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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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Health services administration Perspectives 14 June 2014 Free

Can we sustain health spending?

Australian governments currently spend relatively little on health. Are cutbacks really what's needed? The assertion that health spending is unsustainable has been made with remarkable regularity, most recently by the Federal Minister for Health, Peter Dutton.1 Despite publication of a major review by the National Health and Hospitals Reform Commission2 less than 5 years ago, the Minister has called for a far-reaching debate about the health system.3 Consistent with the rhetoric, the recent federal Budget has introduced copayments and foreshadowed cutbacks that are expected to reduce federal health spending by $8.6 billion over the 4-year forward estimates.4 The evidence usually cited to demonstrate the unsustainability of health spending is its impact on government finances. Between the 2001–02 and 2011–12 financial years, health expenditures by all levels of government rose from 19.8% to 25.6% of total tax revenues,5 and projections by the National Commission of Audit prior to the recent Budget suggested that federal spending alone could rise from $65 billion in 2013–14 to over $120 billion in 2023–24.6 These trends are commonly linked to the ageing of the population to conclude that significant structural reforms are needed to reduce spending on health services, and the recent budget measures may be seen as a first step in this direction. Despite these projections, the unsustainability thesis is remarkably weak. Economies are flexible and the composition of spending varies significantly over time and between countries. At the time of federation, agriculture, manufacturing and the services sector accounted for 19%, 12% and 31% of gross domestic product (GDP), respectively. By 2011–12, the shares were 2%, 6% and 56%, respectively.7 Technological change reallocates resources, and the expansion of industries is usually seen as desirable because it employs the displaced workforce and generates additional benefits. The anomalous concern with the costs and not the benefits of an expanding health sector implies comparative lack of concern or confidence in the benefits despite evidence that better health is one of the diminishingly few ways in which we can improve the quality of life of the population. The flexibility of economic systems is also apparent when countries are compared. Australia currently devotes 9.5% of GDP to health, while the proportion in the United States has reached 17.7% (Box). The efficiency of the US health system may be questioned, but there is no suggestion that it has impaired the economy or sapped the vitality of the country. The US case is interesting for another reason. Despite having the largest health expenditures in the world, when compared with the wealthy countries of the Organisation for Economic Co-operation and Development (OECD) the proportion of the population above the age of 65 years in the US is the smallest. In contrast, the country with the oldest population – Japan – spends little more than the OECD average on health. This illustrates a common error: the belief that health spending is tightly linked to the demographic structure and that ageing necessarily drives health expenditures. Historically, this has not been true, as health expenditures have been driven by technology and the increasingly generous provision of health services as GDP rises.12 Nevertheless, the pressure from ageing is likely to intensify. By 2050 the proportion of the population above 65 years of age in Australia is likely to rise from 14% to 22% and the proportion over 80 years to double from 4% to 8%.8 The pressure is likely to be exacerbated by expensive health technologies targeting individuals rather than broad disease categories. However, even with the slowing in the rate of per capita GDP growth to the average 1.4% per annum that occurred between 1970 and 1990, by 2050 GDP per capita will expand by 65%. Even if total health expenditures rose to the US level of 17.7% of GDP there would be an expansion of non-health-related per capita GDP of 50%, which could be devoted to the improvement of the material standard of living. This is not a paradox. Even if GDP grows more slowly than health expenditures, the absolute (not percentage) increase will be greater than the absolute increase in health expenditures. A 65% rise in GDP from a (index) base of 100 will increase resources by 65 points. A 200% rise in health expenditures from a (index) base of 9.5 increases resource use by 19 points. Resources for other uses would rise by 46 points. Given the evident sustainability of health spending for some decades, it might be asked why health has been targeted for cutbacks. At 6.6% of GDP, public health expenditures by all governments in Australia are the tenth lowest of the 33 countries in the OECD database and the lowest among wealthy countries in the group (Box). Even US governments, which channel 8.3% of GDP into public health programs, outspend Australian governments. Further, as indicated in the Box, Australia has been relatively successful in restraining the growth of health