steverobson

Critical condition

Sun, 16 Jun 2024 23:42:58 GMT

The medical profession is failing to take care of its own – and the consequences can be disastrous, writes Stephen Robson

It was hardly a salubrious setting for what was almost the final day of my life. A sparsely furnished tiny brick box of a flat, oppressively warm even at night, an easy walk from the Rockhampton Base Hospital where I worked as a junior doctor. I had carefully laid out a large sheet of black plastic atop the cheap acrylic carpet, the kind of plastic you place at the bottom of a lovingly tended garden bed. In the central Queensland humidity, I didn’t want my decomposing body to make a mess. In my mind, with my thoughts scrambled by overwhelming guilt, infected by a pervasive sense of failure that I carried alone like a toxic secret, I felt I had been a burden enough to others already.

A few days earlier a man had died in my care. A local man, a father and grandfather, someone loved by his family. My decisions – or lack of them – had led directly to him losing his life. At that time in regional hospitals around the country, interns straight out of medical school (like I was) often worked as the only doctors on duty. A major hospital at night can be a lonely place. Senior clinicians could be consulted and called to come in during emergencies, but interns often made life-and-death decisions in the course of patient care. A terrible mix of my inexperience and fatigue had led directly to

my patient’s death. The consequences of my actions came as a shattering blow, an arrow through my heart.

To this day medicine is not very good at responding to adverse events. It is difficult to prepare a young doctor on how to cope with a patient death that – despite whatever system failures might have contributed – they believe ultimately is their fault. It is the risk and reward calculus of medicine. The rewards of a lifetime in medical practice can be extraordinary, but the risk that error or miscalculation can result in harm or death is ever-present. When that happens to a young doctor, there can be a sense that the system piles blame on top of you, amplifying the already overwhelming feelings of guilt. For me as a young doctor, it was a burden too great to carry.

In my Rockhampton apartment, as evening fell, I put a cannula in my vein – not an easy undertaking one-handed. I was preparing to feed insulin that I had taken from a hospital supply cupboard through an intravenous drip when there was an insistent rapping at my apartment door. The visit from a fellow junior doctor, which for 30 years I believed was a matter of chance, was in fact a matter of instinct. Colleagues had seen me take the insulin from the cupboard, and feared what I planned to do. They had interrupted me with seconds to spare.

When I first alluded to the story of my own near-suicide in the Medical Journal of Australia six years ago, I urged readers: “If you feel now the way I did 30 years ago, seek help and support as soon as you can.” Today, that advice remains just as true – yet I see now, with clarity, that seeking help is only part of the solution. A recent audit by the medical regulator found that 16 Australian practitioners it had placed under investigation took their own lives in a three-year period alone. Some of these doctors had self-referred to the regulator, suffering mental distress – and instead of receiving a plan and support to move out of the dark place they found themselves in, they were faced with delay and a dysfunctional system.

Seeking help is important but it is not enough. The system in which we work must take responsibility for the pressures it places on doctors, acknowledge the harms inflicted on

many who seek to heal, and reform.

It alarms me that junior doctors continue to experience poor mental health, unsustainable pressure in their working conditions, bullying and appalling treatment by others working in the system, and kill themselves in numbers that are simply intolerable. After more than two years I will step down as Federal President of the Australian Medical Association, and it is not lost on me that I have taken a journey from feeling that my prospects as a doctor were so poor that death was preferable, to standing as one of the most visible doctors in the country.

I cannot change the system single-handedly, but as someone who has experienced the most profound feelings of inadequacy at the birth of my career, who faced a night so black it was only the luck of timing I survived it, and who was ultimately, unfathomably, gifted a professional life marked by wonder and renewal as an obstetrician, I want to issue a plea to young doctors to hang in there, reach out, and believe in the future. I also want to issue a plea to the system to not let them down.

In the decades since my life almost ended in a stifling Rockhampton cinder block flat I have become immersed in medicine, sometimes almost to the exclusion of everything else. More than once since that night, medicine has extracted a heavy toll. Its demands, at times, have almost broken me. In the decades after my suicide attempt, I tied myself in knots trying to deal with the experience. Indeed, a GP from whom I sought care told me never to mention what had happened to anyone lest it ruin my career prospects and my reputation. Denial was my stock in trade. Although I thought about it a little each day, I told nobody else and believed it was a secret that should never be shared. It became a dark, black hole deep within me, drawing in the matter from my world and compressing it until it was gone.

I am now telling my story, because the burden of responsibility that so many doctors feel cannot be carried alone. I don’t want any other young doctor to feel they need to carry a secret like I did for 30 years. I don’t want any young doctor to ever feel as inadequate as I did, and I want our health system – which in far too many hospitals is characterised by blame, fear and oppression – to face up to its too often toxic culture. The ramifications for staff welfare are obvious, but it’s also a matter of patient safety.

It’s a tragedy to me that some junior doctors abandon the system, burned out and dispirited (or worse), and will never know the joys that may lie ahead. I have had the privilege literally of holding many lives in my hands, often of newborn babies and sometimes of their mothers. I have spent decades helping people dealing with every experience from the deepest grief to the highest exhilaration. I have learned about fear, about love, about when to ask for help. About caring and about the power of hope. I want every young doctor to hold on to hope.

When I was growing up in a small town in 1960s Queensland, no one in my family had ever been to university. My father trained as a carpenter and my mother was a ballerina. They ran a motel in citrus country in rural Queensland before we moved to Toowoomba, where my father began a wholesale fruit and vegetable transport business. One of the people we delivered to was a medical specialist we called Doc Stringer, whose home seemed to be a place of perpetual chaos and fun. He was a wonderful conversationalist, the owner of a fleet of old Mercedes, a fascinating and gregarious character. He encouraged me to be a doctor.

My school careers counsellor, Mr Bradley, was sceptical that I could get the marks necessary for acceptance to Queensland’s medical school. I was determined, though, and to the amazement of everyone I managed to reach the standards. I wish I could tell a story of breezy inevitability, but that was not the case for me. I had to give up almost everything except study and, still, just scraped enough marks.

The experience of moving to Brisbane, and the adjustment to university, was overwhelming. I failed key subjects and had the humiliation of sitting supplementary examinations. Most of my fellow medical students seemed to take study in their stride but I felt like I was standing before a sheer cliff. Over my career I have learned that fear does not have to be the enemy, though. Fear affects how we act, and recognising this can also help us care better for people in our lives.

Fear was something I learned a lot about soon after I left Rockhampton. To pay my way through the last years of medical school I had taken a scholarship with the Royal Australian Navy and become a Medical Officer (I would eventually go to the Gulf War as a doctor). During this time I completed the Army’s parachuting course – despite having an acute fear of heights. During the course, a large part of which involved jumping out of the back of C-130 Hercules transport planes at 1000 feet, I spent several weeks in a state of fearful panic. Prolonged fear has a profound effect on one’s physiology, and I could barely sleep or eat. But despite my paralysing fear, I did manage to complete the course and earn my parachute “wings”, much to my own amazement. It was the most physically and mentally challenging training I had ever undertaken. The experience gave me a deep and enduring respect for fear.

Ultimately, I devoted my professional career to pregnancy and birth. I often cared for people who were fearful. If a birth is complicated, and urgent action is required to save baby or mother, fear is often in the air. Fear is contagious. It can spread not only from mother to staff, but also in the other direction. The appearance of panicky staff can turn a dangerous situation into a completely out-of-control one. That is when bad things can happen and scar those involved – whether patient or carer – for life.

I found that I had a sixth sense about fear and could pick it in people, even if they were doing their best to hide it. This allowed me to articulate fear and raise it first. Sometimes it would be like our shared secret – many times I would explain that I, too, had experienced it. I could understand how fear changes people and distorts their decision making.

Many doctors – especially those completing their specialist training – confront fear in themselves too. Something I have learned on my long journey through medicine is that love can overcome fear, yet rarely do we talk about this. Just as I have learned about the effects of fear, I never underestimate the power of love. In the same way that fear affects our perceptions and our decision-making, so too does love. I want junior doctors who are navigating the health system to understand just what love can do.

Almost a decade ago I received a call about a situation that would, over time, utterly transform my understanding of the effects of love. That call was from a colleague who worked interstate. He told me the story of a man who’d been killed in a motorcycle accident several years before. Reproductive tissue containing sperm was taken from his cold body 48 hours after his death, but his partner had struggled to obtain a court order on a weekend allowing the sperm to be retrieved. It had remained frozen ever since.

Overwhelmed with grief, as all of us would be if the love of our life was taken from us, she had worked through the courts to demonstrate that, had her partner survived the accident, their intention was to have a child together. It has been an incredible emotional and financial challenge. My colleague was calling to ask if I would be prepared to perform IVF treatment with the long-frozen sperm with a view to this man’s widow having a child. I was extremely dubious – taking sperm 48 hours after death had never been done, and nobody knew what the outcome would be. Yet I was intrigued, so I flew interstate to meet and speak with the woman seeking treatment.

She and I spent a morning talking over coffee near a suburban park. She told a story of love that was irresistible to me. Of plans for a life together, of their commitment to each other, of their wish for a family. By lunchtime I had been won over and wanted to help, to take the journey with her. This was a love story for the ages. Incredibly, her eggs were fertilised and we were able to achieve a healthy pregnancy using the long-frozen sperm. Over the course of the pregnancy I kept in close contact both with her and her interstate obstetrician. A healthy child was born and I was so overwhelmed by the outcome that I flew over to see the new mother and baby. To this day, and under close surveillance, her child appears to be healthy and normal in every way.

Love is perhaps the most powerful force in decision-making. We’ve all done crazy things for love, and I’ve had the privilege to play a very small part in a love story for the ages. When young doctors feel overwhelmed, or struggle with dark thoughts, I want them to look towards love and its power to heal.

At the time I tried to fill my body with insulin and end my life, I saw no hope. I know that many other people have reached this point. I now never underestimate the power of hope. Being given hope can reshape the experience of illness or injury, for patients and everyone around them. It was something I had lost as a new doctor – and something that took a long time to regain after my suicide attempt.

I am not the only doctor who has attempted suicide. I have had close friends take their own lives, and the data tells us that the suicide rate among doctors is 34 percent higher than the community more broadly. For female doctors, the suicide rate increased almost five-fold between 2006 and 2017, according to a study published in 2023. Surveys of young Australian doctors reveal that half of them report high levels of emotional distress.

Understanding this and offering hope and support, particularly to young doctors, should be a priority not only for my profession but for those who control and regulate medical practice. The feeling of being overwhelmed, particularly when things go wrong for our patients, can be terrible.

As I have become older, the temptation to sidestep difficult problems when the going gets tough has not gone away. As a doctor, though, things are not so easy. A recent case demonstrated powerfully that patients depend on you – absolutely – not to take away hope.

