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The Health Wrap: #LibSpill, Closing the Gap refresh, opioid deaths, killer austerity policies in Greece, and World Humanitarian Day

In the latest edition of The Health Wrap, Associate Professor Lesley Russell assesses the health impacts of #LibSpill, sounds the alarm about Tony Abbott’s appointment as a special envoy for Indigenous Affairs, and provides an update on the Closing the Gap refresh.

She also investigates an increase in opioid deaths in Australia, suggests that “politicians everywhere” should take note of the impact of austerity policies upon people in Greece, and spotlights global humanitarian crises, including Australia’s shameful role in destroying the health and wellbeing of asylum seekers and refugees, including children.


Lesley Russell writes:

I am back in the United States, but still caught up in political machinations both here and in Australia. I’m managing to escape the endless media commentary with some high altitude “forest bathing” in among the pines and aspens of the Rocky Mountains.

After the political brouhaha

It looks like more of the same from the same players.

After what was described as the “ugliest, messiest leadership challenge in history”, what can we expect for health and related portfolios? The early signs indicate more of the same.

There are no significant changes in the ministry:

  • Greg Hunt remains the Minister for Health
  • Ken Wyatt is the Minister for Indigenous Health and the Minister for Senior Australians and Aged Care. Does the addition of “senior Australians” to his title mean there will be an improved focus on healthy ageing?
  • Bridget McKenzie is the Minister for Regional Services, Sport, Local Government and Decentralisation. There are concerns that Rural Health is no longer a distinct portfolio
  • Nigel Scullion remains the Minister for Indigenous Affairs.

In his first press conference after becoming Australia’s 40th Prime Minister, Scott Morrison told us: “what Josh and I are here to tell you, as the new generation of Liberal leadership, is that we’re on your side” and that he “has always been a big fan of the NDIS”.

But not a mention of health until, in response to a media question about priorities, he said:

In healthcare I am distressed by the challenge of chronic illness in this country and those who suffer from it.

Affordable medicines, aged care, Medicare, small- and medium-size businesses, and to ensure that we are continuing to deliver support to that enterprise ethic that exists across our economy.”

It’s a garbled jumble of thoughts. I am slightly disturbed about the segue from healthcare to the “enterprise ethic” and suspect that we will see reforms in the name of competition and choice (of the sort proposed in the 2016 Productivity Commission report) in the future.

As Treasurer, Morrison has had his fingerprints on a raft of cuts in health and aged care, so I’m not at all sure we will see a change in focus from healthcare as a budget impost to healthcare as an investment.

Frank Quinlan, CEO of Mental Health Australia summed it up when he tweeted that in seven years he has worked with six Ministers (Roxon, Butler, Plibersec, Dutton, Ley, Hunt) and now faces his sixth Prime Minister and wonders what needed mental health reform might look like with stable national leadership.

As it stands, there is a plethora of reviews and reports underway in health, with little sign of action. In particular, what is being done about revitalising the Health Care Homes proposal?

Indigenous Affairs becomes a political pawn

In response to political pressures from the right, Morrison offered to appoint Tony Abbott as a special envoy for Indigenous Affairs.

Indigenous leaders were quick to speak out, blasting the offer. “We reflect on his history of supporting harmful and paternalistic policies relating to our people,” said Jackie Huggins, co-chair of the National Congress of Australia’s First Peoples. “One of his accomplishments has been to rob our people of a right to self-determination. And not listening to us – but listening to the selected few.”

Labor Senator Patrick Dodson tweeted: “The suggestion that Tony Abbott could act as some kind of messenger or representative for First Nations people is condescending and a serious worry for First Nations people.”

Abbott spent several days considering the offer – saying he wanted more than an honorary title – and then, ever the astute listener, accepted it. He has already made a number of pronouncements and recommendations about where his focus will be – again, without consultation.

“We do not need a ‘special envoy’ when we have so many capable and talented Indigenous people in Australia more than able to speak for ourselves.”  IndigenousX

“Just astonishing that First Nations people have clearly asked the Government for a Voice to Parliament – and the new Prime Minister Scott Morrison has given them Tony Abbott! The Government has once again demonstrated their unwillingness to listen to First Nations people.” Senator Patrick Dodson.

