Hope exists beyond the government's Medimuddle

The start of a new year, in conjunction with the appointment of a new federal health minister, raises hope. An agenda of important health matters awaits her attention.
Incoming Health Minister Sussan Ley takes up her portfolio with strong professional experience in guiding education policy through community consultation in city and country. These skills should serve her well in the health portfolio.

Related News: 6 questions for the new health minister 
First, however, the ground must be cleared of the wreckage of the co-payment proposal.
Driven by ideology, uninformed by policy or accurate analysis of the health system, it was always going to be a debacle. In its latest manifestation, the co-payment plan, which will see doctors forego income, is festooned with a host of confusing exceptions.

It looks like a Scandinavian assemble-it-yourself gazebo built without instructions or an allen key.

But unfortunately it is no joke. Were it to quietly disappear, a sigh of relief would be heard across the land. However, it is proceeding amid a storm of justifiable anger from GPs.
Beyond this ‘Medimuddle', there are actions of far greater substance needed to help secure the future of healthcare in Australia.

Related News: The new co-pay plan: full details
First, energy should be applied to clarifying for all the purpose of the health system and explaining how it has come to be. We need a narrative about why we invest public money in healthcare. We pay for Medicare to meet the needs of all Australians.

The equity thing — a ‘fair go' — is an honoured Australian value. When it comes to healthcare, those who can pay more do so already. We recognise that much illness can strike anyone, and we seek to help those who get sick or injured. That's the story of us, but we need to hear it retold quite often.
Chatter about the necessity for an additional price signal for healthcare, on top of the ones we have already, has never made sense.

We aim for a universally accessible system because as a society we care about the health of all our citizens. We care and value equity.

We are a remarkably altruistic community and we do not neglect those who need care simply because they are poor. We placed many wreaths recently because we care. This narrative needs to be clarified, corrected and repeated.

Second, because money does matter in health, waste should be rooted out. The principal areas of waste in healthcare are attributable to archaic management, most notably failure to apply IT where we can. Yes, we have done well in bringing the computer into the surgery and ward, and into pathology and radiology services. But there is so much more we can do to unite the fragments of healthcare by wiring them together.

Then there is the matter of lots of medical and hospital care provided in the face of evidence that it does no good or is unnecessary. The unnecessary parts should not be confused with humane care or time spent in doctor—patient communication, and in showing concern and compassion. That's quite different.

Waste is not simply a matter of too much hi-tech machinery, but as was shown decades ago, the accumulated waste of doing and repeating far too many small-ticket investigations and prescribing little dollops of unnecessary medication (and this still includes unneeded antibiotics).
Waste is also to be found in the overpricing of generic pharmaceuticals where we continue to pay considerably more for many generics than is the case in, say, Canada.

To tackle this waste will require political skill in negotiating and implementing policy, because professional groups often become vigilant and aggressive custodians of the waste product and the income it generates.

Third, repair work is needed in general practice, especially where the co-payment train wreck blocks the tracks.

There is an urgent need to reduce red tape and improve quality of care in general practice, and to increase its availability in rural and regional Australia and on the edges of our cities.
Most economically advanced countries now recognise the critical importance of general practice in providing co-ordinated care and a medical home for the growing number of people with chronic health problems.

Damage to primary care harms both patients and the bottom line of the national health budget.
Health has many determinants — education, income, environment, diet, genes — and the healthcare system is complex. But these features are no excuse for the substitution of ideology and thought bubbles for a careful and steady approach to the changes needed to secure quality healthcare for all Australians.

Let 2015 be the year when health policy that enables this to occur reappears and is implemented.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy in the University of Sydney.

Published in Australian Doctor 19 January 2015 http://bit.ly/1J1CHeH

The year that reminded us about public health

2014, from the perspective of public health, was the year of Ebola. 

The Red Cross website states that, “The current Ebola outbreak is the worst in history. More than 7000 people have died from Ebola and over 17,200 cases have been reported [since the epidemic began in May 2014 in Sierra Leone]. Sierra Leone, Liberia and Guinea are the hardest-hit countries”.
There are over 10,000 volunteers, many from the affected countries, working with the Red Cross on Ebola. Christmas and New Year celebrations have been cancelled in the ironically-named capital, Freetown, in Sierra Leone.  Palo Conteh, head of the Ebola response unit, said, "We will ensure that everybody remains at home to reflect on Ebola”.

But Ebola is there and not here and, barring serious mutation, it is unlikely to come. The reasons for this are clear and have to do with the poverty and lack of health services in the affected countries. Sierra Leone is tropical and small with a population of about six million people, 70 per cent of whom are in poverty despite the country’s deep harbour, its diamonds and gold, rutile and bauxite exports.
Civil war between 1991 and 2002 left the country in a shambles, its infrastructure smashed, with 50,000 dead and millions displaced. Only half the population has reliable access to clean drinking water and so diarrhoeal diseases are common and kill children.