I saw a patient who was pregnant for the second time. Her first baby had been born by caesarean section, and all had gone well. In this pregnancy, however, there was a major problem. It was the pregnancy complication obstetricians fear the most. The baby’s placenta had implanted low and was growing through the scar of the previous caesarean and into my patient’s bladder. This complication – given the horrifying name “morbidly adherent placenta” – is dangerous to both mother and baby.

I had a series of frightening discussions with the patient and her husband as their toddler played in the room. “Just how serious is the situation?” they asked. About as serious as it gets. “Could I die?” she asked. Yes . The patient and her husband shared anxious looks but she told me: “Well – we trust you and are glad to be in your hands.”

I have been a surgeon for over 30 years and spend a lot of time performing difficult surgery for conditions such as endometriosis and large tumours. I knew that the surgery required to safely deliver this baby, and to prevent the woman bleeding to death, would be difficult and complex.

As the baby’s birth day approached I felt more and more anxious; I would lie in bed at night, unable to sleep, playing out the birth in my head and fretting about leaving the baby motherless, the father a widower.

I had assembled a very experienced team to help me: vascular and urological surgeons, a top-flight anaesthetist, an intensive care team. The baby was delivered early in the morning, healthy and well, and we set about dealing with removing placental tissue that had invaded widely in the mother’s pelvis. The bleeding was extraordinary – overwhelming for us. We worked at the peak of our skills for hours. By late morning, I had a very grim feeling that we had no hope. The blood vessels were so large, so widespread, that controlling things would not be possible. It was a horrifying feeling. But we packed her abdomen with sponges and caught our breath. As overwhelming as the situation felt, we were not going to give up.

Gradually, we began to gain control. By the time she was wheeled to the waiting ICU bed we estimated her blood loss at 12 litres. Yet she recovered quickly, without complication, and went home with her baby. Rarely have I been so gratified by a result. The family – mum, dad and two children – moved interstate soon afterwards. I received a message on the child’s first birthday: a photo of the whole family, smiling and happy in their new home. It was awe-inspiring. Never give up hope.

The pandemic wreaked havoc with our health system, and a pervasive sense has taken hold that hospital administrators don’t care about their workforce. Wage-theft class actions reveal that hundreds of millions of dollars in fairly earned wages were never paid to junior doctors, who have been expected to work excessive overtime under great pressure for free.

This has compounded a burden that so many already shoulder. Bullying and harassment is commonplace. There is a crippling sense that nobody cares for the carers, in an era when many are at their most vulnerable. Yet shouldn’t the patients who seek care in our health system receive medical care from doctors who are at their peak?Fewer mistakes will be made, problems will be solved more efficiently, and the care will be better.

In the years after I tried to take my own life, I struggled with my emotions and my shame. So many people across Australian society – from every profession and vocation – have told me that they have experienced the same things.

Doctors are famously secretive with their own health conditions, and for many years I was no different. I worried that referrals to my practice would dry up if word spread among colleagues that I was impaired by mental health conditions, or that I might try to kill myself again.

Help was available. Indeed, as a physician, I was literally surrounded by people who could help. But I’d decided it was better to bottle up these problems, to hide them and try to deal with them myself, than to admit what I was suffering. Recovery from the mental health problems of my early career was an arduous, draining and isolating process. If there is a single message that I want to pass on to anyone in such a dark place, it is that help is available. I had the incredible luck to have a second chance, to have colleagues intervene just at the critical moment.

It has been possible for me to build a career based around caring. To deal with fear and embrace love. To give hope to others. It was a difficult and steep path, and I don’t want to suggest for even a second that climbing from the depths has been easy or that I am unscarred. It is possible, though. For doctors who have spent years trying to master their craft, and so many hours memorising the body of knowledge that underpins everything they do, the burden of responsibility can be overwhelming. Working in a system that is overstretched and places so many demands on individuals, and yet is so unforgiving, can be a devastating experience.

Ultimately the system that provides our healthcare must value those who work in it. It is not enough to leave young doctors unsupported and adrift in a system that is so important to so many people. Patients have a right to expect that they are treated by people who are functioning at the highest level, not crushed by the demands of the system. Yet over the years since I first wrote of my experience, and made my plea that other young doctors do not suffer like I did, nothing of substance has happened. Hospitals and health systems seem to care less, and regulatory systems place burdens that are ever more stressful. Nobody takes responsibility.

I was more lucky than I could ever have imagined. I was saved by caring colleagues at the last moment. But it should not fall to colleagues to save their own. That is the responsibility of the systems that run our hospitals and medical training institutions. Unfortunately this message has not gotten through yet, despite the evidence of harm the system inflicts. Each life lost is a tragedy that further diminishes our system. I should know.

Lifeline 13 11 14;

beyondblue.org.au

samaritans.org.au

If this were a men's issue, we would've solved it a generation ago

Fri, 19 Apr 2024 04:57:37 GMT

This year almost 3 million Australian women will find themselves in an age group where menopause is likely to affect their lives in some way.

While many women find this life transition relatively smooth, hundreds of thousands will be severely affected.

The symptoms and consequences of menopause can have a profound effect on women's lives. It can disrupt their work, their relationships, and their ability to live life to the full.

Menopause also can drain women's finances with surveys showing that more than a quarter of Australian women reporting having taken breaks from work and study at the time.

From a strictly economic perspective it has been estimated that dealing with menopause has had a $100 billion effect on Australian women when lost earnings and superannuation are taken into account.

Late last year the Senate launched a long-overdue inquiry into menopause and its effects on Australian women, their families, and the country's health system. The inquiry is due to report in September this year: that report can't come soon enough.

Despite the millions of women affected, and the costs both to the country as a whole and to individual women, Australia has no national framework or plan to deal with menopause.

There is no high level visibility of menopause as an issue, and because of this Australian women are subject to yet another injustice.

The Senate inquiry aims to deal with the physical, mental, and emotional wellbeing of women affected by menopause, and access to healthcare services. Part of this remit will be to raise levels of awareness among doctors, and to improve the availability and affordability of menopause treatments.

To help the millions of Australian women who are experiencing the negative effects of menopause, perhaps the most important goal should be to lift the stigma associated with this normal life transition. It is well past time that we started a national conversation about menopause and how it affects women.

It is difficult not to think that, if menopause had a direct physical effect on men, the issue would have been dealt with a generation ago.

Yet in 2024 many women still face discrimination, bias, and a sense of shame speaking about menopause and how it affects them.

Woman are already facing financial headwinds dealing with menopause. The cost of seeking care should not be an additional burden, or a disincentive to asking for medical help if it is needed.

The government must respond and ensure that every Australian woman - no matter her cultural background, where she lives, or her financial capacity - has affordable access to healthcare . Many of the issues around menopause are not suited to a rapid visit to the doctor.

Affordable long consultations, where all of the issues affecting women can be dealt with properly, must be available to any woman who needs them.

The cost of treatments to relieve symptoms and protect women from conditions such as osteoporosis must be affordable for everyone.

Many Australian women are reluctant to talk about menopause, or downplay its effects on their lives. Where help is available many women either are not aware or find it difficult to access care and support.

Putting menopause back on the national agenda and acknowledging what a critical issue it is for so many women must be the main goal of the inquiry.

This will put advocacy for women's health at an important time of their lives front and centre.

It also gives us the opportunity to deal with dangerous mis- and disinformation on social and other media. Poor information that holds so many women back from embracing care that can improve their lives, relationships, and work.

Millions of Australian women are looking to this inquiry to put things right. To sweep away healthcare injustices that have had such a cost for so many women over so many years. Let us not miss this opportunity to improve the health of the nation.

The next public health epidemic is here. Can we butt it out?

Tue, 26 Mar 2024 03:57:17 GMT

Originally Published Canberra Times

When federal Health Minister Mark Butler addressed the National Press Club at the beginning of May last year, the centrepiece of his speech was about vaping . The minister committed his government to strong action against the scourge of e-cigarette use.

I was one of the many Australians who applauded the announcement - and his government's stance - and I have stood in solidarity with him since that day.

Indeed, I was one of the large group of doctors and public health experts who worked with the minister to formulate the vaping policy.

The legislation to deal with the health catastrophe that is vaping came before Parliament on Thursday. This represented one of the peak public health initiatives of my professional lifetime. I am backing the legislation all the way. The legislation will be debated at a future date.

How did we get here?

E-cigarettes - nowadays called vapes - were invented 20 years ago, supposedly as a way to help smokers to quit.

They use a heating device to create a vapour that the user inhales.

Helping smokers quit tobacco use is an important goal for doctors, and in Australia there has been a steady decline in tobacco smoking for decades now - but this has required a massive public health effort and tremendous investment.

Unfortunately, any hope that vaping would be good for public health has vanished as more scientific evidence comes to light.

Instead, we have seen recreational vaping explode across the Australian community.

Seeing young Australians - high school and, nowadays, primary school children - addicted to vaping is a personal heartbreak of mine. Australian children are being hooked on the nicotine contained in vapes.

A new generation of young Australians are now addicted to harmful vapes, and this is all for the profit of a few greedy suppliers who will stop at nothing to profit from vulnerable children.

Vapes are flavoured sweetly, presented in packaging specifically aimed at young children.

Vape shops are set up near schools, or made easily available online.

The shameless profiteers who prey on Australian children boast about flouting the rules so they can continue to ply the shameful trade.

Worst of all, after decades of work to help Australians quit tobacco smoking, there is scientific evidence that young Australians who vape are more likely to take up cigarette smoking.

What needs to be done?

Australia has a once-in-a-generation opportunity to deal with a public health crisis - the epidemic of vaping.

The more we learn about vaping, the more health problems we discover.

That is a very bad trend.

The world missed the opportunity to stop tobacco smoking, but we have an opportunity before us to take action on vaping that is world-leading and is supported by all of the key health groups in the country.

The next phase of the government's planned reforms include banning the manufacture of e-cigarettes in this country, and restrictions on the supply, advertising and commercial possession of recreational vapes.

For vapes that are genuinely used to help Australians quit smoking, obtaining a prescription for a properly-regulated e-cigarette that is treated like other medical forms of smoking cessation aids makes good sense.

Big tobacco companies, vaping suppliers, and individuals who seek to profit from addicting Australians to harmful vapes will be protesting loudly, and using every platform they have to resist the reforms.

Ahead of the legislation being introduced to Parliament we were seeing misleading and downright deceitful commentary being put out across the traditional and social media by those who seek to profit from hooking Australians on vapes.

I urge Australia's political leaders to heed the evidence and the advice from your health leaders.

We have a chance to protect young Australians and stop this unhealthy profit-driven scourge.

Let's see this important and world-leading legislation passed so we can truly claim a public health success.

