Hep C cure comes with $3 billion price tag

Thousands of Australians living with hepatitis C are a step closer to a cure after the Commonwealth’s chief medicines adviser recommended they be given subsidised access to a hugely expensive but effective drug credited with eliminating the disease in the majority of patients.

But the Pharmaceutical Benefits Advisory Committee (PBAC) has warned that, at its current price tag of around $110,000 for a 12-week course, subsidising the drug for around 62,000 chronic hepatitis C patients would cost the country more than $3 billion over five years.

Nonetheless, in recommending that sofosbuvir (marketed under the name Sovaldi) be listed on the Pharmaceutical Benefits Scheme for the treatment of chronic hepatitis C, the PBAC said there was a “high clinical need” for such a treatment to be available on the PBS.

The Therapeutic Goods Administration approved the use of Sovaldi as part of a combination antiviral treatment for chronic hepatitis C last year, raising hopes of improved outcomes for the estimated 233,000 people living with the disease.

But the medicine’s huge price tag means it will have to be subsidised through the Pharmaceutical Benefits Scheme if it is to be put within financial reach for many patients.

In its initial assessment of the drug in late 2014, the PBAC recommended against listing on the PBS, cautioning that doing so would have “a high financial impact on the health budget”, warning that estimates of its cost to taxpayers were probably understated given the likelihood of a jump in demand.

But in its latest assessment, the PBAC took a more expansive view.

It said “it was appropriate for the new all-oral treatment to be listed in the General Schedule, rather than Section 100 Highly Specialised Drug Program, to facilitate the longer term objectives for access to treatment, increase treatment rates and better outcomes with a view to treat all patients with CHC [chronic hepatitis C] over time”.

However, the Committee said the drug was not cost-effective at the price proposed by the manufacturer, and warned that the expense of providing subsidised access through the PBS would come at “a large opportunity cost to the health care system”.

While viral hepatitis has become increasingly common – the Kirby Institute estimates more than half a million Australians now live with either hepatitis B or C – treatment rates are low.

Fewer than 5 per cent of those with hepatitis B receive treatment, and only around 1 per cent of those with chronic hepatitis C.

Unsurprisingly, in this environment, Sovaldi is regarded as something of a wonder drug.

Manufacturer Gilead Sciences said hepatitis C patients can be cured of the disease in as little as 12 weeks, eliminating the lifetime burden of an otherwise chronic infection.

Director of gastroenterology at Melbourne’s St Vincent’s Hospital, Professor Alex Thompson, told the Herald Sun last year that Sovaldi was a major advance on current hepatitis C treatments.

“This is a game-changing medicine,” Professor Thompson said. “This disease could become rare or non-existent, you could be talking about eradication.”

Hepatitis Australia has warned that hepatitis C could become a major health burden for the country unless urgent action is taken.

Viral hepatitis damages the liver and, without effective treatment, it can lead to liver cirrhosis, cancer and failure – currently around 1000 a year die from hepatitis-related liver cancer, according to the Institute.

“Without urgent investment in rigorous treatment programs, Australia will continue to fail in its efforts to halt escalating rates of serious liver disease due to chronic hepatitis B or C,” Hepatitis Australia said.

It said hepatitis B and C infections had continued to spiral despite national strategies aimed at curbing their growth, showing that “Australia needs to redouble its efforts and investment in prevention”.

“We know what works – educating the community on the risks of infection and improving access to hepatitis B vaccinations and needle and syringe programs for vulnerable populations,” the group said. “It’s now time for the investment to make it happen.”

Clinical trials of Sovaldi evaluated by the TGA demonstrated that the hepatitis C virus was undetectable in up to 90 per cent of patients 12 weeks after completing therapy.

Professor Gregory Dore, Head of the Kirby Institute’s Viral Hepatitis Clinical Research Program, hailed the drug as “a major advance” in the treatment of hepatitis C because it was able to achieve results more quickly than existing treatments, and with fewer side effects.

