Volume 212 Issue 8

Victorian legislation will help the health sector reduce emissions and adapt to climate change

Brett Sutton · Vanora Mulvenna · Daniel Voronoff · Tiernan Humphrys

The origins, scope and significance of the 2019–2020 Climate Health Western Australia Inquiry

Tarun S Weeramanthri · Sarah Joyce · Revle Bangor‐Jones

More nuanced health advice is needed to protect populations and individuals from exposure to bushfire smoke

Sotiris Vardoulakis · Bin B Jalaludin · Geoffrey G Morgan · Ivan C Hanigan · Fay H Johnston

If I am allowed to anaesthetise again, I'll share a few quiet reassuring words with my patients I had spent the past 25 years working in hospitals, intensive care units (ICUs) and theatres. So many thousands of operations on so many patients, and yet here I was, fearful and frankly embarrassed. I lay motionless, face fixed in an unconvincing grin for the benefit of former colleagues as I floated past them, a single off‐white sheet covering my goosebumps. Just another patient this time. Paraded down the corridor; relatives and staff trying to guess whether you were haemorrhoids or a vasectomy. I was no longer the operating room DJ, “gasman” and “wannabe comedian”. Rather than choosing a playlist and sipping the first of many espressos that morning, I had stiffly, illegibly signed a consent form and wet my parched lips from a plastic cup. The last time consent for surgery had been requested, it had been during an emergency helicopter flight, given by my shell‐shocked wife, thousands of miles away. She had tearfully agreed to the trauma team's plans to stabilise my broken neck and jaw, sew my ear back on and drain my exploded right chest, ruptured lung and kidney. The good news was that the pulverised hands and multiple lumbar fractures could wait for another day. It hadn't been clear at that stage if walking was going to be an option, nor whether the brutal deceleration would take a longer term toll upon my brain. It would be a week in the ICU, ventilated and restrained, plus many months of interminable rehabilitation before anyone would know for certain. I remembered accelerating down that long steep hill into Apollo Bay, tucking low on the frame, not even having to pedal to gain speed rapidly, looking ahead for the group I had lost contact with. I flew past other riders, cautiously feathering their brakes on the descent. My eyes watered in the chill jet stream and the bike's carbon wheels chattered on the gleaming tarmac. Then darkness. Silence. Darkness. A large, calloused hand gently, insistently squeezed mine. Like waking from a deep restful sleep, I realised that I had been aware of the pressure on my palm for some time before I understood to try to respond. Slowly, hesitantly, I opened my eyes. The voice was deep, resonant and strangely familiar. It was my son. The brain damage that I sustained on that cold morning in Melbourne, head on into a street pole at 65 km/h tossed me onto the other side of life's road. Each of us doctors spends our training and junior years formulating our own personal and crucially professional identity. Born from repetitive, regular crises of confidence through patient deaths, personal errors and sometimes just promotion to the next terrifying level of responsibility. It wasn't so much learning what to do to be a competent doctor; it was more learning what it was to be a doctor, how we saw ourselves and how society regarded us. I realised that I could no longer muster that theatre blues’ confidence, that surgical squad strut. Laying on a theatre trolley, in a queue for the lifts, I was just another tremulous punter, nervous about the loss of control. I was most afraid of the drug‐induced, return to the darkness. The maxillofacial surgeon had asked me, many weeks after the plates and metalwork had been screwed in, between loosening yanks on the wires holding my face together, if I remembered the accident. I gargled denial noises, my mouth jammed open. “That's a good job,” she laughed. “What a mess!” Operating lists had been my working day and I missed them and my colleagues too, diligent and quirky, good‐hearted and generous. I watched them quietly busy around me, hushed and focused as they made their last detailed preparations. Part of me was ashamed that I knew so little about each of them individually, especially since so many had spontaneously sought me out, given me support and warmth during my months in rehabilitation. Perhaps there was more to medicine than just caring for