2024 must be the year of the baby

Sun, 24 Mar 2024 03:56:56 GMT

Originally published insightplus.mja.com.au

The “baby bust” must be part of Australia’s political agenda, so we can overcome this existential crisis, write Dr Clare Boothroyd, Dr Katharine Bassett and Professor Steve Robson.

The “baby bust” is a unique and existential crisis, never before encountered in human history. In 2020, fewer than 300 000 babies were born for the first time since 2007, and the total fertility rate (TFR) estimate for the year had fallen to 1.58 babies per woman over the lifetime. This is the lowest TFR in Australia’s history, representing a fall of 56% from the peak in 1961 (when the TFR reached 3.55 babies per woman).

Although a slight rebound in the number of babies born was observed in 2021, perhaps the result of people delaying pregnancy rather than abandoning the idea altogether, the fertility situation again appeared grim with release of the latest 2022 statistics . Australia’s TFR has remained stuck below 1.7 babies per woman since before the coronavirus disease 2019 (COVID-19) pandemic, the longest period in the nation’s history.

These cumulative results rung alarm bells, prompting former Australian federal Treasurer and architect of the “Baby Bonus” initiatives of the early 2000s, Peter Costello, to make a public call for new policy measures to increase Australia’s birth rate.

In the most recent Intergenerational report , released by the Australian Treasury in 2021, the significance of falling birth rates for Australia and its economy was noted but not addressed. The Treasury comments were predicated on concerns that, “for the first time in an intergenerational report, the population projection is being revised down”. An ageing population has a number of well recognised and interrelated effects :

an increased need for social services;
increased demand for health care;
increased demand on pensions;
a reduced labour supply and likely reduced productivity of older participants in the labour market;
a likely reduction in unemployment in the younger members of the population.

As an example of just how high the stakes are, we need only look to Japan, where the twin threats of catastrophically low birth rates and a ballooning elderly population are rapidly coalescing. At the beginning of 2023, Japanese Prime Minister Fumio Kishada told the world “Japan is standing on the verge of whether we can continue to function as a society”.

The factors influencing birth rates

It is tempting to blame the “baby bust” on effects of the COVID-19 pandemic but, in reality, the pre-pandemic year 2019 also had a historical low TFR of 1.66 babies per woman. Indeed, Australia’s birth rate has been in established decline over the decade prior to the COVID-19 pandemic (Figure 1).

Putting this in a global context, the data for fertility rates in Australia are not unique: across the globe, birth rates and resulting TFR estimates have been in decline since the 1960s (Figure 2).

In January 2023, Treasurer, the Hon Jim Chalmers MP, announced unprecedented increases in migration rates , with as many as 300 000 new arrivals expected yearly in the short term, providing a boost in the availability of human capital. Studies suggest that migrants generally have higher TFRs. However, this has not proven to be the case in Australia.

Replacement-level fertility rates will keep a country’s population steady but will not lead to population growth if mortality rates remain unchanged and migration has no effect. Virtually all high income countries now have TFRs well below replacement level ( here ), with population increases dependent upon migration. Migrants generally do not arrive as newborns, so migration-based population increases distort the age distribution of a population with a skew towards older ages, with a resulting increase in the proportion of older people in the population.

Education of women is a significant component. Globally, there is a well recognised negative relationship between a woman’s level of education and the ultimate size of her family. The situation is no different in Australia, where women are investing time, effort and money in increasing their education . That is great news, but it will affect fertility. There is evidence from the United States that the greatest reduction in family size are women from disadvantaged backgrounds who receive tertiary education. Improved education usually makes life better for people, but the trade-off will be further reductions in birth rates. For this reason, increasing the flexibility of educational options will need to be an early and key policy target.

What can be done?

Convincing a large number of women and their partners to have an additional child will be no easy task. Indeed, pro-natal policies introduced in high income countries around the world have had, at best, patchy success. Australia’s own “baby bonus”, a suite of financial incentives for new parents introduced in the mid-2000s, for a short period of time had a modest effect on the birth rate and, importantly, resulted in an increase in a third child being born ( here ). Paid parental leave policies, which Australia has had for over decade now, have been recognised globally as having a positive effect on fertility , at least in the short term. We welcome the Australian Government’s recent announcement of women on maternity leave being paid superannuation , but more needs to be done.

The first step will be moving babies and children up the national priority list. To justify this will require taking the community along on the fertility journey. Unfortunately, most political objectives barely span the electoral cycle. If we are to increase Australia’s population through birth, then a very long term view will be required.

In addition, there needs to be general support to become a family-friendly society. This will mean starting a national conversation about the long term economic importance of having children, supporting current and prospective parents, as well as supporting family members such as grandparents who may have to help in the raising of children. This would have to become our social purpose for the next 25 years.

The most common family size in Australia is two children, yet studies report that the most commonly desired family size is actually three children. Economic incentives to increase birth rates might usefully be targeted at a third child, taking the approach that families might respond to different incentives for a first child as compared to a third or fourth child. The nature of incentives would need to be broad as well, and include support of quality, possibly work-based childcare, afterschool care centres as well as schemes that provide support to university students who wish to parent children.

For better or worse, it is important to understand and accept that the appropriate biological age for women to have children is between 20 and 35 years, and we all need to facilitate sufficient social change to allow this. One way is to encourage egg freezing by the age of 34 years (and earlier if the woman has a low number of eggs), at an age when eggs are healthy . With modern techniques, the freezing of eggs is now effective and should be considered for Medicare funding in Australia. It is quick, safe and inexpensive compared with the consequences of not preserving fertility.

Case studies from around the world demonstrate that there are few low hanging fruits left, and no easy answers. The “baby bust” is a unique and existential crisis, never before encountered in human history. To overcome it, we will need to be adaptive and insightful. Let us pool our resources to find the best solutions so we do not follow the course of some other countries. Let us make this part of our political agenda.

Dr Clare Boothroyd is a female fertility specialist and obstetrician gynaecologist in Brisbane and the President of the Asia Pacific Initiative in Reproduction.

Dr Katharine Bassett holds a PhD from the Australian National University and conducts research focused on health system reform.

Professor Steve Robson is an obstetrician gynaecologist in Canberra.

What does the future look like for COVID-19?

Sun, 14 Jan 2024 03:56:32 GMT

Originally Published Canberra Times

In 2024, the world at the threshold of its fifth year dealing with the COVID-19 pandemic, and the holiday season has coincided with the eighth major wave of infections.

Most infections now are due to the globally dominant JN.1 type of virus. Its new variant - BA.2.86 - known as "Pirola" seems to infect the deep lung tissues with great efficiency just as the early, pre-Omicron, strains did.

As we experienced with the Omicron variant, these new strains have appeared in our communities unexpectedly and rapidly, and have spread quickly causing the current wave of infections.

As a result, hospitalisations required for COVID treatment continue to stress our hospitals, just at the time when health resources are at their thinnest.

To make matters worse, a study published in the prestigious medical journal The Lancet last week confirmed that long COVID could persist for up to two years and has potentially adverse health effects for many people who have suffered infections.

With information about test results - RAT swabs taken at home, or formal PCR tests through pathology laboratories - now unavailable, it is difficult to make assess just how common COVID infections are.

The results of wastewater testing, however, suggest that infection is widespread.

Many deaths are still occurring, with the Actuaries Institute estimating that 20,000 more Australians died in 2022 that would have lost their lives if there was no pandemic.

These excess deaths were still occurring in the first half of 2023.

Most of those who have succumbed are older and vulnerable Australians.

The cost of anti-viral medications for vulnerable Australians is approaching a billion dollars.

That is money that could well be spent on other areas of our stretched health system were it not for the pandemic.

With this gloomy news, many of us are asking - where do we go from here? What does the future hold for the COVID pandemic, and is there anything we can do about it?

While it seems very unlikely that COVID will disappear, at least any time soon, the good news is that there is plenty we can do to protect our health and reduce the effects of the virus on the most vulnerable Australians.

The first thing is to make sure that as many Australians as possible are up-to-date with their COVID vaccinations.

For various reasons, perhaps most importantly "vaccine fatigue", rates of vaccination boosters are dismal at the moment.

Indeed, mis- and deliberate disinformation about vaccination has been peddled to the community and this is undoubtedly affecting uptake, not only of COVID vaccines but others too.

This could well be part of the reason that countries like Australia are seeing cases of polio and measles, diseases which doctors like me had thought eradicated long ago.

COVID can have long term effects on the lungs, heart, brain, kidneys and blood vessels so protection from serious infection makes very good sense for all of us.

The newer COVID vaccines have been available to Australians since mid-December, so checking if you're eligible for a booster should be a high priority for all of us.

If you are vulnerable and catch COVID, then seek urgent treatment with anti-viral tablets.

Australian researchers have shown that timely treatment with antivirals in older Australians reduces the chance of requiring hospitalisation or dying.

What more can we do, though, to protect ourselves and - importantly - the millions of vulnerable Australians who are most likely to be harmed by COVID infection?

It seems very unlikely that an elimination approach to COVID could work now.

There is little evidence for the political will for a massive international effort such as occurred to deal with polio and smallpox.

However, control strategies can be very effective if used properly.

Beyond vaccination, these include the use of masks in crowds, sensible and practical social distancing, and ongoing education programs.

More broadly, our community needs to think carefully about increasing our resilience not only to COVID but to other serious infections such as influenza, RSV, and other respiratory viruses.

One area in which there is enormous scope for improvement is in the ventilation and airflow in our workplaces, social spaces, and homes.

This could well have an enormous pay-off for our health in the long term.

Since workplaces are very common sites for transmission looking at work-from-home options where practical for the obviously sick, and simply building a culture where people don't come to work if they're sick and risk infecting others.

For many vulnerable Australians, these infection-safe work options are not available.

Ensuring that those at disadvantage don't feel they have to come to work for financial reasons if they're infectious should be a priority for society.

None of us want to be having the same conversation about COVID in January of 2025. To avoid that, our community needs to come together now and make 2024 the year we all saw off the pandemic.

How your healthcare is about to change, and change dramatically

Fri, 05 Jan 2024 03:56:08 GMT

Originally published Canberra Times

Artificial intelligence will begin to have a dramatic impact on healthcare and health services in 2024 - but will it make things better or worse?

We are about to see the start of a quiet revolution that will, in the long run, be almost as transformative as the introduction of technologies such as antibiotics, blood banking and safe anaesthesia.

The rollout of AI as a routine part of medical care has the potential to deliver mind-blowing innovation in healthcare in Australia.

It has the potential to be transformative for patients, doctors, other health professionals and the whole economy.

Every Australian who has seen a doctor or been treated in a hospital will already have experienced the role that computers and information technology play in their care.

Patients in hospitals will be used to seeing staff pushing computers on wheels around and typing information into these systems as care is provided.

