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VOICES, VISION, ACTION

The Official Delegate Publication for the 15th World Congress on Public Health CELEBR

ATING

50 th

ANNIV E O F T H E R S A RY WFPHA 19 67-2 01 7

• Melbourne Australia • 3rd - 7th April 2017 •


What do IV catheters, pneumonia and nutrition advice have in common? They are all part of ground breaking research undertaken at the Menzies Health Institute Queensland, at Griffith University in South East Queensland, Australia.

Eight hundred biomedical, clinical, allied health researchers and higher degree research candidates are committed to addressing public health challenges through globally significant research and community engagement. Our institute’s three research programs, Understanding Chronic Conditions, Building Healthy Communities and Optimising Health Outcomes, are driving knowledge, embracing technology and creating innovative solutions to catalyse change for a healthier future.

menzies.griffith.edu.au /MenziesHealthInstituteQueensland @MenziesHealth Menzies Health Institute Queensland Griffith University, Queensland, Australia Ph: +61 (0) 7 5678 9308 | E: mhiq@griffith.edu.au


Research focused on knowledge to inform practice and policy with measurable improvements that result in a healthier and more productive world. Shining the spotlight on our researchers making a difference. Renowned immunologist, Professor Allan Cripps AO has dedicated two decades to infectious diseases research, including the childhood killer pneumonia; making significant contributions to the identification of vaccine antigens and vaccine delivery systems for respiratory infections. Professor Cripps launched a peer-reviewed, open access journal, pneumonia, establishing an international forum for pneumonia, bringing together knowledge related to its pathogenesis, treatment and prevention.

Professor Allan Cripps AO

“Pneumonia is part of an overall pledge to raise the global profile of this forgotten killer and advance the fight against childhood mortality.”

Dr Lauren Ball

Dietitian, Dr Lauren Ball is an NHMRC Early Career Research Fellow, whose research contributes to a better understanding of how patients with, or at risk of chronic disease can be supported to make healthy nutrition choices. Two thirds of GP consultations concern patients with chronic disease issues such as obesity, hypercholesterolemia or diabetes. Dr Ball’s latest research is investigating GPs’ confidence in providing nutrition advice to patients. This will inform the design of an appropriate intervention, including an educational workshop, to help GPs raise the topic with patients in a timely and supportive manner. International leader in IV catheter research, Professor Claire Rickard is eliminating ineffective IV catheter practices through rigorous and independent testing of new products and current practices. The success of her research can be measured in hundreds of millions of dollars of reduced healthcare costs worldwide, as well as improved patient care. Professor Rickard’s research team works in partnership with more than 100 hospitals and universities around the world and their influence is growing rapidly. Their aim is to make IV complications history.

“Nutrition is the most influential factor affecting how chronic conditions are managed, however we know from previous research that the level of nutritional advice provided by GPs is extremely low.”

Professor Claire Rickard

“Overseas hospitals contact us regularly to say they have changed their standard of practice for catheter replacement based on our research findings. In the UK it is now mandatory for all adult NHS hospitals to follow clinically indicated catheter replacement.”


THE TOP CHOICE FOR PUBLIC HEALTH TRAINING

The Monash Master of Public Health is an internationally recognised passport for careers in government, industry, aid organisations and throughout the health sector, both in Australia and abroad. Taught by Victoria’s leading public health professionals and with strong links to the Alfred Hospital in Melbourne, the Master of Public Health is highly regarded in both industry and academia, with a reputation for excellence in teaching and outstanding graduates.

Take your career to the next level with a Master of Public Health from Monash University.

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Phone: +61 03 9903 0563

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More information regarding fees, scholarships and course structure can be found online at study.monash Email: pgradenq@monash.edu


PRIME MINISTER

MESSAGE FROM THE PRIME MINISTER 2017 WORLD CONGRESS ON PUBLIC HEALTH On behalf of the Australian Government I would like to extend a warm welcome to all delegates and speakers involved in the 2017 World Congress on Public Health. It is an honour for our nation to host this event, and to welcome health experts from around the globe. Australians are proud of our world class health system, the outcome of longstanding institutional arrangements such as Medicare and the Pharmaceutical Benefits Scheme, and the calibre of our health professionals. To ensure Australia remains at the cutting edge and able to deliver the outcomes our community expects, we must continue to drive innovation, invest in health and medical research and ensure that these findings are translated into best clinical practice. The World Congress is a valuable contribution to ongoing efforts in Australia, and internationally, to address the latest challenges and opportunities in public health. As a global community, we must work together to support the advancement of promising discoveries, strive for healthy communities around the world, improve the delivery of healthcare, and boost the efficiency and effectiveness of our public health systems. I trust that you will enjoy the congress programme, and learn much from the varied experiences, opinions and perspectives of your peers. This is an exciting time for health and medical research, and I thank you for your continuing efforts to deliver better health outcomes for the benefit of all.

The Hon Malcolm Turnbull MP Prime Minister of Australia 15 December 2016


INSTITUTO NACIONAL DE SALUD PÚBLICA THE SCHOOL OF PUBLIC HEALTH OF MEXICO

T

he School of Public Health of Mexico (ESPM by its Spanish acronym) was the first school of public health in Latin America and the second in the Americas, after the School of Hygiene and Public Health at Johns Hopkins University. It was founded in 1922, in order to respond to the great need to build a strong health and sanitary workforce to address the complex health and social situation that the country faced during and after the armed movement of 1910; as well as to establish training stations to combat infectious epidemics in the country in respond to the Flexner and Welch-Rose reports. During its 95 years, the ESPM has undergone several structural changes to respond to historical public health challenges as well as to national health reforms. One of the most important for the ESPM was made in 1987, with the creation of the National Institute of Public Health (INSP by its Spanish acronym), which was created by the fusion of the ESPM with the Center of Public Health Research and the Infectious Disease Research Center. Since then, the INSP has become a leading institution for research and training public health professionals and is one of the largest public health institutions in Latin America. It offers more than 30 professional and research-focused degree programs, including: Master of Public Health with 10 concentration areas; Master on Health Systems Quality; Master of Health Sciences with 8 areas of concentration; Doctorate in Public Health; Doctorate in Public Health Sciences, Nutrition and Environmental Health; a Residence Program in Preventive Medicine, as well as certificate programs. Its courses are given through diverse educational formats besides the face-to-face educational program, as executive programs on weekends and intensive on-line programs.

During the last 10 years, the continuing education program has allowed the INSP to strengthen the public health workforce by training over 60,000 professionals. Moreover, the development of its Massive On-line Open Courses, has been fundamental to up-date the in-service workforce facing epidemiological emergencies such as Influenza, Cholera and Zika, where more than 250,000 health workers have been trained. To guarantee its high academic standards and continuing improvements, the INSP has been accredited by the National Council on Science and Technology in 1994 and by the USA Council for Education in Public Health in 2006 –making it the first institution with this accreditation outside the US-. The ESPM, as part of the INSP, has been key to improve Mexico’s public health programs and public policies by generating scientific evidence to orient strategic health decisions as well as developing the workforce’s competencies through its educational programs, many of which are implemented in partnership with Mexico’s Ministry of Health and state-level health departments. At present, the INSP, stands as a pioneer, modern and continuously evolving institution that not only responds to the different array of local and global public health challenges, but also transforms the future of the population’s health.

www.insp.mx Contact: Laura Magaña, Academic Dean, lmagana@insp.mx


The Hon Daniel Andrews MP Premier

M16/9486

M16/9486

MESSAGE FROM THE PREMIER Welcome to the Melbourne Convention and Exhibition Centre, host of the 15th World Congress on Public Health.

MESSAGE FROM THE PREMIER

The Congress is strengthening and transforming global public health efforts through the sharing of knowledge, ideas and experiences. Good health and wellbeing is important to everyone, and th enables people more fullyConvention participate and in their community, education work. Welcome to the to Melbourne Exhibition Centre, host of and the 15 World Congress on Public Health. There is no better setting to celebrate a Festival of Public Health than Melbourne, the events capital of Australia. Victoria hasand onetransforming of the most efficient healthhealth systems in the world,the supported The Congress is strengthening global public efforts through sharing by some of the best doctors, nurses, health workers, scientists and researchers. As a world of knowledge, ideas and experiences. Good health and wellbeing is important to everyone, and leader inpeople healthcare as fully well participate as health and medical research, Victoriaand strongly enables to more in their community, education work.encourages close collaboration between sectors, all levels of government, professional organisations and the wider community. There is no better setting to celebrate a Festival of Public Health than Melbourne, the events capital of Australia. Victoria has one of the most efficient health systems in the world, supported Thesome landmark $1best billion Victorian Comprehensive Cancer Centre isand driving future innovations in by of the doctors, nurses, health workers, scientists researchers. As a world cancer research, treatment, care and education. Victoria also continues to build and strengthen leader in healthcare as well as health and medical research, Victoria strongly encourages close partnerships across Australia and the of globe through professional Victoria's International Health Strategy collaboration between sectors, all levels government, organisations and the wider 2016-2020: Partnering for a healthy and prosperous future. community.

Events such as cement Victoria’s ambitious Cancer health vision state as outlined in the The landmark $1this billion Victorian Comprehensive Centreforis the driving future innovations in Victorian public health and wellbeing 2015–2019: a Victoria free of the avoidable burden of cancer research, treatment, care andplan education. Victoria also continues to build and strengthen disease and injury, that all and Victorians can enjoy the Victoria's highest attainable standards health, partnerships across so Australia the globe through International HealthofStrategy wellbeing and participation at every age. 2016-2020: Partnering for a healthy and prosperous future. IEvents encourage andVictoria’s interstateambitious guests to health immerse themselves in ouras cosmopolitan such our as overseas this cement vision for the state outlined in city the culture, someand of wellbeing our great attractions, including the MCG theavoidable National Gallery of Victorianmarvel public at health plan 2015–2019: a Victoria freeand of the burden of Victoria, and enjoy the spectacular scenery and outdoor activities of regional Victoria. disease and injury, so that all Victorians can enjoy the highest attainable standards of health, wellbeing and participation at every age.

I encourage our overseas and interstate guests to immerse themselves in our cosmopolitan city culture, marvel at some of our great attractions, including the MCG and the National Gallery of Victoria, and enjoy the spectacular scenery and outdoor activities of regional Victoria. The Hon Daniel Andrews MP Premier

The Hon Daniel Andrews MP Premier


COLLEGE OF HEALTH

PRACTICAL PUBLIC HEALTH SOLUTIONS START WITH A MASSEY MPH

Roger Hughes Prof Roger Hughes is a public health nutrition specialist and an international public health workforce development leader. He leads the MPH programme as Head of School.

Barry Borman

Anna Matheson Dr Matheson is a public health researcher within the School of Public Health, interested in innovative systems approaches to addressing public health challenges.

Prof Borman is a Professor of Epidemiology, Director of the Environmental Health Indicators Programme and Director of the New Zealand Birth  Defects Registry.

DEVELOP YOUR PRACTICAL PUBLIC HEALTH COMPETENCIES BY LEARNING FROM THE BEST Why Massey University? • Flexibility delivered – you can study part time, via distance, or integrated with work experience • Practice focused – you’ll develop public health solutions and go beyond analysis to effective action • Tailor made – the course can be tailored to your interest areas within public health, such as public health nutrition, epidemiology, indigenous health, systems thinking, and health promotion.

TO FIND OUT MORE OR APPLY FOR THIS PROGRAMME VISIT MASSEY.AC.NZ/MPH


UC HEALTH RESEARCH INSTITUTE UC UC HEALTH HEALTH RESEARCH RESEARCH INSTITUTE INSTITUTE GLOBAL OUTREACH TO HELP TACKLE THE LEADING GLOBAL GLOBAL OUTREACH OUTREACH TO TO HELP HELP TACKLE TACKLE THE THE LEADING LEADING HEALTH PROBLEMS OF OUR TIME HEALTH HEALTH PROBLEMS PROBLEMS OFOF OUR OUR TIME TIME

Photograph taken by Louise Whelan

Photograph Photograph takentaken by Louise by Louise Whelan Whelan

GLOBAL CHARTER

HEALTH-EARTH (H-EARTH) HEALTH-EARTH HEALTH-EARTH (H-EARTH) (H-EARTH)

H–earth is an international and interdisciplinary network of institutions and

FOUNDING MEMBERS FOUNDING FOUNDING MEMBERS MEMBERS

Colin Butler, Professor of Public Health, Centre for Research and Action in

individuals to build knowledge about global change and health and andColin Public Health, University Canberra, Australia (initial co-chair) H–earth H–earth is which anisinternational anaims international and and interdisciplinary interdisciplinary network network of institutions of institutions Colin Butler, Butler, Professor Professor of Public of of Public Health, Health, Centre Centre for Research for Research and and Action Action in in develop capacity for aims effective responses by policymakers, practitioners and andJouniPublic Jaakkola, Director, Centre for Environmental and (initial Respiratory Health individuals individuals which which aims to build to build knowledge knowledge about about global global change change and and health health Public Health, Health, University University of Canberra, of Canberra, Australia Australia (initial co-chair) co-chair) communities thereby long-term population health. H-earth has six major Research, WHO Collaboration in Globaland Change, Environment develop develop capacity capacity forensuring effective for effective responses responses by policymakers, by policymakers, practitioners practitioners and andJouni Jouni Jaakkola, Jaakkola, Director, Director, Centre Centre for Centre Environmental for Environmental and Respiratory Respiratory Health Health research themes: communities communities thereby thereby ensuring ensuring long-term long-term population population health. health. H-earth H-earth has six hasmajor six major

and Research, PublicWHO Health, University of Centre Oulu, Finland (initial co-chair) Research, WHO Collaboration Collaboration Centre in Global in Global Change, Change, Environment Environment

research research themes: themes:

Tonyand Capon, Director, United Nations University Institute of Global Health, and Public Public Health, Health, University University of Oulu, of Oulu, Finland Finland (initial (initial co-chair) co-chair)

Kuala Lumpur, Malaysia TonyTony Capon, Capon, Director, Director, United United Nations Nations University University Institute Institute of Global of Global Health, Health,

Poverty

Climate Change • Poverty Poverty

Trevor Hancock, Professor and Senior Scholar, School of Public Health & Social Kuala Kuala Lumpur, Lumpur, Malaysia Malaysia

Infectious Disease • Climate Climate Change Change

Policy, University of Victoria, Trevor Trevor Hancock, Hancock, Professor Professor and Senior andCanada Senior Scholar, Scholar, School School of Public of Public Health Health & Social & Social

Ecosystem disruptions • Infectious Infectious Disease Disease

JohnPolicy, Potter, Professor ofCanada Epidemiology, University of Washington; Policy, University University ofEmeritus Victoria, of Victoria, Canada

Security • Ecosystem Ecosystem disruptions disruptions

Senior Advisor to the Fred Hutchinson CancerUniversity Research Center , Seattle, JohnJohn Potter, Potter, Professor Professor Emeritus Emeritus of Epidemiology, of Epidemiology, University of Washington; of Washington;

Transformation • Security Security

• Transformation Transformation

USA; Professor Epidemiology, Centre forResearch Public Health Research, Senior Senior Advisor Advisor toof the to Fred the Fred Hutchinson Hutchinson Cancer Cancer Research Center Center , Seattle, , Seattle, Massey University, Zealand Centre USA; USA; Professor Professor of New Epidemiology, of Epidemiology, Centre for Public for Public Health Health Research, Research,

TEACHING: Knowledge and expertise that is created, synthesised and assembled

WaelMassey Al-Delaimy, Professor of Epidemiology and Chief of the Division of Massey University, University, NewNew Zealand Zealand

by H-earth willKnowledge be used to create units forthat incorporation intosynthesised university and Global Health Professor at the University of California, Diego, USA TEACHING: TEACHING: Knowledge and expertise and expertise that is created, is created, synthesised anddegree assembled and assembled WaelWael Al-Delaimy, Al-Delaimy, Professor of Epidemiology of Epidemiology andSan and Chief Chief of the of Division the Division of of short well journal and an edited text book. H-earth Ebi, Professor ofatGlobal Health and Professor, Environmental by H-earth bycourses, H-earth willas be will used beas used toreports, create to create unitsunits forarticles incorporation for incorporation into into university university degree degree and andKristie Global Global Health Health at the University the University of California, of California, San San Diego, Diego, USAUSA and will have affiliations similar networks such as Future and H-earth the Occupational Health Sciences, School Public Health, Universityand of and short short courses, courses, as well aswith well as reports, as reports, journal journal articles articles and and an edited an Earth edited textHealth text book. book. H-earth Kristie Kristie Ebi, Ebi, Professor Professor of Global of Global Health Health and of and Professor, Professor, Environmental Environmental Rockefeller Commission for Planetary Health. will have will have affiliations affiliations withwith similar similar networks networks suchsuch as Future as Future EarthEarth Health Health and and the the

Washington, USA Occupational Occupational Health Health Sciences, Sciences, School School of Public of Public Health, Health, University University of of

UC HEALTH RESEARCH INSTITUTE

AndyWashington, Morse, Professor of Climate Impacts in the School of Environmental Washington, USAUSA

RESEARCH: The foci of H-earth’s research activities include to investigate health

Sciences, University Liverpool; Adjunct Professor National Institute Andy Andy Morse, Morse, Professor Professor ofofClimate of Climate Impacts Impacts in the in School the School of Environmental of Environmental

Louise Whelan

Rockefeller Rockefeller Commission Commission for Planetary for Planetary Health. Health.

consequences, risks and potential from inter-linked, aspects RESEARCH: RESEARCH: The The foci of foci H-earth’ of H-earth’ s benefits research s research activities activities include include tointegrated investigate to investigate health health

for Health Research Protection Research Unit in Professor Emerging and Zoonotic Sciences, Sciences, University University of Liverpool; of Liverpool; Adjunct Adjunct Professor National National Institute Institute

of adverse global such asbenefits from climate change, regional scarcities of consequences, consequences, riskschange, risks and and potential potential benefits fromfrom inter-linked, inter-linked, integrated integrated aspects aspects

Infections, Liverpool, UK.Protection for Health for Health Research Research Protection Research Research UnitUnit in Emerging in Emerging and and Zoonotic Zoonotic

energy, food and clean fresh water, altered infectious diseases dynamics, and of adverse of adverse global global change, change, such such as from as from climate climate change, change, regional regional scarcities scarcities of of

Infections, Infections, Liverpool, Liverpool, UK. UK.

fromenergy, lifefood in dense urban settings. It altered will also examine barriers and enablers of and energy, food and and clean clean fresh fresh water, water, altered infectious infectious diseases diseases dynamics, dynamics, and transformation, to urban systems, andbarriers develop innovative from from life in lifedense in including dense urban urban settings. settings. Itand willIthealth also will also examine examine barriers and and enablers enablers of of metrics to investigate, generate translate new understandings ofinnovative emerging transformation, transformation, including including to urban to and urban and and health health systems, systems, and and develop develop innovative health risks. Ittowill also seek fundsand to investigate discreet research topics, as metrics metrics to investigate, investigate, generate generate and translate translate new new understandings understandings of emerging ofsuch emerging whether important, currently unknown ofdiscreet prolonged heat exposure exist, health health risks. risks. It willIt also will also seekseek funds funds to investigate toeffects investigate discreet research research topics, topics, such such as as affecting vulnerable groups such as the effects elderly and workers unavoidably exposed whether whether important, important, currently currently unknown unknown effects of prolonged of prolonged heatheat exposure exposure exist,exist,

GLOBAL OUTREACH TO HELP TACKLE THE LEADING

affecting affecting vulnerable vulnerable groups such as the aselderly theand elderly and and workers workers unavoidably unavoidably exposed exposed to occupational heat,groups such as firesuch fighters defence personnel. to occupational to occupational heat,heat, suchsuch as fire as fighters fire fighters and and defence defence personnel. personnel.

