Stepping outside of health to be healthy

Published in  Australian Medicine, 2 September 2014.

How should we respond to the Ebola virus threat?

We Australians live in an exceptionally safe country compared with many others today (and compared with our own in times gone by) when it comes to serious infectious diseases.

Our immunisation programs have succeeded brilliantly against whooping cough, polio and the other diseases of childhood.

The basics of public health -- clean water and waste disposal -- are secure in urban and much of rural Australia. Huge gains in life expectancy have followed.

We no longer need the rituals and beliefs to comfort us as did families in Victorian England when the death of children from infections was commonplace. We are not a society facing the loss of 16 million deaths of combatants and civilians as happened in World War I, followed by about 50 million more who lost their lives from the larger scourge of H1N1 influenza in 1918.

Being unaccustomed to catastrophe, especially those due to infections, it is understandable that we are shocked and frightened by the current outbreak of Ebola virus in West Africa.

Well, even if we aren't ourselves, then at least a friend of mine is. This man, a retired, successful and highly intelligent businessman living in the north-east of the US, recently cancelled his summer holiday in the south of France.

You can read about the fascinating history and virology of Ebola on Wikipedia. The virus was named after the river in the Democratic Republic of the Congo (then Zaire) where it was first isolated in 1976. The current outbreak in West Africa is the first recorded for that area.

On 8 August, the WHO declared the outbreak to be an international public health emergency.

As of 21 August, the WHO reported there had been 2473 cases of Ebola virus in places such as Guinea, Liberia, Nigeria, and Sierra Leone, and 1350 people had died from the disease.

Infectious agents can kill in epidemics by being highly lethal and highly contagious. Highly lethal infections that are not contagious do not create epidemics.

Viruses that spread by airborne droplets such as influenza are highly contagious, but many forms of flu are benign because their pathogenicity is low.

It is only when a strain of influenza that has high lethality and is highly contagious -- such as the H1N1 influenza that followed World War I -- is circulating abroad that serious flu epidemics occur.

In the case of Ebola, there is high lethality associated with human infection. About half of the reported cases see the patient die due to massive cytokine disruptions to the vascular tree. But bodily contact, or contact with bodily fluids, is necessary for infection.

The Ebola virus does not mutate rapidly -- it's 100 times slower than influenza A and about the same as hepatitis B. If we could develop a vaccine, it would not be quickly out-of-date.

So what should we, in Australia, do? First, we need to ensure our surveillance strategies are sound and in place, concentrating especially on plane arrivals of people from West Africa.

Second, we need quarantined treatment facilities available to effectively manage cases.

Two US medical attendants, Kent Brantly and Nancy Writebol, who were exposed to Ebola while treating patients in Liberia were repatriated by air on 2 August to a special facility at Emory Hospital in Atlanta, built with the Centers for Disease Control. The US is thus taking seriously the possibility of treating patients with Ebola on its shores. So should we.

Third, we should, as a nation, contribute what we can to the advancement of scientific understanding of this threat, with an eye on antiviral therapy and vaccine development.

Australia's response has been appropriate to date, but we still do not have a national centre for disease control.

The surveillance networks that we have are generally adequate, but relatively informal and for a nation of our wealth, aspiring to international leadership, 'adequate' is not the word that comes to mind as an expression of appropriate ambition or responsiveness.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board, and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 26 July 2014 http://bit.ly/ZEx5FW

WHY CO-PAYMENTS ARE NOT ALL GOOD

In celebrating the one-year survival of the Abbott government former prime minister John Howard was reported to have asked why, if we have co-payments on pharmaceuticals, we should not have one on general practice. Five reasons stand out.  

First, the co-pays on prescription drugs stop poorer people from accessing to them. Ask general practitioners. Extending co-pays to general practice compounds rather than solves this problem.  

Second, seeing a doctor for a health worry is different to filling a script. A consultation with a doctor may dissipate the worry without further cost or action.

Third, a timely, uninhibited consultation for the first symptom – chest pain, let’s say – of a serious problem may save a life and nip the progress of a disabling illness. Co-payments diminish easy access for less affluent Australians to general practice

Fourth, a consultation may lead to preventive changes – quitting smoking, behaviour modification, stopping unnecessary medications – that are positive investments, not sunk costs.  Co-pays that inhibit preventive consultations diminish the chance of a healthy life.

Fifth, many general practitioners in poorer parts of the country who entirely bulk-bill do not have the financial systems to raise fees.  The logistics of collecting and remitting a co-payment could drive them out of business.

Maybe the co-pays on pharmaceuticals are a public policy error that permits gouging of pharmaceutical prices and diminishes the search for efficiency in drug supply. Rather than asking where else we can impose a co-payment, the question should be, “We don’t have co-payments on general practitioner bulk-billed consultations, so why should we have them on prescribed pharmaceuticals?’

By way of postscript, the current debate about how much the Medicare levy contributes to health care costs is informed by figures from the federal minister that are all wrong.

ASSESSING VALUE BEFORE DEMOLISHING

In the current confusion in health that has followed from a swath of defunding, abolitions, co-payments and diminished Commonwealth funding, it is easy to lose sight of the needs of the individual patient. 

Typically and increasingly, the people who need our health care have a combination of problems such as diabetes and heart disease requiring concerted attention from hospitals, community nurses, general practitioners and community-based specialists. We do not have the firm evidence to say how best to do this, and hence in NSW the state minister for health, Jillian Skinner, has allocated $130m over 3 years to test out alternate ways of achieving this end.  Recently Medibank Private and other private insurers have expressed interest in testing strategies using community nurses to achieve the best alignment of care for our typical patient.

One of the casualties of the federal slashing has been what was called a Medicare Local, an organisation established by the previous government to create an environment of support for general practitioners and the long-term care of patients with chronic problems.  Their function was patchy, as expected from new entities, but where they worked they worked well. But the decision was taken recently to scrap all 61 and start again, with different, fewer entities called primary health networks.  Demolition and rebuilding is an expensive hobby.

In NSW, where we have 17 hospital districts or networks, there were 16 Medicare Locals.  While the match was imperfect, you get the drift.  In places such as western Sydney, fortune favoured us and the Medicare Local and the hospital district covered the same geographic area – from Mt Druitt to the Hills to Parramatta and Auburn.  Good things followed in coordinating care and hospitals and community practitioners learning to work together – for the good of the patient.

The document that evaluates the Medicare Locals concedes the value of a one-on-one relationship but envisions larger organisations combining the roles of smaller Medicare Locals.  What a pity. We know from past experience that the size of the NSW health districts is just about optimal – make them bigger and they are a managerial nightmare; make them smaller and you lose economy of scale.  Each has a degree of local identity and that identity is reflected in the Medicare Locals that serve the community especially when the overlap is complete.

If the federal minister wishes to experiment with how to meet the needs of the patient with chronic problems, why not leave NSW as it is and try out different models in other states such as Victoria that has no fewer than 90 hospital networks.  Or Queensland.  He has encouraged private insurers to experiment so why not his own ministry? 

Tearing up the crop before it has had a chance to bear fruit is expensive and wasteful.  Even more so with Medicare Locals.  Of course many of them can benefit from more energetic and focussed management, but there is no monopoly on that.  Let the plants grow.  We’ll find out soon enough whether the NSW model – one Medicare Local per hospital network – is the best way to go or whether we have been trumped by the Victorians again.