On June 1, health workers in New South Wales will be required to have a flu vaccination if they work in high-risk clinical areas, such as wards for neonatal care, transplants and cancer. Otherwise staff are required to wear surgical masks during the flu season or risk being redeployed.
The most effective way to improve vaccination rates among health workers is to make it mandatory. State, territory and Commonwealth governments should consider making the flu shot mandatory for all health workers in high-risk clinical areas and aged care facilities.
Why health workers need to be vaccinated
For most of us, vaccination is for individual protection. In the case of those caring for sick and vulnerable people such as children and the elderly, vaccination protects others from devastating illness, complications and even death.
Hospitals and aged care facilities can experience explosive outbreaks of influenza.
Aged care facilities may have to close their doors to new admissions, which can also have a significant economic impact. It’s also important that staff absenteeism in hospitals is kept low, especially in areas with limited specialist expertise.
Some argue vaccination of health workers is a moral duty, while others state individual freedom of choice is more important than protection of patients.
The use of immunisation mandates for health-care workers is not new in Australia. In most states and territories, staff are required to have vaccines for (or show evidence of protection against) measles, mumps, rubella, diphtheria, tetanus, pertussis, hepatitis B, and varicella (chicken pox).
NSW, for example, introduced mandatory vaccination of health care workers for several vaccines (but not the flu) in 2007. NSW health workers generally accepted this change in policy, with only 4% objecting.
Making the flu shot mandatory, as NSW has done this year, would simply add the the list of vaccinations health workers are required to have.
The evidence suggests it’s worth it; a five-year study in one hospital in the United States showed mandatory hospital policies can raise coverage rates to close to 100%.
Institutions that have implemented a mandatory policy have dramatically reduced employee sick days as well as flu in hospitals, thereby improving patient safety and reducing health care costs.
Staff vaccination programs
Most workplaces run intensive vaccination programs, which may include mass immunisation clinics, mobile carts, posters and email reminders. But in most cases, these programs aren’t successful at boosting vaccination levels above 60%.
Some hospitals have been able to achieve higher vaccination rates in the short term through easy access to vaccines, education, reminders and multiple opportunities for vaccination. But these initiatives require ongoing resources and continual efforts – a one-off vaccination day is not enough.
The Victorian health system used a slightly different approach in 2014 when it made high rates of flu vaccination a hospital performance target. The government also provided the vaccine free to all Victorian hospitals.
This raised vaccination rates among Victorian hospital staff from 60% to 75% overall (higher in some hospitals). But higher rates may be achieved through mandatory flu vaccination.
But it’s not always the best policy
For each situation, we need to consider the overall risks and benefits of mandatory vaccination, as well as the gains in protection and vaccination coverage.
For infant vaccination, for example, vaccination rates are already at a high baseline of more than 93%. So, the risk of coercive policies may be greater than the relatively small gains achieved by coercive methods. Similar results may be achieved through other methods.
In the case of health and aged-care workers, however, we start with a lower base of vaccine coverage, of 16-60%. Adding financial incentives or disincentives, or making it mandatory, would result in much larger gains in vaccination rates.
Vaccinating health-care workers also has benefits beyond their individual protection: it reduces the risk of their patients contracting influenza and maintains the health workforce capacity. This shifts the balance in favour of mandatory vaccination.
Given large potential gains and low resource requirements, mandatory flu vaccination for all health workers in high-risk areas is a good idea. Governments should consider this and other strategies to improve flu vaccination rates health and aged care workers.
The winners of this year’s health budget are aged care, rural health and medical research.
The government has announced A$1.6 billion over four years to allow 14,000 more older Australians to remain in their home for longer through more high-level home care places. For those in aged care, an additional A$82.5 million will be directed to improve mental health services in the facilities.
The budget includes A$83.3 million over five years for a rural health strategy, which aims to place more doctors and nurses in the bush and train 100 additional GPs.
There’s A$1.3 billion over ten years for a National Health and Medical Industry Growth Plan, which includes A$500 million for new research in the field of genomics.
Other key announcements include:
– A$1.4 billion for new and amended listings on PBS – A$302.6 million in savings over forward estimates by encouraging greater use of generic and bio similar medicines – A$253.8 million for a new Aged Care Quality and Safety Commission.
Helen Dickinson, Associate Professor, Public Service Research Group at UNSW
It was well foreshadowed that this budget would bring with it significant provisions for aged care. It has been widely reported that reforms to pension and superannuation tax have resulted in disaffection in the Coalition within older age groups.
Making older Australians the cornerstone of budget measures is a calculated political tactic in a budget that in the short term makes only limited tax cuts for low- and middle-income earners.
The A$1.6 billion for 14,000 new places for home-care recipients will be welcome, but are a drop in the ocean, given there are currently more than 100,000 people on the national priority list for support.
Additional commitments around trials for physical activities for older people, initiatives to improve connections to communities and protections for older people against abuse will bolster those remaining in homes and communities.
