TAKING HEART FROM INDIAN PROGRESS

India, with its population of 1.2 billion, is planning to build 150 new medical schools in the next five years and at least 250 more in the following five years.  “India,” as Venkat Narayan, a lean, lively and vocal Indian academic who had flown in that morning from Emory School of Public Health in Atlanta to Delhi, put it, “is a place of magnificent chaos, where poverty and wealth co-exist, almost with no self-consciousness, a place where it is very difficult to get things done because of stifling bureaucracy but a place where you can get things done because of the permissive chaos!”  No-one minds a cow slowly crossing the road or minicab drivers lining up and having a pee on the verge even in prosperous neighbourhoods.

“When I was a medical student at Bangalore in 1980, there were two medical colleges and two colleges of engineering.  Now there are nine medical schools and 86 schools of engineering!” Venkat told me, with an energetic laugh. He admits that equity gets rough treatment in India.

I was visiting Delhi as a member of a review panel that has visited India eleven times in the past decade and reports to the prime minister, the minister for health and the ministry to offer informed comment on progress with the National Rural Health Program.  The panel is headed by Jeffrey Sachs, an economist who leads the Earth Institute at Columbia University. He is a valiant warrior for global awareness of poverty.  He has ‘skin in the game’ as his Institute has auspiced the formation of over 40 experimental development villages in Africa where education, health and agriculture capacity building is under way but self-limited to a sustainable budget.  

Sachs has strongly supported a rural health initiative in India to enlist social health workers, respected women in the villages who, with only days of training and no salary, assist young pregnant women to access facilities for safe delivery and neonatal care. There are now 800,000 of these women working effectively in rural India. Mobile phones and bicycles are their basic equipment.  Maternal mortality rates have continued to fall.  Infant mortality rates have been declining in India as a whole (more so in the cities, less so in rural areas) at 6% per annum. 

The rural health program is achieving other goals: there have been no reported cases of polio in India for two years.  Five years ago I recall learning how the polio vaccination team, concentrated around Kolkata, numbered an astonishing 400,000.

And now India, as we have done in Australia, is actively pursuing a program of managed decentralisation of health services.  Expenditure is slowly, slowly rising from 1% to 2% GDP.  Health districts, generally much larger than ours and working on budgets of about $40 per capita per annum, are forming.  It is interesting to see the complex tensions between federal, state and district, so familiar to us in Australia, played out at a mind boggling scale and stupendous complexity.  India gives democracy as a conversation among all citizens powerful and astonishing meaning.

Health statistics are sparse and hard to interpret.  What stats there are point upwards.  As I drove through urban slum areas all my thoughts about chronic disease prevention and primary health care were pounded by rough surf of the social realities of that vast country.  But India is moving and progress is occurring.  No shortage of work for doctors there!

THE APOLOGY – FIVE YEARS ON*

On February 13^th five years ago, the then Prime Minister, Kevin Rudd, and the leader of the opposition, Brendan Nelson, together presented an apology on behalf of the Australian people to our Indigenous brothers and sister.  The apology was offered on behalf also of the parliaments that passed the legislations that led to the forced removal of Aboriginal children from their parents.  http://www.dfat.gov.au/indigenous/apology-to-stolen-generations/rudd_speech.html .  Mr. Rudd explained the reason for the apology.

Let the parliament reflect for a moment on the following facts: that, between 1910 and 1970, between 10 and 30 per cent of Indigenous children were forcibly taken from their mothers and fathers; that, as a result, up to 50,000 children were forcibly taken from their families; that this was the product of the deliberate, calculated policies of the state as reflected in the explicit powers given to them under statute; that this policy was taken to such extremes by some in administrative authority that the forced extractions of children of so-called ‘mixed lineage’ were seen as part of a broader policy of dealing with ‘the problem of the Aboriginal population’.

Mr. Rudd then went on to say:

We need a new beginning—a new beginning which contains real measures of policy success or policy failure; a new beginning, a new partnership, on closing the gap with sufficient flexibility not to insist on a one-size-fits-all approach for each of the hundreds of remote and regional Indigenous communities across the country but instead allowing flexible, tailored, local approaches to achieve commonly-agreed national objectives that lie at the core of our proposed new partnership; a new beginning that draws intelligently on the experiences of new policy settings across the nation.

Let us resolve over the next five years to have every Indigenous four-year-old in a remote Aboriginal community enrolled in and attending a proper early childhood education centre or opportunity and engaged in proper preliteracy and prenumeracy programs.

