tag:theconversation.com,2011:/global/topics/chronic-disease-management-5538/articlesChronic disease management – The Conversation2024-02-05T05:12:15Ztag:theconversation.com,2011:article/2196122024-02-05T05:12:15Z2024-02-05T05:12:15ZMillions of Australians have a chronic illness. So why aren’t employers accommodating them?<figure><img src="https://images.theconversation.com/files/573331/original/file-20240205-22-173q39.jpg?ixlib=rb-1.1.0&rect=35%2C188%2C5955%2C3799&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-working-in-a-factory-with-a-lot-of-boxes-NixrmlDt-6E">Kat von Wood/Unsplash</a></span></figcaption></figure><p><a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/health-conditions-prevalence/2022">More than 20 million Australians</a> have at least one long-term health condition, <a href="https://www.abs.gov.au/statistics/labour/employment-and-unemployment/barriers-and-incentives-labour-force-participation-australia/latest-release#data-downloads">63%</a> of whom are in the workforce. </p>
<p>The <a href="https://www.health.gov.au/topics/chronic-conditions/about-chronic-conditions">causes of chronic illness</a> are complex and are often unconnected to a person’s work. But at times, the continued exposure to work stressors can lead to or exacerbate chronic health conditions including <a href="https://www.ccohs.ca/oshanswers/psychosocial/musculoskeletal.html">musculoskeletal disorders</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674745/">heart disease</a>, <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-8-280">anxiety</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/18417557/">depression</a>. </p>
<p><a href="https://apo.org.au/node/322034">Our research</a> found 73% of people believed their chronic illness was at least partially caused or worsened by their job. Almost one in five people believed work entirely caused or worsened their illness. </p>
<p>These findings accord with data from <a href="https://data.safeworkaustralia.gov.au/insights/key-whs-stats-2023">Safe Work Australia</a> which indicates health conditions (particularly mental health) account for an increasing proportion of serious workers’ compensation claims.</p>
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Read more:
<a href="https://theconversation.com/the-impact-of-work-on-well-being-6-factors-that-will-affect-the-future-of-work-and-health-inequalities-215047">The impact of work on well-being: 6 factors that will affect the future of work and health inequalities</a>
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<p>Our research <a href="https://apo.org.au/node/322034">also found</a> people with chronic illness were likely to report various forms of workplace discrimination, including being rejected from a job (63%), being treated unfairly in the workplace (65%) and harassment (52%). </p>
<p>So what are employers getting so wrong? And what are the solutions to improving working conditions for people with chronic illnesses? </p>
<h2>Employers’ responsibilities have grown</h2>
<p>In 2022, <a href="https://www.safeworkaustralia.gov.au/doc/model-whs-regulations">Safe Work Australia</a> updated its work health and safety regulations to include specific guidelines on the management of “psychosocial” hazards in the workplace. </p>
<p>A <a href="https://www.safeworkaustralia.gov.au/doc/model-whs-regulations">psychosocial hazard</a> is anything that can cause psychological and physical harm, including the design or management of work and workplace interactions or behaviours. </p>
<p>Common examples include job demands, low job control, poor support, lack of role clarity, exposure to traumatic events, harassment and bullying. The failure to eliminate or minimise psychosocial hazards can cause work-related stress, resulting in poor health outcomes for workers.</p>
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<img alt="Waiter sets table" src="https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573334/original/file-20240205-27-wkdls6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Employers have an obligation to manage psychosocial hazards.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-white-top-standing-next-to-table-OB7ol699Iww">Chuttersnap/Unsplash</a></span>
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<p>Organisations need to improve their engagement and management of chronically ill workers to meet their legal obligations. </p>
<h2>How employers are getting it wrong</h2>
<p>Few organisations have sophisticated approaches to <a href="https://link.springer.com/article/10.1186/1472-6963-11-104">managing employees who are chronically ill</a>. And managers often feel <a href="https://hbr.org/2021/02/how-managers-can-support-employees-with-chronic-illnesses">ill-equipped</a> to effectively support chronically ill employees. </p>
<p>Instead, there is a tendency to rely on outmoded human resource and occupational health and safety systems originally designed to accommodate short-term absences and acute illnesses. </p>
<p><a href="https://theconversation.com/how-employers-can-help-cancer-survivors-return-to-work-based-on-my-own-experience-128568">Return-to-work</a> policies tend to fall short because they assume a phased and linear return to full working capacity. This is often not the case for people with chronic illness, whose symptoms may be degenerative or fluctuate over time. </p>
<p>Chronically ill workers are <a href="https://www.researchgate.net/profile/Joy-Beatty/publication/256924077_An_Overlooked_Dimension_Of_Diversity_The_Career_Effects_of_Chronic_Illness/links/5b8887b94585151fd13dc5cf/An-Overlooked-Dimension-Of-Diversity-The-Career-Effects-of-Chronic-Illness.pdf">rarely considered</a> in organisational diversity and inclusion policies and procedures. At best, they may be incorporated into umbrella disability policies, which can be problematic as people with chronic illness do not necessarily <a href="https://chronicillnessinclusion.org.uk/wp-content/uploads/2021/12/DRUK-CII-survey-report-Nov-2021.pdf">self-identify as “disabled”</a>. </p>
<p>Many chronically ill workers fly under the radar. This is partly because organisations don’t collect this data but it’s also due to the often invisible nature of chronic illness. Someone living with conditions such as long COVID or endometriosis, for example, may present as unimpaired to their colleagues. However, they will often be dealing with complex, fluctuating symptoms that are largely invisible at work. </p>
<p>Workers may also choose <a href="https://hbr.org/2023/08/research-when-leaders-disclose-a-chronic-illness-at-work">not to disclose</a> their illness due to fears of being stigmatised, treated differently, or passed over for promotion. <a href="https://fbe.unimelb.edu.au/__data/assets/pdf_file/0007/4639318/Disclosing_Illness_at_Work_Ghin_Ainsworth.pdf">Our research</a> on leaders living with chronic illness found only 18% fully disclosed their illness to their employer. Almost three-quarters of leaders with chronic illness (73%) deliberately hid their illness at work. </p>
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Read more:
<a href="https://theconversation.com/should-you-tell-your-boss-about-your-mental-illness-heres-what-to-weigh-up-200907">Should you tell your boss about your mental illness? Here's what to weigh up</a>
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<h2>What can employers do?</h2>
<p>Here are three ways employers can begin to proactively meet their obligations to workers with chronic illness. </p>
<p><strong>1. Make adjustments</strong> </p>
<p>Workers with chronic illness sometimes experience fluctuations in their condition which can impact their ability to complete tasks or meet deadlines. It may be necessary for managers to consider sensitively discussing a revised work schedule, the delegation of time-sensitive tasks, or discuss implementing reasonable adjustments to improve workflow.</p>
<p>These can be challenging conversations, but engaging with them directly means employers can allocate the resources they need to meet their business objectives, while also reducing employee experiences of overwhelm.</p>
<p><strong>2. Accept reasonable requests</strong></p>
<p>Workers with chronic illness may require reasonable adjustments, such as flexible working, to enable them to perform to the best of their ability. </p>
<p>Take these requests at face value and minimise the administrative hurdles associated with approving such accommodations. Failing to do so is likely to erode trust, entrench feelings of not being supported and increase an employee’s psychological distress. </p>
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<img alt="Woman puts sticky notes on whiteboard" src="https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573332/original/file-20240205-23-ofrizq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Accepting reasonable requests will make employers feel supported.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/woman-placing-sticky-notes-on-wall-Oalh2MojUuk">Jason Goodman/Unsplash</a></span>
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<p><strong>3. Train managers</strong></p>
<p>Managers may sometimes deny a request for a reasonable adjustment based on the belief that this creates a precedent for all team members. Decisions like these can compound feelings of stress, as they may be experienced as a lack of procedural fairness by employees living with chronic illness. </p>
<p>With appropriate training, managers are more likely to recognise that chronically ill workers are generally not seeking “special treatment”, but ways to work more effectively within their changed capacities.</p>
<p>By recognising the value of employees of all abilities, and proactively and systematically addressing the needs of their chronically ill workforce, employers can minimise extended workplace absences and improve the productivity of their workforce. </p>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Employers have a duty to address work stressors and make adjustments for workers with long-term illnesses.Peter Ghin, Research fellow, Future Of Work Lab, Faculty of Business and Economics, The University of MelbourneSusan Ainsworth, Professor of Management and Marketing, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1822082022-05-09T21:13:23Z2022-05-09T21:13:23ZSocial prescriptions: Why some health-care practitioners are prescribing food to their patients<figure><img src="https://images.theconversation.com/files/462063/original/file-20220509-11-i115lu.jpg?ixlib=rb-1.1.0&rect=0%2C145%2C4897%2C2880&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Food prescriptions provide patients with vouchers that can be spent on fruits and vegetables.</span> <span class="attribution"><span class="source">(Jonathon Barraball)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Angela is a 54-year-old mother of two living with Type 2 diabetes in a small apartment in Guelph, Ont. Despite steady access to health care and a physician who encourages regular exercise and healthy eating, Angela’s complications have worsened in recent years. These complications cause mobility challenges, sometimes rendering her unable to leave the house. </p>
<p>Angela blames her poor diet. Due to her limited income, she frequently misses meals, goes some days without food and can often only afford nutrient-poor (but more affordable) foods. </p>
<p>Angela is classified as severely food insecure, which means she is <a href="https://proof.utoronto.ca/food-insecurity/">one of more than 4.4 million people in Canada</a> who are unable to acquire a diet of sufficient quality or quantity. <a href="https://www.theglobeandmail.com/opinion/childhood-hunger-is-a-canadian-public-health-crisis/article4106595/">Food insecurity is a public health crisis in Canada</a> that has <a href="https://www.doi.org/10.25318/82-003-x202200200002-eng">worsened during the COVID-19 pandemic</a>.</p>
<p>During one of Angela’s recent visits to the <a href="https://guelphchc.ca/our-mission/">Guelph Community Health Centre</a>, a nurse practitioner surprised her with a new <a href="https://theseedguelph.ca/fresh-food-prescription-spotlight/">“prescription” for fresh fruits and vegetables</a>. The prescription <a href="https://doi.org/10.1186/s13690-021-00657-6">included weekly $40 vouchers that could be spent on fruits and vegetables at a local farmer’s market</a>. Speaking after 12 weeks of enrolment, Angela expressed gratitude for the initiative. </p>
<p>“The program’s fantastic,” Angela said, “I’m eating a diet with a lot more fruits and vegetables and proteins, which is so good for me when I’m trying to get my diabetes under control.”</p>
<h2>Social prescribing</h2>
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<img alt="A woman writing on a clipboard at a table with a stethoscope and a big selection of fruits and vegetables on it" src="https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&rect=590%2C5%2C3023%2C2026&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461381/original/file-20220504-27-lqnln2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Social prescriptions are issued by health-care practitioners to provide patients with non-pharmaceutical interventions.</span>
<span class="attribution"><span class="source">(Jonathon Barraball)</span></span>
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<p>Food prescriptions are part of a broader concept of <a href="https://www.england.nhs.uk/personalisedcare/social-prescribing/">social prescribing</a>. Pioneered in the United Kingdom and growing in popularity in the United States and Canada, social prescriptions are issued by health-care practitioners to provide patients with non-pharmaceutical interventions, including dance classes, walking groups, volunteer work, art lessons and, of course, fresh fruits and vegetables. </p>
<p>The <a href="https://doi.org/10.1177%2F08901171211056584">rise of food prescriptions has been particularly pronounced in the U.S.</a>, largely driven by <a href="https://www.wholesomewave.org/">not-for-profits</a> and the 2018 <a href="https://sgp.fas.org/crs/misc/R45525.pdf">Federal Farm Bill</a>, which provided US$25 million to support produce prescription programs across the country.</p>
<p>In Canada, food prescriptions have been slower to gain traction, with independent <a href="http://guelphchc.ca/wp-content/uploads/2019/08/Social-Prescribing.pdf">community health centres</a>, <a href="https://foodshare.net/program/foodrx/">regional not-for-profits</a> and <a href="https://doi.org/10.1136/bmjopen-2021-050006">researchers</a> implementing produce prescriptions in partnership with allied health professionals in a more localized and unco-ordinated manner. </p>
<p>Our interdisciplinary health research team has collaborated with the Guelph Community Health Centre since 2019 to implement and evaluate multiple phases of a food prescription program. Food security is important to disease prevention and management, so it makes sense that health-care practitioners should be able to prescribe healthy foods and reduce barriers to healthier diets.</p>
<p>As exemplified by Angela’s experiences, preliminary results are promising. <a href="https://doi.org/10.1186/s13690-021-00657-6">Participants report improved food security and increased consumption of fruits and vegetables</a>. Meanwhile, during interviews, patients perceived the program to reduce financial stress and improve health outcomes.</p>
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<img alt="Vegetables displayed for sale" src="https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461825/original/file-20220506-18-htzlcr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Food is medicine approaches strive to better incorporate food and nutrition interventions in health care settings.</span>
<span class="attribution"><span class="source">(Unsplash/Sean Nufer)</span></span>
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<p>And yet, food prescriptions should not be immune to scrutiny. One question is whether such initiatives <a href="https://theconversation.com/prescribing-social-activities-to-lonely-people-prompts-ethical-questions-for-gps-105439">respect and honour people “as people.”</a> </p>
<p>Do food prescriptions trivialize the suffering of food insecurity and ignore its underlying determinants, which are often <a href="https://doi.org/10.1186/s12889-018-6344-2">rooted in poverty, mental health, substance use, race and racism and systemic oppression</a>? </p>
<p>Do they leverage the power differential between practitioners and patients to coerce patients into making different food choices, thereby eroding patients’ sense of control over their own health decisions? </p>
<p>Do they promote the false dichotomy of “good” and “bad” foods and reinforce <a href="https://doi.org/10.1080/23293691.2019.1653577">the stigmatization of fat bodies in the health-care system</a>? </p>
<h2>Why not cash?</h2>
<p>If the health-care system can provide vouchers for food, why not just prescribe cash? <a href="https://doi.org/10.17269/s41997-022-00610-2">Cash transfers can empower recipients by providing choice and shifting the balance of power in favour of recipients</a>. By contrast, providing food vouchers for restricted items might be considered paternalistic, limiting choice and assuming the best interests of recipients on their behalf. </p>
<p><a href="https://openknowledge.worldbank.org/bitstream/handle/10986/23922/The0revival0of0or0an0old0quandary00.pdf;sequence=1">The cash versus food debate has played out repeatedly in social and economic policy spheres</a>, especially in academia and the conference rooms of the World Bank and the <a href="https://www.fao.org/3/i5424e/i5424e.pdf">Food and Agriculture Organization</a> of the United Nations. The growing popularity of food prescriptions should trigger a revival of this debate, but re-centred on the focal question: How can health-care systems best address food insecurity? </p>