spending. A possible reason for the Minister's concern is that, irrespective of comparative statistics, health spending in Australia — or public health spending in particular — may be inefficient. For example, a survey by Runciman and colleagues13 found that compliance with indicators of appropriate care was highly variable as judged by a retrospective review of medical records and telephone interviews with at least 1000 Australians. However, neither this nor the many other problems with the organisation and provision of services are likely to be resolved by increased copayments or reduced public spending. Both options would increase pressure for private health insurance (PHI) to cover the gap, and there is little or no evidence that private insurers would be more willing than the public sector to undertake the reforms needed to improve the quality of care. In principle, managed care might be used by private health insurers to achieve this goal, but the evidence of its success is limited and it appears unlikely that this is an option that Australian governments would be prepared to pursue, at least in the short run. It is possible that copayments are seen as a way of controlling total costs; however, the effect of the recent budgetary measures on economic costs — resource use — will be miniscule. Evidence unequivocally indicates that copayments have a relatively small effect on service use. The $6 copayment initially proposed by the Australian Centre for Health Research14 was estimated to reduce service use sufficiently to save $750 million over 4 years — 0.3% of federal health spending, 0.14% of total health spending. The greater part of the 4-year federal budgetary saving of $5.5 billion on Medicare Benefits Schedule items and $866 million from the Pharmaceutical Benefits Scheme will therefore be a result of cost shifting to the public, not reduced service use. However the burden of private spending falls unevenly on the public: it self-evidently falls on the sick. Bulk-billing primarily assists those who are on a low income. The principle effect of its elimination will be a redistribution of income from this group to the healthier, wealthier members of the community. Copayments will, additionally, divert patients from lower-cost general practitioner care to higher-cost outpatient care. Those who defer needed treatment are likely to eventually need more expensive specialist care. Perversely, in the longer run, eliminating bulk-billing is likely to increase GP fees and expenditures by reducing competitive pressures. An increase in the copayment from $7 to $10 is less likely to adversely affect an individual GP practice than the cessation of bulk-billing and the initial introduction of a copayment. Inflation of fees will be accelerated when the government succumbs to pressure to allow PHI to cover the widening gap. Increased GP fees may be independently desirable given the low level of GP incomes — the lowest relative to average wages listed by the OECD after Estonia and Hungary. However, a more equitable remedy would be to increase, not decrease, the rebate. Reduced budgetary expenditures are not a necessary response to unsustainable spending or a solution to demonstrated inefficiencies. Rather, they are a response to budgetary pressures arising from inadequate tax collections and the failure of successive governments to implement suggested reforms. The 26.5% of GDP raised by all forms of taxation in Australia in 2012 was the fourth lowest of the 34 OECD countries after Chile, Mexico and the US. Proportionally, Northern European countries collect 40%–75% more than Australia. The result of lower taxation is lower levels of community services and infrastructure, and a long-term structural problem for government finances — outcomes which are strikingly evident in the US. The damage to be inflicted on the health sector by reduced public spending is part of the price Australians will pay for the persistent failure of government to address this problem and to raise taxation to a level that allows improvement in the economic infrastructure, better community services and spending on all of the health services which — after careful evaluation — have been shown to provide cost-effective health benefits to the Australian community. Health spending, older population and taxes for selected countries Total health spending* Public spending Population aged 65+* Taxes† 1980 (% GDP) 2011 (% GDP) PP increase 2012 (% total)‡ 2011 (% GDP)¶ 2011 (% total) 2012 (% GDP) Australia 6.1% 9.5%** 3.4 69.7%** 6.6%** 13.7% 26.5%†† France 7.0% 11.6% 4.6 76.9% 8.7% 17.1% 45.3% Canada 7.0% 11.2% 4.2 70.1% 7.4% 14.7% 30.4% Japan 6.4% 9.6% 3.2 82.5% 7.8% 23.3% 28.6% Sweden 8.9% 9.5% 0.6 81.7% 7.7% 19.3% 44.2% Netherlands 7.4% 11.9% 4.5 79.8% 9.5% 15.9% 38.6% United Kingdom 5.6% 9.4% 3.8 82.5% 8.1% 16.2% 35.7% United States 9.0% 17.7% 8.7 46.4% 8.3% 13.2% 24.0% OECD 6.6% 9.3% 2.7 na na 15.4% 34.1% GDP = gross domestic product. PP = percentage point. OECD = Organisation for Economic Co-operation and Development. na = not applicable. AIHW = Australian Institute of Health and Welfare. * OECD.8 † OECD.9 ‡ World Bank.10 ¶ OECD.11 ** AIHW.5 †† 2011 figure, as 2012 figure was not available.

Jeffrey R Richardson PhD

14 00564

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