tag:theconversation.com,2011:/uk/topics/queensland-health-3681/articlesQueensland Health – The Conversation2019-11-07T04:20:46Ztag:theconversation.com,2011:article/1262722019-11-07T04:20:46Z2019-11-07T04:20:46ZQueensland Health’s history of software mishaps is proof of how hard e-health can be<figure><img src="https://images.theconversation.com/files/300581/original/file-20191107-12495-9a0n6z.jpg?ixlib=rb-1.1.0&rect=0%2C35%2C3994%2C2628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Queensland Health's current electronic medical records system is what you could call a "monolithic" system, meaning it's an all-in-one system designed by one company. Such systems may not be the best option for the health sector's future. </span> <span class="attribution"><span class="source">SHUTTERSTOCK</span></span></figcaption></figure><p>A directive ordering Queensland Health staff to avoid upgrades to the state’s hospital electronic medical record system during parliamentary sitting weeks <a href="https://www.brisbanetimes.com.au/national/queensland/leaked-queensland-health-email-reveals-order-to-halt-it-upgrades-during-parliament-20191031-p5367x.html">was recently reversed</a>. After the email containing the directive was leaked, the state’s health minister Steven Miles revoked the directive. He said the timing of upgrades should be based on “what’s best for clinical care”.</p>
<p>Queensland’s integrated electronic medical record system (ieMR) is designed to provide information about patients in the state’s health system. The ieMR was built by Cerner, a global provider of electronic medical record software. Like any IT project of this scale, it’s extensively customised for Queensland Health and individual hospitals.</p>
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<img alt="" src="https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.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">The directive to avoid the ieMR upgrades was overturned after an email to Queensland Health staff was leaked to the media.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
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<p>The directive to refrain from ieMR upgrades during sitting weeks seems to be connected to 38 system outages earlier this year. Most of these happened following upgrades performed by Cerner. On at least one occasion, upgrades didn’t go smoothly, and led to system outages that required clinicians to <a href="https://www.brisbanetimes.com.au/national/queensland/more-trouble-for-queensland-hospital-software-after-statewide-issues-20190911-p52q46.html">revert to paper-based methods</a>. </p>
<p>The rollout of the <a href="https://www.health.qld.gov.au/clinical-practice/innovation/digital-health-initiatives/queensland/integrated-electronic-medical-record-iemr">ieMR system</a> to new hospitals, which began back in 2011, was put on hold earlier this year. </p>
<h2>Monolithic systems may not be the future</h2>
<p>A major difficulty with “monolithic” (that is, all-in-one systems developed by a single company) e-health systems is that a single design team is attempting to solve an incredibly broad set of complex problems. </p>
<p>Health systems involve interactions between dozens of different types of highly trained professionals. Building software to effectively support just one speciality to do its job efficiently is enormously challenging. Developers of unified electronic medical record systems must build systems that support dozens of them. As a result, it’s unlikely that such systems provide the best possible solutions for any particular speciality.</p>
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<a href="https://theconversation.com/everything-you-need-to-know-about-australias-e-health-records-5516">Everything you need to know about Australia's e-health records</a>
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<p>Because of this, research and development in e-health systems is moving away from monolithic, one-size-fits-all systems. Companies are instead working on allowing smaller, more specialised health IT systems to work together using <a href="https://en.wikipedia.org/wiki/Fast_Healthcare_Interoperability_Resources">parallel systems designed to work in concert</a>. </p>
<p>In theory, this means clinicians and departments will be able to use the best software for their particular requirements, while each system can communicate with the others in a common language.</p>
<p>Of course, it won’t be quite that simple in practice. But Queensland Health’s current adoption of massive centralised systems imposed from the top down is extremely hard to get right.</p>
<h2>A history of e-health system problems</h2>
<p>The ieMR project isn’t the first time Queensland Health has had difficulties with a health-related IT system. An attempt to replace the payroll system, prompted in the late 2000s, was disastrous. </p>
<p>The <a href="http://www.healthpayrollinquiry.qld.gov.au/">Commission of Inquiry report</a> into the payroll system is such a compelling description of an IT project failure that I use it to show my undergraduate students an example of what not to do. </p>
<p>The report describes a litany of problems including conflicted advisers, unrealistic timetables, woefully insufficient attention to software requirements, inadequate testing and, to top it all off, a lack of any contingency plan in case the system wasn’t ready in time. This led to the deployment of a system with known critical flaws. </p>
<p>The results were predictably catastrophic, costing the state hundreds of millions of dollars.</p>
<p>It’s important to point out, however, that the ieMR is a completely separate system. Nonetheless, a consultant’s report in 2014 <a href="https://www.brisbanetimes.com.au/national/queensland/no-lessons-learned-from-payroll-disaster-queensland-health-was-warned-20190129-p50u8l.html">reportedly said</a> “no lessons have been learned” from the earlier payroll system disaster.</p>
