The G20, human health and sustainability: an interview with Jeffrey D Sachs

We must reinvigorate our sense of humanity, justice and foresight

Jeffrey Sachs is an American economist and Director of The Earth Institute, Quetelet Professor of Sustainable Development and Professor of Health Policy and Management at Columbia University. He is Special Adviser to United Nations Secretary-General Ban Ki-Moon on the Millennium Development Goals, having held the same position under former UN Secretary-General Kofi Annan. He is known as a commentator and advocate for the relief of poverty, the achievement of improved health in developing countries and for environmental sustainability. From 2000 to 2001, he chaired the World Health Organization Commission on Macroeconomics and Health, which made clear the linkage between health gain, relief of poverty and economic growth.

Sachs is author of The end of poverty: economic possibilities for our time (2005). His most recent book is To move the world: JFK’s quest for peace (2013).

He was interviewed by the Editor-in-Chief of the Medical Journal of Australia, Stephen Leeder, who worked with Sachs in New York in 2003–2004, about the upcoming G20 meeting in Brisbane, Australia, in November.

What is your primary message as an economist interested in the relief of poverty about sustainability and its relation to both economics and human health?

It is not possible to consider ending poverty in the midst of human-induced climate change. Even if poor countries, such as those in Africa, make some short-term progress in the fight against poverty, this progress will be overtaken by climate disruption. Africa already is suffering from food price shocks, famine, heatwaves, droughts and other extreme climate shocks. We’ve got to get real: fighting poverty and environmental degradation go hand in hand.

How could the upcoming G20 meetings in Brisbane be an important forum for consideration of the economics of sustainability?

The G20 countries are the world’s most important economies. They account for the lion’s share of global greenhouse gas emissions. If the G20 gets its house in order, the world can be saved. If not, the G20 will wreck the world, pure and simple. So what will it be? Will the richest and most powerful countries also be the most short-sighted, or will they understand that they hold not only their fate but the fate of humanity in their grasp? Brisbane is therefore crucial. The prospects are not bright. The Australian Government claims it is driven by science, but it seems to us on the outside that it is driven by mining interests, or by the likes of Rupert Murdoch, the world’s number one anti-science propagandist.

The G20 should acknowledge that 2015 is the most important year of diplomacy on sustainable development in at least 15 years. We have three mega-summits next year. The first is on Financing for Development, in Addis Ababa, Ethiopia, in July 2015. The next is on Sustainable Development Goals, at the UN headquarters in New York, in September 2015. The third is on climate change — the so-called COP21 [21st Conference of Parties] of the UN Framework Convention on Climate Change — in Paris in December 2015. The Brisbane G20 should help to prepare the world’s leading countries to be true forward-looking problem solvers during these three crucial summits next year.

Can the world still prevent runaway climate disaster?

Yes, but we’ve almost run out of time. In 2009, and again, 2010, the world’s governments agreed to fight to keep global warming below 2°C. Yet we are on a trajectory of 4–6°C by the end of this century. In fact, we could trigger runaway climate change, in which warming unleashes various feedback processes (such as the release of carbon dioxide from vegetation, soils and permafrost) that could lead to runaway climate disaster. That’s why the 2°C limit is also called a “guardrail” for the world: one that keeps us from spinning completely out of control.

So, to be more specific, can we still keep warming below 2°C?

Yes, just barely, if all major economies of the world begin to take very strong and consistent actions to decarbonise their national energy systems in three main ways: shifting to low-carbon electricity, moving from fossil fuels to electricity in vehicles and buildings, and massive gains of energy efficiency. A fourth main global pillar is to shift from deforestation to reforestation and to reduce emissions from agriculture. These transformations are deep, but they are feasible. And they will not only protect the climate but also boost prosperity if we apply our efforts and ingenuity to the effort. We are running out of our planet’s carbon budget — that is, the amount of carbon the world can burn and still remain below 2°C.

But do you see these transformations being achieved by economic reasoning alone?

No. A reinvigoration of a global moral code must also be a lifeline in the 21st century. Pope Francis is utterly correct and compelling when he speaks of the “globalisation of indifference”. We have lost our moral compass as a global society. The mass media, the cynicism of Murdoch and others, have crowded out decency, humanity, justice and foresight. Yet each of us wants our children and grandchildren to survive and to flourish. We each have an instinct, a moral fibre, to keep the world safe for the future and for each other. Yet we have to reinvigorate this morality, to overcome the immorality of greed and power that drive our societies today.

At a time when our societies have unprecedented technological capacity in hand to end extreme poverty, a billion people worldwide are chronically hungry and destitute; in a period when health care technology enjoys astounding advances, 6 million children under the age of 5 worldwide still die each year of utterly preventable causes; and in an era when sustainable technologies for energy, industry, buildings and transport could reign in climate change, the world rushes headlong towards climate catastrophe — our attitudes and moral judgements will be the most important determinants of our fate, not our resources or our capacities.

At this stage of history, humanity is at a crossroads, with the future course of our own choosing. We have the technical means to solve our national and global problems — to banish poverty, fight disease, protect the environment, and train the illiterate and unskilled. But we can and will do so only if we care enough to mount the effort.

President John F Kennedy made the point compellingly a half-century ago. In his inaugural address in January 1961, he noted: “For man holds in his mortal hands the power to abolish all forms of human poverty and all forms of human life”. Two years later, on the quest for peace with the Soviet Union, J F K made the most essential point, the key reason for hope in peaceful problem solving, on poverty, climate change and the end of war itself:

So, let us not be blind to our differences — but let us also direct attention to our common interests and to the means by which those differences can be resolved. And if we cannot end now our differences, at least we can help make the world safe for diversity. For, in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s future. And we are all mortal.

The Australian’s dissembling campaign on tobacco plain packaging

As plain packaging bites into smoking, The Australian newspaper relentlessly attacks the legislation

This year marks two 50th anniversaries — the first United States Surgeon General’s report on smoking and health1 and the establishment of The Australian newspaper.

