Returned to her desk in Australia, Dr Lesley Russell investigates the latest news on tuberculosis prevention and control, the impact of trauma and toxic cultures upon veterans, and the need for greater investment and effort in preventing falls.
She also reports that the erosion of reproductive health rights in the United States is proving a winning issue at the polls for Democrats, to the extent that the Biden campaign now sees Florida (a red state) as winnable with abortion front and centre in the Democrats’ campaign.
The column also covers Birthing on Country, the latest climate health news, and brings a feel-good story about Yaren, a stork whose name means ‘companion’ in Turkish.
Meanwhile, a lack of leadership and narrow self interest from the world’s wealthiest countries is impeding global pandemic treaty negotiations.
The quotable?
A handful of powerful countries are sabotaging the best chance to translate the lessons from the COVID-19 pandemic into legally binding commitments that will protect us all.”
Lesley Russell writes:
This edition finds me back in Australia after a wonderful #skibumsojourn at our Colorado mountain home.
My photos this week are from Deer Creek, one of our favourite places for snowshoeing in the winter and hiking in the summer. It’s reached by a drive through the old mining town of Montezuma, just a few miles outside of Keystone.
In the summer we can hike to the base of the snow-covered cirque in the distance – usually some snow remains as the elevation is about 3500 metres above sea level.
And below are some photos from last summer: one taken in much the same place and the other after we had hiked up to the wall of the cirque.
Tackling tuberculosis
Tuberculosis (TB) is the world’s deadliest infectious disease. The most recent data from the World Health Organization shows that globally an estimated 10.6 million people fell ill with TB in 2022, up from 10.3 million in 2021.
Most people who developed TB were in the WHO Regions of South-East Asia (46 percent), Africa (23 percent) and the Western Pacific (18 percent).
Each week 25,000 people die of TB; the total number of TB-related deaths was 1.3 million in 2022, down from 1.4 million in 2021. TB continues to be the leading killer among people with HIV/AIDS.
This is a disease that can be cured, although that’s not easy: the best standard of care requires between four and nine months of antibiotics taken daily and multidrug-resistant TB is a public health crisis.
The estimated costs associated with treating a case of TB increase substantially when going from drug-susceptible to multi-drug resistant disease. One estimate from the United States is that average costs increase from US$17,000 to US$134,000 per case.
The cost of TB diagnosis and treatment is central to why the disease remains so deadly. Of the 10 million or more people who will develop TB this year, between three million and four million will go undiagnosed, often dying before they can get an accurate test.
March 24 was World TB Day – but it seems the day passed barely noticed outside of infectious disease circles. 
However, it was great to see the Albanese Government announce a $17 million investment in the Global Alliance for Tuberculosis to develop more effective treatments for tuberculosis and help ensure they reach those who need them, with a focus on the Pacific region.
On World TB Day, ABC News published a long and very interesting article on how Tasmania treated TB patients in the era spanning the 1930s to the 1950s.
I’m old enough to remember those days, when TB screening by X-rays was compulsory for adults and those infected with what was called “the white plague” were then isolated, often for years, as they underwent treatment.
There’s a history of TB control in Australia here.
Today the majority of Australian TB cases are in people born outside Australia, with migration from high-TB incidence countries flagged as Australia’s most significant TB control challenge.
In The Health Wrap edition of 20 September 2023, I wrote about recent outbreaks of TB in remote Indigenous communities. Globally, First Nations people are inordinately affected by TB and Australian First Nations are no exception. Rates of TB infection for Indigenous Australians are five to six times higher than for the Australian-born, non-Indigenous population.
When I wrote that piece, I missed a seminal paper, published in 2019, that highlights the need for Indigenous Australians to lead, be partners and to have ownership of decisions about how to eliminate TB.
The authors argue that: “A social determinant of health approach will shift the focus to the social structures that cause TB.
“For Indigenous Australians, TB is more than a biomedical diagnosis and treatment; it is a consequence of European invasion and a contributor to dispossession and the ongoing fight for justice. The introduction and spread of TB has resulted in the stealing of lives, family, community and cultures for Indigenous Australians. Racist policies and practices predominate in the experiences of individuals and families as consequences of, and resulting in, ongoing structural and systematic exclusion.”
