CHIEF MEDICAL OFFICER’S REPORT
Events of the past year have emphasised that, in health matters, no country can regard itself as an island, cut off from outside developments. Health crises in our region and in the broader world demanded our attention and were the focus of increasing allocations of Australian health resources.
Much effort was devoted to preparing the nation for an emergency such as an influenza pandemic. The resulting planning and stockpiling of medicines has greatly increased our ability to respond to such an eventuality and to minimise the cost to Australians in health, social and economic terms.
The last 12 months have also seen national initiatives to improve the health of all Australians and to tackle areas of concern which have the potential to reverse the long-running trend to longer life expectancy - such as obesity, chronic disease, mental illness and Indigenous health and shortages in the health workforce.
The challenges that face Australia and virtually all other countries in respect of the health workforce shortages are being addressed in a multi-faced approach. As well as increasing training for doctors, nurses and allied health professionals, we are examining new and more efficient ways of delivering vital services. However, until these measures have their full impact, we will continue to rely to some degree on overseas trained health professionals to assist.
Protecting our Health from Major Threats
Improved public health and vaccinations in the 20th century have led to greatly reduced mortality and morbidity from traditional infectious diseases. The current environment, however, requires us to be vigilant against both old diseases such as polio, which has re-emerged in our neighbour, Indonesia, and new diseases such as avian influenza, H5N1, and Severe Acute Respiratory Syndrome.
A significant part of my work this year focused on the continued preparations for the possible emergence of an influenza pandemic arising from the H5N1 avian influenza strain. While it is impossible to predict when such a pandemic might occur, or to be certain that it will occur, the potential death toll in an uncontrolled epidemic is such that we must have robust systems in place to contain or prevent the spread of the virus as much as possible if a significant outbreak occurs.
To focus our efforts, in early 2006 the Office of Health Protection (OHP) was established within the Department to boost Australia’s capacity to develop and coordinate planning and responses to health threats. The OHP will have a major role in coordinating expert advice on the risk of disease outbreaks and in developing a national disease surveillance system. The OHP will also consolidate and build on the work already undertaken by the Australian Government to manage communicable diseases and to maintain Australia’s biosecurity.
Our plans have focused on the possibility of the deadly influenza H5N1, or 'bird flu' virus, mutating from a poultry virus to one that is easily transmitted from human to human. While there have been some subtle shifts in the genetic make-up of the virus, it remains predominantly a disease of birds, with relatively few cases of human infection to date, but one which causes serious consequences to humans when transmission does occur. Of the 228 worldwide human H5N1 cases reported up to 30 June 2006, 130 (57 per cent) were fatal.
An important development was the recent research into types of vaccines that might be of value in a pandemic. We are working collaboratively with several vaccine producers both in Australia and overseas on a variety of strategies to ensure that we have optimal access to the right types of vaccines when needed.
We are continuing to build our national stockpile of drugs and medical equipment to supplement stocks presently available in the states and territories in the event a pandemic should occur.
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Australian Health Management Plan for Pandemic Influenza
In May this year, Minister Abbott launched a revised Influenza
Management Plan that draws on the latest epidemiological modelling.
The plan suggests that strict containment strategies employed at the onset
of a pandemic could prevent or slow wider spreading of the virus, and
buy time for laboratories to develop an effective vaccine.
We are working closely with the states and territories to ensure that
the principles contained in the Australian
National Action Plan for Human Influenza Pandemic are harmonised across
all national and state and territory plans.
Containment measures in the Australian Health Management Plan for Pandemic Influenza that would need to be adopted early in the development of a pandemic include:
- escalating border control and quarantine measures to reduce the risk of overseas travellers bringing a pandemic virus into Australia, including potential restrictions on travel from affected regions if a pandemic emerges;
- adoption of basic infection control, such as cough and sneeze etiquette, frequent hand washing and the wearing of masks on public transport;
- social distancing practices, like avoiding crowded public gatherings and short-term home quarantine for people exposed to an infected person; and
- targeted provision of antivirals to people exposed or at continuous high risk of exposure to the virus rather than to broad categories of workers (to ensure the stockpile is used to best effect in slowing or stopping the spread of the virus and to ensure it lasts as long as possible).