In 2012, according to the WHO, the Government spent $15 per person on health.  Each year in Sierra Leone 220,000 children are born. The infant mortality rate of 73 deaths per 1000 births puts the country near the top of that league. There is one doctor per 50,000 of the population, and 70,000 children younger than five years die each year, the highest rate in the world.

Maternal mortality is also high, at eight per 1000 births. As humanitarian organisation Amnesty International puts it, one in eight women risk dying during pregnancy or childbirth. “Thousands of women bleed to death after giving birth. Most die in their homes. Some die on the way to hospital; in taxis, on motorbikes or on foot. In Sierra Leone, less than half of deliveries are attended by a skilled birth attendant, and less than one in five are carried out in health facilities.” Female circumcision is rife.

So, while 6000 deaths from Ebola are tragic, the underlying social conditions in Sierra Leone enable this to occur, and many times that number of children and women die of conditions also attributable to the environment. That is the central message of public health.

To achieve good levels of public health and avoid death from childbirth, diarrhea, malaria and Ebola, we must go back to basics. You can’t contain or prevent Ebola without clean water and cups to drink the rehydrating fluids, and without basic medical amenities. If you can’t stop a hemorrhaging mother bleeding to death you can’t treat Ebola.  

You cannot do these things without improving the environment.

Clinical teams can be rushed in to help Ebola victims – a thoroughly worthy response. But the longer term requires action that addresses poverty, provides aid, and costs money. Serious money. That’s what Ebola reminded us about this past year.

The second environmental lesson 2014 has taught us is that our fantasy, created as though we were turtles lolling in the warm waters of the Galapagos Islands remote from the mainland of reality that global warming either doesn’t happen or doesn’t matter, is that there is no protection against the serious health problems arising from it in future. This is something we need to learn and act upon despite the bipartisan chaos that surrounds the Australian politics of climate change.

Time to get serious, time to stop pretending that the carnival that is life in Australia is free and instead see that the environment – physical, human and global – will set the agenda for our future health. 

Published in Australian Medicine, Opinion, 23 Dec 2014.  http://bit.ly/1xORSzt

 

Summit a chance to end nation's decades-long drinking binge

Published in Australian Medicine 25 November 2014

Ebola demands our full attention

The cheery and intelligent man who operates our local dry cleaning agency and I often chat. He has a son doing medicine, and last week, he was worried about Ebola.

He feared that casual contact in his shop or, in the case of his son, on the wards might lead to the disease.  

It made me realise that it is easy to overestimate community understanding of the basic facts about Ebola.

Not that as health professionals we know all there is to know about it - even the precise details of its transmission are uncertain - but sharing what we do know can help the public manage its anxiety.

And quality vigilance depends on good intelligence. So what do we know? The first good thing - and there are not many - is that over half the people who contract it recover.

It is less certain how recovery occurs and whether classic principles of immunity apply, but a 50% recovery rate is a lot better than we saw with HIV in the early years.

Medical care also helps. Fluid replacement and intensive care make a difference to survival chances.

Second, the disease thus far appears to spread through blood, sweat and other body fluids, especially the excreta of infected people, to those who touch them during life or death.  Airborne transmission has not been documented.

In theory, this means that enhanced infection control procedures can protect family and health professionals.

However, as of the end of October, about 500 healthcare workers had contracted Ebola and half of them had died, so protection as practised at present is far from perfect.

Third, we live in an age of brilliant technological possibility, so the search for a drug to treat Ebola or a vaccine to prevent it is likely to yield dividends quickly.

The most likely limits, with so few cases, will be political and economic, as the cost of developing a drug or vaccine may not be a good commercial deal. But the accolades that would come to the inventor of a drug or vaccine would be great.

Furthermore, technological fixes are not always expensive. As reported in the 27 October issue of the New Yorker, a recent competition run by Columbia University yielded several inexpensive innovations designed to assist in managing Ebola.

The competition, auspiced by the schools of public health, and engineering and applied sciences, was open to all students and faculty. Among them was an inexpensive hose that sprayed bleach foam rather than a solution, because unlike a bleach solution, with foam you can see where it has been sprayed. 

But there are significant endemic barriers to combating the virus in West Africa.

The impoverishment of the countries where Ebola has become an epidemic is a major limitation, both in the treatment of those with the disease and the control of its spread. 

Poverty means fewer healthcare facilities and medical supplies, which is why the military support offered by the US, with its sophisticated logistic capability, will make a huge contribution.

Last month, 4000 US troops with cargo planes stuffed with all necessary equipment and transport were deployed to Monrovia in Liberia as part of Operation United Assistance.

With that as a background, groups such as Médecins Sans Frontières and other NGOs' efforts will be enhanced by field hospitals and supply lines for IV fluids and material needed to care for Ebola patients.

