Their investigations raise concerns for the wellbeing of many vulnerable groups – especially in rural Australia – but also show there are many unanswered questions about the relationship between recession and health.

Dr Megan Keaney and Rebecca James from Research Australia, write:

“Amongst the millions of column inches written and hours broadcast about the global financial crisis, very little attention has been given to whether recession is bad for our health. It is not difficult to imagine that becoming unemployed is bad for our mental health but are there wider impacts? If so what will they be, who will bear the burden and is our health and welfare system prepared to meet the challenge?

Mental health professionals are already seeing a steady stream of recession casualties.  “BJ” is one such person. At age 57, he lost his business and savings late in 2008 and by November was severely depressed. He took an overdose of medication that left him with memory problems. When he left hospital, his ex-wife of 10 years took him home to a rural town, thinking that he would recover in a few weeks.  Twelve months later she remains his carer and his brain injury means that he has no prospects of returning to work or living independently.

A report released this week by Research Australia, Australia’s Financial Crisis: Implications for Health and Research reveals that becoming jobless is associated with higher rates of a variety of mental health disorders. Suicide rates in young men track the unemployment rate and even keeping a job in an environment where job insecurity is heightened is associated with higher rates of psychological disturbance.

Although the jury is still out, studies from previous recessions suggest that becoming unemployed is bad for physical health too.  For instance, a  UK study from the 1980s showed that job loss led to a 37% higher chance of dying in the next 10 years.

The good news is that for mental health at least, return to the workforce as the economy recovers, leads to improved mental health. If that was the whole story then health departments might be comfortable that although some extra mental health services might be needed to meet extra need during recession, with economic recovery, the status quo should return. However, as BJ’s case highlights, it may not be that simple. And the difference is that recessions don’t have the same impact for everyone.

It is well accepted that there is a strong correlation between socio economic status and health. In Australia people who live in disadvantaged communities with higher rates of joblessness, lower household incomes, lower levels of education and lower social status have much poorer health outcomes across the board than the well off. In Australia there is a strong link between poverty and unemployment.

The real risk of recession is that it adds to the pool of long term unemployed (those people who are out of a job for 12 months or more). The longer people are out of job, their return to the workforce is less likely. Unemployment impacts on those who can least afford it – people with lower education, fewer skills, and intercurrent health problems. Not surprisingly rising unemployment concentrates disadvantage in already struggling communities on the urban fringe and in rural Australia.

We know that long-term unemployment and poverty is bad for our health. So what will this recession bring and are we well prepared to meet that challenge?

During the early 1990s recession the number of long term unemployed receiving income support increased from 170,000 to a peak of 438,000. Although the percentage of unemployed who are long term unemployed in 2009 is low relative to the early 1990s (about 13%) it is feared that this group will rise by 150% over the next two years.

Treasury’s recently revised forecast that unemployment will peak at 6.7% might appear reassuring given that in the last two recessions unemployment rose to well over 10 percent. However the number of people looking for work is not the whole story.

Over the last 20 years there has been enormous uptake of the Disability Support Pension with the number of recipients increasing from 307,000 in 1989 to 750,000 this year. This recession too is a story of underemployment with the labour under-utilization rate increasing from 9.9% to 13.6 % in the 12 months to August 2009.

In other words, 1.5 million Australians are unemployed and looking for work or would like to work more hours. There is no doubt that for these people and their families, financial stress is real. So how will their health suffer?

Long-term unemployment might mean higher rates of illness and premature death from a wide range of illness including heart disease, cancer, mental illness and even accidental injury. Importantly the impacts are likely to be intergenerational.

Western Australian research shows that children from disadvantaged families start out life behind the eight ball with problems including lower birth weight which are carried through to higher rates of childhood illness such as respiratory and mental illness, and even into adult life with international research suggesting that chronic adult disease has its roots in early childhood and even prenatal factors.

Much of this health disadvantage is mediated through social factors such as lower educational levels, fractured families and communities and in turn higher rates of health risk behaviours including smoking, alcohol use, less physical activity and obesity. A good start counts for a lot when it comes to health.

At the other end of life, research shows that for older workers ill health and unemployment is a two way street. Close to half of Australians aged over 45 who retire early do so because of ill health. Older workers who develop heart disease or mental illness are especially unlikely to re-enter the workforce.