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Our whole-of-government approach has positioned Australia as the regional leader in preparing a response to emerging diseases and potential pandemics, and to health disasters and emergencies.
Significant progress was also made in 2005-06 on improving our infrastructure for surveillance of disease threats, particularly influenza, within South East Asia and the Pacific. This surveillance will be crucial in providing Australia with notice of an impending pandemic and is an important aspect of our overall strategy for managing threats from influenza.
The new World Health Organization (WHO) Collaborating Centre for Reference and Research on Influenza in Melbourne, is performing an integral role in the national surveillance system. The centre forms part of the WHO’s international influenza surveillance network, and monitors the frequent changes in influenza viruses with the aim of reducing the incidence of influenza through the use of vaccines that target circulating strains. We are working closely with the WHO to expand and co-locate the centre with the Victorian Infectious Disease Reference Laboratory in Melbourne to build on its capacity for disease surveillance in Australia and overseas.
We will also continue to help countries in the region to strengthen their own national surveillance systems, train local health professionals, and purchase equipment and antiviral medicines to combat emerging diseases such as avian influenza. These offshore initiatives will be guided by the OHP.
New Infectious Diseases
As well as avian influenza, we must strengthen surveillance for and response capability against other zoonotic diseases which have emerged in the region. Zoonotic diseases are diseases transmitted from vertebrate animals to people, and include mosquito-borne diseases such as dengue fever, Japanese encephalitis and the chikungunya virus.
The Department is working closely with agricultural agencies such as the Department of Agriculture, Fisheries and Forestry to improve surveillance for diseases not yet in Australia, diagnostic laboratory skills, and awareness in the community of the dangers posed by these diseases.
National Chronic Disease Strategy
The WHO has long warned that the global burden of chronic disease is increasing rapidly and predicts that by the year 2020, chronic disease will account for almost three quarters of all deaths.
Australia’s chronic disease burden and its consequent effect on disability and death are of course growing in line with this trend. We must start building capacity now to deal with this challenge. Failure will have an impact not only upon the affected individuals in terms of pain and suffering, but also on their families and carers, and on the whole Australian community in terms of productivity losses and high health care costs.
Much of our chronic disease burden is caused by avoidable lifestyle factors. While we have made major advances in reducing smoking in the community, regrettably the current epidemic of obesity threatens to outweigh these health gains. Across all age groups there is a marked increase in body weight and the associated downstream health effects such as diabetes and other chronic diseases and their complications.
The role we as doctors and health professionals play in this difficult and complex area cannot be underestimated. Each time we see patients is an opportunity to help get vital health messages across. To do this, we need to understand the best way to approach our patients. As well as this, we need, as community leaders, to use our influence to create the best environment where a healthy lifestyle is made easier, not harder.
The Australian Government and the State and Territory governments have all recognised the need to support health professionals and individuals in these endeavours over the last three years, and have worked closely to develop a united national approach. In November 2005, the Australian Health Ministers’ Conference endorsed a national strategic policy to manage and improve chronic disease prevention and care in the Australian population. The National Chronic Disease Strategy represents a major step forward, providing an overarching framework of agreed national directions for improving chronic disease prevention and care in Australia.
The strategy is supported by five disease-specific National Service Improvement Frameworks covering asthma; cancer; diabetes; heart; stroke and vascular disease; and osteoarthritis, rheumatoid arthritis and osteoporosis. The frameworks draw on scientific evidence to identify opportunities for improvements to health service arrangements at the national, state and territory levels.
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Challenges of Mental Health
Mental health has been the subject of considerable community concern and debate during 2005-06. Since the 1960s, there has been a shift in the service orientation towards people with severe mental health disorders, from care in long-term mental health hospitals to care provided within the community. More than 22,000 mental hospital beds were closed by the early 1990s. This shift was deliberate because of the poor quality of institutional life but was relatively unplanned before 1993, and limited community services were developed to replace the ‘whole of life’ function played by these hospitals.
Despite the efforts of all governments through the introduction of the National Mental Health Strategy in 1993, the community-based care system has struggled to address the needs of individuals with mental disorders, their families and the wider community. Recent reports, and the Australian Government’s own reviews, have identified the need to improve access to services for people with severe mental disorders, and to improve the effectiveness of treatments for people with common mental disorders.
