Perspectives

Lack of policy development hinders the effective integration of research, education and health care delivery

David E Theile MB BS(Hons), MS, FRACS · Ian A Scott FRACP, MHA, MEd · Jennifer H Martin MB ChB, FRACP, PhD · Areti Gavrilidis MBA, BSc, BAppSc

Vigilance is needed to keep supply, training and the working environment strong

Tarun Sen Gupta FRACGP, FACRRM, PhD

In the absence of universal dental care there are still ways to improve oral health for all

Lesley M Russell BSc(Hons), BA, PhD

A country doctor confronts the devastating realities of needing specialist care in a distant city

Linda J Samera FRACGP, CertRHPr, MRIH

The government needs to develop better policies now to ensure a future for rural health care

Ian J Kamerman FACRRM, FRACGP, DRANZCOG

Making the most of rural and remote health research through collaboration

Gordon N F Gregory BA, MPhil

Medical tourism: future boon or future bane for Australia’s consumers and health care system?

David Greenfield PhD · Marjorie Pawsey MB BS, DPH

Public health advocates coordinate programs to reduce salt intake and prevent iodine deficiency

Jacqui Webster PhD · Mary-Anne Land MPH · Anthea Christoforou MIPH · Creswell J Eastman AM, MD, FRACP, FAFPHM · Michael Zimmerman · Norman R C Campbell MD · Bruce C Neal PhD, FAHA, FRCP

Implementing recommendations of the parliamentary inquiry and international codes of practice on employment of IMGs

Carlos Zubaran MD, MHM, PhD · Susan Douglas MD, FACRRM, GradDipHE

Major education reform requires a narrative, time, investment and communication

Kevin D Forsyth MD, PhD, FRACP

We need to increase testing and treatment and keep searching for a cure

Levinia Crooks BA(Hons), DipEd, MBA · Michael R Kidd AM, MD, FRACGP · Robert Lake DCOM · Edwina J Wright MB BS, PhD, FRACP · Edward Reis BA

Biopsy should be routinely considered for intermediate thickness melanoma

David E Gyorki MB BS, MD, FRACS · Michael A Henderson BMedSc, MD, FRACS

A call for ongoing government commitment to rural oncology care

Peter Fox BSc(Med), MB BS, FRACP · Adam Boyce MB BS, FRACP

Further improvement will be due to population health efforts

Nicola J Reavley PhD · Anthony F Jorm PhD, DSc

The National Pain Strategy is driving improvements in pain management, but greater impetus is needed

Michael J Cousins MD, DSc, FFPMANZCA · Lesley Brydon BPharm

Pushing public health to where it needs to go

Henry Greenberg MD

Good infection control minimises the risk to Australia from the largest outbreak of Ebola virus disease

Arinjay Banerjee BS, MS · Siobhan M Mor BVSc, PhD, MANZCVS · Jen Kok MB BS, FRACP, FRCPA · Tania C Sorrell MB BS, MD, FRACP · Grant A Hill-Cawthorne MB BChir, MA, MRCP

Asylum seekers are not receiving acceptable standards of medical care. Should doctors boycott the system?

John-Paul Sanggaran MB BS, MHMed, BHSc · Grant M Ferguson BSc(Hons), MB BS · Bridget G Haire PhD, MBioethics

Front-line staff need tools for dealing with the vast array of synthetic cannabinoids

Michelle M Williams BSc, MBA, MDR · Paul J Taylor BSc · Colin B Page MB ChB, FACEM, MMedSci(ClinEpid) · Jennifer H Martin MA, FRACP, PhD

This much maligned galactagogue may carry no direct risk to breastfeeding women

Luke E Grzeskowiak PhD, BPharm(Hons), GradCertClinEpid · Lisa H Amir MB BS, MMed, PhD

The “ending HIV” movement calls for new and innovative approaches to testing

Marianne Gale MB BS, MPHTM · Joanne Holden MHlthPolicy · Christine Selvey MB BS, MSc · Kerry Chant MPH, FAFPHM · Bill Whittaker

Managing the risks associated with domestic gas heaters

Barbara Robertson MB BS, FANZCA · Amanda J Cohn

A call for active leadership on climate change This week the Journal publishes an open letter from 12 medical and health scientists to the Prime Minister urging that climate change be included on the agenda for the upcoming G20 meeting that he is hosting in Brisbane in November. The letter argues that climate change and health are interlocked with the global economy, and that vigorous and enlightened debate about the consequences of climate change on human health is justified at a meeting focused on international economics. An interview with Professor Jeffrey D Sachs, a prominent American economist and Director of The Earth Institute at Columbia University and past Chair of the World Health Organization's Commission on Macroeconomics and Health, calls on Australia to show leadership. Sachs has served as special adviser to two Secretaries-General of the United Nations, first guiding the development and then the implementation of the Millennium Development Goals, which seek to reduce global poverty, particularly through health gain for mothers and children and through reduced HIV and AIDS, by 50% by 2015. His primary concern today is with achieving sustainable development before a malignant tipping point occurs in global temperature. The interview and the open letter both call for action from the Australian Government. We look forward to a positive response.