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For For further information contact: Professor Butler, UC Health Research Institute, University of Canberra: Colin.Butler@canberra.edu.au further information contact:Colin UC Health Research Institute, University of Canberra: uchri@canberra.edu.au

further information contact: Professor Butler, UC Health Research Institute, University of Canberra: Colin.Butler@canberra.edu.au For For further information contact: Professor Colin Butler, UC Health Research Institute, University Colin.Butler@canberra.edu.au For further further information information contact: contact: UCColin UC Health Health Research Research Institute, Institute, University University of Canberra: of Canberra: Canberra: uchri@canberra.edu.au uchri@canberra.edu.au

W O R L D C O N G R E S S O N P U B L I C H E A LT H 2 0 1 7


ADVOCACY

WFPHA 50th Birthday. Voices, Vision, Action

wfpha Promoting Global Public Health since 1967

Welcome to the celebration of the 50th Anniversary of the World Federation of Public Health Associations (WFPHA) and to the 15th World Congress on Public Health in Melbourne, Australia. For WFPHA’s members and friends, this is a time to raise our Voices, to incorporate past achievements into a Vision for the future, and to plan Action. Turning 50 is a time for celebration. The WFPHA has reached a distinguished age, presenting us with a great opportunity to reflect on achievements and to understand the past. These celebrations give us an occasion to plan the next phase. A 50th is a time to build on robust relationships, to strengthen friendships and to work closely with allies. It is not an accident that the theme of the World Congress this year is ‘Voices, Vision, Action’. Public health professionals around the globe are working together to adopt a joint direction needed to improve the public’s health for the future. Voices have been heard. Public health associations internationally, and many of our international civil society colleagues and friends have participated in the development of the Global Charter for the Public’s Health (Charter). The Charter sets out a clear Vision for improving health globally. Now it is up to the WFPHA and each of its member organizations, NGOs and governments to develop Action strategies for implementing this important Vision. The WFPHA has matured in its 50 years, learning lessons, gaining expertise and becoming an established thought leader for addressing public health needs around the world at local, national and international levels. With this stature comes responsibility. The WFPHA must stridently oppose the strong forces constantly undermining the public’s health. The WFPHA needs to be persistent in opposition to vested interests behind conflict, environmental degradation, displacement of whole populations, poor nutrition, saturation marketing of unhealthy products, and disregard of the most vulnerable including, but not limited to, women, children, and Indigenous peoples. It is time to demand global support, in both words and deed, in support of the concept of “health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity and health as a human right”. It’s time all WFPHA members, our Congress Partners and our allies to use our Voice and our Vision to drive Action. The WFPHA’s 50th birthday party is one for celebrating legacy and driving a clear understanding of the future public health directions. It’s a time to appreciate and recognize the present, to learn from the achievements, the mistakes, the action and inaction of the past. We are poised for a new phase: the next 50 years. We have the benefit of the wisdom of our predecessors. Let’s not waste this opportunity. Let’s be strident. Let’s be demanding. Let’s fight for better health – not just for ourselves but for everyone on this planet. Welcome to a better future.

20 Napier Close Deakin ACT Australia, 2600 – PO Box 319 Curtin ACT Australia 2605 T (02) 6285 2373 F (02) 6282 5438 E phaa@phaa.net.au W www.phaa.net.au W O R L D C O N G R E S S O N P U B L I C H E A LT H 2 0 1 7

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To all who would join wiTh us in sharing healTh and hope for a beTTer life, Thank you. www.sanitarium.com.au

560K

$

has been donated to communities since 2003 through the Trans-Tasman Spirit of Sanitarium Awards

549

on-site exercise classes for employees through BetterU last year

760,000 contacts with Australians on health and wellbeing last year

8 million

breakfasts to kids through our Breakfast Club program since 2001

16,000+

370 Aussie kids get active each year through Weet-Bix Kids TRYathlon

tonnes of product has been donated to Foodbank Australia since 2010


ADVOCACY

CONTENTS VOICES, VISION, ACTION.................. 20 The 15th World Congress on Public Health will share knowledge, while also hosting themes around commitment as public health professionals.

A GLOBAL CHARTER......................... 22 A challenge to the global health community resulted in the establishment of a set of development goals, which aim to promote health and wellbeing for everyone, at all ages.

ADVOCACY....................................... 24

The pioneers who established the WFPHA set an important course consistent with a vision for better health internationally. We now have the opportunity to build on that vision.

PROMOTION.................................... 25

PROTECTION......................................28 An example of vaccine development and evidencebased health policy.

GOVERNANCE....................................29

Resistance to change is natural; overcoming it takes time, patience, courage and a clear sense of purpose.

CONNECTION.....................................30 Connectedness influences how public health is seen, how public health works, and where it has to aim for.

INFORMATION....................................31 There is a need for more reliable and comprehensive information in public health at the global level, to plan, implement and evaluate public health practices and targets.

The Australian Health Promotion Association seeks to advance the health of all people in Australia through leadership, advocacy and support for health promotion practice, research, evaluation and policy.

WOMEN’S HEALTH.............................35

PREVENTION................................... 26

WFPHA TIMELINE & PRESIDENTS...... 38

Climate change is a public health emergency. Can we act fast enough and will we do enough to prevent devastating adverse health outcomes?

W O R L D C O N G R E S S O N P U B L I C H E A LT H 2 0 1 7

Some of the key elements for success in improving women’s health and wellbeing; plus why support for women experiencing violence is more urgent than ever.

A look back across the past 50 years at some of the key developments in the history of the World Forum of Public Health Associations.

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Stronger evidence: better healthcare RDNS is one of Australia’s most respected providers of home healthcare, with a commitment to provide compassionate, professional support to as many people as possible. RSL Care is a leading not-forprofit provider of aged care services, with a focus on residential aged care, retirement living and community care. Like RDNS, they have a long history of working with seniors, veterans, families and communities. Just over a year ago, the merger of these two thriving for-purpose organisations marked the creation of a new generation of not-for-profit enterprise enriched by a shared heritage of care that empowers people to regain health, independence and dignity. Through the acclaimed RDNS Institute, RDNS has forged a unique place in the investigations of primary and community care supporting practical solutions and informing models of care and staff training. The merger between RDNS and RSL Care has expanded the Institute’s arena beyond community nursing and community care to include residential and retirement living services. “Our objective is to conduct high quality translational clinical, health services and aged care research in order to inform credible innovation and improve quality in service delivery in the business, influence practice and policy in the health and aged care sectors and identify future service opportunities for our business.” Professor Colette Browning is the Institute’s Director joining the organisation in 2015. With Professor Browning’s appointment the Institute now has strong research connections in China.

Professor Browning is the Research Director of the Shenzhen International Primary Health Care Research Institute, China. The Institute’s research focus is on China’s primary health care system. Through her honorary appointment at Peking University Professor Browning has conducted a number of studies in ageing and chronic illness management. With these relationships the Institute is able to contribute to research and policy development in China pertinent to the business interests of RSL Care and RDNS including training opportunities for the aged care and community nursing workforce in China. The Institute manages numerous projects that have made an impact on clients and community. An example is the development of ‘talking book’ resources supporting better care outcomes for clients with dementia in the form of a bilingual screen-based multimedia tool. This teaching and learning resource supported community nursing staff to provide dementia management education to Vietnamese clients by covering aspects of dementia using simple information sheets and easy-to-understand, nontechnical terminology.

“I look forward to an exciting future for the Institute drawing on the strength of our team’s experience and the new opportunities a combined RDNS and RSL Care brings.” Professor Colette Browning Director of Institute

For more information on the RDNS Institute please visit www.rdns.com.au


CONTENTS INFORMATION TECHNOLOGY................. 46 A recent attempt to collate articles from global experts around the relationship between digital technology and health/health equity from a public/population health perspective was a world first.

INFECTIOUS DISEASES.......................... 50 The National Disability Insurance Scheme is well established, and has quickly become a critical part of the health system for the millions of people who need it.

POLIO................................................... 57 The success of the war against polio, and how it too can be eradicated, like smallpox before it.

SOCIAL DETERMINANTS OF PUBLIC HEALTH.................................... 58

Equality is everyone having the same thing. Equity is everyone having what they need. In health, this is more evident than anywhere else.

RESEARCH............................................ 62 To keep the population safe in their environments, research needs to identify potential hazards and how to avoid them. Both technological and social change continue to accelerate.

DANGEROUS CONSUMPTION................. 71 The biggest challenge for society is unhealthy consumption, and finding a way to combat this will have the greatest impact of all on our future health systems.

W O R L D C O N G R E S S O N P U B L I C H E A LT H 2 0 1 7

RURAL HEALTH.............................. 78 The Royal Flying Doctor Service has been servicing people who live, work and travel in country Australia for almost 90 years.

INDIGENOUS HEALTH..................... 80 Insight into Australia’s research sector.

COMPLEMENTARY MEDICINE......... 85 Traditional and complementary medicine is an increasingly important – yet often underestimated – part of healthcare systems globally.

TOBACCO CONTROL....................... 92 Can we get to a smoke-free Australia? The fight – ongoing for decades – continues.

INJURY PREVENTION..................... 95 The evolution of society means there will always be an increasing number of ways people can injure themselves.

ORAL HEALTH................................ 98 A look into the development of oral healthcare and the issues that remain today.

EXERCISE.................................... 101 Modern lifestyles are seriously impacting health, especially children. Action is needed to help promote the varied benefits of even moderate activity.

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VOICES, VISION, ACTION

The Official Delegate Publication for the 15th World Congress on Public Health

THINK BIG ACT NOW CHANGE TOMORROW Explore the study and research options at Western Sydney University: ≥ Public Health ≥ Epidemiology ≥ Humanitarian and Development Studies ≥ Health Research For more information: westernsydney.edu.au/ future_students or call 1300 897 669

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VOICES, VISION, ACTION

The 15th World Congress on Public Health will share knowledge, while also hosting themes around commitment as public health professionals, building on the past while looking to the future, and using advocacy to create change. By Profesor Helen Keleher.

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VOICES, VISION, ACTION

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n 2014, the Public Health Association of Australia and the bi-annual Population Health Congress partners were successful in winning the bid to bring the 15th World Congress on Public Health (WCPH) to Australia. The 14th WCPH was held in Kolkata in 2014 and before that, the 13th WCPH was held in Addis Adaba. Both events left an impressive legacy for the 15th WCPH scheduled for Melbourne from 3-7th April 2017. The 15th WCPH will bring together expert researchers, field workers, practitioners, and policy and decision-makers who are committed to public health. The sharing of knowledge through keynote papers by leading international and national figures, the presentations of the latest international research, and all the discussions that follow, will be just the beginning. Kolkata’s Congress Call to Action set an outstanding precedent for the agenda set by the National Organising Committee for the 15th World Congress on Public Health. The Melbourne Statement from WCPH2017 and the Global Charter for the People’s Health from the World Federation of Public Health Associations underpin the agenda for WCPH2017. The theme for the 2017 Congress is ‘Voices, Vision, Action’, culminating on World Health Day, Friday 7th April 2017. A major focus of the Congress is on the United Nation’s Sustainable Development Goals, which are also known officially as Transforming Our World. The SDGs recognise that for the goals to be reached, everyone needs to do their part: governments, the private sector, civil society and people like us.

discussions, Congress delegates will raise their voices in unified commitment to: • Improve health outcomes for all • Fight inequality as the primary driver of poor health particularly with regard to the impact on women, children, Indigenous and First Nations people, those people who are most vulnerable, and

“KOLKATA’S CONGRESS CALL TO ACTION SET AN OUTSTANDING PRECEDENT FOR THE AGENDA SET BY THE NATIONAL ORGANISING COMMITTEE” those dispossessed of the basic necessities to support a healthy life • Political, social, environmental and economic change across all sectors for better and sustainable health.

VISION This theme is about building on the past, and looking to the future. • We recognise the role played to improve health through the 1978 Declaration of Alma-Ata in Primary Health Care, the 1986 Ottawa Charter on Health Promotion and a series of declarations of preceding

World Congresses on Public Health. We seek to build on these. • Our future vision for a healthier world is set out in the WFPHA’s Global Charter for the Public’s Health and the UN Sustainable Development Goals.

ACTION This theme is about using strong advocacy to create change, and build capacity for sustainable development. Public health professionals and practitioners work in a wide range of organisations that impact on people’s lives and health including: • Governments and government bodies at local, national and international levels • Civil society including all nongovernment organisations • Universities and other educational institutions • Corporations and businesses. We recognise the critical importance of health in all policies, of cross-sector and multisector action to influence health. The 15th World Congress on Public Health is a wonderful opportunity for public health advocates to meet, network, and share their visions for a world that prevents poverty, poor health and injustices, protects the people’s health, and promotes intersection action for health in all policies. ●

VOICES This theme is about our commitment as public health professionals and National Public Health Associations who represent the interests and voices of public health at a global level. Through their papers and

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THE GLOBAL CHARTER

THE GLOBAL CHARTER FOR THE PUBLIC’S HEALTH I A challenge to the global health community resulted in the establishment of a set of development goals, which aim to promote health and wellbeing for everyone, at all ages. By Michael Moore, President of the WFPHA.

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n September 2015, world leaders issued a challenge to the global public health community. Meeting in New York, they agreed on a programme of 17 Sustainable Development Goals that effectively places health at the centre of the global agenda between now and 2030. Goal 3 deals explicitly with health, stating “ensure healthy lives and promote well-being for all at all ages”. Yet that is only the beginning. The classic determinants of health, such as poverty (Goal 1), food (Goal 2), or water (Goal 6), feature prominently, as do core public health concerns such as inequality (Goal 10). More recent thinking on planetary health is recognised too. For example in Goals 1315, on climate and ecosystems, while governance, increasingly recognised as key to achieving health, features in Goal 16. These goals demonstrate a clear ambition to improve the health of all of the people living on this planet. However, if the corresponding targets, now numbering almost 170, are to be achieved, everyone must play a role.

