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Perspectives 11 August 2014 Free

An open letter to the Prime Minister, the Honourable Tony Abbott, MP

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

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Perspectives 11 August 2014 Free

Open letter to the Hon Tony Abbott MP

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

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Perspectives 11 August 2014 Free

The G20, human health and sustainability: an interview with Jeffrey D Sachs

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

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Infectious diseases Perspectives 28 July 2014 Free

AIDS, loss and renewal

Opening address to the 20th International AIDS Conference, Melbourne, Australia, 20 July 2014 Jonathan Mann, loss and grief We who gather at this conference in Melbourne are no strangers to cruelty and loss. We know about suffering, irrationality and hatred. We have not been free of these forces for a single day since HIV/AIDS first appeared in our midst 30 years ago. Every one of us can tell stories about horrible acts and brutal conduct that have added to the misery and danger faced by people living with HIV and by those who love and care for them. We know of people who have died, or are dying, of AIDS; who are seeking love and the human right to respect and to life-saving health care. We know many who are denied justice and human empathy. We are here to affirm that there is another path. We point the way. It is why we have come to Melbourne. It is why we must lift our voices. This is not a time for silence. In the immediate loss of friends and colleagues who were coming to the conference on MH17, we are reminded, most cruelly, of the earlier death of Jonathan Mann: the first director of the Global Program on AIDS of the World Health Organization. This inspired humanitarian, who did so much to alert the world to the dangers of AIDS, perished with his wife and a plane full of passengers off St John's, Newfoundland, in 1998. He too was on his way to a conference on AIDS. He too had precious gifts to impart. It was a terrible loss to us and to the world. His memory drives us on. When I was asked to give this opening plenary weeks ago, I little thought that the plane crash that caused those deaths would be multiplied and magnified, this time by deliberate conduct of human beings. That it would kill delegates to our conference and many other peaceful travellers going about their lives, with no harm in their hearts to others. How cruel and self-centred these murders appear to be. How reckless and outrageous to make such means available to zealots. How much more pain do we have to face in the world of AIDS before we are through this bleak experience? Be in no doubt that irrational cruelty is, and will remain, our companion on this journey. It requires us to remember the past president of the International AIDS Society, Joep Lange, and his wife. To think of all the other delegates who expected to be sitting here with us in this hall at this occasion. They devoted themselves to scientific research, to patient care, to law reform and human rights. Would that we could turn the clock back. Would that we could laugh, and think, and dream, and struggle shoulder to shoulder with them here tonight. Yet we cannot. No strangers to suffering So we think of them and of others who have suffered, or are suffering, through irrational, unjust and destructive acts: Of Dwayne Jones, murdered in Montego Bay, Jamaica, in July 2013 when she identified as a woman. She was beaten, stabbed, shot and then run over by a car and dumped in a ditch. No one brought to justice. We think of David Kato, a gay activist in Uganda. He too was killed, in January 2011 — hammered to death for opposing the anti-homosexual law that has now been brought into effect in his country. We think of Eric Lembembe, a gay activist in Cameroon who was murdered in Yaounde in July 2013. We think of Charles Omondi Racho, who was killed and dumped by the roadside in western Kenya. The violence does not end. Yet brave reformers continue to stand up for their idea of equality and to suffer brutality as a result. Forgive me for speaking of the dead. But their suffering, in our context, is a demand for action. We think of the mothers and families in South Africa who, inspired by global efforts, challenged the denial to them of antiretrovirals which, for a mere dollar, would save their babies from HIV infection. We think of sex workers, drug users, prisoners, transsexuals, the disabled people living with HIV. For them our conference theme of “Nobody left behind” must often seem a cruel irony. We think of the bitter disappointments of legislatures that have failed to act. And of courts that have shown no