For the health care system, more illness means more demand. Australians enjoy relatively good access to the health care system and long-term data tells us that unemployed people and those who reside in urban disadvantaged communities see their GPs more often and have more hospital visits.

However recent polling by Research Australia and MBF reveal that for many Australians, this recession is already affecting choices we make about our health. For instance, over the last 6 months financial stress has caused close to 20% of people to put off seeing a doctor or dentist and a staggering two million people have gone to work ill, rather than take sick leave, because of concern about job security.

Many questions remain unanswered. Recessions might be bad for our health – particularly if we lose our job and never work again. However, as the economy recovers jobs will be regained and fears about joblessness and financial stress will fade. But are there lingering problems for our health? We really do not now whether cyclical economic downturns impact our health in the long term and well accepted research demonstrating that relative socio- economic status correlates with health outcomes provides only some of the answers.

Most importantly when reflecting on the possible consequences of this downturn for our health, we need to consider whether government policies and programmes designed to limit the economic fall out of this recession are working.

Do we need different strategies that better target social and health impacts? Are we making the right investments now to support vulnerable groups so that we have a healthy and productive workforce as we come out of recession?

What is clear is that we need to better integrate our health, economic and social research effort so that we learn the lessons of this recession. Only then will we be able to deal with the public policy challenges that are the legacy of this recession or accompany the next one.”

• (Declaration: Croakey’s moderator Melissa Sweet had a hand in editing the report)

Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

But Ron Batagol, a pharmacy and drug information consultant, says this will require us to examine some of our somewhat hypocritical attitudes towards breasts.

He writes:

“A meeting of Health Ministers on 13th. November has endorsed the Australian National Breastfeeding Strategy 2010-2015.

The Strategy recognises the biological, health, social, cultural, environmental and economic importance of breastfeeding and provides a framework for priorities and action for Australian governments at all levels to protect, promote, support and monitor breastfeeding throughout Australia.

Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond if both mother and infant wish.

It is concerning that a longitudinal study of Australian children conducted in 2004 found that while 92 per cent of new borns were initially breastfed, by one week, only 80 per cent were fully breastfed. The study also indicated a steady decline each month with only 56 per cent fully breastfed at three months and 14 per cent at six months.

The new federal strategy would include increasing community acceptance of breastfeeding as a cultural and social norm, establishing breastfeeding support networks for pregnant women and improved breastfeeding training for health professionals.

But, since it has been estimated that over a quarter of Australians still think that breastfeeding in public is unacceptable, obviously there is still a long way to go!

And  I have to say that it’s quite paradoxical. In the post-modern world of the 21st century, when the fairer sex “frocks up”, as they call it these days, no one gives a second thought about exposed cleavage.  In fact, the dress designers have lead the charge to make the breasts the focal point of society’s attention when women’s attire is “out there” being critically scrutinised by all and sundry.

On the other hand, as we’ve seen in recent times, with unfortunate regular monotony, the sight of women, anywhere outside the confines of their own homes, trying to nourish their infants with the most natural of all beverages, mother’s milk, provokes an outcry of pompous indignation.

Oh, yes, excuse me, I forgot!  On a plane, with all those complete strangers sitting in close proximity? In the sacrosanct and hallowed corridoors of Parliament of all places!  And for God’s sake, worst of all, in a 5-star restaurant – a place where other people pay good money to sit down, quaff a fine wine or three and gourmandise their way through their mouth-watering degustation.

Suddenly, the notion of these mammary glands doing what they were actually created to do in a “public place” is deemed to be titillating, and breastfeeding is transmogrified into something wicked and evil.

Yet, 28 years ago, a worldwide Marketing Code was established for synthetic milk formulas, because millions of infants died in developing countries where well meaning mothers tried to copy their emancipated, more affluent counterparts by preparing formulas despite lack of clean water, refrigeration or education about how to make up the feeds.

So now, breast-milk  is “in” again- transported in  unbreakable packages, and satisfying consumer demand- all in all, the perfect 21st century product, with breast-fed babies having better immunity, and better long-term medical benefits than their bottle-fed buddies.

One can only live in hope that, as a society we may become a little less hypocritical and to try to remember why these mammary appendages were given to women in the first place.