Fifty years on, there is literally universal acceptance of the massive harms caused by smoking — 178 governments have signed the World Health Organization’s Framework Convention on Tobacco Control — but smoking still causes 6 million deaths each year. Given the preventability of the problem, action has been distressingly slow, largely because of the power and ruthless opposition of the global tobacco industry.

Expert reports have noted over the years that there is no magic bullet: a comprehensive approach including legislation and education is needed. In December 2012, legislation came into force in Australia mandating plain packaging of tobacco products, despite ferocious opposition from tobacco interests. This was recommended by the National Preventative Health Taskforce as part of a comprehensive approach, and Health Minister Nicola Roxon was explicit about the main aim: “we’re targeting people who have not yet started, and that’s the key to this plain packaging announcement — to make sure we make it less attractive for people to experiment with tobacco in the first place”.2

Eighteen months later, The Australian ran a front-page story headed “Evidence ‘world’s toughest anti-smoking laws’ not working: Labor’s plain packaging fails as cigarette sales rise”. This was based on a tobacco industry report, still unpublished, claiming a 0.3% increase in tobacco sales volume during 2013. The Australian‘s campaign against plain packaging continued with (thus far) 14 articles, including three front pages and three editorials attacking plain packaging and its advocates, and even defending the tobacco industry’s right to advertise.

The Australian failed to declare a lengthy past association between News Limited and the Philip Morris tobacco company (Rupert Murdoch was on Philip Morris’s board from 1989 to 1998), or that some of its journalists and commentators on the issue have associations with the tobacco industry-funded Institute of Public Affairs,3–5 including the author of the original article, who also has a history of attacking the “nanny state”6 and “health fascists”.7

The industry’s report remains secret, but Treasury has since published authoritative data showing that “tobacco clearances (including excise and customs duty) fell by 3.4% in 2013 relative to 2012”;8 according to the Australian Bureau of Statistics “total consumption of tobacco and cigarettes in the March quarter 2014 is the lowest ever recorded”;8 and newly released National Drug Strategy Household Survey results show that between 2010 and 2013, daily smoking rates among people aged 14 years and over “declined significantly” from 15.1% to 12.8% (Box); the average number of cigarettes smoked weekly by smokers fell from 111 to 96; and the average age of starting to smoke has increased to 15.9 years.9

Australia is a small market, but plain packaging has massive global implications for an industry desperate to maintain its capacity to promote and glamorise its products. The history of tobacco control shows that when one country implements a measure previously thought difficult, others speedily follow. Governments committed to introducing plain packaging already include New Zealand, the United Kingdom, Ireland and possibly France. The British debate is currently at a crucial phase. Legislation there would be a massive blow for Big Tobacco, not only because it is a much larger market than Australia, but because many countries still look to the UK as an exemplar in areas such as this.

The Australian‘s misleading reports are unlikely to achieve much in Australia, where there is long standing bipartisan support for plain packaging and comprehensive approaches to tobacco control. Other media have provided accurate and unbiased coverage on this issue, as well as the reality that all the tobacco industry’s predictions about disastrous consequences from plain packaging have failed to eventuate.

But The Australian‘s reports have — as their authors must have expected — attracted attention overseas. UK headlines include “Plain packaging has backfired in Australia — don’t bring it to the UK”, “Australia tobacco sales increase despite plain packaging”, “Plain packaging can increase smoking. That’s the power of branding”, “Plain cigarette packaging hasn’t worked in Australia and it won’t work in Britain”. Tobacco companies and their allies have assiduously promoted a similar line — for example, the Institute of Economic Affairs (a tobacco industry-funded group, like Australia’s Institute of Public Affairs10) asserts that “with tobacco sales rising after plain packaging was introduced in Australia, the public health case for this policy looks increasingly weak”.11

What can we conclude from this? Plain packaging passes the tobacco “scream test” — the more the industry screams, the more impact we know a measure will have. There is nothing new about deception and distortion from tobacco companies: this has been their practice for six decades. Fifty years on from the landmark Surgeon General’s report, it is disappointing that a newspaper such as The Australian provides support for such approaches. Health campaigners should continue to promote measures that will benefit the community, especially children, even if opposed by powerful commercial interests, and to take pride in Australia’s capacity to lead the world.

Proportion of Australians aged 14 years and over smoking daily, from the National Drug Strategy Household Survey 1991 to 20139

The Australian’s dissembling campaign on tobacco plain packaging

As plain packaging bites into smoking, The Australian newspaper relentlessly attacks the legislation

This year marks two 50th anniversaries — the first United States Surgeon General’s report on smoking and health1 and the establishment of The Australian newspaper.

Proportion of Australians aged 14 years and over smoking daily, from the National Drug Strategy Household Survey 1991 to 20139

After the Quality in Australian Health Care Study, what happened?

Milestones in Australia’s journey to high-quality care

The 1995 Quality in Australian Health Care Study (QAHCS) demonstrated the potential to improve the quality and safety of health care.1–3 Using a modified version of the earlier Harvard Medical Practice Study on medical negligence, the QAHCS focused on the more useful measure of preventability of medical error. The incidence of adverse events was higher than in the Harvard study, and at first the Australian rates were queried by government: 16.6% of hospital admissions were associated with an adverse event, of which 51.2% were judged to have high preventability. Many countries replicated the Australian study, using one medical reviewer rather than two as in the QAHCS, which reduced the estimate by about 3%. Overall, a consistent rate of about 10% of hospital admissions associated with an adverse event was seen in New Zealand, Japan, Singapore, the United Kingdom and Denmark. In 2012, a World Health Organization study on adverse events in developing countries showed a similar result.4

The Australian Government responded with a succession of initiatives: the Australian Council for Safety and Quality in Health Care was established by Australian health ministers in 2000 and operated until 2005; the Australian Commission on Safety and Quality in Health Care (ACSQHC) was created in 2006 and written into legislation with the National Health Reform Act 2011. The ACSQHC promulgated 10 national quality and safety standards as part of national accreditation processes. Health reform has also included the Independent Hospital Pricing Authority, the National Health Funding Body and the National Health Performance Authority. Linking costs to quality outcomes, combined with national comparative performance measures of safety, efficiency, access and patient experience, has to be considered a milestone in Australia’s journey to high-quality care.