insight. Like the recent decision in India that reversed the noble judgment of the Delhi High Court in the Naz Foundation case invalidating the colonial law on gays. We think of horrible new laws spreading throughout Africa and the violence that they breed. That violence sets back the struggle against AIDS. And we think of the lonely patients dying without hope. And the injecting drug users and other outcasts, rejected by family and society, where therapy would restore their lives and sense of self-worth. These thoughts too propel us on. All of us in Melbourne, and many far away, know that those of our companions who were lost on their way to join us also knew these things. They too had these images in their minds, as they set out to this continental and welcoming country. They would expect us to pick up our shattered spirits. They would demand that we renew and redouble our efforts. They would see those efforts as small but vital pieces of the great human puzzle that seeks to build a world that respects human rights, and heralds the day when the suffering of AIDS will be over. Apologies and affirmations I owe many apologies for presuming to speak at this moment of grief and pain: Apologies because the voice should really belong to those who knew and could tell us the simple stories of our friends who have been lost. And of the individual and collective contributions that they have made to the struggle in which we are still engaged. Apologies because I am not a person who is living with HIV or AIDS. Jonathan Mann always insisted on the importance of listening to the voices of those who are infected and understanding what they say. Who will ever forget the electric words of Justice Edwin Cameron, at the Durban Conference, as he castigated the government of his country for the crazy, wrong refusal (now reversed) to acknowledge the true science of HIV. Apologies because I am not a disabled person facing HIV. I know now that it had been hoped, and urged, that a voice would be given on this occasion to such a speaker so that truly no one would be left behind. I hope that such voices will be raised in these days in Melbourne, loud and clear. Yet I can speak as one who has tasted the bitter dregs of discrimination and hatred, because of my sexuality. By reason of that ethos, I lost 12 greatly loved friends in the early days of the epidemic. They too suffered discrimination, hostility, indifference, disgust. But they overcame these emotions. They lived and then they died in the sure conviction that things would get better. And so, through science, and education, and knowledge and human kindness, this has happened. It has occurred in Australia and in other lands. Step by step it has happened. Yet the enlightenment has still to reach many places where all too many get left behind. Six vital lessons In 1988, I spoke not at the opening but at the closing session of the Stockholm AIDS Conference. Re-reading my remarks has taught the essential simplicities of the key messages that must guide us still, here in Melbourne. They were true then. They are still true today. We must rediscover their clarity and direction. By repeating the basic lessons, we may gain success in persuading the sceptical. We may influence change in the directions essential if no one is to be left behind. First, there is the vital importance of science. All laws and strategies to deal with HIV and AIDS must be based on science, not mythology and prejudice. Science has brought us the miracle of triple combination therapy and new lines of treatment. Science has relieved suffering. It has made a big difference. And nearly 15 million people with HIV are now the beneficiaries. Second, we must listen to the voices. As Jonathan Mann taught us, people living with HIV and AIDS must be at the very forefront of our efforts. They will bring us realism. They will demand action. Third, we must help political leaders to understand the AIDS paradox, taught by Jonathan Mann. Paradoxically, and almost counterintuitively, the best way in current circumstances to get people to testing and to reduce the toll of death and suffering is not by punishing and isolating those infected with HIV. It is actually by protecting them. By entering their minds. By getting them to seek help. Law and policy must be made part of the solution, not part of the problem, of AIDS. Fourth, the HIV paradox can be explained and accepted by politicians, including on both sides of the political divide. No side in politics has a monopoly on wisdom or compassion on AIDS. Many have contributions to make. We saw this in Australia in the early frantic days, 30 years ago. Dr Neal Blewett, Labor federal health minister, and his Coalition counterpart, Dr Peter Baume, came together to embrace the AIDS paradox. They reached out in protection of gay men, sex workers, injecting