Commitments made for specific initiatives for Aboriginal and Torres Strait Islander people and aged care facilities in rural and remote Australia will be welcomed, although their size and scope will likely result in little to address older age groups with complex needs.
While investment in aged care services will be welcome, it remains to be seen whether this multi-million-dollar commitment will succeed in clawing back support from older voters.
Recent years have seen around A$2 billion of cuts made to the sector through adjustments to the residential care funding formula. The current financial commitments go some way to restoring spending, but do not significantly advance spending beyond previous levels in an area of the population we know is expanding substantially in volume and level of need and expectation.
A number of new budget commitments have been announced in relation to mental health services for older people in residential aged care facilities, for a national mental health commission, and for Lifeline Australia.
However, given the current turbulence in mental health services, it’s unclear whether these will impact on the types of issues that are being felt currently or whether this will further disaggregate an already complex and often unconnected system.
Equity, prevention and Indigenous health
Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy at the University of Sydney
The government states its desire for a stronger economy and to limit economic imposts on future generations, but this budget highlights a continued failure to invest in the areas that will deliver more sustainable health care spending, reduce health disparities, and improve health outcomes and productivity for all Australians.
There is nothing new to address the harms caused by excessive alcohol use or opioid abuse.
The crackdown on illegal tobacco is about lost taxes rather than smoking prevention.
There is A$20.9 million over five years to improve the health of women and children – an assorted collection of small programs which could conceivably be claimed as preventive health.
There is nothing in this budget to address growing out-of-pocket costs that limit the ability of many to access needed care.
Additional funding (given in budget papers as A$83.3 million over five years but more accurately described as A$122.4 million over 2018-19 and 2019-20, with savings of A$55.6 million taken in 2020-21 and 2021-22) is provided for rural health that should help improve health equity for country Australians.
Continued funding is provided for the Indigenous Australians’ Health Program (A$3.9 billion over four years); there is new money for ear, eye and scabies programs and also for a new Medicare item for remote dialysis services.
There are promises for a new funding model for primary care provided through Aboriginal Community Controlled Health Services (but no details) and better access for Indigenous people to aged care.
The renewal of the Remote Indigenous Housing Agreement with the Northern Territory will assist with improved health outcomes for those communities.
PBS, medicines and research
Rosalie Viney, Professor of Health Economics at the University of Technology Sydney
The budget includes a notable increase in net expenditure on the Pharmaceutical Benefits Scheme (PBS) of A$1.4 billion for new and amended listings of drugs, although most of these have already been anticipated by positive recommendations by the Pharmaceutical Benefits Advisory Committee (PBAC).
Access to a number of new medicines has been announced. The new and amended medicine listings are clearly funded through savings in PBS expenditure from greater use of generic and bio-similar medicines, given the net increase in expenditure over the five year outlook is around A$0.7 billion.
In terms of medical research, there is an encouraging announcement of significant further investments through the Medical Research Futures Fund. This will be welcomed by health and medical researchers across Australia.
What is notable is the focus on the capacity of health and medical research to generate new jobs through new technology. While this is certainly important, it is as much about boosting the local medical technology and innovation industry than on improving health system performance. And the announcements in the budget are as much about the potential job growth from medical innovation as on providing more or improved health services.
There is new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs. The focus on a 21st century medical industry plan recognises that health is big business as well as being important for all Australians.
All of this is welcome, but it will be absolutely critical that there are rigorous processes for evaluating this research and ensuring the funding is allocated based on scientific merit. This can represent a major challenge when industry development objectives are given similar standing in determining priorities as health outcomes and scientific quality.
Andrew Wilson, Co-Director, Menzies Centre for Health Policy at the University of Sydney
Rural Australians experience a range of health disadvantages including higher rates of smoking and obesity, poorer survival rates from cancer and lower life expectancy, and this is not solely due to the poor health of the Aboriginal community.
The government has committed to improving rural health services through the Stronger Rural Health Strategy and the budget has some funding to underpin this.
The pressure to fund another medical school in rural NSW and Victoria has been sensibly addressed by enhancing and networking existing rural clinical schools through the Murray Darling Medical Schools network. This will provide more opportunities for all medical students to spend a large proportion of their studentship in a rural setting while not increasing the number of Commonwealth supported places.
There is a major need to match this increased student capacity with a greater investment in specialist training positions in regional hospitals to ensure the retention of that workforce in country areas. Hopefully the new workforce incentive program will start to address this.
Hospitals and private health insurance
Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University
Although the National Disability Insurance Scheme (NDIS) is relatively young, there has been much debate over how it will be funded.
Treasurer Scott Morrison recently said Labor had left a A$57 billion shortfall in funding for the NDIS. So many were left scratching their heads at the announcement that next year’s proposed increase in the Medicare levy – which was supposed to cover some of this shortfall – would be scrapped.
So how much does, and will, the scheme actually cost? Who is supposed to pay for it and why is there debate over the funding?