Veterans’ suicide
At the end of last month, the chief of the Australian Defence Force, General Angus Campbell, appeared before the long-running Royal Commission into Defence and Veteran Suicide, which is in its final week of public hearings, and issued an unreserved apology for “deficiencies” in providing wellbeing support and care for veterans during and after their service.
You can watch the video of General Campbell’s testimony here.
It made me realise that I have paid little attention to this Royal Commission, which was set up in July 2021 to inquire into the systemic issues and risk factors relevant to suicide and suicide behaviours of serving and ex-serving members of the Australian Defence Force (ADF). Its final report is due in September.
In the period leading up to the announcement of the Royal Commission, Croakey Health Media ran an article on the need for such an examination of veteran suicide: One veteran on average dies by suicide every two weeks. This is what a Royal Commission needs to look at.
Regular reports from the Australian Institute of Health and Welfare (AIHW) highlight the shocking statistics.
The most recent AIHW report, released in November 2023 and the sixth in the series, showed that between 1997 and 2021, there were 1,677 certified deaths by suicide among members with ADF service since 1 January 1985 (report results are summarised here.)
The data show that serving permanent males and reserve males were less likely to die by suicide than the general Australian population. However, ex-serving males and females were more likely to die by suicide and the rate is especially high for those ex-serving males who were involuntarily medically separated.
AIHW data from 2022 delves into the socio-economic characteristics of ex-serving ADF members who died by suicide. It shows that younger males, living alone and with little income were most at risk.
The Royal Commission brought down its interim report in August 2022. It made 13 recommendations for the Australian Government. The Department of Veterans Affairs website states that “the DVA is working with Defence and the Attorney-General’s Department to implement the Government’s response to the Royal Commission’s Interim Report.”
The head of the Royal Commission, Nick Kaldas, has been quite outspoken about the lack of progress. Last September, in a fiery speech at the National Press Club, he said there was “too much talk and not enough action” on veterans’ suicide and said the Government and the ADF were moving at a “snail’s pace” to address a situation that is a “national crisis”.
He also warned of “deep-rooted cultural and systemwide issues within the Department of Veterans’ Affairs” that has left veterans “re-traumatised” and “driven to the brink”.
More recently, in an article in The Guardian, Kaldas was again forthright and judgemental about what needs to be done and what has not been done. He said, about the work of the Royal Commission: “We’ve uncovered evidence of a toxic culture where abuse, bullying and harassment is often not dealt with appropriately and perpetrators are not held to account. In some instances, complainants are targeted, leaving them re-traumatised.”
And he sees the military’s toxic culture as a major cause of the ADF’s current recruitment and retention challenges.
He expressed the hope that the ADF leadership “sees this landmark inquiry as a once-in-a-generation opportunity – and gets on board with what is needed to effect the necessary changes.”
The Guardian has an excellent archive of stories on this issue which you can access here.
For assistance
Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467
beyondblue: 1300 224 636
13Yarn: 13 92 76
Kids Helpline: 1800 551 800
QLife: 1800 184 527
Check-In (VMIAC, Victoria): 1800 845 109
Lived Experience Telephone Line Service: 1800 013 755
Political and health consequences of US abortion restrictions
The June 2022 decision of the United States Supreme Court that overturned Roe v Wade and the federal guarantee of abortion rights, together with the subsequent enactment of restrictive anti-abortion laws by a number of Republican governed states, is having continuing adverse consequences, not only for women but also for doctors and hospitals.
Vague state laws, and a lack of guidance on how to interpret them, have led to some pregnant patients being denied care until they are critically ill. Fearful that they will be sued under new abortion bans, many doctors must beg hospital administrators for help with key decisions.
US newspapers now regularly carry distressing stories. Here are just a few examples:
An article in The Washington Post from last November outlines how many hospitals have failed to provide specific guidance or policies to help doctors navigate high-stakes decisions over how to interpret new state abortion bans — leading to situations where patients are denied care until they are on the brink of permanent injury or death.
