A nail in the heart of the MJA

Efforts to cut the cost of producing the Medical Journal of Australia have driven a nail into its heart.  

An obsession with the bottom line, a failure to understand how the journal is produced, a failure to comprehend its content, nature and purpose, an ignorance of the immense social network of people of goodwill who have supported the Journal by providing articles and reviews over its 101 years, a predominant financially-dominated management approach, an absence of clarity regarding future managerial (as opposed to editorial) direction, have caused this calamity.  

I have received hundreds of emails, text messages and phone calls from doctors, research workers, managers and readers of every stripe, aghast at what is happening with the Journal. 

As the old adage goes, if all you have is a hammer, everything looks like a nail.  Financial challenge for every newspaper, magazine and journal is not in dispute.  Economies are needed.  But these must be carefully tailored to publication in question, not bought off the shelf.

Here is an analogy for what has happened at the MJA. 
Suppose a health service board took the view that the cardiac surgery unit was costing too much and, without telling the surgeon, asked for bids from cheaper, external providers of dubious repute and questionable practices to provide the by-pass pump service.  This false economy would catastrophically mistake the nature of the integrated surgical team.  Quality would be threatened. A Mid Staffordshire Hospital-style catastrophe, http://qualitysafety.bmj.com/content/23/9/706.extract. where the board did not regard clinicians as colleagues, never ventured into the wards and had no idea of what was going on, would be in the making.

Take an economic fundamentalist approach if you wish, and say that voluntarism is out of date, but the MJA has always run and depended on a community – yes, a community – of scholars.  

More than 900 research workers, scientists, clinicians and other scholars provide peer assessment of research papers,  write critical reviews, editorials, perspectives, eulogies, letters (and even the occasional poem) at no charge.  

The unpaid Editorial Advisory Committee helps guide decisions about the form, content and style of the Journal. They do so because of their love of Medicine, the value they attach to collegiality, the value they attach to science, to evidence, to education and to understanding in research, clinical practice, public health and health policy, the pleasure they get from communication, the rewards that come from seeing their ideas, critically refined by review, appear in print.  

You will never understand how the MJA or any other respected scientific journal works by staring at its bottom line, however long you look.

Now acknowledging the true nature of the MJA community affects how you view its economy.  The view that I have provided does not prevent careful quest for efficiency and indeed encourages the search for new outlets and revenue lines.

It encourages the exploration of new media and new communication platforms, and it does not entrench antiquated, paper-based production.  

It takes account of the editorial team in its entirety – the medical editors, the associate editors, the members of the production team – and does not categorise them as those who do the thinking and the others who just ‘move words around on the page’ as the AMA president put it recently, ‘and make the Journal look pretty’. 

What I call the MJA community can be the dynamo for genuine innovation and reform that has a better chance of sustainability than simply outsourcing part of the operation – the equivalent to the pump team – to an outside agency, especially one that causes academics, librarians, students and research managers to express horror at the prospect, based on their experience.

Professor Leeder is former editor of the MJA and emeritus professor at the Menzies Centre for Health Policy at the University of Sydney.

Published in Australian Doctor 8 May 2015.  http://bit.ly/1L5wCPb

Limiting the availability of essential medicines for all

Published in Australian Medicine, 20 April 2015. http://bit.ly/1OxPFXS

 

Designing hospitals to meet new needs

Published in Australian Medicine 16 March 2015 http://bit.ly/1ILl2ra

Tobacco threat still smokes like a dormant volcano

In 2006, I found myself caught within a crowd of 267,153 fellow New South Welshmen. No, it was not at a one-day cricket match or even a State of Origin rugby league clash.

All of us were aged 45 years or above — considerably above in my case. We comprised the subjects for a long-term survey from the Sax Institute, a public health research agency in Sydney, known as the 45 and Up Study.

It is technically described as a “cohort study randomly sampled from the general population of NSW”.