<h2>The medicalization of food</h2>
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<a href="https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two combines in a field of wheat, one of them surrounded by a dusty cloud" src="https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=327&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=327&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=327&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=411&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=411&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461822/original/file-20220506-10983-37b10a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=411&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A drought devastated the wheat crop in eastern Washington in August 2021. The food supply is dependent on the health of the planet and our society.</span>
<span class="attribution"><span class="source">(AP Photo/Ted S. Warren)</span></span>
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</figure>
<p><a href="https://www.livescience.com/62515-hippocrates.html">Hippocrates supposedly said</a>, “Let food be thy medicine and let thy medicine be food.” Now, almost 2,400 years later, the “<a href="https://doi.org/10.1136/bmj.m2482">food is medicine framework</a>” promotes the idea that health-care systems should offer food interventions alongside pharmaceuticals. This <a href="https://doi.org/10.1001/jamainternmed.2019.0184">framework has gained popularity</a> as an easily digestible model that plays into basic truisms about the links between food and health. </p>
<p>However, the medicalization of food should be cautioned. Food is more than its nutrient value. It is cultural identity. It is history. It is belonging. Food is <a href="https://doi.org/10.1111/mcn.12499">connection to the land</a> and <a href="https://blogs.scientificamerican.com/observations/vanishing-nutrients/">dependent on the health of our planet</a> and our <a href="https://reliefweb.int/report/world/impact-ukraine-russia-conflict-global-food-security-and-related-matters-under-mandate">society</a>. To argue that food is a commodity to be sterilized and medicalized would undermine the true significance of food. </p>
<h2>Improving access to healthy foods</h2>
<p>Despite these questions and critiques, we are not arguing against food prescriptions. Indeed, our team facilitates food prescription programs that have been immensely beneficial for patients. Within these programs, our motivations are simple: to improve access to healthy foods for those who need it. This includes individuals like Angela who face difficult choices every day about whether they can afford a healthier diet. </p>
<p>We must, however, interrogate food prescriptions to determine if they are in fact the best way to leverage health systems to promote the nutritional health of low-income and other marginalized communities. And if we do provide food prescriptions, we need to recognize and be responsive to the fact that each patient — like Angela — has a different and complex relationship with food based on their own health, histories, culture, worldview, traumas and triumphs. </p>
<p><em>This article was co-authored by Abby Richter, a registered dietitian and a Master of Applied Nutrition. She is the program lead for The Fresh Food Prescription program, an initiative of The Guelph Community Health Centre</em>.</p><img src="https://counter.theconversation.com/content/182208/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Little receives funding from Michael Smith Health Research BC, the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, and the Danone Institute of North America. </span></em></p><p class="fine-print"><em><span>Eleah Stringer receives funding from Michael Smith Health Research BC.</span></em></p><p class="fine-print"><em><span>Warren Dodd receives research funding from the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, and the New Frontiers in Research Fund.</span></em></p>Food security is crucial to disease prevention and management, so prescribing healthy foods and reducing barriers to better diets makes sense. But food prescriptions should not be immune to scrutiny.Matthew Little, Assistant Professor, School of Public Health and Social Policy, University of VictoriaEleah Stringer, Research assistant, School of Public Health and Social Policy, University of VictoriaWarren Dodd, Assistant Professor, School of Public Health Sciences, University of WaterlooLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1605882021-05-18T21:06:38Z2021-05-18T21:06:38Z3 lessons the COVID-19 pandemic can teach us about preventing chronic diseases<figure><img src="https://images.theconversation.com/files/401417/original/file-20210518-23-1d2i3e0.jpg?ixlib=rb-1.1.0&rect=202%2C0%2C4291%2C2991&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unequal access to preventive resources such as healthy foods, a family doctor, health screening and health promotion programs put some groups at increased risk for chronic illness.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Forty-four per cent of <a href="https://www.canada.ca/en/public-health/services/chronic-diseases/prevalence-canadian-adults-infographic-2019.html">Canadian adults live with at least one chronic health condition</a> such as heart disease, diabetes or a mood disorder. <a href="https://www.who.int/chp/chronic_disease_report/media/Factsheet2.pdf">Up to 80 per cent of these conditions can be prevented</a>. </p>
<p>However, chronic disease prevention and health promotion are not taken seriously enough. Instead, Canadian health care is focused on treating acute and chronic conditions. As a result, the treatment of chronic diseases <a href="https://www.csih.org/sites/default/files/resources/2016/10/elmslie.pdf">costs our health-care system $68 billion per year</a> and overburdens health-care providers.</p>
<p>While the pandemic has focused the world’s attention on how to prevent infectious disease, many of the lessons learned from COVID-19 prevention can also be applied to chronic disease prevention. </p>
<p>We — a scientist who develops health behaviour-change interventions, and a family doctor who is passionate about preventive medicine — have noted several pandemic lessons that could be used to improve chronic disease prevention. Here are three:</p>
<h2>1. Address the inequities</h2>
<p>COVID-19 infections are not evenly distributed among Canadians. Infection rates are <a href="https://doi.org/10.1111/cars.12336">higher in regions with greater proportions of low-income and Black residents</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An urban streetscape" src="https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401420/original/file-20210518-19-gt41p8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People cross the street in a Toronto neighbourhood that Ontario designated a COVID-19 infection hotspot. Infection rates are [higher in regions with greater proportions of low-income and Black residents.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>Likewise, health iniquities mean that racialized and Indigenous people, immigrants, people with disabilities and those affected by poverty <a href="https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research/key-health-inequalities-canada-national-portrait-executive-summary/hir-full-report-eng.pdf">are at increased risk for developing chronic diseases</a>. These groups may not have equitable access to preventive resources such as healthy foods, a family doctor, health screening and health promotion programs. In addition, the stress caused by poverty, trauma and discrimination can affect the body, <a href="https://doi.org/10.24095/hpcdp.35.6.01">increasing the likelihood of developing a chronic disease</a>. </p>
<p>COVID-19 has exposed long-standing health inequities. In response, we’ve seen community groups, public health agencies and governments work together to <a href="https://doi.org/10.1016/j.eclinm.2021.100812">provide free masks, community testing sites, vaccines, and other services in low-income and racialized communities</a>. Health inequities that increase the risk for chronic disease could be eliminated by continuing to provide these types of services to the people most in need.</p>
<h2>2. A one-size-fits-all approach doesn’t work</h2>
<p>Physical distancing can work to reduce the risk of COVID-19, but is impossible if you live in a multi-generational household, use public transportation or have a disability and rely on caregivers. From masks to physical distancing to physical barriers, different types of protection are needed to reduce the risk of COVID-19 spread for people in different circumstances. Even better is when <a href="https://www.cbc.ca/news/canada/british-columbia/south-asian-community-covid-bc-1.5903837">communities are engaged and empowered</a> to develop their own culturally appropriate advice and messages. </p>
<figure class="align-right ">
<img alt="A finger-prick blood sugar monitor" src="https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401422/original/file-20210518-17-19vzjje.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Forty-four per cent of Canadians live with at least one chronic conditions such as diabetes, heart disease or a mood disorder.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Likewise, chronic disease prevention programs must be tailored to take into account a community’s needs and priorities. This is best accomplished by designing programs and policies in partnership with the communities who will use them. Community involvement helps ensure programs are tailored to community members’ needs and that users will benefit. </p>
<p>For instance, researchers from the University of British Columbia <a href="https://ccdpm.med.ubc.ca">Centre for Chronic Disease Prevention and Management</a> worked with nearly 300 community members to design a physical activity program specifically for people with disabilities. Over six months, <a href="https://doi.org/10.1007/s40279-019-01118-5">program participants increased their weekly physical activity by 363 per cent and significantly improved their heart and lung health</a>. The program would not have been so successful had community members not <a href="https://news.ok.ubc.ca/2019/07/09/partnership-key-to-fitness-success-for-people-with-spinal-cord-injury/">helped to tailor the program to the unique challenges and needs of people with disabilities</a>.</p>
<h2>3. We can (and must) get research into practice faster</h2>
<p>The pandemic has shown that science can be drastically accelerated to move innovations quickly from the lab to the community to individual citizens. The pandemic prompted many researchers to pause their own projects and <a href="https://www.the-scientist.com/news-opinion/researchers-from-all-over-the-world-pitch-in-to-fight-covid-19-67698">collaborate worldwide</a> to detect and identify the virus, study its transmission and create and test vaccines. <a href="https://www.canada.ca/en/institutes-health-research/news/2020/03/government-of-canada-funds-49-additional-covid-19-research-projects-details-of-the-funded-projects.html">Funding was allocated to facilitate research collaborations</a>. </p>
<figure class="align-right ">
<img alt="Hands holding a syringe and a vial of vaccine" src="https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=758&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=758&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=758&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=953&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=953&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401421/original/file-20210518-13-ywpk7p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=953&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Funding and co-operation expedited the development, testing and distribution COVID-19 vaccines.</span>
<span class="attribution"><span class="source">HE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>These actions sped up the research process. The findings were then quickly translated into public health advice, guidelines for medical care and vaccines that have been shared and used around the world. </p>
<p>Research can guide which evidence-based chronic disease prevention programs are put into practice. However, the translation of health research evidence into practice is notoriously slow.</p>
<p>A frequently cited study estimated that <a href="https://doi.org/10.1258%2Fjrsm.2011.110180">it takes 17 years to put just a fraction of health research into practice</a>. One reason for this delay is that the scientists who develop and test chronic disease prevention programs, and the community, health-care and government organizations who deliver programs, typically do not work together.</p>
<p>The pandemic has <a href="https://cen.acs.org/biological-chemistry/infectious-disease/How-COVID-19-has-changed-the-culture-of-science/99/i3">changed the culture of science</a>. We have seen the benefits when scientists collaborate across disciplines, and industry and government partners are at the ready to quickly move new discoveries into practice.</p>
<p>If we approached chronic disease prevention with the same urgency, promising evidence-based interventions could be quickly scaled up and delivered in communities across the country. </p>
<p>Applying the lessons of COVID-19 to chronic disease prevention has the potential to benefit millions of Canadians and save billions in health-care costs. The response to the COVID-19 pandemic has proven that focused attention and collaborative efforts can yield effective results in disease prevention and treatment.</p><img src="https://counter.theconversation.com/content/160588/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathleen A. Martin Ginis receives funding from Canadian Institutes of Health Research, Social Sciences and Humanities Research Council of Canada, PRAXIS Spinal Cord Institute, Canadian Tire Jumpstart Charities, and Canada's Digital Supercluster.</span></em></p><p class="fine-print"><em><span>Sarah Brears does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While the pandemic has focused the world’s attention on how to prevent infectious disease, many of the lessons learned from COVID-19 prevention can also be applied to chronic disease prevention.Kathleen A. Martin Ginis, Professor and Director of Centre for Chronic Disease Prevention and Management, University of British ColumbiaSarah Brears, Regional Associate Dean, Interior, Faculty of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1602752021-05-10T14:55:12Z2021-05-10T14:55:12ZOur research shows gaps in South Africa’s diabetes management programme<figure><img src="https://images.theconversation.com/files/398929/original/file-20210505-19-898bla.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes is a leading cause of death in the country.</span> <span class="attribution"><span class="source"> PixelCatchers via GettyImages</span></span></figcaption></figure><p>Diabetes is currently the ninth most common cause of death in the world. Around <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">420 million people or 6% of the world’s population is affected</a>. This number is expected to rise beyond half a billion by the end of the decade with the biggest increase occurring in low- and middle-income countries. </p>
<p>Most people with the condition have <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">type 2 diabetes</a>. This type of diabetes is the result of excess body weight and physical inactivity. </p>
<p>In South Africa, diabetes affects <a href="https://diabetesatlas.org/en/">approximately 4.5 million</a> people. The proportion of the adult population living with the condition is estimated at 12.8%. It’s the leading <a href="https://www.statssa.gov.za/publications/P03093/P030932017.pdf">cause of death</a> among women. In 2019, 89,834 people died of diabetes. This number exceeds the capacity of <a href="http://www.stadiummanagement.co.za/stadiums/fnb/">Soccer City</a>, the biggest football stadium in South Africa.</p>
<p>Most people living with diabetes in South Africa access treatment and care in primary healthcare facilities. Unfortunately, the clinics are often congested and patients have to wait in long queues to receive their medication during their monthly visits. To address these challenges, the National Department of Health initiated a programme in 2014 to improve access to medication and patient adherence. </p>
<p>The programme gives patients with controlled diabetes the option of collecting their medication at pick-up points of their choice such as shops, places of worship, community halls or schools.</p>
<p>But our <a href="https://pubmed.ncbi.nlm.nih.gov/33764132/">recent research</a> found that only a minority of patients enrolled in the programme achieved the treatment targets at the time of the study. We audited the files of patients who had been on the programme for an average of two years (minimum of one year and maximum of five years). Our findings suggest that the criteria used to select people with diabetes for the programme should be revised. In addition, healthcare managers should explore strategies to incorporate diabetes education into the programme.</p>
<h2>Better access to medicines but suboptimal management</h2>
<p>The <a href="https://getcheckedgocollect.org.za/ccmdd/">centralised chronic medicine dispensing and distribution programme</a> was launched in February 2014.