National Public Radio recently covered a report about the alarming ways in which pregnancy care has changed and been disrupted in Louisiana since the state banned abortions.
The group Physicians for Human Rights has told lawmakers that abortion bans in the United States are causing a health and human rights crisis, harming patients and putting clinicians in impossible situations.
These abortion bans serve to make the high rates of maternal and infant mortality in the United States even worse.
A study by the Commonwealth Fund found that, compared to states where abortion is accessible, states that have banned or have restricted abortion have: fewer maternity care providers; more maternity care “deserts”; higher rates of maternal mortality and infant death, especially among women of colour; higher overall death rates for women of reproductive age; and greater racial inequities across their health care systems.
Now abortion opponents are going after medical abortions, which comprise some 60 percent of all abortions in the United States.
Last month the US Supreme Court heard oral arguments in a challenge to the FDA’s rules for the abortion pill mifepristone, first approved in the United States in 2000.
The plaintiffs — who want to overturn FDA decisions that increased access to mifepristone by, among other things, allowing it to be prescribed online and mailed directly to patients — are represented by Alliance Defending Freedom, the conservative Christian legal fund that led the successful legal campaign to overturn Roe v. Wade.
They are looking to resurrect the Comstock Act, a 19th-century morality law that could be used to outlaw mailing abortion pills, and possibly even some forms of birth control.
You can read more about this case here. The US Supreme Court decision is due in June.
At the same time as the US Supreme Court case was proceeding, Florida’s Supreme Court handed down two important abortion rulings.
They upheld a 15-week ban that will trigger a six-week ban supported by Governor Ron DeSantis in 30 days.
And they ruled that a ballot initiative that would establish a state constitutional right to abortion before foetal viability (around 24 weeks) could go before voters in November.
The erosion of reproductive health rights has proved to be a winning issue at the polls for Democrats.
In every single state that has held an abortion-rights referendum since Roe fell, the pro-abortion rights side has prevailed. That’s been true in states as blue (Democratic) as California and as red (Republican) as Kentucky.
The Biden campaign now sees Florida (a red state) as winnable with abortion front and centre in the Democrats’ campaign.
International pandemic treaty falters
In March 2021, at the height of the pandemic, a group of world leaders proposed to the World Health Organization (WHO) a pandemic treaty that would obligate countries to work together to prevent future health emergencies like COVID-19. Such a treaty would be underpinned by the WHO International Health Regulations.
There is a useful WHO briefing paper on the treaty (updated to June 2023) here.
On 29 November – 1 December 2021, the WHO’s World Health Assembly (WHA) met in a special session to discuss the proposal and the way forward. The WHA agreed to establish an Intergovernmental Negotiating Body (INB) to draft and negotiate “a WHO convention, agreement, or other international instrument on pandemic prevention, preparedness and response.”
The Zero Draft of the treaty was published on 1 February 2023, and discussed at the Intergovernmental Negotiating Body’s (INB) fourth meeting between 27 February 2023 and 3 March 2023.
The INB then met a number of times and in October 2023 published a new version of the negotiating treaty: the Proposal for negotiating text of the WHO Pandemic Agreement.
At the same time, the WHO was undertaking a review of the International Health Regulations with more than 300 proposed amendments.
In September 2023, the first-ever head-of-state summit on pandemic preparedness at the United Nations General Assembly approved a political declaration calling for further strengthening of the global health emergency architecture to better protect the world from a repeat of COVID-19.
This called for the work on the pandemic treaty to be completed by May 2024 and laid out the measures required to do this.
Such a proposal, involving so many nations, with so many different pandemic experiences, was never going to be easy – and so it has proved.
Early drafts of the treaty were described by Professor Larry Gostin from Georgetown University, who works in global health law, as “really transformational”. There was a focus on a One Health approach to fighting pandemics, looking at the interactions between people, animals and their environments.
There were hopes that the treaty would make things more equitable between nations so that the dependency on other countries for access to vaccines and technologies during pandemics won’t be so necessary.
But negotiations have seized up around a series of issues. How would such a treaty be enforced? How would it be financed?
“[The treaty] has a lot of high-mind[ed] phrases, a lot of self-congratulation,” Gostin said. “But almost nothing in terms of action, commitments or funding.”
