A recent article in The Conversation questioned whether we should all get flu vaccinations, given 99 people would have to go through vaccination for one case of flu to be prevented.
But this position ignores the purpose of immunisation programs: whole populations of people need to take part for just a small number to benefit. So how do we decide what’s worth it and what’s not?
Decision-making in public health
When we consider a treatment for a patient, such as antibiotics for an infection, we first consider the evidence on the benefits and potential harms of treatment. Ideally, this is based on clinical trials, where we assume the proportion of people in the trial who respond represents the chance an individual patient will respond to treatment.
This evidence is then weighed up with the individual patient. What are the treatment options? What do they prefer? Are there factors that might make this patient more likely to respond or have side effects? Is there a treatment alternative they would be more likely to take?
In public health, the framework is the same but the “patient” is different – we are delivering an intervention for a whole population or group rather than a single individual.
We first consider the efficacy of the intervention as demonstrated in clinical trials or other types of studies. We then look at which groups in the population might benefit the most (such as the zoster vaccine, given routinely to adults over 70 years as this group has a high rate of shingles), and for whom the harms will be the least (such as the rotavirus vaccine, which is given before the age of six months to reduce the risk of intussusception, a serious bowel complication).
Compared to many other public health programs, immunisation is a targeted intervention and clinical trials tell us they work. But programs still need to target broad groups, defined by age or other broad risk factors, such as chronic medical conditions or pregnancy.
Explainer: what is herd immunity?
Risks and benefits of interventions
When considering vaccination programs, safety is very important, as a vaccine is being given to a generally healthy population to prevent a disease that may be uncommon, even if serious.
For example, the lifetime risk of cervical cancer is one in 166 women, meaning one woman in 166 is diagnosed with this cancer. So even if the human papillomavirus (HPV) vaccine was completely effective at preventing cancer, 165 of 166 women vaccinated would not benefit. Clearly, if we could work out who that one woman was who would get cancer, we could just vaccinate her, but unfortunately we can’t.
It’s only acceptable to vaccinate large groups if clinically important side effects are low. For the HPV vaccine, anaphylaxis (a serious allergic reaction) has been reported, but occurs at a rate of approximately one in 380,000 doses.
An even more extreme case is meningococcal vaccination. Before vaccination, the incidence of meningococcal serogroup C (a particular type of this bacterium) infection in children aged one to four years old was around 2.5 per 100,000 children, or 7.5 cases for 100,000 children over three years.
Vaccination has almost eliminated infection with this strain (although other serotypes still cause meningococcal disease). But this means 13,332 of 13,333 children didn’t benefit from vaccination. Again, this is only acceptable if the rate of important side effects is low. Studies in the US have not found any significant side effects following routine use of meningococcal vaccines.
This is not to say there are no side effects from vaccines, but that the potential side effects of vaccines need to be weighed up against the benefit.
For example, Guillain Barre syndrome is a serious neurological complication of influenza vaccination as well as a number of different infections.
But studies have estimated the risk of this complication as being around one per million vaccination doses, which is much smaller than the risk of Guillain Barre syndrome following influenza infection (roughly one in 60,000 infections). And that’s before taking into account the benefit of preventing other complications of influenza.
What other factors need to be considered?
We also need to consider access, uptake and how a health intervention will be delivered, whether through general practices, council programs, pharmacies or school-based programs.
Equity issues must also be kept in mind: will this close the gap in Indigenous health or other disadvantaged populations? Will immunisation benefit more than the individual? What is the likely future incidence (the “epidemic curve”) of the infection in the absence of vaccination?
A current example is meningococcal W disease, which is a new strain of this bacteria in Australia. Although this currently affects individuals in all age groups, many state governments have implemented vaccination programs in adolescents.
This is because young adults in their late teens and early 20s carry the bacteria more than any other group, so vaccinating them will reduce transmission of this strain more generally.
But it’s difficult to get large cohorts of this age group together to deliver the vaccine. It’s much easier if the program targets slightly younger children who are still at school (who, of course, will soon enter the higher risk age group).