drug users and others. In Australia, throughout the Hawke, Keating, Howard, Rudd, Gillard and Abbott governments, we have retained this steady course. It is something we can be proud of. It is a strategy with occasional imperfections and failings. But we can put it before the world as a basic model for effective AIDS policies. Fifth, we have resisted many traditional approaches to epidemics. From the earliest days, it was clear that quarantine, law's conventional response, would not work. The early promises of a medical “silver bullet” — a cure or a vaccine — did not eventuate. They continue to elude us. Yet the antiretrovirals and then the dramatic outreach to provide therapy as prevention to 15 million people made human rights a reality. Perhaps after all, no one would be left behind. Sixth, in many countries, leaders have tragically failed to embrace the paradoxes of AIDS. They have talked about action. They have received the subventions for antiretroviral drugs. But they have failed dismally to defend the human rights and lives of their own citizens. It is beyond time for the adoption by these leaders of initiatives that work. Without such reforms and also without changing the global laws on intellectual property, people will die needlessly. It is as simple as that. Someone must tell those who will not act the practical facts of life in our world. They cannot expect taxpayers in other countries to shell out, indefinitely, huge funds for antiretroviral drugs if they simply refuse to reform their own laws and policies to help their own citizens. Mickey Mouse in Fantasia in 1940 portrayed the global state we are now in. Too many countries are leaving the tap running full pelt. To sweep up the flood with a solitary broom is not going to work. We must turn off the taps. And that will not happen without an embrace of the kind of laws and policies we have long adopted in Australia. Sustaining the Australian model Do not think for a moment that it was easy for us to do as we have done in this country. It was hard. But it has held firm over 20 years. So how have we maintained our model on the AIDS response for so long? AIDS activists have done so by working closely and respectfully with political leaders of every persuasion. By appealing to human empathy, to human rights and to the cold realities of economics and the costs of leaving the taps running. Australia's Prime Minister, Tony Abbott, and his government, have engaged with AIDS activists. They have worked with them in search of common ground. This dialogue surely has lessons for other countries. We can learn from them. But I believe they can learn from us: Reversing the predecessor government's decision, the Abbott government in Australia has restored Australia's practical commitment to the Global Fund. It has promised $200 million in the place of a zero subvention that reversed past commitments. Our Foreign Minister, Julie Bishop MP, has been a stalwart defender of Australia's regional overseas aid model. The government knows that viruses can enter this country far more easily than boats. They realise that it is in our interests, as much as those of others, to help our neighbours to reverse the pandemic in their own lands. Julie Bishop has also insisted, as Jonathan Mann did at the outset, that AIDS is a major women's health issue. As a conviction politician and an unabashed conservative, Tony Abbott may be able to help us in this world to reach out to those political leaders, at the coming G20 Summit in Brisbane and in the meetings of the Commonwealth of Nations, to break the deadly logjam of inaction or wrong actions. Many of those who have left the taps of infection still open are more likely to listen to him than to others that talk a language that they abhor. Conservatives can be vital allies in the struggle against AIDS. We should never forget that it was President George W Bush in the United States who established the PEPFAR fund and promoted the Global Fund that has helped save millions of vulnerable lives. Renewing our commitment And so, once again, we remember Jonathan Mann and meet together in this struggle. We come to renew our commitment to ourselves, to our lost friends, and to the strategies that work. Rich and poor. Men and women. People living with HIV and those who love and support them. Religious and non-religious. Straight and gay. Liberals and conservatives. We are in this together. To those who live with HIV, to those who have died of AIDS and to those who have died in the struggle to advance the principles of the Melbourne Declaration, this conference should give a renewed commitment: to continue down the paradoxical path that has been shown to work. Never to allow the forces of cruelty and ignorance to deflect us. And never to be content while anyone is at risk of being left behind.

