The global tuberculosis epidemic will be the focus of high level discussions at the United Nations on Friday, and come as Australian health authorities deal with significant outbreaks in remote Indigenous communities, reports Adjunct Professor Lesley Russell.
Her latest column also reviews the glacial pace of mental health reform, and the fentanyl crisis in the United States, with concerns raised about a marked increase in the number of overdoses in Australia over the past 15 years.
And hooray for the New York City ex-pats who marched over the Brooklyn Bridge!”
Lesley Russell writes:
The United Nations will convene a high level meeting this Friday (22 September) to consider, amongst other things, a declaration calling urgently for an end to the global tuberculosis (TB) epidemic, “by ensuring equitable access to prevention, testing, treatment and care”.
The meeting is timely for Australia, as we face significant and ongoing outbreaks of TB in remote Indigenous communities in both Western Australia and South Australia.
Because TB is an almost forgotten scourge in Australia (although it is one of the most significant public health threats to the global population), a little background information might be useful.
TB is a nationally notifiable disease and cases are monitored through the National Notifiable Diseases Surveillance System. In the past year 1,422 cases of respiratory TB were reported. There don’t appear to be any annual reports on TB on the Department of Health and Aged Care website since 2018.
There is a national strategic plan for the control of TB. The most recent plan was issued in 2021. It is interesting to note that, unlike the previous 2016-2020 plan, this does not have disease elimination as an upfront goal, in the plan’s title. The Global Plan to End TB, 2023-2030 has the goal of ending TB as a a public health challenge by 2030.
The new report admits that “following a small decline from 2011 to 2015, there was an increase of 21 percent in absolute case numbers from 2015 to 2020” – so hopefully this means elimination efforts have been increased and there is no resiling from the initial aim.
Ninety-one percent of all notifications reported in 2020, where the country of birth was recorded, occurred in people born overseas. Twelve percent of cases were identified as being resistant to at least one of the standard, first-line anti-tuberculosis drugs and 2 percent were identified as multi-drug resistant.
The good news is that there was a 38 percent reduction in the rate of TB in Aboriginal and Torres Strait Islander Australians in 2020 compared to 2015; however, the rate is four times that seen in the non-Indigenous Australian-born population.
Why are Indigenous Australians at greater risk of TB?
There is useful information in a retrospective observational study, published in 2021 and conducted over a 31-year period (1989-2020) in the “Top End” (the north of the Northern Territory, includes Darwin and Arnhem Land).
It found that: mortality was significantly higher in Australian First Nations than overseas-born cases (12.5 percent vs 3.1 percent, respectively); the median age of death for First Nations people with TB was significantly younger than in both Australian-born non-Indigenous cases and overseas-born cases (49, 63 and 77 years, respectively); and almost 80 percent of all paediatric cases were First Nations children.
Further analyses suggested that both reactivation from latency and recent transmission with progression contribute to TB incidence in Indigenous populations.
The multiple factors that contribute to increased infections and poor outcomes of TB are common to a range of other diseases, including rheumatic fever. These include overcrowding, homelessness, smoking, malnutrition, alcohol misuse and diabetes.
Treatment delay is also a factor and this has likely been aggravated during the COVID-19 pandemic, as Professor Nicola Spurrier, Chief Public Health Officer for South Australia, told ABC RN listeners this morning. Also, in remote communities a chronic cough is considered “normal” and this, with under-recognition of TB by clinicians, contributes to delayed diagnosis.
The current outbreaks in Kalgoorlie and Tjuntjuntjara in Western Australia and in the Aṉangu Pitjantjatjara Yankunytjatjara (APY) Lands (mostly in South Australia) appear to be linked to a young woman who died of TB in Kalgoorlie in November 2022 and who was a visitor to these communities.
According to Spurrier, genetic testing has linked both the current SA and WA outbreaks back to a case in 2010 in WA.
In Western Australia there are concerns that contact tracing has not been seen as an urgent issue and that lack of culturally appropriate resources has meant that only minimal screening of Tjuntjuntjara residents (located in the Great Victoria Desert, about 650 kilometres north-east of Kalgoorlie) has been possible. ABC News has recently reported on these issues.
There has been a more concerted testing blitz in South Australia where 13 people on APY Lands have tested positive. Again, ABC News has reported on this.
