CHIEF MEDICAL OFFICER’S REPORT
‘PROTECTING AUSTRALIA’S HEALTH’
The past year has been an eventful and occasionally dramatic period. The most notable event was the Boxing Day Indian Ocean tsunami which caused untold devastation. The response of the Department and our colleagues in the States and Territories was admirable. The years of preparation and planning bore fruit and the major relief effort helped many people in a time of very great need.
Throughout the year, preparation for the possibility of a world-wide influenza pandemic was an important part of my work. It is very gratifying to have the efforts of so many people rewarded by the release of a comprehensive national pandemic action plan, which has received favourable comment both at a local level and also by a number of international agencies. In addition, the Australian Government announced in the Federal Budget in May 2005 that it is providing funding of $23.2 million over four years for the establishment of an independent influenza research centre, incorporating the World Health Organization (WHO) Collaborating Centre.
While planning for an influenza pandemic and health disasters attract the most media attention, the Department continued to contribute to the development of the National Chronic Disease Strategy, the review of the governance of the National Health and Medical Research Council (NHMRC), efforts to change and diversify the vocational training of medical specialists, and a range of initiatives to improve Indigenous health. Many of these projects have developed substantially during the year.
Indian Ocean Tsunami Disaster - a National Response
International events have demanded Australia’s constant attention over the past twelve months. The Indian Ocean tsunami was one of the most devastating natural disasters in our region’s recent history. Like most Australians, I was relaxing with my family on Boxing Day 2004 when the first pictures of the tidal waves appeared on our television.
It was clear that this was a human tragedy, but I don’t think any of us immediately grasped the enormity of the disaster which claimed over 300,000 lives across Indonesia, Thailand, Sri Lanka, India, Malaysia, the Maldives, Myanmar and Somalia, including twelve Australian citizens and six permanent residents.
My immediate thoughts focused on the need to prepare for a major relief effort for our neighbours in the region, and the many Australians who were bound to be holidaying in these countries. By 8am the next morning I was teleconferencing with the Chief Health Officers of all the States and Territories, and by noon Australia’s peak health emergency committee the Australian Health Disaster Management and Policy Committee (AHD-MPC) was meeting in a national teleconference. These meetings continued twice daily for the duration of the emergency.
Australian Health Disaster
Management and Policy Committee
The Australian Health Disaster Management and Policy Committee (AHD-MPC),
an inter-jurisdictional committee, was formed in the wake of the 2002
Bali bombing to help improve national health disaster preparedness. It
is chaired by the Department of Health and Ageing Deputy Secretary, Ms
Mary Murnane, and comprises all of Australia's Chief Health Officers,
plus crucial emergency services such as Emergency Management Australia.
The Department coordinated a collaborative health response effort through its National Incident Room in Canberra. AusAID prioritised the health needs, while the States and Territories, together with the Department of Defence, provided the personnel and equipment. Emergency Management Australia provided logistical support. As a result we were able to rapidly supply nine medical teams comprising doctors, nurses, paramedics and other health care professionals to the tsunami affected regions.
The Australian response effort was largely focused on Banda Aceh in Indonesia, the area worst hit by the tsunami. The Australian medical teams deployed to Banda Aceh provided emergency medical care including many complex surgical procedures and life-saving treatments for patients with serious injuries and infections related to the tsunami. Public health experts in the teams made rapid health assessments and coordinated improvements in the health and sanitation services for displaced persons in Indonesia, Sri Lanka and the Maldives. Teams returning to Australia told harrowing stories of desperately injured people who could not reach medical care for several days. Medical team members required complete logistical support, including accommodation, food and water, because of the devastating destruction of the local infrastructure.
I am very grateful to my many colleagues, ranging from the many doctors and nurses in the field, to staff across the health portfolios who returned from leave to organise and contribute to the health response. All sacrificed their holidays to play an enormous part in the relief effort. My gratitude also extends to the 5,000 other volunteers who offered assistance but were unable to be deployed due to the severe logistical, transport and supply constraints.