people. Health teams build something together. Trust, empathy, a united resolve to do the best we can. It looked simple enough when you saw staff doing the same operation a thousand times, but it was the commitment to excellence and good outcomes that defined these humble, generous people. Many of the staff knew me that day as I arrived in the cool clinical space, air conditioner humming, the last stop before the deep dive. A familiar face checked me in for the final time. Knowing her well as I did, I was fleetingly relieved that it was my arm, and not some more delicate area that had been crushed as I was catapulted from the bike. I lay there quietly and felt the emotions rise again, tears welling up. The crash trauma and the rehabilitation had made me afraid of the absence, the journey into that anaesthetic void. I could picture the theatre scene on the day of the accident. Probably not much different to today really. Relaxed, professional and all quite routine. Shredded Lycra, chest drains, ruptured organs and the rest. Sometimes, when I had been the boss, patients would get worried when I told them that things were routine. That wasn't to say we weren't concentrating, it's just that we had done it many times before. I would deliberately avoid the patient's back story just to keep my own anxiety at bay, ignore the injustice and bypass the random cruelty of their situation. Just put an airway into them and keep them asleep while the damaged bits got sorted. No doubt, when they lay my broken body onto a theatre table after the crash, it was much the same. Maybe some passing banter about the weekend's footy results, the crappy Melbourne weather and “middle‐aged men in Lycra” who really should know better. How ironic it would have been had I not hit the pole with my chin, but with my forehead and pithed my brain. Imagine the plaudits for the State Medical Director for DonateLife who felt so impassioned about saving other people's lives through organ donation, that he selflessly became a donor himself. Surely at least an Order of Australia for me? It could have been one of my team informing my family, hands held tight, that their husband and father was not going to make it but that he could save other people's lives. Drugs now flowed into a vein. I often tried to excel at the flippant and the ridiculous in the face of the worst of emergency situations, but not today, not on the other side, a scared patient. “Another one bites the dust” had always got a giggle if I played it from my Spotify favourites, just before sleep time. I used to jokingly tell patients before I put them under that being worried was quite understandable and that if anything bad happened, they would never know because they'd be dead. Strangely, that didn't seem funny anymore. Perhaps if I am allowed to anaesthetise again, once my brain is straight, I'll just share a few quiet reassuring words with my patients, tell them that it's okay to be frightened, that they're safe and that I won't leave their side until they awake. I used to pat myself on the back when a patient left my ICU. Now I have seen that leaving the ICU is not the end of the journey but the start of a new journey. I tried to explain through the mist of my confusion to the nurse caring for me that without her company and support, I wouldn't have survived. She started to cry. I hadn't meant to upset her but I wanted her to know that I was grateful. The outpatients’ clinic since then has been shocking and revelatory. I was the only one not in a wheelchair and for that I felt terrible guilt. Proper patients with proper injuries, courage and optimism by the bucketload have been a sombre reminder of what might have been. I have no memory of those first few steps, my wife's tears or the cheers from my hemiplegic room‐mate as I edged back onto my bed for a well earned rest. Because of the brain injuries, the thought of anaesthetising someone now fills me with an unfamiliar fear. It took me all my waking hours to craft this cast‐iron professional identity of mine and an instant to fatally fracture it. I even had the Rod of Asclepius tattooed on my biceps on my 50th birthday just to affirm a life's commitment to medicine. The supreme irony that I may never practise again and the loss of that coveted persona have been the most traumatic part. Who am I now? I used to be a doctor until that day on the Great Ocean Road. Not anymore. Perhaps one day I will accept the crash and its consequences; move on with my life. Not quite yet.