Surely that’s not too much to ask, is it?”

Some of the most critical comments have come from breast cancer consumer advocates - overtones, perhaps, of how prostate cancer consumer groups have sometimes reacted to evidence about the potential harms of prostate cancer screening.

Now Hazel Thornton, an independent advocate for quality in research and health care in the UK, and an Honorary Visiting Fellow, Department of Health Sciences, University of Leicester, gives us another perspective. Thornton describes herself as having being “given the breast cancer label” as the result of undergoing mammographic screening in 1991.

She writes:

“It is unsurprising that women find it hard to accept the facts from papers such as that by Stephen Morell and colleagues from the University of Sydney, and from robust systematic reviews of screening by mammography, or of breast self-examination.

Twenty years of being told what to do in paternalistic promotional literature extolling the benefits of ‘finding it early’, and being frightened by being told that ‘it could save your life’, are difficult to reverse.

As we see, many women’s support and information groups are still encouraging women to disbelieve good evidence of over-diagnosis and over-treatment. They assert that it is acceptable to accept unnecessary lumpectomies, mastectomies, radiotherapy, chemotherapy and hormonal treatments “just in case”.

Promotion and arguing that this utilitarian ethic is acceptable by those in authority is unethical and harmful: it denies those women who trust them proper respect and the right to be properly helped to make up their own minds by neutral presentation of balanced facts. For more information, see the English version leaflet that can be downloaded here.

For too long ‘The Facts’ that women have been provided, e.g. by the UK NHS Breast Screening Programme, have been short on fact, short on evidence-based data, but full of persuasion, estimates, promise of benefit – but silent about harms.

Until this year, that is, when they at last capitulated to exposure by a letter in The Times 19th February 2009 signed by 23 international experts, stating that their invitation leaflet was short on the truth and totally inadequate for the purpose of enabling women to make an informed decision about whether to attend.

Many women were and still are unaware that they have any choice in the matter – and, as Iona Heath entitled her paper in the BMJ: “It`s not wrong to say no!” (abstract is here)

Strenuous objection had repeatedly been made to informing invited women about pre-invasive cancers such as DCIS.

Yet, in the UK, on Sunday 1st November 2009 it was reported in The Sunday Times that “The Government has been forced to rewrite its advice on breast cancer screening after research showed that thousands of women have been misled into having unnecessary surgery.”

Joan Austoker (who is leading the revision of the invitation leaflet) “had admitted it had been a mistake to withhold information about unnecessary treatment for DCIS”. It was also reported that they “want to make sure that all the risks of breast screening are referred to in appropriate detail.”

Only this week, 17th November 2009, the US Preventive Task Force has published guidelines with the following recommendations: “The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation)” .

Quite a turnaround!

This month in the UK, Sense about Science, addressing poor public understanding about what screening can and cannot do, launched a booklet: “Making Sense of Screening”.

Little by little, reason is beginning to prevail over blind belief!”

Would such a move be useful and welcomed in Australia? Read on…

Associate Professor Tim Gill, Institute of Obesity, Nutrition and Exercise, University of Sydney:

“Requiring calories counts to be placed on menu boards in restaurant chains is a good thing but as Jane Martin points out, it is unlikely to have a profound effect on food choice by itself.

It is akin to putting up speed advisory signs at dangerous bends in the road. They are useful if you understand and are accepting of the benefits of such advice; recognise your own limitations and the need to be cautious of road conditions; are not distracted by other issues and thus fail to acknowledge such advisory signs; or over-ride the advice because of your perceived lack of time to slow down.

Unfortunately with both calorie counts and speed advisory signs they are often ignored.

This is not a reason to avoid instituting such measures because they will be of benefit to those who are in a receptive state and can effectively process and act on the information.

Rather it is a reminder that such measures need to be instituted in combination with a variety of other strategies to encourage and support people to be more receptive to these signals.

Of course the preferred method of dealing with dangerous bends in the road is not to encourage people to slow down but rather to take that responsibility away from them by remaking the road at great expense to remove the bend.

Funny, no one ever suggests that this is a nanny-state approach to road safety.”

***

David Gillespie, author of Sweet Poison, Why Sugar Makes us Fat:

“Would you feed your kids a glass of milk or a glass of Coke for breakfast?  Yep, I’d go with the milk too.