Calculating the costs
These are difficult questions to answer because we lack high-quality data about the extent and nature of disability in Australia. The information we do have is based on predictions, and work is underway to check these are accurate.
The case for creating an NDIS was made by the Productivity Commission in its 2011 inquiry on Disability Care and Support. The commission recommended Australia’s system of inequitable, fragmented and inefficient disability services be replaced by a new national scheme that would provide insurance cover to all Australians in the event of significant disability.
The one thing all sides of politics agree on is the NDIS represents a significant increase in disability spending, which stood at around A$8 billion per year at the time of the initial Productivity Commission report.
Original estimates suggested the NDIS would cover 411,000 participants and cost A$13.6 billion at maturity. However the Productivity Commission now estimates that around 475,000 people with disability will receive individualised support at a cost of around A$22 billion per year.
The A$8.9 billion difference between the Productivity Commission’s original estimates and the current estimate is a substantial gap. But A$6.4 billion of this difference is due to pay rises awarded to social and community services employees.
The remainder is due to the growth in the population and also the inclusion of participants over 65 years who were not included in original estimates. Once we account for these, estimates are fairly close to those originally predicted.
Last year’s Productivity Commission review of costs found the NDIS was broadly coming in on budget. Greater-than-expected numbers of children with autism and intellectual disability were accessing the scheme, but not all those with an individualised plans were able to spend their budgets.
So, for now, the NDIS seems to be tracking as intended. The NDIS budget is estimated to gradually increase over time to 1.3% of GDP by 2044-45 as participants age. Estimates also suggest the scheme will produce benefits adding around 1% to the GDP.
Where the money comes from
The original Productivity Commission report suggested the federal government be the single funder of the NDIS and that revenue to support the NDIS be paid into a separate fund (the National Disability Insurance Premium Fund) to provide stable funding for the scheme.
The Productivity Commission suggested this approach because disability services have long been subject to debate about who should bear the costs of these services: the Commonwealth or the states and territories. Indeed, part of the reason for the NDIS was to guarantee funding for disability services and stop these debates and blame-shifting.
The way the NDIS is funded is complex, with revenue coming from a number of sources. The NDIS is funded via a pooled approach from Commonwealth and state and territory governments. The Commonwealth provides just over half of the funding for the NDIS and the rest comes from state and territories. This arrangement is governed by a number of bilateral agreements that are revisited every five years.
At the creation of the scheme, all existing money spent by various governments was directed into the NDIS to cover costs. Then, in July 2014 we saw a first increase in the Medicare levy: from 1.5% to 2% of taxable income.
Any additional funding the NDIS needs has to come from general budget revenue or borrowings.
The NDIS Savings Fund Special Account was established to collect the Commonwealth’s contribution to the scheme. This fund pools underspends or savings from across government, protecting these as a forward contribution to the scheme as it grows over future budgets.
When the Labor government originally introduced the NDIS, it said it would fund the scheme through an increase in the Medicare levy, reforms to private health insurance and retirement incomes, and a range of “selected long-term savings” including an increase in tobacco excise and changes to fringe benefits tax rules.
Labor said the combination of these revenue streams would ensure the NDIS was fully funded to 2023. But many of the savings Labor promised were intentional, rather than set in stone, and were not dedicated to the NDIS as the Medicare levy was.
It’s estimated the Commonwealth will contribute around A$11.2 billion to the NDIS in 2019. Of this, around A$6.8 billion will come from the redirection of existing disability funds and the Commonwealth’s share of the DisabilityCare Australia Fund.
This leaves an annual funding gap of around A$4 billion once the scheme becomes fully operational, accumulating to around A$56 billion by 2028.
The Commonwealth announced it would increase the Medicare levy from 2% to 2.5% of taxable income from July 2019 as a way of filling the funding gap. Estimates predicted this would raise an additional A$8 billion in revenue over its first two years.
The bill needed to do this had stalled in the Senate, with Labor and the Greens opposed. They suggested the increase should only be applied to those in higher income tax brackets.
Last week the Treasurer announced tax receipts were running A$4.8 billon higher than was estimated in December, meaning the levy was no longer needed.
For now it looks like funding for the NDIS is assured, but many within the disability community have expressed concern this does not assure funding for the long term and uncertainty may continue to prevail.
Tonight’s ABC Four Corners program investigates the influence of the sugar industry on global policy efforts to curtail the rise of obesity. This includes the industry’s involvement in thwarting implementation of a sugar tax, and in watering down Australia’s now largely ineffective health star rating system.
Called Tipping the Scales, the program will highlight some of the tactics the industry employs. The ABC reports companies such as Coca-Cola, Pepsico, Unilever, Nestle and Kelloggs “have a seat at the table setting the policies that shape consumption of their own sugar-laced products”.
A public health advocate is quoted as saying:
The reality is that industry is, by and large, making most of the policy. Public health is brought in so that we can have the least worse solution.