The service is free and benefits the patient in a number of ways. These include: </p>
<ul>
<li>fewer clinic visits, </li>
<li>taking less time off work, </li>
<li>not having to travel long distances, </li>
<li>not waiting in queues, and </li>
<li>collecting medication at any time and place. </li>
</ul>
<p>By definition, patients who are on the programme are stable – meaning that they are doing well. </p>
<p>The clinic nurse or doctor measures the levels of sugar in the blood with a test called <a href="https://www.diabetes.co.uk/fasting-plasma-glucose-test.html">Fasting Plasma Glucose</a>. If two consecutive tests are normal the patient qualifies for the programme. Once enrolled, the patient does not have to come to the clinic to collect medication. Patients on this programme visit the clinic every six months to get checked. </p>
<p>We conducted an audit of the medical records of people with type 2 diabetes who were enrolled in the centralised chronic medicine dispensing and distribution programme at 23 primary healthcare facilities in the Tshwane District of the country’s capital city. The aim was to assess how well the patients were doing at the time. We looked at the most recent test results recorded in their files, namely <a href="https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c">haemoglobin A1C or HbA1c</a>, blood pressure and blood cholesterol. Test results were missing from some patient records, suggesting that patients are not always receiving the tests they are entitled to.</p>
<p>Only 29% of patients in the study had acceptable blood sugar levels. This is concerning because to be eligible for enrolment in the programme, these patients should have been stable controlled patients. Our findings suggest that some patients enrolled in the programme were not stable to begin with. </p>
<p>The suboptimal management of people with type 2 diabetes is worrying especially in the era of the COVID-19 pandemic because <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/covid-19-and-diabetes/1-covid-19-and-diabetes.html">people living with diabetes are more vulnerable</a> to becoming ill or dying from COVID-19. The consequences of high levels of sugar in the blood include blindness, kidney failure, heart attack, stroke, and leg amputation. These complications result in reduced quality of life and higher healthcare costs, and place unnecessary stress on families.</p>
<p>To ensure that patients benefit fully from this programme, the selection criteria should be revised. Instead of using Fasting Plasma Glucose to determine whether a patient qualifies, the HbA1c should be used. Fasting Plasma Glucose is not a reliable indicator of how well a person with diabetes is doing because it measures blood sugar levels at a single point in time. In contrast, HbA1c provides an indication of blood sugar concentrations over the previous two to three months. The benefit of measuring HbA1c is that it gives a more reasonable and stable view of what’s happening over time (three months). And the value does not vary as much as finger-prick blood sugar (Fasting Plasma Glucose) measurements.</p>
<p>This programme limits a patient’s contact with healthcare providers. An unintended consequence is that the person has limited opportunities to be informed about the condition and to be educated on how to best manage diabetes. </p>
<p>For people with chronic conditions such as diabetes, education and empowerment are crucial to ensure better outcomes. The person with diabetes should be equipped to eat well, get enough physical activity and take the correct amount of medication at the right time. </p>
<h2>Addressing the gaps</h2>
<p>Authorities have <a href="http://www.kznhealth.gov.za/mediarelease/2018/nearly-2-million-people-now-fetch-04112018.htm">claimed the success of the programme</a>. But our study identified some gaps that should be addressed. </p>
<p>The centralised chronic medicine dispensing and distribution programme should consider revising how people with type 2 diabetes are selected. It should also include additional measures for patient empowerment and education. </p>
<p>Improving the management and care of people living with diabetes requires innovative evidence-based interventions. Strategic public-private partnerships are key to ensure that the South African government reaches its objectives in terms of providing better lives for people with diabetes. One such initiative is our <a href="https://www.diabetessa.org.za/the-tshwane-insulin-project/">Tshwane Insulin Programme</a> at the University of Pretoria.</p>
<p>Our programme is a partnership between the University of Pretoria and <a href="https://www.lilly.com/impact/lilly-foundation">the Lilly Global Health Partnership</a>. We work closely with the national, provincial and local health authorities to develop sustainable solutions to improve the management and outcomes of people living with diabetes in South Africa.</p><img src="https://counter.theconversation.com/content/160275/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder receives funding from the Lilly Global Health Partnership.</span></em></p><p class="fine-print"><em><span>Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In 2019, 89,834 people died of diabetes. This number exceeds the capacity of Soccer City, the biggest football stadium in South Africa.Patrick Ngassa Piotie, Project Manager, Tshwane Insulin Project, University of PretoriaElizabeth M. Webb, Senior Lecturer, University of PretoriaPaul Rheeder, Project Head, Tshwane Insulin Project, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1584152021-04-06T20:09:41Z2021-04-06T20:09:41ZTargeted texts and peer support: how smarter health care can cut costs and help Australians with chronic conditions<figure><img src="https://images.theconversation.com/files/393495/original/file-20210406-13-1fgfjpi.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C2556%2C1590&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Australia has a health problem. Our health system works well for acute conditions that require short-term treatment such as fractures, pneumonia and appendicitis. </p>
<p>But <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release#chronic-conditions">almost 40% of us</a> have at least one long-term (chronic) physical health condition, such as diabetes, arthritis, a respiratory condition, or kidney disease.</p>
<p>Chronic health conditions need to be managed over time. However, this can be difficult in a health system where payments to health professionals are built around “patient activity”, such as surgeries and consultations. There are few dollars for initiatives that keep people out of hospital or help them to manage their own care.</p>
<p>The result is a high cost — more than <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/disease-expenditure-australia/contents/the-aihw-disease-expenditure-database">A$38 billion per year</a> spent on care for people with chronic health conditions — and too much time spent in hospital. </p>
<p>Our health system can do better. A recent report from the <a href="https://www.pc.gov.au/research/completed/chronic-care-innovations">Productivity Commission</a>, of which I am one of the commissioners, looked at innovations in health care for chronic conditions around Australia. We found many examples of innovative programs in local communities. </p>
<h2>17 innovations</h2>
<p>The Productivity Commission presented case studies of 17 initiatives that have delivered, or are on track to deliver, sustainable outcomes for people living with chronic health conditions and the health system.</p>
<p>Some of these focused on helping people manage their own health. For example, <a href="https://www.semphn.org.au/resources/nellie.html">Nellie</a> is an automated SMS-based persona that sends patients text message reminders about medication, exercise or testing. </p>
<p>Others focused on innovative work practices. For example, on the Sunshine Coast, <a href="https://www.health.qld.gov.au/sunshinecoast/healthcare-providers/gpsi">general practitioners with special interests</a> assist specialists by dealing with less complex episodes of care at hospital outpatient clinics. This helps reduce waiting times. </p>
<p>In <a href="https://phexchange.wapha.org.au/choices-expansion">Perth</a>, peer workers provide support for people with social needs, such as housing, who are at risk of unplanned presentations to emergency departments. For example, the peer workers might offer emotional support and help to navigate community services.</p>
<figure class="align-center ">
<img alt="A woman tests her blood sugar by pricking her finger." src="https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393497/original/file-20210406-23-1fk0ae9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Around 40% of Australians have at least one chronic physical health condition, such as diabetes.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Meanwhile, certain innovations involved the use of health data. For example, <a href="https://primarysense.healthygc.com.au/about">Primary Sense</a> software helps GPs on the Gold Coast better identify people who are at risk of hospitalisation from a chronic health condition in the next 12 months. This helps GPs proactively provide preventative care.</p>
<p>Health data can also improve system coordination and design. <a href="https://www.health.nsw.gov.au/lumos/Pages/default.aspx">Lumos</a>, in New South Wales, uses anonymised data to help GPs better understand their client population, and to identify gaps in health care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-australians-can-stay-healthier-and-out-of-hospital-heres-how-55746">More Australians can stay healthier and out of hospital – here's how</a>
</strong>
</em>
</p>
<hr>
<p>Innovations that have been evaluated often show significant benefits. For example, <a href="https://monashhealth.org/services/monashwatch/">Monash Watch</a>, run by Monash Health in Melbourne, is a simple telephone-based outreach service for people likely to have three or more unplanned hospital admissions in a year. </p>
<p>When it started, Monash Watch aimed to reduce days spent in acute hospital care for these people by 10%. In practice, it’s reducing bed days by <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2018.00376/full">about 20%-25%</a> compared to care as usual.</p>
<h2>Benefits for everyone</h2>
<p>The report shows our health system can deliver better care for people with chronic conditions. In many cases we need funding reform, but this doesn’t have to be large in dollar terms. </p>
<p>For example, <a href="https://www2.health.vic.gov.au/primary-and-community-health/integrated-care/healthlinks">HealthLinks</a>, a program in Victoria, allows hospitals to use existing funds for chronic care innovation. An algorithm identifies people at high risk of multiple unplanned hospitalisations in one year. If the hospital chooses to, it can use the <em>expected</em> funds it would receive from that patient being in hospital for alternative community-based care.</p>
<p>Monash Watch is one of the innovations funded under HealthLinks, while other hospitals have used HealthLinks to fund alternative approaches to chronic health care. But despite underpinning a range of programs, the total funds involved in HealthLinks are small, <a href="https://www2.health.vic.gov.au/primary-and-community-health/integrated-care/healthlinks">around A$40 million</a> in 2016-17, or roughly one-quarter of 1% of Victoria’s annual expenditure on public hospitals.</p>
<figure class="align-center ">
<img alt="A hospital corridor." src="https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=347&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=347&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=347&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=436&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=436&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393498/original/file-20210406-15-1im2ewi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=436&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Innovations which help people manage their chronic medical conditions can free up hospital resources.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Improving care to help people with chronic conditions maintain their health and avoid hospitalisation benefits everyone. </p>
<p>It benefits the individual. I have yet to meet someone who wanted to spend more time in hospital rather than out in the community. </p>
<p>It benefits the community by freeing up hospital beds and shortening waiting times for care. </p>
<p>And it benefits taxpayers, by reducing the need for new hospitals as the population both grows and ages.</p>
<p>So, how can more Australians benefit from these and other health innovations?
Our report highlights three key factors. </p>
<h2>Support, evaluation and communication</h2>
<p>First, our health system needs to better support innovation. Currently, innovations are usually led by a few inspired people. But they face barriers in terms of funding, time and information about what works. They need a “license to innovate” — to try new approaches based on the best available evidence.</p>
<p>If we establish this figurative “license to innovate”, then some failure is inevitable. So second, we need a health system that evaluates innovations, working out which are the best and which were simply a good idea at the time.</p>
<p>Finally, when successful innovations are identified, this must be communicated so they can be scaled up. Sometimes this will involve local adjustments, to allow for population or geographical differences that can affect service delivery. But the key is information — identifying success and letting people know about it.</p>
<p>Creating a culture of innovation and sharing best practice throughout our health system will benefit the growing number of Australians living with chronic health conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/balancing-the-health-budget-chronic-disease-investment-pays-big-dividends-46598">Balancing the health budget: chronic disease investment pays big dividends</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/158415/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen King is a Commissioner with the Productivity Commission. </span></em></p>There are many initiatives around Australia designed to keep people with chronic conditions out of hospital. But to take these further, the health system needs a ‘license to innovate’.Stephen King, Adjunct professor, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1392982020-05-27T07:01:20Z2020-05-27T07:01:20ZA disease that breeds disease: why is type 2 diabetes linked to increased risk of cancer and dementia?<figure><img src="https://images.theconversation.com/files/337527/original/file-20200526-106819-1u4ndjf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5966%2C4028&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In Australia, more than <a href="https://www.aihw.gov.au/reports/diabetes/diabetes-snapshot/contents/how-many-australians-have-diabetes">1.1 million people</a> currently have type 2 diabetes.</p>
<p>A host of potential complications associated with the disease mean a 45-year-old diagnosed with type 2 diabetes will live on average <a href="https://pubmed.ncbi.nlm.nih.gov/18810385/">six years less</a> than someone without type 2 diabetes. </p>
<p>This week we published a <a href="https://baker.edu.au/impact/advocacy/dark-shadow-diabetes">report</a> bringing together the latest evidence on the health consequences of type 2 diabetes.</p>
<p>Aside from demonstrating the complications we know well – like the link between diabetes and <a href="https://pubmed.ncbi.nlm.nih.gov/29520964/">heart disease risk</a> – our report highlights some newer evidence that suggests type 2 diabetes is associated with an increased risk of cancer and dementia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-5-diabetes-57874">How Australians Die: cause #5 – diabetes</a>
</strong>
</em>
</p>
<hr>
<h2>Common complications of type 2 diabetes</h2>
<p>Type 2 diabetes, which typically develops after the age of 40, is usually due to a combination of the pancreas failing to produce enough of the hormone insulin, and the cells in the body failing to adequately respond to insulin. </p>
<p>Since insulin is the key regulator of blood glucose (sugar), this causes a rise in the blood sugar levels. </p>
<p>Risk factors for developing type 2 diabetes include being <a href="https://pubmed.ncbi.nlm.nih.gov/2389754/">overweight</a>, being <a href="https://pubmed.ncbi.nlm.nih.gov/2052059/">physically inactive</a>, having a <a href="https://academic.oup.com/ajcn/article/76/1/274S/4689498">poor diet</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/26429079/">high blood pressure</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746083/">family history of type 2 diabetes</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337844/original/file-20200527-141307-sd1a6m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Being overweight is a risk factor for type 2 diabetes – but not all people with type 2 diabetes are overweight.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>People with type 2 diabetes are about <a href="https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html">twice as likely</a> to develop heart disease than people without type 2 diabetes.</p>
<p>While heart attacks, due to blockages in the coronary arteries, are perhaps the better recognised form of heart disease, heart failure, where the heart muscle is unable to pump enough blood around the body, is becoming more common, especially in people with type 2 diabetes.</p>
<p>This is due to a number of factors, including better treatment and prevention of heart attacks, which has allowed more people to survive long enough to develop heart failure.</p>
<p>People with type 2 diabetes are up to <a href="https://pubmed.ncbi.nlm.nih.gov/29520964/">eight times</a> more likely to develop heart failure compared to those without diabetes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/got-pre-diabetes-heres-five-things-to-eat-or-avoid-to-prevent-type-2-diabetes-80838">Got pre-diabetes? Here's five things to eat or avoid to prevent type 2 diabetes</a>
</strong>
</em>
</p>
<hr>
<p>Meanwhile, diabetes is the most common cause of <a href="https://www.usrds.org/2017/view/Default.aspx">kidney failure</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/17896294/">vision loss</a> in working age adults, and accounts for more than <a href="https://www.safetyandquality.gov.au/publications-and-resources/australian-atlas-healthcare-variation-series">50% of foot and leg amputations</a>.</p>
<p>But beyond these common and familiar complications of diabetes, there’s mounting evidence to suggest type 2 diabetes increases the risk of other diseases. </p>
<h2>Emerging complications of type 2 diabetes</h2>