Medical volunteers from Australia are also contributing to the Ebola effort ­- including supporting diagnostic laboratories that are hard-pressed to keep up in the affected countries, and are working with MSF and the Red Cross on the front line. 

This month, the Federal Government pledged $20 million in funds for the private healthcare company Aspen Medical to operate a 100-bed hospital in Sierra Leone that will be run by 240 healthcare staff, some of whom will be Australian.

The move came after weeks of public accusations by the AMA and NGOs that the government was not doing enough. 

However, until effective treatment and infection control measures are more widely implemented in Africa, the course of the epidemic is hard to predict.

I understand that the mutagenic potential of the Ebola virus is no match for influenza, but if its mode of transmission does expand to include airborne routes, the challenge of the epidemic would grow enormously.  

Figures published by the US Centers for Disease Control and Prevention say almost 5000 people in West Africa have died from the virus, with the number of cases in Sierra Leone and Liberia said to be doubling every 20 days, which means that by year's end, those affected will be approaching 1.4 million.

It is clear Ebola deserves our serious attention: just as we view the extremist Islamic State as a distant threat to Australian security, so too we should view Ebola.  

As for my friend the dry cleaner, when he asked if he should wash his hands after handling unfamiliar garments, my cautious (but not entirely rational) answer was, yes.

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 17 November, 2014 http://bit.ly/16p4FTz

H2O: putting health on the global agenda

Published in Australian Medicine 28 October 2014
 

Stronger focus on drug side effects needed

Randomised controlled trials are the supreme method for determining whether a new treatment, frequently a new pharmaceutical, is superior to current best practice.

They were originally used in agriculture to assess the added value of a new plant or soil additive, but are now firmly ingrained in medical practice.

I recall 30 years ago, an eminent professor of surgery railing against randomised controlled trials, which he considered utterly inappropriate to determine the value of surgical interventions.

He wrote a scathing article in which he referred repeatedly and disparagingly to such trials as "agricultural statistics".

While the randomised controlled trial has given us the best possible evidence about the effects of new therapies for a range of conditions, especially cancer and cardiovascular disease, and have underpinned the evidence-based medicine movement, they do not cover the entire treatment waterfront. This is especially so in relation to side effects.

The way randomised controlled trials work is that they aim to find out how many patients need to be treated — either with the new therapy or the old — to determine if the new drug is better.

The expected improvement in cancer trials is small, usually less than 10%, and so these studies require larger numbers of patients to be sure that even the slightest difference in outcome can be seen.

Sample size calculations, therefore, are based on the detection of relatively rare events, such as a gain in life expectancy or quality of life.

But side effects are another matter. They often fall beyond the vision of the trial, or out of focus of its carefully calculated sample size.

Side effects may not occur for months or years after a trial has finished, or they may be so rare that the randomised controlled trial's sample size is insufficient to detect them, even if they occur during the trial.

With some medications, side effects are of huge importance — for example, if the trial is testing a preventive intervention such as immunisation, rather than a treatment for a serious illness where side effects may be tolerated.

Nobody wants to enter a trial feeling whole and well and leave it with a nasty side effect.

Publicity around claims of side effects from immunisation illustrate this point, and show how critical it is to be secure about the proposed preventive interventions.

Similar concerns surround trials of cholesterol-lowering drugs in very low-risk populations. Side effects can be hard to detect, and if the treated trial subjects are at low risk of the disease (such as an MI) that the drug is intended to reduce but then develop problems with, for example, muscle power, a hard-to-resolve problem arises. Witness the controversy around the Catalyst TV programs on exactly this topic.

So there is a sizeable challenge to be sure that we know what side effects occur, and brilliant randomised controlled trials will not necessarily tell us about rare and distant ones.

Currently, especially in the case of new drugs, the pharmaceutical company sponsoring the trial will have given serious thought to this matter and have in place systems to collect information about side effects.

Of course, it is not only in the context of randomised controlled trials that side effects occur and old remedies, especially in specific genetic subsets of the population, may cause rare problems. Often more information, especially long-term data, is needed.

An intelligence system to learn about possible side effects is far more feasible today than even 10 years ago.

The high degree of electronic connectivity that we all enjoy (and sometimes loathe) can put us in touch with agencies, such as the TGA, to report possible side effects at the click of a mouse.

Now the TGA has come up with an online reporting system for patients as it's concerned that the vast majority of side effects go unreported. Doctors report some and drug companies others, but for over-the-counter and alternative medicines, there have been no formal reporting pathways.

The TGA may easily be overwhelmed with side effect noise and it will need a good filtering system to detect the signals. But this is surely a move in the right direction; another step to ensure medication safety as well as efficacy as we continue to advance our capacity to prevent and to treat.

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 8 October 2014 http://bit.ly/1BRzk91

 

Coming to terms with Ebola

Published in Australian Medicine, 30 September 2014