Have the rates of adverse events declined? A repeat of the same study would be costly, and the changed context of health care would complicate interpretation. However, there have been significant process changes that reflect an increasing attention to quality. Federal and state governments are reporting infection rates and triage times. The Australian Council on Healthcare Standards reports annually on 360 indicators in Australasia and, for the years 2005–2012, more indicators improved (125) than worsened (38), with no significant trend for 62 indicators.5 For example, the proportions of emergency department presentations meeting the triage benchmarks increased by about 6% over the 8-year period.

Quality principles have been introduced into medical and health professional education and expanded as a research theme. Early on, the University of Newcastle introduced a quality-of-care project, winning Australian Council on Healthcare Standards student quality improvement awards.6 Other schools have followed, and national and international curricula have been developed from Australia.

Notwithstanding the good progress, there remains much to do to improve health care systems. There is increasing focus on process re-engineering, applications of reliability science, human factor mitigation strategies, teamwork, communication, patient-based care and greater application of evidence-based medicine.

Integrating maternal and neonatal care in resource-poor settings

Improving facility-based outcomes for mothers and newborns is achievable

Of the patients Médecins Sans Frontières (MSF) and other organisations treat in settings affected by conflict, neglect or disaster, most are women and children. In MSF’s facilities, they present against a backdrop of unacceptably high maternal and under-5 child mortality rates worldwide. Neonatal death in particular is seemingly intractable, growing to comprise 44% of all deaths of children aged under 5 years, or about three million deaths annually.1 Additionally, there are an estimated 2.7 million stillbirths each year, a large proportion occurring in the intrapartum period.2

Maternal mortality and its risk factors are well documented. Infection, low birthweight or prematurity, and asphyxia are the main reasons for newborns’ high risk of dying. The highest loss of life occurs during birth or within the subsequent 24 hours.3 Most of these deaths are preventable. Relatively low-tech interventions have the potential to substantially improve the survival and health of newborns, but there are clear challenges to implementing them. Nonetheless, the experience of MSF highlights the importance and achievability of improving facility-based care in resource-poor settings for better outcomes for mother and infant, focusing on the concept of the continuum of care in the perinatal period.

One example where such initiatives are being implemented is the Republic of South Sudan. Health needs remain urgent in the world’s newest country. South Sudan’s maternal mortality ratio was last estimated to be 2054 women per 100 000 live births, with a neonatal mortality rate of 36 per 1000 live births. In comparison, the respective figures for Australia are 7 per 100 000 and 3 per 1000.1,4

MSF works alongside South Sudan’s Ministry of Health in Aweil Civil Hospital, 800 km north-west of the capital, Juba. MSF provides free emergency obstetric and paediatric care and responds to epidemic outbreaks for an estimated population of 900 000. In 2013, some 4400 births in the hospital included 182 caesarean sections.

Conditions for mother and child, such as haemorrhage
or fetal distress, can be treated if they are recognised early enough and if staff know how to respond. A skilled birth attendant is crucial to manage any maternal complications. In addition, every health professional attending births should be able to perform basic newborn resuscitation. Since 2011, MSF has been rolling out the Helping Babies Breathe curriculum
of the American Academy of Pediatrics (http://www.helpingbabiesbreathe.org), to ensure that a baby not breathing well within 1 minute of birth is adequately ventilated with a bag and mask.

Newborns are cared for in the hospital’s maternity ward or the neonatal unit, opened in 2011. In 2013, there were just over 1100 admissions to the neonatal unit. Four out of five births occur in the community or without skilled supervision, and many babies present with serious infection. Lack of proper cord care creates a high risk of infection transmission, including tetanus, which also reflects the poor vaccination coverage that is typical of a country affected by conflict.

The three-ward unit offers “kangaroo mother care”, involving skin-to-skin contact and regular breastfeeding,
for premature or small newborns (under 2500 g), if they are stable. This approach can be highly effective, although progress can be slow. Higher-level care is offered for sick babies, as well as specific care for those with tetanus. All these children need close monitoring, which tests staffing levels, and there is a dearth of nurses familiar with neonatal care.

Long hospital stays create dilemmas for the family that should not be underestimated. Patients’ families often reside far from the hospital, and “public” transport is unreliable.
A mother may have to temporarily abandon her newborn to care for the rest of the family; or she may take her baby home early, at risk of its health.

The need for skilled health personnel in South Sudan is huge and, because of their scarcity, expatriates are relied on to provide in-service training for their local colleagues. To tackle this problem more fundamentally, MSF has commenced practical training of midwifery students from emerging schools in the area. Further, MSF is currently working with the Ministry of Health to prioritise stronger district birthing services and their role in managing more uncomplicated births, and improve early identification of complicated cases and referral to Aweil Civil Hospital. MSF is also assisting with strengthening of vaccination programs and advocating for more robust antenatal care.

The experience in Aweil not only demonstrates the ongoing work to improve knowledge, skills and obstetric and perinatal care in many under-served communities worldwide, it also points to the broad need for markedly better outcomes in resource-poor settings, and for additional research into appropriate strategies to achieve them.

