Editorials

Integrating pharmacists into general practice, aged care, and hospital services will enhance the quality use of medicines

Justin Beilby

Choice of therapy will be determined by the compromises and uncertainties most acceptable for the patient and their clinician

Ian JS Cook

While apparently non-inferior to originator biologics, other factors need to be considered before switching

Gregory T Moore · Charlotte Keung

We need more robust strategies with targeted, customised approaches, and increased funding for evidence-based interventions

Michael J Dudley · Ping-I Lin

Models must be supported by a range of qualitative and quantitative assessments and tools to translate their projections into policy

Allen C Cheng

Non-academic personal qualities are also desirable in doctors: higher mental abilities, empathy, ethics, creativity

David A Powis · Don Munro · Miles R Bore

The MJA aims to be an outstanding general medical journal, broadly relevant to all specialties in medicine and health, with a national and global focus, a journal that influences policy and practice

Nicholas J Talley

Adequate capacity — beds, equipment, consumables, and, crucially, trained personnel — is needed to cope with a surge of critically ill patients

Mervyn Singer

Inappropriate behaviour harms health workers and patients, and evidence-based solutions are needed

Anthony Scott · Danny Hills

At the end of 2019 and into 2020, catastrophic fires in Australia consumed homes, lives, wildlife and land. Just as the fires subsided, Australia, like the rest of the world, faced another emergency — the COVID‐19 pandemic.1 It is instructive to reflect on lessons from the health disasters of the past year. Following publication of The Lancet Countdown on health and climate change,2 the Medical Journal of Australia (MJA)–Lancet Australian Countdown on health and climate change was published in December 2020.3 This annual report on health and climate change in Australia is in its third year and comprises the efforts of five Australian institutions, in collaboration with University College London, facilitated by a partnership between The Lancet and the MJA.3 All three reports make sobering reading.3,4,5 2019 was Australia’s hottest and driest year on record, with average temperatures 1.52°C above normal and mean rainfall 40% below the 30‐year average before 1991.3 Australia’s 2019–20 bushfires burned 10 million hectares, directly killed 33 people and destroyed more than 3000 homes.6 Smoke engulfed major capital cities, including Sydney and Melbourne, and smoke exposure caused an estimated 417 excess deaths and over 3000 hospital admissions.3,7,8 The catastrophe laid bare how extreme heat is a severe health risk.9 The ecological damage of the bushfires was enormous;6 almost 3 billion animals were killed or displaced, and natural systems of biodiversity and species were harmed, perhaps irreparably.6 Severe storms and floods followed the fires, bringing further damage. Insured losses from disaster events totalled AU$3.7 billion in 2019, with bushfires accounting for $2.2 billion, although the total costs of the so‐called Black Summer fires could be much higher.3 The devastation of the bushfires led the Australian Government to establish the Royal Commission into National Natural Disaster Arrangements. The final report of the Royal Commission in October 2020 identified climate change as a major driver and acknowledged the risk of increasing extreme weather events.6 However, the Royal Commission’s scope was limited to disaster management (mitigation, preparedness, response and recovery) and did not discuss root causes of climate change such as the fossil fuel industry’s grip on Australia’s energy infrastructure, economy, political will and public discourse. Australia has no decisive national plan to address climate change and its health consequences.3 The Australian Government is a signatory to the Paris Agreement, but has declined to affirm net zero carbon emissions by 2050 — or by any date — unlike the UK and the EU; China has also committed to this goal by 2060. Unlike this inadequate approach to the climate crisis, Australia’s response to COVID‐19 was rapid and effective, despite facing the pandemic while the last bushfires still burned.10,11 Strong community engagement with public health measures enabled effective management of the first and second waves, making Australia’s, together with those of New Zealand and parts of Asia, among the more successful responses to COVID‐19.12 Key to this success was the valuing by governments of science and data to guide decision making. The pandemic forced politicians from across the Australian political divide to prioritise the evidence and expertise of the medical, scientific and public health communities over the voices of conservative commentators, business leaders and politicians. Tough political decisions were