Tackling the growing problem of diabetes requires action on many fronts, including ensuring that Indigenous communities have affordable access to healthy foods and priority access to essential medicines that are currently in short supply, according to the column below by Associate Professor Lesley Russell.
Also addressed are efforts to tackle the inverse care law, primary care reform, and the Measuring What Matters framework, as well as an update on various infectious diseases. As always, don’t miss the good news stories.
The quotable:
The data suggests that crochet offers positive benefits for personal wellbeing with many respondents actively using crochet to manage mental health conditions and life events such as grief, chronic illness and pain. Crochet is a relatively low-cost, portable activity that can be easily learnt and seems to convey all of the positive benefits provided by knitting.
This research suggests that crochet can play a role in promoting positive wellbeing in the general population, adding to the social prescribing evidence base.”
Lesley Russell writes:
I thought I would continue the (new) tradition of starting each edition of The Health Wrap with a photo of my activities from the previous week.
We recently took overseas guests on the wonderful Bondi to Bronte walk that connects some of Sydney’s beautiful beaches– it’s the best way to recover from jet lag. The day was extremely windy and there were very few surfers and people on the beach. But the seagulls were there, enjoying the day regardless.
Australia’s diabetes epidemic hits the most disadvantaged
Since May 2023 the House of Representatives Standing Committee on Health, Aged Care and Sport has been conducting – at the request of the Minister for Health and Aged Care, Mark Butler – an inquiry into diabetes.
The terms of reference are here.
Submissions for this inquiry closed in August 2023. The 470 submissions received are here and there’s a set of additional documents (mostly answers to questions put on notice at hearings) here.
It appears that the Committee, chaired by Dr Michael Freelander, has recognised the wide range of issues that need to be addressed as part of the broad Terms of Reference, as a new series of hearings were convened for November last year and continue into 2024. To date 15 hearings have been held; transcripts are here.
The Committee travelled to Yarrabah, an Aboriginal community outside of Cairns, to hear from the local Aboriginal Community Controlled Health Organisation, Gurriny Yealamucka, about its experiences with diabetes. The transcript of this hearing is here.
Where is this inquiry headed?
It’s imperative that it does not simply describe the problem but that it comes up with meaningful and well-targeted solutions.
“Submitters have raised many proposals to prevent and/or better manage diabetes, such as greater access to subsidised diabetes technology, changes to the Medicare Benefits Schedule, a low carbohydrate diabetes, and policies to improve access to healthy diets including a sugar tax or strengthened Health Star Rating system. The Committee looks forward to exploring these and other ideas at the upcoming hearings,” commented Dr Freelander back in November.
The Yarrabah hearing made a strong case that affordable access to healthy foods was a critical factor in addressing the rising rates of diabetes in Indigenous communities.
Why action is needed – now
The most recent data from Diabetes Australia estimates that the total number of people with diabetes (both type-1 and type-2) in Australia is around two million (or 7.5 percent of the population), including 500,000 people who are undiagnosed.
In addition, it is estimates that one in six adult Australians over the age of 25 (approximately two million people) are living with pre-diabetes.
Diabetes is associated with approximately 11 percent of all deaths in Australia, more than 19,000 deaths a year. The number of diabetes-related deaths almost doubled from 2000 to 2020.
The costs to the healthcare system, individuals and families and society as a whole are huge. In 2020-2021, the costs to the healthcare system alone were estimated at $3.4 billion. The total cost to the economy has been estimated at more than $17.6 billion per annum.
A series of articles in The Australian last year described diabetes as a “silent epidemic that ravages nation’s poorest citizens”, a “crisis in slow motion”, with babies of diabetic mothers the forgotten victims.
- The diabetes epidemic: a crisis in slow motion.
- Diabetes surge needs major public health initiatives.
- Babies of diabetic mums born with birth defects.
Modelling done last year by Diabetes Australia estimates that the cost to the healthcare system when Australians living with type-2 diabetes do not receive the recommended care was around $3,564 per person per annum.