The Conversation’s experts in health policy and economics have weighed into this debate over the years. Here’s our pick of five analysis pieces that will get you informed before tonight’s program.
1. How industry influences research
The sugar industry hasn’t only had its finger in the policy pie, it has also pulled some strings behind the scenes of scientific research into sugar’s health effects.
A study published in the Journal of the American Medical Association in November 2016 revealed that, in the 1960s, the sugar industry paid scientists at Harvard University to minimise the link between sugar and heart disease. The paper’s authors suggested the sugar industry may largely have shaped many of today’s dietary recommendations. And some experts have since questioned whether such misinformation may have led to today’s obesity crisis.
In an essay on health, the University of Sydney’s Professor Lisa Bero – an internationally renowned expert in the integrity of scientific research and its use in policy-making – has outlined how food companies can sneak bias into scientific research:
Pharmaceutical, tobacco or chemical industry funding of research biases human studies towards outcomes favourable to the sponsor…
A 2007 paper that compared over 500 studies found those funded by pharmaceutical companies were half as likely to report negative effects of corticosteroid drugs (used to treat allergies and asthma) as those not funded by pharmaceutical companies.
The ABC’s Four Corners team interviews the Obesity Policy Coalition’s executive manager, Jane Martin, who is frustrated that industry lobbying has scuttled efforts to make the health star system mandatory.
The health star rating system was introduced in June 2014. It’s a front-of-pack labelling system that rates the nutritional profile of packaged food and assigns it a rating from ½ a star to 5 stars. The more stars, the healthier the choice.
As Deakin University’s public health and nutrition professor, Mark Lawrence, and Curtin University’s public health research fellow, Christina Pollard, explained:
The system is supposed to help consumers discriminate between similar foods within the same food category that contain different amounts of undesirable ingredients. It should, for instance, help compare two loaves of bread in terms of their salt content …
Writing a year after the rating system’s implementation, the authors note the flaws in the policy. The main flaw is its voluntary nature, which can lead to manufacturers putting labels on only those foods that will get a high rating:
While manufacturers might be happy to display stars on foods that attract between two and five stars, they are less likely to put one or half a star on their products.
Since Mexico introduced a sugar tax in 2014, nearly 30 countries have gone on to do the same. Last month the UK introduced a levy that manufacturers must pay for their high-sugar products.
Companies will have to pay 18 pence per litre on drinks with more than 5g of sugar per 100g. Drinks with more than 8g per 100ml will face a tax rate equivalent to 24p per litre.
But the ABC reports efforts to introduce such a policy in Australia have failed, due to the lobbying efforts of the Beverages Council.
The evidence for sugar’s negative effects on our health is well known. A study published in the journal PLOS ONE in April 2016 showed a tax on sugary drinks in Australia would prevent 4,000 heart attacks and 1,100 strokes.
The researchers examined the potential impact of a 20% rise in the prices of sugar-sweetened carbonated soft drinks and flavoured mineral waters on health, healthcare expenditure and revenue.
Writing for The Conversation, the study’s authors note:
As expected, the tax would result in people decreasing their consumption of sugary drinks. The influence of a price increase would be greatest on those who drink a lot of sugary drinks, so the greatest impact would be on younger age groups. This is an important result that is difficult to achieve through other obesity-prevention measures.
The UK’s Treasury is estimating the sugar tax will raise £240 million per year. Modelling done in Australia by the Grattan Institute shows that a tax of 40 cents per 100 grams of sugar could raise about A$400-$500 million per year.
The Institute’s Stephen Duckett and Trent Wiltshire write that the sugar industry’s concerns over the tax are overblown. They say:
A sugar-sweetened beverages tax will reduce domestic demand for Australian sugar by around 50,000 tonnes, which is only about 1% of all the sugar produced in Australia. And, while there may be some transition costs, this sugar could instead be sold overseas (as 80% of Australia’s sugar production already is).
And finally, if you’re wondering how much sugar you can eat to stay healthy, here’s an article written by Flinders University nutrition lecturers Kacie Dickinson and Louise Matwiejczyk that explains exactly that.
If you’re an average-sized adult eating and drinking enough to maintain a healthy body weight (roughly 8,700 kilojoules per day), 10% of your total energy intake from free sugar roughly translates to no more than 54 grams, or around 12 teaspoons, per day.
A 600ml bottle of Coke contains more than 14 teaspoons of sugar.
The government is scrapping its $A8.2 billion planned increase in the Medicare levy, declaring a stronger budget outlook means it is not needed to fund the National Disability Insurance Scheme.
The levy, the biggest new revenue measure in last year’s budget, had no foreseeable prospect of passing the Senate in full, because Labor only supported a rise for those with incomes of more than $87,000.
Abandoning the measure will give more credibility to the budget numbers, which will be carefully scrutinised by the credit-rating agencies, and enable the government to sharpen its differences with Labor in the election battle on tax.