<p>People with <a href="https://www.bmj.com/content/350/bmj.g7607">type 2 diabetes</a> are approximately two times more likely to develop pancreatic, endometrial and liver cancer, have a 30% higher chance of getting bowel cancer and a 20% increased risk of breast cancer.</p>
<p>Increased cancer risk is of particular concern for the growing number of people <a href="https://www.nature.com/articles/s41574-020-0334-z?proof=true19">under 40</a> living with type 2 diabetes. In Australia, this group saw a significant <a href="https://pubmed.ncbi.nlm.nih.gov/27208325/">increase in deaths</a> from cancer between 2000 and 2011.</p>
<p>Dementia, too, is a recently recognised complication of type 2 diabetes. A meta-analysis involving data from two million people showed people with type 2 diabetes have a <a href="https://pubmed.ncbi.nlm.nih.gov/26681727/">60% greater risk of developing dementia</a> compared to those without diabetes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/type-2-diabetes-increasingly-affects-the-young-and-slim-heres-what-we-should-do-about-it-61283">Type 2 diabetes increasingly affects the young and slim; here's what we should do about it</a>
</strong>
</em>
</p>
<hr>
<h2>Why the increased risk?</h2>
<p>It’s important to acknowledge the studies we looked at are observational and can’t tell us diabetes necessarily caused these conditions. But they do suggest having diabetes is associated with an increased risk.</p>
<p>The two <a href="https://pubmed.ncbi.nlm.nih.gov/25488912/">leading theories</a> for why cancer risk is increased in people with type 2 diabetes relate to glucose and insulin. </p>
<p>Many types of cancer cells use glucose as a key fuel, so the more glucose in the blood, potentially, the more rapidly cancer will grow. </p>
<p>Alternatively, insulin can promote the growth of cells. And since in the early stages of type 2 diabetes insulin levels are elevated, this might also promote the development of cancer.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337843/original/file-20200527-141291-wnuxfk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It’s especially important people with diabetes take up cancer screening programs.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>There are several possible explanations for the link between diabetes and dementia. First, <a href="https://pubmed.ncbi.nlm.nih.gov/24738668/">strokes</a> are more common in people with type 2 diabetes, and both major and repeated mini-strokes can lead to <a href="https://pubmed.ncbi.nlm.nih.gov/19782001/">dementia</a>.</p>
<p>Second, diabetes affects the <a href="https://pubmed.ncbi.nlm.nih.gov/23349494/">structure</a> and function of the smallest blood vessels throughout the body (the capillaries), including in the brain. This may impair the delivery of nutrients to a person’s brain cells. </p>
<p>Third, high glucose levels and other <a href="https://pubmed.ncbi.nlm.nih.gov/16257476">metabolic</a> disturbances associated with diabetes may, over time, directly affect the way certain types of brain cells function. </p>
<h2>Room for improvement</h2>
<p>Despite well-established recommendations for the management of type 2 diabetes, such as guidelines for medication use, healthy diet and regular physical activity, there remains a significant gap between the evidence and what happens in practice. </p>
<p>A study from the US showed only <a href="https://pubmed.ncbi.nlm.nih.gov/30609214/">one in four</a> patients with type 2 diabetes met all the recommended targets for healthy levels of glucose, cholesterol and blood pressure.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/30402916/">Australian data</a> has shown having diabetes is associated with 14% increased likelihood of discontinuing cholesterol medication after one year.</p>
<p>In our <a href="https://baker.edu.au/impact/advocacy/dark-shadow-diabetes">report</a>, we showed increasing the use of a range of effective medications would prevent many hundreds of people with diabetes developing heart disease, strokes and kidney failure each year.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/unscrambling-the-egg-how-research-works-out-what-really-leads-to-an-increased-disease-risk-103990">Unscrambling the egg: how research works out what really leads to an increased disease risk</a>
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<p>With the burden of diabetes complications in our community casting such a large shadow in terms of death rates, disability and impact on the health system, we need greater education and support for people with living diabetes, as well as health professionals treating the condition. </p>
<p>For people with type 2 diabetes, close monitoring for other diseases such as cancer through screening programs is particularly important. </p>
<p>And alongside managing their blood sugar levels, it’s essential Australians with type 2 diabetes are supported to keep risk factors for complications, such as blood pressure and cholesterol, at healthy levels.</p>
<p>A healthy diet and regular physical activity is a good place to start.</p><img src="https://counter.theconversation.com/content/139298/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Climie receives funding from the Heart Foundation. </span></em></p><p class="fine-print"><em><span>Jonathan Shaw receives funding from the National Health and Medical Research Council, AstraZeneca, Merck Sharp & Dohme, Abbott, Sanofi, Eli Lilly, Boehringer Ingelheim and Mylan.</span></em></p>We’ve known for some time type 2 diabetes causes a range of health complications, like heart disease. But now we’re starting to see people with diabetes are more likely to get cancer and dementia too.Rachel Climie, Exercise Physiologist and Research Fellow, Baker Heart and Diabetes InstituteJonathan Shaw, Deputy Director, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1337662020-03-19T04:23:44Z2020-03-19T04:23:44ZCoronavirus will devastate Aboriginal communities if we don’t act now<figure><img src="https://images.theconversation.com/files/320921/original/file-20200317-27648-1kh6m0b.jpg?ixlib=rb-1.1.0&rect=323%2C784%2C4477%2C2411&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/">Kelly Barnes/AAP</a></span></figcaption></figure><p>As the COVID-19 pandemic evolves, we need to ensure the most vulnerable people in our communities aren’t left behind. This includes Aboriginal and Torres Strait Islander people, especially those living in remote and very remote areas.</p>
<p>COVID-19 particularly impacts the elderly and those with underlying conditions such as cardiovascular (heart) disease and diabetes.</p>
<p>For Aboriginal Australians, COVID-19 has great potential to wreak havoc in our communities.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-older-people-more-at-risk-of-coronavirus-133770">Why are older people more at risk of coronavirus?</a>
</strong>
</em>
</p>
<hr>
<p>Around <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-disease/overview">50% of adult First Nations people</a> live with one of the major chronic diseases such as cardiovascular (heart) disease, kidney disease or cancer. Almost one-quarter have two or more of these chronic conditions. </p>
<p>These risks are compounded by where we live. <a href="https://www.aihw.gov.au/reports/indigenous-australians/housing-circumstances-of-indigenous-households/contents/summary">One in eight First Nations people</a> live in overcrowded housing. This means COVID-19 could spread rapidly. And overcrowding poses real challenges for isolating suspected cases. </p>
<p>This overcrowding is worse in remote settings, which face significant challenges in containing and responding to the COVID-19 pandemic because:</p>
<ul>
<li><p>health services are already at capacity</p></li>
<li><p>the workforce is already reliant on fly-in-fly-out staff, including many from New Zealand which has imposed quarantine restrictions</p></li>
<li><p>there is little access to testing for COVID-19, with long delays for results</p></li>
<li><p>little information is available, especially for those who speak English as a second, third or fourth language.</p></li>
</ul>
<h2>How can we mitigate the risk?</h2>
<p>Our communities aren’t sitting idle. They have put in place mitigation strategies and are awaiting further instructions, assistance and financial stimulus to help them through this pandemic. </p>
<p>Some regional groups – such as the Northern Land Council, the <a href="https://www.sbs.com.au/news/indigenous-lands-in-south-australia-are-being-locked-down-to-fend-off-the-risk-of-coronavirus">Anangu Pitjantjara Yankunytjatjara Lands</a> (APY Lands in South Australia) and the Torres Strait Islands and Papua New Guinea <a href="https://www.theguardian.com/world/2020/feb/20/travel-between-torres-strait-islands-and-png-banned-due-to-fears-over-coronavirus">border cross regions</a> – have stopped issuing new permits for visitors and cancelled all non-urgent travel and visits by government and non-government agencies. </p>
<p>The Northern Territory government is <a href="https://www.sbs.com.au/news/do-whatever-it-takes-nt-chief-minister-michael-gunner-says-closing-border-is-still-an-option">also considering a full lockdown</a>, Territory wide. </p>
<p>But these measures are only the start of what is required. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321478/original/file-20200319-129630-1l2097a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some communities are already closed for non-essential visits.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/outback-road-northern-territory-australia-67458217">Shutterstock</a></span>
</figcaption>
</figure>
<p>The National Aboriginal Community Controlled Health Organisation (NACCHO), the peak body representing more than 140 Aboriginal community-controlled health services, has <a href="https://www.abc.net.au/radionational/programs/breakfast/very-very-risky:-indigenous-communities-vulnerable-to-covid-19/12058570">called for</a> urgent information about: </p>
<ul>
<li><p>evacuation procedures for people with COVID-19 and suspected cases</p></li>
<li><p>how to ramp up the workforce and health services in the case of an outbreak </p></li>
<li><p>how to get appropriate, clear and concise messaging out to communities. </p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-singapores-coronavirus-response-worked-and-what-we-can-all-learn-134024">Why Singapore's coronavirus response worked – and what we can all learn</a>
</strong>
</em>
</p>
<hr>
<p>The peak body has also <a href="https://www.abc.net.au/radionational/programs/breakfast/very-very-risky:-indigenous-communities-vulnerable-to-covid-19/12058570">called for</a> a suite of measures to help communities prepare for the pandemic, including:</p>
<ul>
<li><p>regional COVID-19 testing services to be urgently implemented</p></li>
<li><p>support for existing Aboriginal health services to modify their structures and create respiratory clinics away from normal health services </p></li>
<li><p>urgent supplies of personal protective equipment (PPE, which includes gowns, masks and goggles) to be made available</p></li>
<li><p>urgent identification and sourcing of appropriate housing for suspected and confirmed cases</p></li>
<li><p>existing medication supplies not to be interrupted but rather prioritised across all settings </p></li>
<li><p>for access to food and other essential items – such as sanitation supplies, cleaning products and soaps – not to be compromised as the pandemic progresses.</p></li>
</ul>
<h2>We can’t wait long for action</h2>
<p>The warnings from around the world are clear: the earlier these requirements are met, the better the outcomes will be. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321492/original/file-20200319-129679-1l4pg4d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Access to soaps and other sanitation supplies to Aboriginal communities cannot be compromised.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-person-washing-hands-soap-under-219221530">Shutterstock</a></span>
</figcaption>
</figure>
<p>We have a moral responsibility to do better than we did in the 2009 H1N1 pandemic. This pandemic <a href="https://www.mja.com.au/journal/2010/193/6/aboriginal-and-torres-strait-islander-communities-forgotten-new-australian">ended up with</a> 3.2 times more Aboriginal people admitted to hospital than non-Aboriginal people, four times as many admissions to intensive care units and 4.5 times the number of deaths. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-dreaded-duo-australia-will-likely-hit-a-peak-in-coronavirus-cases-around-flu-season-132964">The 'dreaded duo': Australia will likely hit a peak in coronavirus cases around flu season</a>
</strong>
</em>
</p>
<hr>
<p>The Aboriginal Community-Controlled Health services sector has mobilised and leading an advisory group alongside Governments and is meeting regularly to work on a management plan specific to the Aboriginal and Torres Strait Islander populations. </p>
<p>In the coming days and weeks much more will be required to ensure Aboriginal and Torres Strait Islander communities across Australia have protocols in place to respond to the virus, contain it and eventually recover. </p>
<p>In the meantime, we must do all we can to protect our most vulnerable in our communities including our Elders, who are the keepers of knowledge and stories, and the backbones of our communities. If we don’t, we should all hang our heads in shame.</p><img src="https://counter.theconversation.com/content/133766/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Ward is a member of the Communicable Diseases Network Australia. </span></em></p><p class="fine-print"><em><span>Jason Agostino is a Medical Advisor at NACCHO. He is a member of the Aboriginal and Torres Strait Islander Advisory Group on COVID-19.</span></em></p>Aboriginal people are at greater risk of severe illness from COVID-19 than non-Aboriginal people. But plans to protect remote communities and keep the virus out are progressing too slowly.James Ward, Director of POCHE Centre for Indigenous Health, The University of QueenslandJason Agostino, General Practitioner, Gurriny Yealamucka Health Service; Lecturer and Research Fellow, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/876762017-11-27T19:10:15Z2017-11-27T19:10:15ZLow-income earners are more likely to die early from preventable diseases<figure><img src="https://images.theconversation.com/files/196447/original/file-20171127-2009-lwnxxl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you're unable to work as much as you want, you can’t build your wealth, so it’s much tougher to improve your health. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/high-angle-closeup-cashier-entering-price-759735001?src=gRw8Pq4pM3Za2JyqGM-kEQ-1-17">SeventyFour/Shutterstock</a></span></figcaption></figure><p>Australians with lower incomes are dying sooner from potentially preventable diseases than their wealthier counterparts, according to our new report. </p>
<p>Australia’s Health Tracker by Socioeconomic Status, released today, tracks health risk factors, disease and premature death by socioeconomic status. It shows that over the past four years, 49,227 more people on lower incomes have died from chronic diseases – such as diabetes, heart disease and cancer – before the age of 75 than those on higher incomes.</p>
<p>A steady job or being engaged in the community is <a href="https://theconversation.com/unemployed-and-at-risk-more-help-needed-for-those-out-of-work-52968">important to good health</a>. Australia’s unemployment rate is low, but this hides low workforce participation, and a serious problem with underemployment. Casual workers are often <a href="https://theconversation.com/the-costs-of-a-casual-job-are-now-outweighing-any-pay-benefits-82207">not getting enough hours</a>, and more and more Australians are employed on short-term contracts. </p>
<p>There’s a vicious feedback loop – if your health is struggling, it’s harder to build your wealth. If you’re unable to work as much as you want, you can’t build your wealth, so it’s much tougher to improve your health. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-improve-the-nations-health-start-by-reducing-inequalities-and-improving-living-conditions-64434">Want to improve the nation's health? Start by reducing inequalities and improving living conditions</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.vu.edu.au/australian-health-policy-collaboration">Our team</a> tracked health risk factors, disease and premature death by socioeconomic status, which measures people’s access to material and social resources as well as their ability to participate in society. We’ve measured in quintiles – with one fifth of the population in each quintile.</p>
<p>We developed <a href="https://www.vu.edu.au/sites/default/files/AHPC/pdfs/targets-and-indicators-for-chronic-disease-prevention-in-australia.pdf">health targets and indicators</a> based on the <a href="http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1">World Health Organisation’s 2025 targets</a> to improve health around the globe. </p>
<p>The good news is that for many of the indicators, the most advantaged in the community have already reached the targets. </p>
<p>The bad news is that poor health is not just an issue affecting the most vulnerable in our community, it significantly affects the second-lowest quintile as well. Almost ten million Australians with low incomes have much greater risks of developing preventable chronic diseases, and of dying from these earlier than other Australians. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196438/original/file-20171127-2025-3i6zts.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Australian Health Policy Collaboration</span></span>
</figcaption>
</figure>
<h2>Big disparities</h2>
<p>People living in the two lower socioeconomic quintiles (the poorest 40% of the population) are much more likely to be obese; less likely to do exercise; and much more likely to smoke. For these measures, the differences between the highest two socioeconomic quintiles and the lower two are stark. Obesity is 35% more prevalent, activity levels are 22% lower, and smoking rates – which are going down overall – are almost double. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=661&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=661&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=661&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=830&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=830&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196439/original/file-20171127-2016-xop58z.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=830&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Australian Health Policy Collaboration</span></span>
</figcaption>
</figure>