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THE GLOBAL CHARTER

The Global Charters Group Of Core Services

GOVERNANCE

INFORMATION

PROTECTION ADVOCACY

The World Federation of Public Health Associations (WFPHA) has risen to this challenge. Working with the World Health Organization, it has asked how the global public health community should position itself to influence all of the key actors across the entire spectrum of public health issues, whether in government, civil society, or industry. The result is the Global Charter for the Public’s Health (The Charter). Recognising the need to adapt policies to differing circumstances, The Charter provides “a clear and flexible framework that can be applied globally and within individual countries”. It builds on a long tradition of public health thinking, from the time of The Declaration of Alma Ata through to The Ottawa Charter and the Commission into the Social Determinants of Health. Individually and collectively, these have long provided inspiration for measures to improve public health. There have been many successes. The Global Burden of Disease studies have demonstrated health gains that few thought possible. Yet there have also been many setbacks. Too often, the public health community remains fragmented, and many governments pay little more than lip service to the commitments that they have made. This recognition provided a catalyst for the development of the document. By identifying the enabling functions of “Governance, Advocacy, Capacity and Information” The Charter provides the groundwork necessary to deliver the most effective public health policy and outcomes locally, nationally and internationally. The focus of many of the previous declarations and charters has been on specific issues such as health promotion or the social determinants of health. The role of The Charter is to ensure a comprehensive approach to tackle the threats to health everywhere. Of course, the production of The Charter is only the first step. The challenge that the WFPHA has set itself is to ensure that it becomes embedded in the work of as many as possible of its member public health associations around the world, who can use it to support and advance the ambition that their political leaders

PREVENTION

PROMOTION

CAPACITY

have signed up to in the Sustainable Development Goals, which The Charter should be read in conjunction with, using both as an opportunity to influence their governments. Crucially, The Charter speaks to the entire public health community, whether in policy, practice, training, or research. All have a role to play. There is an enormous need to build public health capacity in many countries, to foster and sustain the next generation of public health workers, and to undertake high quality multidisciplinary research to generate the knowledge needed to inform policy. The process has commenced and needs to be extended. The Public Health Association of Australia is in the process of embedding The Charter into its strategic planning approach. By tying the Branches, Special Interest Groups and members into the policy approach there is an increasing opportunity to provide significant improvements in public health practice, advocacy and implementation. EUPHA is beginning a similar process, working through its sections with their in-depth knowledge of key issues. There is no silver bullet to

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improving public health. However, the comprehensive approach identified by The Charter provides an opportunity for those approaches to public health that can make a difference. The Charter provides a comprehensive, coordinating tool for ensuring that public health outcomes improve whether internationally, nationally or at the local government level. It recognises the need to challenge new threats to public health in a globalised world. These include the power of industries dealing in unhealthy commodities, the challenges to public health posed by international treaties, and an ideology, peddled by powerful forces, that attacks any sensible regulation as an infringement on individual freedom or the creation of a ‘nanny state’. Just as The Alma Ata Declaration provided a catalyst for comprehensive primary care and The Ottawa Charter provided a driving force for health promotion, The Charter has the potential to provide a driving force for widespread adoption of public health principles and practice. The challenge now for public health associations and professionals internationally is to ensure its visibility, use and implementation. ●

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ADVOCACY

THE WFPHA AT A CROSSROADS

THE NEED FOR EFFECTIVE ADVOCACY

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n celebrating its 50th Anniversary, the World Federation of Public Health Association (WFPHA) finds itself at a crossroads. The last 50 years have been dedicated to growing the organisation in a parallel manner to the international trend towards globalisation. When the handful of public health associations (PHAs) came together in 1967, the meeting on Primary Health at Alma Ata and its Declaration had not even been envisaged. It would be nearly another 20 years before the Ottawa Charter for Health Promotion was launched. However, public health was a key element in the thinking of many pioneers of the time. They were already well beyond the basics of clean water and sanitation. They could see better solutions than just treatment of the many diseases that were plaguing the world. The widespread introduction of vaccines, universal health care and use

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of sound epidemiological research were on their agenda. In 2017 we have the opportunity to build on the work of these pioneers. They were innovators who were looking forward while at the same time being cognisant of what had preceded them. We can do the same, building understanding of the importance of equity and the social determinants of health. We cannot move forward without understanding the health impacts of climate change and we cannot move forward without understanding the impact of globalisation on health. The Global Charter for the Public’s Health recognises the importance of advocacy, good governance, capacity building and circulation of sound information in establishing a sound approach to prevention along with health protection and promotion. The key element to bringing about change is more effective advocacy.

The WFPHA has the option to rest on its laurels, having developed the Global Charter with the World Health Organization (WHO) and a range of NGOs and other key stakeholders. Or it can build on the work that has commenced. More of the same is one possible choice – supporting our public health associations across the world, taking responsibility for the World Congress on Public Health and taking some leadership on specific current public health issues such as antimicrobial resistance and Ebola. However, it is becoming clear that this is not enough. The WFPHA can also take the more challenging path of developing a series of toolkits that build on the work of the Global Charter. Using these toolkits as a basis for effective advocacy is a key challenge for the future. Demonstrations of how to carry out advocacy in order to engage our own member public health associations (and their membership) is how the WFPHA will influence governments in better health policy at the local, national and international levels. There are real challenges in achieving these goals. As there is a tiny international headquarters of the WFPHA, there is a need to plan for two things. First to rely on its membership base to assist with the range of advocacy and other tasks. Secondly, to build the capacity in the headquarters to remain engaged with the WHO and a wide range of stakeholders internationally. The pioneers who established the WFPHA set us on an important course consistent with a vision for better health internationally. We now have the opportunity to build on that vision and to plan to ensure the next 50 years is an era of improving public health for all. ● – Michael Moore

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PROMOTION

PROMOTION

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he Australian Health Promotion Association Ltd (AHPA) is the peak professional body for health promotion in Australia. AHPA is delighted to be a partner organisation for the 15th World Congress on Public Health and a member of the National Organising Committee and Scientific Committee. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. This definition comes from the World Health Organization’s Ottawa Charter 1986. The health promotion profession has evolved alongside, and in response to, the international health promotion movement and the broader public health movement. Health promotion not only embraces actions directed at strengthening the skills and capabilities of individuals but also

actions directed towards changing social, environmental, political and economic conditions that impact on individual and population health. AHPA seeks to advance the health of all people in Australia through leadership, advocacy and support for health promotion practice, research, evaluation and policy. AHPA members work across all areas of health promotion practice and scholarship: within health service population health units, research and academia, policy, community-based projects, and advocacy programs. The membership has a broad base of knowledge and expertise with members from government, non-government, academic, private and community organisations. AHPA is committed to the following principles:

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Ethical practice – supporting culturally informed, participatory, respectful and safe health promotion practice Health equity – addressing the social determinants of health to build health equity Innovative & evidence informed approaches – promoting and supporting evidence informed research, policy and practice Collaboration – working in partnership with other organisations to improve health and wellbeing. AHPA provides support and direction in the field of health promotion through the provision of a range of member services including professional development, scholarships, awards, advocacy for the health promotion workforce and for specific health issues, mentoring, publication of the peer reviewed Health Promotion Journal of Australia, regular Branch and National newsletters, and national health promotion conferences. AHPA is the National Accreditation Organisation (NAO) for Australia for the International Union for Health Promotion and Education (IUHPE) Health Promotion Accreditation System. As the NAO, AHPA is responsible for ‘IUHPE Health Promotion Practitioner’ registration in Australia. AHPA is governed by a National Board of Directors and has local Branch Committees across Australia. All Directors and Branch Committee members are volunteers elected from and by the membership. The Board is composed of a number of national committees that provide strategic and operational work on conferences, the journal, advocacy and partnerships, communication, career structure, business development and governance. ● – Andrew Jones Roberts

To find out more about AHPA, the benefits of membership or how to become a member, go to AHPA’s website www.healthpromotion.org.au, email members@healthpromotion.org.au or contact member services on 1300 857 796.

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PREVENTION

CLIMATE IS CRITICAL

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he greatest prevention opportunity for the global public health community is to slow catastrophic anthropogenic climate change as quickly as possible. As I write this, the World Meteorological Association has confirmed 2016 as the hottest year on record for both global land and sea temperatures. This follows 2015 and 2014 which were in turn the hottest years on record. The planet is now 1.1oC hotter than pre-industrial time. Change is happening and faster than expected. For example, record high ocean temperatures in January 2016 caused massive international coral bleaching. Here in Australia on the northern Great Barrier Reef, previously the least damaged part of the reef, 94% of the coral was so severely bleached that it died. Also lost is the broader biodiversity that shares the reef ecosystem. A previously vibrant, colourful, diverse environment is now

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a brown skeleton covered in algae. It presents a disturbing illustration of the fragility of our biosphere, of how quickly environmental damage and loss can occur, and that this is often irretrievable. Our survival is interwoven with the survival of the planet’s biodiversity with which we have co-evolved; Pacific Island nations and low lying coastal regions who face inundation and massive disruption to their environment have strongly argued this. The Paris COP21 Agreement, which seeks to limit temperature rise to 2oC and possibly 1.5oC, provides the global opportunity and commitment for change. We know, however, that there is no safe level of global warming – humans are already suffering and dying from the 1oC increase. Greater mitigation and adaptation actions are required. (See https://www.racp.edu.au/advocacy/ policy-and-advocacy-priorities/climatechange-and-health for recent easy-read

position statements by RACP on Climate Change and Health.) Indeed, whole of system change is needed immediately. As public health practitioners we know much about creating change at all levels of society. The Agreement established ‘the right to health’ and the Sustainable Development Goals provide a framework for broad international action – Goal 13 urges countries to take urgent action to combat climate change and its impacts. The second WHO Global Conference on Health and Climate, held in Paris in July 2016, provided a global forum ‘to encourage the health community to participate fully’. Despite the well described health benefits of preventing (mitigating) climate change, the health sector has been slow to move. There are, however, inspiring examples of action, such as The Wellbeing of Future Generations (Wales) Act 2015 legislation that demands long term decision-making at the national level to protect the Welsh environment, culture and economy to ensure a healthy, sustainable future. The Lancet Countdown International Collaboration is developing a series of indicators that can be used to Track Progress on Health and Climate Change. Our organisations, professions, practice, training and research must all reorientate to achieve successful mitigation and adaptation. We know what needs to be done. With such a short time frame, (we have 5-10 years at the most), collaboration to learn from and support each other will be essential. Even David Attenborough thinks the situation, while desperate, can still be saved: ‘But it isn’t as though we don’t understand what the problem is or we don’t have ways of solving it – we do. What we need to do is get together.’ Climate change is a public health emergency. The WCPH affords an opportunity to renew our commitment to act together as a global public health community. The question is, can we act fast enough and will we do enough to prevent devastating adverse health outcomes? ● – Professor Lynne Madden

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CHANGING THE SYSTEM

INNOVATIVE COLLABORATION TACKLES THE ROOT CAUSES OF CHRONIC DISEASE

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hronic diseases are embedded in a complex system – a system of biological, social, physical, cultural and economic factors that combine to shape individual choices. If we can better understand the system, its parts and the relationships between them, we will be better able to make decisions about where and how to intervene to achieve significant and sustainable change. That’s the rationale behind an ambitious National Health and Medical Research Council (NHMRC) Partnership Centre established in 2013 to find innovative ways of preventing chronic disease. The Australian Prevention Partnership Centre is a national inter-disciplinary collaboration of individuals and organisations from policy, practice and academia. Its research focuses on systems approaches to complex chronic diseases that are largely preventable through addressing lifestyle-related behaviours such as smoking, alcohol use, nutrition and physical activity. Recognising that co-production is one of the most effective ways of ensuring research findings are used in policy, the research is conducted by teams consisting of academics, policymakers and practitioners. There are more than 150 investigators from 28 agencies nationally working on 35 different, but interconnected, projects. ‘At the heart of this is good relationship building,’ says Deputy Director Associate Professor Sonia Wutzke. ‘Researching in partnership helps to increase the use of evidence in policy and practice – when researchers, policy makers and practitioners work together, the research produced is more relevant and useful.’ The Prevention Centre’s work spans the economics of prevention,

implementation of complex public health interventions, communicating the value of prevention, food and nutrition, the built environment and public health law. The Prevention Tracker project, for example, is working with local communities to better understand how the people, processes, activities, settings and structures in a community all connect in a system that shapes the existence of chronic disease, and then to develop a common set of methods to improve that system. After a successful pilot in Tasmania, Prevention Tracker is expanding to several other communities, including Albany in WA. Another project is using dynamic simulation modelling to help governments test the likely impact of their policies over time, before real investments are made. The NSW and ACT governments are using the tool to plan policies around alcohol-related harm, gestational diabetes and childhood overweight and obesity. ‘Policy makers can’t wait five years for the evidence … This tool is looking at a Premier’s priority and showing

something that is really useful now for policy makers,’ says Associate Professor Sarah Thackway, Executive Director, Epidemiology and Evidence, NSW Health. In addition to its research activities, the Prevention Centre produces resources that help policy makers use evidence in their work, a range of communications products to assist with rapid knowledge translation, and an active program of capacity building to foster a new generation of leaders in systems-based prevention research, policy and practice. Professor Diane Finegood, a leader in systems thinking based at Simon Fraser University in Canada, says the Prevention Centre is doing work that no one else is doing. “It respects the complexity of the challenge of chronic disease prevention and focuses on solutions appropriate for complex problems like putting a focus on collaboration and building trust across silos.” • For more information visit preventioncentre.org.au


PROTECTION

EPIDEMIOLOGY IN ACTION

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accination is considered one of the most successful public health interventions. Health policies enforcing vaccination uptake and compliance have been implemented globally, with concomitant development of criteria for legitimate exemptions. Despite overwhelming scientific evidence supporting the population benefits of vaccination, the ‘anti-vaccination’ movement has become increasingly vocal in response to these restrictions. Epidemiology is a core element of developing evidence-based vaccination policy. Epidemiological study designs are used during pre-licensure vaccine development in the form of safety and efficacy trials. These experimental study designs are perceived as being the gold standard in evidencebased medicine. Vaccination policy scrutinises the evidence from trials to weigh the potential benefits and risks to the population, including those unable to be vaccinated (e.g. babies too young for vaccination). When a sufficient proportion of the population is vaccinated, the likelihood of that population experiencing an epidemic is reduced, indirectly protecting those who cannot be vaccinated. This phenomenon is known as ‘herd immunity’. Calculating the proportion of

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the population needed to be vaccinated in order to achieve herd immunity is another epidemiological method. While pre-licensure trials are large enough and long enough to detect common side effects, they are often too small and too short to detect rare adverse events and long-term safety issues. Post-licensure monitoring for safety and adverse events also use epidemiological study designs, including cohort, case control and self-controlled case series, and may utilise routine health registry databases, immunisation registries and adverse event databases. These types of observational studies have less capacity to demonstrate causality than experimental designs. As such care must be taken to limit biases, control for confounding and ensure studies have a sufficient number of people to detect statistical associations. The well-known discredited study that reported an increased risk of autism associated with measles vaccination used an inappropriate study design to explore potential harms associated with the vaccine (a medical case study of just 12 cases). However, case studies can be useful to signal alarms and highlight areas for future investigation. The series of high-quality observational studies that followed the initial measles vaccination

study found no link between the measles vaccine and autism. The results of these observational studies have been compiled into another epidemiological study design, meta-analysis, where all available evidence has been synthesised to generate a pooled estimate of the risk of autism associated with vaccination. Meta-analyses have again confirmed the absence of an effect. Epidemiological studies have also shown robust evidence of the detrimental effects of anti-vaccination sentiment. For example, declines in the uptake of measles vaccinations have resulted in increased measles outbreaks. This in turn has increased the prevalence of rare measles-associated neurological disorders, particularly among those infected during infancy when they would have been ineligible for vaccination, but might have been protected by herd immunity. The benefits of vaccination operate at the population level and epidemiology is concerned with population-level outcomes. Sound epidemiological theory forms the foundation for current vaccination policies and sound epidemiological evidence must continue to underpin and inform future policy developments. ● – Dr Michaela Riddell

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GOVERNANCE

STEERING THROUGH TROUBLED TIMES

GOVERNANCE AND THE ORGANISED EFFORTS OF SOCIETY

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he role of PHAs in fulfilling our commitment to the promotion and protection of health through ‘the organised efforts of society’ requires that we must first be very well-organised ourselves, as our societies increasingly embrace the uncertainty, excitement and inherent value of diversity and change. If we thought the last few years were rough, what are we expecting for the next few? So what might we need to do differently to steer the organised efforts of society through troubled waters around us? Most of us join our PHA for the sense of belonging to a movement for change and to contribute to a collective voice for a population approach to health. By joining with colleagues from such a wide range of professional disciplines we can maximise our strengths to promote and protect the public’s health. So, as doers and thinkers, we expect our PHA to minimise organisational constraints, enabling us to focus on making the world a better place. To do this well, we need good governance of and for ourselves; in fact, the less we want to be distracted from our mission by administration, the more important really good governance is. Strategic governance and effective management of scarce resources require as much careful thought and attention to detail as a health promotion campaign. And here’s the rub: we expect people whose expertise is in public health to volunteer their time to take responsibility for leading, governing, and supporting management so that the rest of us can pursue the causes we espouse. While each PHA operates in a very different social, economic and political context, we can start with a set of shared assumptions. First, the external environment we operate in is both fluid and demanding, as our public health system responds to changing demographics, health profile, government policies and resource availability. Similarly,

our internal context – that is, capacity and capability, human and financial resources, and perceptions of our mission and purpose – must also respond and adapt. Sustainability within such a turbulent context requires both strategic thinking and creative leadership. What elements of skilled governance are needed for our particular situations? I entered the public health sector in response to the HIV/AIDS epidemic in the 1980s, knowing little of public health and less of organisation development. Since then, through wide involvement with national and international bodies and local research, the importance of appropriate governance has become more apparent, as well as the usefulness of a framework for thinking about organisations like ours. From this combination of experience and research I’d like to highlight five essential governance tasks as having value specific to PHAs: Charting new waters. Research and environmental scanning, identifying new opportunities as well as challenges, risk assessment and leadership. For each PHA, this means knowing one’s own health sector, politics and health threats, and the ability to look and lead creatively into the future. Continuous reappraisal of mission and strategy. To ensure our relevance and

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credibility, we need to adapt and articulate our purpose, guiding principles and strategic direction, which are fundamental to the PHA’s identity, stakeholder interests and sustainability. Maintenance of infrastructure adequate to support action. This includes both capacity (human and financial resource) and capability (knowledge, skills and systems) necessary to achieve organisational goals. Vision and goals won’t get us anywhere without back-up systems in place to get the work done. Relationship management. Formal and informal relationships within the organisation, especially between governance and management, as well as with stakeholders and potential collaborators, are what bind people together in collective effort. Resilience in the face of change. Balancing the complexity of both external and internal pressures requires juggling any number of things in motion simultaneously. Resistance to change is natural; overcoming it takes time, patience, courage and a clear sense of purpose. ●

Warren Lindberg Chief Executive Officer Public Health Association of New Zealand

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CONNECTION

THE WFPHA AT THE AGE OF CONNECTEDNESS

A GLOBAL NETWORK FOR A HEALTHY PLANET

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he World Federation of Public Health Association (WFPHA) was created 50 years ago. In those days the Vietnam War, the fight of African Americans for civil rights, the constitutional recognition of indigenous Australians as citizens being counted on the national census, the Six-Day war and Che Guevara’s end were moving the world. The first human heart transplant was performed and DNA was created in a test tube. We look back and we look around: today’s wars take place in other parts of the world, the fights of minorities for equal rights continue and the fact that all these political determinants influence health has not changed. We are facing a more connected world though, where people, goods and especially news move faster than 50 years ago. The connectedness influences how public health is seen, how public health works and where it has to aim for. At

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the headquarters of the WFPHA in Geneva we are not only working with our official partners but we are continuously creating new bounds with other similar minded partners. Our core goal is the advancement of health, while at the same time preserving cultural, ethical, environmental and human values. We will only succeed if we all aspire for the same goals. The over 300 NGOs besides the UN systems organisation located in Geneva facilitate the exchange and help us develop our strategies. The guidance for our future work has been elaborated this way: by collecting the inputs of public health professionals around the world at United Nations and government as well as non-government level we came up with the Global Charter of the Public’s Health. The Charter will serve as the framework for our and hopefully others’ work for a healthier world. As the executive director of the

WFPHA I am driven and empowered to work with my local team and all the advocates of the PHAs around the world to get closer to this aim. We are aware of the important political and economic determinants of health. We know that our work will be political in nature and that we have to prepare our members and colleagues for this. It is a particular pleasure to see many young people not only interested but deeply concerned and engage in work around health on a safe planet. It is a privilege and an honour to value and further develop the networks between different groups and the networking across generations. We at the WFPHA see the next 50 years as a task for a prominent, loud and inevitable voice for health in all countries on our single and deeply connected planet. ● – Professor Bettina Borisch

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I N F O R M AT I O N

INFORMATION

ENSURING EQUAL ACCESS FOR EMPOWERED CHOICES AND ACTIONS?