In rolling out this vaccine program, even factors such as the size of schools (it is easier to vaccinate children at high schools rather than primary schools, as they are larger), the timing of exams, holidays and religious considerations (such as Ramadan) are also taken into account.
For government, cost effectiveness is an important consideration when making decisions on the use of taxpayer dollars. This has been an issue when considering meningococcal B vaccine. As this is a relatively expensive vaccine, the Pharmaceutical Benefits Advisory Committee has found this not to be cost effective.
This is not to say that meningococcal B disease isn’t serious, or that the vaccine isn’t effective. It’s simply that the cost of the vaccine is so high, it’s felt there are better uses for the funding that could save lives elsewhere.
While this might seem to be a rather hard-headed decision, this approach frees up funding for other interventions such as expensive cancer treatments, primary care programs or other public health interventions.
Why is this important?
When we treat a disease, we expect most people will benefit from the treatment. As an example, without antibiotics, the death rate of pneumonia was more than 80%; with antibiotics, less than 20%.
However, vaccination programs aim to prevent disease in whole populations. So even if it seems as though many people are having to take part to prevent disease in a small proportion, this small proportion may represent hundreds or thousands of cases of disease in the community.
Winter has started, and with it, flu season. Inevitably, all of us (young, old and sick) have been implored to be immunised against influenza, with some eligible for a subsidised vaccine. And people are heeding the message, to the point that there is now a shortage of available vaccines.
At the same time, findings from three important Cochrane reviews on the effectiveness of the influenza vaccination aren’t consistent with the advice we’re been given.
Cochrane reviews are independent systematic reviews, which are comprehensive analyses of most of the literature relevant to a research topic. Cochrane reviews summarise the results in a multitude of studies, and are regularly updated to absorb new research.
These three Cochrane reviews have been recently updated, as well as stabilised, which is what happens when it looks as if it seems unlikely new research would be published that would change the conclusions.
What the reviews found
The first Cochrane review looked at the effects of the influenza vaccine in healthy adults from 25 studies conducted over single influenza seasons in North America, South America, and Europe between 1969 and 2009. It found the vaccine reduced the chance of getting laboratory confirmed influenza from 23 cases out of 1,000 to 9 cases out of 1,000.
While this seems to be a reduction of more than 50%, that seems less optimistic expressed in absolute terms.
The infection rate in adults drops from 2% per year to 1%. You could say that’s halved, but it effectively only drops by 1%. So this means that out of every 100 healthy adults vaccinated, 99 get no benefit against laboratory confirmed influenza.
The second Cochrane review – which looked at trials in children over single influenza seasons in the US, Western Europe, Russia, and Bangladesh between 1984 and 2013 – found similar results.
The third Cochrane review looked at vaccines for the elderly in nursing homes. It found much less good evidence, with only one randomised trial – considered the gold standard in clinical trials as it establishes causation rather than correlation.
There are also potential harms from influenza vaccines noted in the reviews. They range from serious (a neurological disease called Guillain Barre) through to moderate (fevers, in children especially – some of which will cause febrile convulsions), and trivial (a sore arm for a couple of days).
Why are we so scared of the flu?
There is a special concern about influenza from a public health point of view. This comes about from its potential to cause pandemics. The first in modern history was the Spanish influenza pandemic of 1918-19, when tens of millions of people died worldwide.
There have also been been several, less severe pandemics. These include the most recent swine flu that, although while affecting some (unexpected) groups of people (including pregnant women, those who were obese, and had asthma), caused little more effect on the overall population than the usual seasonal influenza.
Public health experts worry about another pandemic that can be more harmful and contagious, which could be devastating. But it’s important to note the vast majority of deaths from Spanish influenza were from secondary bacterial infections and predated the antibiotic era.
The reasons influenza virus has this ability to cause new pandemics comes from its instability – it changes genetically easily, making it more difficult for our immune systems to recognise newer strains. The effect is that new vaccines must be prepared every year for a best-guess at next year’s virus, and we need vaccination every year.