Bruce Powell

Reducing smoking during pregnancy among Aboriginal and Torres Strait Islander women is a national priority, but there has been little exploration of their experiences and desired support

Michelle Bovill

Memoir of an accidental ethicist: on medical ethics, medical misconduct and challenges for the medical profession

Gin S Malhi

Excellence in environmentally sustainable health care must be the goal of the Australian medical profession

Diana L Madden · Anthony Capon · Philip G Truskett

Early empirical evidence provides grounds for optimism about eliminating HCV by 2030

Marianne Martinello · Behzad Hajarizadeh · Gregory J Dore

Technology is revolutionising medicine, and telemedicine is having a measurable impact on stroke care

Richard I Lindley

Objectives: To assess progress in Australia toward the 2030 WHO hepatitis C elimination targets two years after the introduction of highly effective direct‐acting antiviral (DAA) treatments. Design: Analysis of quarterly data on government‐subsidised hepatitis C RNA testing and hepatitis C treatment in Australia, January 2013 – June 2018. Changes in testing and treatment levels associated with DAA availability were assessed in an autoregressive integrated moving average (ARIMA) statistical model, and the impact by 2030 of different levels of testing and treatment were estimated using a mathematical model. Major outcome measures: Hepatitis C prevalence among people who inject drugs; annual hepatitis C incidence relative to 2015 levels; projections for the hepatitis C care cascade in 2030. Results: The mean annual number of treatments initiated for people with hepatitis C increased from 6747 during 2013–2015 (before the introduction of DAAs) to 28 022 during 2016–18; the mean annual number of diagnostic RNA tests increased from 17 385 to 23 819. If current trends in testing and treatment continue (ie, 2018 testing numbers are maintained but treatment numbers decline by 50%), it is projected that by 2030 only 72% of infected people would be treated (by 2025 all people diagnosed with hepatitis C would be treated). The incidence of hepatitis C in 2030 would be 59% lower than in 2015, well short of the WHO target of an 80% reduction. The identification and testing of people exposed to hepatitis C must be increased by at least 50% for Australia to reach the WHO elimination targets. Conclusion: Hepatitis C elimination programs in Australia should focus on increasing testing rates and linkage with care to maintain adequate levels of treatment.

Nick Scott · Rachel Sacks‐Davis · Amanda J Wade · Mark Stoove · Alisa Pedrana · Joseph S Doyle · Alexander J Thompson · David P Wilson · Margaret E Hellard

Objectives: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. Design: Historical controlled cohort study comparing outcomes during a 12‐month control period with those for the initial 12 months of full implementation of the VST program at each hospital. Setting: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. Participants: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. Main outcome measures: Indicators for key processes of care, including symptom onset‐to‐arrival, door‐to‐first medical review, and door‐to‐CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. Results: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door‐to‐CT scan time (median, 25 min [IQR, 13–49 min] v 34 min [IQR, 18–76 min]) and door‐to‐needle time for stroke thrombolysis (73 min [IQR, 56–96 min] v 102 min [IQR, 77–128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. Conclusions: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

Chris F Bladin · Joosup Kim · Kathleen L Bagot · Michelle Vu · Natasha Moloczij · Sonia Denisenko · Chris Price · Nancy Pompeani · Lauren Arthurson · Casey Hair · Justin Rabl · Mick O'Shea · Patrick Groot · Leslie Bolitho · Bruce CV Campbell · Helen M Dewey · Geoffrey A Donnan · Dominique A Cadilhac

Objectives: To estimate the carbon footprint of five common hospital pathology tests: full blood examination; urea and electrolyte levels; coagulation profile; C‐reactive protein concentration; and arterial blood gases. Design, setting: Prospective life cycle assessment of five pathology tests in two university‐affiliated health services in Melbourne. We included all consumables and associated waste for venepuncture and laboratory analyses, and electricity and water use for laboratory analyses. Main outcome measure: Greenhouse gas footprint, measured in carbon dioxide equivalent (CO2e) emissions. Results: CO2e emissions for haematology tests were 82 g/test (95% CI, 73–91 g/test) for coagulation profile and 116 g/test (95% CI, 101–135 g/test) for full blood examination. CO2e emissions for biochemical tests were 0.5 g/test CO2e (95% CI, 0.4–0.6 g/test) for C‐reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95% CI, 45–53 g/test) for arterial blood gas assessment, and 99 g/test (95% CI, 84–113 g/test) for urea and electrolyte assessment. Most CO2e emissions were associated with sample collection (range, 60% for full blood examination to 95% for coagulation profile); emissions attributable to laboratory reagents and power use were much smaller. Conclusion: The carbon footprint of common pathology tests was dominated by those of sample collection and phlebotomy. Although the carbon footprints were small, millions of tests are performed each year in Australia, and reducing unnecessary testing will be the most effective approach to reducing the carbon footprint of pathology. Together with the detrimental health and economic effects of unnecessary testing, our environmental findings should further motivate clinicians to test wisely.