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ver two thousand years ago, Aristotle wrote: ‘All human beings by nature desire to know.’ The concept was strengthened 500 years ago by Francis Bacon, who affirmed that ‘Knowledge itself is power’. Nowadays, the importance of having access to information at the global level is reinforced by the creation in 2016 of the International Day for Universal Access to Information. To know requires having free and equal access to information. This is a fundamental human right; it is essential for inclusion and dialogue, it is a basis for the rule of law and good governance, and it is crucial for shaping new paths towards sustainable development. It is challenging work to guarantee a common and equal level of information to public health organisations and professionals worldwide. It is hard work to ensure information reaches ministers and policy-makers. Inequities in information creation, production, distribution, and use are well-known. However, in this age of mass social media, access to information has varied dramatically. Information access and use are, to a large extent, determined by demographic traits, economic resources,

and social status. Information equity can be achieved by an even distribution of resources and technologies among social groups equipped with the necessary skills to understand the information shared. There is a need for more reliable and comprehensive information in public health at the global level, to plan, implement and evaluate public health

“INFORMATION IS ONE OF THE FOUR ENABLER FUNCTIONS OF THE WORLD FEDERATION OF PUBLIC HEALTH ASSOCIATIONS” practices and targets, including the Sustainable Development Goals (SDGs). Continuous and systematic public health surveillance by accountable organisations should be guaranteed as a basis to evaluate intervention and set priorities but also as an early warning system for public health emergencies. Information is one of the four enabler functions of the World Federation of Public Health Associations (WFPHA)

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Global Charter for the Public’s Health (Charter). It embraces surveillance; evaluation, monitoring of health determinants; research and evidence; risk and innovation; dissemination and uptake. Equity is at the heart of this Charter. A common conceptualisation of global public health and a common vocabulary to build up information should be adopted by the WFPHA and its members, and used as a basis for public health education and training, and to inform future professional, organisational, and political actions. It should be followed by a process of engagement with partners and Member States to adopt a WHO action plan on public health functions, based on the Charter. The Charter indeed paves the path to create an effective dialogue among all public health actors and with the public that should be empowered through equal and accountable access and understanding of information. Considering the use and misuse of public health information at the global level, it is time to take stock, review and evaluate how to create a global, equal and common vision and understanding of global public health. ● – Dr Marta Iomazzi

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C A PA C I T Y

CAPACITY IS THE BIGGEST CHALLENGE FOR AUSTRALIAN HEALTH

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n addressing our national health capacity, the evidence is in (Australian Institute of Health and Welfare Australia’s health 2016 report) – funding for health prevention initiatives in Australia has reduced from 2008 levels of 2.2% to 1.4%. Australia is also experiencing a significant rise in chronic disease combined with an increase in recurrent spending on hospital admissions. Chronic diseases are escalating, and the number of Australians with multiple chronic diseases is also increasing. Thus, our health capacity and response capability is severely compromised simply because we are not tackling the causes before people require major treatment interventions and hospitalisation. This situation can only get worse and add to health capacity shortfalls when combined with an ageing (and living longer) population--more than 50% of Australians are living with more than one of major chronic diseases. When we consider that there has been a 35% rise in obesity in the past 25 years, if this continues at this rate, obesity rates will be at 91% and certainly our health response capacity will be at breaking point. I liken this health prevention scenario to another, recently advanced by the

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Insurance Australia Group concerning investment in mitigation strategies in relation to natural disaster, where again only 3% of government expenditure is spent on mitigation and the remainder on disaster relief. A 2015 review undertaken by the Productivity Commission (PC) recommended that state and federal governments commit to significant investment to disaster resilience to assist communities with a major mitigation investment, and thereby limit the large and repetitive costs of disaster impact. The government is yet to respond to the PC report, and again will be caught napping when we continue to see around 20% of Australia’s economic output is at heightened risk from cyclones and more than 25% of our national gross domestic output is in areas with high risk to flooding. Given this picture, my fundamental concern is we have created a complacent mind-set in society where there is an expectation that appropriate response and recovery arrangements will always be there whether it’s a disaster or health emergency. Hence, my key concerns are around our health capacity into the future, and when considering intergenerational trends and priorities for expenditure, which opens a key debate on prevention investment not only in health but

many areas of community need. The social, ecological and environmental determinants of health cannot be ignored. We need simple messages and explanation to leadership so they can appreciate the joined-up impact of failing to act on prevention. If we are going to be successful in keeping people out of hospitals, we in preventive health have a remit to explain. Determinants such as housing, employment, transport, communications, domestic/ family violence, mental health, diet and drug/alcohol use – they all have direct and well established links to our growing chronic disease problem which overburdens our health capacity in dealing with critical last-minute crises. Key Australian preventive and public health professionals continually advocate for better understanding by leadership of our inadequacies in health response capability, and they seek urgent attention to their commitment and investment in health prevention, protection and promotion to tackle community chronic disease priorities. Related to this, we must also maintain the highest order of need for the health of our First People Aboriginal and Torres Strait Islanders in all aspects of national strategic health planning. ● – David Templeman

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WOMEN’S GLOBAL CHARTER

ACHIEVING WOMEN’S HEALTH Australian Women’s Health Network CEO Kelly Bannister reflects on some of the key elements for success in improving women’s health and wellbeing.

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omen’s health and wellbeing is one of the key public health issues to be discussed during the 15th World Congress on Public Health 2017, in Melbourne Australia. The invitation to write this article to contribute to the discussion came with a suggestion we could focus on the Women’s Global Charter for Humanity. This got us thinking about our own public health experience and the elements necessary for success in improving women’s health and wellbeing. The Australian Women’s Health Network (AWHN) Women’s Health and Wellbeing Position Paper 2012 argues broadly for recognition of principles essential to establishing a firm basis upon which to redress health inequities for women. These are: • It is impossible to understand women’s health outcomes without also understanding the social context of women’s lives; • International human rights and cultural conventions are a powerful mechanism for mobilising action on women’s health and wellbeing; • Gender power relations impact on social and health outcomes for women; • The factor of gender accounts for the fundamental differences between women’s and men’s experiences of health issues. Therefore, improvement of women’s health care necessitates affording high priority to gender issues in all aspects of health care; • In determining health and illness outcomes, health systems have a responsibility to acknowledge the importance of gendered social relations, social factors and conditions of living; • Understanding the ways in which gender impacts on chronic health

conditions will be enhanced by explicitly mainstreaming gender in the process of informing genderspecific services; • It is vital to infuse gender analysis, gender sensitive research, women’s perspectives and gender equity goals into policies, projects and institutional ways of working. These principles apply to women’s health inequities within a diverse range of global political, religious, cultural and social environments. In actioning these principles it is useful to identify within your own country context which overarching framework is available to support your public health advocacy agenda from the number of existing international tools. Many governments have committed to the United Nations (UN) Beijing Platform for Action (1995), the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW), and the International Covenant on Economic, Social and Cultural Rights (UNHCR 1966).

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These commitments affirm women’s inalienable rights and fundamental freedoms, including their rights to health, control over their own bodies and freedom from violence and discrimination. They are intended to guarantee women ‘the possibility of realising their full potential in society and shaping their lives in accordance with their own aspirations’ (UN 1995, p.1). These UN instruments provide the global context for action on women’s health. They are powerful mechanisms for mobilising action on women’s health and wellbeing but need to be consistently applied and implemented. In the 35 years since CEDAW was established it has had a small but significant positive effect but we have a long way to go to achieve CEDAW’s aim of ‘formal and substantive gender equality and in changing individual beliefs to eliminate gender stereotypes’. It is also difficult to identify which gains have arisen simply because a country has ratified the convention. Though women make up half the world’s population they are still overwhelmingly at the margins of society

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WOMEN’S GLOBAL CHARTER

and if visible at all are treated as a special interest group. In addition to having an underpinning mobilising framework then, there must be mobilising capacity. In our experience, few if any public health gains have been achieved because the government of the day thought it would be a good idea or an international convention existed, or in fact a national framework was in place. The things important to women’s health from a woman’s perspective across the social context of their lives, such as the right to vote, own property, have an education, financial security, to decide if and when to bear children, and to live free from violence and fear to name a few, have been achieved where they exist by women mobilising and making their voices and demands heard. This action, which we call women’s health promotion advocacy, seeks to change cultural mores, legislation and government policy which have an impact on the determinants of poor health at individual, intermediary and structural levels. Meaningful power will never be given to women because it is the right thing to do. Nor will it be achieved through one charter, one treaty, one thing, action or person. It will be achieved through the concerted, consistent and intelligent

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advocacy effort of many over time. Taking action to make public the differences between women’s and men’s experience of health, the ways that gender power relations impact on women’s health and wellbeing, and in building capacity for gender analysis, gender sensitive research and service delivery requires money. Ideally this funding is external to and independent of government, otherwise organisations undertaking this work are extremely vulnerable to the vagaries of political and economic change. There are many examples of governments shutting down dissent or external voices by minimising or denying mobilising capacity. Momentum and achievements gained under one government can be halted and wound back under a change to government. In times of economic downturn financial support for equality or health promotion advocacy often falls away. This is true for both domestic funding and international aid. For example, a government that supports and promotes a gender stereotypical view of women’s role as being less than men’s will be averse to supporting feminist advocacy or fertility control and family planning services. Where there is also a lack of private or philanthropic support it is difficult

to undertake advocacy work in any sustainable way. In addition, these are some of the things that work for us: • Strive to have a healthy, high profile and well regarded organisation that can maintain a credible presence through the tough times. • Meaningful change takes time – a lifetime’s and sometimes generational commitment – so celebrate every victory! However small a win, it is an important step along the way. • Be ever-vigilant as gains made can so easily be wound back. • Envision your ultimate goal, identify the most important things you can achieve, decide how these can best be done over time and then maintain your focus on doing them. • The idea that policy is based on the best available evidence is nonsense. It usually has more to do with who had the ‘loudest’ voice and the most people saying the same thing. • Mobilise across a wide sector, keep the language inclusive and accessible, so make it relevant, avoid jargon and be consistent. • Don’t compete with existing organisations doing good work. Work with them and profile yourselves working together, building an image of ‘many voices’. • Make many friends and be a good friend, especially to those who seem to have a different point of view. They could surprise you. • Don’t lose sight of your primary objectives. Maintain your knowledge of and engagement with government policy but don’t be distracted by where it may or may not go. • While honouring the past work of others, take in new ideas. Test your understanding, undertake secondary research and share learning. And finally, nurture your passion, be courageous and take good care of yourself and each other. The most sustainable achievements which contribute to women’s health and wellbeing take a long time to achieve! ● – Kelly Bannister

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DOMESTIC VIOLENCE

PREVENTING VIOLENCE AGAINST WOMEN The need to improve care for women experiencing violence is urgent.

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here is a profound cost at many levels in societies around the world as a result of violence against women and serious consequences for children, families and the wider community. The issue is not a women’s issue, it is a global issue and requires an international collaborative, coordinated integrated approach to address the complexities and far reaching negative impacts. Violence against women is now recognised as one of the most widespread violations of human rights. Whilst the rates of physical violence experienced by men and women are comparable (Australia) and in both groups the perpetrator highly likely to be male, the context for the violence is different. Violence against men commonly occurs in public whereas women are more likely to experience violence in the home. The differing contexts are supported by gender stereotyping and sexist norms which reinforce gender inequality and an unequal power balance between men and women. Violence in the home is largely considered a private issue shrouded in secrecy. Violence is the result of the complex interplay of individual, relationship,

social, cultural and environmental factors. The concern of violence against women is fundamentally one of culture and environment, rather than one of deficits in individuals. Violence against women is a pattern of behaviour that violates the human rights of women and girls, limits their participation in society and damages their health and wellbeing (Garcia-Moreno et al 2013). Worldwide approximately 40% of women have experienced physical, sexual or intimate partner violence (Garcia et al 2013). Health impacts of violence against women include death and injury, depression, sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), unwanted pregnancy and abortion, low birth weight babies and alcohol and drug problems. Violence perpetrated by men against women (gender based violence) takes many forms and results from unequal power relations based on gender differences. There is a strong link between gender based violence and the systemic inequalities rooted in structural power imbalances between men and women (United Nations General Assembly 2006). Inequalities are enabled by a belief

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in the inferior status of women in relation to men and are supported by a combination of gender stereotyping, the sexualising of women and consumption of pornography and group disrespect. Sexist peer norms and aggressive and rude behaviours are normalised and justified as an acceptable way for men to communicate which validate and further glorify violence. Rigid gender roles (supported by gender stereotyping) lead to a masculine sense of entitlement and male dominance and their control of wealth in relationships undermining gender equity. Appropriate responses and multiple strategies are essential at a societal level, in all structures of government, community and interpersonal relations, to create a change in values and attitudes towards women and their role in communities. Addressing the social nature of violence against women, by promoting gender equity and respectful relationships and behaviours, is required to understand and prevent violence from occurring in the first place. There is an urgent need to improve care for women experiencing violence and a major increase in global efforts to prevent all kinds of violence against women. ● – Kelly Bannister

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WFPHA MILESTONES

WFPHA MILESTONES

We look back across the past 50 years at some of the key developments in the history of the World Federation of Public Health Associations. By Jim Chauvin.

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1966

1978

1978: June: WFPHA releases its first policy statement, NonGovernmental Organizations and Primary Health Care, during the Federation’s second international congress, hosted by the Canadian Public Health Association (CPHA) in Halifax (Nova Scotia), marking the first time the Congress is held in North America.

1967

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1967: Three meetings took place (inaugural business meeting, first meeting of the WFPHA Executive Board, first WFPHA Annual General Assembly meeting) which launched the WFPHA. Dr KN Rao (President, Indian Public Health Association) elected as the WFPHA’s first President; Dr A Hutchison (Chair, Royal Society of Health – UK) as Vice-President; and Dr EL Stebbins (American Public Health Association) as the WFPHA’s first Executive Secretary.

1967

September: WFPHA’s President delivers this policy statement in a keynote address at a plenary session during the landmark WHO/ UNICEF International Conference on Primary Health Care in Alma Ata (former USSR).

1977

1977: WHO and UNICEF invite the WFPHA to prepare a position paper representing views of NGOs about primary health care, to be a key document at the WHO/UNICEF International Congress on Primary Health Care the following year.

1977

1979

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1966

1966: Initial meetings to discuss the concept of forming an international organisation representing national public health associations. Decision taken to call it World Federation of Public Health Associations (WFPHA). October: meeting in San Francisco during 94th American Public Health Association (APHA) Annual Meeting during which WFPHA constitution drafted.

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1979: WFPHA launches the Hugh R Leavell lectureship. It is transformed in the 1980s to be combined with an award in recognition of an individual who has made an outstanding contribution to global public health.

1985: Canadian Public Health Association (CPHA) launches Strengthening of Public Health Associations (SOPHA) Program, an initiative that helped create more than 30 public health associations over the next 25 years.

1981: Third WFPHA Congress held in Calcutta (India), hosted by the Indian Public Health Association. First time the Congress is held in Asia.

1987: Fifth WFPHA Congress, held in Mexico City (Mexico), hosted by the Sociedad Mexicana de salud pública. First time the Congress is held in Latin America.

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1985

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WFPHA MILESTONES

1968

1970

1968: WFPHA establishes WHO Liaison Office in Geneva. APHA begins housing/supporting the WFPHA secretariat office.