Influenza can also undergo a more radical change, such as when a new form of the virus emerges from an animal host (wild or domesticated birds or pigs, for example). This moving target makes it more difficult to vaccinate against – especially with the genetic shifts of pandemics. Just when we need protection most, vaccines can provide it least.
So what, if not the vaccine?
There are physical barriers that can prevent the spread of influenza. These are the masks (to reduce the spread of aerosol-borne virus particles), hand washing (to reduce the spread if virus from hands onto shared surfaces), and quarantine measures (isolating infected people to reduce their infectivity).
There is now reasonable evidence such measures reduce infections considerably. It might take a bit of effort to change the psyche of Australians to make wearing a facemask acceptable if you have an acute respiratory infection. Even the heroic “soldiering on to work” (or school) with your virus needs to be reversed as a public health act.
Some of us like to stroll along and smell the roses, while others march to their destination as quickly as their feet will carry them. A new study out today has found those who report faster walking have lower risk of premature death.
We studied just over 50,000 walkers over 30 years of age who lived in Britain between 1994 and 2008. We collected data on these walkers, including how quickly they think they walk, and we then looked at their health outcomes (after controlling to make sure the results weren’t due to poor health or other habits such as smoking and exercise).
We found any pace above slow reduced the risk of dying from cardiovascular disease, such as heart disease or stroke. Compared to slow walkers, average pace walkers had a 20% lower risk of early death from any cause, and a 24% lower risk of death from heart disease or stroke.
Those who reported walking at a brisk or fast pace had a 24% lower risk of early death from any cause and a 21% lower risk of death from cardiovascular causes.
We also found the beneficial effects of fast walking were more pronounced in older age groups. For example, average pace walkers aged 60 years or over experienced a 46% reduction in risk of death from cardiovascular causes, and fast walkers experienced a 53% reduction. Compared to slow walkers, brisk or fast walkers aged 45-59 had 36% lower risk of early death from any cause.
In these older age groups (but not in the whole sample or the younger age groups), we also found there was a linearly higher reduction in the risk of early death the higher the pace.
What it all means
Our results suggest walking at an average, brisk or fast pace may be beneficial for long term health and longevity compared to slow walking, particularly for older people.
But we also need to be mindful our study was observational, and we did not have full control of all likely influences to be able to establish it was the walking alone causing the beneficial health effects. For example, it could be that the least healthy people reported slow walking pace as a result of their poor health, and also ended up dying earlier for the same reason.
To minimise the chances of this reverse causality, we excluded all those who had heart disease, had experienced a stroke, or had cancer when the study started, as well as those who died in the first two years of follow up.
Another important point is that participants in our study self-reported their usual pace, which means the responses were about perceived pace. There are no established standards for what “slow”, “average” or “brisk” walking means in terms of speed. What is perceived as “fast” walking pace by a very sedentary and physically unfit 70-year-old will be very different from a sporty and fit 45-year-old.
For this reason, our results could be interpreted as reflecting relative (to one’s physical capacity) intensity of walking. That is, the higher the physical exertion while walking, the better health results.
For the general relatively healthy middle-aged population, a walking speed between 6 and 7.5 km/h will be fast and if sustained, will make most people slightly out of breath. A walking pace of 100 steps per minute is considered roughly equivalent to moderate intensity physical activity.
We know walking is an excellent activity for health, accessible by most people of all ages. Our findings suggest it’s a good idea to step up to a pace that will challenge our physiology and may even make walking more of a workout.
Long term-health benefits aside, a faster pace will get us to our destination faster and free up time for all those other things that can make our daily routines special, such as spending time with loved ones or reading a good book.
This article is part of a three-part package exploring immunity and infectious diseases around the world. Read the other articles here.
Human beings are large, complex, multicellular, multi-organ systems. We reproduce slowly and rely on a breadth of mechanisms that allow us to control the myriad of rapidly replicating, simple life forms that have evolved to live in or on us.
The system of defence is referred to collectively as immunity.