As mental health continues to be a shared Australian Government and State and Territory government responsibility, significant reform needs to be progressed at the highest level through the Council of Australian Governments (COAG). The reforms announced by the Australian Government following the COAG agreement in February 2006 will make significant inroads to addressing the needs of all people affected by mental illness.
These reforms will provide people with severe mental illness with better access to appropriate clinical treatment in the community, including services by appropriately trained GPs, psychologists and psychiatrists. The reforms will improve services for people with common mental disorders and for particular groups including people in rural areas, Indigenous people, and will promote early intervention for children and families.
The Department is playing a key role in the development of the new mental health package and will continue to do so in coordinating the implementation of the new measures.
Mental Health Package
The $1.8 billion mental health package announced on 5 April 2006 included a major increase in clinical and health services available in the community and new team work arrangements for psychiatrists, GPs, psychologists and mental health nurses; new non-clinical and respite services for people with mental illness and their families and carers; an increase in the mental health workforce; and new programs for community awareness.
The second terrorist attack in Bali, Indonesia in October 2005, which resulted in the death of four Australians and injury to 19 others, demonstrated the capacity of Australia’s health and emergency management communities to respond rapidly and effectively at critical times.
The then Australian Health Disaster Management Policy Committee (AHDMPC) - comprising Chief Health Officers of all jurisdictions and emergency services health experts - worked closely with the Australian Defence Forces to rapidly assess medical needs, provide medical treatment to victims and manage their evacuation. The AHDMPC met regularly by teleconference to coordinate resources and direct them to where they were most needed, such as the formation of civilian medical teams and their deployment to Bali. In Australia, Darwin hospitals responded quickly, initially acting as staging facilities for the evacuated injured, and in the end treating the majority of injuries caused by the bombing.
As a result of the lessons learned from the 2002 Bali bombings, the Department established the National Incident Room (NIR) that can be activated for national health emergencies such as an influenza pandemic, and the health aspects of other emergencies in which the Australian Government has a role. This may include health emergencies of all types, including natural disasters, acts of terrorism, or communicable disease outbreaks. The NIR was officially opened on 7 September 2006.
The NIR has been used extensively by the Department during the past 20 months, to monitor and coordinate the national responses to global outbreaks of SARS and avian influenza, as well as recent mass casualty incidents such as the second Bali bombing, Yogyakarta earthquake and the medical evacuation of injured from East Timor. The NIR has close information linkages with operational centres in other Australian Government agencies which ensures coverage of both crisis and consequence management aspects of acts of terrorism.
After the recent review of the Australian Health Ministers’ Advisory Council sub-committee functions, the role of the AHDMPC has been significantly expanded to cover a broader range of health protection related activities that go beyond disaster management. The committee has also been renamed the Australian Health Protection Committee (AHPC), and is supported by the Department.
Soon after its inception the AHPC was called on to respond to two new crises in April-May 2006:
- violence in East Timor: the Department’s National Incident Room, in consultation with the AHPC, mobilised 17 medical evacuations from Dili, East Timor, to Darwin and supported local facilities and nursing and medical personnel who were rapidly recruited from other states and territories to work with Darwin Hospital staff; and
- massive earthquake in Indonesia: immediately following the earthquake, the AHPC worked with AusAID and Emergency Management Australia to deploy two Australian medical assistance teams to Java, Indonesia.
These events confirmed our preparedness to act in health disaster events and the effectiveness of the current inter-jurisdictional arrangements. They also reinforced the prospect that continuing demands will be placed on Australia to cope with health disasters throughout the region.
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This year saw two Australian doctors, Barry Marshall and Robin Warren, receive the 2005 Nobel Prize in Medicine for their careful clinical research which identified the cause of and appropriate treatment for the common disease of stomach ulcers.
Professor Ian Frazer from Queensland was named the 2006 Australian of the Year for his work in developing vaccines against cervical cancer. For the last 20 years, Professor Frazer has researched the link between papilloma viruses and cervical cancer. He has now developed vaccines to prevent and to treat the cancer. The first, a preventative vaccine, is in the final stages of world-wide trials and is expected to be available in late 2006. The creation of these vaccines is an exciting breakthrough and another example of the high standard and enormous benefits of Australian medical research.
