By Kellie Bisset

Ebola: a study in disadvantage

More than 900 people have died in the West African Ebola epidemic from a total of just over 1700 suspected cases. Apart from awakening our latent fears of rampant infectious disease, what else does this outbreak tell us?

Well, a lot about the way we value some lives over others if you subscribe to the view of UK Faculty of Public Health president Professor John Ashton. In a piece for the Independent on Sunday titled They’d find a cure if Ebola came to London, Ashton said the moral bankruptcy of capitalism underpinned the pharmaceutical industry’s tardiness in finding a cure for the disease, whose numbers to date and impact on powerless minority groups had placed it down the priority list as an attractive investment proposition.

“The real spotlight needs to be on the poverty and environmental squalor in which epidemics thrive, and the failure of political leadership and public health systems to respond effectively,” he wrote.

Turns out, there is an experimental cure, but in another example highlighting discrepancies in access to care, it has so far only been offered to American aid workers, as this New Republic article points out.

How worried we should be about the worst Ebola epidemic in history getting even further out of control will be a question considered by the WHO as it meets to decide whether to officially declare it a Public Health Emergency of International Concern. Sierra Leone has already declared a state of emergency and with travel restrictions on the cards, British Airways has already announced it is  suspending flights to both Sierra Leone and Liberia as a safety measure until the end of the month.

The toll on health workers is particularly sobering. This postcard in The New Yorker gives a first-hand account of Ebola claiming those who are the last line of defence against its spread.

While the Centers for Disease Control and Prevention took to Twitter to answer questions about the disease and reassured Americans the risk of the outbreak taking hold in the US was low, this article in the Boston Globe points out that not all US states have ethical guidelines in place to ration the treatment of patients in the event medical services are oversubscribed.

Australia’s Chief Health Officer Professor Chris Baggoley offered assurances that the risk of an Ebola epidemic would be low here, though UK Chief Scientist Sir Mark Walport said our interconnected world was increasing the likelihood that countries in the west would be affected by previously remote threats.

Meanwhile, UK media reported that a Welsh woman had placed herself in quarantine over fears she had contracted the virus on a recent trip to Africa. These pieces in The Guardian and Mother Jones though, argue the average westerner would be better served losing sleep over the influenza virus (a huge global killer) rather than their risk of contracting Ebola.


Social determinants: the evidence keeps rolling in

Croakey focussed its attention on the theme of disadvantage this fortnight with Dr Tim Senior’s fourth Wonky Health column.

Evidence from around the world points to the same place: that poorer people tend to develop more complex medical problems and at a younger age than richer people. But, writes Senior, it’s important that when we try to tackle this problem, we put the right lens over our activities – and not impose solutions that only work from the perspective of the advantaged.

The evidence Senior refers to seems to be rolling in on a steady stream. News stories this fortnight have, for example, reported on poor people with diabetes being 10 times more likely to lose a limb than those who are better off, children with jailed family members experiencing poorer health in later life, and children who are intellectually stimulated being less likely to develop Alzheimer’s.

A new report from Australia’s National Health Performance Authority has found that young children are up to three times more likely to die depending on where they live and women are up to 18 times more likely to smoke while pregnant in some areas.

When might this evidence might reach critical mass and have a strong and widespread impact on policy and funding?  

In the US this goal might be a step closer, with the introduction of the Health Equity and Accountability Act of 2014 to the US House of Representatives. The American Public Health Association’s Public Health Newswire reported that if passed, this law “would provide resources to eliminate health disparities in all populations, regardless of race, ethnicity, immigration status, age, ability, sex, sexual orientation, gender identity or English proficiency”. 


Primary care policy – the Power and the Passion 

Strong reactions to the Federal Government’s Budget announcement of a $7 GP co-payment are still making headlines, and while The Guardian reported on Health Minister Peter Dutton’s confidence of being able to get the policy through the Senate, PUP Senator Clive Palmer suggested he might be engaging in “wishful thinking”.

Minister Dutton still contends that bulk billing in Australia is unsustainable and so it’s a fair bet he may not agree with this thesis from economics lecturer Peter Sivey published in The Conversation: if you pay GPs more via increased Medicare rebates, you incentivise medical students to move into general practice and away from supercharged specialty incomes – and they will end up costing the system less.

The idea of capping specialist fees is an attractive proposition, according to former Howard Government adviser Terry Barnes – who reinvigorated the co-payment idea. The AMA, however, isn’t enamoured of capping its members’ incomes, though Medical Observer reported the Grattan Institute’s Professor Stephen Duckett was supportive.