The word itself comes from the Latin immunis, describing the status of returned soldiers (Genio immunium) in the Roman state who were, for a time, exempt from paying taxes.
Our immunity protects us from many illnesses, including some forms of cancer. New cancer therapeutics, called immunotherapies, work by boosting our immune cells to fight cancer cells that have found ways to evade them.
The immune system is divided into two interactive spheres, the much older “innate” sphere, and the more recently evolved “adaptive” sphere. A primary challenge for the very specifically targeted cells that form the basis of adaptive immunity is to distinguish “self” (our own body cells and tissues) from “non-self” – the foreign invaders. When that goes wrong, we can develop autoimmune diseases such as multiple sclerosis or rheumatoid arthritis.
Explainer: what are autoimmune diseases?
The organisms we carry around with us
The human body is host to many organisms over a lifetime. Some are dangerous to health (pathogens), some are benign, and some are necessary for proper functioning.
Most of the genetic material we carry around with us is “non-self”: principally harmless bacteria (called “commensals”) that live in the gastrointestinal tract.
Traditionally, studies focused on the “bad bugs” in our gut that cause diarrhoea and dysentery. But more recently, we’re learning there are also good guys. And there’s a general consensus we need to know more about the “microbiome”, the mass of bacteria in any “clinically normal” gut.
Gut bacteria provide essential vitamin B12 and when they die, release myriad proteins that will be broken down into amino acids, which the body needs. About 30% of our poo is comprised of dead bacteria.
Apart from our microbiome, normal human beings also have a substantial “virome”. Viruses differ from bacteria (which are cells in their own right) in that they are much simpler and can only replicate in living cells.
The greatest number of viruses we carry around are the “bacteriophages”, which infect the commensal bacteria in our gut. Not all “phages” are, however, benign. For example, the toxin that causes human diphtheria is encoded in the genome of a bacteriophage.
There’s also a spectrum of viruses that persistently infect our body tissues. The most familiar are herpes viruses, like those that cause cold sores (H. simplex) and shingles (H. zoster). Both viruses hide out in the nervous system and are normally under immune control. They re-emerge to cause problems as a consequence of tissue stress (such as a sunburnt lip) or as immunity declines with age (shingles). This is why a booster shingles vaccine is recommended for the elderly.
Our innate and adaptive immune systems
The innate system ranges from processes as basic as phagocytosis (ingestion of bacteria), to molecules like the interferons produced by any virus-infected cell that can limit replication. Such innate systems are found right across the evolutionary spectrum and don’t target specific pathogens.
The much younger adaptive immune system is what we stimulate with vaccines. A property of small white blood cells called lymphocytes, it divides broadly into two lineages: the B cells and T cells. These bear the extraordinarily diverse and very specific immunoglobulin (Ig) and T cell receptor (TCR) recognition molecules that detect invading pathogens (bacteria, virus, fungi and so on).
The immunoglobulins bind to “non-self” (foreign) proteins called “antigens”, while the T cell receptors are specifically targeted to “self” transplantation molecules.
The assassins of the immune system are then switched on; the killer T cells that eliminate virus-infected (or cancer) cells. Also activated are the “helper” T cells that secrete various molecules to “help” both the B cells and killer T cells differentiate and do their work.
Explainer: what is the immune system?
How does our immune system learn and remember?
All lymphocyte responses work by massive cell division in the lymph nodes (the “glands” in our neck that swell when we get a sore throat). This process is started by small numbers of “naive” B and T cells that haven’t encountered the invader before, and only stops when the foreign invader is eliminated.
The B cells differentiate into large protein-secreting cells called plasma cells, which produce the protective antibodies (immunoglobulins) that circulate for years in our blood.
Most of the T cells die off after they’ve done their job, but some survive so they can remember how to target specific invaders. They can be rapidly recalled to their “killer” or “helper” function.
Prior infection or the administration of non-living or “attenuated” (to cause a very mild infection) vaccines sets up the memory so protective antibodies are immediately available to bind (and neutralise) pathogens like the polio or measles virus. While immune T cells are rapidly recalled to “assassin” status and eliminate pathogen-infected cells.