made for the sake of the nation’s health. This bipartisan, science‐based approach is a model for the future management of climate change, if implemented alongside an appropriate national plan. Australia’s First Nations people, who are at increased risk of poorer health outcomes than the general population in a pandemic, have provided exceptional leadership in their response to COVID‐19, resulting in low rates of virus transmission thus far.13,14 The country’s Indigenous populations are also disproportionately vulnerable to future climate change natural disasters.6 Since the traditional owners of Australia’s land are effective, resilient caretakers of the country and experts in land and fire management, the Royal Commission recommended federal, state and territory governments learn from and engage with their expertise.6 As another initiative capitalising on local expertise, The Lancet Countdown’s regional report in partnership with the MJA has led to improved performance indicators for climate change. For example, the Australian Countdown reports3,4,5 developed the wildfire (bushfire) indicator, which the Countdown is now adopting globally. These data have encouraged more direct engagement with Australian policy makers and health professionals, and provided direct funding guidance to Australia’s National Health and Medical Research Council (NHMRC), which is expected to translate into funding changes in 2021.15 Australia’s leading medical and nursing bodies have recognised climate change as a health emergency.8 Governments of states and territories have committed to zero net carbon emissions by 2050, with climate change adaptation plans incorporating the health sector and investment in renewable energy.3,16 With the unprecedented disasters of 2020, public sentiment in Australia has shifted, as more people realise climate change is here now, with impacts for all. In November, the Climate Change (National Framework for Adaptation and Mitigation) Bill 2020 was introduced into the Australian federal Parliament by the independent Member of Parliament Zali Steggall, with wide public support, including from the Australian Medical Association and more than 100 major businesses.17 The outcome of the 2020 US election and the environmental platform of the incoming administration of Joe Biden coincides with a more positive stance in Australian politics towards addressing climate change.18 In the MJA–Lancet Countdowns,3,4,5 Australia embraced the importance of local data, local experts and local stories. A regional China Countdown report is also being published in parallel this year,19 and in 2021, there will potentially be Countdown collaborations for the EU, South America, the US, and Small Island Developing States. Looking forwards, Australia should as a priority establish a National Health and Climate Change Centre within the Australian Government Department of Health to develop a National Plan for Health and Climate Change with real‐time monitoring. As well as preparing to manage climate‐related health sequelae, Australia’s health sector should commit itself nationally to zero net carbon emissions by 2040 in line with the National Health Service in the UK, preferably with the states and territories responsible for implementing evidence‐based interventions.20 Reducing unnecessary medical tests and procedures will serve to reduce carbon emissions, health care costs and harmful outcomes.21 Research funded by the NHMRC and the Medical Research Futures Fund should guide better ways to efficiently reduce the carbon footprint of Australia’s health care services. Australia has an obligation under the Paris Agreement to submit enhanced nationally determined contributions by the end of 2020. We recommend that the Australian Government agree to a target of a 50% reduction in carbon emissions by 2030, which is what is likely required to limit global warming below 1.5°C.3,4,5 The Australian Government needs to recognise that fossil fuels are no longer a sound investment and join with other jurisdictions that are committed to shifting completely to renewable energies to make that sector the most cost‐effective for jobs and energy security. In Australia the crises of 2020 were unprecedented, shocking and predictable. We remain hopeful all Australian governments will aspire to the leadership shown nationally with the COVID‐19 pandemic and effectively deal with climate change now, understanding the major health risks of neglecting this issue. We anticipate health and corporate leaders, as well as leaders across other sectors, will continue to drive change. Interrogating successes and failures nationally in the MJA–Lancet annual Australian Countdown provides a robust model for monitoring and positive change. The flow on benefits to health and wellbeing, the economy and society from such change will be enormous. This article is co-published in The Lancet.22

