminology research showing one in six women suffer physical or sexual violence at the hands of their current or former partner, and a quarter suffer emotional abuse.

In a sign of the extent to which family violence is underreported, the study, conducted in 2012, found 58 per cent of women had not reported the attack to police and almost a quarter had never sought advice or support.

The AMA President said family violence could be “a very uncomfortable and difficult issue”, not only for victims but also for GPs, who might have both the victim and the perpetrator as patients.

A/Professor Owler said one of the important features of the toolkit was that it started from the very basics, describing what GPs needed to look for to identify potential victims, and providing crucial advice on how to broach the issue in a way that made people safe and comfortable about talking of what was happening in their home.

He said often patients would see their doctor with an unrelated complaint, and the toolkit helped GPs to ask the right questions as a way of initiating the discussion.

Importantly, he added, the toolkit also talked about what should not be asked when someone disclosed they were a victim of family violence, such as asking ‘what might you have done to avoid this?’, which could be taken as implying blame.

Law Council of Australia President Duncan McConnel said the toolkit was an important step in improving the co-ordination of services to help victims of family violence, which was “not just a law and order issue. It’s a broader issue, and in particular it’s a health issue”.

Mr McConnel said one of the big barriers encountered by victims seeking help was the fact that they had to go through a “sort of revolving door of seeking help from different service, after different service, after different service. It’s been identified as a critical issue”.

He said it was important that doctors helping a victim of family violence knew how to get help and who to contact, including being able to identify safe houses, specialist legal services and other supports.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at: article/ama-family-violence-resource

Adrian Rollins