1970: Milbank Memorial Fund provides a grant to the APHA to work with the WFPHA to determine the potential of NGOs and national PHAs to become more effective advocates and help their respective governments improve basic health services to all of their population. WFPHA publishes its member newsletter. WFPHA launches annual Public Health Technical Discussions at WHO headquarters in Geneva, to coincide with World Health Assembly.

1969: WFPHA appoints Liaison Officers for each WHO region as a means of helping expand WFPHA membership and coordinate the federation’s activities within each region.

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1971: WHO executive board approves the WFPHA’s status as an NGO in official relations with the WHO.

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1968

1972: UN Economic and Social Council (ECSOC) approves the WFPHA’s status as an NGO in official relations with the ECSOC.

1972

1975

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1975: First WFPHA international conference held in Bonn-Bad Godesberg (Federal Republic of Germany – West Germany), hosted by the Bundesverband der Arzte des Offentlichen Gesundheitsdienstes. Congress theme: ‘Public Health Service Yesterday and Tomorrow’. 1976: WFPHA approves its first five-year strategic plan, a major objective of which is the establishment and organisational nurturing of new PHAs.

1988

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1988

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>>

1974

1991:

1988:

Margaret Conley of Australia becomes the first female WFPHA President (1991-1993).

WHO Director General Dr Halfdan Mahler presents WHO Health for All medal to Russell Morgan Jr, former WFPHA Executive Director, in recognition of the Federation’s involvement in promoting Primary Health Care strategy and the role of NGOs.

1991

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1991

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WFPHA MILESTONES

1993

1993:

WFPHA approves resolutions calling for a ban on smoking in UN buildings; marks beginning of WFPHA’s advocacy related to tobacco control and smoking prevention.

2004

1996:

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WFPHA approves a resolution on persistent organic pollutants, its first published position on an environmental health issue.

2004:

WFPHA expands membership to include regional associations of schools of public health. WFPHA inaugurates its triennial Organizational Excellence Award, bestowed on the London School of Hygiene and Tropical Medicine during the 10th World Congress on Public Health (Brighton, UK).

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1993

2005

1998

1997:

The WFPHA holds its international congress for the first time in Africa (eighth WFPHA Congress hosted by the Tanzanian Public Health Association in Arusha). 1998:

Tobacco Control Working Group established. WFPHA membership reaches 50 member associations and organisations.

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2000:

WFPHA releases the Beijing Declaration, a call to action to address the challenges for public health at the dawn of the 21st century at the close of the ninth WFPHA Congress, held in Beijing (People’s Republic of China), hosted by the Chinese Preventive Medicine Association. WFPHA launches in collaboration with ColgatePalmolive a global program to increase awareness and educate the public about the importance of hand washing as a means to reduce communicable diseases. WFPHA Environmental Health Working Group established.


WFPHA MILESTONES 2006:

11th WFPHA Congress, held in Rio de Janeiro (Brazil), hosted by Brazilian Association of Collective Health – ABRASCO, marking the first time the Congress takes place in South America. Partnership established with Journal of Public Health Policy and the publication begins of the Federation’s Pages in the JPHP.

2009

2007: WFPHA publishes first full-colour online Annual Report.

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2009:

WFPHA’s Asia-Pacific Regional Liaison Office established, housed within the Chinese Preventive Medicine Association in Beijing (PRC). WFPHA inaugurates its triennial Lifetime Achievement Award of Excellence in Global Health Award during the 12th World Congress on Public Health (Istanbul, Turkey).

2009

2011

2011:

2011

2012

2015

2012:

The African Federation of Public Health Associations is established, the secretariat of which is set up in collaboration with the Ethiopian Public Health Association in Addis Ababa (Ethiopia). Global Health Equity and Oral Health Working Groups established. Ababa (Ethiopia). Global Health Equity and Oral Health Working Groups established.

2010 2010:

Public Health Professionals’ Education and Training Working Group is established. WFPHA membership reaches 75 member associations and organisations. WFPHA signs MoU with University of Geneva and Swiss Society of Public Health to set up secretariat in Geneva.

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WFPHA international secretariat moves to Geneva (Switzerland) from Washington (DC) where it was housed and supported for 44 years by the American Public Health Association. WFPHA sets up Africa region sub-office within Ethiopian Public Health Association. WFPHA Advisory Board, composed of WFPHA PastPresidents, is established.

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2015:

The Alliance of Public Health Associations in the Americas Region is established, the secretariat of which is housed within the Sociedad cubana de salud pública in Havana (Cuba).Women, Adolescent and Children’s Health Working Group established. 2016:

First African woman elected as WFPHA Vice-President/ President-Elect (Professor Laetitia Rispel of South Africa). Governing Council reconfigured, adding a new seat for a Young Public Health Professional. WFPHA releases A Global Charter for the Public’s Health—the public health system: role, functions, competencies and education requirements to adapt today’s public health to its global context in the light of and in conjunction with the Sustainable Development Goals (SDGs).

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2017

2014:

WFPHA launches its Fellowship Program, a mentorship initiative to enhance the organisational, programmatic and advocacy capacity of PHAs. WFPHA’s membership surpasses 100 associations and organisations.

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2017

2017: WFPHA celebrates its 50th anniversary.

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W F P H A PA S T P R E S I D E N T S

WFPHA PAST PRESIDENTS

The World Federation of Public Health Associations has been built by many great men and women. Here is a selection of them from across the decades. By Jim Chauvin.

Kamaraju N Rao 1st President (1967-1968)

James Kimmey (1972-1973)

Margaret Conley (1988-1996)

Dr. K.N. Rao passed his MBBS in 1930 and became a Fellow of the Royal College of Physicians (UK). He joined the Indian Medical Service, Military Wing in 1935 and was a prisoner of war in Singapore from 1942 to 1945. Following his return to India, Dr Rao became a Professor of Jurisprudence at the Christian Medical College (Vellore) and later as Professor of Tuberculosis at Stanley Medical College (Madras). He served as the Tuberculosis Advisor to the Government of Madras (1951-54). Dr Rao then served for several years as Director of Health Services of Andhra Pradesh. In 1963, he was appointed Additional Director General of Health Services to the Government of India; he became DG the following year, and served in this post until 1968. He was also the President of the Tuberculosis Association of India and also of the Indian Public Health Association. He represented the IPHA at the initial discussions about the creation of the World Federation of Public Health Associations in San Francisco in 1966 and was one of the ‘fathers of the WFPHA’ at its founding in May 1967 during the 19th World Health Assembly in Geneva. He served as Chair of the WHO Executive Board in 1967-68, and Executive Director of the National Academy of Medical Sciences (India) between 1975 and 1979. He passed away in 1988.

In 1963, shortly after completing his medical residency, James Kinney joined the US Public Health Service and served as the first chief of the Federal Kidney Disease Branch, guiding federal efforts to establish the effectiveness of chronic haemodialysis as a clinical tool. After receiving his MPH in 1967 from the University of California, Berkeley, he served as the regional health director for the Public Health Service in New York City. He left federal service in 1968 to become the founding Executive Director of Community Health, Inc., a national planning assistance program sponsored by the American Public Health Association and the National Health Council. In 1970, Kimmey became APHA’s Executive Director. In 1973 he served as Wisconsin’s Secretary of the Health Policy Council and Director of Health Policy and Planning. Dr Kimmey served in several key capacities at St Louis University, where he was appointed Professor Emeritus in 2001. From 2001 through 2011, Dr Kimmey served as President and Chief Executive Officer of the Missouri Foundation for Health.

Margaret Conley has spent the majority of her working life in public health and international development. Commencing as a hospital radiographer, she then moved to policy development, working for the then Federal Minister of Health at a time when HIV first came into focus on the public health horizon. She then began a 20-year career as Chief Executive Officer with not-for-profit organisations, including the Public Health Association of Australia, Australian Business Volunteers and the Australian Veterinary Association. During these years and subsequently she has held a number of non-Executive Director positions on a range of Boards. Her current Board roles focus on veterinary, health and international development themes. She acted as PHAA’s representative to the WFPHA between 1988 and 1996. She holds an honours degree in health politics, plus postgraduate studies in management and comparative religion. Conley has been a Fellow of the Australian Institute of Company Directors since 1999. She was the WFPHA’s 1st female President.

Presidency Highlights: • WFPHA’s 1st President • Oversaw the WFPHA’s initial year of existence

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Presidency Highlights • Oversaw with the WFPHA’s Executive Secretary the preparation of the WFPHA study of the role of national voluntary health organisations in supporting national health objectives

Presidency Highlights • Co-chaired the planning of the 6th WFPHA International Congress (Atlanta, USA: November 1991) • WFPHA membership expanded and member consultation enhanced • Strategic planning commenced to reenvision ways in which WFPHA might operate and continue to grow and be influential into the future

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W F P H A PA S T P R E S I D E N T S

Dr Alex Papilaya (1985-1995) Dr Papilaya was the Director for the Graduate Studies on Hospital Administration, University of Indonesia and served as the Head of the Maintainance Department, RS Citomangunkusumo, Jakarta, Indonesia, the largest public, teaching hospital in Indonesia. He was President of the Indonesian Public Health Association for three terms (1985-1995), where he expanded membership of the association and developed various public health initiatives at national, provincial and local levels. Dr Papilaya was the Director of the IPHA’s Tobacco Control Support Center, organising the efforts of 52 anti-tobacco organisations in Indonesia. He was also President of the Asia Pacific Academic Consortium for Public Health and Dean of the Faculty of Public Health University of Indonesia. He is the Director of the Indonesian Foundation for Better Health and Country Representative for the Dreyfus Health Foundation, New York, which solves problems for better health and hospitals. He has worked to improve the quality of over 150 hospitals in Indonesia, as well as hospitals in Vietnam and Lesotho, Africa. Presently he is the founder and shareholder of PT. CURE International Indonesia, a foreign investment company, based in Pittsburg, USA, which aims to improve quality of hospitals in Indonesia to meet international standards.

Dr Fernando Treviño (1995-1997) After graduating from medical school, Dr Treviño served as a Social Science Analyst at the National Center for Health Statistics, before becoming Senior Scientist at the American Medical Association. In 1986, he became Director of the Center for Cross-Cultural Research and Associate Professor of Preventive Medicine and Community Health at the University of Texas Medical Branch at Galveston. Dr Treviño then served as Dean of the School of Health Professions and was professor of Health Administration at Southwest Texas State University. Following his three-year tenure (1993-1996) as Executive Director of the American Public Health Association, Dr Treviño was professor and chairman of the Department of Public Health and Preventive Medicine in the Texas College of Osteopathic Medicine, part of the University of North Texas Health Science Center. He became chancellor of Southern Illinois University Carbondale in 2007. Presidency Highlights • Expansion of WFPHA membership into Central & Eastern Europe • WFPHA Resolutions on Globalization, Health, Economics & Development • Decision to hold 8th WFPHA International Congress in Arusha, Tanzania

Wenceslaus L Kilama (1997-1999)

Presidency Highlights • Oversaw the first major revision of the WFPHA’s By-Laws • Chaired the planning of the Federation’s 7th International Congress (Bali, Indonesia: December 1994)

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Wenceslaus L Kilama is a retired malaria researcher and Professor of Parasitology and Medical Entomology. He earned his doctorate in

biology from the University of Notre Dame, USA; his doctoral thesis was on genetics of mosquito susceptibility to malaria. On his return to Tanzania in 1970 he founded and headed the Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences (then the Faculty of Medicine of the University of Dares Salaam). Professor Kilama founded and became first Director-General of the National Institute for Medical Research of Tanzania, in 1980, a position he held for 17 years. In 2002 in collaboration with international malaria researchers he founded and was Managing Trustee of the African Malaria Network Trust (AMANET), a successor to the Africa Malaria Vaccine Testing Network (AMVTN). AMANET led Africa in researching, developing and deploying pertinent malaria intervention tools. Dubbed the ‘Grand Old Man of African Malaria Research’, he has to his credit more than 100 scholarly publications. He is among other things a former Chairman of the Malaria Foundation International, a member of the WHO global Advisory Panel on Health Research and an Honorary Fellow of the Royal Society of Tropical Medicine and Hygiene. In Tanzania he served as Chairperson of the Tanzania Public Health Association, Chairman of the Board of the Tropical Pesticide Research Institute, Board member of the Ifakara Health Institute, and Commissioner of the Tanzania Commission for Science and Technology. Presidency Highlights • Organised and chaired the 8th WFPHA International Congress (Arusha, Tanzania: September 1997), the first time this event was hosted by an African public health association • Expansion of WFPHA membership base in Africa

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W F P H A PA S T P R E S I D E N T S

44

Margaret Hilson (1999-2004)

Dr. Mengistu Asnake (2006-2009)

Dr. S.M. Asib Nasim (2007-2012)

Margaret Hilson trained as a nurse with a specialisation in Environmental Studies. Her long career in international health development began in 1968 with Canadian University Services Overseas as a community health nurse educator in India. She was subsequently appointed by WHO to a regional training team in Nepal, Thailand and Indonesia. Hilson was the Director, International Programs of the Canadian Public Health Association from 1985 until her retirement from CPHA in 2006. She managed CPHA’s internationally recognised Strengthening of Public Health Associations (SOPHA) Program. Hilson recently retired from the Faculty of Health Sciences at Simon Fraser University. Hilson’s 20-yearlong contribution to the WFPHA was recognised when she was awarded the Federation’s prestigious Lifetime Achievement Award, presented to her in Addis Ababa in 2012. Her service in public health was also recognised with the awarding of the International Council of Nursing’s Florence Nightingale Award for International Achievement, PAHO’s Health Heroes (one of 17 Canadians to receive this honour), the Order of Canada (the country’s highest civilian honour), and the Queen’s Diamond Jubilee Medal.

Dr Mengistu Asnake is a public health specialist with 30 years’ experience in reproductive health, primary health care, child survival, community health services, program management, training, operational research, and clinical service delivery both in government and non-governmental organisations. Dr Asnake is currently the Country Representative for Pathfinder International in Ethiopia. He served as an expert in global discussions for FP/HIV integration, community-based family planning, long-acting reversible contraceptives, and adolescent issues. In addition, he is the Chief of Party for a USAID flagship FP/MNCH program led by Pathfinder International in Ethiopia. In a voluntary capacity, Dr Mengistu served as President of the Ethiopian Public Health Association (EPHA) from 2006 to 2009 and as an Executive Board member of the World Federation of Public Health Associations (WFPHA). Dr Asnake is an Honorary Assistant Professor in the graduate program of the Addis Ababa University’s School of Public Health and Institute of Population Studies. He has published over 40 scientific and technical papers in peer reviewed journals and technical publications.

Presidency Highlights • Strengthened WFPHA’s management and organisational capacity • Co-chaired the planning of the 9th World Congress on Public Health (Beijing, China: September 2000) • Organised and hosted a prestigious Global Health Leadership Forum with over 40 invited public health leaders from UN organisations, governments and civil society organisations

Presidency Highlights • Led the successful implementation of the 14th World Congress on Public Health in Kolkata (India) with major responsibility of co-chairing the Congress Scientific Committee • Establishment of the regional alliance of public health association in the Americas region • Formation of a Women, Children and Adolescent Health Working Group

Dr. S.M. Asib Nasim started his career as a physician at subdistrict health facilities in Bangladesh. He was actively engaged in the policy formulation, strategic programme planning and health sector reforms in Bangladesh and became one of the leading public health professionals of Bangladesh. Dr. Nasim worked as a team member in formulating and overall drafting of the Program Implementation Plan of the Health & Population Sector Program, as the basis for the first sector-wide management reform programme of the GoB supported by the World Bank. He joined UNICEF Somalia and coordinated the emergency health and nutrition response during the Horn of Africa famine emergency in 2011-2012. Later on he moved to Iraq and supported health and nutrition service delivery in the world’s worst humanitarian crisis, the Syrian refugee influx during 2013. After working in Zambia he again moved to Iraq to organise and manage the emergency humanitarian nutrition and health response to the children and women affected by the conflict (both IDPs and Syrian Refugees) and as an emergency humanitarian aid worker. Currently he is supporting the World Bank Task Team in driving forward the Global Financing Facility goals, methods and processes. Presidency Highlights • Led the development and initial implementation of the WFPHA Strategic Plan 2007-2012 • Updated the Federation’s vision, mission, goals and strategies

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W F P H A PA S T P R E S I D E N T S

Ulrich Laaser (2010-2012) Ulrich Laaser is a doctor of internal and social medicine and holds degrees from the London School of Hygiene and Tropical Medicine and Johns Hopkins Bloomberg School of Public Health. He was professor at the Faculty of Health Sciences in Bielefeld (Germany) and is visiting professor at the Faculty of Medicine in Belgrade (Serbia). In the 1990s he was President of ASPHER and later Andrija Stampar Medalist (2008). Professor Laaser helped establish new schools of public health in Belgrade, Bielefeld, Sofia, Tirana and in Gaza. He published more than 400 articles, books and chapters and was co-editor of Gesundheitswissenschaften, a comprehensive handbook for teaching, research and practice, now in its 5th edition. He also coordinated the publication of six volumes of the Handbook for Teachers, Researchers and Public Health Professionals in the framework of the Stability Pact for South Eastern Europe (20012011). His main areas of interest are population health, cardiovascular epidemiology, and the globalisation of public health and health sciences. Presidency Highlights • Co-chaired the planning of the 13th World Congress on Public Health (Addis Ababa, Ethiopia: April 2012) • Began the WFPHA’s regionalisation process with the opening of the Regional Liaison Office for the Western Pacific in Beijing and the creation of the African Federation of Public Health Associations • Oversaw the move of the WFPHA’s international secretariat from Washington (DC) to Geneva, Switzerland

James Chauvin (2012-2014)

Theo Abelin (2001-2004)

Over his 40-year professional career, James Chauvin worked with members of the public health community and health researchers in more than 40 countries. Besides Canada, Chauvin has lived and worked for extended periods in South Africa, Haiti, Tunisia and in the former Yugoslavia. Between 1992 and 2013, he was employed by the Canadian Public Health Association (CPHA), where he was Director of Global Health between 2005 and 2008; and CPHA’s first Director of Policy between 2008 and 2013. Prior to this, Chauvin worked at the International Development Research Centre, the Canadian International Development Agency, and with CARE International. He sits on the Board of Directors of the Canadian Society of International Health and the Association pour la santé publique du Québec. In September 2015, he was named for a five-year term to the Canadian Commission on Building and Fire Codes, representing “the public’s interest”. Jim Chauvin is an Associate Editor, European Journal of Public Health and a member of the Editorial Board of the Journal of Public Health Policy.