As you may have gathered from this very brief and far too simplified account, the immune system is extraordinarily complex. And it’s also very finely balanced with, for example, cross reactive responses to bacterial proteins sometimes setting us up for autoimmune diseases.
Another example of autoimmunity is rheumatoid arthritis, which can be triggered by blood-borne chemicals from tobacco smoke that modify “self” transplantation molecules in the joints.
And when we talk about the possible effects of the microbiome, or the “too clean” hypothesis, we’re discussing how exposure to bacteria and viruses can modify that immune balance in ways that directly affect our wellbeing. This is a very active area of research which, given the underlying complexity, presents scientists with big challenges as we seek to reach verifiable conclusions.
Peter C. Doherty, Laureate Professor, The Peter Doherty Institute for Infection and Immunity
Consider the scenario. You’re driving on a long, straight stretch of country highway at about 2pm on a sunny afternoon, and you’re desperately keen to reach your destination. You’re trying to stay alert and attentive, but sleep pressure is building up.
In response you yawn, sit up straighter in your seat, possibly fidget around a little and engage in other mannerisms that may increase your level of arousal.
Is this the purpose of yawning? Yawning is generally triggered by several things, including tiredness, fever, stress, drugs, social and other psychological cues. These are generally well documented and vary between individuals.
The question of why we yawn evokes a surprising amount of controversy for what is a relatively minor field of study. We don’t have evidence that can point us to the exact purpose of yawning.
But there are several theories about the purpose of yawning. These include increasing alertness, cooling the brain, and the evolutionary theory of alerting others in your group that you’re too tired to keep watch, and someone else should take over.
1. Helps us wake up
Yawning is known to increase with drowsiness. This has led to the arousal hypothesis of yawning. Associated with the yawning are increased movement and stretching behaviour. The increased fidgeting behaviour may help maintain vigilance as sleep pressure builds.
Also, specific muscles in the ear (the tensor tympani muscles) are activated during yawning. This leads to a resetting of the range of movement and sensitivity of the eardrum and hearing, which increases our ability to monitor the world around us after we may have tuned out before the yawn.
Additionally, the opening and flushing of the eyes will probably lead to an increase in visual alertness.
2. Cools the brain
Another theory for why we yawn is the thermoregulatory hypothesis. This suggests that yawning cools the brain. Yawning causes a deep inhalation that draws cool air into the mouth, which then cools the blood going to the brain.
Proponents of this theory claim a rise in brain temperature is observed prior to yawning, with a decrease in temperature seen after the yawn.
But the research report that gave rise to this theory only shows excessive yawning may occur during an increase in brain and body temperature. It doesn’t suggest this has a cooling purpose.
Increased yawning rates are seen when fevers have been experimentally induced, which does suggest a correlation between body warming and yawning. But there is no clear evidence it leads to body cooling – just that body warming seems to be a trigger for yawning.
3. Sentry duty
Yawning-like behaviour has been observed in almost all vertebrates, suggesting that the reflex is ancient. The evolutionary based behavioural hypothesis draws on humans being social animals. When we are vulnerable to an attack from another species, a function of the group is to protect each other.
Part of our group contract has included sharing sentry duties, and there is evidence from other social animals of yawning or stretching signals when individuals are becoming lower in arousal or vigilance. This is important for changing activities to prevent the watch from slipping, or to indicate the need for another sentry.
The yawning reflex involves many structures in the brain.
One study that scanned the brains of those who were prone to contagious yawning found activation in the ventromedial prefrontal cortex of the brain. This brain region is associated with decision-making. Damage to this region is also associated with loss of empathy.
Stimulation of a particular region of the hypothalamus, which contains neurons with oxytocin, causes yawning behaviour in rodents. Oxytocin is a hormone associated with social bonding and mental health.
Injecting oxytocin into various regions of the brain stem causes yawning, too.