Scott McAlister · Alexandra L Barratt · Katy JL Bell · Forbes McGain

In 2014, we reported in the MJA our findings, based on linked data for cervical screening and human papillomavirus (HPV) vaccination of women in Victoria, that participation of young women in cervical screening during 2010 and 2011 was significantly lower among HPV‐vaccinated than among unvaccinated women.1 In 2018, we had the opportunity to repeat the study at the national level as part of a broader data linkage study of cancer outcomes and screening behaviour across the three national cancer screening programs in Australia.2 In the original study (2014), the Australian Institute of Health and Welfare (AIHW) data linkage unit applied probabilistic name‐based linkage to HPV vaccination and cervical screening data. We acknowledged it was likely that some screened women who were vaccinated would be incorrectly identified as unvaccinated because many young women would have changed their names and addresses between vaccination and cervical screening. In the more recent study (2018), the AIHW again used probabilistic name‐based linkage, but first updated HPV vaccination and cervical screening data by obtaining histories of name and address changes from the Medicare Enrolment File. Medicare registrants’ details are updated when new data are provided to Medicare, the national health care scheme, and are recorded in new records with dates of change. The Australian Department of Human Services agreed to provide these data to the AIHW for data linkage purposes for our 2018 study. Our investigation was approved by the AIHW Ethics Committee (reference, EO 2014‐4‐130) and by state and territory human research ethics committees. After incorporating Medicare data, annual cervical screening rates for Victorian women aged 20–24 years or 25–29 years were higher during 2010 and 2011 for vaccinated than unvaccinated women,2 contrary to our 2014 findings.1 For 20–24‐year‐old Victorian women, the difference in rate changed from 10.1% lower to 14.7% higher for vaccinated women, and for 25–29‐year‐old women from 13.5% lower to 10.0% higher (Box). Our updated findings are consistent with findings from other countries of higher cervical screening participation among women who have been vaccinated against HPV.3,4,5 Incorporating the Medicare Enrolment File into the 2018 linkage was a test of proof of concept. Its successful use in this and similar studies has led to the AIHW data linkage unit granting ethics approval and relevant authorisations for employing the Medicare Enrolment File as a tool for improving the quality of other data linkage studies. The key message of our original study, however, remains unchanged. All women, whether vaccinated against HPV or not, should be encouraged to participate in cervical screening: the HPV vaccine does not protect against all HPV types, and many women in Australia were sexually active before they were vaccinated. While it is as yet unclear whether the association between vaccination and screening will persist for women who were routinely vaccinated at school, it is crucial that we focus on strategies that effectively engage women who do not currently participate in screening. Box – Estimated participation of Victorian women in cervical screening during 2010 and 2011, by HPV vaccination status and age group: 2014 and 2018 data linkage studies HPV = human papillomavirus.

Alison C Budd · Andrew Powierski · Theresa Chau · Marion Saville · Julia ML Brotherton

Editor’s note: This is an update of a Letter to the editor originally published as a preprint on 16 March 2020 (https://www.mja.com.au/journal/2020/212/8/covid-19-precautions-easier-said-done-when-patients-are-homeless). To the Editor: Implementation of advice to the public and general practitioners on minimising the risk of COVID‐19 exposure and transmission is immensely difficult for people experiencing homelessness and for the health services working with them. Yet this is a population group more vulnerable to infection than most.1 The elevated risk factors for COVID‐19 are substantial, as people experiencing homelessness have a much higher prevalence of comorbidity and chronic disease compared with people of the same age who are housed.2 To illustrate further, among the 4000 active patients seen by Homeless Healthcare (Australia's largest specialist homelessness GP practice based in Perth), nearly all patients have comorbidities, 13% have chronic respiratory conditions, 79% smoke (associated with poorer lung health and risk) and 8% have diabetes (associated with supressed immunity). There are parallel calls in Australia and the United Kingdom for clearer government guidance as to how the precautionary measures can be applied in homeless populations. There are a myriad of challenges to this, both for people who are homeless themselves and for those providing health care to this vulnerable population group. These challenges include: Regular hand washing and hygiene (and accessing soap or sanitiser and bathrooms in order to do this) is extremely problematic if living on the street. Self‐isolation by staying at home if you feel unwell and suspect having symptoms is impossible if you do not have a home to live in. Reducing face‐to‐face health service contact is being advocated to GPs and health services in Australia and the UK. The Australian Government has just announced Medicare rebates for bulk‐billed telephone consultations,3 but this is problematic for people who are homeless without a phone. Similarly, technological solutions such as video or virtual consultations are digitally prohibitive for people without a home let alone a computer. Outreach health services are among the most effective ways of enabling people who are rough sleeping to access health care.4 Homeless Healthcare, for example, runs clinics at drop‐in centres and crisis accommodation settings and has nurses out on the streets each day and doing home visits to those recently housed. However, implementing the use of personal protective equipment is difficult in these settings, and in the absence of primary care outreach, emergency department presentations are likely to escalate. Cancelling outreach GP clinics and other outreach services for this population to reduce exposure risks would have severe unintended consequences. If risk factors for COVID‐19 or patients with COVID‐19 are untreated in this highly susceptible population, the mortality risk is high.1 Moreover, many people will not receive critical treatment for other medical conditions, such as depot medications for psychotic illness and, as articulated in a recently published article, “lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration”.1 The higher risks of COVID‐19 for people experiencing homelessness and, consequently, for those working closely with them present an enormous challenge that has no easy answers. As new precautionary measures are being announced daily, it is critical that further marginalisation for this group is not an unintended consequence.

