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The Health Wrap: climate change heats up, Nobel women, Australia’s suicide reckoning, & investing in primary care

Back from another epic walk, Dr Lesley Russell is as incisive as ever in this edition of The Health Wrap.

It’s posted ahead of World Mental Health Day, which occurs on Wednesday 10 October. The World Health Organisation has designated this year’s theme as, Young people and mental health in a changing world.

It’s always been a changing world, of course, but the reading below provides some sobering material, as we reflect upon the challenges our future generations are set to inherit.  If they can solve some of these wicked problems, there’ll be some deserving Nobel Prize winners in their ranks.

Lesley Russell writes:

After a break while I walked the Cotswold Way (a marvellous experience which I totally recommend, and will write up soon for #CroakeyExplore), The Health Wrap is back.

Australia is a laggard on climate change

Was anyone surprised that the Morrison Government sat on the latest bad news about climate change – the Department of Environment’s quarterly Update of Australia’s National Greenhouse Gas Inventory – for seven weeks, before releasing it late on the Friday afternoon of a long weekend when football finals and the interim report from the Royal Banking Commission were dominating the headlines?

It’s called “putting out the garbage” or, as West Wing characterised it, Take Out the Trash Day: the perfect opportunity to bury bad news.

The report shows that, in the first three months of 2018, Australia had the highest levels of carbon pollution since 2011. The office of the Environment Minister Melissa Price put out a media release headed “Emissions intensity at lowest levels for 28 years” – a statement achieved by comparing current figures with those from 1990. It also (accurately) highlighted the fact that emissions per capita have declined, a fact that does not offset Australia’s status as one of the worst-performing countries in the world on climate action (SDG 13).

These sins were compounded when Prime Minister Scott Morrison was interviewed by Barrie Cassidy on ABC’s Insiders. “I know people will want to use that one figure and ignore the fact that emissions per capita are the lowest in 28 years,” he said. “So people choose and pick their figures to make their political arguments. We’re going to meet those in a canter, our 26 percent target.”

As has been demonstrated in some detail, this is simply not true. The government’s own official projections show that under business as usual, emissions will increase steadily and Australia will fail to reach the 2030 target by a wide margin.

Since he became Prime Minister Morrison has dumped the National Energy Guarantee, which would have curbed emissions from the electricity sector, and declared Australia will not increase its emissions reduction targets agreed to under the Paris climate change accord in order to keep global warming well below 2°C.

A French diplomat and key architect of the Paris accord, Laurence Tubiana, was reported in Fairfax media as saying, “[Mr Morrison’s stance] goes against the science, spirit and letter of the Paris agreement. As we see other countries preparing to increase their levels of ambition, I strongly urge Australia not to fall behind.” Ms Tubiana told Fairfax Media.

This week I wrote a piece for Inside Story that outlines what the Trump Administration is doing to rollback regulations that protect health and the environment in the name of jobs and growth and boosting the coal mining industry, and how they are both sidelining and attacking science in the process. It’s a frightening story – and now I see echoes of this here in Australia.

The Intergovernmental Panel on Climate Change report

The Intergovernmental Panel on Climate Change (IPCC) is about to release the most politically charged report in its history.

There is growing concern that the Paris accord target to limit future global warming to 2°C is not enough, and there is pressure, especially from small island states, to lower the bar to 1.5°C. The IPCC has been tasked with preparing a report to give governments an indication of what this would mean in practical terms.

The substance of the report was being thrashed out in South Korea this past week and is due to be delivered on Monday October 8.

Climate change and health

How can organisations and individuals make a difference when the government of the day is not paying attention to the impact of climate change? This question was on the minds of participants at two recent health events: the Climate and Health Symposium in Melbourne, and the Public Health Association of Australia conference in Cairns. At both conferences, Professor Peter Sainsbury pushed that it is important to vote for climate action.

Sainsbury’s recent piece for Croakey is a must-read.

This year’s Nobel prizes

Did you notice something wonderful about the winners of this year’s Nobel prizes in physics and chemistry? There were women!

Of the 599 Nobel medals awarded in scientific disciplines, only 18 have gone to women. In the awards’ history, women have won only 3% of the science prizes and the overwhelming majority have gone to scientists in Western nations. The slow pace of progress was especially evident in 2016 and 2017, when there were no female laureates.

There’s an interesting article in Nature about the Nobel imbalance in science and efforts to address this. In 2019, for the first time, the committee will explicitly call on nominators to consider diversity in gender, geography and topic.