<p>The targets in <a href="https://www.vu.edu.au/sites/default/files/australias-health-tracker-adult.pdf">Australia’s Health Tracker</a> are modest and achievable. Our target for obesity, for example, is to reduce the rate from 27.9% to 24.6% (<a href="http://www.oecd.org/health/health-systems/Obesity-Update-2017.pdf">the OECD average is under 20%</a>). The most advantaged in the community have already achieved this target, while the rate in the most disadvantaged quintile is over 33%.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=665&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=665&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=665&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=836&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=836&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196429/original/file-20171127-2055-597iq8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=836&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Australian Health Policy Collaboration</span></span>
</figcaption>
</figure>
<p>Disease rates are also higher. Bowel cancer is 30% more likely to be detected, even though fewer people are tested. Diabetes is 33% more prevalent in the two lower socioeconomic quintiles than the top two. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=658&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=658&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=658&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=827&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=827&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196430/original/file-20171127-2004-58qi4w.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=827&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Australian Health Policy Collaboration</span></span>
</figcaption>
</figure>
<p>The differences in rates of early death between the lowest and highest categories are most staggering. People in the lower two socioeconomic quintiles (40% of the community) are:</p>
<ul>
<li>Almost twice as likely to die from a cardiovascular disease such as stroke or heart attack</li>
<li>Almost 40% more likely to die from cancer</li>
<li>More than twice as likely to die from a respiratory disease</li>
<li>Almost three times as likely to die from diabetes. </li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-5-diabetes-57874">How Australians Die: cause #5 – diabetes</a>
</strong>
</em>
</p>
<hr>
<p>Even where there is no disease causing death, suicide is much more likely the more disadvantaged you are. The suicide rate is 50% higher in the lower two quintiles than the top two socioeconomic quintiles. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=664&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=664&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=664&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=834&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=834&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196440/original/file-20171127-2009-1vm0r1f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=834&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Australian Health Policy Collaboration</span></span>
</figcaption>
</figure>
<p>One in two Australians have a chronic disease and those on a low income are disproportionately affected. But, crucially, <a href="https://www.aihw.gov.au/reports/burden-of-disease/australian-burden-of-disease-study-impact-and-causes-of-illness-and-death-in-australia-2011/contents/highlights">one-third of the disease burden</a> is preventable.</p>
<h2>What can we do about it?</h2>
<p>Australia’s health services are well regarded internationally. Our expenditure on health services, <a href="https://www.aihw.gov.au/reports-statistics/health-welfare-overview/health-welfare-expenditure/overview">10.3% of GDP</a>, compares favourably with <a href="http://www.oecd.org/health/health-systems/health-data.htm">that of like countries</a>. </p>
<p>One glaring exception is investment in prevention and early intervention strategies. Only 1.3% of the Australian health budget <a href="http://fare.org.au/wp-content/uploads/Preventive-health-How-much-does-Australia-spend-and-is-it-enough_FINAL.pdf">is spent on prevention</a>. This is significantly less than countries such as <a href="https://www.vu.edu.au/sites/default/files/AHPC/pdfs/Chronic-diseases-in-Australia-the-case-for-changing-course-sharon-willcox.pdf">New Zealand, Finland and Canada</a>, which spend around 6% on prevention. </p>
<p>We have limited investment in national screening programs other than for high profile cancers. <a href="https://www.vu.edu.au/sites/default/files/ahpc-heart-health-policy-paper.pdf">A national screening program for risks for heart disease</a>, for example, would save lives and reduce health care costs for individuals and the national health budget.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
</strong>
</em>
</p>
<hr>
<p>Improving health for people with low incomes and resources needs a comprehensive government commitment. We need to: </p>
<ul>
<li><p>invest in prevention and early intervention through <a href="https://www.vu.edu.au/sites/default/files/getting-australias-health-on-track-ahpc-nov2016_0.pdf">targeted health funding and services</a></p></li>
<li><p>provide healthier environments, better access to healthy food and improved support for improved physical activity, such as encouraging more children to walk to school, and</p></li>
<li><p>protect children from junk food and soft-drink marketing and supply, through a levy on drinks with added sugar and restricting advertising to children. </p></li>
</ul>
<p>We need to tailor health care to prevention and early intervention for those most at risk, and we need to invest in healthy environments. Both are sound economic investments that will improve health, productivity and economic prosperity.</p><img src="https://counter.theconversation.com/content/87676/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australians with lower incomes are dying sooner from potentially preventable diseases than their wealthier counterparts, according to our new report.Ben Harris, Policy Associate, Australian Health Policy Collaboration, Victoria UniversityRosemary V Calder, Director, Health Policy, Victoria UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623482016-07-22T00:28:45Z2016-07-22T00:28:45ZFive tips to get the government started on real health reform<p>Since the election, the Turnbull government has received a <a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">great deal of advice</a> on how to counter the pervasive public scepticism about its ongoing commitment to the universality of Medicare. </p>
<p>While the impacts of the so-called <a href="https://theconversation.com/labors-mediscare-campaign-capitalised-on-coalition-history-of-hostility-towards-medicare-61976">Mediscare campaign</a>, the <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">Medicare rebate freeze</a> and the <a href="https://theconversation.com/federal-budget-2016-health-experts-react-58638">“zombie” policies</a> left over from the 2014-15 budget have driven these calls for Coalition action, the real issue is that the previous Abbott-Turnbull government had no health policy agenda, other than budget cuts and the <a href="http://www.powertopersuade.org.au/blog/social-service-futures-the-marketisation-of-healthcare-services-when-political-mantras-win-out-over-evidence-and-patients-needs/7/4/2016">covert exploration</a> of privatisation and competition in the delivery of health-care services.</p>
<p>In this new term, the government must do more to deliver the health-care system we need for the 21st century – not just to improve its standing with voters, but to meet the health needs of all Australians. Much of this can be achieved through new ways of thinking about policy development and implementation rather than new spending.</p>
<p>Even so, some new funds will be needed. The government and its bean counters must move beyond seeing the health-care budget as a drain on finances and treat it as an <a href="http://ftp.iza.org/pp57.pdf">investment</a> in the health, productivity and prosperity of the nation. This approach will help concentrate efforts on evidence and value rather than ideologically based, slash-and-burn approaches.</p>
<h2>1. Patients must be the centre of the health system</h2>
<p>The health-care system exists primarily for the benefit of patients, but their voices are so rarely heard. Every policy, budget measure and proposal must be considered through the patient lens. </p>
<p>That does not mean the impacts on providers (hospitals, clinicians and health insurers) should not be considered; they are also stakeholders and usually the decision-makers. But the government’s first instinct has been to consult with privileged groups such as the Australian Medical Association and private health insurers, rather than with the public, patients and providers at the coalface.</p>
<p>Importantly, viewing health reform through a patient lens will help policymakers identify disadvantaged groups so they can target their specific needs. </p>
<h2>2. Invest in health promotion, not just illness treatment</h2>
<p>Prevention is as much a responsibility of government as it is for individuals. This is particularly the case for obesity. </p>
<p>As a nation, we all bear the substantial and growing economic and social <a href="http://www.health.gov.au/internet/preventativehealth/publishing.nsf/content/E233F8695823F16CCA2574DD00818E64/$File/obesity-2.pdf">costs of obesity</a> and its consequences, especially <a href="https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/e7282521-472b-4313-b18e-be84c3d5d907.pdf">diabetes</a>. Every day, 12 Australians have an <a href="https://www.diabetesaustralia.com.au/news/15266?type=articles">amputation</a> related to diabetes at a cost of A$875 million a year. Almost all of this is preventable.</p>
<p>The investments made in prevention must be proportional to the <a href="http://www.powertopersuade.org.au/blog/an-evidence-based-approach-to-tackling-the-burden-of-disease-and-injury-lessons-from-the-recent-aihw-burden-of-disease-study/16/5/2016">burden of disease</a> in terms of resources and commitment. Concerns about sensible budget policies must override ideological concerns about the nanny state.</p>
<h2>3. Make health-care reforms sustainable</h2>
<p>This means ceasing the start-stop approach of small-scale pilot programs that never go beyond three years and are evaluated only after they are concluded in reports that never see the light of day. Real reforms will also require time frames well beyond those of the election cycle.</p>
<p>Labor has proposed a promising way forward: a permanent <a href="http://www.100positivepolicies.org.au/australian_healthcare_reform_commission_fact_sheet">Australian Healthcare Reform Commission</a>, which would include a new Centre for Medicare and Healthcare System Innovation to embed continuous reform into the health-care system. </p>
<p>This type of approach – where models can be seamlessly developed, implemented, assessed, adjusted and expanded – is essential for reforms such as the government’s proposed <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley021.htm">Health Care Homes trial</a> to better manage chronic disease, and for complicated issues such as mental health reforms.</p>
<h2>4. Apply a whole-of-government approach to health</h2>
<p>The health and well-being of the population depend on issues well beyond the health portfolio and require a health-in-all policy approach in all government portfolios. This is a matter of leadership and cultural change, not new expenditures and regulations.</p>
<p>“Wicked” issues such as obesity, mental health, healthy ageing and Closing the Gap on Indigenous disadvantage can only be effectively addressed through such whole-of-government approaches.</p>
<h2>5. Data is key</h2>
<p>Research, data analyses and evaluation are key to health-care reforms.</p>
<p>The antipathy of the previous government to evidence-based policymaking was exemplified by the <a href="http://www.smh.com.au/business/federal-budget/more-than-70-government-agencies-to-be-scrapped-consolidated-in-federal-budget-20140513-3884k.html">scrapping or downgrading</a> of key agencies and the <a href="http://www.smh.com.au/comment/australias-primary-health-care-research-needs-an-urgent-check-20160418-go8xig.html">defunding</a> of the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy and the Better Evaluation and Care of Health (BEACH) study.</p>
<p>These losses must be rectified, but it is also time for the Department of Health to start mining the archives. There are mountains of reports, papers and evaluations, together with significant, policy-relevant primary health care research commissioned by the department through the <a href="http://aphcri.anu.edu.au/">Australian Primary Health Care Research Institute</a>, to be used in improving the delivery and financing of health-care services.</p>
<p>At the same time, there should be a moratorium on shunting off difficult problems to committees as an excuse for inaction. There will be occasions when it is necessary to convene advisory groups. That should be done using the experts who will provide the advice that is needed, not the usual hacks who provide the advice the government wants.</p>
<h2>So where do we start?</h2>
<p>I rate the following as the key issues:</p>
<ul>
<li><p>the renewal and revitalisation of the commitment to Close the Gap, with the inclusion of a <a href="https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/projects/close-gap-indigenous-health">social justice target</a> and meaningful involvement of Indigenous communities</p></li>
<li><p>federal leadership in the implementation of <a href="https://theconversation.com/mental-health-changes-should-be-judged-on-outcomes-not-promises-51303">mental health reforms</a> to improve access to treatment and care, and to tailor responses to individuals’ needs. Such mental health reforms have been left to flounder between the <a href="https://theconversation.com/au/topics/ndis">National Disability Insurance Scheme</a> and the Primary Health Networks</p></li>
<li><p>the effective implementation of <a href="http://medicalhome.org.au/what-is-a-medical-home/">patient-centred medical home</a> models of care for people with chronic illness. This means patients have a regular general practice that coordinates all their primary, specialist and allied health care</p></li>
<li><p>fast-tracking the <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mbsreviewtaskforce">review of the 5,700 items on the Medical Benefits Schedule</a>, removing items that aren’t evidence-based or no longer reflect good clinical practice, and adding necessary new items. Progress on this important work is too slow</p></li>
<li><p>tackling inequalities in <a href="https://theconversation.com/for-real-health-reform-turn-the-spotlight-on-specialists-fees-37111">access to specialist out-patient care</a>, including high rates of out-of-pocket costs</p></li>
<li><p>containing the <a href="https://theconversation.com/for-real-health-reform-turn-the-spotlight-on-specialists-fees-37111">cost blow-out of the private health insurance rebate</a> and ensuring health insurance provides value to consumers who purchase it.</p></li>
</ul>
<p>In 2007, my colleagues and I outlined the <a href="https://www.mja.com.au/journal/2007/187/9/challenges-health-and-health-care-australia">challenges to health care</a> facing the incoming Rudd government. Regrettably this nine-year-old document could serve the same purpose today, so little has changed. </p>
<p>Will Prime Minister Malcolm Turnbull now bring to the health-care sector the innovation he says holds the key to Australia’s future?</p><img src="https://counter.theconversation.com/content/62348/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government must do more to deliver a 21st-century health system – not just to improve its standing with voters but to meet the health needs of all Australians.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/618662016-07-10T06:03:38Z2016-07-10T06:03:38ZRemind me again, what did the Coalition promise during the election campaign?<figure><img src="https://images.theconversation.com/files/129058/original/image-20160702-18294-9xtlnr.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1522%2C995&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After days of waiting, Malcolm Turnbull will form a government.</span> <span class="attribution"><span class="source">AAP/Lukas Coch</span></span></figcaption></figure><p><em>After a protracted wait Bill Shorten has conceded the election to Malcolm Turnbull, meaning the Coalition will form government. The Conversation’s editors have assembled a guide to what the Coalition says it will do in 11 key policy areas.</em></p>
<hr>
<p><iframe id="tc-infographic-197" class="tc-infographic" height="800" src="https://cdn.theconversation.com/infographics/197/b2b0c056c7d030d3c6f04633950ea4f6c9d0b75a/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p><img src="https://counter.theconversation.com/content/61866/count.gif" alt="The Conversation" width="1" height="1" />
What did the Coalition promise during the campaign in 11 key policy areas, from health to infrastructure to jobs?Michael Courts, Deputy Section Editor: Politics + SocietyEmil Jeyaratnam, Data + Interactives Editor, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/610832016-06-23T20:05:29Z2016-06-23T20:05:29ZWhat do the Liberal and Labor election health promises mean for you?<figure><img src="https://images.theconversation.com/files/127853/original/image-20160623-30278-1lumbqs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health is the most important election issue for Australians aged over 50.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-50920687/stock-photo-closeup-of-joined-hands-of-nurse-and-elderly-patient.html?src=m7AgHlsCbB9aJ5lCxmHYqw-3-66">StockLite/Shutterstock</a></span></figcaption></figure><p>Health is always a key factor in deciding which way to vote. A recent survey found health is the <a href="http://www.smh.com.au/federal-politics/federal-election-2016/federal-election-2016-council-on-the-aging-survey-finds-health-matters-most-20160612-gphfix.html"><em>most</em> important issue</a> for over-50s this federal election, moving past economic management for the first time. </p>
<p><a href="http://www.cota.org.au/australia/News/NewsList/2016/healthcare-retirement-incomes-aged-care-economy-say-older-australians.aspx">One-third of respondents</a> believe Labor is best placed to manage health care, with 14% preferencing the Coalition and just 8% favouring the Greens.</p>
<p>So what have the major parties promised in health? And what could these changes mean for consumers? </p>
<h2>Medicare</h2>
<p>Labor claims that under the Coalition, Medicare will be “sold off”. Opposition leader Bill Shorten reminded the electorate that one of the first activities of the Abbott government was to <a href="http://www.abc.net.au/news/2014-03-26/government-announces-sale-of-medibank-private/5347136">privatise</a> Medibank Private. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"744687539609436160"}"></div></p>
<p>Prime Minister Turnbull has accused Labor of running a scare campaign, <a href="http://www.news.com.au/national/federal-election/scare-campaign-could-hamper-attempts-to-boost-medicares-efficiency/news-story/fe9e1ae2b30ee2e2f8ec9aa817448579">saying</a>:</p>