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<a href="https://theconversation.com/app-technology-can-fix-the-e-health-system-if-done-right-49891">App technology can fix the e-health system if done right</a>
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<p>While later efforts attempted to fix issues identified at that time, decisions made previously - especially major architectural decisions such as the choice of a particular off-the-shelf software system - cannot easily be undone.</p>
<h2>The problems are varied</h2>
<p>Difficulty managing service upgrades is <a href="https://www.brisbanetimes.com.au/topic/e-health-queensland-1mlk">one of many challenges</a> the ieMR project has faced. Other issues identified include:</p>
<ul>
<li>extensive delays in the rollout across hospitals</li>
<li>cost increases and an inability to accurately <a href="https://www.brisbanetimes.com.au/national/queensland/queenslanders-health-at-risk-from-electronic-medical-record-software-clinicians-say-20190129-p50u8i.html">predict deployment costs</a></li>
<li>concerns that software settings may have <a href="https://www.brisbanetimes.com.au/national/queensland/baby-born-with-brain-damage-after-fragmented-care-at-queensland-hospital-20190301-p5119a.html">compromised the flow of information</a> between clinicians treating a pregnant woman with serious health problems.</li>
<li>other patient safety concerns, including <a href="https://www.brisbanetimes.com.au/national/queensland/alerts-warn-of-patient-risk-software-glitches-in-electronic-medical-record-20190315-p514nl.html">corrupted medication records</a>. While no specific health events were reported as a result of this, incorrect medication poses an obvious safety concern.</li>
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<h2>Other states have struggled, too</h2>
<p>While the concept of electronic medical records is attractive to clinicians and administrators alike, Queensland Health is not the only health operator to have struck trouble with electronic medical records projects. </p>
<p>Emergency departments in New South Wales hospitals implemented a new electronic medical records system (also supplied by Cerner) in 2009 as part of a planned statewide rollout. The system was <a href="https://www.itnews.com.au/news/nsw-health-to-act-on-firstnet-issues-265617">unpopular with clinicians</a>, and one peer-reviewed academic study indicated it was <a href="https://www.mja.com.au/journal/2013/198/4/effect-electronic-medical-record-information-system-emergency-department">associated with longer emergency department wait times</a>.</p>
<p>Since the commencement of the ieMR project in 2011, <a href="https://www.abc.net.au/news/2018-12-04/digital-hospitals-blow-out-auditor-general-scathing-report/10581322">hundreds of millions of dollars</a> have been invested. Sunk costs of this kind, and institutions that tend to follow the status quo, often discourage critical analysis and the exploration of alternative paths. </p>
<p>As the decision has been made to pause the rollout, now seems like an opportune time to properly consider whether current e-health system architecture is the best option for the future. </p>
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<p class="fine-print"><em><span>Robert Merkel is a member of the Australian Greens.</span></em></p>Past upgrades to the state’s medical record system have cost tremendous amounts of money, and on at least one occasion, forced clinicians to revert to paper-based methods.Robert Merkel, Lecturer in Software Engineering, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/362962015-01-28T02:55:16Z2015-01-28T02:55:16ZQueensland health has a better outlook, so who deserves credit?<p>It’s a sign of how much has changed in a few years that health has barely featured in the Queensland election campaign, despite being <a href="http://www.theaustralian.com.au/national-affairs/state-politics/lnp-holds-ace-cards-but-hand-has-slipped/story-fnr8rfrw-1227181571969">one of the issues that voters still say they care most about</a>.</p>
<p>That doesn’t mean that everything has gone smoothly in Queensland health over the past three years. But after the health controversies that dogged the previous Labor government, the fact that the issue has slipped out of the spotlight ahead of the January 31 poll is a sign of improvement. </p>
<p>Interestingly, the current Liberal National government and Health Minister Lawrence Springborg, as well as the previous Labor government in certain areas, all deserve to share some of the credit for those recent improvements.</p>
<h2>How Labor lost its edge on health</h2>
<p>Health and education are traditionally two areas where state Labor parties tend to poll better than their conservative opponents, in contrast to other areas like law and order and the economy.</p>
<p>But in Queensland, an early election campaign poll of 800 voters found that the Liberal National Party still held an edge over Labor (46% to 43%) on which party was seen as better able to manage health and public hospitals.</p>
<p>Queensland Labor’s reputation for managing health took a beating under the Beattie and Bligh governments. As well as the damaging fallout from the investigations into the clinical performance of <a href="http://www.brisbanetimes.com.au/queensland/jayant-patel-finally-leaves-queensland-20131122-2y0aq.html">Dr Jayant Patel</a> at Bundaberg Hospital, the long-standing under-resourcing of public hospitals and Queensland Health’s failed payroll system provided a string of public relations disasters throughout Labor’s last two terms of government.</p>