Nicholas J Talley · Fiona J Stanley · Tamara Lucas · Richard C Horton

Despite a year of floods, fires and pestilence, we approach 2021 with optimism

Nicholas J Talley

Researchers who live and work in community can respond to local clinical questions and provide feedback to community on their findings Australians enjoy some of the best health outcomes in the world1 and those benefits are concentrated in our urban centres. Australians who live in rural and remote Australia have poorer health than their urban peers. The more remote your residence, the shorter your life span and the greater the burden of disease carried by your community.2 Australians living in remote areas are admitted to hospital at 1.3 times the rate of those living in urban and regional areas. For Australians living in very remote areas, the rate is nearly double the urban rate.2 Potentially preventable hospitalisations also increase steeply with remoteness. The difference is most marked for acute conditions where remote rates are almost 2.5 times those of urban areas.2 The median age at death in major cities in Australia is 82 years; in outer regional, remote and very remote areas it is 3, 9 and 18 years younger, respectively, and the statistics are much worse for First Nations Australians.3 Social determinants such as lifestyle factors, poor housing conditions, and lower average levels of educational attainment and employment in rural and remote communities predispose members to increased rates of disease and illness. Rural and remote residents experience increased difficulty in accessing timely care, which is a key factor in effective prevention and management of chronic disease and in improving population health outcomes. For example, 20% of people who live in remote and very remote areas report not having a general practitioner nearby as a barrier to seeing one, compared with 3% of those living in major cities, and 58% report not having a specialist nearby as a barrier to seeing one, compared with 6% in major cities.4 These factors contribute to the higher burden of chronic disease and shorter life expectancy in remote locations.2 Given this high burden of disease, an overload of social determinants of poor health and increased barriers to care, one might expect to see greater expenditure on health research and services in rural and remote Australia. This is not the case.5 Non‐community controlled health expenditure decreases with remoteness, but the detail here is telling. Medicare services and Pharmaceutical Benefit Services decline with remoteness but expenditure per patient admitted to hospital increases.6 The investment is in people after they become ill rather than on preventing illness. I have seen many examples of innovative models of care in rural Australia. I have seen health services, training providers, health professionals and communities co‐designing solutions that work for them, making a difference to the lives of rural people. To improve rural health we need to better understand it. We need to understand the why of health outcomes and evaluate which interventions are acceptable and effective. Evidence to inform such answers is scarce. Gaps in the Australian rural health research evidence base threaten to leave holes in Australian health policy. Ongoing engagement with rural communities that deepen understandings of local context and experience enrich research outcomes. In the Torres Strait, people talk of “seagull” research. They are not referring to studies of marine birdlife. They are referring to researchers who fly in, rapidly collect data and fly off with it, leaving only guano behind. Researchers who live and work in community can respond to local clinical questions and provide feedback to community on their findings. The Supplement published with this issue of the MJA7 comes from the Spinifex Network, which comprises such community‐based researchers. Within this network, researchers are able to find collegiate support and collaboration and conduct research that will lead to improved rural and remote health outcomes. The Supplement presents a number of review articles relating to people living in rural and remote Australian communities, covering issues such as food security, the impact of natural disasters, recruitment and retention of health workforce, and global crises. Australians living outside urban centres will benefit from such community‐based research.

Ruth Stewart

The increasing use of split livers for in children has effectively increased the donor organ supply

James Neuberger

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

More evidence is required to explain the differences in cancer treatment reported by data linkage studies

Ian N Olver

The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed

Stephan A Schug

High cumulative doses are often unnecessary and can have major adverse effects

Christine F McDonald · Christopher J Worsnop

Air pollution poses global health, equity, and environmental problems with short and long term consequences

Julie M Marchant · Anne B Chang

Patience and well designed studies are important for balancing opportunity and risk in uncertain times

Michael Wagels · Dietmar W Hutmacher

The medical profession has the opportunity to prevent further harm to patients and damage to public trust

Cherrie Ann Galletly

Our approach to estimating risk in some patients should be updated and the role of coronary artery calcium scoring evaluated

Harry Klimis · Clara K Chow