Also read Jack Latimore in The Guardian: Abbott as Indigenous affairs envoy? Be disturbed. Be very disturbed.

And at Croakey: Some challenges to the health sector in wake of LibSpill and Ministerial reshuffle Two over-arching themes emerge – Where is the leadership? And business as usual.

Changing the guard: health and social justice groups respond to Scott Morrison as PM and express some concerns about the implications for vulnerable and disadvantaged communities.

Liberal leadership crisis – the health sector responds.

Climate change

I don’t have time or space in this edition of The Health Wrap to analyse what the Morrison Government means for action on climate change and specifically, for addressing the impacts of climate change on health both here in Australia and internationally.

But given that climate change and energy policies have been major contributors to the downfall of so many Australian political leaders, I don’t think we will see any bravery on this front.

However, as many parts of Australia go through one of the worst droughts in centuries, the issue of climate change remains on the people’s agenda. It’s important for health professionals and groups to step up to and carry the debate.

Peter Sainsbury and David Pencheon wrote a recent Croakey post on how climate change affects global health and the efforts being made in the UK to reduce the environmental footprint of their health system.

Bill McKibben has called climate change World War III and Professor David Shearman, writing for ABC News, states that “the United States and Australia have deserted the trenches of WWIII by trading ideology for human lives.”

As Katharine Murphy has noted at The Guardian, in an article titled, Options on energy policy leave Coalition in a sticky situation:

The Morrison government is in a position where it is a signatory to the Paris agreement, yet there are no policies to deliver the outcome.”


Closing the Gap refresh

It’s ten years since the Closing the Gap initiative began, and progress on the refresh seems to have slowed and is certainly not helped by the recent political upheavals. As far as I can tell, neither the new Prime Minister nor the new Envoy for Indigenous Affairs has said anything about the need to close the gap on Indigenous disadvantage.

The 2018 Closing the Gap: Prime Minister’s Report noted that three of seven targets were on track to be met, although there are differences of fact and opinion on this. Four of the existing targets (covering employment, school attendance, reading and numeracy and mortality rates) expire in 2018.

It is instructive to read the Close the Gap – 10 year review (2018) from the Australian Human Rights Commission, which is a critical reflection on efforts to date and also the recent report from the Australian Institute of Health and Welfare Closing the Gap targets: 2017 analysis of progress and key drivers of change.

As part of the refresh effort, there have been community consultations and many submissions have been received. A public discussion paper can be read here. The new Closing the Gap framework, targets, and performance indicators are due by 31 October.

The six implementation principles that have been developed to guide the new Closing the Gap agenda are:

  • Funding prioritised to meet targets
  • Evidence-based programs and policies
  • Genuine collaboration between governments and communities
  • Programs and services tailored for communities
  • Shared decision making
  • Clear roles, responsibilities and accountability.

There are issues with the refresh process other than its timeliness. In April the National Congress of Australia’s First Peoples expressed dismay that Indigenous voices and expertise were not being privileged in the consultations.

A Topical Issue paper from the ANU Centre for Aboriginal Economic Policy Research argues that the failure of gaps to close is a reflection of a failed policy-making process and that there is a need for substantial change and structural reform. The concern is that the current refresh will simply “paper over the gaps”.

A recent media report indicated that some 23 targets were now under consideration and indicated that there was concern that this explosion in potential new targets was simply a scattergun attempt to answer criticism of the failures to date of Closing the Gap.

Proposed new targets include disability and social inclusion, culture and language, racism and systemic discrimination, connection with land and waters, healing and trauma, entrepreneurship, child protection and justice and family violence.

There are issues about whether the data to accurately assess progress in these target measures is available or could readily be made so. Targets will do little to close the gap if consultation, policy design and implementation and funding allocations are not addressed.


Opioid deaths increasing in Australia

There were 2,177 drug-related deaths in 2016, the highest in 20 years and now 142 people die every month in accidental drug overdoses.

Annual drug deaths almost doubled in the decade to 2016, a period that claimed 13,471 lives through unintentional overdose and saw drug deaths overtake the road toll.