<p>It wasn’t all bad under Labor. Making up for past under-funding, state government expenditure on health more than doubled. Labor’s time in office also saw the establishment of a quality and safety program that was a national leader, for example, in public reporting of adverse events. And there was a massive capital program, which included commitments to three new teaching hospitals and expansion of almost every main hospital across Queensland.</p>
<p>But as <a href="http://www.abc.net.au/news/2012-03-16/queensland-2012-election-policies/3894274">many analysts noted</a>, Labor’s mishandling of health was one of the deciding issues of the last election. As I wrote <a href="https://theconversation.com/queenslands-top-five-health-priorities-this-election-5923">in 2012</a>, there were serious challenges in the state’s health system that needed to be tackled.</p>
<h2>What’s changed under the LNP</h2>
<p>Compared with the spate of bad news stories under Labor, the past 12 months under the LNP government have produced relatively few adverse media reports.</p>
<p>There have still been some major issues involving Queensland Health services in that time. In particular, there was a prolonged and unnecessarily bitter dispute with salaried doctors over their contracts (although services were minimally disrupted). </p>
<p>In response to that and other government decisions, the then assistant minister for health and former Australian Medical Association state president, Dr Chris Davis, <a href="http://www.abc.net.au/news/2014-05-23/chris-davis-resigns-as-qld-member-for-stafford/5473702">quit as the LNP member for Stafford</a>. The government <a href="https://theconversation.com/inside-operation-boring-the-lnps-strategy-to-reclaim-queensland-36146">lost the seat in the by-election</a>. Dr Davis has become an outspoken critic of the Newman government, recently <a href="https://www.youtube.com/watch?v=-3FrF7z76b8">urging voters to put the LNP last</a>.</p>
<p>The health services have also had significant job losses, including a dismemberment of the health promotion and prevention services. That is hardly a rational decision in the face of the current chronic disease epidemic. </p>
<p>Allegations of corrupt behaviour by one of the new chief executive officers brought in following the change of government are the subject of an ongoing investigation. And there have been major clinical disasters, such as the events associated with a <a href="http://www.abc.net.au/news/2014-05-06/doctor-under-investigation-over-4-operations-at-rockhampton-hosp/5432892">urologist at Rockhampton Hospital</a>, in which a patient had the wrong kidney removed. </p>
<p>But notable improvements have been made too, which account for Labor largely running quiet on health in this election.</p>
<h2>Greater local management and an experienced minister</h2>
<p>There has been a very different approach to the leadership of the health portfolio. The LNP government implemented the district health services model effectively. It appointed boards and largely let them get on with their roles of managing health services. It progressively devolved responsibilities from central office to districts, taking into account local capability.</p>
<p>In the main, the government has trusted the boards it has appointed to do their job. The politics of public health services are frequently driven by local concerns, and should be managed locally. Of course, it is easier to ignore squeaky wheels and get on with the job when you have a massive majority in Queensland’s single-house parliament, as the LNP has enjoyed in the past three years.</p>
<p>Health Minister <a href="https://theconversation.com/who-are-queenslands-unofficial-premiers-in-waiting-35952">Lawrence Springborg</a> is an experienced politician who has served as a minister in previous LNP governments, as well as being a leader in opposition. He has largely successfully managed the policy directions – and sometimes misdirections – from the Premier’s office. </p>
<p>In my view, Springborg has appropriately distanced himself from the day-to-day operational issues of the health services. That is a problem that plagued health ministers under Labor, who were continually flying about “fixing” hot-spots identified by the media. He has also followed through on some hard commitments, such as bringing back birthing services to country hospitals like Beaudesert. </p>
<p>The LNP and Springborg have benefited from the massive investment in hospitals started under Labor, which has increased capacity for elective surgery and for managing emergency department waits. Most of the hard decisions, such as the location and size of the new hospitals, occurred under Labor. </p>
<p>The minister has still had to manage some big challenges along the way, such as the <a href="http://www.couriermail.com.au/news/queensland/abuse-used-in-union-queensland-childrens-hospital-site-strike-campaign-court-told/story-fnihsrf2-1226817096084">prolonged strike at the new children’s hospital</a> in Brisbane. Bravely, the minister has also committed – albeit after the election – to ensure that all surgery patients will <a href="http://www.abc.net.au/news/2014-11-23/springborg-announces-wait-time-guarantee-to-reduce-elective-surg/5912122">have their operations within the recommended times</a>, even if this means outsourcing these to the private sector. </p>
<p>I would be more impressed if the minister had committed to tackling the hidden lists: the waits for specialist outpatient services and allied health services.</p>
