Australia can lead the fight against Asia’s lifestyle disease epidemic*

Think Asia and we think millions – or billions when you combine the populations of both India and China.

Unfortunately, millions is also an appropriate unit with which to measure the number of people in Asia who suffer from chronic illnesses such as heart disease, stroke, cancer, ongoing respiratory disease (like asthma and emphysema) and diabetes.

The causes often spin out of rising affluence, shifts from traditional to processed diets, decreased physical activity – as people move from rural to city employment and living – and the pervasive, rising influence of tobacco smoke.

Snapshot of China

In China, around 80% of deaths and considerable disability are now attributable to chronic disease; this percentage is set to grow as the population ages and these conditions become more prevalent.

Around 300 million Chinese men smoke, but rates are much lower among women (it’s less socially acceptable for women to smoke). Sample surveys conducted among about 20,000 people living in nine counties suggest that around half of China’s smokers have high blood pressure and are missing out on treatment. This means they’re at heightened risk of heart disease and stroke.

For a health-care system committed to reform but struggling to come to terms with contemporary expectations of rural and urban populations, this is the stuff of nightmares.

Snapshot of India

The scene isn’t any happier in India. Around half of all deaths – around five million each year – are now due to chronic illness.

In 2004, my colleagues and I published a study which estimated that India was losing more than nine million years of productive life each year from heart-disease deaths in people aged under 65 years. On current projections, this would double by 2030.

Comparable figures for China were six million years of lost life in 2004, which could rise to 11 million years by 2030.

Snapshot of Thailand

Similarly to India, chronic illness accounts for around half of all deaths in Thailand.

But there are some positives to report. The World Health Organization (WHO) estimates that the proportion of men who are overweight is likely to remain steady, at around 35%.

Rates of excess weight among women, however, are expected to rise from 47% in 2005, to 57% in 2015, which reflects local cultural norms. These cultural factors alert us to the power of the environment in setting the range of individual behaviours, which can be as strong as conventional risk factors such as high blood pressure.

Efforts to reduce tobacco consumption in Thailand have been successful, with ratesdeclining over the past two decades. Unsurprisingly, this has raised the ire of the tobacco industry, which sees its market shrinking.

But other parts of Asia haven’t done so well in reducing rates of smoking. In fact, as the tobacco trade journal, Tobacco Reporter, noted in 2009, Asia is one of the world’s most promising cigarette markets, with Indonesia (southeast Asia’s largest market) selling 231 billion cigarettes in 2007 alone.

Health promotion

So, what can Australia do to improve our neighbours' health? There are several compelling options.

First, we can provide an encouraging example of successful health promotion initiatives, particularly in tobacco control.

Thankfully, this has already been happening. Australia was a major advocate for the WHO’s Framework Convention on Tobacco Control, which aims to eliminate trade in illicit tobacco products. Now we should push for its full implementation among all signatory countries, including those in Asia.

Likewise, Australia’s approach to the detection and management of patients with elevated blood pressure has paid dividends, with an 83% drop in rates of death due to heart disease since 1968. This, too, can serve as a model that other nations can study and possibly adopt.

The commitment of the current federal government to health prevention is unusual and exemplary. Of note is the recently established Australian National Health Preventive Agency, which other nations may wish to emulate.

Managing trade

Second, we should consider reviewing our trade relations with Asia so that our exports, especially for food, don’t compound the disease risk profile of Asian countries.

We can learn from the Pacific, where an aggressive trade push (not so much from Australia but other big economies) allowed multinational food companies and food producers to push their high-fat products to a new market. Small, relatively powerless countries fought hard to keep these companies out but, in the end, were defeated by edicts promoting commerce through the World Trade Organisation.

So, a thoughtful “health ethics” review of our trading relations with Asia may be possible. We could, at the very least, articulate a set of national expectations of our corporations in their dealings with Asia, in the form of a health “bottom line”. While these expectations may need the support of law, first we need a discussion about corporations' ethical obligations.

People power

We should think carefully about the role we can play in helping our Asian neighbours develop effective, relevant health workforces.

Our obsession with recruiting overseas students to fuel our tertiary education institutions should be abandoned and replaced with a more responsive approach to assisting other countries appropriately develop their workforces.

This could include increased funding for the Colombo Plan, where Asian students are sponsored to study in Australia and, on completion, return home. The Plan operates on a shoestring budget but has provided 16,082 scholarships to 23 member countries in its lifetime.

Much else could be written about health in the Asian Century, including the need to implement a sophisticated surveillance and control system for emerging infectious diseases. Maternal and child health, and mental health, remain challenges for poorer countries and the disadvantaged in nations such as India.

But in priority order, we must focus on controlling chronic diseases, through heavy investment in prevention programs and effective, affordable health systems to treat existing patients. Australia can – and must – help.

*Published in The Conversation 18 April 2012

Can we stand for this?*

SITTING is not good for us. We should be up and about.

In a recent Australian-based study, published in the Archives of Internal Medicine, hours spent sitting was shown to confer a small increase in the risk of death from all causes.

Is the chair the problem? Historically, “chair” suggested power and authority, not vulnerability and death.