Stephen R Leeder MD, PhD, FRACP

Dear Prime Minister, We urge you to include human-induced climate change and its serious health consequences on the agenda for this year's G20 meeting. The world community looks to high-income countries for a strong lead. Current climate trends, driven by global warming, threaten the basis of future economic prosperity, regional political stability and human health. As concern rises in many countries, including increasing awareness of the risks to human health and safety, many G20 members are strengthening their commitment to substantive mitigation action. The new United States regulations limiting coal-fired power plant emissions are explicitly linked to the protection of health. Meanwhile, if Australia passes up opportunities for new energy technologies and efficiencies, we will forfeit gains in long-term economic security and fail to contribute fairly to reducing worldwide risks to human health. There are serious risks from climate change to the health of populations everywhere — widely documented in national and international scientific assessments. The risks include, but extend well beyond, intensified heatwaves, floods, fires and the spread of disease-bearing mosquitoes. Regional food yields and hence child and adult nutrition are at risk. Water shortages threaten the quantity and quality of drinking water, hygiene and agriculture. Warming and acidification of oceans endanger marine food sources. Infections such as gastroenteritis increase with warming, as do levels of important hazardous air pollutants. Threats to rural and coastal assets and livelihoods will adversely affect mental health. Adverse health outcomes related to climate change are already evident in many regions of the world. By mid century, serious health risks are likely to be widespread, particularly in vulnerable communities, including in Australia. Workloads and economic and logistical demands on the nation's health system will also rise as these impacts increase. Near-term cost savings from health gains resulting directly from emission-reducing actions could be substantial. For example, the savings from health gains due to reduced heat extremes and accompanying air pollution would greatly exceed those accruing to agriculture from the same reduction in exposure. In the long run, the harm to human health from climate change is more than an avoidable burden of suffering, injury, illness and premature death. It signals that our mismanagement of the world's climate and environment is weakening the foundations of health and longevity. This issue warrants urgent consideration at the G20 meeting. The health of present and future generations is at risk from ongoing human-induced climate change.

Anthony J McMichael AO, MB BS, PhD, FTSE · Stephen R Leeder AO, MD, FRACP, PhD · Bruce K Armstrong AM, MB BS, DPhil, FRACP, FAFPHM · Antony Basten AO, MB BS, DPhil, FRCP, FRACP, FRCPA · Peter C Doherty AC, BVSc, MVSc, PhD · Robert M Douglas AO, MB BS, MA, MD, FRACP, FAFPHM, FRACGP · Adele C Green AC, MB BS, PhD, MSc, FAFPHM · Gustav J V Nossal AC, MB BS, BSc(Med), PhD · David J C Shearman FRACP · Fiona J Stanley AC, MSc, MD · Graham V Vimpani AM, MB BS, PhD, FRACP, FAFPHM · Alex D Wodak AM, MB BS, FRACP, MRCP, FAFPHM, MRACP