After Mr. Rudd and Dr Brendan Nelson had completed their speeches they greeted members of the Stolen Generation in the distinguished visitors’ gallery in Parliament House.  The official report of the day http://www.fahcsia.gov.au/our-responsibilities/indigenous-australians/programs-services/recognition-respect/apology-to-australias-indigenous-peoples describes how ‘Aunty Lorraine Peeters [then] presented the Australian Parliament with the gift of a glass coolamon [created by Indigenous artist Bai Bai Napangarti].

Peeters

The coolamon contained a message thanking the Parliament for the apology on behalf of all those affected by removal from their families. In the message Aunty Lorraine explained that the coolamon was a traditional vessel for carrying children, and "a symbol of the hope we place in the new relationship you wish to forge with our people".’ 
‘‘The idea of the empty coolamon was poignant;’ said Brenda Croft, senior curator of Aboriginal and Torres Strait Islander Art at the National Gallery of Australia at the time. “It reinforced the idea of children being taken away from their communities,’’ she says. ‘‘It’s the indigenous form of the cradle. It was no accident.’’  The coolamon, together with the apology documents, are displayed in Parliament House.

How are we doing?  The Australian Bureau of Statistics offers encouragement. Infant mortality is improving.

INFANT MORTALITY RATES:  Aboriginal and Torres Strait Islander and non-Indigenous people 2001–2010

Source: ABS Deaths collection.

It remains the case, though, that we have an incomplete picture of life expectancy of our Indigenous people.  If it mattered to us we would probably do better at measuring it.  At present it is like sending soldiers into battle and not knowing how many are shot dead.  But

‘For those jurisdictions with reasonable information about Indigenous deaths, the median age at death in 2010 for Indigenous males ranged from 50.8 years for those living in the NT to 58.3 years for those living in NSW. These levels were around 20 years less than those for non-Indigenous males, which ranged from 64.9 to 79.6 years. The median age at death for Indigenous females in 2010 ranged from 55.4 years for those living in the NT to 67.1 years for those living in NSW. These levels were also around 20 years less than those for non-Indigenous females, which ranged between 75.2 and 84.9 years.’ http://www.healthinfonet.ecu.edu.au/health-facts/overviews/mortality

We get the parliament we elect:  that’s democracy.  Neither Mr. Rudd nor Dr Nelson lasted long and our parliament has descended from the mountain top to once again concentrate on the things that really matter to us and to them.  But it is a wonder, a treasured memory, that day, five years ago, when the cant, self-comforting delusion and bluster were stripped off the reality of the way in which we had treated Aboriginal Australians, and we said sorry.  Maybe other great days will dawn.  Maybe the coolamon is not empty after all.

*This article has been published in Australian Doctor

A challenging, clarifying, provocative style*

Gavin Mooney entered my life in the mid 1980s when he addressed the Sydney PHA conference entitled Just Health.  What does equity mean, he asked us?  Same cash-for-health for everyone?  Same opportunity for access to care for everyone?  Same outcome after treatment for everyone?  His challenging, clarifying, provocative style remained during the 25 years I knew him.

Gavin’s concern was always with the ethical quality of equity, which he came to summarise in relation to health, as equal access to equal care for equal need.  He developed with other health economists including Culyer the concepts of vertical equity (positive discrimination for those in unequal circumstances) and horizontal equity (giving equal care to those in the same socioeconomic bracket) as applied to health.  He was a strong communitarian, aligned in many respects with Amartya Sen, and a deep critic of neoliberalism, as his last book showed.  His criticism was his strongest card: in speaking with him about his final book I asked him “What now?  What can we do?”  This was far from clear. But a man of action he could be – witness his interest and work in Indigenous health and citizen’s juries.

A Scot to the core, and from Glasgow to boot, I was always surprised not to see him dressed more often in kilt and sporran.  His polemic and critique were modelled on tossing the caber.  This was a symbol of the way he criticised, assembling his arguments like a huge wooden pole, heaving the thing up on his shoulder, running and then letting it fly until it thudded into the ground with a mighty impact.

I have a picture of Gavin in my head, walking the Valley of the Waters in the Blue Mountains of New South Wales with us, when our son James was two.  Gavin had him on his shoulders and James, never one then or now to miss a moment for a politically correct and endearing statement (he is now 19), kept saying, as was indeed true as we passed cascade after cascade, ‘Bootiful waterfor!’ Bootiful indeed – a memory I feel fortunate to possess.

*Previously published in Croakey

Australians' attitudes about the health system improve!

In recent weeks, two important surveys have been released that provide insight into the health of Australians and their beliefs about the health system - The Menzies-Nous Australian Health Survey and the Australian Health Survey. These surveys highlight areas of success and opportunities for further work to be done. The key findings from the two surveys are outlined below.