Yet the vast majority of software used in these settings has a very limited role in guiding treatment decisions.

That is about to change, and change dramatically.

Moving past the role of simply acting as a repository of information about patients, AI will begin to assist with the diagnosis and - importantly - the types of treatments offered to patients.

This will be just as big a culture shock for doctors as it will be for their patients. The most advanced AI that most doctors use at the moment is often Siri, or their Netflix preference guides.

The first doctors to embrace the potential of AI have been the radiologists who specialise in reading our x-rays, ultrasounds and MRI scans.

For several years now, AI software applications have been introduced to assist with image recognition and, increasingly, with decision-support.

Interpreting X-rays and other medical scans can be challenging for even the most experienced specialists, and the stakes are high.

Missing an important diagnosis, such as an early cancer or a subtle bone fracture, can have serious consequences for patients.

The use of AI to assist radiologists as they work to read multiple images has been shown to enhance accuracy and improve outcomes for patients. There is, however, an important drawback that has major implications for patients.

AI is so powerful in its capabilities that it may detect subtle changes in human tissues that elude the human eye. It has the potential to detect changes in brain structure long before any disease becomes evident, or even is suspected.

This situation has the potential to lead to several possible consequences.

What happens when AI unearths subtle changes that may not ever cause significant health problems, such as neurological diseases?

Some medical journals are now warning that this situation has enormous potential to cause distress and ongoing concern for patients and could lead to further unnecessary tests or even surgery.

Another area where AI has enormous potential to improve patient care is in pathology. An excellent example is the diagnosis of cancers by specialist pathologists.

Accurate interpretation of cancers under the microscope is the cornerstone of modern cancer care.

AI technologies have the potential to improve the precision and accuracy of such a diagnosis, and to pave the way for bespoke cancer treatments that reflect subtle patterns in the architecture of cells in a cancer.

At a time when the pathology workforce is under great pressure, the introduction of AI technologies that act as a co-pilot and assist the pathologist in dealing with high workloads will be attractive to health services.

But it will be vital to harness the potential power of AI in a way that does not introduce diagnostic confusion or uncertainty.

We must also ensure that processes are in place to confirm that the AI technology is actually improving care, not just adding to its complexity.

AI applications will be introduced across the health system to both improve patient care and to compensate for healthcare worker shortages. It will be vital that the cure is not worse that the disease, though.

The introduction of clinical decision support systems - where AI systems tell healthcare workers how to treat patients - is likely to be rapid from this point forward.

There is no doubt that, in a time when the pressures on our health system are unprecedented, help will be welcome.

As this rollout of AI technology occurs, it may not be visible to patients receiving care or, indeed, to the doctors, nurses and healthcare workers being directed by computer.

For this reason, the community must have trust in the systems and processes that we have in place to monitor just how well AI is achieving these aims.

At a time when the demands on our health system are overwhelming, the system is under-resourced, and staff are under more pressure than ever, the lure of AI to solve these problems will be irresistible.

The AI revolution is upon us and gathering momentum at an extraordinary pace.

If we are to harness its power for the greatest good, then we need to ensure it is a safe and trustworthy co-pilot in human health care, and never takes over the controls.

It is going to be an exciting ride.

Hot summer predictions show climate change risks

Mon, 11 Sep 2023 04:55:44 GMT

Originally published insightplus.mja.com.au

With a hot summer expected in Australia, only global action by governments can achieve the society-level change required to tackle climate change.

After an unusually warm winter , many of us are approaching summer with some concern as we face what is likely to be another El Niño season . The news from the northern hemisphere’s summer has been grim and difficult to watch. Terrifying wildfires raced across the tropical Hawaiian island of Maui, razing the historic tourist city of Lahaina and taking dozens of lives in unprecedented and horrific scenes. Much of the north-eastern United States was blanketed in toxic levels of smoke from Canadian wildfires, while Mediterranean countries such as Greece faced punishing heatwaves and battled fires threatening towns and popular tourist destinations ( here ).

For many Australians, the disasters unfolding in North America and Europe — not only fires but floods — have triggered distressing memories of Australia’s own recent “ Black Summer ” and subsequent flood events . These compounding and consecutive environmental disasters have been unprecedented in their scale and impact, leading to staggering economic losses for the country. After three years of La Niña conditions that halted preventive burning and led to prolific growth of bush and grasslands, predictions are that this summer will bring a strong risk of bush and grass fires, as has occurred after every previous triple La Niña.

The recent environmental catastrophes in Australia and elsewhere have been described as unprecedented and that, certainly, is true, but they are not unexpected. Indeed, the observed pattern of increasingly severe climate-related natural disasters was predicted by economist Professor Ross Garnaut almost 20 years ago . The narrative that recent events are merely a reflection of a pattern of bushfires that is normal for Australia is contradicted by the evidence . The bad news is that climate change is predicted to make everything worse; that Australians should expect more frequent, more severe, and less predictable natural disasters .

Putting aside the extraordinary economic effects of climate-related natural disasters — including the potentially bankrupting effects on the insurance industry — the immediate human cost falls not only on those in the path of fire and flood, but directly on the emergency services and recovery teams who battle to protect and care for us all. As fires and other climate-related natural disasters inflict more damage in Australia and globally, the effects on firefighters and other frontline workers will only intensify. The report from Australia’s 2020 Royal Commission into National Natural Disaster Arrangements concluded that, among many other concerns, “the increasing complexity of disaster risks presents new challenges that have the potential to overwhelm the capabilities of our fire and emergency services”. The more recent Strategic Defence Review described how the increasing use of Australian Defence Force assets in disaster response cannot be sustained and is degrading our defence capabilities.

Health care workers and emergency management personnel are used to working closely together. In a country such as Australia, it is likely that climate change will play out with a series of health crises . The Australian health system — and its workforce — have been challenged by the stress of the coronavirus disease 2019 (COVID-19) pandemic on an already stretched and underfunded system. Providing an adequate health workforce is difficult enough as things stand, without the inevitable further addition of stress as the health ill-effects of climate change play out. In concert with greater and greater demands being placed on all our emergency response and recovery services , parallel demands will be placed on Australia’s fragile health system .

In response to national responses — or the lack of — to climate change, former leaders from every Australian fire service, from Emergency Management Australia, and some State Emergency Services (SES), forestry, and national parks agencies, set up the group Emergency Leaders for Climate Action before the Black Summer bushfires. They warned the government of an approaching bushfire disaster and measures that should have been taken to prepare. They continue to lobby for more action on the underlying problem, greenhouse gas emissions, as well as the need for a massive funding boost for climate change adaptation. Their success shows that expert commentary can positively influence the national picture and political landscape, including community understanding.

There are competing narratives on Australia’s response to the effects of greenhouse gas emissions. However, Australia is in a position to demonstrate strong leadership to the global community: this has been demanded by our Pacific neighbours . Unfortunately, our policy and other responses to emissions and resulting climate change are shaped not by science or a sense of ethical responsibility to the next generation, but largely by politics . Polling suggests that people want climate action in Europe , the United States and Australia , yet politicians have found to their cost that trying to introduce pro-environmental policies has the potential to lead to an electoral backlash . Indeed, the United States’ Brookings Institute has described curbing emissions as “the toughest, most intractable political issue we, as a society, have ever faced” . Here in Australia the situation is similar: most people agree that climate change is an important issue, but few state that they are willing to make the “major personal sacrifices” necessary to effect change.

As frightening climate records continue to fall around the world, and the prospect of large parts of the world becoming uninhabitable become more real, it is clear that strong leadership is vital if we are to at least stabilise the situation. It is unlikely that any actions we take will reverse the effects of climate change, certainly in our lifetimes , but trying to prevent the worst case outcomes must be our highest priority.

What does this leadership look like? Leadership is about understanding and acknowledging the issues and using personal and organisational influence and credibility to take society along on the journey. This will require major cultural change for our community , so transparency is critical. As we watch more and more climate disasters unfold, we need to inform and help the community to understand that climate adaptation is an urgent priority, with the limits of our emergency management capabilities already being overwhelmed by extreme, compounding weather events.

The emergency management and health sectors are among the most trusted groups in our community .

We must repay that trust by putting the interests of our community first and ensure that sustainability and environmental responsibility are at the heart of our culture, in the way that safety currently is embedded in the work of emergency services and health care. Trusted voices can inform, can inspire, and can set the examples through action. Australians know that, when things go wrong, our emergency service and health care workers will always step up to protect them. We need to scale this up to make our mission one of protecting the whole community and, indeed, future generations.

Estimates suggest that the health care sector contributes as much as 7% of Australia’s domestic greenhouse gas emissions . Although Australia’s onshore domestic emission of greenhouse gases contribute less than 2% of the global output, it is important to remember that our export products are significant contributors to greenhouse gas emissions in other parts of the world. If voices from the health care sector are to have credibility when calling for climate action, then it is important that we take steps to reduce the emissions created during our work.

This is easy to say but, in practice, not so easy to achieve. Already a great deal of work has been done to guide the major redesign that will be necessary to prepare health care for a low carbon future. The system changes necessary for greening health care will include a strategy to deal with low value health care , greening health activities with a large carbon footprint such as surgery , and reducing greenhouse gas emissions with virtual consultations . These actions demonstrate that the health sector is fundamental to the fight against the climate crisis ( here and here ), and we urge our medical community colleagues to continue to take an active role in this effort.

Nobody should be surprised that leaders from emergency management and health care sectors are calling for urgent climate action. We stand among the groups who have the responsibility of dealing with the consequences of unchecked global warming: heatwaves, droughts, fires, floods and diseases. A recent protest by paediatricians about fracking in the Beetaloo Basin makes perfect sense: children are disproportionately vulnerable to the health effects of climate change.

There are worrying signs that climate change is accelerating at a pace greater than anticipated . These changes will affect all of us and, importantly, our children and their children. The worst case scenarios are terrifying and, almost certainly, would be irreparable. The actions we take now must be large, decisive, and urgent.

Although it is important that each of us strive to make our lives and work sustainable, only global action by governments can achieve the society-level change required to wrest control and protect all of us.

Working with political leaders — a group, rightly or wrongly, considered among the least trustworthy — to build credibility and help our community on the journey to global sustainability is now a clear obligation for emergency management and health care workers.

As Ban Ki-moon, the former Secretary-General of the United Nations who convened the 2007 Climate Change Summit, wrote :

“What we do not have is time … Our earth is more fragile than we might think … and the effects are being felt most acutely by those least able to cope and least responsible for the problem. This is a moral issue … a defining moment. We all have [a] historical responsibility to future generations. Our grandchildren will be our judges.”

Professor Steve Robson is the President of the Australian Medical Association.

Greg Mullins AO AFSM is an Australian firefighter, a former Commissioner of Fire and Rescue New South Wales, a climate councillor with the Climate Council and a founding member of Emergency Leaders for Climate Action.