How about if you know that the milk has 168 Calories but the Coke has only 108.  Would you switch to the Coke then?  No? You’ve just explained to yourself why Calorie labelling is a pointless waste of time.

You’ve also explained to yourself why Big Sugar is particularly keen on Calorie labelling.  They know a few things which most nutritionist have either forgotten or didn’t know in the first place.

Fat serves up 9 Calories per gram whereas everything else (including sugar) is only 4 Calories.  Calorie labelling is therefore really just fat labelling by another name.  The reason the milk has more Calories than the coke is because it contains fat and the Coke doesn’t.

The study referred to by Dr Russell tells us that it doesn’t really matter anyway.  Just over a quarter of the respondents noticed the Calorie information and it didn’t influence their choices anyway.

Big Sugar knows that no-one knows or cares what a Calorie label means and even if they did, sugary products would come out looking good by comparison.  Do we really want people being steered towards high sugar, low fat foods by Calorie labels?

Ignorance of the number of Calories in food has nothing to do with why we are all fat. We are fat because our food supply is laced with sugar.  Sugar has been proven to significantly interfere with our body’s internal Calorie counter (by making us resistant to the hormones which tell us when are full).

When our appetite control system is working, we eat exactly the number of Calories we need.  If they come from fat, we eat less of everything else.  If they come from protein or carbohydrate, we eat more.

We are fat because our fuel gauge is broken.  We are not fat because we don’t know how much fat is in what we are eating.  We don’t need Calorie counts on menus, we need our built in Calorie counters to start working again.  And the way to do that is eliminate sugar from the food supply.

But don’t fret too much about lobbying for Calorie counts, Big Sugar will implement them voluntarily soon enough.”

****

Stephen Leeder,  Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy:

“My personal view is that the more nutritional information that consumers can be given access to, the better.  The work that Tom Friedan, former chief health officer of New York City and now boss of CDC, in getting restaurants to label their menus is part of a larger enterprise to raise community and commercial awareness of nutritional responsibility. He did the same with tobacco control to good effect.

People DO take an interest in food labelling. Come with me one weekend to Coles in Katoomba – hardly the socioeconomic pinnacle of NSW society – and observe how often customers stop and read and compare food labels.

Many would argue, with evidence, that colour coding of foods with red, orange and green to indicate the safety levels of key components such as saturated fat, calorie density and whatever else.

The food industry presents elaborate objections to the ‘traffic light’ labelling. But in the meantime, until this is resolved, clear nutritional labelling makes sense. I think one of the craziest moves ever was the move away from the calorie, which many people understood, to kilojoules, which people don’t understand.

Food labelling is very political and much engagement with the food industry by action oriented politicians (and not all are) makes great sense.”

***

Boyd Swinburn, Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention Deakin University:

“I am just travelling at the moment but have discussed this people here in the US.  It started in New York City where to got in regulations to include the calorie content next to the price on the menu boards of chain restaurants.  They also had an anchor that about 2000 kcal is what was needed for a typical day for a typical adult.

Several other cities/states started following suit and expending the provisions. The industry could foresee an escalating situation and called for federal regulations which require the calorie information but prevent local authorities for pushing it further.

I definitely think the Australia should follow suit and all the arguments that it is not possible have evaporated. Our use of kJ will add complexity however.”

That is the suggestion of this very interesting piece below from Patrick Bolton, who has long and diverse experience in the industry.  He has worked as a GP and hospital administrator in urban and rural Australia in several states and territories. He has researched and published in health data, information management and health systems evaluation. He is national vice-president of the Australian Hospitals and Healthcare Association, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of NSW.

Bolton writes:

“When he is not solving the world’s climate and economic problems, I understand that the Prime Minister is touring the nation consulting about the future direction of the healthcare system. I’ve knocked around in, and been an observer of, that system for a while, and I offer the following observations in the hope of informing that debate.

There are always more things that can be done in healthcare than money to do them

As a result, some people miss out on some care some of the time, and this will always be so. This isn’t rationing because there is nothing rational about it.  At present the system responds to this truth by pretending it doesn’t exist. A problem must be acknowledged before it can be addressed.

Some of the people who miss out make a noise – for example by complaining to an MP – and then get what they want. This is unfair on those who don’t complain because it means that limited resources are shifted to the loudest.