Menzies-Nous Australian Health Survey - The full report can be found here. 

How did Australians rate their health in 2012? 

• The majority of Australians rated their health as excellent, very good or good (86%)
• Younger Australians were more likely to rate their own health positively
• Higher levels of financial stress were associated with lower ratings of personal health
• Higher levels of education were associated with more positive health ratings

Has this changed since surveys conducted in 2008 and 2010?

• The ratings by Australians of their own health improved slightly between 2008 and 2012

How did Australians rate the health system in 2012? 

• Australians expressed a high level of confidence in the health care system. Over 85% of Australians expressed confidence in how the health care system would serve them if they were severely ill
• General Practitioners and pharmacies were the most highly used health care services in Australia between July 2011 and July 2012. Pharmacists had the highest rating of services as good-excellent. Services offered by mental health providers received the lowest rating. Australians were most satisfied with their recent visit to a pharmacy. They were least satisfied with their last visit to a residential aged-care facility or nursing home
• Australians living in capital cities generally had a more positive view of the health care system
• The need for more doctors, nurses and other health workers was identified as the area of the health system needing the most improvement
• Australians under high levels of financial stress were substantially less confident in being able to afford the care they needed compared with those with no financial stress. They were also more likely to use mental health providers and less likely to use dentists

Has this changed since surveys conducted in 2008 and 2010?

• Australians have a more positive view of the healthcare system compared to 2008
• Australians rated the services offered by dentists lower in 2012 compared to 2012
• Accessibility to General Practitioners did not change significantly in 2012 when compared with 2010, both for waiting time for an appointment and for after-horus acccess

Australian Health Survey - The full report can be found here.

Have risk factors changed since 2007-08?

Tobacco smoking - Rates of daily smoking have continued to drop to 2.8 million people (16.3%) aged 18 years and over in 2011-12 from 18.9% in 2007-08 and 22.4% in 2001.

Alcohol consumption

• The proportion of people aged 18 years and over who consumed more than two standard drinks per day on average, exceeding the National Health and Medical Research Council lifetime risk guidelines decreased to 19.5% in 2011-12 from 20.9% in 2007-08
• 44.7% of people aged 18 years and over consumed more than four standard drinks at least once in the past year, exceeding the National Health and Medical Research Council single occasion risk guidelines

Overweight and obesity

• Prevalence of overweight and obesity in adults aged 18 years and over has continued to rise to 63.4% in 2011-12 from 61.2% in 2007-08 and 56.3% in 1995
• However the prevalence of overweight and obesity in children aged 5-17 has remained stable at 25.3% in 2011-12

Physical measurements

• In 2011-12, the average Australian man (18 years and over) was 175.6 cm tall and weighed 85.9 kg. The average Australian woman was 161.8 cm tall and weighed 71.1 kg
• Between 1995 and 2011-12 the average height for men increased by 0.8 cm for men and 0.4 cm for women
• Between 1995 and 2011-12 the average weight for men increased by 3.9 kg for men and 4.1 kg for women

Waist circumference

• In 2012-12, 60.3% of men aged 18 years and over had a waist circumference that put them at an increased risk of developing chronic disease, while 66.6% of women had an increased level of risk
• On average, men had a waist measurement of 97.9 cm while women had a waist measurement of 87.7 cm

Blood pressure - In 2011-12, just over 3.1 million people (21.5%) aged 18 years and over had measured high blood pressure (systolic or diastolic blood pressure equal to or greater than 140/90 mmHg)

SOCIAL MEDIA AND THE MEDICAL PROFESSION

I am a Luddite when it comes to social media, the web-based interactive media such as Facebook and other more professionally oriented ones like Linkedin.  I do have a Facebook page but I rarely use it. I have a blog where I post my poetry http://stephenleeder.blogspot.com.au/ but no one ever visits and another blog where I post extended versions of articles like this
http://steve-leeder-better-health.blogspot.com/. And yes, I have Tweeted 30 times!  Basically, I stick to email.

But my youngest son (19) belongs to a generation for whom social media are a principal social communication channel. Recent medical graduates know all about it and how to use it wisely and well. It serves to link doctor to doctor and to some extent patient to doctor.

Social media according toWikipedia includes “web- and mobile-based technologies that are used to turn communication into interactive dialogue among organisations, communities and individuals”.

Today, news travels like lightning via Twitter and Facebook.  "A common thread," says Wikipedia, "running through all definitions of social media is a blending of technology and social interaction for the [rapid] co-creation of value."

Social media are cheap to use.  Anyone can publish on them unlike on the commercial media.  And they are immediate: whereas it may take weeks to get an idea into print, with social media communication is now. You can edit an article easily on social media whereas reprinting to correct an error is a nightmare. 