<p>However, that will remain a challenge for the next health minister – whoever that may be after Saturday’s election.</p><img src="https://counter.theconversation.com/content/36296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Wilson is Director of the Australian Prevention Partnership Centre which is funded jointly by the NHMRC, Commonwealth Department of Health, NSW Ministry of Health, ACT Health and the HCF Research Foundation. The Menzies Centre for Health Policy receives funding from Menzies Foundation. Andrew Wilson's previous roles include being the Executive Dean, Faculty of Health, Queensland University of Technology; Deputy Director of General Policy, Strategy and Resourcing at Queensland Health; and Deputy Dean and Director of Research, Faculty of Health Sciences, University of Queensland.</span></em></p>It’s a sign of how much has changed in a few years that health has barely featured in the Queensland election campaign, despite being one of the issues that voters still say they care most about. That…Andrew Wilson, Director, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/85712012-11-08T00:12:01Z2012-11-08T00:12:01ZExplainer: what is dengue fever?<figure><img src="https://images.theconversation.com/files/14736/original/8cmscfm2-1346212694.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This mosquito – Aedes aegypti – can spread the dengue, Chikungunya and yellow fever viruses.</span> <span class="attribution"><span class="source">Paul Zborowski</span></span></figcaption></figure><p>Dengue is caused by four different serotypes (strains) of the dengue virus that can cause mild to severe illness in people, who are infected via mosquito bites. Dengue has been spreading through most urbanised areas in the tropics in the last 30 years. <a href="http://www.cdc.gov/dengue/epidemiology/index.html">Up to 40%</a> of the global population live in dengue-infected tropics, and an estimated 50 to 100 million cases occur annually.</p>
<p>Classical dengue, the most common type of the illness, is characterised by a high fever, splitting headaches, vomiting, a rash and body aches. It’s referred to colloquially as “breakbone fever”. The severe form of the illness, dengue haemorrhagic fever (DHF), is rare and its symptoms include blood plasma leakage, which may lead to shock and, potentially, death.</p>
<p>There’s no vaccine or specific medication to prevent dengue but both types can be treated with early diagnosis and fluid-replacement therapy. While fatalities are rare (less than 1% of cases), dengue epidemics can bring illness to thousands of people within weeks, causing chaos in communities and costing millions of dollars. </p>
<h2>Dengue in Australia</h2>
<p>The illness was once common in eastern Australia from the late-19th century through mid-20th century, stretching south nearly to Sydney. Large epidemics occurred in eastern New South Wales and Queensland. But with the demise of rainwater tanks after World War II and the advent of piped water, dengue-carrying mosquitoes retreated to north Queensland, where ample rains provide year-round breeding sites.</p>
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<span class="caption">The prevalance of rainwater tanks could result in more dengue in Australia.</span>
<span class="attribution"><span class="source">Michael Jefferies</span></span>
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<p>Dengue is now limited to the urban areas of north Queensland, the only region in Australia that has the carrier <em>Aedes aegypti</em> mosquito. Highly urbanised and feeding almost exclusively on humans, this mosquito loves unscreened old Queensland houses. </p>
<p>And the area is increasingly subject to outbreaks of the illness. Since 2000, there have been 36 dengue outbreaks in north Queensland, resulting in 2,364 confirmed cases that led to three deaths – all this from the bite of a rather innocuous-looking mosquito.</p>
<p>The increase in dengue activity overseas is also responsible for an escalation of imported cases into Australia. In the dengue-receptive cities of Cairns and Townsville, the number of imported dengue cases has jumped from ten a year to between 30 and 50 a year in the last four years. All four dengue types have been active in the area, resulting in multiple outbreaks. </p>
<p>To date, Queensland Health staff based in Cairns and Townsville have been able to eliminate the virus in each of the 40 different outbreaks in the region since 1995, preventing the virus from becoming established (endemic) in north Queensland. This is important as persistent outbreaks of multiple dengue viruses is associated with increased incidence of severe illness and deaths. </p>
<p>Current global dengue trends suggest the virus will become more common in Australia. Rainwater tanks are again decking suburban yards, and outbreaks of the virus have increased overseas (like the <a href="http://www.nytimes.com/2012/11/07/world/asia/alarm-over-indias-dengue-fever-epidemic.html?pagewanted=all">current epidemic in India</a>), which means more imported cases of dengue.</p>
<h2>Controlling dengue outbreaks</h2>
<p>While mosquitoes breed in obvious stagnant water sites such as tyres, buckets, pot plant bases and boats under the mango tree, they also exploit hidden, flooded “cryptic containers” that are even harder to remove or treat. These include sump pits, telecommunication pits, septic tanks, roof gutters and rainwater tanks.</p>
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<span class="caption">Water buckets provide a breeding ground for mosquitoes.</span>
<span class="attribution"><span class="source">How Big/Flickr</span></span>
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<p>Dengue cases are also hard to isolate, especially the all-important index case (the initial case imported from overseas that kicks off an outbreak). Australia’s love affair with Bali has resulted in hundreds of cases among cash-flushed youth seeking a brief tropical holiday. And the epidemic in India could have a strong impact unless controlled before the end-of-year holidays. </p>
<p>All of Queensland’s recent large outbreaks, from the 500 cases in 2003 to the recent 1,000 cases in 2008-09, were initiated by a traveller who was not detected by the health system for over four weeks. By the time Queensland Health knew about the ignition point for the outbreak, several other people had been infected, and had spread the virus throughout the Cairns area.</p>