Drug-resistant tuberculosis: collaborative regional leadership required

The drug-resistant tuberculosis crisis provides urgency and focus for coordinated action to improve regional health and development

Success in stabilising the global tuberculosis (TB) epidemic is threatened by the emergence and spread of drug-resistant (DR) strains. The DR-TB challenge is similar in scale and impact to HIV infection in the 1980s; however, the international response has been slow and insufficient. Those worst affected by TB or DR-TB are from disadvantaged communities in low-income countries with little visibility or political influence. The Asia−Pacific region carries the bulk of the global TB burden (58%), including the majority of all estimated multidrug-resistant (MDR) cases (54%) (resistance to isoniazid and rifampicin).1,2 The regional DR-TB challenge is daunting and needs to be tackled before it overwhelms health systems, as happened in some former Soviet Union countries. Visionary political leadership is urgently needed to champion a comprehensive regional strategy that draws on novel and creative solutions,1 similar to the Asia Pacific Leaders Malaria Alliance created to contain the emergence of drug-resistant malaria.3

Four years ago, the World Health Assembly declared DR-TB a “global public health threat” and ministers from 22 high burden countries signed a “call to action”.4 This global resolution aimed to achieve universal access to diagnosis and treatment of DR-TB by 2015; but the response will fall well short. The number of people living with MDR-TB has risen from an estimated 440 000 in 2008 to 680 000 in 2012, and less than 20% receive appropriate treatment.2 These estimates are limited by insufficient laboratory capacity for drug-susceptibility testing and inaccurate reporting. The existing tools to diagnose, treat and prevent DR-TB are inadequate and much more costly than for drug-susceptible TB. Widespread rollout of the GeneXpert (Cepheid) test should improve the situation, but its impact will be limited in the absence of quality-assured laboratory infrastructure, shorter and more effective drug regimens and the scale-up of treatment programs for DR-TB. Modelling studies show that if TB control strategies only focus on drug-susceptible disease, DR-TB will become the predominant strain.5 This is supported by new evidence showing that DR-TB has the potential for true epidemic spread in high burden settings.6

The vast majority of countries in the Asia–Pacific region have limited capacity to mitigate the imminent threat of DR-TB. The Global Fund to Fight AIDS, Tuberculosis and Malaria, an international public–private partnership for financing, provides most of the global funding for TB and DR-TB control activities, but there remains a gap of US$2.3 billion per year until 2015 for a full response to the epidemic.2 Investment and coordinated action from growing national economies and business enterprises within the Asia–Pacific region are urgently required to avert this regional threat. While “ownership” of the DR-TB response should be in the hands of the countries most affected, Australia is presented with an opportunity to show regional leadership and collaboration, serving a pivotal coordinating function. Although ultimately health systems should be strengthened to provide universal coverage, the threat of DR-TB provides a clear focus to initiate action and develop regional solutions to complex, interrelated health and development issues.

It is estimated that if the global TB funding gap for the period 2013–2016 is not financed, an additional 1 million lives will be lost.7 Besides the human cost, TB (and DR-TB in particular) places an extraordinary economic burden on communities and traps people in poverty. TB does not respect international borders, and while numbers of DR-TB cases are low in Australia, a steady increase has already been seen.8 Investment in DR-TB treatment programs is required which, despite the high individual treatment cost (400 times higher than for drug-susceptible TB), are cost-effective overall.9 TB control is intimately linked to health system development and socioeconomic factors.10 Failure to specifically address DR-TB will result in major long-term human and economic costs, and ultimately may pose a major threat to regional development.

Defining a course of action requires careful consideration and discussion with the many stakeholders, but the global challenge posed by DR-TB presents an urgent need for bold regional leadership to:

1) Engender political commitment at the highest level among key regional players;

2) Explore a range of regional financing options, including joint funding from national governments, external organisations, donors and private industry;

3) Ensure quality-assured drug supply and control mechanisms;

4) Prioritise the urgent scale-up and implementation of DR-TB programs with strong oversight and laboratory support to contain the epidemic. Innovative and context-specific models of care should be integrated with existing health care structures; and

5) Identify mechanisms for increased regional investment in research (basic science, epidemiology, operational research). The development of new tools to fight TB is urgently needed. This is an area where Australia can make a major contribution.

There is a compelling case for Australia to facilitate a coordinated response to the DR-TB threat by mobilising regional political commitment and resources. Such an investment serves the most vulnerable populations, while promoting stability and sustainable development in our region.

Sometimes you have to give a man a fish

Top-down and bottom-up approaches are both needed to improve diabetes outcomes worldwide

“The effort of diabetes care is great, but the reward is also great, for the prize is life itself.” Unfortunately, this statement by Elliot Joslin, made in 1928, is still true today. Over 90 years after Banting and Best’s Nobel prize-winning discovery of insulin, a front cover of The Lancet in 2006 posed Edwin Gale’s question “What is the commonest cause of death in a child with diabetes? The answer — from a global perspective — is lack of access to insulin.” This tragedy has particular relevance to people with type 1 diabetes in developing regions. Children and adults who develop this increasingly common, incurable condition, through no action or inaction of their own or their family, are totally dependent on insulin treatment for their survival, and if that is achieved, then for their quality of life. Even in affluent countries that subsidise insulin, blood tests and health care, the demands of balancing insulin doses with food, exercise, hormonal changes, intercurrent illness and stress are challenging.

In disadvantaged countries I have found that the average HbA1c (glycated haemoglobin) of people with type 1 diabetes is 10%–12%, reflecting blood glucose levels three times higher than normal. The consequences: growth retardation, malnutrition, recurrent infections and diabetic ketoacidosis, early vision loss and renal failure (in settings where laser therapy and dialysis are not often available), and premature death. I have seen stunted listless children with little energy to play, met families who choose to buy insulin rather than enough food and education for their children, and who have moved from their farms and villages to near an urban hospital. I know parents who have watched their child die from diabetic ketoacidosis. I have admired the dignity of a teenager with type 1 diabetes hours away from her death from renal failure and watched the distress of her endocrinologist who (fortunately) could provide morphine and valium then, but, unfortunately, not dialysis or enough insulin in the preceding years. I have met the health minister and the head of the national diabetes centre in one of these countries and negotiated an 80% reduction in the purchase price of insulin from industry. The government took up the lower price offer, but did not increase the quantities of insulin purchased. The savings in funds for diabetes were “needed elsewhere”. Due to early deaths, the type 1 diabetes prevalence in that country was 30 times less than expected based on the population and the type 1 diabetes incidence rate. While many people with type 1 diabetes in developed countries live long and full lives, with 50 or more years of diabetes, the life expectancies of far too many in disadvantaged countries can be measured in days, weeks or just a few years.