David Templeman AM is a former Director-General of Emergency Management Australia, the President of Public Health Association of Australia and founding member of the Emergency Leaders for Climate Action.

Will the pandemic have an effect on men’s fertility in the long term?

Fri, 23 Jun 2023 03:18:52 GMT

Although it is always difficult to provide an exact figure, the proportion of couples who experience a fertility delay is likely to be high.

Recent, pre-pandemic, estimates suggest that as many as one in nine couples will experience infertility. It is also commonly reported that men’s fertility issues contribute to about half of all diagnoses of infertility. These findings are not confined to high-income countries - male infertility is recognized as a health issue globally .

Although the evidence initially was contentious, recent reviews have confirmed that there has been a gradual decline in semen parameters globally over the last few decades. While a sperm concentration of about 15 million/mL is accepted as the lower limit of normal in a semen analysis, there is good evidence that the fertility potential of sperm begins to fall with concentrations well about this level .

The pandemic initially saw a significant reduction in birth rates across the world. While there has been some evidence of a ‘ baby bounce ’ after the first wave of the pandemic, the longer term trend is fertility is gloomy with birth rates dropping across the world.

Before the pandemic it was clear that the use of technologies such as IVF was increasing, with a major trend to IVF conception in countries like Australia. Are there reasons to be concerned that the COVID-19 pandemic could affect the family plans of Australians?

In the first instance, there has been a large amount of anti-vaccine propaganda circulated on social media. It can be difficult for people without scientific training to understand and interpret mis- and disinformation that crops up in their social media feeds. Fortunately, the news about COVID-19 vaccination and Systematic reviews have been unequivocal – there is no adverse effect of vaccination against COVID-19 on men’s fertility . That is very reassuring news.

The information we have about COVID-19 infection and men’s fertility is not so good, however - I’d like to run you through that

The COVID-19 virus enters human cells by interacting with angiotension converting enzyme 2 (ACE-2) receptors. Cells that express the ACE2 receptors are very vulnerable to infection with the virus. There are a number of cells, organs, and tissues – including the lungs and blood vessels – that carry high numbers of receptors.

The hormones that control and regulate sperm production in men originate in the hypothalamus and anterior pituitary gland. COVID infection has been identified in the pituitary gland and hypothalamus . It shouldn’t be surprising, then, to find that men recovering from infection have alterations in pituitary hormones such as luteinizing hormone (LH) and the hormone LH stimulates production of – testosterone.

While there is the potential for COVID infection to cause transient changes in a man’s hormonal status, is there any evidence for more direct effects on fertility?

Well, yes. Studies suggest that sperm parameters in men who have recovered from COVID infection are lower than men who were not infected. Indeed, in studies in which testicular tissue could be examined , investigators have found that coronaviruses are associated with inflammation of the sperm-manufacturing cells in the testes – a situation that has potential for long-term damage. This is the mechanism by which mumps can cause sterility in men.

It seems that we have evidence that COVID infection involves the glandular and hormonal controls of sperm production and fertility in men. We also have direct evidence that the virus infects the testes – indeed, the testes have been found to have high levels of ACE2 receptors .

How could we tell if the pandemic was affecting men’s fertility? It is a notoriously difficult question to answer – being able to discern people’s intentions obviously is impossible. However, we can find clues if we know where to look.

One possible example is the uptake of sperm testing. If men’s fertility was being affected across the population, then we would expect to see a greater number of couples seeking evaluation for infertility. The primary test of male fertility is the semen analysis . On possible signal that male fertility problems are resulting from COVID infection at a population level would be a persistent rise in the number of sperm tests being performed around the country.

The hypothesis that fertility problems are more common since the pandemic – and have resulted in a greater need to perform sperm tests – is easy to test. Virtually all diagnostic sperm tests performed in Australia are billed through Medicare. It is possible to monitor Medicare billing in close to real time by searching the Services Australia website .

I have downloaded data from the main Australian states – and excluded Western Australia as the hard border protected the population from the pandemic for a long time – to assess the number of sperm tests performed prior to, during, and after the acute medical disruptions of major waves. Interestingly, and discounting the disruption caused during lockdowns and the major initial pre-vaccination waves, the raw number of sperm tests performed since the start of 2022 is higher that the pre-pandemic period, and shows a steeper upward trend.

These are early days and Medicare billing data are, at best, a crude way of looking at a complex clinical phenomenon. However, there is enough of a signal in these data to suggest that we need to watch closely. In particular, while a man who had healthy sperm production is very unlikely to have been rendered infertility by COVID infection, there are many men with borderline sperm parameters. The physiological insult of COVID infection and its selective effect on sperm production could potentially be enough to tip that man into true physiological infertility.

It may well take several years to form a true and interpretable picture of the effect of the pandemic on the men of Australia and their fertility. However, it seems that we have a physiological basis to be concerned and there already is a signal in the data that is consistent with a population-wide effect on men’s fertility.

I will be watching very closely.

Chronic health conditions and our relationships – some thoughts.

Sun, 18 Jun 2023 23:24:39 GMT

Last week, I had the privilege of addressing the National Press Club. While the essence of the talk addressed how keeping people healthy is good for the economy, I spoke quite a bit about chronic disease and how common it is.

Last week, I had the privilege of addressing the National Press Club. While the essence of the talk addressed how keeping people healthy is good for the economy, I spoke quite a bit about chronic disease and how common it is.

The Australian Institute of Health and Welfare (AIHW) estimates that half of all Australians have at least one chronic health condition . In anyone’s book, that is an enormous amount of ill health. The amount of money spent on health care for chronic conditions in Australia is estimated to be close to $40 billion annually .

Chronic disease affects the Australian economy both through the direct costs of treating the conditions, and also through the lost productivity of people unable to work or contribute to the economy in other ways . Indeed, some reports include frightening conclusions such as, “the burden of chronic disease in Australia threatens to overwhelm the health budget, the capacity of health services and the health workforce.”

The AIHW delves, in particular, into ten common and important chronic health conditions: arthritis , asthma , back pain , cancer , cardiovascular disease , chronic obstructive lung disease , diabetes , chronic kidney disease , mental health conditions , and osteoporosis . These are not the only chronic health problems but represent some important ones for Australians.

While there certainly is a place for thinking about the effort and cost that goes into treating these conditions, I often think about the effect chronic health conditions have on our relationships. Human relationships are pivotal to our wellbeing and self-esteem. Facing health challenges without healthy relationships can make everything so much worse.

American psychotherapist Katie Willard Virant puts it like this :

“Illness challenges relationships. It’s no wonder that many wedding vows contain a promise to love one another “in sickness and in health.” Chronic illness affects, not only the person bearing the symptoms, but also the person loving them, living with them, and caring for them. As one partner expressed to me, ‘My wife lives with the illness, and I live with her. So, in a way, I live with the illness, too.’”

In many cases, the partners and family members of people affected by chronic illness also face many challenges themselves . The potential effects of a chronic illness on a person’s family and carers has long been recognised , but seldom figures in our discourse:

“In the past, quality of life studies focused almost exclusively on changes in the quality of life of patients, but increasing attention is now being paid to the impact of chronic disease on carers. The ageing of the population and changes in medical practice resulting in shorter inpatient hospital stay and longer survival have substantially increased the burdens on carers, most of whom are partners.”

Chronic mental health problems, in particular, can place a heavy burden on family and romantic relationships. This is a factor that is difficult to capture when we discuss the effects of chronic health problems on people. Many chronic conditions – cancer being another important example - can affect the relationships that are important for us to nurture for our wellbeing.

So, when I spoke about the ‘burden’ of chronic disease for Australians, remember that it was difficult to capture the richness of our lives and how important they are for our wellbeing. Rest assured, though, I hope that all of us are thinking beyond the disease and the dollar and we consider the true scope of what it means to be healthy.

Counting the cost of online gambling

Mon, 03 Apr 2023 00:36:22 GMT

Problem gambling has a compounding cost not just for individuals but also for their families and their communities, write Professor Steve Robson and Associate Professor Jeffrey Looi.

Australians have long been recognised as the world’s biggest losers – in terms of gambling.

The Australian Institute of Health and Welfare (AIHW) has reported that Australians lose around $25 billion each year from legal gambling.

That equates to annual per capita losses of close to $1500 each year. From the industry itself : “When it comes to gambling on an individual scale, Aussies’ currently lead the way. In 2014, Australians gambled over $916 per person, with Singaporeans coming a close second on $891.16. Singapore only recently legalized casino gambling, and the per-head spend isn’t a surprise”.

Gambling expenditure per person is the highest in New South Wales , with $1508 spent on gambling per capita in 2019–20.

Whereas individual Australians are the clear “winners” in the global stakes for the biggest gambling losers, our state and territory governments are living off the ill-gotten proceeds, raising around $6.6 billion in 2018–19 .

Despite the coronavirus disease 2019 (COVID-19) pandemic putting a dent in gambling activity, Australians bet around $175 billion in the financial year 2019–20 — before the pandemic, that figure was well over $200 billion a year.

It’s clear that Australians like a bet, but traditional ways of gambling in person are substantially disrupted by online gambling.

The amount spent through internet-based gambling in 2022 was estimated to be close to $7 billion (US$4.5 billion), and ongoing profitability may contribute to advice to investors to consider shares in the gambling industry.

Estimates suggest that as many as one in ten Australians participated in online gambling in 2022, an increase from 8% in 2020.

In the privacy of your own home

Australia has one of the most “normalised” gambling environments in the world, with socially and culturally valued organisations endorsing gambling, such as pubs, clubs, sporting teams and codes.

However, due to the COVID-19 pandemic, online gambling has become firmly established in Australia.

Gambling online seems to pose much greater risks for problem behaviours due to a number of unique factors.

Online gambling is commonly done in isolation, without interruption, and access is constant and easy.

The design of websites and smartphone applications influences behaviour through push notifications of time-limited promotional offers, or the elimination of natural breaks in play, or nudge messages (eg, “people like you bet on …”).

There are also potentially new gateways for young people to be encouraged to gamble online, such as the controversial practice of “pay-to-play” online video-gaming involving microtransactions to progress levels or achievements and the inclusion of features such as “loot boxes” . These “loot boxes” were the subject of an Italian study that hypothesised that their inclusion in video games may result in problem gambling.

Harm

There is overwhelming evidence that, for many people, gambling is harmful , not only to individuals but potentially to their loved ones and others around them.

These harms form a spectrum , ranging from mildly negative experiences to full-blown crises, some of which can leave a legacy of ill-effects for years.

There also the substantial opportunity costs to work, personal interactions, personal development and life experiences due to time consumed by gambling instead of more holistic living.

Problem gambling can hurt an individual’s relationships .

The partners and family members of people with gambling problems can be involved in financial and material losses.