<p>Dengue control involves careful synchronisation of a multi-disciplinary team of public health nurses, epidemiologists, entomologists and mosquito control experts, and health promotion workers. Loss of any part of this team can seriously impact the overall success of a control program.</p>
<p>While some control methods in development hold some promise – the Wolbachia bacteria that blocks dengue infection in mosquitoes, for instance, and Sumitomo’s smokeless mosquito coil that repels and kills mosquitoes in the house – they’re still in some years away from becoming available. </p>
<p>Given the increase in dengue activity overseas, the need to support current dengue infrastructure has never been greater.</p>
<p><br>
<em>See more <a href="https://theconversation.com/topics/explainer">Explainer articles</a> on The Conversation.</em></p><img src="https://counter.theconversation.com/content/8571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Scott Ritchie receives funding from FNIH, NHMRC, Queensland Govt., CSIRO</span></em></p>Dengue is caused by four different serotypes (strains) of the dengue virus that can cause mild to severe illness in people, who are infected via mosquito bites. Dengue has been spreading through most urbanised…Scott Ritchie, Professorial Research Fellow, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/97892012-09-30T20:40:12Z2012-09-30T20:40:12ZBrace yourself for a fatter, unhealthier Queensland after health promotion cuts<figure><img src="https://images.theconversation.com/files/15963/original/wvbh2x6v-1348804744.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">All available evidence tells us that more investment is needed in preventive health – not cuts.</span> <span class="attribution"><span class="source">angelsk</span></span></figcaption></figure><p>Queensland appears intent on dismantling its public and preventive health services. Health Minister Lawrence Springborg last week outlined the rationale for <a href="http://www.couriermail.com.au/news/payroll-workers-in-queensland-health-facing-premier-campbell-newmans-cost-cutting-axe/story-e6freon6-1226479804782">getting rid of more than 150 jobs</a> in nutrition, health promotion and Indigenous health, <a href="http://www.couriermail.com.au/news/payroll-workers-in-queensland-health-facing-premier-campbell-newmans-cost-cutting-axe/story-e6freon6-1226479804782">arguing</a> previous “campaigns” and “messaging” around obesity were “piecemeal” and had “grossly failed”.</p>
<p>The plan now, the minister <a href="http://statements.cabinet.qld.gov.au/Statement/2012/9/24/springborg-calls-in-commonwealth-debt-on-national-health-reform">argued</a>, is to focus on a new centrally-driven and high-profile approach.</p>
<p>On the surface that doesn’t sound so bad. But even a cursory glance at the details suggests something else is going on.</p>
<p>Of particular concern is the Queensland government’s call for the Commonwealth to invest more in preventive health through the Australia-wide <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/medilocals-lp-1#.UGUVu_lNtHg">Medicare Local</a> network. This may be a bold attempt to shift costs, or a fundamental misunderstanding of what preventive health is all about – or both.</p>
<p>Although it’s good to see Minister Springborg confirming a commitment to “health prevention campaigns” and “evidence-based medicine”, questions remain as to what this really means for public health in Queensland.</p>
<h2>Tackling obesity</h2>
<p>One challenge working in the area of obesity is that most people, including decision makers, eat and move, and so are self-informed experts. If this was brain surgery, expert briefings on the evidence would be sought before decisions were made. But addressing obesity is more complex.</p>
<p>To inform decisions about obesity intervention, the scientific evidence needs to be assessed at three levels. Firstly to identify <em>whether</em> something should be done, then to investigate <em>what</em> should be done, and finally to inform <em>how</em> something should be done.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=772&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=772&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=772&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=970&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=970&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15962/original/tpx3nx92-1348804186.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=970&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s unclear what Minister Springborg has in mind for health promotion in Queensland.</span>
<span class="attribution"><span class="source">AAP</span></span>
</figcaption>
</figure>
<p>At the first level, there is little disagreement about the magnitude of the problem; something definitely needs to be done about obesity – and urgently. The epidemic of overweight and obesity is sweeping most developed economies. In Australia, the <a href="https://theconversation.com/mapping-australias-collective-weight-gain-7816">prevalence</a> has doubled over the past 30 years – it’s now above 60% in adults and around 25% in children.</p>
<p>Obesity is bad news for the health system. In Queensland, excess body weight has now overtaken cigarette smoking as the single greatest risk factor contributing to the burden of disease. In 2008, the health system <a href="http://www.health.qld.gov.au/epidemiology/documents/overweight-2011-fs.pdf">cost of obesity</a> was A$391 million, with an additional cost of about A$9.96bn in lost well-being across all sectors throughout the state.</p>
<p>But the good news is that most obesity-related conditions are preventable. That such an enormous expense and burden is avoidable, must surely be of interest to any government concerned about its economic outlook, and the well-being and health of its people.</p>