Disparities in diabetes care are also emerging in affluent nations. Access to insulin pumps in Australia is predominantly supported by private health insurance, and continuous glucose monitors that can be linked with a pump that can suspend insulin delivery in a life-threatening hypoglycaemia are entirely self-funded. When I was a young doctor in the 1980s, this inequity in diabetes care based on ability to pay did not exist. As an endocrinologist I now see it often. People with diabetes who may benefit from and want an insulin pump or a glucose sensor often cannot afford it. Many with diabetes cannot afford the multiple drugs to control their glucose, blood pressure and lipids, goals that evidence-based medicine has shown can substantially improve health outcomes. Our governments and the health insurance industry are rightly worried about the economic impact of diabetes. The problems of diabetes prevention and care are global problems.

As Martin Silink, an Australian endocrinologist and past President of the International Diabetes Federation (IDF) commented regarding poor diabetes outcomes, “We must move from awareness to action”; and he has done this and continues to do so. His leadership, and that of his individual and organisational partners in addressing the global health challenge of diabetes, is worth supporting and emulating. Martin Silink and like-minded partners, such as the IDF, the United Nations, Diabetes Australia and Insulin for Life (IFL), realise that type 1 and type 2 diabetes are major personal, social and economic challenges for all countries, and that a medical solution alone is not enough. A persistent multipronged approach by many, including health care professionals, people affected by diabetes, academia, industry, organisations and governments, is needed to address the already daunting problem of diabetes, a condition estimated to affect 552 million people worldwide by 2020.

As well as diabetes-related medicines and a sustainable health care system to prevent or delay diabetes onset, to diagnose it and deliver treatment, culturally appropriate diabetes education in local languages and for those who cannot read is essential. It is not only people with or at risk of diabetes and their families and clinicians who need diabetes education — the community, including teachers and employers, policymakers, economists and people in the media, town planning, agriculture and the food industry need to know about diabetes. Research and development and postmarketing surveillance need to continue in academia and in the pharmaceutical and medical device industries. Health care delivery systems, including telemedicine, must be used effectively, and must include rural and remote communities. Costing needs to be fair to all.

Local, national and international agencies and governments must be aware of and responsive to diabetes. Bangladesh and the IDF led a global campaign that resulted in the unanimous passing of a UN resolution on diabetes in December 2006. Resolution 61/225 affirms diabetes as a major global health threat and encourages the development of sustainable national policies for diabetes prevention and care. The roll-out of this resolution is an important work in progress.

As well as empowering people with diabetes, we must first keep them alive. A wise statement is “give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime”. True, but sometimes we must do both. People with insulin-requiring diabetes in disadvantaged countries cannot wait. I am active in the IDF Life for a Child program, led by Martin Silink and Graham Ogle, which facilitates local medically supervised diabetes care to young people with type 1 diabetes. Currently over 12 000 youth in 43 countries are supported. I am also extensively involved at board level and in running a distribution centre of IFL. Established over 20 years ago by two Australians with long-term type 1 diabetes (Ron Raab and Bruce Wainwright), IFL aims to ease and save the lives of people with diabetes around the world. We collect and provide in-date insulin and related supplies to clinics in over 30 disadvantaged countries, supporting thousands of people with diabetes. IFL has collection centres in nine countries, most staffed by lay volunteers and supported by thousands of community-based donors. Both top-down and bottom-up approaches are needed to improve diabetes outcomes.

It is vital that the current and the next generation of leaders, including health care professionals, address the global diabetes challenge. Similar needs exist for other health problems. Readers of the Journal, please lead or be led.

Use of Royal Darwin Hospital emergency department by immigration detainees in 2011

Several thousand people arrive in Australia without a visa each year and seek asylum by applying for recognition as refugees. While awaiting processing, these asylum seekers are involuntarily detained by the Australian Government for periods ranging from 1–2 months to several years, and, in 2011, the majority of detainees had been in detention for at least 6 months.1 Previous studies have shown a high burden of physical and psychiatric morbidity — especially mental health problems, self-harm and suicide attempts — in asylum seekers, particularly those held in immigration detention.2–5

Darwin, in the Northern Territory, receives a substantial proportion of the asylum seekers who arrive in Australia and on Christmas Island by boat, and had two major immigration detention facilities in 2011. The first, the Northern Immigration Detention Centre, is a high-security detention centre that houses men, and has a capacity of 456 people. The second, Darwin Airport Lodge, houses families and unaccompanied minors, and has a capacity of 435 people. A third major facility opened in Darwin at Wickham Point in December 2011, and has a capacity of 1500 people. In a 2010 report, the Australian Human Rights Commission raised serious concerns about the provision of health services to immigration detainees in Darwin.6 In a 2013 Auditor-General report, it was shown that about 40% of surveyed immigration detainees in Australia said that their basic health care needs had not been met.7

Despite large numbers of immigration detainees in Darwin, only one public hospital serves their needs — the Royal Darwin Hospital (RDH), a 350-bed teaching hospital with an emergency department (ED) that sees about 65 000 patients per year. We noticed a large burden of morbidity, particularly self-harm, in asylum seekers attending the RDH ED in 2010 and 2011. Since no data quantifying this burden were publicly available, we undertook a retrospective audit of RDH ED attendances by immigration detainees during 2011.

Methods

We retrospectively audited RDH ED attendances during the 2011 calendar year for people identified, using the hospital’s financial coding, as immigration detainees. The number of detainees attending, demographic information, and time and date of attendances were extracted from the hospital’s data warehouse. Clinical information was manually extracted by reviewing the ED clinical database, a custom-built database for prospectively recording details of each episode of care. Broad categorical primary and secondary diagnoses were those recorded by the ED doctor at the time of presentation. The primary diagnosis was defined as the primary reason for attending the ED. The secondary diagnosis, if any, was defined as a coexisting active medical problem that contributed to the ED attendance.