Chemistry

Three scientists – including Dr Frances Arnold, a professor of chemical engineering at the California Institute of Technology – shared this year’s Nobel Prize in chemistry for tapping the power of evolutionary biology to design molecules with a range of practical uses. Dr Arnold is only the fifth woman to win a chemistry Nobel Prize and the first since 2009.

Physics

The 2018 Nobel Prize in physics was awarded to three scientists – including Donna Strickland who is an Associate Professor at the University of Waterloo in Canada – for their pioneering work to turn lasers into powerful tools.

Dr Strickland is only the third woman to be awarded the physics prize, following Maria Goeppert-Mayer in 1963 and Marie Curie in 1903.

Her win was also a breakthrough for another reason: she was a graduate student at the time she did the research on “chirped pulse amplification”. The 1985 article that announced the achievement was her first scientific publication.

Students have historically not been recognised by the Nobel Committee, something critics say overlooks the work done by young scientists who are more frequently women and under-represented minorities.

Yet graduate students are the backbone of most scientific research, doing most of the scutwork. The prizewinning discovery of pulsars relied on the work of Jocelyn Bell Burnell, who built the telescope and spotted the first signal when she was earning her PhD in 1967. But Burnell was not among the list of laureates for that prize in 1974.

Physiology or Medicine

The two winners of the Nobel Prize in physiology or medicine were both men – for their work on unleashing the body’s immune system to attack cancer, a breakthrough that has led to an entirely new class of immunotherapy drugs. The genesis of this work was a desire to understand how T-cells work.

The dreadful toll of suicide in Australia

Last month the Australian Bureau of Statistics released 2017 data for deaths from suicide. The figures have shocked everyone – hopefully enough to galvanise needed actions to address this. Despite an increased focus on suicide prevention, it’s clear, as the suicide rate rises, that these efforts are insufficient and not reaching everyone.

The ABS data show that in 2017, in Australia, 3,128 people died from intentional self-harm, and increase of 9.1 percent from 2,866 in 2016. The suicide rate among males is more than three times greater than that for females.

The Australian Institute of Health and Welfare has suicide as the leading cause of death for people aged 15 to 24 years (34 percent of deaths) and for people aged 25 to 44 years (21 percent of deaths), although the media age for death by suicide is 44.5 years. Suicide rates are also high in men aged over 85.

The ABS paper has an interesting section on associated causes and looks at these by age cohort.  Some 80 percent of suicide deaths have co-morbidities as contributing factors. Mood disorders, including depression, were the most common in 2017 (43 percent of deaths), followed by drug and alcohol disorders and misuse (41.6 percent in the 25-44 year age group). People aged over 65 years were more likely to have a chronic health condition and cancer was present in approximately 25 percent of suicides of persons aged over 85 years.

It is recognised that many antecedent factors related to a suicide death are not a diagnosable health condition but may be issues such as financial difficulty or relationship distress. The ABS has completed a pilot study with 2017 suicide data where certain psychosocial factors have been coded in as associated factors to the death. This additional data will be released at a later date, as part of an information paper.

Calls for a suicide reduction target

In the wake of this news there have been calls for Australia to follow Scotland’s lead and set a national target for suicide prevention – a target of a 25 percent reduction over five years has been suggested.

In 2002, the Scottish government set a target to reduce suicide by 20 percent in ten years. It achieved a reduction of 17 percent by 2016 and the number of suicides in Scotland in 2015 was the lowest it has been since 1974.

Monitoring Mental Health and Suicide Prevention Reform: National Report 2018

Last week the National Mental Health Commission (NMHC) its sixth national report – Monitoring Mental Health and Suicide Prevention Reform: National Report 2018 – which provides a clear, comprehensive and sober analysis of the current status of Australia’s core mental health and suicide prevention reforms, and their impact on consumers and carers.

It covers:

Mental health and suicide reforms

  • Primary Health Networks
  • The National Disability Insurance Scheme
  • Suicide prevention initiatives
  • The Fifth National Mental Health and Suicide Prevention Plan

Mental health system performance

  • Expenditure
  • Workforce
  • Seclusion and restraint
  • Consumer and carer engagement and participation
  • Mental health outcomes

Social determinants of health

  • Prevention and early intervention
  • Housing and homelessness
  • Physical health

This is such a valuable report; I just hope minister and shadow ministers take the time to read it and to analyse and work on its findings and recommendations.