Professor Theo Abelin is Professor Emeritus of Social and Preventive Medicine, University of Bern, Switzerland. After graduating from medical school in 1960 and initial research experience in occupational health at the Swiss Federal Institute of Technology, he spent nine years at the Harvard School of Public Health, initially as a student, then as a researcher and faculty member in Epidemiology and Behavioral Sciences. In 1971 he returned to the University of Bern to develop a new Department of Social and Preventive Medicine. He retired from the University in 2000. His research interests include risk factors of chronic disease, especially tobacco, and the use of Epidemiology and Health Statistics in Health Services Planning and Public Health. Around 1990, his research moved to environmental epidemiology. His first contacts with the WFPHA were in 1980, leading the Swiss Society for Public Health to apply for membership. Professor Abelin was a member of the WFPHA’s Governing Council starting in 1991. In 2004, he received the Andrija Stampar Medal from the Association of Schools of Public Health in the European Region (ASPHER), and in 2015 the WFPHA Lifetime Achievement Award.

Presidency Highlights • WFPHA 2013-2017 Strategic Plan adopted and implemented • Planned the successful 15th World Congress on Public Health, which drew over 1600 people from more than 70 countries • Secured funding with Aetna Foundation (two-year initiative examining the use/impact of digital technologies on population health and health equity)

Presidency Highlights • Led WFPHA’s advocacy for the creation and ratification of the WHO Framework Convention on Tobacco Control (FCTC) • Modified the WFPHA Constitution to admit regional Associations of Schools of Public Health as WFPHA members • Began the redistribution of influence within WFPHA to a more broad-based worldwide membership

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A CASE STUDY IN UNDERSTANDING DIGITAL TECHNOLOGY

A recent attempt to collate a series of articles from global experts around the relationship between digital technology and health/health equity from a public/population health perspective was a world first and highlighted the need for a global effort. This is an overview of that process. By Jim Chauvin.

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otwithstanding major progress during the Millennium Development Goal (MDG) era, the global challenges of health inequalities, complex disease burdens, and weak health systems remain. In the past decade, several authors have pointed to the potential and power of digital technology (DT) to address some of these challenges. The health care system is replete with examples about the use and impact of digital technologies on human health, ranging

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from magnetic resonance imaging, personal electronic health cards, through to nanotechnology and genomics. The focus of many of the DT applications, however, tends to be on individual health and personalised medicine, on patients (once the person needs a medical intervention or health care service), about how digital technologies are revolutionising the delivery of diagnostic and treatment services, and to help those within the health care system make better clinical and cost decisions.

In contrast, there was until recently a dearth of information about the extent to which and how digital technologies have been used within the realm of public health, as a means of preventing disease and injury and promoting/ protecting health, and the benefit of such technologies in terms of population gains in health and health equity. In early 2014, the World Federation of Public Health Associations (WFPHA) conducted a literature review, and found that none of the articles on DT assessed the impact of its use on population health outcomes, nor did they take into consideration the impact of the social determinants of health on the uptake, use, and effect of DT on human health, nor on health equity. The WFPHA’s interest in the use of DT in public health and its potential impact on human health was influenced by the work of its

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member organisations, the revision and preparation of the WFPHA’s strategic plan in 2013, and the intention to use information, communication technologies (ICT) to improve its own advocacy effectiveness, and knowledge about several innovative applications of DT within the health sector. This piece focuses on the DT initiative of the WFPHA. The purpose of the initiative is twofold: first, to increase knowledge about and use of DT among frontline health workers and general population for population health and health equity gains, and second, to encourage the use of DT, when appropriate, to contribute to improvement in population health (disease & injury prevention, health promotion, health protection) and to address issues of health equity.

APPROACH AND PROCESS In late 2014, the WFPHA obtained funding from the Aetna Foundation for three interlinked components: a themed session at the 14th World Congress on Public Health held in Kolkata (India) in February 2015; the publication of a special section of the Journal of Public Health Policy; and a WFPHA discussion paper on the topic, to be released at the 15th World Congress in Melbourne. We adopted several approaches to commission the articles: inviting preeminent scholars to compose articles; extending invitations to well-known and highly respected international organisations to write about their experiences with digital technologies; to select potential authors from among the abstracts on the issue submitted as oral and poster presentations for the 14th World Congress and to consult with different groups and individuals familiar with the topic, seeking their advice as to who might be invited as a potential author. Following some challenges with this approach, a small ad hoc WFPHA editorial committee adopted a more proactive and selective approach. The Committee invited Dr. Alejandro Jadad, Founding Director, Centre

for Global eHealth Innovations and Professor, Dalla Lana School of Public Health/University of Toronto, to write an article based on his future-looking presentation [(Mis)information and (mis)communication technologies?] delivered at the 14th World Congress on Public Health. In response to a call issued by the WFPHA to national PHAs to share their experiences in the use of DT, the

“THE WFPHA’S INTEREST IN THE USE OF DT IN PUBLIC HEALTH AND ITS POTENTIAL IMPACT ON HUMAN HEALTH WAS INFLUENCED BY THE WORK OF ITS MEMBER ORGANISATIONS” Public Health Association of South Africa referred the call to the country’s national health department, which was subsequently invited to prepare an article about its experiences in the application of DT to improve maternal and infant health outcomes. The Faculty of Health Sciences/

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American University in Beirut, which submitted a synopsis of its work with refugee and displaced populations, was invited to prepare an article on the use of DTs to improve health of populations affected by humanitarian crises. A group of researchers from Latin America, identified through the IDRC’s SEARCH initiative, was also commissioned to examine the use of DT in reproductive health services in the Latin America/Caribbean region. The Aetna Foundation contributed an article about the results and lessons learned through a USA-based initiative funded through its grants program. Finally, upon learning in early 2016 about its intention to conduct a panCanadian survey to assess how digital technology including social media is being used to support action on the SDOH and health equity, we invited the National Collaborating Centre on the Social Determinants of Health in Canada to prepare an article for us. For each paper, we selected peer reviewers to ensure that papers would be sound, relevant, and interesting to an international audience. The authors revised their articles between January and April 2016 following receipt of reviewers’ comments. We edited the papers during April and May for quality assurance and to comply with JPHP guidelines.

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THEMES AND FOCUS This special section on the relationship between DT and health/health equity is, to the best of our knowledge, a first attempt to examine the issue from a public/population health perspective. Although the seven commissioned articles have their limitations and shortcomings, they do provide a snapshot about how DT is used in a variety of public health settings within differing contexts. Barron et al. reported on an analysis of the metrics used to assess the effectiveness of an innovative mobile phone-based application in South Africa to improve health outcomes of pregnant and post-partum women and their infants by increasing access to and the quality of maternal–newborn health services. They discuss how DT empowers service users. Although the study did not assess the impact of the technology on health outcomes, it did confirm greater use of maternal–neonatal services by women using the app. Technology also assisted health service personnel improve patient interaction and the quality of services provided. The authors found that the DT made a difference to the overall quality and use of primary health care services.

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Nigenda et al. presented a systematic review of the use of DT for the prevention of sexually transmitted infections and the promotion of sexual and reproductive health services in the Latin America and Caribbean region. As they noted, mobile phone coverage in most countries in this region exceeds 80 per cent and over 60 per cent have access to the internet. The Pan American Health Organisation’s promotion of DT for health has helped garner political support for its adoption in many countries. Mesmar and her associates at the American University in Beirut (Lebanon) examined the use and impact of DT among people caught up in and affected by humanitarian crises (HC), and how such technology helps responders better understand complex HC situations and the needs of affected communities, to facilitate response efforts, and to engage the affected populations in the response. They identified several technologies that have played an important role in improving the effectiveness of HC responses. Of note is the role played by Geographic Information Systems (GIS), which Mesmar et al. describe as a ‘major game changer’. They also cite gaming software, real-time surveillance systems, social media, and the increasing

availability of low-cost computer hardware and software. Graham and his associates at the Aetna Foundation described its approach to grants-making and drew on the results and lessons they learned from several initiatives supported in the USA. The aim of the Foundation’s program is to inspire healthier lifestyles and create healthier communities. The use of mobile phone applications in underserved areas helped create better understanding about healthier food choices, increased consumption of fresh fruits and vegetables, improved people’s capacity to read and understand nutritional labelling, and increased the effectiveness of poststroke rehabilitation. Chauvin, Perera, and Clarke explored the use of DT by national public health associations (PHA), its impact on their organisational and programmatic activities (including advocacy) and whether/how PHAs assess the impact of such technologies. PHAs use DT primarily as a means to communicate with their members and to disseminate information about best practices and policies to other stakeholders, government authorities, and to the general public. It tends to be restricted to websites, the use of mobile phone applications, social media (primarily Facebook and Twitter), blogs, online fora, and webinars. Only a few NGOs, mainly those located in higher-income, digitally advanced countries, have experience with more sophisticated DT usage. The assessment of DT impacts tends to focus on process and output metrics (for example, the ‘uptake’ of mobile applications, the number of hits on a PHA website). The evaluation of the potential impact of DT on population health outcomes and health equity remains missing from the picture. Ndumbe-Eyoh and Mazzucco reported on the results of the pan-Canadian survey about how digital technology is being used to support action on the SDOH and health equity. The survey’s findings indicate that public health workers use social media for knowledge translation, relationship building, and specific public

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health roles to advance health equity. Organisations in which they work could develop policies and provide training opportunities to enhance skills to enable a more substantive use of digital technologies to advance public health practice and to address health equity. Jadad asks us to adopt a new concept of health. The question is not how DT affects health; rather, how DT can be used to mobilise the assets at the disposal of individuals and communities to elevate the status for those who do not feel healthy while protecting those who already consider their health to be good. Can we shift from thinking about what causes disease and injury, to what causes health? It would require adopting the concept of resilient people and communities.

ISSUES RELATING TO THE USE OF DT FOR HEALTH GAINS A review of the articles, plus information drawn from several articles and reports published in recent months reveals a rich experience in the use of DT for health results from around the world. Perhaps the largest application of DT within the field of public health is happening within the areas of disease surveillance, population health surveillance, and emergency and pandemic response. Considerable effort has been made in recent years to create and promote apps and other DT-related tools in the area of health promotion, especially to aid lifestyle choices and behaviour change. These are important advances and their impact on the capacity of health systems to respond and address conditions that affect human health cannot be overlooked or denied. That being said, the literature, including the seven commissioned articles, identifies several challenges in the use of DT for health and health equity gains. We can only list a few of them here, but we believe these are the most important ones: • Scalability, reproducibility, transferability, sustainability of digital technology interventions, especially

in low- and middle-income countries. Incorporating the use of DT within population health approaches requires an understanding and acceptance that people come first and technology second. Getting swept up in hype about technology and ignoring the community’s needs and perspectives about how the factors

excellent starting points. But more needs to be done to put into place the methodologies and the metrics to assess the impact of DT on population health and health equity. Otherwise, we focus on the means rather than on the desired collective global end. The use of digital technologies is reshaping our health care systems

“PERHAPS THE MOST SIGNIFICANT CHALLENGE IS HOW DIFFICULT IT WILL BE TO DEMONSTRATE IMPACT AND ATTRIBUTE POSITIVE OUTCOMES FOR POPULATION HEALTH AND HEALTH EQUITY DIRECTLY TO THE USE OF DT” that affect human health could and should be addressed; • Few initiatives are founded on a usercentred design approach to DT, as the industry pushes digital technologies for profit; • Focus on personalised (not population) medicine/health; • Resource constraints (financial, human resources, organisational capacity); • Unequal access to and/or digital literacy/exclusion. Who actually benefits?; • Ethics & privacy. Perhaps the most significant challenge is how difficult it will be to demonstrate impact and attribute positive outcomes for population health and health equity directly to the use of DT. The Lancet report on global health technologies reported that evidence of effectiveness gleaned from the nine randomised controlled trials for mHealth in lowincome countries cited was ‘weak.’ Most studies of effectiveness tend to focus on the impact of DT on health worker performance, quality of service, and health service efficiency. The launch of the WHO’s mHealth Assessment and Planning for Scale (MAPS) Toolkit and the mHealth Evaluation, Reporting and Assessment (mERA) checklist are

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and prompting us to rethink how we extend life and improve health. We have only begun to scratch the surface. “The Internet of Things,” artificial intelligence, robotics (including drone technology, 3D-printing), have the potential to transform not only healthcare, but the way we live our lives. The UN 2030 Agenda for Sustainable Development recognises the potential impact of digital technologies and calls for investment in and access to them as a means to support the SDG’s implementation and achievement. There is a huge potential for DT within public health, with a high pay-off in terms of health and health equity. What is evident to the authors of this article is the urgent need for the global public health community, and especially national public health associations and the WFPHA, to show leadership and contribute to the discussion on the place of DT for population health and health equity gains. We can no longer sit on the sidelines. If we are to represent the civil society voice of public health in our respective countries and internationally, then we need to define a public health approach to the use of DT, and help address the challenges related to its use, especially when it comes to assessing the impact of DT on health and health equity. ●

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NEGLECTED TROPICAL DISEASES

NO ONE LEFT BEHIND

More than one billion people are affected by neglected tropical diseases, resulting in chronic and costly care. The rise of global warming and the growth of tropical zones means the potential for further impact is high. By Janice Wormworth.

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n January 2017, the World Health Organization (WHO) celebrated five years of collaboration toward defeating neglected tropical diseases, ancient afflictions of poverty that generate vast misery. The same month, the World Meteorological Organization announced that 2016 was the hottest year on record, continuing a decades-long warming trend that has toppled successive global heat records like dominos. Though seemingly unrelated, the latter announcement has considerable import for the former. Climate change

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is expected to accelerate the spread of several neglected tropical diseases. One such disease, dengue fever, has already re-emerged in countries where it was absent for decades. This article examines the evolution of the global push to combat neglected tropical diseases, and touches on some of the challenges ahead.

NEGLECTED TROPICAL DISEASES DEFINED Neglected tropical diseases affect more than one billion people. Many are devastating and require chronic, costly care.

Yet these diseases are neglected because they mainly affect poor populations – often people who lack a political voice. Though communicable, they are not readily or frequently spread to developed countries. Poorly understood, these diseases are generally not the focus major research initiatives. Though diverse and numerous, collectively they inflict as much damage as HIV/AIDS, malaria or tuberculosis (the ‘big three’ global diseases).

A NEW MILLENNIUM TO REVERSE CENTURIES OF NEGLECT Though most are ancient diseases, the drive to defeat them as a group is relatively young. This grouping was first conceptualised in the years after the 2000 Millennium Development Goals. The conceptual framework recognised common features of certain parasitic and tropical

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infections: chronicity, ability to wreak long-term disability, and status as overlooked diseases. Efforts to promote science, policy and advocacy to combat neglected tropical diseases were boosted further in 2007, when the Public Library of Science (PLoS) launched the Neglected Tropical Diseases journal.

A LIST OF 17 DISEASES – FOR NOW Today the WHO lists 17 infections it recognises as neglected tropical diseases. Two of the 17, dengue fever and rabies, are viral infections. Four are bacterial: Buruli ulcer, leprosy (Hansen’s disease), trachoma and yaws. Protozoans are responsible for transmitting three, Chagas disease, sleeping sickness (human African trypanosomiasis), and leishmaniasis. Parasitic worms, helminths, are responsible for the remaining eight: taeniasis/cysticercosis, Guinea-worm disease (dracunculiasis), echinococcosis, foodborne trematodiases, lymphatic filariasis, river blindness (onchocerciasis), schistosomiasis and soil-transmitted helminth infections. The WHO’s list notwithstanding, infectious disease experts continue to debate which diseases to include. Should the grouping include those most common? The most treatable? Should it be broadened to include as many as 30 neglected diseases of poverty? Dengue, some argue, poorly fits the model because it is an acute emerging febrile disease (not chronic and debilitating). Others counter that it does fit because it leads to lifetime disability that is a neglected impact.

THE TOLL: UNTOLD SUFFERING AND ECONOMIC HARDSHIP Neglected tropical diseases continue to be some of the planet’s greatest health problems. The diseases are characterised by high morbidity in terms of years lived with disabilities that make life miserable. They blind, maim and disfigure. They complicate pregnancies, stunt children’s growth and lead to

“THOUGH FEW IN NUMBER, DONOR-FUNDED NONGOVERNMENTAL ORGANISATIONS THAT FOCUS EXCLUSIVELY ON NEGLECTED TROPICAL DISEASES CAN BE A COST EFFECTIVE AND EFFICIENT WAY TO TREAT AND PREVENT” cognitive impairment. Some, if undetected and untreated, can kill. People who live in extreme poverty may have more than one such disease. The social stigma of some, such as leprosy, further complicates public health efforts to combat them. Their chronic nature, coupled with the high economic burden for care and treatment, drains billion from developing economies each year, a serious impediment to poverty reduction and development. Take Guinea-worm disease (dracunculiasis). Spread by water fleas that harbour larvae of Guinea-worm parasites, this disease thrives where sanitation is poor. When someone swallows water contaminated with the fleas, the larvae enter the person’s intestines, then their body. The female worms grow as long as 100cm, then painfully emerge from the skin. The worm must be carefully and completely removed over a period of weeks to avoid bacterial infection, septicaemia and permanent disability. With no cure or

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vaccine, the only way to combat Guineaworm disease is to treat those infected and prevent its transmission.