Countries have now been rehashing the same arguments for nine sessions in a row.
Rich countries have never yielded on their demand that any sharing of intellectual property for products such as vaccines should only be on voluntary and mutually agreed terms. That is not acceptable to developing countries.
A perspectives article in The Medical Journal of Australia last June outlines how intellectual property rights are a critical issue in these negotiations.
On March 20, with time running out, more than 100 global leaders – from all continents and fields of politics, economics and health management – issued a joint open letter urging accelerated progress in current negotiations to deliver a treaty. (The WHO news release about this letter is here.)
“A pandemic accord is critical to safeguard our collective future. Only a strong global pact on pandemics can protect future generations from a repeat of the COVID-19 crisis, which led to millions of deaths and caused widespread social and economic devastation, owing not least to insufficient international collaboration,” the leaders wrote.
Ex-New Zealand PM Helen Clark (who was a signatory to the letter) has revealed that, as it stands, “there is nothing to sign off on” at the 77th World Health Assembly in May.
“In a sense, I’m shocked but not surprised because the response to COVID-19 should have told us, I guess, how wafer-thin global commitments to equitable access were,” she said.
“These are hard core issues of equity. And they’re not easy to resolve without goodwill towards those who have much less of anything… so it is shocking to think that we could head into fighting another pandemic threat with these issues unresolved.”
A recent editorial in The Lancet looks for more leadership from the wealthiest countries and says that “a handful of powerful countries are sabotaging the best chance to translate the lessons from the COVID-19 pandemic into legally binding commitments that will protect us all.”
What has been Australia’s role here?
There is some information on the Department of Health and Aged Care website, along with answers to frequently asked questions.
My googling did not give me any information about who is representing Australia at the negotiations, other than that the office of the Chief Veterinary Officer is involved.
The DoHAC website states that: “Between 7 August and 24 September 2023, in collaboration with DFAT, we invited the Australian community and key stakeholders to provide their views on:
- what they wanted to see in the new pandemic instrument
- amended IHR to inform Australia’s engagement in negotiations.”
(Well, I missed that – I guess a lot of others did too!)
A three-page report summarising the key themes of the submissions received and the Government’s response is available here.
Falls are killers
April is Falls Month.
The recent death of Senator Joe Lieberman (Al Gore’s running mate in the 2000 US presidential election) as the consequence of a fall serves to remind us how vulnerable even fit older people are to serious injury and even death from falls that may seem quite innocuous.
Falls are Australia’s leading cause of injury hospitalisation and death, representing 43 percent of injury hospitalisations and 42 percent of injury deaths (AIHW data).
Falls requiring hospitalisation occur more frequently in adults with increasing age and are most likely to occur in the home. One in four people aged 65 and over have at least one fall per year.
Every year in Australia, 19,000 people fracture their hip, usually after a fall. Most hip fractures happen to people over 65 years and it’s often a life changing event.
Hip fracture significantly increases an older person’s risk of death, with one in four people dying within 12 months after a hip fracture injury. Of those who survive, many lose their ability to live independently or to return to their former lifestyle.
With public hospitals under increasing pressure, too often people with hip fractures wait longer than is best practice for surgery. The updated Hip Fracture Clinical Care Standard (2023) for hospitals has reduced the maximum time to surgery from 48 hours to 36 hours in line with international guidelines. For the first time, this explicitly includes patients who need to be transferred to a hospital that can perform the surgery.
In 2022, the average time to surgery ranged from 16 to 92 hours, with the longest waiting times for people being transferred for surgery; 78 percent of patients had surgery within 48 hours.
The 2023 annual report from the Australian and New Zealand Hip Fracture Registry shows how much more progress must be achieved to reach the recommended clinical standards.
There has been no national focus on preventing falls in older Australians since the National Injury Prevention and Safety Strategy 2004 – 2014 and its adjunct document, the National Falls Prevention Plan 2004 onwards.
In 2019 the Department of Health and Aged Care announced the development of a new National Injury Prevention Strategy 2020-2030 but this is yet to see the light of day.