Australia has a National Diabetes Strategy 2021-2030, released almost three years ago, but there is no implementation plan or dedicated funding for the strategy. Health Minister Butler has stated that he is waiting for the parliamentary report.
Meanwhile the Australian Institute of Health and Welfare has indicated that there are data gaps and limitations. It states: “Comprehensive, accurate and timely data are necessary for effective population health monitoring of diabetes with Goal 7 of the [strategy] outlining the need to ‘Strengthen prevention and care through research, evidence and data’.”
Currently diabetes organisations are campaigning for more research funding. They say funding for diabetes research has declined over the past decade and are calling for $10 million in emergency funding for research in this year’s federal budget and a Diabetes and Obesity Health Mission under the Medical Research Future Fund (MRFF) to distribute $270 million over ten years. Diabetes Australia’s 2024-2025 Pre-Budget submission is here.
Indigenous communities
Type 2 diabetes is one of the leading causes of the gap in life expectancy between Indigenous and non-Indigenous Australians. Aboriginal and Torres Strait Islander people are more than three times as likely to live with diabetes and nearly five times more likely to be hospitalised with diabetes-related complications.
A 2022 study showed that the burden of diabetes in the remote Aboriginal population of the Northern Territory is among the highest in the world.
There’s a good summary of the current data here.
I look at the sage advice provided by Professor Kerin O’Dea and colleagues back in 2007 and see so many lost opportunities to tackle the social determinants of diabetes and its causes and consequences.
That said, there are some really excellent examples of Indigenous-led programs to address the diabetes crisis.
These include:
- The Menzies School of Health-led Diabetes across the Lifecourse: Northern Australian Partnership, which includes Diabetes Australia. This has been recognised by The Lancet as an example of best practice to improve diabetes in minority ethnic groups.
- Ray Kelly’s Too Deadly for Diabetes program. Kelly, a Gomeroi man, has developed a lifestyle / exercise program provided primarily through Aboriginal medical services in rural and remote NSW that has proven effective in delivering major improvements in clinical outcomes. There is more information here.
A recent paper lists what Indigenous people with diabetes see as essential components of their type-2 diabetes care: culturally responsive service delivery; suitable transport provision; a flexible approach to accommodate for individuals’ unique social circumstances; appropriate client education and appropriate cultural education for health professionals; support mechanisms and community support services.
More must be done to take these programs that are shown to be working and the principles of community engagement that underpin them into all the affected communities.
Who gets the new drugs for diabetes management?
There is growing evidence that the new GLP-1 agonist drugs like Ozempic and Mounjaro, which were developed to treat diabetes and its complications but are increasingly being prescribed off-label for weight loss, are not reaching priority populations.
Currently, drug shortages and an exploding demand in the cities (often from people who do not have a genuine need for these drugs), combined with the fact that the drugs are not licensed or funded to treat obesity, means that disadvantaged populations in the Northern Territory and Western Australia are unable to access the new drugs at all.
The Central Australian Aboriginal Congress is urging priority access to these new drugs.
“The Australian Government should ensure that all Aboriginal people have affordable access to GLP-1 receptor agonist medication, including by listing these medicines on the Pharmaceutical Benefits Scheme and in the highly specialised drugs program, for both diabetes and obesity formulations,” Congress chief executive Dr Donna Ah Chee told the parliamentary diabetes inquiry last month.
Professor Rachel Betterham, the senior vice-president of international medical affairs at Elli Lilley, the manufacturer of Mounjaro, said in her testimony to the diabetes inquiry: “We need to ensure that these medications get to the people who really need them. There are mechanisms where medications can be ring-fenced for the people with the greatest need. And I would have thought that that would be possible.”
She implored the Government to “do something about prevention now, not in a year’s time when you write the report”.
Chairman of the diabetes inquiry, Dr Michael Freelander, has backed the call for priority access for Aboriginal people in remote Australia.
“The new GLP-1 agonist medications and some of the other newer medications are gamechangers, but only if regular supply is available.