<h2>What should be done about it?</h2>
<p>To answer, it’s necessary to look at both causes and treatment outcomes.</p>
<p>A surprisingly small daily excess in energy intake is sufficient to account for the weight gain seen in Australians over time. </p>
<p>It’s now clear that changes to our <a href="https://theconversation.com/education-wealth-and-the-place-you-live-can-affect-your-weight-7941">socioeconomic environment</a> are responsible for the current epidemic. These changes actually make it easier for all of us (but particularly those who have limited resources and opportunities) to consume more energy-dense and nutrient-poor foods and drinks, to eat too much, to sit longer and move less. </p>
<p>Being overweight is a normal physiological response to an abnormal “<a href="https://theconversation.com/fat-of-the-land-how-urban-design-can-help-curb-obesity-6445">obesogenic</a>” environment. And this is exactly why losing weight is so hard – and keeping it off is harder still. </p>
<p><a href="http://www.nhmrc.gov.au/nics/nics-programs/clinical-practice-guidelines-management-overweight-and-obesity-adults-children-an">Studies show</a>consistently that just telling people to change their behaviour is bound to fail. Generally, mass media advertising increases awareness, but only leads to behaviour change when supported by complementary policies, programs and services provided within the community.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15958/original/kpz63n3m-1348803755.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">To reduce obesity, we need to make it easier for people to make healthier choices.</span>
<span class="attribution"><span class="source">robnguyen</span></span>
</figcaption>
</figure>
<h2>How can we achieve healthy weight at a population level?</h2>
<p>Strategically, the best approach to obesity prevention involves <a href="https://theconversation.com/why-were-losing-the-battle-of-the-bulge-the-politics-of-obesity-prevention-8304">regulatory reform</a>. This has been demonstrated repeatedly in other public health areas such as infectious disease, traffic safety and tobacco control. However, there is little evidence that any governments in Australia currently want to go down this path to combat obesity.</p>
<p>So at a more pragmatic, operational level, the evidence points to two main areas:</p>
<ol>
<li><p>Counteract the gross misinformation about food, dieting and exercise so rampant in our society and, at the same time,</p></li>
<li><p>Influence sectors beyond health to improve the social and physical environment to make it easier for people to make healthier choices.</p></li>
</ol>
<p>And that is exactly what the dismissed nutrition, Indigenous and health promotion workforce <em>was</em> doing in Queensland.</p>
<p>Among many projects, they worked to improve the food supply in child care centres, schools, workplaces, health facilities and remote communities, and encouraged greater physical activity through urban planning. They ran effective, group-based behaviour modification programs to support adoption of healthy habits. </p>
<p>In areas such as mental health and infant feeding, they developed evidence-based training materials and resources to help lighten the workload of clinicians. And their efforts <em>were</em> having traction and providing cost- effective health outcomes for the state. </p>
<p>In 2007, the rate of measured (rather than self-reported) healthy weight among children in Queensland was <a href="http://www.health.qld.gov.au/cho_report/2008/documents/2008choreport.pdf">2% to 3% higher than in other states</a> where comparable data was available. This equates to 3,000 less children becoming overweight per year, and 1,200 fewer future cases of Type 2 Diabetes per year by 2015.</p>
<p>At its peak, the multi-strategy <a href="http://www.gofor2and5.com.au/">Go for 2 and 5</a> fruit and vegetable promotion program exceeded targets, <a href="http://www.health.qld.gov.au/ph/documents/hpu/healthykidsqld2006.pdf">resulting in</a> an additional turnover of A$9.8 million of fresh produce per month in Brisbane alone, and a technical saving of A$55 million per year to the ill-health system state-wide. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15961/original/9c3gb72t-1348804123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health promotion activities work to improve rates of breast feeding.</span>
<span class="attribution"><span class="source">Ania i Artur Nowaccy</span></span>
</figcaption>
</figure>
<p>Since 2004, adult physical activity participation rates had <a href="http://www.health.qld.gov.au/cho_report/2008/documents/2008choreport.pdf">increased by over 34%</a>. </p>
<p>And since 2003, rates of exclusive breastfeeding for the first six months of life <a href="http://www.health.qld.gov.au/cho_report/2008/documents/2008choreport.pdf">had quadrupled</a>, and the proportion of infants breastfed at one and six months had increased substantially.</p>
<p>These results demonstrate that preventive health services provided the front line, indeed the vanguard, of medical ill-health services – helping to reduce waiting lists and increase the likely effectiveness of clinical treatment.</p>
<h2>What happens next?</h2>
<p>Within the health sector, preventive health interventions to address obesity must be applied across the whole continuum – not only in primary care settings like Medicare Locals. But most importantly, concerted, sustained effort is needed beyond the health sector, with non-government organisations, industry and all members of the community.</p>
<p>So, fingers crossed that the promised new “campaigns” will provide more than expensive advertising telling us all to lose weight. And fingers crossed that Medicare Locals will have the resources and abilities to foster partnerships to improve the toxic “obesogenic” environments that continually undermine health messages.</p>