On suicide, the report makes the following conclusions:

The local area suicide prevention trial sites are an important development, but they do not cover the whole country and do not have the capacity or responsibility to address issues such as data gaps.

The NMHC remains concerned that, at all levels of government, significant gaps persist in the collection and distribution of key real-time data. There is also a lack of appropriate care and support for people in crisis, and insufficient training on suicide prevention for people working in the health, allied health and community sectors.

Who cares for the mental health of those who provide mental health services?

As efforts are made to reduce the suicide rate, there’s a crucial factor that needs consideration – the mental health of those who provide mental health services.   A 2013 beyondblue survey found doctors had substantially higher rates of psychological distress and attempted suicide than Australians in general.

A quarter of doctors had had suicidal thoughts – almost double the rate of the general population – and 21 percent had at some time been diagnosed with or treated for depression. I haven’t been able to find data for other health professions, but we can assume burnout and psychological distress rates are similar.

In conclusion:

Frank Quinlan, the CEO of Mental Health Australia, wrote this week: “We will only reduce the suicide rate when we make a lasting and concerted commitment to do so. When we set goals and targets and monitor progress closely and expertly. When we address each of the specific factors that contribute and invest to scale in the interventions that work to address mental health issues, loneliness, economic disadvantage, relationship breakdown, social exclusion and disconnection – to name just a few.”

A paper published this week, entitled What would a society designed for well-being look like? makes the case that economic justice goes a long way to improving mental health up and down the socioeconomic ladder.

As this graph taken from the paper shows, there is a close correlation between income inequality and rates of mental illness. The more unequal the country, the higher the prevalence of mental illness – and look where Australia is sitting.

An article published at Croakey, to coincide with World Suicide Prevention Day last month, drew heavily on interviews with Professor Pat Dudgeon and Professor Tom Calma AO, former co-chairs of the National Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group.

Dudgeon and Calma said sporadic and insecure funding was a real problem for mental health and suicide prevention initiatives in Indigenous communities, and contributed to a “cycle of disempowerment”.

And even as I write this, an article in The Saturday Paper claims that millions in government funding is going to unproven programs, with the mental health sector (and Minister Hunt) captured by lobbyists). This is sure to generate some controversy!

How to turn primary care into primary health care?

Nowadays there are very few working in health care who doubt the role social factors play in patients’ health.  But how to translate that into action by health care professionals and funding by providers?

Recently I was making the case that all the “wicked” problems in health (obesity, mental health, chronic illness, ageing well) require an integration of social services with health care services, and then I was asked how this might be done.

I wasn’t able to give a ready answer, but since then I’ve done some (very preliminary) research.  I found some really useful information on the Commonwealth Fund’s website – admittedly from the US perspective.

I present the following in order to stimulate some discussion, and to propose that this pragmatic approach to looking at returns on investment is a necessary first step for Australia.

Return on Investment (RoI) calculations

As early as 2008, the US Center for Health Care Strategies developed a RoI forecasting calculator (a web-based tool) which was designed to help Medicaid agencies, health insurers and other stakeholders estimate the RoI from initiatives intended to more effectively manage the care of high cost, high risk patients.

This calculator includes an evidence base which summarises published studies documenting utilisation changes from chronic care management interventions.

More recently the Commonwealth Fund has developed two additional RoI calculators: one for assessing the risks and rewards of integrating social services with health care services and how these partnerships might be structured in an equitable way; and another for partnerships to address the Social Determinants of Health such as nutrition support, transportation, home modifications, housing, care management, and legal, financial and social support counselling.

Much of this work is underpinned by a 2014 paper Addressing patients’ social needs: an emerging business case for provider investment which explores the impact of social factors on health and health care costs.

The only similar work that I am aware of in Australia is the Assessing Cost Effectiveness in Prevention (ACE-Prevention) study that was done in 2010 and has been ignored by governments since.

In case you missed it …

How Department of Health officials muscled the Parliamentary Library into rewriting its My Health Record analysis

The original article Law enforcement access to My Health Record data is available here. It has now been replaced by a version more agreeable to the government.

The story behind the change was published in some detail in The Mandarin.

And a backhander to the Lancet and other pay-for-access academic journals

Ex BMJ Editor, Richard Smith reviews the movie Paywall: The Business of Scholarship, In the Lancet (open access but you need to register)

  • Previous editions of The Health Wrap can be read here.
  • Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

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