Relationships with people affected by problem gambling can be characterised by psychological and social stresses, conflict both in home life and other relationships, and by having to fulfill roles and responsibilities neglected by the affected partner.

Problem gambling is associated with health effects including depression, sleep disorders, even hypertension and cardiovascular disorders.

Beyond the physical, problem gambling is associated with mental health conditions such as depression and anxiety .

It is now recognised that people with gambling problems pose harm to themselves and others in the workplace : they can be distracted, with lower productivity and resulting safety risk-proneness.

Dealing with the health issues of online gambling

Although most Australians gamble at levels unlikely to lead to any harms, there is still a strong uptake, with estimates that almost 7 million Australians gamble regularly in some form or another.

Of those, the AIHW has estimated that 1.33 million Australians, just over 7% of the population, gamble at levels that are potentially harmful – that is a very large number of Australians.

Data from the Productivity Commission suggest that as many as 170 000 Australians are problems gamblers.

Because online gambling has the potential to ensnare a new generation of people, the Australian Government is completing an inquiry into online gambling and its impacts on those experiencing gambling harm.

The inquiry has received almost 150 submissions, including one from the Australian Medical Association and a joint submission from the Royal Australasian College of Physicians and the Royal Australian and New Zealand College of Psychiatrists.

One of us (Stephen Robson) gave evidence to the inquiry in Canberra recently.

The data tell us that Australians have a big issue with gambling , and because governments and gambling providers make such enormous amounts of money from gambling, reform is not going to be easy.

This is especially so now that sports and gambling are becoming intertwined.

There are increasing concerns about how gambling advertising affects young people who are exposed to it during sporting events.

As David Gallant and Sean Cowlishaw from the University of Melbourne warn us: “… the gambling industry in Australia today is now so connected to our sport that it’s now almost impossible to enjoy a sporting event without being exposed to gambling”.

Gambling advertising has become synonymous with sport.

To deal with this threat to Australians, particularly the new generation of young Australians who seem to be taking up online gambling — increasingly via online gaming — urgent action is needed.

The data tell us that many Australians are potentially affected, making awareness of our patients’ gambling important to screen for. Excellent screening resources have been developed for Australian settings and are readily available.

New resources will need to be developed to support young people with online video-gaming-related gambling gateways such as pay-to-play microtransactions and loot boxes, as well as limiting excessive play and spending.

In Belgium and the Netherlands , and more broadly in the European Union, there have been legislative measures to protect young people in relation to online video-gaming, such as the outlawing of loot boxes as illegal gambling.

More importantly, dealing with the root causes of online gambling is the key to protect our community in the long term.

One of the major issues is advertising and the linking of gambling with sport.

We support the Australian Medical Association’s call for bans on these forms of advertising and sponsorship because of the effects these corrosive practices can have on the next generation of Australians.

There also needs to be similar awareness and, potentially, regulation of gambling-gateway features of online video games that target players, especially children and youth.

With the current parliamentary inquiry, we have an opportunity to wrest back the initiative when it comes to protecting Australians.

Gambling is always a losing hand for individuals and the community.

It won’t be a “lay down misère”, but without doubt it is the right thing to do.

Depressionomics? Win for mental health investments

Sun, 19 Feb 2023 23:16:00 GMT

Investing in mental health care will pay off for the Australian economy, write Australian Medical Association President Steve Robson and Australian National University Associate Professor Jeffrey Looi.

Just over two years ago, the Australian Productivity Commission’s report into mental health was released to the public.

The report had been instigated by then federal Treasurer Josh Frydenberg, giving terms of reference directing the Commission to: “consider the role of mental health in supporting economic participation, enhancing productivity and economic growth. It should make recommendations, as necessary, to improve population mental health, so as to realise economic and social participation and productivity benefits over the long term.”

Implicit in the task, then, was the fact that mental health has an important effect on the economy and that community-wide improvement in mental health had the potential to benefit everyone — whether they have mental health problems or not — through an improved economy.

How do mental health issues affect the economy?

Estimating the effect of mental health conditions across the community — beyond the direct costs of diagnosing and managing individuals — presents challenges.

There are three common approaches to making this type of economic estimate: the human capital approach, the economic growth approach, and the value of statistical life approach. Such analyses aim to account not only for the hidden costs of mental health conditions, but on broader effects on the economy as a whole.

Studies that have used these approaches estimate that the broader costs to the economy of mental health conditions dwarf the direct costs of treating the disease for the individual. The Productivity Commission report calculated the cost to the Australian economy of between $40 billion and $70 billion each year.

Systematic reviews of the direct and indirect costs of mental health conditions at a global level paint a picture confirming the economic burden of common mental health conditions .

How can mental health problems have such an enormous effect on the economy?

Beyond the direct costs of providing care to individual patients, people affected by chronic or severe mental health conditions are less likely to work in higher paid jobs, or to work at all. This means that they buy fewer things, pay less tax, take fewer holidays or travel, and spend less into the economy. They are also more likely to require financial assistance to live their lives, such as through social security benefits and the National Disability Insurance Scheme.

Providing care for people with mental health conditions has an obvious human benefit. Mental health conditions can cause great distress and debility for those affected, and for family and friends who love and care for them. There are overwhelming compassionate reasons to treat mental health conditions to help alleviate suffering. Yet for those who are not directly involved and who take an economic approach , providing effective treatment for mental health conditions makes good sense.

Mental health conditions are common

Data from the Australian Institute of Health and Welfare (AIHW) reveal that as many as one in five Australians will have had a mental health condition each year. Fortunately, most of these conditions will be relatively mild and self-limiting. However, close to 800 000 people will have a severe mental illness. To put these figures in perspective, mental health conditions represent about 13% of the total burden of disease in Australia, behind only cancer, musculoskeletal conditions and cardiovascular diseases.

Although it is difficult to make accurate assessments, data from the AIHW confirm that the coronavirus disease 2019 (COVID-19) pandemic has increased the burden of mental health conditions across the Australian community. This trend is global and, importantly, pandemic measures such as lockdowns have been found to have a disproportionate effect on women and those at disadvantage .

Since the ongoing COVID-19 pandemic has had adverse effects both on the fiscal position of the government and the mental health of people in the community, it would seem prudent to improve treatment of those with mental health conditions not only to make lives better for those directly affected but as a way of boosting the government financial position overall. So, if we are going to accomplish this, and spend money on addressing mental health needs, where is expenditure most likely to have an effect?

Three key innovations for a sustainable mental health care system that
meets the needs of Australians

There is a need to address the burden of disease measured as years of life lost to disease and injury (ie, disability-adjusted life years), and the five chronic disease groups that are the main burden identified by the AIHW in 2022 were cancer (17%), musculoskeletal conditions (13%), cardiovascular diseases (12%), mental health conditions and substance use disorders (12%) and neurological conditions (8%).

Of the individual diseases, the leading burdens were from coronary heart disease (5.5%), dementia (4.4%), back pain and problems (4.2%), chronic obstructive pulmonary disease (3.7%) and anxiety disorders (2.9%). Due to the pandemic, there was a considerable burden because of COVID-19 .

Across the lifespan, there is prominence of the burden of mental health and substance misuse conditions , especially in children (five to 14 years), youth (15–24 years) and mature adults (25–44 years), with anxiety disorders ranked first or second for females, and anxiety and suicide or self-related injuries ranked first or second for males in these age ranges. For older men and women (aged over 65 years), dementia is first or second.

Matching the initiatives to these needs requires strengthening and innovation for mental health care, founded on several key innovations. First, there is an urgent need to reinstate the federal and state funding of acute hospital services. By clearing the hospital logjam , the capacity to improve the emergency department flow and bed access should increase, improving the experience of acute mental health care for patients with mental health conditions and substance use disorders. Currently, patients with severe illness experience difficulty accessing emergency care and inpatient treatment. Improvements in acute hospital care will also flow through to enhance the effectiveness of public community mental health care .

Second, suicide not only has an extraordinary effect on Australians but is estimated to cost the Australian economy close to $2 billion each year . The prevention of suicide remains an enormous challenge, although economic and social support s have been demonstrated as important factors, and improving the quality of acute hospital and community care will underpin emergency responses.

Third, modernising Medicare around general practice by innovation in the co-location of allied health staff, such as psychologists, occupational therapists and social workers, and streamlining shared care with psychiatrists in public and private sectors, through specific purpose-built liaison services hosted in general practice and public sector services, will enhance early intervention at the point of first consultation in general practice.

In exactly the same way, there should be targeted initiatives to diagnose and treat anxiety disorders in youth and mature adults through general practice that is supported with access to specialised psychological therapy for anxiety and related disorders, including by psychologists, psychiatrists and allied health professionals in shared care.

Lastly, providing general practice-led multidisciplinary care for people with dementia is necessary to address both their physical and mental health needs. GPs will need support in relation to diagnostic assessment, treatment planning, and ongoing consultative advice on management of complications of dementia (behavioural and psychological symptoms etc) from geriatric medicine, old age psychiatry and other specialised in-reach support services for outpatient, community and residential aged care facilities.

Similarly, strengthening the private health care system by preserving patient and doctor choice of treatment and venue of care will complementarily support public mental health services, as private services provide the majority of inpatient care for severe anxiety and mood conditions and substance misuse disorders.

There has been relative stasis of public hospital bed numbers across all Australian states, while there has been a relative increase in private hospital bed over time. Therefore, if there is not an increase for beds overall, as a result of expansion in the private sector, psychiatric bed capacity overall declines and remains below international benchmarks for the number of beds per 100 000 population for high income countries. This can contribute to hospital access blocks , as there are short lengths of stay that may potentially mitigate against full recovery for safe discharge of patients to follow-up community care.

As things stand, mental health conditions — both acute and chronic — have an enormous impact on the Australian economy. Government investment in evidence-based targeted programs has the potential to deliver a significant economic payoff at a time when governments at all levels are facing major funding challenges.

The evidence is already pointing us in the right direction — 2023 should be the time for action.

Who’s afraid of the deficit? What it means for health care

Mon, 14 Jun 2021 00:29:06 GMT

TO say that the COVID-19 pandemic has had a major effect on the Australian economy is quite an understatement.

Despite the fact that, in global terms, Australia has weathered the pandemic relatively well to date and has seen strong recovery in recent months , the pandemic drove a record contraction in gross domestic product (GDP ) in Australia as elsewhere. The International Monetary Fund warns that, “ there can be no lasting end to the economic crisis without an end to the health crisis ,” while governments around the world (Australia’s included) have clearly concluded that high levels of spending and consequent deficits cannot yet be wound back.

The federal Budget, delivered in May 2021, revealed that the Commonwealth government will preside over a decade of deficits and debt set to peak at almost $1 trillion in 2025 .