<blockquote>
<p>Medicare will never be privatised. It is a core government service. </p>
</blockquote>
<p>Beyond Medicare remaining a public entity, there are some key differences in the parties’ election promises.</p>
<p>The Coalition has committed to <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">extending the Medicare rebate freeze</a> to 2020 and abolishing the bulk-billing incentives for pathology (blood and tissue tests) and radiology (X-rays and MRIs). </p>
<p>Extending the rebate freeze means doctors will be paid the same for consultations in 2020 as they were in 2014. They’re likely to eventually pass the difference on to patients. </p>
<hr>
<blockquote>
<p><em>Further reading:</em> <a href="https://theconversation.com/confused-about-the-medicare-rebate-freeze-heres-what-you-need-to-know-59661">Confused about the Medicare rebate freeze? Here’s what you need to know</a></p>
</blockquote>
<hr>
<p>Removing bulk-billing incentives may mean patients have to pay a co-payment and some providers have stated this could amount to around <a href="http://www.abc.net.au/news/2016-04-20/bulk-billing-incentives-to-be-scrapped-sussan-ley-says/7340198">A$30</a> per patient. </p>
<p>Labor has committed to ending the rebate freeze in early 2017 and will continue to fund bulk billing incentives for pathology and radiology. Ending the freeze is anticipated to cost <a href="https://theconversation.com/shorten-government-would-end-freeze-on-medicare-rebates-59655">A$2.4 billion</a> in forward estimates and keeping bulk-billing incentives a further <a href="http://www.smh.com.au/federal-politics/federal-election-2016/federal-election-labor-promises-to-continue-funding-bulkbilling-incentives-for-pathology-radiology-20160618-gpmd3m.html">A$884 million</a> over the next four years. </p>
<p>But Labor argues this is important to stop patients being charged co-payments and to encourage people to seek scans and tests to diagnose illnesses such as cervical cancer. </p>
<p><strong>What do the Medicare promises mean for voters?</strong> </p>
<p>Under the Coalition, GPs, pathologists and radiologists may pass on some of the reductions in funding to the consumer. This could result in lower rates of bulk billing and higher co-payments. </p>
<p>Under Labor, costs of visits to the GP, blood tests and X-rays are less likely to rise, but these come with a significant cost to the public purse.</p>
<h2>Private health insurance</h2>
<p>Private health insurance is one of the few areas in health in which Labor has announced funding cuts, <a href="http://www.news.com.au/national/federal-election/pledge-to-remove-natural-therapies-from-health-insurance-cover-could-turn-off-the-young/news-story/b4c8b70f041c2cc316f73bf0a88ade6c">projecting A$3 billion in savings</a> by freezing the private health insurance rebate for another five years and removing the rebate for natural therapies.</p>
<p>The Coalition argues Labor’s plans amount to charging those who use private health insurance to pay for the opposition’s other health commitments. The Coalition says private health insurance is a fundamental element of the health system, which is important to offer consumers greater choice over their care and take pressure off the public system.</p>
<p>The Coalition’s election promises for private health insurance focus on creating a more simplified scheme that it is <a href="https://www.liberal.org.au/latest-news/2016/06/12/coalitions-plan-ensure-private-health-insurance-delivers-value-money">easier to navigate</a> and understand which company provides best value for money. </p>
<p>Rules will be introduced for plain English disclosures and there will be gold, silver and bronze categories of cover so that policies are easy to compare. Simplified billing will be developed, as will standard definitions for procedures so they are easily comparable.</p>
<p><strong>What do the private health insurance promises mean for voters?</strong> </p>
<p>Under Labor, people with health insurance will face rising costs and some therapies that are currently covered will be removed. </p>
<p>Under the Coalition, private health insurance will become easier to navigate and use.</p>
<h2>Hospital funding</h2>
<p>Hospital funding has long been the focus of funding disputes between state and federal governments. Following the 2014 budget, when the Abbott government cut <a href="http://www.abc.net.au/news/2016-06-12/federal-opposition-promises-to-increase-hospital-funding/7502940">A$80 billion</a> in health and education funding, hospitals argued they were significantly underfunded and that this would have implications for the quality of care. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127861/original/image-20160623-30267-1b9a8hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The additional hospital funds are a drop in the ocean.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-143642491/stock-photo-female-nurse-with-patient-in-hospital-bed.html?src=4ElAHlborgpiVhBAFdyG9Q-1-39">Blend Images/Shutterstock</a></span>
</figcaption>
</figure>
<p>The recent Council of Australian Governments (COAG) agreement to <a href="https://theconversation.com/another-day-another-hospital-funding-dispute-how-to-make-sense-of-todays-coag-talks-57058">give the states additional funding</a> for public hospitals has been welcomed, but hospitals have maintained it’s not enough to guard against increased waiting times for emergency and elective care. </p>
<p>Given this history, it’s no surprise to see both parties promise more funding to hospitals. The Coalition has pledged an extra A$2.9 billion to states for hospital funding and committed to fund 45% of the growth in costs. Labor has promised <a href="http://www.billshorten.com.au/reduced_hospital_waiting_times_better_health_for_all_australians_sunday_12_june_2016">an additional A$2 billion</a> – on top of the Coalition’s A$2.9 billion – and will fund 50% of the growth in costs.</p>
<p><strong>What do the hospital funding promises mean for voters?</strong></p>
<p>Around <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547594">A$42 billion</a> is spent on Australian public hospitals each year. Although the extra funding promised by both parties may seem like it should improve access to emergence and elective care, the additional funds are a drop in the ocean. </p>
<p>There is also a growing case to suggest more money for hospitals won’t necessarily fix the challenges they face. Instead, hospitals need to work in a <a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">smarter</a> way. </p>
<h2>Chronic disease management through strengthening primary care</h2>
<p><a href="http://www.aihw.gov.au/media-release-detail/?id=60129552034">One in five</a> Australians has a chronic and complex disease such as diabetes, heart disease, asthma, or cancer. All the major parties have recognised the need to do more to allow these people to stay in their own homes for longer and prevent unnecessary hospital admissions.</p>
<p>The Coalition has committed <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley024.htm">A$21million</a> to trial Health Care Homes. These will introduce a more flexible payment structure for general practitioners, with the aim of better supporting the chronically ill to stay out of hospital.</p>
<hr>
<blockquote>
<p><a href="https://theconversation.com/time-for-better-chronic-disease-management-in-primary-care-57035">Read more on the Health Care Homes trial</a></p>
</blockquote>
<hr>
<p>Labor has committed A$100 million to trial a new primary care model known as <a href="http://www.100positivepolicies.org.au/strengthening_medicare_new_models_of_care">Your Family Doctor</a>. As with the Coalition’s Health Care Homes, these focus on improving the relationship between GPs and patients, providing more integrated and preventative services, and developing more innovative ways to deliver primary care.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127862/original/image-20160623-30278-1pfeelv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Good primary care is the bedrock of a strong health system.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-284516555/stock-photo-female-consultant-working-at-desk-in-office.html?src=SQRxw8Hrpw5QTHpNhl2rLQ-1-42">Monkey Business Images/Shutterstock</a></span>
</figcaption>
</figure>
<p>The Greens have also made significant commitments in this space, arguing that primary care in Australia does not sufficiently meet the needs of those with multiple chronic diseases. The party has promised <a href="http://greens.org.au/primary-care">A$4.3 billon</a> over four years.</p>
<p>Central to this plan is bolstering the role of Primary Health Networks (PHNs) to give them primary responsibility for improving chronic disease management. Of the $4.3 billion:</p>
<ul>
<li>A$1.5 billion has been earmarked to give GPs A$1,000 per patient with a chronic disease to provide high quality care for one year</li>
<li>A$2.8 billion is to give patients access to allied health practitioners via PHNs</li>
<li>A$11.9 million will be used to develop standardised models of chronic disease management which will be used across the country.</li>
</ul>
<p>These promises to strengthen primary care are in line with the international literature, which suggests this is the bedrock of <a href="http://www.bmj.com/content/347/bmj.f4627">high quality health services</a>. </p>
<p><strong>What do the chronic disease management promises mean for voters?</strong></p>
<p>Although it may look like Labor and the Coalition are promising significant funds to improve chronic disease management and primary care, these pale next to the amounts promised to hospitals. </p>
<p>It’s unclear whether Your Family Doctor and Health Care Home will be able to make a significant difference to people with chronic disease. They have broadly similar visions for changes to payment structures, preventing hospital admission and making greater use of a range of professionals in the care of individuals. </p>
<p>Only the Greens have promised a significant injection of cash and seem to have developed a comprehensive vision for the future of primary care. </p>
<h2>Long-term reform is still missing</h2>
<p>All parties argue they are committed to maintaining universal health services. Labor, and to some extent the Greens, plans to do this through a cash injection to the system and making savings on private health insurance. The Coalition is committed to more limited investments but with a desire to better use existing resources – including the private health system.</p>
<p>But none of the election commitments will deliver the level of reform <a href="https://books.google.com.au/books?hl=en&lr=&id=nIwtDAAAQBAJ&oi=fnd&pg=PT25&dq=australian+health+system+fundamental+reform&ots=v910Vi1pXN&sig=dKWsE_yRNq4gzLzslmGiqOS2vKc#v=onepage&q=australian%20health%20system%20fundamental%20reform&f=false">needed</a> to ensure the health system performs as well in the future as it does now.</p><img src="https://counter.theconversation.com/content/61083/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Dickinson receives funding from Federal Department of Health </span></em></p>Health is always a key factor in deciding which way to vote. So what have the major parties promised in health? And what could these changes mean for consumers?Helen Dickinson, Associate Professor, Public Governance, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/570582016-03-31T19:20:43Z2016-03-31T19:20:43ZAnother day, another hospital funding dispute – how to make sense of today’s COAG talks<p>The Council of Australian Governments (COAG) will today consider a <a href="https://www.scribd.com/doc/306421107/DRAFT-Heads-of-Agreement-Coag">proposal from the Prime Minister</a> to give additional funding to the states for public hospitals. </p>
<p>The Commonwealth is partially reversing cuts it made to public hospital funding in its 2014 budget, offering a new A$3-5 billion three year deal. But the deal has some unwelcome strings attached and <a href="https://ama.com.au/ausmed/hospital-funding-deal-%E2%80%98not-enough%E2%80%99">does not meet the funding gap created by the 2014 cuts</a>.</p>
<h2>The history</h2>
<p>Hospital funding has long been the subject of acrimonious and unedifying funding disputes between the federal and state governments. </p>
<p>The first one of these <a href="http://search.proquest.com/openview/567499823ded382396bd555639785a32/1?pq-origsite=gscholar&cbl=1816419">occurred in 1976</a>, just one year after Medibank – the precursor to Medicare – was introduced. In a saga strangely similar to what ran 40 years later, a Liberal government had promised prior to the election to maintain the hospital funding scheme and then ignored its promise. The Australian Financial Review editorial on the topic was headed, “Mr Fraser’s Shabby Renege.” </p>
<p>The introduction of Medicare in 1984 started a see-saw approach to hospital funding (see the graph below). Three- to five-year hospital funding agreements were negotiated between the Commonwealth and the states. This was adequate in the first few years but less so in the last few.</p>
<p>Renegotiations were always vociferous and bitter, with each level of government blaming the other for system inadequacies. Each new agreement resulted in an injection of funds which were, in time, whittled away.</p>
<p>The Gillard government attempted to push the reset button by moving to a long-term funding arrangement where the Commonwealth took on a specific share of the growth in hospital costs, initially set at 45%, due to rise to 50% from July 1, 2017.</p>
<p>In opposition, then Leader Tony Abbott endorsed this approach. The <a href="http://www.liberal.org.au/latest-news/2013/08/22/tony-abbott-coalitions-policy-support-australias-health-system">election policy of the Coalition</a> made this commitment:</p>
<blockquote>
<p>Our public hospital system needs certainty … A Coalition government will support the transition to the Commonwealth providing 50% growth funding of the efficient price of hospital services as proposed. But only the Coalition has the economic record to be able to deliver. </p>
</blockquote>
<p>The 2014 Budget, though, led to another “shabby renege” as this commitment was tossed aside in a flurry of broken promises across a range of portfolios. The 2014 budget created a huge fiscal cliff for the states from July 1, 2017 by replacing a 45% cost sharing scheme with indexation unrelated to either actual hospital cost movements or increases in hospital demand. </p>
<p>This is the problem to be addressed today.</p>
<h2>The Turnbull proposal</h2>
<p>On the table for discussion today is a return to 45% cost sharing for a three year interim period (July 1, 2017 to July 1, 2020) with a couple of twists. </p>
<p>First, growth will be capped at 6%, protecting the Commonwealth’s budget position but imperilling the states.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=354&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=354&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=354&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=445&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=445&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116890/original/image-20160331-9712-ufsq2f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=445&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.aihw.gov.au/publication-detail/?id=60129553112">Australian Institute of Health and Welfare, Health Expenditure Australia 2013-14.</a></span>
</figcaption>
</figure>
<p>Over the decade 2003-04 to 2013-14, expenditure on public hospitals <a href="http://www.aihw.gov.au/publication-detail/?id=60129552713">increased by around 8% each year</a> (in current dollars). Growth in the last five years (2008-09 to 2013-14) has been slightly less at 6.4%, still above the Commonwealth’s proposed 6% cap. </p>
<p>With states spending around A$25 billion on public hospitals in 2013-14, 0.1% is not a rounding error but is worth millions of dollars to states.</p>
<p>Second, the Commonwealth will top-slice the hospital funding by a further A$70 million to fund its <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2016-ley021.htm">primary care reforms</a> announced yesterday. </p>
<p>It is a puzzle why the Commonwealth wants to muddy the waters this way as these reforms – which essentially involve pilots of major system reform – could quite reasonably fit within the guidelines for spending from the <a href="https://www.legislation.gov.au/Details/C2015A00116">Medical Research Future Fund</a> which <a href="http://www.futurefund.gov.au/">currently has</a> more than A$3 billion in assets interest on which could easily cover the A$70 million requested.</p>
<p>Other proposed reforms include incorporating financial incentives for improving quality and safety of care and reducing avoidable re-admissions. Both are to be welcomed.</p>
<p>Missing are other potential reforms such as ditching a cluster of small grants to states that tie them up in red tape, and constrain their autonomy to design the best way of meeting local health needs.</p>
<h2>Prognosis</h2>
<p>Although there may be some posturing, the states will probably sign off on the broad direction of the public hospital proposals put before them. After all, they are a significant improvement on where they were left after the 2014 Budget. </p>
<p>The debate will probably be around the edges. The A$70 million primary care irritant should be withdrawn or modified. There is probably some room to move on both the 6% cap and how it is implemented – 6% is probably too tight.</p>
<p>On the whole, the day will probably result in a good outcome for the public hospital system, avoiding, at least for the time being, the perilous position created by the 2014 Commonwealth Budget.</p>
<p>Some may quibble about the difference between the Turnbull 45% share and the previous Gillard 50% promise, and the difference is significant both for the states (who miss out on substantial potential funding) and the Commonwealth (who restrain their outlays). I am not in that camp. </p>
<p>A major benefit of the proposal on the table today is that it restores cost sharing. This means that the Commonwealth again has skin in the game in terms of increases in public hospital costs. It again will cause the Commonwealth to focus its mind on what it can do in areas of its policy responsibility to rein in those costs. </p>
<p>A 45% share is clearly enough to create such an incentive on the Commonwealth as evidenced in the primary care proposals linked to the public hospital funding proposal.</p>