The Grattan Institute has produced yet more evidence that the co-payment would hit the disadvantaged the hardest — evidence that is backed up by Treasury’s own figures, according to this story in The Guardian. The AMA has also come out swinging on the co-payment, with claims the policy would  be an $8 billion burden on patients.

The Australian Health Care Reform Alliance (AHCRA) – an alliance of 37 member organisations – has issued a communique expressing concern over the Government’s health policy direction, in particular the threat of a two-tier health system and what they say is a weakening of primary care, in the face of evidence that primary care is part of the solution not the problem.

And in one of a series of editorials published in the latest issue of the Australian and New Zealand Journal of Public Health, Wollongong University Professor of Health Economics Professor Simon Eckermann has written that mandatory co-payments not only lead to under-servicing of those who can’t afford to pay, they give GPs an incentive to over-service those who can.

Michael Moore and Heather Yeatman describe the budget as a literal killer — and were challenged on this by ABC Radio’s David Mark on The World Today.

The ANU’s Professor Sharon Friel put it this way: “Social spending saves lives and austerity kills …What has the majority of the Australian population done to deserve such a brutal cull of services?”

The impact of a Medicare co-payment would not be a ripple effect, The University of Technology’s Margaret Faux wrote for Croakey — it would be more like a House of Cards effect if the UK’s experiment with access barriers is anything to go by.

Also writing for Croakey, Professor Stephen Leeder said the uproar of the co-payment has raised bigger questions about how we organise and pay for care.

Australia is not the only country grappling with these questions, said Croakey contributor Jennifer Doggett, who compiled a handy summary for readers on recent research and policy reports on health system funding and the important role primary care plays in keeping systems sustainable.

In a new book profiled by Croakey, Professor Fran Baum and Professor Judith Dwyer argue that while free markets are effective in some areas, they aren’t the answer to controlling healthcare costs and achieving health and equity in the community.

And John Menadue takes aim at “health insiders” in this withering blog post contending that reform is impossible unless current power structures are disabled.


What happened to the principle of self-determination in Aboriginal health?

The much discussed Creating Parity report from mining magnate Andrew Twiggy Forrest has opened up a debate about the dignity of individuals to manage their own affairs.

NACCHO Chair Justin Mohamed said the review, whose recommendations included a health welfare card that quarantines the income of welfare recipients from being spent on things such as drugs and alcohol, missed the point.

While he backed some of the recommendations, Mohamed said the report had ignored the important role Aboriginal Community Controlled Health Services already played  as a pathway for employment, training and economic development for Aboriginal and Torres Strait Islander people. Their potential to do more was there he said, but the report had failed to recognise this.

NACCHO (and many others) criticised the harsh welfare measures, which it said would not improve Aboriginal self-esteem or self reliance.

Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda offered similar sentiments, telling The Australian there were some good ideas raised but the welfare quarantine ideas needed more considered analysis.

Eva Cox didn’t pull any punches in her assessment of the report in The Conversation. Punitive paternalism had a long history of failure, she wrote, saying that Forrest had pulled his personal experiences into his recommendations but they had little to do with evidence, ignored what had been learned over time, and represented a step backwards.

This column from Jeff Sparrow in The Guardian raises a pertinent question: how is it that ‘classical liberals’ who denounce ‘nanny state’ proposals for government intervention in areas such as obesity or alcohol seem to have no difficulty advocating controlling the incomes of the disadvantaged to encourage healthier behaviours?

Australian Indigenous Health InfoNet has released a report, Overview of Australian Indigenous Health Status 2013, which shows that while there have been some improvements, such as in smoking rates, the health of Indigenous Australians remains much worse than their non-Indigenous counterparts.

Beyondblue has called out racism with a new campaign highlighting its impact on Aboriginal and Torres Strait Islander health. Stop.Think.Respect challenges everyone in Australia to check their behaviour and will run for six weeks in traditional and online media. Writing for Croakey, beyondblue CEO Georgie Harman said a wider public discussion is needed to affect behavioural change.

To mark National Aboriginal and Torres Strait Islander Children’s Day, Suzanne Ingram, a Wiradjuri woman and a Senior Research Fellow at the George Institute for Global Health, wrote this thought-provoking piece about the importance of culture and community-led solutions to Aboriginal and Torres Strait Islander children being removed from their families – the rate of which has actually increased by 400% over the past 17 years. This PerthNow story also adresses the issue.


Have our bodies become Temples of Doom?