The Hon Michael Kirby AC, CMG*

Perspectives 28 July 2014 Free

The Australian's dissembling campaign on tobacco plain packaging

As plain packaging bites into smoking, The Australian newspaper relentlessly attacks the legislation This year marks two 50th anniversaries — the first United States Surgeon General's report on smoking and health1 and the establishment of The Australian newspaper. Fifty years on, there is literally universal acceptance of the massive harms caused by smoking — 178 governments have signed the World Health Organization's Framework Convention on Tobacco Control — but smoking still causes 6 million deaths each year. Given the preventability of the problem, action has been distressingly slow, largely because of the power and ruthless opposition of the global tobacco industry. Expert reports have noted over the years that there is no magic bullet: a comprehensive approach including legislation and education is needed. In December 2012, legislation came into force in Australia mandating plain packaging of tobacco products, despite ferocious opposition from tobacco interests. This was recommended by the National Preventative Health Taskforce as part of a comprehensive approach, and Health Minister Nicola Roxon was explicit about the main aim: “we're targeting people who have not yet started, and that's the key to this plain packaging announcement  —  to make sure we make it less attractive for people to experiment with tobacco in the first place”.2 Eighteen months later, The Australian ran a front-page story headed “Evidence ‘world's toughest anti-smoking laws' not working: Labor's plain packaging fails as cigarette sales rise”. This was based on a tobacco industry report, still unpublished, claiming a 0.3% increase in tobacco sales volume during 2013. The Australian's campaign against plain packaging continued with (thus far) 14 articles, including three front pages and three editorials attacking plain packaging and its advocates, and even defending the tobacco industry's right to advertise. The Australian failed to declare a lengthy past association between News Limited and the Philip Morris tobacco company (Rupert Murdoch was on Philip Morris's board from 1989 to 1998), or that some of its journalists and commentators on the issue have associations with the tobacco industry-funded Institute of Public Affairs,3-5 including the author of the original article, who also has a history of attacking the “nanny state”6 and “health fascists”.7 The industry's report remains secret, but Treasury has since published authoritative data showing that “tobacco clearances (including excise and customs duty) fell by 3.4% in 2013 relative to 2012”;8 according to the Australian Bureau of Statistics “total consumption of tobacco and cigarettes in the March quarter 2014 is the lowest ever recorded”;8 and newly released National Drug Strategy Household Survey results show that between 2010 and 2013, daily smoking rates among people aged 14 years and over “declined significantly” from 15.1% to 12.8% (Box); the average number of cigarettes smoked weekly by smokers fell from 111 to 96; and the average age of starting to smoke has increased to 15.9 years.9 Australia is a small market, but plain packaging has massive global implications for an industry desperate to maintain its capacity to promote and glamorise its products. The history of tobacco control shows that when one country implements a measure previously thought difficult, others speedily follow. Governments committed to introducing plain packaging already include New Zealand, the United Kingdom, Ireland and possibly France. The British debate is currently at a crucial phase. Legislation there would be a massive blow for Big Tobacco, not only because it is a much larger market than Australia, but because many countries still look to the UK as an exemplar in areas such as this. The Australian's misleading reports are unlikely to achieve much in Australia, where there is long standing bipartisan support for plain packaging and comprehensive approaches to tobacco control. Other media have provided accurate and unbiased coverage on this issue, as well as the reality that all the tobacco industry's predictions about disastrous consequences from plain packaging have failed to eventuate. But The Australian's reports have — as their authors must have expected — attracted attention overseas. UK headlines include “Plain packaging has backfired in Australia — don't bring it to the UK”, “Australia tobacco sales increase despite plain packaging”, “Plain packaging can increase smoking. That's the power of branding”, “Plain cigarette packaging hasn't worked in Australia and it won't work in Britain”. Tobacco companies and their allies have assiduously promoted a similar line — for example, the Institute of Economic Affairs (a tobacco industry-funded group, like Australia's Institute of Public Affairs10) asserts that “with tobacco sales rising after plain packaging was introduced in Australia, the public health case for this policy looks increasingly weak”.11 What can we conclude from this? Plain packaging passes the tobacco “scream test” — the more the industry screams, the more impact we know a measure will have. There is nothing new about deception and distortion from tobacco companies: this has been their practice for six decades. Fifty years on from the landmark Surgeon General's report, it is disappointing that a newspaper such as The Australian provides support for such approaches. Health campaigners should continue to promote measures that will benefit the community, especially children, even if opposed by powerful commercial interests, and to take pride in Australia's capacity to lead the world. Proportion of Australians aged 14 years and over smoking daily, from the National Drug Strategy Household Survey 1991 to 20139

Mike Daube BA(Hons), HonDSci · Simon Chapman PhD, FASSA, HonFFPH(UK)

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