<p>Because, if not, we will definitely lose the war against obesity and growing rates of chronic disease in Queensland. All available evidence tells us that <em>more</em> investment is needed in preventive health – not cuts.</p><img src="https://counter.theconversation.com/content/9789/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Lee 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>Queensland appears intent on dismantling its public and preventive health services. Health Minister Lawrence Springborg last week outlined the rationale for getting rid of more than 150 jobs in nutrition…Amanda Lee, Professor, School of Public Health and Social Work; School of Exercise and Nutrition Sciences, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/97332012-09-25T20:19:49Z2012-09-25T20:19:49ZCensoring public health in Queensland - a dangerous precedent?<figure><img src="https://images.theconversation.com/files/15743/original/h4x4h45v-1348206803.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Queensland Health Minister Lawrence Springborg announcing job cuts in his department on September 7, 2012.</span> <span class="attribution"><span class="source">AAP</span></span></figcaption></figure><p>Beyond the recent publicity around cuts to health and other portfolios, something deeply disturbing – even sinister – is occurring in Queensland. </p>
<p>The state government is implementing health policies on the run and cutting health jobs and services. This has happened before around the country and will eventually be turned around, albeit not before a deal of harm has been done. </p>
<p>Even this week, <a href="http://www.smh.com.au/queensland/another-44m-cut-from-health-grants-20120924-26fsf.html">there is news</a> of yet more cuts to prevention programs. But more disturbing still, and a move that should send alarm bells ringing around the country, is the Queensland government’s decision to gag health organisations, health professionals and public debate on health issues.</p>
<p>A number of of Queensland Health’s recent problems – from Bundaberg to payroll disasters – followed historical underfunding of key control processes, and came to light in part because concerned people had the courage to speak out.</p>
<p>There is a long history in public health of measures that were initially resisted or opposed, speedily becoming accepted as part of a modern, civilised society. We would not be one of the world’s longest-lived populations without advances in public health such as sanitation and safe water, safe food, safe environments, immunisation, control of infectious diseases, screening, speed limits, seat belts, random breath testing, and tobacco control. </p>
<p>Each of these advances met initial resistance. None of them – not a single one of the public health advances we now regard as vital – would have been implemented without public health advocacy.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=779&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=779&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=779&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=979&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=979&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15744/original/tf6xx94d-1348207021.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=979&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pioneering epidemiologist John Snow (1813-1858).</span>
<span class="attribution"><span class="source">Rsabbatini/Wikimedia Commons</span></span>
</figcaption>
</figure>
<h2>A troubled history</h2>
<p>There is nothing new about opposition to public health advocacy. When sanitary reforms were being debated in England in the 1850s, led by the pioneering epidemiologist John Snow, the London Times thundered, “We prefer to take our chances of cholera and the rest than be bullied into health by Mr. Snow”.</p>
<p>But Snow persevered, achieving changes that led the way to advances there and elsewhere. Since then, we have seen a plethora of public health advances because of pressure from health groups, whether professional organisations such as the <a href="http://ama.com.au/">Australian Medical Association</a> (AMA), or issue-based non-governmental organisations (NGOs), such as the various cancer councils and the <a href="http://www.heartfoundation.org.au/Pages/default.aspx">Heart Foundation</a>. </p>
<p>These external pressures are often encouraged by health ministers who need help generating support for action in Cabinet and the community: after legislation or other action, they frequently express their appreciation to the organisations concerned.</p>
<p>It is reasonable and normal for governments to expect that public servants follow conventional protocols in relation to public comment. It is also reasonable to expect that NGOs engaged in advocacy do so in a sensible and civilised manner. It is, however, unreasonable and dangerous for governments to gag health NGOs, and to take action that will specifically preclude them from advocating for change.</p>
<h2>Gagging order</h2>
<p>Health departments traditionally fund large numbers of NGOs to carry out crucial work in the community. Queensland Health Department contracts with these NGOs will now be subject to censorship. Any NGO receiving 50% or more of its funding from the state will be precluded from advocating for state or federal legislative change – even from providing website links to other organisations’ websites that do so.</p>
<p>NGOs justifiably fear that the 50% figure is just a starting point, and that this censorship may ultimately apply to any funding. Many now dare not speak out. Even those not currently in receipt of funding but thinking of applying will feel constrained.</p>