Following the completion of our role in the relief effort we took part in Departmental and cross agency debriefs, which highlighted the successful role of the Department and the AHDMPC in providing effective communication and rapid response in a health emergency. The days following the tsunami proved that all Australian health authorities at the national, State and Territory levels can work together with the medical professions towards a common goal. It also demonstrated that Australia has effective coordination and communication systems to respond to emergency health situations, both domestically and overseas.
In the future, the National Centre for Trauma and Critical Care at the Royal Darwin Hospital, funded in May in the 2005-06 Budget, will further enhance Australia’s capacity to mount a prompt response to any health emergency in northern Australia or nearby regions.
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Australia has been reminded of the continuing threat posed by new and emerging infectious diseases through our recent experiences with Severe Acute Respiratory Syndrome (SARS) and the ongoing outbreaks of avian influenza in Asia. The WHO recently warned that the world is now closer to a new pandemic outbreak of influenza than at any time since the pandemic of 1968.
In 2004-05, Australian governments and institutions have been improving our capacity to monitor infectious disease outbreaks, increasing our laboratory diagnostic capacity and developing response plans to contain both known and newly emerging diseases. The Department has contributed to the development of a national plan that will aim to reduce the impact of an influenza epidemic on the Australian community. This entails an integrated approach, including infection control to remind those most at risk about the importance of basic hygiene such as hand washing, the purchase of antiviral agents and the planning of vaccine procurement, amongst other measures.
Australia has also stockpiled more antiviral drugs, on a per capita basis, than almost any other country in the world. We have secured supplies of personal protective equipment to protect health care workers treating patients with influenza, for critical workers in essential industries, and border workers at international airports and sea ports. The Department also has contractual arrangements with vaccine manufacturers to ensure a guaranteed supply of any newly developed vaccine for pandemic influenza.
Internationally we are working closely with our regional neighbours to increase our capacity to detect and respond to a range of emerging infectious diseases. We continue to work with the WHO and other international partners, in particular the United Kingdom, the United States of America, Canada, Japan and China, to research these complex diseases.
| Australia’s role in the revised International Health Regulations
At the recent World Health Assembly held in Geneva in May 2005, Australia
played a significant role in ensuring the passage of the International Health Regulations
(IHRs). The IHRs aim to prevent and control the international
spread of disease and facilitate a public health response. Detailed work
on the process for adopting the IHRs by the Australian Government is currently
underway within the Department. The revised IHRs will be effective from
|The independent WHO Collaborating
Centre for Reference and Research on Influenza
The independent World Health Organization (WHO) Collaborating Centre
for Reference and Research on Influenza, announced in the 2005-06 Budget,
will further enhance Australia’s capacity to identify deadly and
contagious influenza strains such as avian influenza. The Centre will
be the main source of influenza expertise in Australia and will provide
advice to the WHO on influenza activity and trends in the Southern Hemisphere.
Although no-one can predict precisely when a pandemic influenza strain might emerge or when some other newly emerging disease is now much better prepared for such events.
Vaccine Preventable Disease
Australia continues to maintain low rates of vaccine preventable disease, and in recent years we have achieved the lowest notifications on record for rubella and measles (Footnote 1)
. Disease rates in children have also been in decline in recent years, most notably for measles, rubella, diphtheria, tetanus, Haemophilus influenzae type b (Hib), mumps and polio (Footnote 2)
Australia has also achieved a considerable reduction in notifications of meningococcal disease and in the reported rate of newly acquired hepatitis B infections (Footnote 3)
. Hepatitis B may further decrease in the future as the impact of the universal infant hepatitis B vaccination, which commenced in 2000, becomes evident.
Immunisation is recognised and accepted as a highly successful public health intervention and has played a large role in preventing many of the diseases identified above. Australia’s immunisation system continues to perform very well by international standards, with over 90 per cent of children at 12 months of age fully immunised. The introduction in 2005 of free pneumococcal vaccine for children and adults aged over 65 years, chickenpox (varicella) vaccine for all babies and teenagers at risk and injectable polio vaccine to replace oral polio vaccine is another important step in the right direction.