But humanitarian organisation Medicins Sans Frontieres has complained that the high cost of the medicine puts it out of the reach of most of the world’s poor.

The medical charity said drugs such as Sovaldi had the potential to revolutionise treatment of hepatitis C, but not at current prices.

Sovaldi, is Gilead’s trade name for sofosbuvir, which in the United States costs $US84,000 ($A90,000) for a 12-week course of treatment – roughly $US1000 a pill. Even in Thailand, its costs $US5000 for a course.

“The price Gilead says it will charge for sofosbuvir in developing countries is still far too high for people to afford,” said MSF Director of Policy and Advocacy Rohit Malpani. “When you’re starting from such an exorbitant price in the US, the price Gilead will offer middle-income countries like Thailand and Indonesia may seem like a good discount, but it will still be too expensive for many of these countries to scale up treatment.”

Adrian Rollins

Detecting malaria – it’s all in the breath

Diagnosing malaria may soon be as simple as undergoing a roadside breath test in what could be a major advance in the detection and treatment of a disease that kills more than 500,000 people every year and infects around 200 million.

A collaboration of Australian researchers from the CSIRO, the QIMR Berghofer Medical Research Institute and the Australian National University has discovered that the concentration of sulphur-containing chemicals in human breath varies with the onset and progression of malaria, opening up the possibility for a novel, cheap and effective method to diagnose the disease at an early stage.

The researchers found that chemicals normally virtually undetectable in human breath increased markedly among volunteers infected with a controlled dose of the disease.

The discovery arose out of two independent studies being conducted to test experimental malaria treatments. In the course of the investigation, the researchers identified four sulphur-containing compounds whose concentration varied over the course of the infection.

“The sulphur-containing chemicals had not previously been associated with any disease, and their concentrations changed in a consistent pattern over the course of the malaria infection,” Professor James McCarthy, Senior Scientist in Clinical Tropical Medicine at QIMR Berghofer, said. “Their levels were correlated with the severity of the infection and effectively disappeared after they were cured.”

CSIRO Research Group Leader Dr Stephen Trowell said what was particularly significant was that the concentration of these chemicals increased from the nascent stages of the infection, boosting the chances of very early diagnosis and treatment.

Currently, most malaria diagnoses involve drawing a blood sample and using a microscope to look for parasites – a cumbersome and invasive process that has changed little in more than 130 years.

But Dr Trowell said the discovery raised the possibility of developing a simple breath test to screen for the disease, which could make task of controlling and eventually eliminating malaria much more feasible.

The researchers have begun collaboration with colleagues in regions where malaria is endemic to see whether the technique works in the field, and work is also being undertaken to develop more cost-effective sensing equipment.

The research has been published in the Journal of Infectious Diseases.

Adrian Rollins

The AMA a persistent and powerful voice on Indigenous health

By Professor Ian Ring, Professorial Fellow at the Australian Health Services Research Institute, University of Wollongong. Professor Ring has worked with the AMA on Indigenous health issues for more than 20 years.

Nothing exemplifies quite so clearly the AMA’s concern with issues far broader than simply representing the interests of doctors as does its role in Aboriginal health.

That interest is broad in scope, genuine and effective, and dates at least from Dr Brendan Nelson’s term as AMA President in the mid-1990s.

Almost every President since has shared Dr Nelson’s deep, personal and organisational concern and involvement in Aboriginal health, and that involvement is the specific reason I, and no doubt others, joined the AMA many years ago.

That involvement has taken a variety of forms – lobbying, promoting public awareness through the media, preparing and disseminating annual Report Cards on a wide variety of relevant topics, and active engagement with Indigenous organisations and leaders.

Promoting public awareness of issues regarding Aboriginal health has been central to the AMA’s role and purpose, and has taken many forms.