The papilloma vaccines suggest further exciting clinical potential for drugs to combat some resilient diseases. Drugs are becoming more sophisticated at targeting molecules and receptors to ensure more effective therapy, including fewer side effects, and many new drugs offer the promise of significantly improved treatment for cancer and metabolic diseases. These new drugs will need to be evaluated to ensure that they are safe and effective before they are made available to Australian patients.
The Health Workforce
The World Health Report 2006
examines the current worldwide shortage of health workers. The WHO estimates there are at present 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives (footnote
). World Health Organization 2006. World Health Report 2006. WHO Press, Geneva Switzerland.
In Australia, the uneven distribution of the health workforce creates areas of particular shortage. Increasing demand for health services and the ageing population are also raising demand for doctors and nurses. In recent years, the Australian Government has introduced a wide variety of initiatives, including increasing the number of medical school places, increasing the number of appropriately qualified overseas trained doctors operating in Australia, and training and funding more practice nurses.
During 2006-07, the Department will manage the implementation of a major COAG health workforce package, which will provide a further expansion in new medical school and undergraduate nursing places. It will also increase the number of doctors in rural areas by allowing more rural students to get into medicine and by training more medical students in rural areas.
There is recognition that medical specialist training in Australia needs to adapt to changes in the way health care is delivered. The changing patterns of disease, increasing complexity of treatment and advances in medical technology have altered the way services are delivered, with more than 75 per cent of all health care expenditure now being distributed outside of public hospitals.
The Department is working closely with medical colleges, private sector health practitioners, the Australian Medical Association, and the states and territories’ health departments to produce a training plan that will enable medical education to be delivered more effectively. It is anticipated the program will commence in early 2007.
There have been significant gains in some areas of the health of Aboriginal and Torres Strait Islander peoples in recent years. Life expectancy for females increased by three years to 67.9 years in the Northern Territory between 2000 and 2003, while mortality for both males and females in Western Australia fell by 25 per cent between 1991 and 2002. There have been significant reductions in infant mortality in Western Australia, the Northern Territory and South Australia between 1991 and 2002 (footnote
Recent research has also shown death rates for the most common chronic diseases in the Northern Territory have been easing or falling since the end of the 1980s. These include slowing death rates from diabetes and ischaemic heart disease (the biggest killer) and falling death rates for chronic obstructive pulmonary disease (chronic bronchitis and emphysema). The investment by the Australian Government and the dedication of many health professionals working in primary care has largely been responsible for this welcome change in health outcomes. New initiatives in preventing chronic disease and modifying high risk behaviour will hopefully improve outcomes further.
Chronic disease such as diabetes is particularly high among Indigenous people. The new Medicare health check will be beneficial, as a focus on children’s health is crucial to the health of future generations. Implementation of the National Chronic Disease Strategy, commencement of the Healthy for Life program to reduce the impact of chronic diseases, and measures to address petrol sniffing and alcohol abuse are also important achievements in 2005-06.
Smoking is almost three times as common in Indigenous people, and contributes to many of the chronic diseases affecting quality of life and life expectancy. Helping Indigenous Australians to quit smoking is another important goal.
The Department is working hard to increase access to mental health services, and programs aimed at specific diseases such as cervical cancer, rheumatic heart disease and trachoma. A continuing focus on Indigenous health is integral to maintaining the outstanding reputation of Australia’s health system.
The Australian Government has invested heavily to improve the capacity and focus of our health systems in the past two years, with a commitment to build on this over the next three to five years. This investment presents us with unprecedented opportunities to meet the challenges facing us to deliver the best health outcomes for Australians.
In doing so, we will build on our achievements in 2005-06 in increasing the preparedness of our health infrastructure for a pandemic outbreak, and adapting our health structures to face the growing burden of chronic disease.
Professor John Horvath AO
Chief Medical Officer
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World Health Organizaton 2006, World Health Report 2006. WHO Press, Geneva Switzerland.
Australian Bureau of Statistics and the Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2005. Canberra: ABS, 2005. (Cat. No. 4704.0).