<p>The three-year term for the agreement means there will be further scope for discussion before the next federal election after this, ensuring that the public hospital hot potato will still be around for a few more years.</p><img src="https://counter.theconversation.com/content/57058/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is a consultant to the Independent Hospital Pricing Authority which sets the National Efficient Price used in Activity Based Funding and is a member of a number of their committees and working groups.</span></em></p>The Commonwealth wants to partially reverse the cuts it made to public hospital funding in the 2014 budget. But the deal has some unwelcome strings attached.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/544002016-03-22T19:38:50Z2016-03-22T19:38:50ZText message medication reminders can save the lives of those with chronic illness<figure><img src="https://images.theconversation.com/files/114802/original/image-20160311-11267-1qqyv65.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with a chronic illness find it challenging to keep to their medication regime.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>If you are diagnosed with a chronic disease, chances are you’ll have to manage it for the rest of your life. This means changing your lifestyle and taking medications as directed.</p>
<p>Many find this challenging. In fact, within a year of being diagnosed with a chronic condition, <a href="http://www.ncbi.nlm.nih.gov/pubmed/19528344">only 50% of patients</a> still take their medications correctly. </p>
<p>Some have stopped altogether. These patients can unwittingly put themselves at greater risk of heart attack, stroke or premature death. So how can we ensure this doesn’t happen?</p>
<h2>Why you should take your medication</h2>
<p>Chronic conditions such as cardiovascular disease, diabetes, cancers, arthritis and high blood pressure <a href="http://aihw.gov.au/chronic-diseases/">are on the rise</a> all over the world.</p>
<p>They are the leading cause of illness, disability and death in this country, <a href="http://aihw.gov.au/chronic-diseases/about/">estimated to cost</a> A$27 billion each year. Currently <a href="http://aihw.gov.au/media-release-detail/?id=60129552034">about half of all</a> Australians have a chronic illness.</p>
<p>As a cardiovascular specialist, I see patients living with heart disease every day. They may have survived their first heart attack but are now at greater risk of having a second.</p>
<p>We do everything we can to prevent that second, often fatal, attack by encouraging people to change their lifestyle and, just as importantly, to take their medications as directed.</p>
<p>This is because poor adherence to a medication routine – when patients don’t take their medications consistently or just stop taking them altogether – is naturally associated with worse health outcomes.</p>
<p>One <a href="http://jama.jamanetwork.com/article.aspx?articleid=205042">study showed survivors</a> of a heart attack who adhered poorly to cholesterol-lowering drugs (statins) had a 25% higher risk of a fatal heart attack one year on. </p>
<h2>Why don’t people take their medication?</h2>
<p>Many people with a chronic illnesses <a href="http://www.nejm.org/doi/full/10.1056/NEJMra050100">don’t always feel sick</a>. Medications are intended to prevent their condition from worsening rather than to make them feel better in the short run. Because they don’t feel immediate benefits, it’s easy to think the medications are not working, which can lead to patients stopping them altogether.</p>
<p>For some, it’s the cost factor. Studies <a href="http://www.ncbi.nlm.nih.gov/pubmed/16961440">looking at cholesterol-lowering statins</a> have shown higher prices are associated with lower adherence.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114804/original/image-20160311-11282-zgevuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We found text messaging doubled the odds of patients with chronic diseases sticking to their medication program.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Those with chronic diseases are often on multiple medications. Some of these they have to take once a day, some twice a day, others with meals, some before meals – all of this makes for a complex routine that can be confusing to follow.</p>
<p>Not having convenient access to a pharmacy can also be a barrier to medication adherence. This is usually a problem for the more vulnerable, such as those on a pension, those from a lower socioeconomic background, shift workers, those dependent on others for transport and those who have mobility problems.</p>
<p>And finally, there are people who are wary of drugs and perceived side effects. </p>
<p>A 2010 study in <a href="http://www.internationaljournalofcardiology.com/article/S0167-5273(16)30032-8/abstract">adults with high blood pressure</a> in Spain found reasons for patients not adhering to their medication regime included having to take several medications at once, having a mental illness, living in a rural area and being younger.</p>
<h2>How we can improve medication adherence</h2>
<p>Patients need support and encouragement to take their medications and SMS messaging is a simple, cheap and seemingly effective way to keep them on track.</p>
<p>A 2015 <a href="http://www.nature.com/bjc/journal/v112/n6/abs/bjc201536a.html">study in the United Kingdom</a> showed a 20% increase in women attending breast cancer appointments after receiving text reminders.</p>
<p>Asthma patients in a Danish trial are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1550628/">keeping SMS diaries</a> to help them monitor and manage their condition. </p>
<p>And <a href="http://www.ncbi.nlm.nih.gov/pubmed/25565587">another study last September</a> found patients with chronic pain had a significant reduction in pain when they received supportive daily text messages.</p>
<p>We <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2484905">reviewed 16 randomised clinical trials</a> around the world evaluating mobile text messaging to promote medication adherence in adults with chronic disease.</p>
<p>The way the text message alerts worked in the studies were varied. In one, patients were sent a text when they failed to open a medication dispenser; others were sent personalised texts at predetermined times about specific medications and dosages. Some were sent daily, others weekly. </p>
<p>Regardless of the method, we found text messaging doubled the odds of patients with chronic diseases sticking to their medication program.</p>
<p>But the studies we surveyed were held over an average of twelve weeks. We’re currently running a text messaging trial to be sure it works over longer periods.</p>
<p>Our <a href="https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448">TEXTMEDS study</a> is taking place at twenty urban and rural hospitals across Australia, involving 1,400 patients with cardiovascular disease. We hope to show these innovative and cost-effective strategies can help large numbers of people over the long term.</p>
<p>Global governments and policymakers should look closely at the research for an effective and inexpensive method of text message reminders that can help get patients with chronic diseases to take life saving medications.</p><img src="https://counter.theconversation.com/content/54400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clara Chow receives funding from the NHMRC and the Heart Foundation. She is affiliated with CSANZ (Cardiac Society of Australia and New Zealand). </span></em></p>Patients with chronic illness need support and encouragement to take their medications. SMS messaging is a simple, cheap and seemingly effective way to keep them on track.Clara Chow, Director of Cardiovascular Division, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/454132016-01-06T11:05:58Z2016-01-06T11:05:58ZWhy isn’t learning about public health a larger part of becoming a doctor?<figure><img src="https://images.theconversation.com/files/102733/original/image-20151122-412-1ubzsdp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Public health isn't a standard part of medical school curricula.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-244312780/stock-photo-science-professor-giving-lecture-to-class-at-the-university.html?src=mG2pzwBL9hAm4L8JvoorEA-1-38">Medical school class images via www.shutterstock.com.</a></span></figcaption></figure><p>Chronic conditions, such as Type II diabetes and hypertension, account <a href="http://www.cdc.gov/chronicdisease/">for seven in 10 deaths</a> in the United States each year. And by some estimates, public health factors, such as the physical environment we live in, socioeconomic status and ability to access health services, determine 90% of our health. Biomedical sciences and actual medical care – the stuff doctors do – <a href="https://uwphi.pophealth.wisc.edu/programs/match/wchr/2008/rankings.pdf">determine the remaining 10%</a>. </p>
<p>Clinical medicine can treat patients when they are sick, but public health provides an opportunity to prevent disease and poor health. But too often, medical students don’t get to learn about public health, or how to use it when they become doctors. That means many of today’s students aren’t learning about health care in a broader context.</p>
<h2>Why doctors need to know about public health</h2>
<p>What should a physician do if patients are unable to visit a physician because their workplace doesn’t give them sick days? What about an obese individual who has trouble following healthy eating recommendations because their neighborhood doesn’t have a grocery store? </p>
<p>If we want the next generation of medical professionals to understand why some patients have an easier time following a care plan than others, or understand what causes these conditions so we can prevent them, medical schools need to look toward public health. </p>
<p>Epidemiology, a core discipline within public health, emphasizes the study and application of treatment to disease and other health-related issues within a population. It is focused on prevention, which means understanding what makes people sick or unwell. </p>
<p>You might hear about epidemiologists who work on figuring out how infectious diseases spread. But they also study obesity, cancer, how our environments affect our health and more. </p>
<p>So a doctor with training in public health would have an understanding of how environmental, social and behavioral factors impact their patients’ health. These physicians might also draw on other medical professionals to treat individuals who are sick, and prevent sickness from occurring in the first place.</p>
<p>Medical schools recognize that their students should learn more about public health. But according to the <a href="https://www.aamc.org/download/397432/data/2014gqallschoolssummaryreport.pdf">Association of American Medical Colleges</a> (AAMC), about one-fourth of 2015 medical school graduates report that they intend to participate in public health-related activities during their career, and nearly one-third of graduates report that training related to community health and social service agencies was inadequate.</p>
<h2>Putting public health into medicine</h2>
<p>But this is slowly starting to change.</p>
<p>For instance, the Medical College Acceptance Test (MCAT), which all medical school applicants in the US take, used to focus on just physical and biological sciences and verbal reasoning. But in 2014 the MCAT added <a href="https://www.aamc.org/newsroom/newsreleases/273712/120216.html">a new section</a> on the psychological, social and biological foundations of behavior. The idea is to provide students with a foundation learn about what public health scholars call the <a href="http://www.who.int/social_determinants/en/">social determinants of health</a>. These are conditions and environments in which we are born, work, live and interact with others.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106135/original/image-20151215-23210-120j6jq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Students are expected to know more about public health.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=243995023&size=medium&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ1MDIzNjEzMywiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMjQzOTk1MDIzIiwiayI6InBob3RvLzI0Mzk5NTAyMy9tZWRpdW0uanBnIiwibSI6IjEiLCJkIjoic2h1dHRlcnN0b2NrLW1lZGlhIn0sImJrTDNNa1JlSDFNcThZemJFbFB6SWowWTlIdyJd%2Fshutterstock_243995023.jpg&racksite_id=ny&chosen_subscription=1&license=standard&src=UoBW67lEKwQV16NN141kNw-2-60">Medical students image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<p>Expectations for students transitioning from medical school to their postgraduate residency are also starting to change. </p>
<p>The AAMC has a <a href="https://members.aamc.org/eweb/DynamicPage.aspx?Action=Add&ObjectKeyFrom=1A83491A-9853-4C87-86A4-F7D95601C2E2&WebCode=PubDetailAdd&DoNotSave=yes&ParentObject=CentralizedOrderEntry&ParentDataObject=Invoice%20Detail&ivd_formkey=69202792-63d7-4ba2-bf4e-a0da41270555&ivd_prc_prd_key=E3229B10-BFE7-4B35-89E7-512BBB01AE3B">list of 13 activities</a> that medical school graduates are expected to be able to do on their first day of residency. The activities (called Entrustable Professional Activities, or EPAs) integrate, among other core competencies, principles of public health into everyday practice. They include guidelines for working with individuals who have different belief systems, patient-centered practice and understanding how to access and use information about the needs individuals have and the community resource available to them.</p>
<h2>Having students make house calls</h2>
<p>At the University of Florida, where I teach, population health-based topics are integrated into our medical school curriculum, and also into curricula for other health professions.</p>
<p>Each fall, 700 first-year health science students studying everything from dentistry to clinical psychology, health administration, pharmacy, nursing and more take part in a service learning project with local families. </p>
<p>Students complete coursework about public health, but they are also assigned to work with a family through the year. Students make a series of home visits, which means that they can see, firsthand, how the family’s home environment shapes their health. Because the project includes students from all the health professions, it helps them understand each other’s roles and responsibilities in providing care.</p>
<p>In these visits, students get a chance to see the myriad factors that can make it easier or harder for a patient to follow the care plan their doctor prescribes. Students may learn that their patients have priorities in life that come before monitoring their own health. And for many students, this may be the only home visit that they make during their entire career. </p>
<p>For instance, a team of our students were humbled to learn that one of the patients they visited, a woman with severe hypertension and Type II diabetes, put her desire to provide Christmas presents for the six grandchildren she was raising over her medication adherence or her glucose monitoring. She was more focused on her grandchildren than spending time on monitoring her health and taking medications. </p>
<p>These home visits show students how complex their patients’ lives really are. And that give these future doctors a perspective on their patients that they may never get in a clinical visit.</p>
<h2>Other medical schools putting public health on the agenda</h2>
<p>The University of Florida isn’t the only medical school investing time and energy to explore new methods to teach students about public health.</p>
<p>Some are adopting dual-degree models that allow medical students to earn degrees in both public health and medicine. Often, these programs extend students’ training by 12 months, but some institutions, like the <a href="http://admissions.med.miami.edu/md-programs/md-mph-program">University of Miami</a> and the <a href="http://som.uthscsa.edu/Admissions/MDMPH.asp">University of Texas Health Science Center at San Antonio</a>, have developed four-year dual-degree programs.</p>
<p>Other institutions, such as the <a href="http://medicine.uic.edu/cms/One.aspx?portalId=443021&pageId=30407454">University of Illinois</a> and <a href="http://medicine.fiu.edu/education/md/index.html">Florida International University</a>, are integrating population and public health perspectives throughout their curricula, to make sure that all students learn about public health.</p><img src="https://counter.theconversation.com/content/45413/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erik Black does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Today’s medical students are tomorrow’s doctors, and they need to understand public health to better help their patients.Erik Black, Associate Professor of General Pediatrics, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/384922015-04-22T19:46:09Z2015-04-22T19:46:09ZFood additives and chronic disease risk: what role do emulsifiers play?<figure><img src="https://images.theconversation.com/files/78870/original/image-20150422-23624-slhkbc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research in mice shows emulsifiers damage the gastrointestinal barrier, allowing bugs to enter the body.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-148983113/stock-photo-man-buys-products-at-the-supermarket.html?src=dmvZzFtWIt1a6B3tyAxT4w-2-11">nata-lunata/Shutterstock</a></span></figcaption></figure><p>Have you ever wondered what those food additive numbers in the ingredients list on your food packaging meant and what they were really doing to your body? </p>
<p>A <a href="http://www.nature.com/ni/journal/vaop/ncurrent/full/ni.3103.html">recent study</a> suggests emulsifiers – detergent-like food additives found in a variety of processed foods – have the potential to damage the intestinal barrier, leading to inflammation and increasing our risk of chronic disease. </p>
<p>The research was done on mice, so it’s too early to say humans should stop eating emulsifiers, but let’s examine the mechanisms involved. </p>
<h2>The gut’s bacterial flora</h2>
<p>The lining of our gastrointestinal tract has one of the toughest jobs around. It must allow fluid and nutrients to be absorbed from our diet, while also acting as a barrier to prevent the invasion of toxins and harmful bacteria into our bodies. </p>
<p>The cells that make up the intestinal lining secrete a gel-like mucus and a variety of antimicrobial substances, which normally protect them from bacterial infection. But changes in the types of microorganisms living in the gut – from drinking too much alcohol, viral infections, certain drugs and exposure to radiation – can all reduce the integrity of the gastrointestinal barrier. </p>