The increase in the levy – which would have taken it from 2% to 2.5% of taxable income – was due to start from July 1 next year. The $8.2 billion revenue was over the forward estimates.
The budget will include income tax cuts. But while it kept the levy rise on the books the government faced the criticism that it would be giving with one hand and taking with the other.
Treasurer Scott Morrison will say in a speech on Thursday that with a stronger economy, the fiscal position has improved compared with a year ago.
“That is why we are now in a position to give our guarantee to Australians living with a disability and their families and carers that all planned expenditure on the NDIS will be able to be met in this year’s budget and beyond without any longer having to increase the Medicare levy,” he will tell an Australian Business Economists function.
The government has not abandoned its argument that Labor left a gap in the funding of the NDIS – which the ALP flatly denies. Morrison will stress: “What I am announcing today is that gap can now be made up over time by continuing to deliver a stronger economy and by ensuring the government lives within its means”.
In an upbeat address just under two weeks out from the May 8 budget, Morrison will say that the economy “is finally shaking off the dulling effects of the downturn in the mining investment boom.”
“Naturally, a stronger economy provides for a stronger budget.”
He will say that company profits were “savaged” in the long come-down from the mining investment boom. This took a heavy toll including on government revenues.
“During this time, businesses put their hands in their own pockets to keep their employees in jobs and provide the modest wage increases they could.
“Since then, the clouds have been lifting. The tangible evidence of this is found in the increased tax receipts to the Commonwealth.
“Tax receipts up until February were running $4.8 billion higher than we estimated at MYEFO in December, including $1.2 billion in higher individual tax receipts and $3 billion in higher company tax receipts.”
Morrison will also emphasise the government’s action in controlling spending, and point out that it has not relied on commodity price assumptions to prop up the budget.
Outlining some themes for the budget, Morrison will say it will see the government “living within its means”. It will continue to give priority to strengthening the economy, and that will “enable us to shore up the nation’s finances and guarantee the essential services that Australians rely on both now and into the future.
“Only a stronger economy, backed up by a government that knows how to live within its means, can provide a real guarantee on these essential services – Medicare, schools, hospitals, aged care and disability services.”
Morrison will say Labor’s proposal to raise the Medicare levy for those earning more than $87,000 and to increase the top marginal tax rate were not to fund the NDIS, but “just another tax increase on working Australians”.
“This is in addition to Labor already boasting of and getting ready to hike more than $200 billion in additional new taxes on Australians if they win power.
“Taxes on small businesses, taxes on retirees and pensioners, taxes on family trusts, taxes on mums and dads who negatively gear their investment properties and taxes on workers.
He will say Labor plans for higher taxes will weaken the economy, ”‘putting at risk the benefits, the jobs, the wages, the incomes and the essential services that depend on a stronger economy. And we all know Labor can never live within their means”.
Labor is now expected to abandon its commitment to a rise in the levy for higher income earners.
The way cities are designed and managed has big impacts on our health. While Australia is considered a world leader in research on health and cities, nationally our planning policies remain underdeveloped relative to our knowledge base. To remedy this, healthy planning advocates need to better understand how urban planning systems can be influenced.
Several recent, mostly positive, experiences in the New South Wales (NSW) planning system provide insights into this process. Each represents a milestone for land-use planning in this state given extensive reforms have been on and off the table for the past decade.
The connections between city planning and health are many and varied. Key aspects include environmental sustainability, pollution risks and liveable places. Being liveable means having access to healthy food, nearby employment and services, and opportunities for active lifestyles.
These issues are increasingly important given projected population growth pressures on urban infrastructure. Other areas facing similar pressures, in Australia and overseas, might wish to take note of what has happened in NSW.
Healthy planning has always had champions in NSW, but really hit its stride during a major legislative reform exercise that began in 2011. This came to a head in November 2017, when the state parliament passed amendments to the Environmental Planning and Assessment Act 1979.
This legislation now lists two objects of direct importance for health:
protection of the health and safety of occupants of buildings
promotion of good design and amenity of the built environment.
Also in 2017, the NSW Office of the Government Architect produced a policy of “design-led planning”. Known as “Better Placed”, this policy positions health as a top priority. It embeds health within design processes, methods and outcomes for different levels of planning from cities and towns to places and buildings.
In our view, Better Placed is an exemplary policy in demonstrating the importance of urban planning for health.
In another positive development, the Greater Sydney Commission recently released Metropolitan and District Plans that position health as a core objective (number 7). The plans consistently refer to health across the central themes of liveability, productivity and sustainability.
To their credit, the NSW government and the commission have developed plans concurrently with transport and infrastructure and released them together. The evidence suggests this integration should have public health benefits. The emphasis across the commission, transport and infrastructure plans on creating a liveable and accessible city increases our confidence in this outcome.
Our research suggests three crucial factors in elevating the status of health in planning.
1. A core group of non-government, government and academic representatives has led health advocacy for over a decade. The group’s messages and activities intentionally focused on collaboration across agencies in the public interest.