For example, Keith Woollard and I travelled to New Zealand during his term as President (1996-98), notionally to learn more about international experience in improving Indigenous health, but with a secondary aim of drawing the attention of the Australian media. Both aims were achieved. There was substantial Australian press coverage and, equally, we learnt a lot about the linkage of health services with community, cultural, social and economic programs.

Lobbying has taken many forms.

During the late 1990s, when the lack of progress in Aboriginal and Torres Strait Islander health was seen as an international disgrace and symptomatic of a national failure to come to grips with the issues concerning Australia’s Indigenous peoples, the AMA arranged to bring together political, public service and health leaders in an effort to bring about a more effective focus on Indigenous health.

It organised meetings with the-then Prime Minister John Howard and several of his ministers, including Senator Amanda Vanstone, Michael Wooldridge, Tony Abbott and John Herron and Commonwealth Department secretaries. It also met with Aboriginal leaders and organisations, notably the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors Association (AIDA) and other leaders of the medical profession.

The AMA’s role became more institutionalised during Dr Kerryn Phelp’s term with the formation of the AMA Indigenous Taskforce, whose membership was drawn from NACCHO, AIDA, the Indigenous branch of RACGP, Aboriginal health leaders, AMSA , AMA council members and other AMA members with an active involvement in Aboriginal health.

Since its inception, the Taskforce has produced annual Indigenous Health Report Cards highlighting issues including infant health, inequality, incarceration, low birth weight, workforce requirements and Indigenous primary health care.

Under the leadership of the current President Associate Professor Brian Owler, the AMA is an active participant in the Close the Gap campaign and lobbies effectively on matters of key importance to Indigenous health, such as patient co-payments.

This is in keeping with the AMA’s well-established role as a persistent, sustained and powerful voice on Indigenous health for at least the past two decades.

During that time, much has changed for the better, particularly as a result of the Close the Gap campaign – although recent cutbacks to funding are a significant concern.

For the future, the development of the Implementation Plan for the National Aboriginal and Torres Strait Island Health Plan will be a priority, including ensuring that it is guided by the voice of Aboriginal people and effectively addresses issues of culture and racism, as well as the practical issues of service models, building service capacity and ensuring an adequate workforce and funding.

Form guide to cutting red tape

The AMA has declared war on unnecessary bureaucratic red tape, issuing guidelines for the design of medical forms and reports that gather critical information in a way that minimises the burden on doctors.

In the course of their daily practise, medical practitioners are required to fill out multiple forms for Government departments including Centrelink, the Department of Veterans’ Affairs and State and Territory WorkCover authorities, with research showing GPs spent an average of 4.6 hours a week on red tape in 2011 – valuable time that the AMA said could otherwise be spent with patients.

The AMA said that although much of the data provided was vital in helping determine patient entitlements, and could have serious consequences for the effective provision of medical services, often forms also asked for details that were repetitive, extraneous or unnecessarily intrusive in nature, and could be dropped or amended without affecting the quality of information provided.

“We understand that organisations depend heavily upon the accurate completion of medical forms to determine patient entitlements,” AMA Vice President Dr Stephen Parnis said. “Unfortunately, many fail to appreciate the real time implications for doctors having to complete these forms. The key is to focus on obtaining necessary information that is easily accessible, and which does not require doctors and medical practices spending excessive time filling in forms.”

“Doctors prefer spending time on patient care, not bureaucracy,” Dr Parnis said.

The AMA has set out 10 standards that it is asking Government departments and other organisations to take into account when designing medical forms.

These include ensuring that doctors are asked to supply only essential information, that patient privacy is protected as much as possible, and that the forms be available in an electronic format compatible with, and available through, existing medical practice software.

In addition, the AMA said forms must carry clear notification that doctors can charge a reasonable fee for their services.

The Association said that in designing forms, government departments and other organisations often failed to take into account the implications for doctors, and suggested that forms be field tested under the supervision of a representative of the AMA or other medical organisation prior to their release.