These include the hippocampus (associated with learning and memory), ventral tegmental area (associated with the release of dopamine, the happy hormone) and the amygdala (associated with stress and emotions). Blocking the oxytocin receptors here prevents that effect.
Patients with Parkinson’s disease don’t yawn as frequently as others, which may be related to low dopamine levels. Dopamine replacement has been documented to increase yawning.
Similarly, cortisol, the hormone that increases with stress, is known to trigger yawning, while removal of the adrenal gland (which releases cortisol) prevents yawing behaviour. This suggests that stress might play a role in triggering yawning, which could be why your dog may yawn so much on long car trips.
So, it seems yawning is somehow related to empathy, stress and dopamine release.
Why is it contagious?
Chances are you’ve yawned at least once while reading this article. Yawning is a contagious behaviour and seeing someone yawn often causes us to yawn as well.
But the only theory that’s been suggested here is that susceptibility to contagious yawning is correlated with someone’s level of empathy.
It is interesting to note, then, that there is decreased contagious yawning among people on the autism spectrum, and people who have high psychopathic tendency. And dogs, considered to be highly empathetic animals, can catch human yawns too.
Overall, neuroscientists have developed a clear idea of a wide range of triggers for yawning, and we have a very detailed picture of the mechanism underlying yawning behaviour. But the functional purpose of yawning remains elusive.
Back to our road trip, the yawning may be a physiological cue as the competition between vigilance and sleep pressure begins to favour drowsiness. But the overwhelming message is that sleep is winning and encouraging the driver to pull over for a break, and it shouldn’t be ignored.
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.
NSW is the only state to make flu vaccination mandatory for some health workers. It aims to protect vulnerable patients and the health system from another disastrous flu season like in 2017. While the federal government has told aged care providers they must offer the flu vaccine to their staff this winter, there is no requirement for staff to accept the vaccine.
Despite the numerous campaigns promoting the flu vaccine to Australian health workers, uptake has been documented to range from only 16-60%, with an even lower rate reported among aged-care workers.
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.
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.
Kees Van Gool, University of Technology Sydney; Andrew Wilson, University of Sydney; Helen Dickinson, UNSW; Lesley Russell, University of Sydney; Peter Sivey, RMIT University, and Rosalie Viney, University of Technology Sydney
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.
Infographic: Budget 2018 at a glance
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.
We know what the best buys in primary prevention are. But despite the fact that obesity is a heavy and costly burden on the health care system, and the broad agreement from experts on a suite of solutions, this can is once again kicked down the road.
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
There was no new money in today’s budget for Australia’s beleaguered public hospitals. The government is still locked in a deadlock with Queensland and Victoria, which have refused to agree to the proposed 6.5% cap on yearly funding increases from the Commonwealth. With health inflation of about 4% and population growth close to 2% the cap doesn’t allow much room for increased use due to ageing or new technology.
There is no change in the government’s private health insurance policy announced last year and nothing to slow the continuing above-inflation premium rises.
On the savings side, there was also no move yet on the private health insurance rebate which some experts think could be scrapped.
Kees Van Gool, Health economist, University of Technology Sydney; Andrew Wilson, Co-Director, Menzies Centre for Health Policy, University of Sydney; Helen Dickinson, Associate Professor, Public Service Research Group, UNSW; Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney; Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University, and Rosalie Viney, Professor of Health Economics, University of Technology Sydney
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.
But this isn’t what happened.
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.
However, the increased Medicare levy doesn’t meet the full costs of the scheme – just as the levy doesn’t cover all the annual costs of Medicare. This revenue was directed into a special fund for the NDIS, DisabilityCare Australia, which is designed to reimburse governments for NDIS expenditure.
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.
Behind the funding debate
Warnings have been sounded about the NDIS’s reliance on multiple sources, fearing it creates a risk of future instability of financing.
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.
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.
2. Sugar’s role in health star ratings
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.
3. How a sugar tax would benefit health
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.
4. How a sugar tax would save us money
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).
5. How bad is sugar, really?
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.