This advocacy has grown in sophistication since the early days of making submissions about “health” issues that risked being treated as peripheral to the main game of planning (infrastructure, for instance).
Within government, NSW Health (both state and local departments) has developed an increasingly effective response to urban planning opportunities for promoting and protecting health.
2. The previous minister for planning (Rob Stokes), the Office of the Government Architect and the Greater Sydney Commission have each provided vital policy mechanisms for including health. This illustrates the importance of particular agents in the right place at the right time.
The minister was essential in establishing the commission. This effectively created a respectful distance between strategic planning and the “economics trumps all” planning agenda seen in some policy environments.
The “design-led planning” emphasis came about when Stokes was planning minister. The starring role given to health in Better Placed gives healthy planning advocates, for the time being, unprecedented opportunity to influence strategies and plans.
3. Delivery now requires close attention, as these positive shifts alone have limited power. For instance, the commission’s plans emphasise collaborative infrastructure delivery to create an equitable city. Infrastructure has profound health impacts, costs and benefits.
Shifting infrastructure funding to benefit the city’s West will be the core fault line for delivering on promises of equitable infrastructure provision. However, infrastructure project funding and appraisal are crying out for reform. Better indicators, transparent analyses to inform options, improved governance arrangements and greater accountability have all been identified as required reforms.
The NSW planning system has begun to recognise the importance of urban planning for health. These developments present a tremendous opportunity to influence how healthy public policy can be delivered for the benefit of the whole city.
According to the proposal, the government agency would licence, monitor and regulate production and sale, and regularly review the regulations. The agency would be the sole wholesaler, buying from producers and selling to retailers it licences.
The proposed policy includes some safeguards that reflect lessons we’ve learned from alcohol and tobacco. These include a ban on advertising, age restrictions, requiring plain packaging, and strict licensing controls. Under the proposal, tax revenues would be used to improve funding to the prevention and treatment sector, which is underfunded compared to law enforcement.
In Australia, cannabis possession and use is currently illegal. But in several states and territories (South Australia, ACT and Northern Territory) a small amount for personal use is decriminalised. That means it’s illegal, but not a criminal offence. In all others it’s subject to discretionary or mandatory diversion usually by police (referred to as “depenalisation”).
In a recent opinion poll, around 30% of Australians thought cannabis should be legal. Teenagers 14-17 years old were least likely to support legalistaion (21% of that age group) and 18-24 year olds were most likely to support it (36% of that age group).
Opponents of legalisation are concerned it will increase use, increase crime, increase risk of car accidents, and reduce public health – including mental health. Many are concerned cannabis is a “gateway” drug.
The “gateway drug” hypothesis was discounted decades ago. Although cannabis usually comes before other illegal drug use, the majority of people who use cannabis do not go on to use other drugs. In addition, alcohol and tobacco usually precede cannabis use, which if the theory were correct would make those drugs the “gateway”.
There is also no evidence legalisation increases use. But, studies have shown a number of health risks, including:
around 10% of adults and one in six teens who use regularly will become dependent
regular cannabis use doubles the risk of psychotic symptoms and schizophrenia
teen cannabis use is associated with poorer school outcomes but causation has not been established
driving under the influence of cannabis doubles the risk of a car crash
smoking while pregnant affects a baby’s birth weight.
What are the arguments for legalisation?
Australia’s official drug strategy is based on a platform of harm minimisation, including supply reduction, demand reduction (prevention and treatment) and harm reduction. Arguably, policies should therefore have a net reduction in harm.
But some of the major harms from using illicit drugs are precisely because they are illegal. A significant harm is having a criminal record for possessing drugs that are for personal use. This can negatively impact a person’s future, including careers and travel. Decriminalisation of cannabis would also reduce these harms without requiring full legalisation.
Reducing crime and social costs
A large proportion of the work of the justice system (police, courts and prisons) is spent on drug-related offences. Yet, as Mick Palmer, former AFP Commissioner, notes “drug law enforcement has had little impact on the Australian drug market”.
Decriminalisation may reduce the burden on the justice system, but probably not as much as full legalisation because police and court resources would still be used for cautioning, issuing fines, or diversion to education or treatment. Decriminalisation and legalistaion both potentially reduce the involvement of the justice system and also of the black market growing and selling of cannabis.
Economic analysis of the impact of cannabis legalisation calculate the net social benefit of legalisation at A$727.5 million per year. This is significantly higher than the status quo at around A$295 million (for example from fines generating revenue, as well as perceived benefits of criminalisation deterring use). The Parliamentary Budget Office estimates tax revenue from cannabis legalisation at around A$259 million.
Many see cannabis prohibition as an infringement on civil rights, citing the limited harms associated with cannabis use. This includes the relatively low rate of dependence and very low likelihood of overdosing on cannabis, as well as the low risk of harms to people using or others.