“The AMA believes that medical forms can be designed in a way that captures the necessary information in a more simple and concise way,” Dr Parnis said. “Our Guide can help organisations design forms that do not impose unnecessary red tape and compliance costs on busy doctors.”

Adrian Rollins

New strains force late start for flu vaccination program

Doctors and patients will for the first time have access to single-dose vaccines covering the four most common flu viruses amid concerns a mutated strain that wreaked havoc in the northern hemisphere could take hold in Australia.

The Therapeutic Goods Administration has approved nine vaccines, including, for the first time, three quadrivalent formulations, as preparations advance for the roll-out of National Seasonal Influenza Immunisation Program from 20 April.

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

Drug company Sanofi Pasteur, which manufactures two of the quadrivalent vaccines, said they were well tolerated and provided additional protection because they covered both B strains of the influenza virus as well as the two A strains – compared with trivalent vaccines that covered both A strains but only one B strain.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

“The double-strain change has resulted in manufacturing delays due to the time it takes to develop, test and distribute the reagents needed to make the vaccine,” a Health Department spokesperson said. “The commencement of the program is being delayed to ensure sufficient supplies of influenza vaccine are available from at least two suppliers in order to mitigate the risk of administration of bioCSL’s Fluvax to children under five years of age.”

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

The TGA has repeated its advice that Fluvax is not registered for use on children younger than five years, and that it should only be used on children between five and nine years following “careful consideration of potential benefits and risks in the individual child”.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

In a stroke of good fortune, the delay in the vaccination program has coincided with a relatively quiet start to the flu season, with reports that influenza activity has so far been weaker than that experienced at the same time last year.

The Health Department and the TGA said that, despite the delay, they do not expect any flu vaccine shortages, and the Government has committed $4.5 million over the next five years to provide free flu vaccination for Indigenous children aged between six months and five years.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

The network, which has been operating for more than a decade, collates information from more than 200 GPs and medical practices across the nation to provide health authorities with an early warning of developing outbreaks. Its information is used in conjunction with data from hospitals.

Adrian Rollins

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.

Form guide to cutting red tape

“Doctors prefer spending time on patient care, not bureaucracy,” Dr Parnis said.

The AMA has set out 10 standards that it is asking Government departments and other organisations to take into account when designing medical forms.

In addition, the AMA said forms must carry clear notification that doctors can charge a reasonable fee for their services.

Adrian Rollins

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Radio

Television

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

New strains force late start for flu vaccination program

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

Adrian Rollins

Commercial in confidence: public health without confidence

Implementing public health measures with obvious benefits becomes a complex struggle when commercial interests are paramount

The evening of 25 March 2009 was cool for the community consultation — a necessary step before the implementation of fluoridation of the Cobram water supply. There were only a few people present in the Civic Centre, but they warmly applauded the initiative. None of the expected antifluoride lobby turned up, and the meeting was a short one …

After all, it is accepted that fluoridation of drinking water is an effective way to ensure the whole community can benefit from fluoride’s preventive role in reducing tooth decay.1,2

Thus, it was expected that Cobram would follow the path of nearby Yarrawonga and this seemingly routine adoption of a well researched public health measure would be quickly achieved.

Wrong! Over 5 years later, Cobram still has not had its water supply fluoridated.

The story so far

Cobram, a small country town on the Murray River in Northern Victoria, is where the Murray Goulburn Co-operative, one of the largest milk producers in Victoria, has existed since 1949. In 1951, the Co-operative diversified into cheesemaking. It is a major contributor to the local economy. In early 2014, the company announced that it would build a $74 million “world class cheese cut-and-wrap facility” in Cobram to serve Australian and Asian markets and, as part of a broader $38 million investment, it would increase the Cobram factory’s capacity to produce infant nutrition products — some for export.3

The reason for the inaction over water fluoridation? Murray Goulburn did not want fluoridated water in their milk products, including the infant formula preparations. This was not disclosed in any of the formal community discussions, and only came to light when the Department of Health enquired about the cause for the delay in fluoridation. It seemed that commercial considerations regarding fluoridation simply outweighed community dental health.