These are figures from Australia’s Annual Overdose Report 2018 from the Penington Institute. The Director of the Institute states that: “Australia is sadly sleepwalking towards a US-style drug overdose crisis.”

Legal pharmaceutical painkillers are the leading killer, but most people are dying with a combination of substances in their system, including alcohol, heroin, amphetamines and synthetic cannabis.

There was an almost 90 percent rise in prescription opioid deaths between 2008 and 2014: increasingly these deaths are older Australians living in rural areas.

There are substantial discrepancies in published estimates of opiate use in Australia, but there is general agreement that the number if opioid prescriptions has increased significantly over the past few years. This is due to multiple factors, such as doctors’ heightened attention to pain management, greater prevalence of chronic pain in the aging population, and the availability of sustained-release opioid preparations.

A report in August from the National Drug and Alcohol Research Centre found natural and semi-synthetic opioids (like morphine, codeine, oxycodone) accounted for most opioid-induced deaths since 2007 (545 deaths in 2016), while deaths from synthetic opioids (like fentanyl, tramadol) have also increased (230 in 2016). Fatal heroin overdoses (360 in 2016) have nearly tripled since 2007 and deaths from methadone (207 in 2016) have nearly doubled.

A national real time prescription monitoring system is needed.

Federal, state and territory governments face a growing challenge to increase awareness about the potential misuse of prescription medications, and to implement mechanisms that promote quality use of medicine and minimise harm.

The implementation of a national Real Time Prescription Monitoring (RTPM) program could be – some say should be – part of this effort, making it harder for people to engage in doctor and pharmacist shopping to gain access to dangerous quantities of addictive prescription drugs.

Real-time prescription monitoring has been sought in Australia since 1980, when a Royal Commission into drugs recommended its implementation and it is regularly brought up at coronial inquests.

A COAG meeting in April led to an agreement to create a federal RTPM model. Currently Tasmania is the only place in Australia where real-time prescription monitoring exists. The Victorian government has pledged to begin it this year.

The many benefits, limitations and challenges that will accompany the implementation of national RTPM in Australia have been outlined. Some experts have spoken out against the proposal saying it will be of limited benefit to reducing the current problems and could introduce a black market.

The plan for a national RTPM system is supported by the Royal Australian College of General Practitioners, the Australian Medical Association, the Pharmaceutical Society of Australia and the Pharmacy Guild of Australians and (cautiously) by Pain Australia.

The Commonwealth Government doesn’t seem to be in any hurry about this. The 2017-18 Budget had $16 million for the roll-out of RTPM – money that remains unspent.

The adequacy of this funding is unclear, given that Victoria has budgeted $29.4 million for this and NSW Labor has said that, if elected to government, it would provide $30.4 million.

Why don’t hospitals treat addiction like heart attacks?

A little off the topic – but provocative – is this recent blog that asks why hospitals don’t routinely screen for addictions.

Admittedly this is a US perspective using US data, but I wonder how different the Australian system is?


Greece – the cost of recovery

The Lancet Public Health July 25 edition has a series of fascinating papers on the impact of Greece’s financial collapse on population health outcomes and the healthcare system (note that these papers are currently open access, but I’m not sure if that is a permanent designation).

Greece has just exited its third and final international financial bailout program after a long and painful odyssey, triggered by the Global Financial Crisis, which plunged the country into an unprecedented recession.

While the fragile economy appears to be recovering, that is not true for the health and wellbeing of many people in Greece. The long crisis combined with an ineffective social protection system caused a surge in poverty and today 14·5 percent of the population reports unmet medical need, more than three times the EU average (4·5 percent).

The all-age mortality increased from 944.5 / 100,000 population in 2000 to 997.8 / 100,000 in 2010 and then to 1174.9 / 100,000 in 2016. Some of this was due to young people leaving the country for better opportunities elsewhere, so it is not surprising that low-income pensioners were most affected by the healthcare cuts. Deaths from suicides increased, but deaths from traffic accidents decreased. There was also an increase in deaths due to adverse events during medical treatment.

The Greek national health system was in need of reform well before its economic crisis. It had been unable to allocate and control spending efficiently, with over-prescription of drugs and services, absence of health technology assessment, and chronic weaknesses in the primary care system.