It is not irrational for the people who complain to complain. They will benefit, assuming the medical care they receive does more good than harm. It is society as a whole that loses. There is no-one arguing on the side of society as loudly as individuals argue in their own self-interest. The hit the individual faces is large, the personal cost to each individual in society small.

Of greater effect on the system is that healthcare workers make choices for individual patients, not for society. Again this is rational. As a healthcare worker I want to provide the best care for each individual that I look after, and as a patient this is the standard I expect of the healthcare workers who care for me. Even were I prepared to favour the interests of society over the individual, I would have to trust that others in the same position will do the same. If they do not, then my altruism is benefiting them and not me.

This factor creates a difficulty because doctors are arguably best placed to assess which patients will benefit most from which interventions, but any management system that asks them to do this puts them in a position of conflict of interest. This is a source of professional dissatisfaction for healthcare workers

The difference between what people want and what the system can provide is one of the sources of dissatisfaction with the system. It contributes to the perception that reform is required.

The only way to make the health system cheaper is to reduce services

Many of the initiatives proposed by the Hospitals and Healthcare Reform Commission are said to improve health outcomes and so make us live longer and healthier lives. This is desirable if it is correct. Unfortunately, we will all still be dead in the long run, and around 80% of healthcare resources are consumed in the last two years of life, whether we die at 70 or 100. None of the proposed changes are about reducing cost as an end in itself. If the proposed changes work we will live longer – so consuming healthcare resources for a longer period, albeit possibly at a slower rate, then cost the same amount when we finally die.

There a no great savings for the healthcare system in this, although there may be increased  productivity as an offset. Health is a superior good, one on which individuals and communities spend more as they become wealthier, and this may justify additional expenditure.

It is not clear what the objective of the health system is

It is difficult to go somewhere unless one knows where one wants to go. Individual needs, expectations, and capacity to assess outcomes of the healthcare system vary. This means that the perceived purpose of the healthcare system varies depending on who you ask.

It would be surprising if the interests of the most vocal group – healthcare providers – coincided with that of the majority who pay for these services. There are no other areas where the interests of vendors and customers coincide, so why expect this in healthcare?

Healthcare doesn’t seem to make much difference to health

This is well known and such a show-stopper that everybody, me included, seems to acknowledge it and move on. I think it reflects several factors. These are:

a)    There is good evidence that the health of first world societies is closely associated with the level of equality in that society, not to the level of healthcare. If this relationship is causal then it can be argued that one should invest in strategies to promote equality in preference to healthcare.

b)    Individuals are not good at assessing the outcomes of the care they receive and the system is not good at measuring outcomes.

Most people recover from illness, but some do not. The outcome is multi-factorial, so it can be difficult to say which part of an individual’s health outcome is a result of the care that they received and which due to other factors. It is particularly difficult for lay people to judge the quality of the care they receive.

Changes in healthcare tend to be incremental, and so outcomes compare current treatments with alternatives which are likely to be only slightly better at best, as opposed to no treatment. It is generally held to be unethical to compare new treatments against no treatment. One might argue that this is irrational in cases where current therapy has not been shown to be superior to no treatment.

The quality of outcomes measurement of the healthcare system is woeful. Given that much of the money for healthcare comes from the public purse this is a significant failing of accountability.

c)    There is a high error rate in healthcare. International studies repeatedly show that errors in healthcare delivery occur in around 10% of cases. In Australia these errors are associated with about half of all in-hospital deaths. If death is the outcome measure then Australian hospitals may be killing as many people as are killed by the conditions for which they were admitted. The harm that the health system causes may offset any benefit that it delivers.

d)    Estimates are that one-third of what is done in healthcare is unnecessary. Two things follow from this. First, if unnecessary care can be identified and stopped, then the efficiency of the healthcare system can be improved by up to 30%. Second, unnecessary care still causes harm, and this offsets the benefit from effective and necessary care for the system as a whole.

Healthcare in Australia is not a very enjoyable place to work

This has important implications for workforce engagement and sustainability.

Poor work hygiene is bound up in the foregoing issues. It is hard to feel satisfied about what one is creating if the value of the product is at best unclear, and possibly negative.