The South Australian Government has committed $1.9 million to combat the outbreak, including work to upskill local doctors. The state’s chief public health officer, Nicola Spurrier, has spoken about how treatment can require months of complex medications.
The possibility of multi-drug resistant TB is a very real threat.
In the far north of Australia, cross-border movements of residents from Papua New Guinea places residents of the Torres Strait Islands at risk. It also means increased costs for Queensland Health. PNG is one of only 14 countries in the world to feature on all three of the World Health Organization’s high burden country lists on TB, due to its high incidences of TB, TB/HIV and multi-drug resistance TB. There is an interesting story here about the work of the Torres and Cape Hospital and Health Service (TCHHS) TB Control Unit.
At the high-level UN meeting this Friday, countries will be asked to reaffirm their commitment to ending TB by 2030.
As pointed out in an editorial in The Lancet, a similar gathering in 2018 saw ambitious targets set for treatment, prevention, and funding. However, all but one (on providing preventive treatment for six million people with HIV) have been missed by a wide margin, and progress towards WHO’s End TB Strategy is falling short.
COVID-19 has not helped, but even before the pandemic funding was stagnant and progress in reducing disease burden was too slow. The disease continues to be neglected.
In Australia, there is broad recognition that Indigenous health will benefit from the Voice to Parliament.
See for example: the statement from Senator Malarndirri McCarthy, Assistant Minister for Indigenous Health; the recent editorial in the Medical Journal of Australia; and an article in Cosmos science magazine.
Croakey’s portal on the Voice lists the statements of more than 30 health and medical organisations supporting a ‘yes’ vote at the referendum.
The current situation with outbreaks of TB in remote communities demands cultural sensitivity for public education, screening and treatment and advice and guidance from community leaders on how this can best be done. It’s a timely example of how listening to and consulting with communities can deliver improved health outcomes.
Mental health reforms are slow
Last year Health Minister Mark Butler announced that the Albanese Government would not extend the temporary COVID-19 measure to subsidise an additional 10 sessions with a psychologist, GP or other eligible allied health worker under the Better Access program.
There was considerable outrage and media attention about this. The Government’s decision was based on an evaluation report that showed that the additional sessions were not being appropriately targeted to those with the greatest mental health needs.
While the pandemic and its consequences disproportionately impacted disadvantaged Australians, less than half of those of low socioeconomic status were able to access and/or afford treatment under Better Access, including the additional 10 sessions.
In his December 2022 media release announcing this decision, Butler stated: “In early 2023, the Government will convene a forum of key experts and people with lived experience of mental illness to assess the recommendations of the independent evaluation and provide reform advice on how to improve Better Access, so all Australians have access to the same level of evidence-based care. The forum will consider how to support access to higher levels of treatment for those who need it, while supporting equitable access for vulnerable and marginalised Australians.
“The Government will strengthen the Medicare Benefits Schedule (MBS) to facilitate family and carer involvement in Better Access treatment and fund mental health case conferencing. The independent evaluation provides compelling evidence in support of these MBS changes, and the Government will proceed to implement these in the first half of 2023.”
In April, in the lead up to the federal Budget (and with expectations that there would be something to address unmet mental health needs in the Budget), the Sydney Morning Herald editorialised on this topic, noting that many are missing out because the demand for the services of psychologists, psychiatrists and mental health nurses is greater than the system can support; that an increasing number of Australians are find cost a barrier to accessing mental health care; and that there months-long waiting lists for consultations for non-critical conditions.
But it was not until the first week in September that any progress towards this goal was seen.
On the same day that the Chair of Mental Health Australia delivered the organisation’s 2023 Report to the Nation, along with a stinging rebuke to the Albanese Government over inaction on mental health, Butler, who was on the ABC RN Breakfast program announcing his new efforts to address tobacco and vaping, was asked about progress on this work.
His response: “I said I’d do that by the end of the year [note the change in timeframe here], and I intend to keep to that timeframe. Only on Friday I had a full day meeting with an advisory committee that I’ve pulled together to help me design that response.”
It appears that an advisory committee has been formed and this met for the first time on 8 September “to discuss what needs to be done to improve the mental health system and respond to the Better Access evaluation”. The webpage states that the advisory committee will meet several times between September and December 2023.
The advisory committee (as briefly referenced in Croakey’s recent ICYMI column) has an excellent array of mental health policy people on board but seems very short on peer workers and people with lived experience of mental health issues.