“When we have supply shortages it is a major concern that the wealthier people can access it and the poorer people can’t and the poor need it the most.”
Peak diabetes organisations have joined this call.
Primary care reforms
I alternate between worrying that I can’t keep up with what’s happening in primary care and concerns that nothing is happening on needed reforms.
An examination of the Department of Health and Aged Care primary care website highlights this dichotomy:
What we’re doing about primary care hasn’t been updated since April 2023.
The last item in the News section was added on 30 October 2023.
The section on Primary Health Networks was last updates in June 2023.
But then, at the bottom of the page, under Resources, I find unannounced treasure:
Unleashing the Potential of our Health Workforce – Scope of Practice Review – Issues Paper 2. Released 16 April 2024.
Primary Health Networks (PHN) Strategy 2023-24 – but not released until 10 April 2024.
Allied Health Industry Reference Group – Summary of outcomes – 5 March 2024. Released 5 April 2024.
The Scope of Practice Review, led by Professor Mark McCormack, is an essential element in workforce planning and in ensuring improved access to primary care services, especially in rural and remote areas. The first issues paper, released in January, is here.
Unfortunately this work has engendered the usual turf fights, the most egregious of which centre around the fact that organised medicine fails to understand that primary care is something more than general practice. There are endless (justifiable) complaints about how busy GPs are – but fights about ceding any responsibilities to other members of the primary care team.
A recent article in The Sydney Morning Herald headed “Doctors fear Medicare reforms could ‘reproduce failures’ of the UK health system” outlines the concerns of organised medicine (specifically the AMA and the RACGP) have about the first issues paper which references the way primary practice operates in the United Kingdom and Canada.
As an accompanying editorial states: “The health system is being hampered because it is built around health worker demarcations, not patients’ needs.”
My Croakey colleague Charles Maskell-Knight has also covered the latest issues paper from the Scope of Practice review here and here, noting support for the review from non-medical groups.
It’s clear that doctors’ groups are concerned about control and income (and promulgation of the private care sector). The Medicare rebate is inadequate and should be increased. But more pay for doctors is only part of the solution and there is a crying need for more robust primary care reforms.
Attention must also be paid to the ongoing privatisation of general practice; the Consumers Health Forum believes Australia’s primary care system is in danger of becoming privatised “by stealth”.
The allied health workforce must be part of scope of practice and primary care reforms. It’s not clear what is happening with the National Allied Health Workforce Strategy; the summary of outcomes from the March meeting seems to suggest that allied health stakeholders are not being given much clarity about the work being done in this space. The development of this Strategy is in the consultation phase and the final report is due in 2025.
There is a National PHN Allied Health in Primary Care Engagement Framework (this is on many PHN websites, but I could not find it on the Department of Health and Aged Care website).
See also this recent article written for Croakey Health Media by Scott Willis, National President of the Australian Physiotherapy Association.
Primary Health Networks?
Despite their relevance for implementation of primary care reforms, we don’t hear much about the Primary Health Networks (PHNs) these days, and we must wonder at the late release of the 2023-2024 PHN Strategy – which is simply a one-page poster, more a PR document than a Strategy outline.
It does provide a breakdown of PHN funding for 2022-2023 (but not for the time frame of the “Strategy”!). It’s worth noting that 49 percent of the total funding for that year ($1.88 billion – that’s a lot of money, definitely requires regular scrutiny for how it is spent)) went to mental health and 12 percent to pilots and targeted programs.
In that light, what do we know about the $232 million that was spent on pilots and targeted programs in 2022-2023?
There’s some information in the Innovative Models of Care Program and further information (somewhat hidden) in the funding provided in the 2023-2024 Federal Budget as part of the Government’s response to the Strengthening Medicare Taskforce report. Tracking this is almost impossible – although it’s a good issue to push at Senate Estimates!
At this point I can’t resist making my usual point about how much money and time has been spent on small scale, pilot programs which never deliver useful outcomes. The issue is summed up nicely in a report from the Grattan Institute: Six Lessons for Australia from Decades of General Practice Reform.