The response of policy makers to these issues has been to tighten the leash and increasingly micromanage healthcare delivery. Healthcare workers are highly skilled employees, expert at making individualised decisions in complex settings. It is unlikely that directive management can lead to better outcomes that professionals can provide themselves, so micromanagement results in alienation of the work force without improving performance.

Suggested pre-requisites to change

There is nothing new in any of this, but it needs to be said because the healthcare system cannot improve until these factors are addressed. Some suggestions to do this are:

1.    The new health system needs to be as clear as possible about what it is trying to achieve, and collect data which measures performance towards these achievements.

2.    The new healthcare system needs to be able to demonstrate that the things that it does are effective, cost effective and done to people who will benefit, and not those who will not.

3.    The new health system is going to have to allocate resources transparently on the basis of 1 and 2 above. This is so that equity and efficiency are maintained in the face of other interests.

Addressing these factors is necessary but may not be sufficient. If they are addressed, then healthcare will improve under the current governance model. Some other governance model may be preferable for the reasons currently being debated, but we can’t know this until the problems discussed here have been addressed.

No governance model can be properly assessed until these underlying distortions are addressed. Introducing the kinds of major change contemplated is not without risk. It will be impossible to manage and measure the impact of this risk until these factors are addressed.”

There I told you – it was worth taking the time for the read, wasn’t it? Plenty of food for thought there.

All these years later, Canada is still mining, manufacturing and exporting asbestos.

At the American Public Health Association conference last week, a resolution (you can download it here) was passed calling for a global ban on asbestos mining, and manufacturing, and the export of asbestos containing products.

Canada received particular mention for continuing to export the stuff to developing countries while banning its local use, and also for blocking the inclusion of chrysotile asbestos in a list of hazardous substances requiring prior informed consent when exporting them under the Rotterdam convention.

But Dr Yossi Berger, an occupational health and safety expert with the Australian Workers’ Union, believes it’s time to shift the debate beyond bans, and to start looking at removing asbestos from buildings and anywhere else it may be putting lives at risk. He writes:

“It’s a good thing that the American Public health Association is calling for a total ban on asbestos containing materials (ACMs).  But it’s now time to shift the paradigm.  There are millions of acres and hundreds of thousands of tonnes of ACMs currently in use around the world.  These, I believe, are ‘faulty’ products that should never have been manufactured.  The Australian Workers’ Union recently called for a once and for all total removal.

Hundreds of thousands more people will be killed by ACMs.  Currently hundreds of thousands of people are the walking wounded as a direct result of exposure to ACMs.  They painfully understand the preciousness of every single unobstructed breath of air.  Their lives and that of their families’ have become nurseries for terror.

Drago told me that, “Each night I don’t know what the morning will bring for me”, and he adds in a rasping voice between laboured breaths and coughing, “I feel guilty when I look into my wife’s eyes and see the pain”.

I believe that ACMs are unsafe in any condition.  This is so despite painting over them, despite cladding over with safer products, and despite various poorly implemented laws and regulations.

No one can tell me which single asbestos fibre entering someone’s lung right now is the one that will not kill them, but if you don’t breathe any fibres you will not suffer an asbestos-related disease.  Doesn’t it follow that whilst extremely dangerous such products can be made safe by reducing exposure to fibres?  Yes, in theory.

But the time I inspect such presumed ‘safe’ ACMs in industry I see a great deal of damaged material, constantly vibrated and shaken material releasing fibres, I see it in broken bits on the ground, split and stuck back on with tape, I see the empty spaces where warning signs should be, I ask in vain for records of the presence and supervision of such materials, I try to find informed people, informed workers about the risks of such materials; in my dreams!  These ‘safe’ materials are temporarily safe only if these things happen, and they typically don’t.  What do I tell the worker who asks me, ‘Can the little bit extra fibres I’ve breathed kill me?’

It’s for these reasons that the AWU makes the case that such materials are ‘unsafe at any speed’.  They present permanent mortal risks that too frequently eventuate.  The AWU has called for what amounts to a total product recall, a total removal program over a 20 year period.

We have called on the federal government to implement a national removal program.  Such a program must be developed as a Prioritised Removal Program (PRP).  Once ACMs are discovered the program commences.  We argue that all buildings – once assessed and the PRP is triggered – (starting with industry, public spaces and schools) must have an asbestos designation and an ACMs identifier that’s colour coded as  red (immediate removal), amber (3-6 months) or green (6-18 months), an  Asbestos Presence Ticket.   This must be prominently displayed.