The Better Access program was introduced in 2006 and has a mixed record of success. A recent article in Psychotherapy and Counselling Journal of Australia, How We Got Here: A Contextual Review of the Better Access Initiative, provides a good over view of the program.
Read Behind the headlines on changes to Better Access by Jennifer Doggett.
It was first evaluated in 2011 (by the same University of Melbourne academics that did the 2022 evaluation), and is widely supported by psychologists because, for the first time, it provided them with direct billing access to Medicare (see the 2016 history of Better Access from the Australian Psychological Society).
There were a number of critiques from mental health experts of the 2011 evaluation (see for example Jorm 2011; Hickie et al 2011) and the program has been modified a number of times since its introduction.
The key issues are that it offers little to the “missing middle” – people with chronic but sub-acute mental disorders – and that it is not easily accessed by those with the greatest need, especially those who live in rural and remote areas.
In 2018 a study by Jorm found that the large increase in the use of mental health services after the introduction of the Better Access scheme had no detectable effect on the prevalence of very high psychological distress or the suicide rate.
In an article in The Guardian in January, Professor Ian Hickie made the case for redesigning mental health care. He argues that fee-for-service and substantive out-of-pocket payments overwhelmingly disadvantage the very population groups that most need mental health services.
In August, Dr Sebastian Rosenberg, writing for Croakey Health Media, took up the same issue and outlined how the system in primary care might be reorganised so that people seeking mental health care can easily navigate their way and not fall through the cracks. Hickie, Rosenberg and Iorfino further outlined this proposal for primary mental health care reform in MJA Insight.
There is clearly a strong overlap between the significant reforms required in mental health and those proposed by the Strengthening Medicare taskforce.
What mechanisms are in place to facilitate this?
Will Medical Research Future Fund (MRFF) grants funded under the new Primary Health Research Plan address the integration of physical and mental health services in primary care?
More on mental health issues
A paper published in July in The Medical Journal of Australia from Professor Patrick McGorry and colleagues described the declining mental health of young Australians and a “public health crisis”.
A damning report from the South Australian Chief Psychiatrist has found that mental health resources in regional South Australia are so inadequate, there are fewer psychiatrists in the state per person than in Mongolia, Ukraine or Russia. That is in stark contrast to the Adelaide metro area, which has the highest rate in Australia. You can read more here.
The Chief Executive Officer of the National Mental Health Commission – the agency responsible for advising the government on mental health – has resigned after a review found the organisation had a poor workplace culture and was operating at a $6 million loss this year.
The review was instigated by Health Minister Butler in April following a report in The Saturday Paper of financial irregularities, dysfunction and workplace bullying. It does not appear to be publicly available.
Butler has promised to reset and strengthen the agency, which the review found has outgrown its systems and capabilities.
Tobacco and vaping
The Albanese Government has recently made new commitments to strengthen tobacco control and address the increase in vaping.
In announcing these measures, the Health Minister Mark Butler said the tobacco control legislation was the “critical” next step in the fight against tobacco and nicotine addiction.
It supports the National Tobacco Strategy 2023–2030, which commits to reducing daily smoking prevalence to below 10 percent by 2025 and to 5 percent or less by 2030 and to 27 per cent or less by 2030 for First Nations people.
Butler said after leading the charge with its plain-packaging reforms, Australia had become slack in the fight against tobacco addiction.
“Australia has been a leader in public health measures to discourage smoking, but after a decade of inaction, the gains of Labor’s world-leading plain packaging laws have been squandered. Since the inception of plain packaging, big tobacco has become increasingly creative and cunning with their marketing tactics. This legislation will allow Australia to reclaim its position as a world leader on tobacco control.”
The Public Health (Tobacco and Other Products) legislation, if enacted, will:
- Update and improve graphic warnings on packaging, including extending warnings to individual cigarettes.
- Standardise the size of tobacco packets and products.
- Prevent the use of specified additives in tobacco products like menthols.
- Standardise the design and look of filters.
- Limit the use of appealing names that imply reduced harm.
- Requiring health promotion inserts in packs and pouches.
- Improve transparency of tobacco sales volumes, product contents, and advertising and promotional activities.
- Capture vapes in advertising restrictions.
The new laws are planned to take effect from 1 April 2024. Industry will be given a year to comply with requirements, with retailers given a further three months.
You can see some of the public health sector’s positive commentary on the legislation in Croakey’s recent ICYMI column.