Lisa J Wood · Andrew P Davies · Zana Khan

To the Editor: Climate change is this century's greatest global health threat. As the MJA considers the role of the health care sector in climate change, we urge readers to consider hospital food environments. Australia's health care system should be promoting diets that are healthy for both humans and the planet. A growing body of evidence suggests that healthier human diets have significant environmental co‐benefits. For example, reduced consumption of processed discretionary foods and red meats and increased consumption of fruits, vegetables and legumes have been shown to reduce the risk of certain non‐communicable diseases while also reducing diet‐related greenhouse gas emissions.1,2 Hospital food environments provide a useful intervention point to model and promote healthy, sustainable diets to Australians, as millions of meals are served to patients and their families in hospitals each year. Hospital food retailer guidelines have recently been developed by state governments and health care providers.3,4 To optimise health care food environments, a first step is to remove fast food outlets, vending machines and sugar‐sweetened beverages from hospitals. Inpatient food guidelines, however, are mostly outdated and sustainability is rarely considered. Inpatient food services should prioritise the delivery of fresh, locally sourced, unrefined foods with minimal packaging. Meals should adhere to dietary guidelines, be personalised to patients’ health needs, and minimise food waste. A recent audit by the Victorian Government into inpatient food services may provide an important opportunity to initiate reform.5 The Mater Group hospitals’ “at your request” room service exemplifies a cost‐effective food service model, showing improvements in patients’ nutrient intake, clinical outcomes, food waste reduction and patient satisfaction.6 Australia can also learn from the growing number of global initiatives to improve hospital food, including the New Zealand Ministry of Health's sustainability commitments, which include recommendations to encourage plant‐based eating, sustainable food sourcing and reductions in food waste.7 We should also look to innovative programs such as hospital rooftop gardens, hospital teaching kitchens, and traffic light labelling systems. To protect the health of humans and the planet, we urge state governments and health care providers to urgently evaluate hospital food quality, inpatient food services and retail food environments and implement new mandatory standards.

Genevieve Moseley · Luke Spajic · Georgia Behrens

To the Editor: We welcome the recent article by Secombe and colleagues1 highlighting the impact of alcohol policy reforms in the Northern Territory, namely the influence of the minimum floor price on critical care admissions.1 We agree that the social costs and harms of alcohol in the NT are too high,2 and are reassured by the improved health outcomes associated with the implementation of emerging alcohol policies.3,4 There have been, however, other notable alcohol and social policy investments in the NT, including the introduction of Police Auxiliary Liquor Inspectors (PALIs). PALIs are uniformed inspectors, stationed at takeaway alcohol outlets, who seek to prevent the consumption of alcohol in restricted areas. These areas include all land defined as Aboriginal land as per the Aboriginal Land Rights (NT) Act 1976,5 within 2 km of a licensed venue, and in certain regulated public and private areas. PALIs ascertain where individuals purchasing alcohol will be consuming their purchase by requesting a form of identification, alongside questions regarding intended drinking location. If a valid (non‐restricted) address cannot be provided, purchase is not permitted. The first squad of PALIs graduated on 20 August 2018. As noted by Secombe and colleagues, the minimum floor price was introduced on 1 October 2018. Considering the time of implementation of both policies, it is imperative that we better understand the intersection between PALIs, the minimum floor price and other alcohol policy initiatives, such as the Banned Drinker Register.6 The recent analysis by Secombe et al provides a partial snapshot of the impacts of a highly complex public health issue. Given that a suite of alcohol policies has been introduced by the NT Government to combat alcohol‐related harms,6 a more sophisticated evaluation approach is required to understand these relationships. This means a broader range of data sources need to be used to evaluate the impacts of alcohol policies in the NT. This should include health, police, corrections, domestic violence, child protection, and education data. Furthermore, to advance comprehensive understandings of these alcohol reforms, it is also imperative to include qualitative approaches that explain how and why different alcohol policies work.

Sarah C Clifford · Kalinda E Griffiths · James A Smith

In reply

Paul J Secombe · Michael J Bailey · David Pilcher

Attending courses overseas at a junior level can foster an interest and understanding of global health

Danielle Taylor · Ha My Nguyen · Richard Gartrell · Matilda Anderson · Justin Yeung