This change in economic outlook is all the more startling considering the fact that, only months before the first reported cases of COVID-19 filtered out of China, Australia was on track to have an “essentially balanced budget” . The Sydney Morning Herald’s senior economic correspondent, Shane Wright, captured these concerns succinctly :

“The pandemic’s devastation of the nation’s finances will be laid bare … revealing huge levels of debt over the next 40 years … [and] a ramp-up in spending in areas such as aged care and health.”

Despite – indeed, because of – the sheer scale of unavoidable spending within the latest federal Budget, some within government are already looking ahead to the need to rein in public spending once Australia is out of the crisis. These voices echo a long-standing line of argument that queries whether continuous increases in health expenditure can be sustained indefinitely. For example, in the year before COVID-19 struck, there was a broad media narrative in the UK that the National Health Service (NHS) was about to become, if not already, “bankrupt” . The narrative was almost identical in the US: Federal Reserve Chair Jerome Powell, testifying before the US Senate Banking Committee in February of 2019, warned that “the US federal government is on an unsustainable fiscal path … The thing that drives our single unsustainability is health care spending”.

Even here in Australia, the long term sustainability of health expenditure has been a subject of deep concern for some time. Five years ago, the amount of money spent on health in Australia exceeded 10% of our GDP for the first time, reaching $195.7 billion by 2018 . That milestone provoked strong reactions: some health economists warned that state and federal governments needed to act urgently to avoid a spending and funding crisis. Now that the COVID-19 pandemic has driven vastly increased government spending and deficits, surely these concerns are even more warranted today?

In a new position paper , we explore a quite different way of thinking about money, public expenditure and government deficits – “Modern Monetary Theory” (MMT) – and what it means for the Australian health care system. Adopting an MMT perspective leads to some very different conclusions about the true fiscal sustainability of Australian health care and provides an opportunity to think differently about how to plan for and fund the health outcomes we want for Australians in years to come.

What is Modern Monetary Theory?

MMT was developed in the 1990s by a group of economists and fund managers, driven by their concern that orthodox economic models simply did not accurately describe the real operation of monetary systems and institutions. MMT starts with the attempt to describe more realistically the true functioning of monetary and fiscal systems and, from that foundation, to build a more accurate (and hence more predictive) model of macroeconomics with which to guide policy. MMT has gained particular prominence in recent years through the work of Professor Stephanie Kelton (one of our co-authors), and notably her recent New York Times bestseller The deficit myth: modern monetary theory and how to build a better economy (2020).

MMT challenges the conventional wisdom that has for decades driven economic policy worldwide: that a government must levy taxes or borrow money before it can spend on public services or benefits, and that a national government, just like a prudent household, must live within its means. Modern monetary theorists tell us that this “common sense” economic narrative used in Canberra and other capitals is decades out of date; it ignores the distinction between currency users and currency issuers. Households, businesses, private organisations and non-currency issuing governments are currency users. Before they can spend money, they need to find it. A state or territory government does need grants from the federal government, tax receipts, or borrowed funds in order to finance its spending. State governments are currency users so, in principle, can become insolvent and this financial constraint must be taken into account.

Yet the federal government is in a completely different position: it is the monopoly issuer of its currency. In the case of the Australian Government, every Australian dollar it ever spends is a new dollar. Every dollar of federal spending adds a dollar to every official monetary aggregate. This happens all the time, every day. All federal spending takes place the same way. Funds are created electronically in private bank accounts and added to the reserves of those banks at the government’s fiscal agent – the Reserve Bank of Australia (RBA). Monetary sovereign governments, such as Australia’s federal government, can never become insolvent – they face no purely financial constraints on spending. Their spending has economic consequences, obviously, but no purely financial limits. They do not need to raise taxes prior to engaging in additional spending.

The COVID-19 pandemic and its effects on the federal Budget deficit have seen our media awash with worried and worrying headlines. Another way to look at the government deficit, though, is as a non-government surplus. A government deficit is a net financial contribution the government has made to the private sector. Indeed, in an economy without a significant trade surplus, a government surplus weakens private sector balance sheets , and either forces the private sector into further debt to support the economy, or leads to a recession, which reduces tax payments, raises welfare payments, and drives the government balance back into deficit in any case.

It turns out that it is not government deficits which are unsustainable, but government surpluses. A surplus, after all, just deletes dollars from the monetary system.

MMT does not suggest that there are no limits on spending but, instead, argues that it is inflation risk – not solvency – which should be the focus when discussing public finance. The real constraint is the productive capacity of the economy, which depends on available labour, skills, equipment, technology, natural resources, infrastructure, and institutional capacity. If the real resources exist to allow for additional spending without that spending driving up inflation, then the currency issuer is always in a position to carry out that spending.

Getting this wrong can and has led to unnecessary austerity in the past, in the name of living within our means.

Modern Monetary Theory, health and health care

The COVID-19 pandemic has shown us just how important population health is in allowing communities and countries to thrive, both economically and socially. Poverty, involuntary unemployment and underemployment, and inequality have an impact on wellbeing and on psychological and physical health.

MMT suggests that the government does not lack the financial resources to address these problems. It enables us to understand better the real options available to a monetary sovereign government like Australia’s and opens the door to far-reaching and ambitious investment by government in public, social, environmental and care infrastructure to meet the needs of coming decades. Our position paper outlines some of these opportunities; for example, the transformational health impacts of a federal Job Guarantee program and the scope for using taxes more effectively to drive healthier production and consumption, not just to raise revenue.

One of the great strengths of MMT is precisely its recognition that money is not everything, that there are real, physical constraints to action.

The Australian health care system, like all others, is deeply complex and heavily reliant on a limited supply of skilled health professionals. Applying the MMT lens to health care policy enables us to focus on areas where the challenges to action are more than simply financial: skills shortages, regional and rural access inequalities, persistent Aboriginal and Torres Strait Islander health inequalities, pervasive difficulties in achieving integrated and coordinated patient care, and the ongoing presence of low value and low quality care.

Yet it also enables us to see where we can achieve transformational change through systematic, planned investment, once we move past unfounded fears about affordability and misplaced austerity measures. If we harness fully the power of the Australian Government as a sovereign currency issuer, we can set in train the investments that will allow us to tackle these deep-rooted problems and more.

We suggest a transformational investment agenda, which might include the introduction of universal dental health care access, a post-pandemic remodelling of the health care system to meet the challenge of chronic diseases in an ageing population, guaranteed access to a high quality public option for aged care, building a resilient domestic base of essential medical supply industries, and renewing Australia’s health care infrastructure to meet the challenges of climate change mitigation and adaptation.

For too long, the accepted narrative – that the direct and indirect costs of health care are unsustainable in the long term – has constrained many governments’ abilities to fund both the direct costs of providing equitable access to health care resources and the costs of addressing the social determinants of health. In the post-pandemic world, MMT will enable us to reimagine health care and explore many ways in which we can promote health, wellbeing, and the productivity of our society.

Climate of fear: summit aims to create action consensus

Thu, 19 Mar 2020 23:22:54 GMT

WHEN Google released its list of “most searched” terms in Australia for 2019 , the phrase “fires near me” stood at the summit – far ahead of searches for sporting events, celebrity deaths, and other tragedies.

This is hardly surprising given that all of the major capital cities on Australia’s east coast were blanketed in bushfire smoke for most of the summer. Canberra, the “bush capital”, took pride of place as the city with the worst air quality in the world for days at a stretch. These plumes of smoke that bore witness to catastrophic fires were so shocking that the situation made headlines globally .

The Australian Academy of Science described this bushfire season as “unprecedented” , pointing out that while past fires have burned greater land areas (the Central Australian fires of the 1974–75 season eventually burned over 100 million hectares), those involved largely grasslands. Grassland fires are typically less intense and allow ecosystems to recover more quickly. They also have a far lesser economic impact, as they burn out in vast remote landscapes.

By contrast, the infernos in the long 2019-2020 fire season were hotter, travelled faster, affected dense and diverse ecosystems and touched the lives of up to 80% of all Australians .

Research just published in Nature Climate Change finds that a staggering 21% of all Australian forests – excluding Tasmania – has burnt so far in the 2019-20 bushfire season. This is far larger than the percentage of forest area burnt on other continents over the past 20 years, which for most continents and forest types has a median of 4-5% annually, with some particular Asian and African forest types showing higher medians of 8-9%.

To make things worse, heat records were broken . In mid-December, Australia recorded its hottest average temperature since records began at 41.9°C, with an incredible maximum of 50°C in the Nullarbor region. In the nation’s capital, the heatwave and suffocating smoke conditions were broken only by a violent hailstorm that pummelled Canberra with the largest hailstones in 20 years . To cap off the catastrophic Australian summer, the sky opened, with dangerous flooding resulting from rain of biblical proportions – up to 3m of rain fell in parts of NSW over a few days – again drawing international media attention .

Yet while these catastrophic events were unprecedented, they were not unexpected. A dozen years before this deadly season, economist Professor Ross Garnaut had released his climate change review . In that exhaustive document, Garnaut predicted that without adequate action on climate change, Australia would begin to experience more frequent and catastrophic bushfires by 2020. Right on cue Australians had a taste of their possible climate future, with estimates of the economic effect of this summer’s disasters reaching $100 billion .

The events of this summer – drought, heat, upheaval, and widespread uncontrolled fires and floods – are predicted to become more common with climate change affecting our country. As the Climate Council points out :

“Australians are already seeing the effects [of climate change], including more frequent, longer lasting and more intense heatwaves, harsher droughts, coastal flooding and longer, more dangerous bushfire seasons.”

Health advocacy groups such as the Australian Medical Association and the Public Health Association of Australia released statements of the adverse health effects that might be expected with climate change.

One of your authors [SR] was on-call for much of the Christmas–New Year period and into the early part of 2020: this was the peak of the fire season. During that time, Canberra was blanketed in acrid smoke – so dense that it infiltrated operating theatres and birth suites. The experience of delivering babies in a birth suite thick with smoke was alarming, to say the least. That was not the worst though; for the first time in a 30-year obstetric career, we were hearing new parents express concern about the climate future that lay in wait for their children. Potential parents were saying that concerns about the climate and the future were affecting their decision-making around starting their families.

As part of the medical profession – and, as an obstetrician, having special responsibility for bringing the next generation of Australians into the world – it is almost impossible not to feel a profound responsibility for children’s welfare. We all want our children’s future to be bright and better than our own, but the season’s “climate anxiety” was affecting Australians in unprecedented numbers . When a young couple asks you, “doctor, do you think we should have another baby with all of this awful climate news?” what, exactly, is the right answer?