In 2019 (under the Morrison Government) the Department of Health conducted a review of tobacco control legislation but did not act on this (you can read the submissions here). The Albanese Government announced that it would proceed with new national tobacco control legislation in November 2022. There was a substantial process of consultation in the lead up to the development of this current legislation.
Last May, in the lead up to the Budget, Butler announced a raft of reforms aimed at vaping and e-cigarettes. These included:
- Banning imports of non-prescription vaping products.
- Authorisation for all GPs to provide scripts for patients to obtain vapes, where they need them.
- Vaping products to be only available in pharmacies.
- Pharmaceutical style packaging with reduced flavours, colours and nicotine volumes.
- Ban on single-use disposable vapes.
- Investment in education and support programs to encourage people to quit.
The 2023-2024 federal budget had $737 million (over four years) for action on smoking and vaping.
This was welcomed in many quarters.
“The long-term health effects of e-cigarettes are unknown, so it’s important to take a precautionary approach,” said the Alcohol and Drug Foundation’s CEO, Dr Erin Lalor.
“Most people who currently vape in Australia are using non-regulated products, so we have no idea what ingredients are in them, including the nicotine levels. Concerningly, a large amount of the non-regulated products sold as non-nicotine vapes, do contain nicotine, which means some people who vape, including young people, may be unknowingly consuming nicotine and have formed a dependence.”
A recent article in MJA Insight highlighted the need for urgent efforts to reduce vaping in adolescents. A recent survey found a fifth of young people had vaped in the past 12 months.
Other studies have found children can easily buy vaping products from retailers without being asked for ID, and also get the products from their friends or online. It has led to a new generation of children who are addicted to nicotine.
Both Butler and Teal MP Dr Sophie Scamps have spoken out about the proliferation of vape stores – often close to schools – which continue to operate despite reforms that mean only pharmacies can import and sell the products in future.
“I can’t overstate the concern that I know parents and school communities have about this public health menace of vaping. These vape stores are selling a product that is deliberately designed to recruit a new generation to nicotine addiction,” Butler told The Guardian.
A growing area of concern has been the importation of illegal tobacco and nicotine products. About $1.5 billion dollars of illicit tobacco has been tracked down since 2018-19, which Butler has flagged as an “ongoing challenge” for authorities.
Tobacco use is estimated to kill more than 50 Australians every day – about 20,000 every year. It is the leading cause of preventable death and disability in Australia.
Further reading on this topic:
- Reigniting tobacco control: returning Australia to the front of the pack by Dr Becky Freeman
- Federal Government outlines sweeping tobacco control reforms and action on vaping. December 1, 2023.
- Crackdown on vaping and tobacco industries draws global acclaim. May 3, 2023
- As Australia moves ahead on tobacco control, the global message is ‘grow food, not tobacco’. May 31, 2023.
And there’s much more at Croakey’s tobacco archives.
Australia is not immune to the threat from fentanyl
The United States is confronting a fentanyl-driven illegal drug crisis that is more deadly than any other drug tragedy the nation has ever experienced.
More than 111,000 people died from a drug overdose in the 12-month period ending in April 2023, according to the new estimates from the US Centers for Disease Control and Prevention.
Fentanyl and other synthetic opioids are involved in nearly 70 percent of the overdose deaths and the vast majority of the overall increase in deaths was due to these drugs.
“Fentanyl is everywhere,” said Dr Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. “It’s not just disguised as heroin, but it’s also actually present in cocaine and methamphetamine.”
Most of the illegal fentanyl found in the United States is trafficked from Mexico using chemicals sourced from China, according to the Drug Enforcement Administration (DEA).
In 2010, less than 40,000 people died from a drug overdose across the country. Most of these deaths were due to heroin or prescription opioids; less than 10 percent of deaths were tied to fentanyl.
The contrast between 2010 and today is outlined in new study from researchers at the University of California, Los Angeles (UCLA) that examines trends in US overdose deaths from 2010-21 using data compiled by the CDC.
The lethality of illegal and inappropriate opioid use is a key factor in the growing gap in life expectancy between the United States and other countries.
While the role of opioids in the deaths of some 1,700 Australians who die of drug overdoses has remained relatively stable, there are concerns the presence of potent synthetic opioids like fentanyl may ramp up.
In Australia opioids (including prescription drugs and heroin) comp