Chair comes from the Greek cathedra and cathedrals were places with chairs on which men of power sat. The occupant of a chair would expect us to take notice, whether a bishop, king or a professor. But the privilege of being seated and treated as a power-person may come at a price.

In fact, doctors who sit 10 hours a day, advising their patients to exercise more, may be in strife themselves.

Sixty years ago a study showed that conductors aged less than 50 years who worked on London double-decker buses had sudden death rates one-third those of bus drivers. Presumably this contrast had something to do with sitting versus standing.

The authors of the paper back then found that the variations in sudden death rates could not be explained by the drivers wearing bigger trousers than the conductors — because they didn’t. “The difference between conductors and drivers in the sudden death rates cannot be explained by differences between the two occupations in physique as measured by uniform size”, they wrote.

The latest study by Australian researchers strengthens growing concern that sitting in and of itself may contribute to all-cause mortality.

So what would be an appropriate public health policy response to this observation?

First, it would be prudent to draw the finding to public attention so that when options present for choosing sitting or standing, people are encouraged to stand (and move).

This has salience when considering ergonomic arrangements in the workplace, where opportunities for working at a computer console might include adjustable desk heights that permit the user to stand rather than sit. Presumably, this would make the temptation to occasionally walk about stronger.

Second, we might encourage doctors and others to consult on our feet as managers who wish to keep meetings short do. Walking clubs organised by several private health insurance funds and the Heart Foundation could be publicised through doctors’ practices. These groups blend physical activity with socialising and chat.

Perhaps a Medicare Local could pilot the value and cost of a walking group for doctors and other health professionals, organised to fit easily into their schedules. This may also save money otherwise set aside for those excruciating team-building and networking retreats.

Third, the Australian National Preventive Health Agency, with the expectation that it will engage in heavy-duty evidence assessment on which prevention programs work best and in what context, may wish to review reportedly successful nationwide activity programs such as Agita São Paulo Program in Brazil.

“The verb ‘agita’ means to move the body, but the term also suggests changing the way of thinking and becoming a more active citizen”, write the program’s protagonists Sandra Matsudo and colleagues.

Launched in 1996 among the 37 million citizens of the state of São Paulo, Agita is now widely adopted by the rest of Brazil and endorsed by WHO. Its message is to encourage people to adopt an active lifestyle by accumulating at least 30 minutes of moderate physical activity per day, on most days of the week.

Following widespread community application, 7% of citizens exposed to the program remained sedentary compared with 14% of those who had not been exposed.

And finally, we should attend to the way we design, build or renovate our urban spaces. In the world’s great cities such as Manhattan, public commuter transport encourages regular incidental walking as well as relieving road traffic obesity and thrombosis.

Time for me to get up from this chair and go for a walk, I think!

*Published in MJA Insight Magazine

What experience teaches

I have been chair of the board of the Western Sydney Local Health District (WSLHD) for twelve months.  As part of the agreements struck between the Commonwealth and the states and territories, NSW’s large area health services were split into 17 much smaller entities.

These networks or districts are based on public hospital services and their community outreach programs and community health services more generally. They are responsible for a goodly portion of preventive and health promotion services and mental health.

Giving clinicians a stronger voice in the running of the services was a central plank of the new structure as was a clearer consumer voice and connection to the new Medicare Locals.

WSLHD is one of these new entities encompassing a population of about 800,00o people living in Blacktown, Parramatta, Auburn, Mt Druitt and related suburbs, including about 10,000 people who identify as Indigenous.

The board’s brief is to assist in the development of policies and strategies to guide the work of the LHD, to co-operate with the minister and the Ministry of Health, and the related Medicare Local and private agencies to help the district achieve the best levels of health possible. This cannot be done by the health system alone, quite obviously, and we are expected to hear what the community has to say and to relate to other agencies and local government in the pursuit of common goals.

I was asked to write about what I have learned as a result of that year in the chair.

First, I have learned the solid truth behind the aphorism, “The board governs but does not manage.  The managers manage, but do not govern.”  When as a board member of another agency I dabbled in management previously, I made a major error, and nothing in the past year has diminished my acceptance of the wisdom of that division of labour.

The second thing I have learned, or relearned, is that the public health system is populated with people of strong humane concern and altruism. When fire struck a nursing home in western Sydney, off-duty staff from Blacktown Hospital phoned in to see if they could help the hospital cope with the load. I am constantly regaled with stories of people throughout the organisation (and there are thousands of them) doing more than they are asked, connecting to patients and families.

The third thing I have learned is that there is a lot of ‘in spite of’ high quality care. In spite of not engaging in best practice health IT support, financial management systems, and building design, an amazing amount of good work gets done. Somehow we muddle through.

It was Andrew Podger, an outstanding secretary of the Commonwealth health department, who introduced me to the management literature on ‘muddling through’ (See George Maddox 1971 paper in Medical Care Vol 9 No.5  Muddling Through: Planning for Health Care in England).

Muddling isn’t as bad as it may first appear and in fact may be the only way through a contentious, politicised health care problem.