Data were entered into a purpose-built Microsoft Access database and analysed using Stata version 10 (Statacorp). As we did not have access to accurate data on the number of people in immigration detention in Darwin during 2011, we estimated the denominators using data summaries on the number of people in immigration detention that are released every 1–2 months by the Department of Immigration and Citizenship.1 These reports provide detainee numbers for immigration detention centres (IDCs) (eg, the Northern Immigration Detention Centre), but only provide national-level summary data for facilities classified as alternative places of detention (APODs) (eg, Darwin Airport Lodge). We assumed that the proportion of total Australian mainland detainees resident in APODs in Darwin was the same as the proportion of total Australian mainland detainees resident in IDCs in Darwin. Hence we estimated the number of immigration detainees in Darwin in each month of 2011 for which data were available as: NIDC + (NIDC ÷ MIDC × MAPOD). In this calculation, NIDC is the number of detainees in the Northern Immigration Detention Centre, MIDC is the number of detainees in all mainland IDCs combined, and MAPOD is the number of detainees in all mainland APODs combined. The mean of these monthly numbers was calculated as an estimate of the average number of detainees resident in Darwin during 2011.

The study was approved by the Human Research Ethics Committee of the Menzies School of Health Research and Northern Territory Department of Health and Families.

Results

In 2011, there were 770 ED attendances at RDH by 518 individual detainees; the mean (SD) age of these detainees was 27.6 (12.2) years, 112 (21.6%) of them were aged < 18 years, and 413 (79.7%) were male. Iran and Afghanistan were the two most common countries of birth (283 and 90 individuals, respectively), followed by Iraq (63), Indonesia (24), Sri Lanka (14), and other countries (44).

We estimated that there was a mean of 776 individuals living in immigration detention in Darwin during 2011 (monthly range, 561–920 individuals) (Box 1). If we assume there was no population turnover during this time, this would mean that 518 ÷ 776 = 66.8% (95% CI, 63.3%–70.1%) of these people attended the ED at least once in 2011. If we assume the entire population was replaced every month, then the proportion who attended the ED at least once would be 66.8% × 1/12 = 5.6%. Given that the median length of stay by asylum seekers in immigration detention in 2011 was about 9 months,1 we estimate that 66.8% × 9/12 = 50.1% (95% CI, 47.0%–53.2%) of immigration detainees in Darwin attended the RDH ED at least once in 2011. The mean monthly ED attendance rate for detainees was 1.06 attendances per person-year and, based on 9-month length of stay, we estimate that 1035 people passed through Darwin’s immigration detention facilities in 2011.

Detainees’ clinical characteristics

Each patient who presents to the ED has the urgency of his or her condition assessed and is assigned a triage category, from category 1 (needs immediate resuscitation) to category 5 (non-urgent problem). In 2011, the pattern of triage categories for immigration detainees was similar to that for all patients, but hospital admission rates were substantially lower for immigration detainees in all triage categories except category 5, and the differences were significant for categories 2, 3 and 4 (Box 2).

The most common primary reason for attendance was a psychiatric problem; it accounted for 187 (24.3%) of primary diagnoses, of which 138 were for self-harm (Box 3) (15 of these attendances were by children, who were aged 9–17 years). These incidents ranged from minor injuries (eg, superficial cuts and burns) to life-threatening injuries (eg, attempted hanging, lacerated arteries and intentional medication overdose). Including primary and secondary diagnoses, psychiatric problems were diagnosed for 223 attendances (29.0%). The proportion of patients admitted to hospital who were diagnosed with a psychiatric problem was not related to country of birth, but males were more likely to attend for self-harm than females (141/624 [22.6%] v 3/146 [2.1%]; odds ratio, 13.9 [95% CI, 4.4–44.3]).

Infection-related presentations were uncommon. Most presentations were for chronic or non-specific conditions, including musculoskeletal conditions (back pain, myalgia or arthralgia), gastrointestinal conditions (non-specific abdominal pain or diarrhoea), respiratory problems (asthma exacerbations), neurological problems (headaches) and non-cardiac chest pain.

Of 146 ED attendances by children, the most common primary diagnoses were musculoskeletal problems (53, 36.3%), respiratory problems (17, 11.6%) and infectious diseases (14, 9.6%). Psychiatric presentations were less common in children (20, 13.7%) than in adults (203, 32.5%) (P < 0.001).

Of the 518 individuals who attended the ED, 155 attended twice or more during 2011, and 56 attended three or more times. One detainee attended 16 times for asthma. Of the 770 attendances, 309 (40.1%) involved one or more pathology tests, 246 (31.9%) involved plain radiography, 39 (5.1%) involved a computed tomography or magnetic resonance imaging scan, and 23 (3.0%) involved ultrasound. In 162 attendances (21.0%), the patient was referred to one or more inpatient teams for assessment. In 99 attendances (12.9%), the patient required admission to the ED or hospital wards.

Discussion

Although it has been clear for years that there is a large burden of physical and mental illness in immigration detainees, our finding that more than half of immigration detainees in Darwin attended the RHD ED over a 12-month period suggests this problem is worse than previously suspected. This is likely to reflect two main contributing factors: a high burden of morbidity and poor access to primary health care services at detention facilities.

A high burden of morbidity has previously been described in asylum seekers and immigration detainees in Australia3,5 and overseas.2,4,8–10 The primary health care services at Australian immigration detention facilities were described as understaffed and inadequate in a 2010 Australian Human Rights Commission report.6 Our 2011 data support that assessment for three reasons: the number of ED presentations was much higher than one would expect for a population with access to primary care services; there was a high number of repeat ED attendances by some individuals; and, compared with all patients, detainees had a low rate of admission after attendance at the ED.