Many activities that are legal are potentially harmful: driving a car, drinking alcohol, bungee jumping. Rather than making them illegal, there are guidelines, laws and education to make them safer that creates a balance between civil liberties and safety.
What has happened in places where cannabis is legal?
Legalisation of cannabis is relatively recent in most jurisdictions so the long-term benefits or problems of legalisation are not yet known.
But one study found little effect of legalisation on drug use or other outcomes, providing support for neither opponents nor advocates of legalisation. Other studies have shown no increase in use, even among teens.
The research to date suggests there is no significant increase (or decrease) in use or other outcomes where cannabis legalisation has occurred. It’s possible the harm may shift, for example from legal harms to other types of harms. We don’t have data to support or dispel that possibility.
As winter draws closer, many Australians are wondering whether this year’s influenza season will be as bad as the last, and whether they should get vaccinated.
For most of us, influenza (the flu) is a mild illness, causing fever, chills, a cough, sore throat and body aches, that lasts several days. But some people – especially the elderly, young children and those with chronic diseases – are at risk of serious and potentially deadly complications.
While not perfect, the seasonal influenza vaccine is the best way to protect against influenza viruses. It’s free for at-risk groups, and available to others for around A$10–A$25 (plus a consultation fee if your GP doesn’t bulk bill). In some states people can also get influenza vaccines from pharmacies.
There are four influenza viruses that cause epidemics: two type A viruses, called A/H1N1 and A/H3N2 and two type B influenza viruses, called B/Yamagata and B/Victoria viruses. All four cause a similar illness called influenza.
In any season, one of the viruses may dominate, or two or even three viruses could circulate.
Last year’s influenza seasons in Australia and the United States were caused by A/H3N2, while B/Yamagata viruses predominated in Asia, and a mix occurred in Europe.
Influenza A/H3N2 viruses cause more severe epidemics that affect the entire population, from the very young to the very old.
In contrast, influenza B and A/H1N1 viruses tend to cause disease in children and young adults, respectively, sparing the elderly.
Developing the vaccine
Although influenza activity around the world is monitored throughout the year, influenza viruses mutate continuously and we can’t predict which virus will dominate. For this reason, the influenza vaccine includes components that are updated to protect against all four influenza A and B viruses.
Vaccination is the best option to prevent influenza and is offered in the autumn, in anticipation of influenza season in the winter. Typically, the influenza season begins in June, peaks by September and can last until November.
It takes about two weeks for the vaccine to induce immunity and the resulting protection lasts about six months.
The 2017 influenza season was severe in all states except WA. The epidemic began earlier than usual, there were more reported cases than in previous years, and there were a large number of outbreaks in residential care facilities in several jurisdictions.
This is important because children are prone to severe illness and they spread the virus to their contacts, at home and in daycare. Previously, only WA offered children the influenza vaccine free of charge.
The second change is “enhanced” vaccines are available for adults over the age of 65. The standard influenza vaccine is not optimally effective in older adults.
Two products have been developed to improve the immunity offered by the vaccine: one is a high-dose vaccine four times the strength of the standard vaccine and the second is an “adjuvanted” vaccine, that contains an additive that boosts the immune response to the vaccine.
These vaccines have been available in other countries for many years but are being introduced in Australia for the first time in 2018. Older adults will be offered one of the two enhanced vaccines for free.
What happens if you still get influenza?
Even if you’re vaccinated, you can still get influenza.
The effectiveness of the seasonal influenza vaccine varies and is usually around 40-50%. But last year’s vaccine was only around 33% effective overall, because it was not effective against the A/H3N2 virus though it was effective against the A/H1N1 and influenza B viruses.
While vaccines are given ahead of time to prevent influenza, antiviral drugs are available via GP prescription for people who get infected.
The antiviral drugs for influenza are most effective when taken within two days of illness and are only effective against influenza viruses. But they’re not effective against other respiratory viruses that cause colds and respiratory symptoms.
Influenza is a contagious virus that spreads through contact with respiratory secretions that are airborne (such as coughs and sneezes) or that contaminate surfaces (after wiping a runny nose, for instance). If you have influenza, stay home to avoid spreading the virus.
Unfortunately, we can’t predict whether the 2018 influenza season will be mild or severe. Once we know which virus or viruses are circulating, we may be in a better position to predict how severe the season will be for older adults.
With each new version of the widely-used manual of mental disorders, the number of mental health conditions increases. The latest version (DSM-5) lists around 300 disorders. To complicate things, many share common features, such as depression and anxiety.
The manual is a useful guide for doctors and researchers, but making a diagnosis is not a precise science. So if the “experts” are still debating what’s what when it comes to categorising disorders, it’s not surprising misconceptions abound in the community about certain mental health conditions.
We learn about mental health conditions in a number of ways. Either we know someone who has experienced it, we’ve experienced it ourselves, read about it or seen something on TV. Movies and TV series commonly portray people with mental illness as dangerous, scary and unpredictable. The most popular (mis)representations are of characters with multiple personalities, personality disorders, schizophrenia and bipolar disorder.