The fourth thing I have had reinforced is the importance of starting where staff – clinical, managerial and support – are in their personal career development.  If we set a goal for more coordinated care in hospitals, or activity-based funding, or patient-centredness in our transactions, then the managers will need to manage that with clinicians and others who are in the thick of service delivery.  If there is to be change, then that change needs careful and often sensitive management.

Fifth, I have learned again just how expensive organisational restructuring is. To make it worthwhile you have to be very clear about what you are trying to achieve, and that the likely benefits outweigh the estimated costs.

Don Berwick, in his birthday advice to the UK NHS, offered ten rules to assure its future health, one of which was ‘Do not restructure.’ His advice was a little more nuanced than the heading, but he recognised the cost.

In this case I do think the restructure into more workable entities was desirable, especially if they change the participation of clinicians and the community.  They also reduce the size of the administrative unity to one that is big enough for a full spectrum of hospital services to be sustained, but not so big that people completely lose touch with one another in the organisation.

The health ministry has coped with stupendous changes with admirable calm and professionalism. Our board itself is a band of splendid people that I am enjoying getting to know.

I do find the work emotionally stressful – the sheer scope of the enterprise is daunting.  I have not had the experience of working in an organisation as complex and huge as this before.  I find my control-freakery and pushiness for practical results needs to be tempered.

In addition, the clinician in me frequently gets upset when I see conditions that do not give patients the best chance of dignified care or optimal outcome. This is one reason why doctors generally do not make good managers – and I guess do not make great board chairs, either.

After one year I find myself wondering whether we have really turned our attention to the big picture quite enough, whether we have done the hard yards of sorting through with managers, clinicians and community where we think it reasonable to expect the LHD to be in five or ten years, delivering what services, to whom, and how? Are we thinking innovatively enough about new models of care?

So we have lots left to do and I feel very privileged indeed to be in the position of chair and to be working with the thousands of dedicated staff in our LHD.

Also posted on Croakey

Matters of life and death*

When in 1968 I worked in Papua New Guinea, my credibility fell sharply when it became obvious several weeks after my arrival that my interest in epidemiology did not mean that I had the skill to diagnose and treat rare rashes and perplexing pimples.

Epidemiologists, famed neither for their sense of humour nor their warmth, have been defined variously as voyeurs who study populations broken down by age and sex, or (rather more engagingly) as magicians who convert death certificates into airline tickets.

In which case, have some sympathy for them. Death certificates are not as plentiful as you may think. A recent document from the World Health Organisation concerning ways forward in combating the universal scourge of chronic disease contains the following surprising information.

Only a third of the global population lives in an area where more than 90 per cent of births and deaths are registered. Currently, only 38 countries have high quality cause of death data, 81 countries have lower quality cause of death data, and 74 countries lack such data altogether. There are some encouraging signs of increased awareness of the need for better vital statistics among decision-makers, and use of information technology holds the promise of overcoming some persistent obstacles…National initiatives to strengthen vital registration systems, and cause-specific mortality statistics, are a key priority.

Now I fully accept that there is much more to good medical care than the information we record. The exceptional durability of the tatty paper-based hospital record alongside high-quality patient management is fair testimony: people get better and deaths are prevented yet we write down the scratchiest of detail – and we are one of the 38 countries deemed by WHO to have good statistics! Spare a thought for the others!

We may not do well with the quality of our medical records in Australia, but we do have a fine system for recording vital statistics, thanks to the Australian Bureau of Statistics, and we are in the top league. But reflect on what the state of the world’s vital statistics means for managing rationally the resources available to us to preserve and promote global health. Although anti retroviral drug treatment for HIV now has a substantial evidence base, in the early days of its application in Africa it was not possible to examine trends in HIV-associated deaths to see what it was doing. This is the problem: what to do and how to know how well we are doing in the absence of dependable evidence.

While the ‘vital’ in ‘vital statistics’ does not mean ‘can’t live without them’ but refers to the life (and death) of the individuals recorded in them, nevertheless global health progress is limited when we cannot get a clear picture of what needs to be done nationally and internationally, and we cannot discern accurately how well we are doing. The most basic of that information is the cause of death. We all know, and studies have confirmed, major inaccuracies occur even in this measure. Certificates that are completed ignorantly or incompletely cloud the picture. But not all is gloom.

First, in several less economically advanced countries, verbal autopsies, whereby relatives provide detailed answers about events surrounding the death of a decedent, have been used effectively to gain insight into causes of death, events surrounding the death (defective care, hazardous environment etc), and as a way of evaluating the effectiveness of interventions.

Second, the WHO points to the role of information technology in remedying this state of ignorance. In India, where information technology capability is high, we are seeing interesting developments. India has fine capabilities in demography and associated statistics. These are now being supplemented by the development of a universal electronic identification system, as I commented last month. This could have profound implications for health intelligence. Although privacy concerns are real, there are many circumstances where accurate medical data – even about causes of death – are an even greater necessity for effective planning of our health care future as a world community. Maybe the branch of epidemiology that studies death certificates still has life!

*Published in Australian Medicine April 2, 2012