Although, perhaps it was not that simple. There were other options — one being whether the government was prepared to fund a separate water pipeline for the Co-operative’s use. The company argued that the options of either precipitating the fluoride out during the manufacturing processes or treating the factory water supply to remove fluoride were less cost-effective.

The possibility that fluoridation might not affect the product was not considered. One can only suspect that commercial motives were paramount. Asian countries are a large importer of dairy products, and these countries are, by and large, averse to fluoridated water. China has no fluoridation4 and Japan, almost none.

There is concern about dental fluorosis, but there is little evidence to suggest that fluoridated water, particularly in infant formulas, causes significant fluorosis.5 A significant number of the infant formulas sold in Australia are imported,6 but these have sufficiently low levels of fluoride for the Australian Research Centre for Population Oral Health and state health departments to deem them safe for reconstitution using water within the target range for fluoridation (0.6–1.1 mg/L). So, what is the fuss about?

Companies do not engage in public health debate about fluoridation. In fact, one international company that sells products on the Australian market refuses to indicate where its factories are; it does, however, admit that its products use unfluoridated water. The degree of secrecy about these matters can lead to comments layered with conjecture.

In November last year, just before the Victorian state election, the member for Murray Valley finally announced a $4.1 million project including, inter alia, a 2.5 km pipeline carrying unfluoridated water from the Cobram water treatment plant to the Murray Goulburn dairy processing plant.7 The Co-operative agreed to make a contribution to the funding, and the project was expected to be completed in 2016.

The cost of living in a small community

This was a win-win situation for Cobram and the Co-operative, with most of the funding coming from the government.

But is it such a win? Cobram, and in particular its children, will have missed out for 7 years on fluoridated water. For the community at large, the Cobram imbroglio barely raised a policy ripple. Small communities of less than 1000 may miss out on fluoridation altogether because it is not regarded as cost-effective. However, these dismissed populations add up to 2 million people nationwide.8

The question, then, becomes one of assessing the effectiveness of advocacy when any proposed change is confronted by the fear, real or otherwise, of losing jobs. However, when advocacy becomes ineffective, change has to be achieved by subtler nagging of government, because there is virtually no sensible person who would disagree about the benefits of fluoride.9

Have we lost the plot?

It is all about cost; especially, as with all public health and commercial considerations, there is a further twist — in this case, the increase in the consumption of bottled water, almost all of which is suboptimally fluoridated. Bottled water is permitted to have the same level of fluoride recommended for drinking water — 0.6–1.1 mg of fluoride per litre. Since its introduction in the 1980s, bottled water has grown into a $500 million a year industry in Australia and has become the main source of drinking water in one in 10 households. However, as the chair of the Australian Dental Association’s Oral Health Committee said, “people who prefer bottled water … risk putting their dental health back to the 1960s, when tooth decay was widespread because there was no fluoride in the water”.10

The rise in bottled water production without any serious move by the multinational manufacturers towards fluoridation is presumably one of those awkward commercial-in-confidence matters. Without concerted nagging of the policymakers, such as occurred in Cobram, nothing happens.

In fact, fluoridation in Australia has gone backwards. In Queensland, where once it was obligatory, legislation has made it a voluntary responsibility. Many local governments have subjugated public health to the commercial imperative of it being “too costly”, despite evidence to the contrary.11

Fluoridation policy is in danger of degenerating into public health anarchy where commercial interests can shelter behind the mantra of freedom of choice with its rehearsed arguments of blind libertarianism, no matter how obvious the public good. Presumably none of these libertarians would want to advocate freedom of choice about a clean water supply.

Ignoring the bleeding obvious should not be allowed to make the community bleed the cost of appalling teeth, especially when there are continual complaints about how disadvantaged rural areas are with regard to dental health.

At least, the Cobram community will eventually know better times in dental health; but now, what about the fluoridation of bottled water?