BLUE MARBLE HEALTH FOSTERS DIALOGUE Most of these diseases are tropical, being especially common among low-income people in developing countries of Africa, Asia and the Americas. Yet those affected include the poor living in the largest emerging market economies, the Group of Twenty (G20). Neglected tropical diseases also exist among poor and disadvantaged populations in very wealthy countries, including the United States and Australia. This blurring of health issues between developed and developing countries has led to the concept of blue marble health (a reference to iconic ‘blue marble’ photographs of Earth, captured by the Apollo 17 crew, which came to reinforce calls for better stewardship of the planet). Blue marble health aims to foster dialogue on poverty as a driver of neglected tropical diseases, regardless of where they occur. It emphasises the

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I N F E C T I O U S D I S E A S E S & V A C C I N AT I O N S

“IF NTDS ARE NOT ADDRESSED, OVER 1 BILLION OF THE WORLD’S MOST VULNERABLE, MOST DISADVANTAGED PEOPLE WILL BE LEFT BEHIND – THE POOREST OF THE POOR, WHO LIVE IN THE REMOTEST, HARDEST TO REACH PARTS OF THE WORLD” — UNITING TO COMBAT NEGLECTED TROPICAL DISEASES WEBSITE major impact G20 countries could have on eliminating these diseases, if they took greater responsibility at home.

A COLLECTIVE MOVEMENT GROWS AND EVOLVES The movement to defeat neglected tropical diseases was launched in the first few years of the new millennium. The first phase of work to combat neglected tropical diseases, known now as Version 1.0 (V 1.0), was initiated and scaled up with support from the United States and United Kingdom. It focussed on 13 neglected tropical diseases, seven of them considered to be ‘major’. The movement entered its second phase (V 2.0) after 2012. This transition reflected responses to important new global health policies, insights and developments, which have major implications for combatting neglected tropical diseases.

NEW INSIGHTS ON ANCIENT DISEASES Key among these were insights from the Global Disease Burden Study 2010. Published in 2012, it highlighted important new findings on the disease burden or threat of specific neglected tropical diseases, providing more information to guide control efforts. This included recognition of the importance of emerging viral infections, dengue and rabies. Also important was increased recognition that neglected tropical diseases disproportionately impact girls’ and women’s health, justifying their designation as special at-risk populations. Urogenital schistosomiasis (Schistosoma haematobium infection), for example, affects up to 150 million girls and women and is associated with bleeding, pain, social stigma and depression. Chagas disease (transmitted from mother to child)

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and dengue during pregnancy also burden women’s health. Other important insights flowed from research confirming links between neglected tropical diseases and the big three conditions, HIV/AIDS, tuberculosis and malaria. Female genital schistosomiasis may be an important contributor to HIV/AIDS in Sub-Saharan Africa, where it is linked to a four-fold increase in acquiring HIV/AIDS during sexual intercourse. Links like these highlight the importance of integrating neglected tropical disease programs with those for the big three. It has become increasingly clear that neglected tropical diseases also make a stealth contribution to non-communicable diseases including cardiovascular disease, cancer, chronic pulmonary disease and diabetes. Schistosomiasis, for example, also causes cancer.

WHO ROADMAP AND LONDON DECLARATION In January 2012, the WHO set new targets and milestones to step up control, prevention, elimination and eradication of 17 neglected tropical diseases (listed above). Known as the WHO Roadmap, it targeted two diseases for eradication: Guinea-worm disease (dracunculiasis) by 2015, and yaws by 2020. It targeted four others for global elimination by 2020: blinding trachoma, sleeping sickness (human African trypanosomiasis), leprosy and lymphatic filariasis. The roadmap also set targets for regional or countrywide elimination of diseases. Days after the WHO Roadmap’s release, and inspired by its goals, the broad forces for the eradication of neglected tropical diseases met in London. Spearheaded by WHO director general Margaret Chan and Bill Gates, the meeting was attended by governments, global health institutions, and pharmaceutical companies. On 30 January 2012, the group endorsed the London Declaration on Neglected Tropical Diseases, announcing ‘a new, coordinated push to accelerate

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D I S E A S E S & V A C C I N AT I O N S

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At the Walter and Eliza Hall Institute more than 800 researchers are working in multidisciplinary teams to develop better ways to prevent, diagnose and treat diseases including cancer, immune disorders and infections. With capabilites spanning from basic research to clinical translation, we are committed to making fundamental scientific discoveries that will benefit our global communities. Our global reach is enhanced by an extensive network of academic, government and industry collaborators in more than 96 countries. For more information, please contact: Dr Julian Clark, Head of Business Development jclark@wehi.edu.au 160901

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Walter and Eliza Hall Institute of Medical Research 1G Royal Parade Parkville Victoria 3052 +61 3 9345 2555 W

www.wehi.edu.au WEHIresearch @WEHI_research WEHImovies wehi_research Walter and Eliza Institute

INFECTIOUS DISEASE

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I N F E C T I O U S D I S E A S E S & V A C C I N AT I O N S

progress toward eliminating or controlling 10 neglected tropical diseases [a subset of the 17 identified by WHO] by the end of the decade.’ The largest coordinated health effort to date, it pledged more than US$785 million in support for R&D, and drug distribution and implementation. Under the banner Uniting to Combat Neglected Tropical Diseases, the reinvigorated movement gained further momentum in 2015 when world leaders adopted the United Nations’ new Sustainable Development Goals. Critically, and for the first time, the goals specifically cited neglected tropical diseases as an issue of global importance, committing global leaders to ensure ‘no one is left behind’ in development progress.

THE FIVE WHO INTERVENTIONS The World Health Organization recommends five interventions to prevent, control, eliminate and eradicate neglected tropical diseases. 1. Preventive chemotherapy includes optimal use of safe, single dose medicines. This strategy is used to combat four helminth infections (lymphatic filariasis, river blindness [onchocerciasis], schistosomiasis and soil-transmitted helminth infections). The high health and economic toll of these diseases often contrasts sharply with their low treatment cost. Schistosomiasis treatment, for example, costs only US$0.20 per child per year. Success in preventive chemotherapy for neglected tropical disease is underpinned by drug donations from pharmaceutical companies. In 2015 alone, they donated approximately 2.4 billion tablets, according to Uniting to Combat Neglected Tropical Diseases, enough for 1.5 billion treatments. 2. Innovative and intensified disease management encompasses better case detection and improved access to specialised care to target complex diseases spread by protozoans and bacteria. Sleeping sickness (human African trypanosomiasis), leishmaniasis, Chagas disease and Buruli ulcer fall into this class. This

type of intervention aims to reduce morbidity, interrupt the cycle of disease transmission, and save lives. 3. Vector ecology and management aims to control disease vectors and hosts. These efforts include well-managed, sustainable and ecologically-sound application of public health pesticides. 4. Veterinary public health services aim to prevent and control diseases spread by vertebrate animals, for example, the spread of rabies by dogs. 5. Water, sanitation and hygiene interventions centre on programs to improve access to safe water, sanitation and hygiene, often referred to as WASH programs. Safe drinking water is still out of reach for 900 million people, and 2.5 billion lack appropriate sanitation. These conditions permit neglected tropical diseases to spread. Trachoma, a leading cause of preventable blindness, is strongly

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related to overcrowding, lack of water for washing, and poor waste disposal. WASH programs can reduce trachoma by 27%. Schistosomiasis, which kills tens of thousands annually, is also combatted by basic sanitation, which can reduce schistosomiasis by 77%.

BILL AND MELINDA GATES FOUNDATION: MAXIMISING EFFECT The Bill and Melinda Gates Foundation’s strategy focuses on neglected tropical disease interventions with ‘the greatest opportunity for elimination or eradication’. It concentrates efforts where existing funding is scarce, and where support ‘can have a catalytic effect’. Making use of donated drugs, the foundation supports mass drug administration where several diseases can be tackled by the same drug or similar drug treatment schedules. Another focus is public health

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surveillance, which recognises that good data on neglected tropical diseases – often lacking – is highly valuable for their screening and control. The foundation also supports vector control efforts, boosting their cost effectiveness by coordinating multiple control efforts.

STRATEGIES TO DEVELOP AND DELIVER DRUGS New drug development is costly. Public-private initiatives are one way to fund affordable drug development. Catalysed by Médecins Sans Frontières and established in 2003, the productdevelopment partnership Drugs for Neglected Diseases is a patient’s-needsdriven, non-profit R&D organisation. It has already developed new treatments, such as a cheaper and more effective treatment against visceral leishmaniasis in Africa. Though few in number, donor-funded non-governmental organisations that focus exclusively on neglected tropical diseases can be a cost effective and efficient way to treat and prevent. One is the Schistosomiasis Control Initiative, which supplies schools with ‘rapid impact’ packages including four or five drugs, and trains teachers how to administer them.

THE BENEFITS OF COLLABORATION: A BILLION TREATED In January 2017, WHO announced that almost a billion people were treated for neglected tropical diseases in 2015, a milestone it attributes to enhanced collaboration. Progress is being made on the WHO Roadmap’s eradication and elimination targets. Although Guinea-worm disease (dracunculiasis) is not yet completely eradicated, there were only 25 reported cases in just three countries in 2016 (compared to 3,500,000 cases in 1986). And fewer than 3,000 cases of sleeping sickness (human African trypanosomiasis) were reported worldwide in 2015 (compared to 40,000 cases in 1998). Cases of leprosy, the ancient disease of affliction and ostracisation, declined from

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5.2 million in 1985 to 176,176 cases at the end of 2015. Gone from all but a few small countries, the WHO goals of elimination (defined as a registered prevalence rate of less than one case per 10,000 persons) were met by the year 2000. A new 2016 strategy seeks to accelerate progress toward a ‘leprosy free world’. The Uniting to Combat Neglected Tropical Disease collective states that progress has benefited from strong

“CLIMATE CHANGE IS NOT THE ONLY HUMAN FORCE OF CONCERN HERE. DEFORESTATION, URBANISATION, AND POLITICAL DESTABILISATION ALSO AFFECT NEGLECTED TROPICAL DISEASES.” partnerships, better data and tools, generous drug donations, and country programs that facilitate the push toward goals in hard-to-reach areas.

THE CHALLENGES AHEAD In 2015, WHO warned that, ‘Despite renewed momentum characterised by unprecedented progress, some neglected tropical diseases (like dengue) remain a significant obstacle to health.’ A key challenge is climate change, specifically its potential to accelerate the spread of several vector-borne neglected tropical diseases. Notable among them is dengue fever, a widespread mosquitoborne viral disease. Indeed, dengue has already re-emerged where it was absent for decades, WHO found, spreading at an alarming pace.

CLIMATE-SENSITIVE VECTORS Diseases transmitted by vectors, such as blood-feeding insects or other animal hosts, are sensitive to climate to some degree.

Mosquitoes and other insects may expand their distributions where warming increases their breeding rate, bite rate and survival. Humidity and water availability may also shift conditions in their favour. What is more, warming can shorten the maturation period for the pathogens these vectors transmit. Dengue’s spread, for example, is influenced by temperature, rainfall, relative humidity and climate variability, mainly through effects on the mosquito vector. Dengue is already endemic in more than 100 countries. Each year brings hundreds of thousands of severe dengue cases and about 3,000 deaths, with the economic burden tallied in billions of dollars. The World Health Organization has factored climate change into its recognition that dengue is a disease of the future, one that may require increasing investments in vector control until 2030.

DISEASE TRANSMISSION SHAPED BY HUMAN ACTIVITY Climate change is not the only human force of concern here. Deforestation, urbanisation, human migration and political destabilisation also affect neglected tropical diseases. Peter Hotez, editor-in-chief of the journal Neglected Tropical Diseases and a tropical disease expert at Baylor College of Medicine, recently highlighted the links between these forces and the increased incidence of several neglected tropical diseases, including Chagas disease, chikungunya, and Zika virus, as well as dengue. Hotez warns that, ‘While we advance through a geological epoch that increasingly reflects human intervention on a massive scale, we might expect to see the continued expansion of epidemic neglected tropical diseases’. The impacts of these profound human interventions will be felt as the movement to combat neglected tropical diseases progresses toward its 2020 targets. The next, crucial, four years will be vital to ensure one billion of the world’s most poor and vulnerable people are not left behind. ●

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P O L I O E R A D I C AT I O N

THE QUEST TO ELIMINATE POLIO AND ITS LESSONS FOR PUBLIC HEALTH Professor Peter McIntyre writes on the success of the war against polio, and how it too can be eradicated, like smallpox before it.

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here has been enormous progress in the Global Polio Eradication Initiative (GPEI), with cases decreasing from 350,000 in 125 endemic countries in 1988 to 334 cases in 2014, 74 in 2015 and 33 – the lowest number of cases ever recorded – in just three countries, in 2016. Following declaration of a Public Health Emergency of International Concern by the World Health Organization in 2014, cases in Pakistan decreased from 306 to 19 in 2016 and in Afghanistan from 28 to 12. Although Nigeria had been free of

polio cases for two years, two occurred in one region affected by a security breakdown in 2016. Of the three types of polio virus, type 2 has been eliminated, allowing replacement of the trivalent with the more efficacious bivalent oral vaccine (bOPV, containing types 1 and 3 only) in 2016 globally; no cases of type 3 have been seen since 2012. Commencing bOPV in countries still using oral polio vaccines has also required introduction of a single dose of inactivated polio vaccine (an intramuscular injection) in the infant schedule – another of many logistic tasks in the road to polio elimination. It is important to note how these huge efforts in polio elimination have had flow-on benefits and lessons for public health generally. These include best practices in communication and community engagement, the value of well-resourced laboratory networks,

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learning how to reach every child, especially those in marginalised groups, and potential synergies between public health programs. Reaching and maintaining elimination will need continued and concerted efforts. 2018 marks 40 years since the last case of smallpox (a campaign taking a decade from 1967) and the last year of the GPEI (2013-18). The GPEI is led by 5 core partners (Rotary, Bill and Melinda Gates Foundation, WHO/UNICEF and the US Centers for Disease Control), with current financial commitments from them, and donor countries, in excess of US$4 billion. The quest culminating in the GPEI, 30 years old in 2018, looks on target to reach its ambitious goal. If so, like smallpox eradication, despite being a much more lengthy, complex and costly goal, it will repay its cost many times over in coming decades. ●

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T SO OB C IAACLC O DETERMINANCE

SOCIAL DETERMINANTS Equality is everyone having the same thing. Equity is everyone having what they need. In health, this is more evident than anywhere else. How can this be challenged? By Professor Sharon Friel.

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hat have we done? Asymmetric economic growth, unequal improvements in daily living conditions, unequal distribution of technical developments and suppression of human rights have seen inequities in health, between and within countries, perpetuate and worsen, particularly over the last three decades. Meanwhile, modern industrialised societies have seriously perturbed the Earth system

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that sustains life. Recent human activity has increased the atmospheric levels of greenhouse gases, particularly CO2, methane and nitrous oxide, to a near-critical state that now threatens an environmental crisis as the world warms, parts of it becoming unusually wetter, and sub-tropical regions becoming drier. This will mean more sea level rise and extreme weather events, disrupted agricultural productivity, displacement of people, and loss of

livelihoods – all bad for human health and tend to impact most on the more socially disadvantaged groups. Without lessening of the background rates of disease, the multiplier effects of climate change on infectious diseases, non-communicable disease and mental health will greatly exacerbate health inequities. These three great contemporary human struggles – achieving global health equity, reducing social inequities and climate stabilisation – would benefit synergistically from alignment of their policy agendas. However, prevailing international and national policies portend various negative effects of unprecedented scale on human wellbeing, health and the planet itself. There is need and opportunity to

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SOCIAL DETERMINANTS

reorient these policies using today’s global knowledge about the social causes of health inequity and the causes of climate change. Appeals for making poverty history, reducing social and health inequities and for climate stabilisation resonate with increasing numbers of civil society organisations, and there is growing public awareness that major changes are needed. Bringing these voices together will help create the new model of governance and of development that is needed.

A COMMON AGENDA FOR HEALTH EQUITY AND CLIMATE STABILISATION Investment in health by reducing social inequity would be enhanced by action to remedy the underlying ‘causes of the causes’ – the structural drivers of social inequities and improve daily living conditions for all. At the same time, mitigation of climate change is prerequisite for avoidance of a widening of health inequities. Environmental scientists and policy-makers are now paying attention to fuel, agriculture, transport, buildings, industry and waste strategies relevant to mitigating climate change. Such a policy framework is central to health equity and is therefore timely to integrate a health and equity dimension into these strategies, seeking multiple ‘wins’ across the different sectors.