We need to move past banning and into total removal.  But a ban is good start.”

Andrew Penman, Chief Executive Officer of Cancer Council NSW, has been considering the complexities of the issues involved, and writes:

“As a public health program, screening for breast cancer makes sense.  It reduces mortality by 30%, the cost incurred in saving a life is competitive, it reduces the number and percentage of women who present with advanced and disfiguring lesions, and opens the door to less invasive treatment options.

Given the impact of breast cancer on population health expectancy and on the lives of women affected it is understandable that there is a large and voluble group of body protagonists for breast cancer screening and their cause is justified.

The evidence that screening reveals early cancers and initiates a treatment pathways in some women who would not have needed to endure it in the absence of screening is well proven.  The size of the effect at around 1 in 4in Australian research also appears a reasonable estimate.

On reflection, it is entirely consistent with our understanding that cancer incorporates an array of neoplasia with varying degrees of biological potential.  However, as our experience of the natural history of cancer has been framed predominantly around clinically significant disease, we are be less attuned to the behaviour of cancers with lesser biological potential.

Given that participation in breast cancer screening remains suboptimal, it is natural for the advocates for screening to be defensive when any evidence to counter the claim for benefit emerges, particularly when that evidence suggest that some participants will bear a burden as a result of screening without commensurate benefit.  But no population health intervention spreads benefit and burdens equally.  If this were a requirement, we would have no immunisation programs. In mammography screening at the very least those who are never diagnosed with cancer carry the burden of participation.

The use of the term “over diagnosis” to describe the detection of cancers with limited biological potential contributes to the defensiveness of advocates for screening.  It carries with it connotations of unnecessary and self-serving medical intervention, of overzealousness with attendant disregard for participant welfare.  Advocates are at pains to downplay any information that may further erode public confidence and participation.

In reality, the detection of cancers (or pre-cancers) with limited biological potential in inherent to the screening methods for all cancers.  It is therefore misleading to represent this as “over diagnosis” with its pejorative connotations, when such detection is part and parcel of the pathway to achieving benefit at the population level as well as at the individual level for the 3 out of 4 women diagnosed.

Screening detects cancers with limited biological potential, but the way the issue is framed affects the way we and participants react.  For participants, a proposition that any lesion detected has a 75% chance of progressing to life endangering cancer is different from a proposition that there is a 25% likelihood that any diagnosis is unnecessary.

Randomised trials of decision aids that deal dispassionately with risks and benefits of screening, including “over diagnosis”, show that women who use the aids are more informed, have less decisional conflict about screening, but continue to participate in screening at the same rate as the control group women.

Screening programs have been fairly criticised for providing inadequate information on the outcomes of screening for participants.  Fears about the dangers of full and unbiased information in the hands of consumers abounds among professionals, but are almost always misplaced, as in this case.   Advocates for screening should welcome the opportunity to engage women more closely in these issues.

The value of accepting and understanding “over diagnosis” lies in how we manage the future.  As more sensitive detection methods are evaluated, the likelihood that “over diagnosis” will increase and diminish population benefit at the margin needs to be assessed.

Research to discriminate between biological potential of cancers should assume a greater priority, and perhaps we should consider trials of more limited primary treatments.  But at the moment, population screening for breast cancer is a very good buy for cancer control, and women who have been given greater opportunity to consider these issues seem to agree that it’s a good buy for them too.”

• A terrific piece bringing some much-needed perspective to discussions about mental illness, especially in the wake of recent murders. By Dr Tanya Ahmed, a registrar in psychiatry and a principal of the health and communications consultancy RaggAhmed.

• More than a million premature deaths across 30 OECD countries could be prevented each year if income inequality was reduced. That’s the best guess of a meta-analysis of studies involving around 60 million people, reported in the BMJ. The authors note that there are many caveats to their findings, including a lack of evidence from developing countries, but say their results have “potentially important policy implications for population health”. Meanwhile, I’m heartened to read that a fellow Crikey blogger is also putting inequality on the public agenda.