We must reinvigorate our sense of humanity, justice and foresight Jeffrey Sachs is an American economist and Director of The Earth Institute, Quetelet Professor of Sustainable Development and Professor of Health Policy and Management at Columbia University. He is Special Adviser to United Nations Secretary-General Ban Ki-Moon on the Millennium Development Goals, having held the same position under former UN Secretary-General Kofi Annan. He is known as a commentator and advocate for the relief of poverty, the achievement of improved health in developing countries and for environmental sustainability. From 2000 to 2001, he chaired the World Health Organization Commission on Macroeconomics and Health, which made clear the linkage between health gain, relief of poverty and economic growth. Sachs is author of The end of poverty: economic possibilities for our time (2005). His most recent book is To move the world: JFK's quest for peace (2013). He was interviewed by the Editor-in-Chief of the Medical Journal of Australia, Stephen Leeder, who worked with Sachs in New York in 2003–2004, about the upcoming G20 meeting in Brisbane, Australia, in November. What is your primary message as an economist interested in the relief of poverty about sustainability and its relation to both economics and human health? It is not possible to consider ending poverty in the midst of human-induced climate change. Even if poor countries, such as those in Africa, make some short-term progress in the fight against poverty, this progress will be overtaken by climate disruption. Africa already is suffering from food price shocks, famine, heatwaves, droughts and other extreme climate shocks. We've got to get real: fighting poverty and environmental degradation go hand in hand. How could the upcoming G20 meetings in Brisbane be an important forum for consideration of the economics of sustainability? The G20 countries are the world's most important economies. They account for the lion's share of global greenhouse gas emissions. If the G20 gets its house in order, the world can be saved. If not, the G20 will wreck the world, pure and simple. So what will it be? Will the richest and most powerful countries also be the most short-sighted, or will they understand that they hold not only their fate but the fate of humanity in their grasp? Brisbane is therefore crucial. The prospects are not bright. The Australian Government claims it is driven by science, but it seems to us on the outside that it is driven by mining interests, or by the likes of Rupert Murdoch, the world's number one anti-science propagandist. The G20 should acknowledge that 2015 is the most important year of diplomacy on sustainable development in at least 15 years. We have three mega-summits next year. The first is on Financing for Development, in Addis Ababa, Ethiopia, in July 2015. The next is on Sustainable Development Goals, at the UN headquarters in New York, in September 2015. The third is on climate change — the so-called COP21 [21st Conference of Parties] of the UN Framework Convention on Climate Change — in Paris in December 2015. The Brisbane G20 should help to prepare the world's leading countries to be true forward-looking problem solvers during these three crucial summits next year. Can the world still prevent runaway climate disaster? Yes, but we've almost run out of time. In 2009, and again, 2010, the world's governments agreed to fight to keep global warming below 2°C. Yet we are on a trajectory of 4–6°C by the end of this century. In fact, we could trigger runaway climate change, in which warming unleashes various feedback processes (such as the release of carbon dioxide from vegetation, soils and permafrost) that could lead to runaway climate disaster. That's why the 2°C limit is also called a “guardrail” for the world: one that keeps us from spinning completely out of control. So, to be more specific, can we still keep warming below 2°C? Yes, just barely, if all major economies of the world begin to take very strong and consistent actions to decarbonise their national energy systems in three main ways: shifting to low-carbon electricity, moving from fossil fuels to electricity in vehicles and buildings, and massive gains of energy efficiency. A fourth main global pillar is to shift from deforestation to reforestation and to reduce emissions from agriculture. These transformations are deep, but they are feasible. And they will not only protect the climate but also boost prosperity if we apply our efforts and ingenuity to the effort. We are running out of our planet's carbon budget — that is, the amount of carbon the world can burn and still remain below 2°C. But do you see these transformations being achieved by economic reasoning alone? No. A reinvigoration of a global moral code must also be a lifeline in the 21st century. Pope Francis is utterly correct and compelling when he speaks of the “globalisation of indifference”. We have lost our moral compass as a global society. The mass media, the cynicism of Murdoch and others, have crowded out decency, humanity, justice and foresight. Yet each of us wants our children and grandchildren to survive and to flourish. We each have an instinct, a moral fibre, to keep the world safe for the future and for each other. Yet we have to reinvigorate this morality, to overcome the immorality of greed and power that drive our societies today. At a time when our societies have unprecedented technological capacity in hand to end extreme poverty, a billion people worldwide are chronically hungry and destitute; in a period when health care technology enjoys astounding advances, 6 million children under the age of 5 worldwide still die each year of utterly preventable causes; and in an era when sustainable technologies for energy, industry, buildings and transport could rein in climate change, the world rushes headlong towards climate catastrophe — our attitudes and moral judgements will be the most important determinants of our fate, not our resources or our capacities. At this stage of history, humanity is at a crossroads, with the future course of our own choosing. We have the technical means to solve our national and global problems — to banish poverty, fight disease, protect the environment, and train the illiterate and unskilled. But we can and will do so only if we care enough to mount the effort. President John F Kennedy made the point compellingly a half-century ago. In his inaugural address in January 1961, he noted: “For man holds in his mortal hands the power to abolish all forms of human poverty and all forms of human life”. Two years later, on the quest for peace with the Soviet Union, J F K made the most essential point, the key reason for hope in peaceful problem solving, on poverty, climate change and the end of war itself: So, let us not be blind to our differences — but let us also direct attention to our common interests and to the means by which those differences can be resolved. And if we cannot end now our differences, at least we can help make the world safe for diversity. For, in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children's future. And we are all mortal.

Jeffrey D Sachs BA, MA, PhD · Stephen R Leeder MD, PhD, FRACP