Despite our successes in achieving reductions in vaccine preventable disease, it is essential that we do not become complacent. In the future, it may become increasingly difficult to maintain high rates of immunisation.
Notifications of rubella, 1993-2003 (Australia)
Source: National Notifiable Diseases Surveillance System, June 2005.
New generations of parents have not seen the terrible effects of many of the diseases that vaccines prevent and may not understand the benefits of immunisation. It is vitally important to continue to protect Australian children through immunisation to ensure that preventable diseases cannot re-emerge and cause large epidemics.
New vaccines promise potential new health gains, with more than 60 currently in development. Within the next five years, it is expected that new vaccines for rotavirus and human papilloma virus, herpes zoster and herpes simplex virus will be registered in Australia. Alternatives to injection as a delivery method (eg patches and sprays) and the development of vaccines which have therapeutic as well as preventive applications are also expected. Policy and practice will need to respond to these developments. Some have clear population-wide benefits through mass immunisation programs, while others may be selectively targeted through primary care.
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Preventing and Managing Chronic Disease
Recent decades have seen a profound shift in the balance of the major causes of death and disease from communicable to non-communicable diseases across the world. The rates of chronic, non-communicable diseases have increased in both developed and developing nations. In 2001, non-communicable diseases accounted for almost 60 per cent of the 56 million deaths annually and 47 per cent of the global burden of disease (Footnote 4 ).
The burden of disease and disability in Australia has reflected this trend. Chronic diseases are estimated to be responsible for around 80 per cent of the total burden of disease, mental problems and injury (Footnote 5).
An increasing focus on the prevention and management of chronic disease has thus been a key objective of health policy development in recent years.
The National Chronic Disease Strategy (the Strategy) will provide a national, overarching framework to guide improvements in chronic disease prevention and care. In my role as Chair of the National Health Priority Action Council, I am pleased to be closely involved with this work.
National Chronic Disease Strategy: key action areas
The Strategy identifies the key action areas of prevention, early detection
and treatment, integration and continuity of care and self-management. The Strategy recognises that achieving change
in these areas is dependent on building workforce capacity, strategic
partnerships, investment and funding opportunities, and infrastructure
and information technology support.
National consultations on the draft Strategy and National Service Improvement
Frameworks for several of the National Health Priority Areas have been
held. Separate consultations were held on a Blueprint for nation-wide
surveillance of chronic diseases and associated determinants, developed
by the National Public Health Information Working Group. Consideration
of the Strategy package by the Australian Health Ministers; Advisory
Council, and subsequently by Health Ministers, is planned for late 2005.
Implementing the Strategy will require innovative thinking and involvement from governments, doctors, other health professionals, the community and individuals affected by chronic disease. Much can be gained from working more closely with industry in an effort to better prevent and manage chronic disease. The National Obesity Taskforce’s national agenda for action,
Healthy Weight 2008,
is a good model that sets out action across a wide range of sectors such as the food industry, advertising and media industries, sport and recreation, consumers, education, retailers and urban planning. The private health industry is also assisting in addressing chronic disease. Emerging trends include health funds offering member incentives for the better management of chronic conditions (for example customised case management for people with higher than average private health claims) and rewards for members participating in preventive activities. However, the success of these initiatives will be ultimately determined by the level of responsibility we each take for our own health. We should all ensure that good nutrition and adequate levels of physical activity form a central part of our daily lives.
Education and Training - Preparing the Future Health Workforce
With the rise in chronic disease, most of the illnesses burdening today’s society are too complex to be addressed by one single health discipline. Chronic disease prevention and management requires interdisciplinary teams, yet our medical education is still delivered in a silo approach.
Today’s medical graduates must acquire interprofessional skills and experience across a broad range of care settings, yet their training focuses on hospital teaching experiences with a narrow clinical focus. This is also predominantly the case with nursing and allied health education, where the professional boundaries begin in the classroom and are entrenched in clinical training.