The conclusion: “Major cuts to health care cost lives.”

The failure to consider the long-term effects on quality of care and health equity of major health cuts might well have harmed the population to an extent yet to be understood.

Politicians everywhere should pay attention to these findings.


Thoughts in the wake of World Humanitarian Day

August 19 was World Humanitarian Day. If you google “global humanitarian crises”, here is what comes up. There’s so much that could be written about this, but I wanted to make just a few notes around just a few of the issues that come to mind.

Yemen – the world’s worst humanitarian crisis

The UN has called the four-year war in Yemen the world’s worst humanitarian crisis, with more than 22 million people — three-quarters of the population — in desperate need of aid and protection.

Since 2015, more than 28,000 Yemenis have been either killed or injured and countless civilians have died from preventable causes including malnutrition, disease and poor health. An estimated 8.4 million people are on the brink of famine and the healthcare system has been bombed out of existence. At least one child is dying every 10 minutes from causes linked to the war.

The Rohingya Crisis – one year on, but no progress

This week marks the one-year anniversary of the attacks that sent Rohingya Muslins fleeing to safety in Bangladesh. In an 18-page report just released, the United Nations Fact Finding Mission on Myanmar declared that the atrocities committed by the military in their campaign to cleanse Myanmar of the Rohingya “undoubtedly amount to the gravest crimes under international law.”

The report said estimates of 10,000 deaths in the campaign were conservative and cited witness accounts of mass killings, gang rapes and destruction of villages by the military. More than a million Rohingya are now living in overcrowded refugee camps in Bangladesh.

The PBS Newshour has done some seminal reporting on this refugee and human rights crisis. You can read and view the reports here

Australia’s humanitarian shame

Last minute efforts are underway on Nauru to get all families and children out of the mouldy tents of RPC 3, the family compound, before the Pacific Islands Forum gets underway in Nauru on 1 September. (Note that new PM Scott Morrison will not be attending; he is sending Minister for Foreign Affairs Marise Payne in his stead.)

The tents have been a known health hazard for years, but requests by families to move were rejected by the Australian Border Force as recently as 7 August. Now the tents that have housed the families for five years have started to be demolished and families are being hurriedly moved to other settlement areas.

Refugees on the island and their advocates in Australia fear that security zones are going to be established to prevent any contact between the media and refugees during the Forum.

The way Australia treats asylum seekers was part of a scathing report earlier this year from the UN’s special rapporteur on torture to the UN Human Rights Council (then chaired by former Foreign Affairs Minister Julie Bishop).

Australia’s migration policies (including boat pushbacks, mandatory and indefinite detention and offshore processing) were seen as part of a global “escalating cycle of repression and deterrence” that has caused “massive abuse” of migrants.

The dreadful cost to the physical and mental health of the people – especially the children – incarcerated on Nauru (highlighted in a series of articles here from The Guardian) taint Australia’s reputation.

Prime Minister Morrison has already demonstrated his commitment to these dreadful policies – will Payne be a more moderate influence?

I am acutely aware that there is so much more that should be recognised and spoken about and addressed in this space. Perhaps then it is appropriate to conclude with these words from Kofi Annan, former Secretary-General of the United Nations, who died this month:

Today, no walls can separate humanitarian or human rights crises in one part of the world from national security crises in another.

What begins with the failure to uphold the dignity of one life all too often ends with a calamity for entire nations.”


  • 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

ICYMI: Reading recommended by Croakey team

Ngaga-dji (hear me): young voices creating change for justice is a new report, published by the Koorie Youth Council, that captures the voices and experiences of Aboriginal children in Victoria’s youth justice system. The report says:

This is the first time that these children will have their voices heard, giving Victoria the chance to understand how policy choices affect their lives and the future of our communities.

These children’s experiences are the missing piece of the youth justice conversation, they hold the key to justice solutions that work. By listening, valuing and acting on Ngaga-dji, the VictorianGovernment and opposition can create a system that supports Aboriginal children to thrive in their communities.”

• Conflicts of interest and journal editors: Getting more light into the dark room of editorial conflicts of interest.


Tweets of note


Link to journal article (paywall)

Read more from Helen Clark here.

See here for details of the event.

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