<p>The hundreds of species of microscopic bugs living in the human gastrointestinal tract (collectively called the “gut microbiota”) play an important role in assisting us to digest food, educating our immune system during its development and increasing the absorption of important minerals from our diet. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78708/original/image-20150421-9032-r19wbm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Emulsifiers make ice-cream smoother and more resistant to melting.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/giovannijl-s_photohut/846212196/in/photolist-2hM4ps-a2LEvv-6ErqQo-qsBc5k-6hda4Q-8a3FCc-4bjXxJ-d4d2w-dUmW46-46mtd-fQXGeC-hcmWX5-88LmaD-4X3rr6-MSnTf-2HFwFT-6VgZfZ-6pcNeB-n2Dccf-fJTiBD-ibVAX9-9UbytN-fNdBcG-5HNgoZ-89vKpH-jcYyeb-pEhFUZ-fxnVmh-mfhQ93-aAE279-x41Sc-fwhk2n-aF7s5M-eJuC6-3oPV8-6Evyfb-3MXAY-gDm8v-nGByZZ-HXL16-rWkir-mpe4RZ-9xmzQu-E8ky-hi7gH7-59fry9-54a75s-7V3VZH-swVYv-nrwjZj">Sebastian Mary/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Some beneficial species of bacteria can even break down the food that reaches our bowel to produce special types of fats, called <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3735932/">short-chain fatty acids</a>. Once absorbed into our bloodstream, these fatty acids can positively influence health by reducing our appetite and lowering our blood sugar levels. </p>
<p>Under normal circumstances, the gut microbiota are unable to grow on the thick mucus layer attached to the intestinal cells. However, if our intestinal lining becomes damaged, specific harmful bacteria are able to move from our gut across the lining and into our bloodstream. </p>
<p>Immune cells in the blood then recognise and try to attack the foreign invaders by producing inflammatory compounds. Over time, this can result in a chronic low level of inflammation in the gut and throughout the body.</p>
<h2>Inflaming the gut</h2>
<p>The word inflammation comes from the Latin “inflammatio”, meaning set alight or ignite. It’s the body’s attempt to protect itself by removing harmful stimuli, including damaged cells, irritants or pathogens, and begin the healing process. </p>
<p>Inflammation is part of the body’s immune response. Initially, it is beneficial when, for example, you scratch your hand and the body mounts an innate immune response to send immune cells to the area to attack foreign microbes and repair the damage. Without inflammation, infections and wounds would never heal.</p>
<p>However, sometimes inflammation can become self-perpetuating; more inflammation is created in response to the existing inflammation. This is known as chronic inflammation. It may be caused by overactive immune system reactions, non-degradable pathogens and infections with some viruses. It
also occurs with autoimmune diseases such as Crohn’s Disease, rheumatoid arthritis and in heart disease, diabetes or stroke. </p>
<p>Uncontrolled chronic inflammation is harmful and leads to tissue damage. This results in side-effects such as fatigue and pain and, in some instances, organ failure. The cause of chronic inflammation in these types of diseases is still unknown.</p>
<h2>So, what do emulsifiers do to the gut?</h2>
<p>Emulsifiers are natural or chemical substances that consist of a “water-loving” end and an “oil-loving” end. They’re commonly used to combine ingredients that normally don’t mix together, such as oil and water. </p>
<p>It would be impossible, for instance, to make mayonnaise without using lecithin (found in egg yolk) as an emulsifier to evenly mix the oil and lemon juice together.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78705/original/image-20150421-9012-lgxkfe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Without emulsifiers,the ingredients in mayonnaise wouldn’t bind together.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jeepersmedia/15058048097/in/photolist-oWCr5V-21QpwN-84158i-cw1qNf-bbbB1X-8415bn-7iGMSQ-KgWFv-5Mebc-9y5qgY-bBXeVa-w9q41-pe7AyF-aaLYVf-pe5DGq-pc5GW7-oWBrt4-oWBq8P-pe5BVu-oWBPWG-pdQNsD-pe7CqX-oWBP2f-pe7C82-oWBNPS-pe5CvC-oWBMg1-4fV4Jz-aSSvRn-9rYtD-ahPHxL-48uoKH-6Dc931-fntP7n-pe5Br3-pc5JCy-pdQPfR-oWBNzd-oWBQT1-oWCrcQ-oWBN3b-oWBqHB-oWBqpF-pc5JWE-pdQPB2-pe5Ees-oWCrBg-oWCr43-6ZrYM2-ay4oV8">Mike Mozart/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Emulsifiers are added to bread, salad dressings, sauces, puddings, margarine and ice-cream, to makes it smoother and more resistant to melting.</p>
<p>The authors of the <a href="http://www.nature.com/nature/journal/v519/n7541/full/nature14232.html">recent Nature article</a> added two common emulsifiers, food additive E466-carboxymethylcellulose (CMC) and polysorbate-80 (P80) to the drinking water and food of lab mice. </p>
<p>The mice showed a change in the species of bacteria growing in their gut when compared to controls, with reduced numbers of bacteria considered beneficial to health, and increased levels of inflammation-promoting microbes. </p>
<p>The mucus layer that usually shields intestinal cells from invading pathogens had become colonised with mucus-eating bacteria in the emulsifier-fed mice, resulting in a thinner mucus barrier. </p>
<p>In comparison to control mice, previously healthy mice that were fed emulsifiers had low-level gastrointestinal inflammation, ate more food and gained more weight (especially body fat), had higher blood sugar levels and were resistant to the action of insulin. </p>
<h2>Increased risk of chronic disease</h2>
<p>The condition of the mice resembles a human condition that is increasing in prevalence called the <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Metabolic_syndrome">metabolic syndrome</a>. </p>
<p>People with the metabolic syndrome have excessive fat around their abdomen, high blood pressure, increased levels of “bad” LDL-cholesterol and reduced levels of “good” HDL-cholesterol, and poor control of blood sugar. It also increases the risk of chronic diseases such as type 2 diabetes, heart disease and stroke.</p>
<p>To demonstrate that the altered gut microbiota were responsible for the inflammatory disorders seen in the emulsifier-fed mice, the researchers transferred gut bacteria from the emulsifier-fed mice into germ-free mice (mice raised in sterile conditions so they have no gut bacteria). </p>
<p>The germ-free mice subsequently developed mild inflammation and symptoms of the metabolic syndrome. When emulsifiers were fed to mice that were genetically prone to develop colitis (inflammation of the colon), these mice developed severe colitis. This may have future implications for sufferers of inflammatory bowel disease.</p>
<p>The authors point out that:</p>
<blockquote>
<p>the last half-century has witnessed a steady increase in the consumption of food additives, many of which have not been carefully tested as they were given “generally regarded as safe” status at the time that government entities charged with regulating food safety were created and/or expanded. </p>
</blockquote>
<h2>Don’t throw out the mayonnaise just yet…</h2>
<p>The United States Food and Drug Administration has approved polysorbate-80 for use in select foods up to 1%, while E466 has not been extensively studied but is deemed “generally regarded as safe” and is used in various foods at up to 2.0%. </p>
<p>Food Standards Australia New Zealand has <a href="http://www.comlaw.gov.au/Details/F2014C01335/Download">approved</a> polysorbate-80 (code number 433 in Australia) and E466 for use in foods with “good manufacturing practice” with no maximum levels. </p>
<p>The study findings highlight the need for regulatory bodies to ensure that food additives are initially tested for safety and continue to undergo long-term monitoring for their effects on chronic health conditions. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=485&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=485&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=485&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=610&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=610&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78702/original/image-20150421-9034-byff2r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=610&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The over-consumption of kilojoules from highly processed diets and insufficient physical activity remain the primary culprits of metabolic disease.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dhammza/259625281/in/photolist-oWDxX-hMeFN-4WjNeb-3ZhXT-hHp42q-9j2kU1-e84UBi-ptSJab-pokFU8-3iyouD-gcDHjZ-5D6qCT-oPVtqD-4Y3PeY-aNJ9qX-uisG1-a3oouQ-racp32-7hZcqR-rNwpEN-odDY9Q-8xA3Q9-BwbFg-6RFrVE-p7QPSG-rpjxbA-5RLim-gHPTbR-6BJrWo-kLno1j-qDUp3w-4fV4Jz-4NNVVU-azydS9-nvQdDH-rDhBvx-ckRwLm-oehPbT-dj2Jkz-jMEu5H-hJqDeW-9mD6Hr-vSk4L-bEXQN1-6fSNKq-iP1PWj-hadiRv-ppgoEX-ovZZqH-qBkYeC">Daniel Horacio Agostini/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>But it’s too early to remove all emulsifiers from our diets in order to prevent developing the metabolic syndrome. </p>
<p>Dietary emulsifiers clearly affect the metabolic health of mice, but it’s unknown whether emulsifiers impact human health. Humans have been consuming natural emulsifiers for thousands of years, while mice don’t eat emulsifiers in their normal diet. </p>
<p>We also need to determine the quantities that humans are likely to consume over long time periods and their possible metabolic consequences. For the main experiments in the study, the mice were fed concentrations of emulsifiers greater than the average daily human intake. </p>
<p>Multiple factors contribute to the development of the metabolic syndrome. The over-consumption of kilojoules from highly processed diets and insufficient physical activity remain the primary culprits and should be addressed in the first instance. </p>
<p>However, these studies drive home the importance of cooking using fresh ingredients and avoiding or minimising the use of processed foods. Everyone should start reading food ingredient labels and become more aware of what they are really feeding their family.</p><img src="https://counter.theconversation.com/content/38492/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melinda Coughlan receives funding from the NHMRC and Juvenile Diabetes Research Foundation.</span></em></p><p class="fine-print"><em><span>Nicole Kellow receives funding from the NHMRC. </span></em></p>Have you ever wondered what those food additive numbers included in the ingredients list on your food packing were really doing to your body?Melinda Coughlan, Associate Professor; Head, Glycation, Nutrition & Metabolism, Baker Heart and Diabetes InstituteNicole Kellow, Dietitian; Diabetes Educator; PhD candidate at Monash University and, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/142972013-05-16T01:04:38Z2013-05-16T01:04:38ZLegalising medicinal cannabis is a leap forward for compassion<figure><img src="https://images.theconversation.com/files/23897/original/y5zykjtr-1368662636.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is a large amount of rigorous research evidence for medical marijuana.</span> <span class="attribution"><span class="source">Rusty Blazenhoff</span></span></figcaption></figure><p>A NSW Parliamentary Committee has recommended legalising the use of medical use of marijuana for people with terminal conditions. This is an approach that should be embraced nationally. </p>
<p>For some years now, people seeking cannabis for medicinal purposes have contacted me every few months asking for help. </p>
<p>Usually the person has cancer or some other terminal illness. Their conditions have included cancer of the breast, large bowel, pancreas and a young man with a malignant brain tumour. One person had advanced AIDS and a cancer. And a senior politician once told me that cannabis was the only thing that comforted his father as he was dying from lung cancer. </p>
<p>So it’s difficult for me to understand why, in 2013, a civilised and compassionate country such as Australia still doesn’t allow people with distressing symptoms from a terminal condition to obtain some relief from medicinal use of cannabis.</p>
<p>The NSW committee’s report, <a href="http://www.parliament.nsw.gov.au/Prod/parlment/committee.nsf/0/fdb7842246a5ab71ca257b6c0002f09b/$FILE/Final%20Report%20-%20The%20use%20of%20cannnabis%20for%20medical%20purposes.pdf">The use of cannabis for medical purposes</a> was tabled yesterday, following months of hearings.</p>
<p>Comprising of members of the coalition, Labor, the Greens and the <a href="http://www.shootersandfishers.org.au/">Shooters and Fishers</a> party, the committee unanimously recommended the medical use of cannabis for people with terminal illnesses and AIDS. The NSW government will now have to consider its recommendations.</p>
<p>But we have been here before. In 2000, the then-NSW premier Bob Carr commissioned a report on medicinal cannabis from a distinguished committee. The committee <a href="http://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/medical_cannabis_v1_1.pdf">strongly recommended</a> the state government allow cannabis use for medicinal purposes. </p>
<p>Much of that committee’s report was based on reports from the <a href="http://www.parliament.the-stationery-office.co.uk/pa/ld199798/ldselect/ldsctech/151/15101.htm">UK House of Lords</a> and the <a href="http://www.nap.edu/openbook.php?record_id=6376&page=1">US National Academy of Science</a>. The recommendation was not acted on. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23895/original/kkrc7jps-1368662306.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical cannabis is now legal in almost a dozen countries.</span>
<span class="attribution"><span class="source">Caveman Choker/Flickr</span></span>
</figcaption>
</figure>
<p>Still, it will be difficult for the government to ignore the unanimous recommendations of this multi-party committee while also knowing that <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421314&libID=10737421314">69% of the community</a> support allowing cannabis to be used as medicine.</p>
<p>And even beyond multi-party agreement and widespread community support, the committee’s recommendations are a victory for common sense, evidence and compassion. </p>
<p>In preparation for this committee, my colleagues and I reviewed the literature on this subject. Although I have followed research in this area for a number of years, I was astonished at the <a href="http://www.cannabis-med.org/data/pdf/en_2010_01_special.pdf">quantity</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/16540272">quality</a> of rigorous evidence which now exists for the medical use of cannabis. </p>
<p>Cannabis is not a “first-line medicine” (the first medication to be prescribed when a patient is diagnosed with a particular condition). But, for a number of conditions, it is a very useful second or third-line medicine, especially when the more conventional drugs have proven ineffective or produced severe and unacceptable side effects. </p>
<p>Cannabis is also considerably less expensive than many conventional medicines. And it allows some ill people to stay at home rather than remain in an expensive hospital bed.</p>
<p>So let’s hope the commonwealth and other states and territories also promptly consider the committee’s recommendations. Cannabis should be a medical option throughout Australia. It’s now used medically in almost a dozen countries. In the United States, it’s used medically in 18 states and the District of Columbia.</p>
<p>There are a few ways to legislate for the medicinal use of cannabis. It could be made available by allowing people with certain conditions to be granted exemption from prosecution for cultivating or purchasing it. But if this is the only available option, then some elderly people who are financially limited after years of severe illness will be forced to purchase it from the black market or cultivate it. </p>
<p>The former has obvious inherent dangers relating to variability in quality, consumer protection and cost. And it seems unnecessarily harsh or cruel to expect a 75-year-old grandmother dying of cancer to start cultivating cannabis plants. Even more so because it would require her pain relief to be on hold until the plants are mature enough to be cured and then cured enough to be consumed. So this approach will not meet the needs of many people who need help most.</p>
<p>A second option is to allow the use of a pharmaceutical product called <a href="http://www.sativex.co.uk/">Sativex</a>, which is the brand name for a pain-relief drug derived from the cannabis plant. This can cost as much as A$500 a month and will be too expensive for many elderly people with depleted savings after several years with an advanced terminal condition.</p>
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<img alt="" src="https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/23899/original/qbm2gm64-1368663612.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The dangers of smoking can be side-stepped with the use of vapourisers.</span>
<span class="attribution"><span class="source">Incurable Hippie/Flickr</span></span>
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<p>A third option is to allow the use of leaf cannabis. The Netherlands now purchases meticulously produced pharmaceutical-grade leaf cannabis from a commercial contractor, and makes it available through pharmacies to approved patients. </p>
<p>Cannabis can now be taken by inhaling its vapour rather than breathing in cannabis smoke. No doctor likes the idea of a patient inhaling their medicine dissolved in smoke, which contains a lot of particulate matter although this can be overlooked in patients with a short-life expectancy. Cannabis vapour has minimal quantities of particulate matter and vaporisers have been available in Australia for some years now. </p>
<p>The advantage of cannabis leaf over Sativex is the former’s better representation of the complex combination of active ingredients. The pharmacology of cannabis is complex as the leaf contains over 60 psychoactive ingredients. It seems that cannabis’ benefits may be enhanced and some of the side effects reduced when there is greater representation of these ingredients.</p>
<p>The NSW Legislative Council committee’s recommendation that medicinal cannabis should only be permitted for selected people with terminal conditions, can be justified at the start. But the arrangements should be flexible enough to be reviewed in a couple of years and, if need be, allow for some modification or relaxation of the initial stringent conditions.</p>
<p>The regulation of medicinal cannabis is a very different issue from the prohibition of the drug’s recreational use. Doctors in Australia prescribe morphine, cocaine and amphetamine for medicinal purposes even though the recreational use of the same drugs is banned.</p>
<p>It’s time to treat the issue of medicinal cannabis on its merits. It is not a panacea but it <em>is</em> a useful drug. We should not allow our obsession with the prohibition of recreational use of the drug to get in the way of allowing compassionate use of cannabis to reduce suffering for people with serious medical conditions.</p><img src="https://counter.theconversation.com/content/14297/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Wodak is President of the Australian Drug Law Reform Foundation. </span></em></p>A NSW Parliamentary Committee has recommended legalising the use of medical use of marijuana for people with terminal conditions. This is an approach that should be embraced nationally. For some years…Alex Wodak, Emeritus Consultant, St Vincent's Hospital, DarlinghurstLicensed as Creative Commons – attribution, no derivatives.