• When the law meets public health – Simon Chapman, professor of public health at the University of Sydney, considers the implications of a recent High Court judgment. It dismissed a duty of care negligence claim against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.

• Investigating the ties between drug companies and doctors – A group of researchers from Australia, Canada and the US have done an indepth analysis of disclosures of pharmaceutical sponsorship of gifts and educational events, as has been required of Medicines Australia members since 2007. They conclude that the disclosure does not go far enough and also give some interesting examples of how companies are wooing doctors. Novartis, for example paid flights, accommodation, food, beverages, and conference registration fees for six ophthalmologists to attend a two-day conference in Spain, at a cost of AUD$10,993 per person. For those who follow this field, it will come as no surprise that the researchers include Ray Moynihan, Lisa Bero and David Henry. The other authors are Jane Robertson and Emily Walkom from the University of Newcastle.

Croakey’s North American correspondent, Dr Lesley Russell, has been investigating the history of calorie-counting menus, while a local obesity policy expert, Jane Martin, looks at whether such an option might be useful in Australia.

Lesley Russell writes:

“In 2006, in a controversial move in response to rising obesity rates, New York City’s Health Department amended the city health code to  require the posting of calorie counts by chain restaurants on menus,
menu boards, and item tags.

This move was based on the following key facts:

*nearly one-third of Americans report that they are trying to lose weight;

*people are unaware of the calorie content of food, and when asked to
estimate the number of calories in food, they greatly underestimate
them; and

*consumers who were provided calorie information were much less likely
to choose the higher-calorie items.

Many fast-food chains make nutrition information available, but not in places or at times when consumers can easily use it when they buy their food. Most often, the information is available for download on Web sites.

According to the company, McDonald’s Web site nutrition page receives approximately 2,000 visitors per day, but since McDonald’s serves more than fifty million people per day, this suggests that only about one in 25,000 customers obtain nutritional information from the Internet.

The law was finally implemented, after a series of tough legal battles with the restaurant industry, in July 2008.  The system has since  become a model for similar rules intended to combat obesity and  promote good nutrition being implemented in California, other parts of  New York state, the cities of Seattle and Portland, and elsewhere.

Now some of the early findings about the success or otherwise of the New York initiative are available, in a paper (sub or pay per view only) published recently in Health Affairs.

The study compared patrons of fast-food restaurants in low-income, minority New York City communities with those in nearby Newark, NJ, a city which had not introduced menu labeling. About half of the New York respondents reported noticing calorie information, but only a  quarter of these reported that the information influenced their food  choices. However the study found that even those who indicated that  the calorie information influenced their food choices did not actually purchase fewer calories.

Last week New York City health officials delivered a more upbeat  assessment of their own, saying that New Yorkers ordered fewer calories at four chains – Au Bon Pain, KFC, McDonald’s and Starbucks – after the law went into effect. There was a significant increase in calories ordered at Subway, which researchers attributed to a continuing $5 special on foot-long sandwiches which has tripled demand for them.

The results are good enough to cause policy-makers to think that calorie labeling might be one component of a multi-faceted plan to  tackle obesity.  Certainly that’s what US lawmakers think.

Tucked away in the 1990-page health care reform bill that passed the  House of Representatives last Saturday night is a provision that will require anyone who operates chain restaurants with more than 20 locations to provide a calorie count for each standard menu item.  In addition, anyone who owns or operates 20 or more vending machines would have to provide a sign in close proximity to each item of food or the selection button that includes a clear statement about the number of calories the item contains.

The National Restaurant Association supports the labeling  requirements; the National Automatic Merchandising Association is less enthusiastic.  We assume that the Republicans, still complaining about  the size of the bill, did not read it and therefore don’t know about  this provision, otherwise we would surely have heard.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Should Australia require calorie-counting menus? Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition, writes:

“This is something the Obesity Policy Coalition supports. This is yet another study showing, like restrictions on junk food advertising, that an initiative with a modest effect can have a large impact on a population.

This study is an excellent assessment of the situation.  Currently in Australia, even if there is information given about meals in chain restaurants, it is on websites or on the packaging of the meal that you order (McDonald’s), therefore people are not making informed decisions at the point of purchase.  If there was a system such as in New York, together with an education campaign, the potential impacts could be large.

This is definitely something that should be on the table here, as part of a comprehensive approach.”