As Chair of the Medical Specialist Training Steering Committee, I have been working with medical colleges, health departments, clinicians and trainees to implement a new model for specialist medical training. Under this model, settings for training will be broadened to include public hospitals, private hospitals, private practices, rural and community-based settings.
An increasing number of medical services are being provided outside public hospitals in private and community-based settings. The settings for specialist training need to reflect this change to ensure that specialist trainees are equipped with the full range of experience needed for safe and effective practice now and into the future.
It would be fair to say that the health care industry is one of the only industries where training has not kept pace with changing practices. We should no longer be confined to the narrow roles of doctors, nurses and other allied health professionals. Instead, we need to take the opportunity to redefine who does what, using broader and more flexible training and service delivery models that consider modern patterns of disease and care.
The changing realities of health service delivery in Australia require health professionals capable of working effectively as part of multi-skilled teams, with the interpersonal skills to work in a variety of health settings to deliver the highest quality care to patients.
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Australia continues to achieve excellent health outcomes, but many challenges remain. In the immediate future, it is anticipated that health services will be improved with the successful implementation of the National Chronic Disease Strategy. This will be particularly important for disadvantaged communities, who have a disproportionate burden of disease.
Looking to the horizon, there are some testing challenges. A growing international shortage of skilled health professionals combined with an ageing population will increasingly place major demands on the health system. Demand and need for health services may outstrip supply unless innovative ways of managing the health needs of the population are developed and implemented. This may require major changes in the delivery of health services in the future.
Disease caused by infection can extend beyond the acute disease process we generally recognise. There is a growing body of evidence that infections may also have an ongoing influence on a range of chronic diseases. Recently, the International Agency for Research on Cancer has suggested that around 20 per cent of all cancers have an infectious component (Footnote 6)
Persistent infections of high risk types of Human Papilloma Virus (HPV) have been shown to be the main risk factor for cervical cancer. Regular pap smears and early treatment have significantly reduced the incidence of cervical cancer, and the current developments in HPV vaccines offer the possibility of preventing the majority of cervical cancer cases through immunisation in the future.
Development in the early years of life makes an important contribution to good health throughout the life course. Ensuring that children have the best opportunities to achieve healthy and productive lives will become increasingly important as a preventive measure. Repeated infections in early childhood can adversely affect development and lead to further health complications later in life. For example, repeated early childhood infections, combined with malnutrition, have been shown to result in chronic kidney problems and renal failure in Aboriginal and Torres Strait adults. Preventing ill health during the vulnerable early childhood years should not be left to chance.
Finally, the ethical complexities arising from knowledge of the genome will need to be addressed. With relatively simple tests, we will be able to predict many diseases. This will place increasing pressure on the health professions and society to use this knowledge wisely for the patient’s benefit. The implications of developments such as these for the future of our health system will engage policy makers, clinicians and the wider community for many years to come.
Despite these challenges, particularly the rising burden of chronic disease, Australia continues to maintain a world-class health system, ensuring that Australians enjoy a high level of health.
Professor John Horvath
Chief Medical Officer
1. Miller et al, Australia’s notifiable diseases status, 2003: Annual Report of the National Notifiable Diseases Surveillance System,
Vol 29, No 1, March 2005.
2. National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, Vaccine Preventable Diseases and Vaccination Coverage in Australia, 2001-2002.
3. Miller et al, Australia’s notifiable diseases status, 2003: Annual Report of the National Notifiable Diseases Surveillance System,
Vol 29, No 1, March 2005.
4. World Health Organization, Global Strategy on Diet, Physical Activity and Health,
5. Australian Institute of Health and Welfare, Chronic Diseases and Associated Risk Factors in Australia 2001
, Canberra: 2002, p5.
6. Stewart, B.H and Kleihues, P (eds), World Cancer Report
Lyon: International Agency for Research on Cancer (IARC) Press, 2003.