As we analysed attendance using broad diagnostic categories, it is likely that we underestimated the extent of psychological morbidity. The most common non-psychiatric complaints (myalgias, headaches, non-specific abdominal pain and non-cardiac chest pain) are symptoms that are commonly due to somatisation in people with psychological distress.

The large number of ED attendances by immigration detainees also puts a substantial burden on the RDH ED. The 770 attendances by detainees during 2011 represented over 1% of all ED attendances. Despite generally low acuity in terms of triage category, resource utilisation was high, with significant proportions of patients needing x-rays, blood tests and referrals to inpatient teams. We did not collect data for 2012 or 2013, but we note that the number of RDH ED attendances by immigration detainees appears to have declined since 2011, probably due to increases in primary health care resources in immigration detention facilities in Darwin and a decrease in average length of stay (277 days in November 2011 v 114 days in February 2013).1 We hypothesise that this was also influenced by the Australian Human Rights Commission and Auditor-General reports6,7 and by public advocacy.

Our study has several limitations. The main limitation relates to the difficulty in obtaining clear and accurate data on the number of people in detention in Darwin during 2011. As a result, we estimated denominators by extrapolation of available data; hence we may have underestimated the number of immigration detainees in Darwin and thus overestimated the proportion who attended the ED. However, as the total capacity of the immigration detention facilities in Darwin during most of 2011 was about 900, we believe our estimated average population of 776 reflects the true situation in Darwin in 2011.

We interpreted the lower admission rates for detainees in each triage category to mean that primary health care services at the immigration detention facilities were deficient, because generally people are discharged from hospital when they have a condition that is of low acuity and severity and could be managed adequately in primary care. Alternatively, for non-medical reasons, doctors might have had a higher threshold for admitting detainees to hospital (eg, detainees were being discharged to supervised accommodation). Irrespective of the explanation, the high numbers of ED attendances and repeat attendances support the assertion that primary care services for people living in immigration detention in Darwin in 2011 were deficient.

We collected our data retrospectively, mostly in categorical form, so our results lack detail about individual diagnoses and presentations. However, the data on diagnoses are likely to be accurate because they were coded and recorded prospectively by doctors as a routine part of ED practice. A prospective real-time study would provide more accurate data, and could include a qualitative component, but this would require time and funding that was beyond the scope of our study.

Our data show that there was a high prevalence of unmet health need, particularly relating to psychiatric morbidity, and limited access to primary health care services, for immigration detainees in Darwin in 2011.

1 Estimated immigration detainee population and numbers and rates of ED attendance by month, Darwin, 2011

	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct	Nov	Dec	Mean	Total

Estimated population	873	912	890	920	853	nd	695	nd	666	561	616	nd	776	1035*
Number of ED attendances	88	76	72	70	61	51	47	50	65	65	63	62	—	770
Number of individuals who attended ED at least once	64	48	51	47	46	31	25	36	45	43	38	44	—	518†
ED attendance rate‡	1.21	1.00	0.97	0.91	0.86	nd	0.81	nd	1.17	1.39	1.23	nd	1.06	—

ED = emergency department. nd = not determined (insufficient data). * Estimated total number of people who passed through Darwin’s immigration detention facilities in 2011, based on 9-month median length of stay. † Total number of unique individuals (ie, individuals were not counted more than once if they attended the ED more than once in the same or subsequent months). ‡ Attendances per person-year (number of ED attendances ÷ estimated population × 12).

2 Hospital admission rates according to triage category for immigration detainees and all patients who attended the Royal Darwin Hospital emergency department in 2011

	Immigration detainees (n = 770)	All patients (n = 63 327)	P*

Triage category 1	9 (1.2%)	547 (0.9%)
Admitted to hospital	4 (44.4%)	395 (72.2%)	0.06
Triage category 2	83 (10.8%)	5 400 (8.5%)
Admitted to hospital	20 (24.1%)	2 808 (52.0%)	< 0.001
Triage category 3	228 (29.6%)	16 808 (26.5%)
Admitted to hospital	39 (17.1%)	6 958 (41.4%)	< 0.001
Triage category 4	428 (55.6%)	37 606 (59.4%)
Admitted to hospital	35 (8.2%)	5 603 (14.9%)	< 0.001
Triage category 5	22 (2.9%)	2 966 (4.7%)
Admitted to hospital	1 (4.5%)	163 (5.5%)	0.83

* P values compare admission rates for immigration detainees in each triage category with admission rates for all patients in each triage category and were calculated using the χ2 test.

3 Primary and secondary diagnoses for 770 Royal Darwin Hospital emergency department attendances by immigration detainees in 2011

	Primary diagnosis (n = 770)	Secondary diagnosis (n = 113)

Psychiatric problem, including self-harm	187 (24.3%)	46
Self-harm	138 (17.9%)	6
Musculoskeletal condition	178 (23.1%)	33
Gastrointestinal or genitourinary condition	117 (15.2%)	8
Respiratory problem	70 (9.1%)	5
Neurological problem	59 (7.7%)	5
Cardiovascular problem	57 (7.4%)	4
Infectious disease	33 (4.3%)	2
Obstetric or gynaecological problem	16 (2.1%)	0
Dental problem	10 (1.3%)	0
Eye problem	8 (1.0%)	0
Other	35 (4.5%)	10

Practising in PNG: pidgin, rugby and yaws

Anthony Radford was the inaugural professor of primary care at Flinders University in Adelaide, South Australia. Before and after that appointment, he accumulated a total of 50 years of experience in Papua New Guinea (PNG). Radford first went to that country as a student in 1951; from 1963 to 1972, he was a public health officer there; and later, he consulted on PNG for the World Health Organization, UNICEF and AusAID. This book records these three phases of his service to Australia’s nearest neighbour.