To conclude, some overseas studies that highlight the central importance for primary care in the healthcare system:
From the United States, a study shows that rates of emergency surgery, serious post-surgical complications, and hospital readmissions are higher in patients living in primary care shortage areas. This study is well-summarised here.
From the United Kingdom, how local health authorities in England and Wales that have been designated Marmot Places are taking a proactive local approach to health inequalities. (Marmot Places develop and deliver interventions and policies to improve health equity – you can read more here.)
Meanwhile, Professor Michael Marmots was speaking on related matters at the World Health Summit Regional Meeting in Naarm/Melbourne today, and you can listen to his recent interview with ABC Radio National’s Fran Kelly here.
Tackling the inverse care law in Scottish general practice. This report analyses the policies and interventions to address access to primary care in deprived areas since 2000. It finds that few of these have been effective or received sustained investment and only two have been rolled out nationally. The most deprived areas have a smaller number of GPs and primary care workforce. (See also this recent Croakey article by University of Tasmania academics on the inverse care law.)
https://www.health.org.uk/publications/tackling-the-inverse-care-law-in-scottish-general-practice
From the UK-based Kings Fund, a report into the relationship between poverty and NHS services. It concludes that: “The NHS has a role to play in addressing poverty, both as an employer and as a provider of public services. There are examples of good work under way, such as poverty-proofing services (making sure every stage of the patient pathway is accessible to more deprived groups), but more needs to be done to support better access and better outcomes for those living in poverty.”
Recent primary care pilots and diabetes management
There’s a major intersection between improving the management of diabetes and primary care reforms.
A recent paper from Sydney-based researchers looked at the impact of the Health Care Homes (HCH) primary health care initiative (remember that?) on quality of care and patient outcomes with a particular focus on diabetes.
It found that the HCH program was associated with greater access to care (both GPs and allied health services) and improved processes of care for people with chronic diseases, but did not improve clinical outcomes for patients with diabetes, most measures of hospital use, or risk of death.
The authors propose that evaluations of patient-centred primary care initiatives should be larger-scale, randomised controlled studies of longer duration, with more efficient linking of primary care records and administrative datasets.
In a second study published late last year, researchers assessed the Diabetes Alliance Program, an integrated care model implemented in the Hunter New England Local Health District of New South Wales in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions.
This study provides supporting evidence that an integrated diabetes care model is beneficial for increasing the skills and confidence of GPs in delivering best practice and evidence-based care for diabetes management. GPs involved in the program reported that the program benefitted their knowledge, skills and approach to managing diabetes.
Budget time approaches – what is happening with Measuring What Matters?
Back in 2020, when still in Opposition, Treasurer Dr Jim Chalmers first proposed the idea of a wellbeing budget. At the time this was greeted with derision by then Treasurer Josh Frydenberg.
His first Budget, delivered after five months in government in October 2022, outlined plans for this going forward. There was to be a focus on measures of wellbeing, such as educational outcomes, access to health, the environment and economic disadvantage, that go beyond the traditional budget metrics such as GDP, inflation and unemployment.
The key commitment was to producing a “Measuring What Matters Statement” in 2023.
The first Measuring What Matters Statement was released in July 2023.
The Measuring What Matters Framework uses 50 indicators to track how healthy, secure, sustainable, cohesive and prosperous Australia is. The dashboard will be updated annually.
Croakey Health Media has published a series of articles around measuring wellbeing as part of the budget process.
- Nieves Murray. How a Wellbeing Budget could help save lives at a critical time. 25 October 2022.
- Jennifer Doggett and Alison Barrett. To make a proper Wellbeing Budget, what are the essential ingredients? 27 October 2022.
- Leanne Wells. Wellbeing budgets are not the soft underbelly of public policy. 14 November 2022.
- Melissa Le Mesurier. With just 56 days left on wellbeing budget consultation, putting some questions and issues on the radar. 7 December 2022.
- Robert Costanza et al. Health is key to our first national wellbeing framework. 19 July 2023.