<p>The condition relating to websites means that funded NGOs may not be able to provide links to organisations such as <a href="http://www.cancer.org.au/">Cancer Council Australia</a>, the Heart Foundation, or even the AMA and the <a href="http://www.who.int/en/">World Health Organization</a>, all of which advocate for legislative change.</p>
<p>Government-funded NGOs are often also funders of research, which may conclude that legislation or regulation is appropriate. The new Queensland Health approach will preclude reputable health organisations from even discussing the implications of such research.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15746/original/4jbn2scg-1348207887.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many public health measures were initially resisted or opposed.</span>
<span class="attribution"><span class="source">AAP</span></span>
</figcaption>
</figure>
<p>An <a href="https://repository.uwa.edu.au/R/-?func=dbin-jump-full&object_id=14938&local_base=GEN01-INS01">important 2007 paper</a> showed that there was already cause for concern about suppression of information in the health sector. It noted international precedents where exposure and comment from outside government were crucial in preventing further public health catastrophes, such as the 1980 <a href="http://www.ncbi.nlm.nih.gov/pubmed/7118327">Black Report</a> in the United Kingdom, the Chernobyl disaster in the Soviet Union, the SARS outbreak in China, and harmful mercury blood levels in the United States.</p>
<h2>But why?</h2>
<p>So what justification has the Queensland Government offered for its descent into the dark ages?</p>
<p>First, they assert that NGOs should focus on their “core activities”, not advocacy. But seeking action that will protect the health of the community is the most fundamental core activity for public health organisations. Even if they cannot understand this, it is outrageous that a government providing only some of an organisation’s funding should prohibit action carried out with funding from other sources.</p>
<p>Second, they state in relation to funded groups that “we would expect that organisation to conduct itself with the political impartiality of any other government sector.” This verges on the bizarre, given that by definition NGOs are not part of the “government sector”.</p>
<p>A third rationale now offered is that this condition will prevent abuses, such as the “<a href="http://www.couriermail.com.au/news/queensland/fake-tahitian-prince-joel-morehu-barlow-seeks-legal-aid-for-defence/story-e6freoof-1226410467322">Fake Tahitian Prince</a>” scandal, and funding of NGOs to pursue political agendas. But any concerns in these areas should be addressed by protocols common to all governments (and indeed other funding agencies) about proper, well-monitored use of funds.</p>
<p>The fourth rationale is that the government is seeking “health outcomes, not political outcomes or social engineering outcomes”. The government is entitled to seek health outcomes from activities that it funds: but that is no justification for gagging the non-government sector. </p>
<p>It is desperately depressing that any health minister should use pejorative phrases such as “social engineering” to describe the aims of health organisations, and, by implication, the aims of his own and other health departments around the country.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/15745/original/s6724syy-1348207243.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Queensland AMA president Alex Markwell has spoken out against the measures.</span>
<span class="attribution"><span class="source">AAP</span></span>
</figcaption>
</figure>
<p>No explanation has been offered as to why health, where advocacy has been so fundamental to our well-being over the years, is being singled out.</p>
<h2>Dark days</h2>
<p>The Queensland government’s approach has already met with some success. It has created a climate of fear. Beyond the AMA, whose Queensland president, Dr. Alex Markwell, has shown herself to be a true health leader, and some courageous public health academics, few in the state are willing to speak out, lest they be victimised and lose their funding.</p>
<p>These are dark days for public health in Queensland. The public health advocacy that has made our community so healthy will be hard to find. By contrast, commercial interests – in areas such as alcohol, tobacco, gambling, junk food, even firearms – are free to pressure governments at will.</p>
<p>Queensland, of all states, should have learned that gagging people in health from speaking out is a recipe for disaster. Censorship is the hallmark of a totalitarian regime; censorship in health sends out the signal loud and clear that the government neither understands public health nor cares for the future health of the community. </p>
<p>Other governments should condemn the Queensland approach though the Standing Council of Health Ministers; the Federal Government should bring all possible pressure to bear; and health professionals around the nation should use every available opportunity to make clear their distaste for this fundamentally unhealthy approach to public health.</p>
<p>Public health has been described as the conscience of the health system. It should be a matter of great concern for the entire community that any government is seeking to silence our conscience.</p><img src="https://counter.theconversation.com/content/9733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Daube has for many years been associated with a wide range of non-government, government and international health organisations.</span></em></p>Beyond the recent publicity around cuts to health and other portfolios, something deeply disturbing – even sinister – is occurring in Queensland. The state government is implementing health policies on…Mike Daube, Professor of Health Policy, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.