We all completed a health questionnaire and gave our consent to be followed by repeat surveys and linkage of our health databases. 

We were asked if we had ever been a regular smoker, at what age we started (if we had), when we quit (if we had) and how much we had smoked. At baseline, 7.7% of respondents (aged 38.5 years on average) said they were current smokers and 34.1% were past smokers. 

With a mean follow-up time of 4.3 years, there had been 5593 deaths. This was a frightening intimation of mortality for those of us in the study.  

When adjusted for other risk factors, current smokers vs never-smokers had about three times the risk of dying — a risk that increased with the heaviness of the smoking habit. “Smokers were estimated to have the same risks of death [about 10] years earlier than 75-year-old nonsmokers,” the study found.

The good news was that “for those smokers who quit before age 45, the death rates were similar to those seen in never-smokers. Mortality diminished progressively with increasing time since cessation of smoking”.

Related News:

·         Smoking still claims millions of lives: report

·         E-cigarettes may help smokers to quit: Cochrane

·         DoH paying for staff to quit smoking with hypnotherapy

·         Highly addicted smokers need extra help: expert

·         No one-size-fits-all for smoking cessation

·         Call to revoke e-cigarette ban

The research team was led by Professor Emily Banks from the National Centre for Epidemiology and Population Health in Canberra and the Sax Institute. Renowned Australian epidemiologist Dame Valerie Beral from the Cancer Epidemiology at the University of Oxford was also part of the research group. The results were recently published in the journal BioMed Central.¹ 

"A mature epidemic of tobacco use is not a picnic ground any more than the side of a seemingly quiescent volcano. People who live near tobacco still die."

Dame Valerie has a serious track record for studying the health of women, especially using cohort studies similar to this one. The idea of such a study is to begin tracking people while they are well. Then when an illness befalls them, it’s easy to compare their prior history with that of a person who has remained well, looking for subtle differences in lifestyle, medications, occupation and so forth.  

The great virtue of cohort studies is the absence of bias in the selection of the study subjects. This makes the comparison of individuals years down the track easier: the researcher and the subject are blind at the start to the possible outcomes.

Related Opinion:

• Health risks of nicotine cast doubt on ‘safer’ e-cigarette
• Should Australia lift its ban on e-cigarettes?
•       Plain packs help deter young smokers as uptake drops to new low

The Sax team concluded that “up to two-thirds of deaths in current smokers can be attributed to smoking. Cessation reduces mortality …the earlier in life [the] greater [the] reduction”.

For those with an epidemiological bent, the study authors argue that smoking in Australia manifests characteristics of a mature epidemic. 

A mature epidemic is rather like a volcano on heavy doses of diazepam: low rate of current smoking; long duration and stable intensity of smoking among those who smoke; young and stable age of commencement; high prevalence of past smoking; and similar levels of relative risk from smoking in successive birth cohorts.

A mature epidemic of tobacco use is not a picnic ground any more than the side of a seemingly quiescent volcano. People who live near tobacco still die. And don’t kid yourself that it will never blow.

Related Feature:

• What if nobody smoked?
•  Clearing the air the air on e-cigarettes

Yes, we have made immense gains in tobacco control. Most people who quit smoking we know do so on their own — impressed, I imagine, by the overwhelming evidence about its harm. But quitting becomes easier if society does not tell people attractive lies about tobacco. Thank goodness we no longer advertise tobacco and so diminish the risk of seduction and deception.

But every smoker who can be urged and helped to quit smoking, when seen in general practice for example, is potentially a life saved.  

They are saved not only from death but also from a huge amount of suffering, and studies such as 45 and Up confirm that if you quit, the results are good.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy at the University of Sydney. He is also editor-in-chief of the Medical Journal of Australia.

 

Published in Australian Doctor 11th March 2015

 

Are we closing the gap?

Published in Australian Medicine 16th February, 2015 http://bit.ly/1OSLIKT

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