- Jennifer Doggett. On the wellbeing framework, and ways forward. 27 July 2023.
- Melissa Sweet. Calling all “frustrated champions” – Australia’s future needs you, now. 26 April 2023.
See also previous editions of The Health Wrap: 27 July 2022; 12 May 2023.
As I was writing this edition of The Health Wrap, Croakey published an article that poses exactly the question that heads this section: As we approach the Federal Budget, whatever happened to “Measuring What Matters”?
This question gains greater significance in the light of comments made more recently by Treasurer Chalmers at a meeting of the International Monetary Fund in Washington DC. While promising budget measures to provide cost-of-living relief, he warned that he would be focussing strengthening the economy in the face of global economic threats.
Reading between the lines, I doubt we will see new investments in improving national wellbeing in this year’s budget, despite the huge need for more mental health services, addressing the growing poverty gap, and helping those communities that have been devastated by floods, fires and drought.
For further reading on this issue:
- Why Australia’s wellbeing framework matters.
- Measuring What Matters: Reflections on Australia’s first national wellbeing framework.
- Measuring what matters: embracing Mental Wealth as an overarching indicator of national prosperity.
Finally, I note that New South Wales has signalled its future budgets will include a performance and wellbeing framework that aims to drive “positive social outcomes” and improve transparency.
In case you missed it
Australian patent reforms abandoned
Among the issues I missed around Christmas (when lots of government things just get dropped out in the hope that they receive little attention) is the announcement that the Albanese Government has dropped the ball on proposed reforms of the patent notification scheme for generic and biosimilar medicines.
This is an issue that impacts pharmaceutical manufacturers more than the Australian public, but it does go to a failure to improve transparency in the drug approval process.
In 2020 when the Therapeutic Goods Administration sought comments on Prescription medicines transparency measures: Implementation of generic and biosimilar medicines early notification of an application to innovators and publication of innovator applications.
Some 22 submissions were received (these were not made public) and apparently there was no consensus as to what should be done. So I guess the Government assigned the issue to the Too Hard basket!
There’s a good outline of the issues here.
And it’s intriguing to note that the Australian Medical Association, in partnership with Medicines Australia and the drug manufacturer Bristol-Myers Squibb, entered the fray with a White Paper on the issue. Now why was this of concern to the AMA? (A question unlikely to ever be answered!)
More threats from more viruses
Monkeypox (now generally referred to as mpox) continues to be a problem in both developed and developing countries.
In the United States, data from the Centres for Disease Control and Prevention shows that the number of mpox cases in 2024 (582) is already nearly double the number of cases that were detected in the same time frame in 2023 (299).
Mpox surged in the S during 2022 when cases spread through the social networks of men who have sex with men. More than 32,000 cases of mpox were detected that year along with 58 total deaths.
There is a vaccine against the disease but there are concerns that vaccination rates are low.
A recently published paper in Cell suggests that the downturn in cases since 2022 was due to individuals in the gay community altering their behaviour (such as reducing the number of partners) in response to public health messaging rather than to vaccination.
A new strain of mpox, described as having “pandemic potential” and with a higher death rate, has emerged in the Democratic Republic of the Congo (DRC) where there has been a dramatic spike in infections. In 2024, as of 29 March, 4,488 cases have been reported and there have been 279 deaths.
The strain of the virus that’s common in the DRC is called Clade I and it’s 10 times more deadly than Clade II, which is found in West Africa and caused the global outbreak. With Clade I, about two-thirds of the cases in the DRC are in children under the age of 15.
To date the DRC Government has not authorised use of any of the three vaccines available for mpox and nor has any other African government.
On a different viral front, in the United States there has been an outbreak of bird flu (H5N1) on dairy farms. Wild migratory birds are believed to be the original source of infection.
Regulatory authorities have repeatedly reassured the public that the spate of infections does not impact the nation’s food or milk supply, and poses little risk to the public, but there are concerns they may not be doing enough.