Are the social media likely to be professionally useful?  My guess is that they will prove to be so.  A group of general practitioners could use social media to discuss how best to manage a group of patients in a local nursing home. But they might get their fingers burnt unless the social medium they were using was fenced off, like a gated village, for their use alone. 

Australian Doctor has established docs4docs for that purpose.  Take a look at http://just4docs.com.au/index.php/forums/topic/26/medicare-locals and see as an example a series of depressing conversational comments on Medicare Locals

If you are going to use social media for professional purposes please be careful.  A list of questions to ask yourself before you get too deeply into social media were provided in a paper published in the Medical Journal of Australia last year by a working group drawn from the AMA Council of Doctors in Training, NZMA Doctors-in-Training Council, AMSA, and the New Zealand Medical Students’ Association (NZMSA).

A guide from which the MJA paper was drawn can be found at http://ama.com.au/socialmedia.  Here are the questions.

Have you ever Googled yourself? Do you feel comfortable with the results that are shown?

Have you ever:

• Posted information about a patient or person from your workplace on Facebook?

• Added patients as friends on Facebook or MySpace?

• Added people from your workplace as friends?

• Made a public comment online that could be considered offensive?

• Become a member or fan of any group that might be considered racist, sexist, or otherwise derogatory?

• Put up photos or videos of yourself online that you wouldn’t want your patients, employers or people from your workplace to see?

• Felt that friends have posted information online that may result in negative consequences for them? Did you let them know?

• Checked your privacy settings?

So there you have it!  Good luck but take care!

GOLD MEDAL DREAMING*

LET the Games begin! As the 2012 Olympic Games get underway in London, the spirit of competition and international goodwill that characterises the Olympics offers a rare chance to enjoy and admire excellence in abundance.

It is no surprise that another highly competitive field — health and medical research — holds an event modelled on the Olympic Games. In 2009, Beijing reprised its hosting of the 2008 Olympic Games, with a medical and surgical Olympiad, sponsored by the International Association of Surgeons, Gastroenterologists and Oncologists in collaboration with the Chinese Society of Surgery and the Chinese Medical Association.

Attending doctors competed, using scientific papers as their currency, the best receiving gold medals.

The Greek Embassy in Beijing described how the closing ceremony of the medical Olympics was dedicated to “the Greek culture, its scientific and medical history, and of course, to the renowned Greek physician Hippocrates who was born in the island of Kos in the Aegean in 460 BC and has been considered one of the most outstanding figures in the history of medicine”.

Greece hosted the first international medical Olympiad in 1996 on the island of Kos.

A different style of health-related Olympics was created by American filmmaker Michael Moore, known for his work on a number of satirical documentaries, including Sicko, an exposé of the inequalities and inefficiencies of the American health care system. Before Sicko, Moore created TV Nation: The Health Care Olympics, where Canada, the US and Cuba were matched against each other in three competitive races, involving the care of legs, ankles and feet, respectively.

This Olympic backdrop does raise the question of how much competition is good for health care.

Private enterprise enthusiasts suggest that we need a lot more competition than we currently have to “drive” efficiency. “Drive” is the new best friend of young managers so caution is advised with any rhetoric that uses it.

Competition may push health care towards excellence — and who could dispute that parts of the US health care system are the best in the world for those who can pay. The problem is the huge disparities that occur in quality of care for those who cannot pay.

What we need is a new set of medals for achieving equity, humanity and reasonable efficiency.

In that race Australia would do well, while at the same time winning many prizes for excellence of care much to the amazement of the market fundamentalists.

The irony is, of course, that while “One World One Dream” was the catchphrase for the Beijing Olympics, there is ultimately no way in our unequal world that a universal dream — the fulfilment of the human right to access to basic health care — can persist into wakefulness … not with more than 3 billion people living on less than $2.50 a day.

We must go beyond the Olympics to find the ethical inspiration needed to enable us to address poverty and inequality to achieve that dream.

Gold, indeed.

*Previously published in MJA InSight

THE MEDICARE LOCAL AS ORCHESTRA!*

I want to try out an idea with you. 

Everyone I meet is struggling to say what a Medicare Local is and what it should do.  I would like to propose an analogy – that Medicare Locals are like large chamber orchestras – many instruments and an unobtrusive conductor who may be one of the principal players with special leadership skills.  

Many Divisions of General Practice operated well, bringing general practitioners together for fellowship, education and program development and into better working relations with community health and allied health professionals.  But with the advent of Local Hospital (or Health) Networks (or Districts), whose size makes good sense in terms of the skill mix that can be maintained to meet the health needs of the community and managerial effectiveness, we need an organisation in the community that more or less matches the networks in size.  One day, I prophesy, Medicare Locals and Hospital Networks will work together seamlessly and be funded from one source.  Not for now.