Yes, say some US legislators, who have bitten the bullet and introduced soda tax legislation into the US House of Representatives.

Dubbed the SWEET Act, it proposes a tax of one cent per teaspoon of sweetener, and this includes sugar and high-fructose corn syrup. This opinion piece in the New York Times is supportive and you can read the analysis here or read here about how US public health experts are preparing for the inevitable fight with the beverage industry a soda tax will bring on.

Meanwhile more than 300 US scientists, physicians and public health officials have added their voices to the call for better food labelling, calling on the Food and Drug Administration (FDA) to include a line for added sugar on the US Nutrition Facts food label.

In Australia, Rosemary Stanton and Christina Pollard laid it out plain and simple for The Conversation and Croakey: Bad food is good for business. Their article (well worth a read) analysed how much more profitable it is for companies to process foods and market them as value add when in fact, little value ends up with the consumer.

What package of interventions might work to reduce obesity levels is the $64million question occupying the minds of public health experts around the world. New Australian evidence suggests that having GPs weigh their patients at each visit could play a role in reducing obesity levels, while efforts to tackle the social determinants of obesity are underway in South Australia, according to this report by Lareen Newman and Michele Herriot, published at both The Conversation and Croakey.

While there are still some researchers questioning whether obesity is an emergency, a new study published in the Journal of Clinical Endocrinology & Metabolism shows that gains in life expectancy over the past four decades, have not extended to those with obesity, and having obesity as an adolescent could shorten your lifespan.

Getting the message of healthy eating across to young people might not be as hard as we think, according to work carried out by the Institutes for Health Research and Policy at the University of Illinois in Chicago, which looked at the impact of the relatively new National School lunch Program in the US, which provides 31 million students with meals. Seventy per cent of schools reported positive feedback from their students, the researchers said, though there was still resistance in rural areas.

But confusing messages in the media continue to be a barrier to public understanding of nutrition, according to this excellent piece carried by the Reporting on Health blog. The article examined a recent study on butter and how it was seized on by journalists eager to tell their publics that saturated fat wasn’t a problem after all. The fact that public health experts roundly criticised the study and the reporting of it seemed to get lost in all the pro-butter hype.

The ongoing conversation about the impact of alcohol on our health and our society took a new turn this fortnight with the release of a report from the Foundation for Alcohol Research and Education,which showed that alcohol kills four times as many people as those who die on our roads. Foundation Chief Executive Michael Thorn, outlined the findings for Croakey.

Signs are pointing to the increased likelihood that Wales will introduce a minimum price for alcohol next year. The BBC reported that an expert panel advising politicians on substance misuse had backed a floor price, saying it would boost public health, protect the vulnerable and improve community life.

And Medical Xpress reports on work from researchers at the Johns Hopkins Bloomberg School of Public Health and the Boston University School of Public Health showing teenagers are three times as likely to drink alcohol brands that are advertised on the television programs they watch compared with other brands.


Electronic health records: nice if you can get them

An observational study has found that eight out of 10 people who tried to sign up for the personally controlled e-health record failed in their attempt because the process was too difficult for users to navigate, Pulse+IT reports.

At the same time, the Department of Health and Ageing is surveying GPs and other stakeholders about the PCEHR in the wake of a review ordered by Minister Peter Dutton last year. However, the reaction to the survey has been less than glowing, with Medical Observer reporting negative feedback from those who had tried to complete it.

And in this great Croakey read from consumer advocate Anne Cahill Lambert, the madness of a system that encourages patients to take responsibility for their own healthcare and yet makes it extremely difficult for them to access their own medical information is blindingly apparent.

At the other end of the spectrum, The Australian reports that some privacy advocates have opposed recommendations to make the PCEHR opt out rather than opt in because they see it as akin to introducing an Australia card by stealth.

But in a story that starkly illustrates that health privacy concerns are not the sole domain of new technology, Medical Observer reports that Victorian GPs have called for an end to hospitals sending handwritten fax messages to convey crucial patient information.


Other important Croakey reading you may have missed this fortnight:

You can find previous editions of the Health Wrap here. Contact me on Twitter @medicalmedia or my colleague Frances Gilham @FrancesGilham with story ideas for the Health Wrap.

  • Kellie Bisset is The Sax Institute’s Communications Director. She has worked in mainstream and medical journalism and communications for more than 20 years. During that time she edited both of Australia’s weekly medical publications for doctors, Australian Doctor and Medical Observer and developed a strong interest in health policy and evidence. The Sax Institute is a not-for-profit organisation that drives the use of research evidence in health policy and planning.



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