As a junior doctor in PNG, Radford’s practice was remarkably broad: obstetric emergencies requiring symphysiotomy; surgery for late appendicitis; common medical conditions such as pneumonia and diarrhoea, as well as uncommon ones like yaws and leprosy. Public health was in the mix: sanitation, safe water and immunisation. And he carried out research into infectious diseases and health care delivery. Meanwhile, his colleagues there were solving the riddles of infectious diseases like pig bel (from eating uncooked pork) and kuru (from eating dead relatives).

Radford and his wife Robin embraced the different cultures of the country; all three of their children grew up speaking pidgin and were given tribal names.

Radford acquired fellowships from three Royal Colleges, a diploma in tropical medicine and a Harvard master’s degree and, in 1971, was appointed associate professor to the emerging medical school in Port Moresby.

He was also active in the local sports scene, and found the time to conquer the Kokoda Track and climb Mt Wilhelm. However, the acme of his rugby career, national selection, was scuttled when an aggressive tackle resulted in a dislocated hip.

Radford’s tendency to name-drop might be a bit distracting, but the prominent people named, many of whom are his relatives, help put the events described into context.

I would have liked to have had a few more maps. It would also have helped if Radford had indicated the chronology where contemporaneous diary entries or letters are inserted. These are minor quibbles, however. On the whole, it is a superb life story. And in telling it, Radford reviews the historical, ethnolinguistic and religious origins of the German and British colonies that became PNG. He then goes on to describe the region’s transition to nationhood, and to foresee its problems and lament its failures.

Are global health leaders effectively strengthening local public health systems?

Winner: Medical practioner category

Global health leadership is, presently and historically, inextricably linked with the provision of billions of dollars of aid (by bilateral aid programs such as the President’s Emergency Plan for AIDS Relief, multilateral agencies such as the Global Fund,
and private donors like the Bill and Melinda Gates Foundation), through the work of large-scale global health non-government organisations (NGOs). This association became particularly evident to me while studying for the London School of Hygiene and Tropical Medicine’s locally taught East African Diploma in Tropical Medicine and Hygiene last year. Throughout the campuses of the school’s urban and rural public health care facilities, the proliferation of signposts declaring multiple partnerships and familiar logos denotes the heavy presence and involvement of these NGOs.

In general terms, most of this global health aid is distributed into “vertical programs”, which tend to focus on specific diseases (HIV and malaria being the most common), by a specialised health service using dedicated health workers, having cost-effective interventions with measurable results. These programs have, among their many laudable achievements, successfully enabled the rollout of a variety of treatments as well as effective prevention and education initiatives to target specific issues on a large scale, and have undoubtedly alleviated suffering and saved millions of lives. Highly educated and motivated regional professionals have undertaken world-class research locally in their fields of interest, exemplifying the principle of ownership so imperative in the practice of quality global health.

As well as their program-specific goals, most of the medically focused NGOs and funding bodies explicitly incorporate health system strengthening into their objectives. While the concept of a health system itself is somewhat all-encompassing, for the most part, health system strengthening refers to the government-run public health system, which includes the primary care clinics and hospitals where most of the population can access medical care. It stands to reason that the ultimate “health for all” primary health care-focused goal declared at Alma Ata can only be realised through true health system strengthening, irrespective of the success of vertical programs.

The World Health Organization has identified six “building blocks” of a health system, which can be used
to evaluate its essential domains or functions. These are service delivery, health workforce, health information systems, access to essential medicines, financing and leadership or governance. Health system strengthening can be defined as any intervention targeting one or more
of these building blocks.

But are global health leaders and funding bodies giving adequate consideration to these building blocks and doing enough to ensure that the rhetoric surrounding health system strengthening becomes reality? Or has the concept been relegated to that of a buzzword, an afterthought that can be disregarded when the primary aims of the program have been achieved or the research question answered?
It is difficult to be convinced of the contrary, when one observes the obvious disparities between the high-quality level of care provided to patients enrolled in NGO-funded vertical programs and the care that members of the same community, suffering from conditions not being targeted by NGOs, receive in the general public health system despite the best efforts of health care workers in this setting.

These speculative observations prompted a debate among my diploma classmates (comprising about 60 medical practitioners from 16 nations, of whom one-third were local to the East African region) about potential explanations why the positive outcomes from health-based NGO involvement do not appear to be conferring a benefit of the magnitude one might expect on the local public health system. While this was by no means an exhaustive or definitive debate, it suggested that a twofold situation may exist: NGOs may not be effectively strengthening local public health systems, and there may be some potentially adverse (while inadvertent) consequences of vertical programs on public health systems.

The idea was reiterated that allocation and recipients of aid can be disproportionate, possibly due to a concurrent distortion of health sector priorities. The presence and involvement of multiple NGOs with similar goals but inadequate communication and coordination between them may result in a fragmentation of services with ensuing inequities. Unfortunately, in some cases, the sustainability and accountability of programs subject to external, non-government funding is difficult to monitor and impossible to guarantee absolutely. The comparatively attractive career prospects offered by NGOs to both medical and non-medical staff can lead to an “internal brain drain” from the public sector. The local ministries of health (MOH) incur an additional administrative burden from the allocation and distribution of the aid received, which they may not be fully equipped to manage. Lastly, the possibility of corruption and misappropriation of aid, sadly, cannot be disremembered.

Clearly, strategies to ensure health system strengthening must be a collaborative effort between donor and recipient. The Paris Declaration (2005) and Accra Agenda for Action (2008) outlined the principles, targets and focus for advancement in making aid more effective. More specifically, the 2008 NGO Code of Conduct for Health Systems Strengthening was created to serve as a guide for international NGOs working to limit their harmful effects and maximise their contributions to strengthening public health systems. Key components of this code include sustainable hiring practices, public sector human resource compensation, improving human resource training, minimising the management burden for MOH, supporting the MOH agenda and advocating for public sector strengthening. There are currently about 50 signatories to the code although, to date, there has been no large-scale evaluation of its implementation or effectiveness.

While applauding the undeniable progress made by vertical programs funded by today’s global health leaders, in the future, we must strive to build on these efforts while ensuring true health system strengthening and health
for all.