The music that Medicare Locals make occurs when the various players are in tune (no matter their instrument) and in time and they stick to a score.  You need many different players and instruments – one of this and half a dozen of that – to get the best results depending on the music.  Rehearsal is critical as is discipline and enjoyment from working well together.

OK – let’s run with the chamber orchestra idea for a bit. What music does it play? 

First let me tell you about a cold winter’s evening a couple of weeks ago when I had the privilege of meeting with about 50 local people in the Carrington Hotel in Katoomba (NOT what you’re thinking!) to talk with them and colleagues from the Nepean-Blue Mountains Medicare Local (ML) about the health needs of their community and how the ML might help to meet those needs.

Once we got over the hurdle of ‘what on earth is a ML?’ the conversation was wonderfully open, focussed, concerned.  I was especially impressed with how often people were thinking well beyond themselves and their own needs, and instead considering the community itself.  Several needs popped up from all over the room – linkage among care providers for patients with continuing and complex problems, mental health and transport. Let’s locate them in the Medicare Local.

Symphony in C Major?  It depends on better linkage among the care providers for people who access different health services.  Time and time again we heard about failed hook-up among providers of care for chronically ill older people.  Yes, yes, I know – when the day of the personal electronic record has fully come all many communication problems will be solved.  In the meantime, we should be thinking about a patient-controlled note book (pen and paper variety) into which the patient puts details of each consultation. 

Many general practitioners have formed informal email and telephone linkages with specialists and other carers and coordinate through those media.  Hospitals increasingly fax or email summaries to general practitioners after patients have been discharged, but more is needed. 

With the pen-and-paper book (and yes, a few will get lost or forgotten) health care professionals may be able to help with summaries that could be printed and stuck into the book, including meds and doses.  By whatever means, we need a common score to play from.

That way when, as one general practitioner put it, a patient with a complex chronic problem consults them, they will be able to go beyond just asking the patient what has been happening to them with other health care providers.

And vice versa – when patients turn up at hospitals at 2 am it would often be helpful to have more detailed accounts of what has been happening.

But you can imagine how much better this symphony would sound if everyone had the same musical score to play from. The RACGP Blue Book gives us a happy precedent: we need something similar for grown-ups.  The ML could help by first sussing out what communication networks exist and work well and where much more work is needed.

Concerto in D Minor?  That must surely be mental health. The Katoomba people perceived many different aspects of this broad-spectrum problem.  Disturbances of mental health come in all shapes, sizes and degrees of severity. We agreed that a blend of community and institutional care is needed and that opportunities for prevention, especially among young people, are frequently slipping through our fingers. How could the ML help?

A comprehensive ML should be in close touch with psychologists, general practitioners, community health, psychiatrists and the education authorities.  This is not impossible and if given real priority could work brilliantly.  All that was said about the need for far better communication among the players in chronic disease symphony can be said for mental health as well. There are so many commissions, reports, inquiries, and task forces that circle the planet like satellites at present that it is hard to know how to use them to best effect.  In the meantime we should focus on the local scene.

Then the third symphony where we need a strong conductor and players recruited from beyond the health arena is transport.  People at the Katoomba meeting meant transport of all forms.  Patients coming from Lithgow – hardly a distant country town – can catch a train to Sydney or Katoomba only once every two hours.  This may be fine if you’re fit but it can impose huge burdens on those who are unwell.  An appointment in Penrith, Westmead or Sydney runs late and you miss a train by five minutes – wait 1 hour and 55 minutes for the next one, with your arthritis, heart failure or COPD.  Tough luck.

Buses often follow routes that do not suit the chronically ill.  Years ago I worked with a bus company in western Sydney that changed its routes after consultation to better serve the needs of older citizens, so change is possible.  By default the ambulance service is pressed into service. 

An ML might seek to learn in detail what transport needs for health care its community has and then advocate with local government and state government departments to organise services better.  That’s a reasonable aim in a democracy.  We bang on about keeping patients with chronic illness out of hospital.  Well, by improving transport for them we may help achieve this goal.

The Medicare Local is not just another institution.  It is a way of organising community-minded health professionals and others interested in the health of the citizenry so that good music follows.  Because of its complexity and function it is a hard idea to get.  Medicare Locals need people to take music seriously – tune up, coordinate, cooperate, read the score (don’t guess), practice and enjoy.  After all the word orchestra literally means ‘a dancing place’ so feel free! 

See how to build one in Spain!

*Previously published in AusDoc