While the media is an important source of information about mental illness, it can misinform the public if reported inaccurately, promoting stigma and perpetuating myths. And research shows negative images of mental illness in the media (fictional and non-fictional) results in negative and inaccurate beliefs about mental illness.
Dissociative identity disorder
“Multiple personality disorder” or “split personality disorder” are colloquial terms for dissociative identity disorder. Despite being colloquially named a personality disorder, it’s actually a dissociative disorder.
A personality disorder is a long-term way of thinking, feeling and behaving that deviates from the expectations of culture. Whereas in dissociative identity disorder, at least two alternate personalities (alters) routinely take control of the individual’s behaviour. The individual is usually unable to remember what happened when an alter takes over: there are noticeble gaps in their memory, which can be extremely distressing.
The popular TV series “The United States of Tara” actually does a pretty good job of portraying dissociative identity disorder. The main character has a series of alters and experiences recurrent gaps in her memory.
While it used to be considered rare, dissociative identity disorder is estimated to affect 1% of the general population, and is typically related to early trauma (such as childhood abuse). People commonly confuse dissociative identity disorder with schizophrenia. Unlike schizophrenia, the individual is not imagining external voices or experiencing visual hallucinations: one personality literally “checks out” and another appears in their place.
Borderline personality disorder
Borderline personality disorder is often misconstrued. People with this condition are often portrayed as manipulative, destructive and violent. In reality, these behaviours are driven by emotional pain: the person has never learned to ask effectively for what they need or want.
It is also often assumed “borderline” means the person almost has a personality disorder. The term “borderline” here creates some confusion. First introduced in the United States in 1938, the term was used by psychiatrists to describe patients who were thought to be on the “border” between diagnoses (mostly psychosis and neurosis). The term “borderline” has stuck in the diagnosis, but there is now a much better understanding of the causes, symptoms and treatment.
Those with borderline personality disorder have difficulties regulating their emotions. This contributes to angry outbursts, anxiety and depression, and relationships fraught with difficulties. It’s also commonly associated with trauma (such as childhood abuse or neglect).
Many actions of a person with borderline personality disorder (such as self-harm and overdose) are done out of desperation in an attempt to manage difficult and intense emotions.
While borderline personality disorder and bipolar disorder can look similar (mood problems, impulsive behaviour and suicidal thinking), there are several key differences.
Bipolar disorder is characterised by extreme mood swings – from severe lows (depression) to periods of high activity, energy and euphoria. The different mood states can seem like a personality change, but a return to the “usual self” occurs once mood stabilises.
While depression is part of borderline personality disorder and bipolar disorder, those with bipolar disorder experience significant “up” mood swings. This is known as mania in bipolar I disorder and hypomania (less intense mania) in bipolar II disorder.
Bipolar mood episodes last longer (four days or longer for “ups” and two weeks or longer for “downs”), with periods of wellness in between, and are less likely to be triggered by external events. And bipolar disorder is more likely to run in families, disrupt sleep patterns, and psychotic symptoms (delusions, hallucinations) can occur during mood episodes.
We all have ups and downs, but bipolar disorder is much more than that with extreme, recurrent mood episodes that are not only distressing, but have a significant long-term impact on key areas of a persons’s life. Positively, with the right treatment, good quality of life is entirely possible despite ongoing symptoms.
Schizophrenia, meaning “split mind” in Greek, is often confused with dissociative identity disorder. However, the “split” refers not to multiple personalities, but to a “split” from reality. People with schizophrenia may find it difficult to discern whether their perceptions, thoughts, and emotions are based in reality or not.
Hearing voices (auditory hallucinations) is a common symptom, along with seeing, smelling, feeling, or tasting things others can’t. Unusual beliefs (delusions), including some that cannot possibly be true (such as a belief that one has special powers) are also common. So too is disordered thinking, where the person jumps from one topic to another at random, or makes strange associations to things that don’t make sense. They may also exhibit bizarre behaviour including socially inappropriate outbursts or wearing odd clothing that is inappropriate to the circumstances.
Other symptoms of schizophrenia look a lot like depression, such as an inability to experience pleasure, social withdrawal and low motivation. Depressive symptoms are also present in schizophrenia, but are slightly different in that emotion is diminished altogether, rather than a depressed mood per se.
Mental health conditions don’t come in neat packages
Unlike physical conditions, we don’t have a biological test that can magically tell us what mental condition we’re dealing with. Mental health practitioners are carefully trained to observe symptom patterns: the right diagnosis guides the appropriate treatment.
For example, first-line treatment of schizophrenia and bipolar disorder often focuses on medication. While dissociative identity disorder and borderline personality disorders are treated primarily with psychological therapy.
Mental health conditions are serious – whether disorders of personality, mood or somewhere in between. Improved understanding and balanced representation of these conditions is needed to shift stigmas and misconceptions in the community.