In November 2022 the Australian and New Zealand Falls Prevention Society released a report titled Why Investing in Falls Prevention Across Australia Can’t Wait. It outlines the huge and growing financial and social burden to patients, families, the healthcare system, and society.
Reviews and enquiries
In March 2023, The Australian ran an article that highlighted how the Albanese Government, then some 10 months in power, had commissioned at least 140 reviews, consultation papers, roundtables, summits and inquiries.
More recently, in March 2024, The Mandarin highlighted that 63 committees of the federal Parliament are presently holding 118 public inquiries for which 18 are open for submissions and 23 have upcoming public hearings.
A list of current federal parliamentary inquiries is here.
There is also the work that is commissioned by the States and Territories that is even harder to track.
My colleague Charles Maskell-Knight and I regularly bemoan the difficulty in keeping track of all this work. Even if you know (roughly) how the system works, it’s a mammoth task to keep track of inquiries and reviews that are open for submissions, reports and responses that are due, and the implementation of recommendations.
This is something that is a regular theme in The Health Wrap (for example, in this edition, where is the new National Injury Prevention Strategy that was due some four years ago?). And where is the Government response to the recent Senate dental inquiry?
At Croakey Health Media we are discussing how we can make the public consultation process for inquiries, reviews and reports more transparent and to ensure that all stakeholders have an equal chance for input. Stay tuned!
Medical rifts
There’s some intriguing news of a rift between the national body of the powerful Australian Medical Association (AMA) and the Western Australian chapter. It seems to be about money, but it might also be about policy directions.
The letter sent from Canberra headquarters to some 5,000 Western Australian doctors who are members of the WA AMA states that “without national membership, WA doctors would not be represented by the AMA when it met with decision-makers at the federal level, including Health and Aged Care Minister Mark Butler”.
You can read the national AMA explanation for this decision here.
There’s an interview with Dr Michael Page, the President of the WA AMA, here.
He says, “[The federal AMA] need to also be cognisant of the fact that we are not the only state that’s raising these issues [of fees paid to the national body] with them. Queensland, Victoria, South Australia, all have been raising exactly the same issues with the federal body, and so it’s not as though we’re the naughty child over here in the Wild West. This is something that other states have been advocating for, but to no real avail. So yes, we’re the first to be carved off but again, we’re going to keep working at it.”
The best of Croakey
The Croakey team continues our longstanding coverage of critical climate and health matters.
Read: Latest national climate and health stocktake underscores this doctor’s plea for health sector action, by Dr Melissa Sweet
See the #iDEA24 coverage of the Doctors for the Environment Australia conference, with Dr Amy Coopes reporting for the Croakey Conference News Service (stay tuned for more on this at Croakey).
See this X/Twitter thread from the launch yesterday of the latest report from the MJA The Lancet Countdown collaboration.
Indigenous health good news story
The Medical Journal of Australia has been posting on social media a series of MJA articles that have ranked highly over the last few years.
It was good to see a paper on Birthing on Country for Yolŋu mothers, babies and communities in North East Arnhem Land rank highly.
There’s a case study on Birthing on Country research supported by the National Health and Medical Research Council here.
There’s an excellent article from Dr Sophie Cousins on how Birthing on Country improves maternal care for Indigenous Australian women (sign in is required to access this).
And this 2023 article, ‘Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol’, outlines how Birthing on Country programs will be further developed and evaluated into the future.
As Adjunct Professor Janine Mohamed wrote for The Guardian: “Aboriginal-led birthing on country programs prove how important it is for mothers to feel trusted, safe, respected, have a voice and choice.”
This is an issue discussed at this week’s Perinatal Society of Australia and New Zealand 2024 conference.
Another good news story
This is a lovely, quirky story of a stork, a Turkish fisherman and their unlikely bond.
Thirteen years ago, a poor fisherman in a small Turkish village was retrieving his net from a lake when he heard a noise behind him and turned to find a majestic stork standing on the bow of his rowboat.
The fisherman fed the bird some fish. And since then the stork and his mate have returned to the fisherman’s boat and his village year after year.
You can read more, with some lovely photos, here.
There’s a 24-hour webcam of the storks’ nest here.
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.