The two of us first met at a government wellness meeting in 2019. It is natural for scientists such as ourselves to sidestep the spin and politics to focus on the best available evidence. For us, climate change is not political, though some powerful forces have attempted to frame it as a dividing, rather than uniting issue. Could the unity that the Australian community felt in the shared trauma of this summer, be mirrored in a common determination to act on the climate science for the good of all? If the broad community could agree, could reach a consensus for effective climate action – then our political leaders have no excuse not to follow that citizen leadership.

Many individual organisations and groups, individually, have issued “climate statements” and calling for action. Passionate and respected groups such as Doctors for the Environment and Lawyers for Climate Justice , have advocated for climate action for some time. We wondered if it was possible to bring together groups and organisations that are not necessarily known for passionate climate advocacy, expose them to the best scientific and economic information available and ask them if they could create consensus for climate action.

The result was the Australian Climate Consensus Forum that we are holding in Canberra on Thursday 12 March. To say the event was “hastily organised” is an understatement, but the response this event has stimulated has taken us by surprise. In this first step, we wanted the best speakers to engage a selected, diverse, invitation-only group with the most trustworthy and up-to-date science and economics. Speaking at the forum will be Fire Commissioner Greg Mullins, farmer and climate advocate Anika Molesworth, burns surgeon and national treasure Fiona Woods, climate economist Frank Jotzo, and earth system scientist Will Steffen.

Those who responded to our invitations – the organisations that we hope will find a unified voice – represent the most diverse group of individuals either of us have ever worked with: faith groups, business peak bodies, workers groups, health organisations and colleges, nursing staff, economics experts, community services, migrant and refugee groups, and Indigenous advocates. All will be spending the day responding to the best information we have and trying to reach a consensus for responsible climate action.

Where will this lead? We don’t know. Our ideal outcome would be a reasoned, rational and responsible call for specific actions that put our children’s – and their children’s – welfare first.

The stakes are high. The changing climate can adversely affect out health directly through the effects of the weather extremes we all have experienced recently. But. more broadly, we face adverse health consequences that are, “traumatic, infectious, nutritional, psychological … that occur in demoralised and displaced populations in the wake of climate-induced economic dislocation, environmental decline, and conflict situations” .

We’ve heard the argument that it doesn’t make sense for Australia to reduce its emissions because Australians are just pawns in a game dominated by China and the USA. We don’t agree. Sure, Australia’s total contribution to carbon emissions is about 1.3% of overall global emissions. Yet we’re only about 0.3% of the world’s population so, on an individual level, we’re big emitters.

If we look at all our actions, including exports and consumption, Australians have a huge role to play in limiting climate change. Australia is the world’s third largest fossil fuel exporter, making up 7% of all fossil fuel exports, behind only Russia and Saudi Arabia. The biggest miners of fossil fuel carbon are China, the USA, Russia, Saudi Arabia, and Australia . We are among the top five countries in the world that could stop carbon emissions at their original source: the mine.

And all that doesn’t take into account our “carbon shadow” – all of the carbon emitted manufacturing goods that are shipped back to Australia for consumption. Health care in Australia is responsible for a whopping 7% of all our carbon emissions , so all of us are part of the problem and need to be part of the solution.

As Matt McDonald of the University of Queensland puts it :

“As a nation so proud of ‘punching above its weight’ in fields such as sport and technology, Australia is missing a big chance to show global leadership on climate.”

This summer – a summer of extremes that we have been anticipating since Ross Garnaut’s report a dozen years ago – gave us a taste of what life could be like for the next generation of Australians. This generation has a responsibility to be good stewards of our environment for our children and their children. It is a privilege we must not waste. The Climate Consensus Forum is a beginning; a beginning of what we hope will be a broad, determined, consensus for effective Australian action on climate change. A microcosm, perhaps, but one that reflects a grand collaboration of trust, leadership and stewardship across all Australian society.

We’re not sure how it will go, or whether anyone will be able to agree on anything. But there’s no way that the two of us are going to die wondering. Because the one thing we do all agree on – whatever your background and wherever you’re from – is that we want the best possible Australia for our kids.

Migration and its implications for health services

Mon, 03 Sep 2018 01:36:54 GMT

THE emergence of modern Australia is a story of immigration. The peaceful settlement of millions of post-war migrants has been one of Australia’s greatest achievements and has been a key driver of our economic and social development.

Of the 19 million Australians aged 15 years and older who live here now, almost seven million were born overseas . Indeed, about 28% of Australia’s overall population was born overseas , among high income countries a proportion only exceeded by Luxembourg and Switzerland.

As a migration nation, the structure and shape of the Australian economy has formed around the constant flow of managed immigration. Australia’s growth rate, labour force capacity, and innovation capabilities all assume the continuation of a robust migration regime. For almost 30 years, Australia’s economy has had about a 3.0% rate of compound annual growth: in the absence of the additional population growth of 1.4% per year, the economy would only have grown at about 1.6% each year in per capita terms . Looking forward, it is estimated that Australia’s migration program will contribute $1.6 trillion to the Australian economy by 2050 , making the continuation of a significant migration program an economic, if not political, imperative.

Annual population increases within Australia comprise births and incoming migration (“net overseas migration”) — the relative values for the year 2015 are shown in Figure 1.

As the population expands, increased demands are placed on infrastructure, housing, and essential services, of which health is a major component . For a child born in Australia, there exists a relatively predictable trajectory of health needs; however, things are not so clear for migrants arriving in Australia.

Since the abolition of the White Australia Policy, our immigration program has been framed around a set of core principles, operating in accordance with Australia’s national interests and values (Figure 2).

The program is non-discriminatory and while it may select for skill sets and language level, selection is irrespective of country or origin, religion, gender or ethnicity. Further, the framework favours permanency and citizenship and has a strong emphasis on family reunion and on family units, enabling skilled visa applicants to be accompanied by their spouse and dependent children. Finally, Australia has made an ongoing commitment to a humanitarian program selected through the United Nations High Commissioner for Refugees (UNHCR), with referrals based on need and vulnerability. In addition, historically relatively generous medical waivers were given to those referred.

The characteristics of our migration system have meant that in the past 30 years, our program has seen the settlement of new arrivals from every corner of the globe and from almost every linguistic and cultural group around the world. This diversity has been a source of national strength, but also requires strategic planning and foresight in the design of our institutions and our systems, particularly those that interface with newly arrived Australians when they are at their most vulnerable. One important interface is the health system.

Australia has a universal health system through Medicare and its medical benefit and pharmaceutical benefit schemes. For universal health care to function, patients must be equipped to access, understand and participate in the system. While some migrant groups will find Australia’s health system familiar to that of their pre-migrant experience, our health systems will be difficult to navigate for many migrants, necessitating a level of assistance to allow equitable access . Barriers to access can have important implications for provision of health care. For example, primary care may be neglected, allowing conditions to go untreated until more serious — migrants are less likely to participate in screening programs or to access vaccination services.

The “healthy migrant effect”

Migrants who come to Australia through skilled migrant programs typically have to meet health standards, thus they tend to have a higher standard of health at arrival than the general Australian population: this is known as the “healthy migrant effect”. However, there is evidence that, once in Australia, this level of health tends to deteriorate . For most migrants, no access to Medicare is permitted for the first 104 weeks after arrival, and this presents another barrier to health care access. At the time of writing, there is a current proposal to increase this waiting period further.

After arrival, migrant groups experience disproportionate disease burden, depending on their ethnicity and pre-migration health status, and increased health care utilisation has been found among migrant populations in Australia . Although older studies have reported that migrants tend to have lower rates of hospital surgical admission than patients born in Australia, overall hospital admissions, emergency department presentations and admissions due to potentially preventable infectious diseases are above the Australian-born averages . Hospital admission rates for vaccine-preventable illnesses are approximately 20% higher in migrants, and rates of admission for diabetes, coronary artery disease and other chronic heart disease may be up to 50% higher .

Many migrants to Australia will face an adverse impact on their health resulting from low English proficiency, or circumstances and considerations relating to their ethnicity and cultural or religious beliefs. The impact of this on primary care in community settings is difficult if not impossible to measure and only marginally less difficult to quantify for hospital-based services. Studies suggest that the cost per weighted activity unit of migrant patients is greater than Australian-born patients .

As a simple example one large study reported that, according to demographics of the areas that hospitals serve, the cost of interpreters varies as an overall overhead from 0.3% to 5.8% in different areas. The same study found that non-English speaking (“culturally and linguistically diverse” – assessed by requirement for an interpreter or preferred language not being English) patients spend longer in hospital in the same diagnostic-related group (DRG), and that they incur higher average ward nursing and ward medical costs by DRG. Importantly, there is also a shift in severity towards more severe adjacent DRGs, suggesting that non-English speaking patients tend to have a higher proportion of comorbidities and complications. Overall, linguistic diversity was associated with a higher cost per weighted activity, ranging from 0.2% to 3.8%. Non-admitted episodes of care, typically to emergency department attendances, also incur a higher cost due to a greater proportion of triage category one presentations and a trend to older age.

The importance of planning

Providing adequate health services for migrants is fundamental: international human rights agreements enshrine the principle that all individuals have “rights to health and to a standard of living adequate for health” . When actions, overt or inadvertent, inhibit certain groups’ access to health care, this fosters a sense of “exclusion, social illegitimacy, and separation from the moral community,” with ramifications beyond the health inequities alone. Vissandjee and colleagues frame it thus:

“For … migrant cohorts whose previous life experiences incorporate vastly different cultural mores and modes of health care practice … [advancing migrant health to assist in] overcoming barriers to accessing care goes far beyond developing language comprehension and an individual’s ability to schedule an appointment.”

Public hospitals in Australia are under pressure to meet the demands of a growing population. Public hospitals are almost entirely the responsibility of state and territory governments — provision of health services comprises the single largest item in all state and territory budgets . The commissioning of new health infrastructure, resources and staffing to cater for community needs has a long lead time so it needs careful planning. However, while planning has focused on aggregate population movements, less attention has been given to the changing characteristics of Australia’s population and the need to manage access barriers for populations with significant language and cultural obstacles to equality of care.

Migration offers Australia enormous social and economic benefits, but responsible policy requires planning around the flow-on effects of a robust migration level. Sixty per cent of Australia’s future population growth is likely to flow from migration. Some 85% of migrants live in urban areas and this pattern is likely to continue. Migration is a national policy that finds its effect on local communities and has an impact on state and territory services. The windfall of migration is a net positive on the budget bottom line and strong gross domestic product growth. However, this economic boon needs to be matched by well coordinated services and systems which are responsive to a changing need .

The unique health considerations pertaining to migrants challenge our health systems, and this in turn places strain on the resources available to provide care to entire communities. We believe that, in the same way that roads and housing must be planned, it is time for greater coordination and investment to enable adequate health infrastructure and resources to be planned and delivered. Indeed, this needs to be a priority for Australia if we are to provide the fundamental services necessary. Health is fundamental to almost everything else.