There are two major concerns. Firstly, there is now evidence that the virus is spreading among cows, and from cows to poultry. And secondly – more seriously – the US CDC has reported that a cattle worker in Texas has contracted H5N1 bird flu.
There are grave international fears about the global threat of bird flu spreading to humans.
On April 18, the chief scientist for the World Health Organization (WHO), emphasised this during a press conference and noted the virus’s “extremely high” mortality rate in humans.
More of the background is in a recent #ICYMI column.
First actions from the (interim) Australian Centre for Disease Control
As winter looms (and in light of the concerns about new viruses outlined above), it’s encouraging to see the first release from the new Australian Centre for Disease Control – Australian National Surveillance Plan for COVID-19, Influenza, and RSV.
The plan’s overarching goals are to:
- monitor trends in diagnosed COVID-19, influenza, and RSV cases
- monitor trends in community respiratory illness activity
- monitor morbidity and mortality associated with these three acute respiratory diseases
- monitor the impact of these three acute respiratory diseases on the health system
- monitor the uptake and effectiveness of interventions, with the aim of informing public health
decision making.
According to the document: “The Plan recognises the need to continue to enhance our understanding of the impact of COVID-19, influenza, and RSV on specific populations, including Aboriginal and Torres Strait Islander people, infants and young children, older Australians and aged care facility residents, people with serious health conditions, people from culturally and linguistically diverse (CALD) backgrounds, and people with a disability. These groups are a priority for surveillance and response as they may be at higher risk of COVID-19, influenza, and RSV infection and/or serious outcomes….enhancing the monitoring of COVID-19, influenza, and RSV infection and severe disease in these populations is recommended for consideration as a high priority.
“Considerations for Aboriginal and Torres Strait Islander populations have been incorporated into the Plan to ensure relevant data is collected; analysis and reporting are carried out; and that these data are reviewed,
reported, and interpreted with an appropriate cultural lens.”
How many lives did COVID-19 vaccines save?
A recent publication looks at the impact of Australia’s mass vaccination campaigns on mortality during the Delta and Omicron outbreaks in New South Wales.
The authors conservatively estimate that COVID-19 vaccines saved at least 17,760 lives of people aged 50 and over in the period August 2021 to July 2022 in NSW. The study also found that unvaccinated people had 7.7 times the death rate of people who were double vaccinated and 11.2 times the death rate of those who got a booster shot.
I immediately wondered about the impact of the delay in vaccine roll-out in late 2021 – early 2022 – and Angus Dalton at SMH Examine answered my question (sorry, this link is to an article behind a paywall).
“The delay of the vaccination program was actually advantageous since it limited the extent of immunity waning, and so increased protection during the Omicron period [which started January 2022]. Fortuitously, Australia’s slow start should, in hindsight, not necessarily be viewed as detrimental.”
This research was also summarised by ABC News here.
Best of Croakey
This article is the first in a series that Croakey Health Media is running in tackling misinformation and disinformation: Stop the spread – of disinformation, lies and conspiracy theories, by Alison Verhoeven.
Bookmark this link to follow Croakey’s ongoing coverage of misinformation and disinformation.
The good news on Indigenous health
This is an absolutely terrific health promotion video from Gurriny Yealamucka Health Services and the young people in their community.
More good news
Pain management is an ongoing and difficult issue for many Australians.
This story, about how some women have found knitting and crochet helpful in bring comfort and healing, was inspiring: How the steady click of knitting needles and crochet hooks is bringing comfort, mindfulness and healing – ABC News.
And to back this up – here’s a peer-reviewed article from 2020 (aptly entitled Happy Hookers) that explored the effect of crochet on wellbeing.
The authors conclude: “The data suggests that crochet offers positive benefits for personal wellbeing with many respondents actively using crochet to manage mental health conditions and life events such as grief, chronic illness and pain. Crochet is a relatively low-cost, portable activity that can be easily learnt and seems to convey all of the positive benefits provided by knitting.
“This research suggests that crochet can play a role in promoting positive wellbeing in the general population, adding to the social prescribing evidence base.”
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