WHAT CAN BE DONE TO IMPROVE GLOBAL HEALTH EQUITY? So what might be done to pursue a fair, healthy and sustainable world? Below are three high order policy suggestions, which, if pursued, would enable communities to live healthy and flourishing lives within environmental limits. Urban planning that ignores issues of equity and environmental needs results in built environments that impact more adversely on socially disadvantaged groups. Cities that do not provide affordable and convenient public transport, or prioritise the need for walking, cycling and playing

and are dependent on a high-volume industrialised food system, fuel the nutrition transition and the decline in physical activity – and, thus, the obesity epidemic. Many such urban landscapes

“POOR NEIGHBOURHOODS AND MANUAL WORKERS ARE LIKELY TO BE MORE EXPOSED TO URBAN HEAT AND HAVE LESS CAPACITY TO ADAPT” predispose to car use, thereby perpetuating air pollution, greenhouse gas emissions, and risk of road traffic accidents. An integrated approach to transport emissions reduction, primarily via technological advances, improved mass transport systems, and congestion charges on private transport use, would bring many health co-benefits. For some cities, such as New Delhi in India and Darwin, Perth and Adelaide in Australia, the average number of days

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forecast to be above 35oC based on mid-level carbon emissions becomes dangerously high in several decades’ time. Poor neighbourhoods and manual workers are likely to be more exposed to urban heat and have less capacity to adapt. The degree to which cities both create greenhouse gases and trap heat can be altered through good city design: occurrence of shade-trees and green space, orientation of buildings relative to wind direction, extent of combustion-based transport, reflectivity of construction and natural materials, and number of local heat sources. Rural investment: Countering the health and environmental pressures associated with urban growth requires sustained investment in rural development. Not only will this help reduce poverty and improve rural health, it will also better enable rural communities to adapt to climate change. Policies aimed at health, sustainable development and poverty reduction will mean action on issues of rural land tenure and rights, and rural infrastructure including health, education, roads, and services. It

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will entail diversification and increase in rural employment opportunities. Government and donor support to provide working capital and marketing linkages is needed, as is sustainable and equitable agricultural development. Lessons learnt from the Green Revolution highlight the need for a multifaceted, multi-agency, approach to agricultural development. Fair and sustainable food systems: The food system influences the amount of food available for consumption, the physical access to food, its safety, nutritional quality, price, and acceptability of different foods. Humaninduced climate change plus other forms of environmental degradation are already affecting the functioning of the global food system, contributing to impaired quantity, quality and affordability of food in many countries but particularly countries in the tropics and sub-tropics, which are already experiencing high levels of food insecurity. The uneven distribution of existing food stocks through protectionist import and export tariffs and subsidies, and the accelerating

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“HUMAN-INDUCED CLIMATE CHANGE PLUS OTHER FORMS OF ENVIRONMENTAL DEGRADATION AFFECTING THE FUNCTIONING OF THE GLOBAL FOOD SYSTEM”

assessments into all future trade and investment agreements would reduce harmful consequences and ensure coherence across sectors. In middleand high-income societies, the type and quantity of food that reaches consumers is largely determined by supermarkets and the food services sector. Within the sector there is a high content of energy dense foods that are highly processed, packaged and with long shelf-life. These same water- and energy-intensive foods have high environmental production costs. As fuel and refrigeration become more expensive, there will be flow-on implications for food prices and the types of foods stocked by retailers and food vendors. The food supply chain can increase its resilience to climatic shocks, decrease its impact on climate change, and improve health equity through diversity in supply chains, in business models, and in land use. Equitable and sustainable social policy: Providing a living wage and social protection that takes into account the real and current cost of sustainable living for health requires supportive social policy. Those policies must be regularly updated and based on the costs of health needs, including adequate nutritious food, shelter, water and sanitation, and social participation. Many countries, rich and poor, face a major challenge in providing affordable housing that is also based on sustainable building standards and is close to transit, schools and shops. Creating more equitable and green housing development requires regulation of land development through, for example, fair-share housing programs that involve inclusionary zoning, and enforcement of green housing laws.

power in agenda-setting and decisionmaking in relation to (food) trade agreements. Better public health and environment representation is needed in key areas of trade negotiations within the WTO and the mega-regional processes. The integration of health equity and environmental impact

Bringing these environmental, health and equity agendas together via coherent policy at global, national and local levels is an essential, transformative step if humans are to survive across future generations, equitably, in a healthy, secure and peaceful manner. ●

demand for certain higher-value food commodities, is stressing international and domestic food stocks and raising food prices. Fairness in international trade arrangements is critical to averting re-occurring global food crises. This means tackling the balance of economic

CONCLUSION

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PUT YOUR SKILLS TO GOOD HEALTH P

ublic Health at the University of Wollongong has a strong reputation for programs and research that engage students and staff with the profession and communities. Our research translates into programs and policies that achieve social impacts. Our active researchers ensure our teaching programs are real world relevant and prepare our students to lead public health practice. Here are just a few examples: Associate Professor Kate Senior: is a Future Fellow and medical anthropologist. Motivated to understand ongoing disparities in health between Indigenous and non-Indigenous communities, her research highlights how complex health problems require deep consideration, culturally nuanced understanding and sensitive communication. She has pioneered contemporary gender politics studies in remote indigenous communities through her work with young women and their decisions regarding relationships and parenthood. Dr Lyn Phillipson: is an Australian Research Council Fellow who leads research into dementia friendly communities and social care policy. Motivated to achieve better outcomes for the communities she works with, she has been a pioneer in her use of participatory and inclusive research approaches and the involvement of consumer and stakeholder panels. Dr Xiaoqi Feng: is a Heart Foundation Fellow who leads research and teaching at UOW focusing on how local health service provision and the built environment – the availability of parks and fast food in neighbourhoods, for example – influence the prevention and management of type 2 diabetes. Dr Bridget Kelly: is linked with a global initiative to audit and improve food environments. Her research focusses on the development of healthy public policy to create supportive environments for health and wellbeing. This includes reducing children’s exposure to unhealthy food and beverage marketing, and the provision of nutrition information at the point-of-sale.

Associate Professor Thomas Astell-Burt: undertakes research located at the interface between population, wellbeing and environmental studies. His recent work has a particular focus on understanding how people’s health, lifestyles and wellbeing are shaped by where they live. Professor Heather Yeatman: undertakes research in food regulation, food policy and the importance of food and nutrition system knowledge to empower communities to not only make informed choices, but to exert their influence on government and commercial environments to create change. She recently completed her terms as President of the Public Health Association of Australia and was awarded the 2016 Sidney Sax Medal for Public Health in recognition of her contributions to public health outcomes in Australia. UOW Public Health students are also highly engaged through their student public health institute, gaining real world experience in policy advocacy and practice, through the Dean’s Scholars program and being engaged in practical experiences both nationally and internationally. UOW offers undergraduate programs in public health, social epidemiology and food and society (from 2018), and postgraduate programs in public health, work health and safety and doctoral research.

We welcome enquiries from students who either want to start their careers in public health, add to their professional skill set, learn from experienced mentors, researchers and teachers, or undertake research to make a difference. To find out more, visit: http://coursefinder.uow.edu.au/publichealth/index.html


RESEARCH

PUBLIC HEALTH RESEARCH OPTIMISING STRUCTURE, FUNDING AND ACTION To keep the population safe in their environments, research needs to identify potential hazards and how to avoid them. Both technological and social change continue to accelerate. By Devin Bowles.

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ne of the central tasks of public health is to keep populations safe in, and from, their environment. ‘Environment’ here encompasses the physical, biological and social settings in which humans operate. Public health research, then, needs to identify potential hazards and determine appropriate alterations to the environment, ideally before anyone’s health is compromised. It is by now trite to observe that the pace of technological change exceeds that at any point in human history, eclipsing most historical cultures by orders of magnitude. The rate continues to accelerate. Social change is also rapid and shows no signs of deceleration. While these observations are seemingly stale, their implications are rarely fully considered. Increasing technological and social change will require massive increases in public health research if humanity is to preserve its health. It will need to be agile, both in terms of its subject matter and its methodologies. It will need to be local if it is to account for the stark cultural and economic differences which persist at a variety of scales, despite the effects of globalisation. It will need to be global, since some of the health effects of modernity emerge only at the planetary scale, including climate change. Funding is the principal policy lever through which governments and others guide public health research. Appropriately structuring funding systems for public health research and ensuring appropriate incentives will be essential to adapt public health research to meet future needs. Research matters most when it informs decisions and changes the world outside of the academy. Public health has a proud history of improving the world practically. The majority of the gains in longevity and quality of life experienced in the last two centuries are due to the implementation of public health research. Nevertheless, much public health policy is not based on scientific evidence. This failure has two major causes: lack of knowledge and lack of will. Both problems are

exacerbated in settings in which the population is poorly educated and has relatively little political control. Some of these issues are within the sphere of influence of the public health research and education community, and progress is possible.

“RESEARCH MATTERS MOST WHEN IT INFORMS DECISIONS AND CHANGES THE WORLD OUTSIDE OF THE ACADEMY”

DYNAMIC ENVIRONMENTS, MOUNTING RISKS Not only is technology evolving at an enormous pace, uptake is also faster than it has ever been. Having been invented well over a century ago, landline telephone technology is still not in use in parts of the developing world, including areas that have already adopted mobile phone technology. Risks from new technology therefore expand through larger populations more rapidly than ever before. The enormous global population and energy intensive nature of the modern economy mean that risks associated with new technology may emerge at a variety of physical and temporal scales. At the level of individual adopter, use or overuse of a technology may be associated with potential health consequences. Substantial use of a computer brings a range of health challenges, from a sedentary lifestyle to occupational overuse syndrome. At the city or regional scale, by-products of technology use can threaten health, in the form of

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car emissions or heavy metal pollution in the soil or water. Climate change is the best known global scale threat to human health, but is certainly not alone, with biodiversity loss and disruptions to the nitrogen and phosphorus cycles posing grave challenges to humanity’s future. Understanding emerging public health challenges is technically challenging because of the diversity of scales on which threats can operate, the potential for interaction between threats, and increasing social and technological complexity generally. For all of the technological homogeneity that accompanies globalisation, cultures continue to differ in ways which substantially alter their health risk profiles, and how they can be influenced to safeguard health. Even when two cultures use the same technology, they may use it in very different ways. The risks to health posed by gun ownership, for example, vary internationally and temporally.

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THE WAY FORWARD: INNOVATION H

ow to manage ongoing public health issues is a challenge facing healthcare professionals across the globe. In a world where technology is getting cheaper and more available, and demand and cost of healthcare is rising, practitioners are challenged with balancing the needs of developed countries against health systems burdened by limited funding, human capital, and infrastructure. The way forward must include innovation evaluated by research. At Bond University, research is an integral part of success. We pride ourselves on our innovative and entrepreneurial commitment to applied research by world class academic staff in collaboration with regional, national, and global industry and government partners. Leading research areas include the Centre for Evidence-based Practice which targets diagnosis, disease monitoring and clinical decision making for best public health outcomes. This leading collaboration of Australian health care researchers were successfully awarded an NHMRC

program grant for approximately 10 million Australian dollars investigating effective health care. Another research intensive collaboration, The Bond University Nutrition and Dietetics Research Group, strive to optimise translation of evidence into practice in the field of nutrition and dietetics. Specifically, the future-focused group has specialised areas of excellence in oncology, older adult nutrition, cardiovascular disease, chronic kidney disease, sports nutrition and professional issues. Current innovative programs include using technology to prioritise allied health services in patients with cancer and telephone counselling to improve diet and reduce complications in patients with chronic kidney disease. Bridging the gap of research and real-life is what makes the Bond University Master of Nutrition and Dietetic Practice program different. A two-year, intensive, Australian Qualification Framework level 9 (extended) program, produces dietitians with a difference, who are ready to make a difference.

During their time at Bond University, our students benefit from small class sizes, world class facilities, field trips, hands-on workshops and clinical simulations. Bond University has just been ranked by students as the number 1 university in Australia for overall student experience for the 11th consecutive year. Real-life experience doesn’t end in the classroom. Students benefit from extensive placements, industry networking opportunities and gain essential business management skills. A unique feature of the Master of Nutrition and Dietetic Practice is the international placement. All Bond University dietetic students participate in this experience, giving them the opportunity to tackle the big issues before they graduate. Recent experiences have included indigenous health projects on Norfolk Island, nutrition education and capacity building in the Solomon Islands and visits to the United Nations and International Atomic energy Agency in Vienna, Austria. Students develop a global perspective on the effects of different cultural, political, economic, and physical environments on nutrition and dietetic issues – just another thing that makes them dietitians with a difference. When they are on home soil, our dietetic students can be found gaining experience in hospitals, community settings, or with an elite sports team or school. The professional placement program at Bond exceeds the requirements for new graduate dietitians set by the Dietitians Association of Australia, producing graduates that are workforce ready. Welcome to the 17th World Congress on Public Health. Keep your eyes peeled – you just might bump into a dietitian with a difference while you are here, so make sure you say hello.


RESEARCH

School shootings were virtually nonexistent in America two decades ago, though the Constitutional protections for gun ownership have not changed substantially in that time. School shootings remain virtually non-existent in some other countries with relatively widespread gun ownership. Not only do public health threats vary with culture, so do potential interventions. The above analysis suggests several characteristics of threats to the public’s health that need to be considered when optimising public health research. As a whole, the risks are: • Large in number and rapidly multiplying • Escalating in terms of the number of people to whom they relate • Novel • Emergent at a variety of physical and temporal scales • Increasingly complex and technically challenging • Optimising public health research and funding structures To best protect the public’s health, research must be shaped to this risk profile. Funding is the primary policy lever used to shape the research agenda and associated infrastructure, and it is essential to structure funding appropriately if public health research is to meet its substantial challenges. Disparate political contexts internationally preclude specific advice, but some general observations may still be useful. To manage the escalating number of risks, the quantum of public health research undertaken annually will need to increase. The trajectory of public health research funding will also need to be one of increase if it is to fund the scale of research needed to minimise emerging public health risks, now and in the future. This trajectory will need to be sustained as long as the pace of technological innovation and uptake continue to increase. In order to rapidly adjust to emerging threats, ideally before they endanger the health of large populations, public

“FUNDING IS THE PRIMARY POLICY LEVER USED TO SHAPE THE RESEARCH AGENDA AND ASSOCIATED INFRASTRUCTURE, AND IT IS ESSENTIAL TO STRUCTURE FUNDING APPROPRIATELY IF PUBLIC HEALTH RESEARCH IS TO MEET ITS SUBSTANTIAL CHALLENGES” health research will also need to be nimble and broad in the areas it investigates. This means that blue sky thinking should be prioritised. The trend in some countries toward centrally directed research priorities is therefore a risky one. Bureaucracies have a number of strengths, but agility and risk-taking are not typically counted among them. Reliance on elected officials to guide research direction invites populist decisions made without a solid grasp of the technically complex evidence. Public health relies on so many fields that no single person has a strong understanding of all of its aspects. For economic matters, most policy makers seem to believe that the marketplace is the best way to progress. The same reasoning holds for the academic marketplace of ideas. Left to their

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own devices and with appropriate funding and incentives, public health researchers will naturally pursue the most pressing public health challenges. Several aspects of the funding structure could help ensure that research is sufficiently nimble. Prioritising funding for inter- and transdisciplinary research would reduce the delay between development of new technologies and appropriate public health research. Similarly, research funds for new public health researchers to cross over from other disciplines or industry should be made available. While efficiency is the mantra of the political sphere and the bureaucracy in many countries, maximising the number of citations or publications per dollar spent may be misguided if the goal is to avoid public health

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RESEARCH

“IN PRACTICE, DESIGNING A PUBLIC HEALTH RESEARCH SYSTEM THAT PROVIDES A HIGH LEVEL OF ASSURANCE THAT IT WILL UNDERSTAND EMERGING PROBLEMS NECESSITATES SUPPORTING SOME RESEARCH PROJECTS THAT ARE LARGELY UNPRODUCTIVE� catastrophes. Unorthodox, risk-taking research must be encouraged if novel, emerging threats are to be identified and circumvented. In complex systems, there is always a tension between adaptability and efficiency, and this reality should be acknowledged by those who structure a public health research system. Ultimately, this tension gives rise to political questions about what level of assurance a society wants that its research will not miss an important incoming public health problem, and what level of inefficiency it is willing to tolerate to achieve this assurance. Given the current pace of

technological change, it is not feasible that any research program will identify all emerging threats without spending time ruling out potential threats which turn out to be innocuous. In practice, designing a public health research system that provides a high level of assurance that it will understand emerging problems necessitates supporting some research projects that are largely unproductive. Achieving this means allowing researchers to have innovative projects which fail to produce interesting results, without ending their careers. From this perspective, tenure is a tool for ensuring the right breadth

of research. The benefit it brings to individual researchers is irrelevant, except in that it may attract more of the best and brightest to research. The fact that public health challenges occur at vastly different geographic scales necessitates certain features for an optimised global health research system. Public health research must be local if it is to discover and address local public health challenges. While a pacemaker developed and manufactured in one country can be used in all countries, an anti-tobacco campaign must be culturally-specific. If it is publicly funded, it must also appeal to the priorities of local political leaders. If all people are to be protected by the global program of public health research, it must be performed on a geographically dispersed network. Such a network is also important for progress against multi-national and global scale public health threats. It enhances dataacquisition, monitoring and facilitates


RESEARCH

the multinational cooperation which is often necessary for countering these health threats, as in the banning of chlorofluorocarbons (CFCs). Conversely, the requirement to draw on expertise from a variety of disciplines, perhaps especially for global-scale threats, means that intensive research must also occur at centres with a broad array of expertise. Practically, this can most easily occur at a relatively small number of elite institutions. The fact that public health challenges come in so many scales means that research requires breadth and depth. Reducing the time between public health discoveries and their widespread uptake in policy is another way to improve public health research. Funding structures should incentivise collaboration between researchers and policy makers at all levels of government. This could also be used to ensure geographic dispersal of public health research. Locating research

Improving health in tropical regions As Australia’s leader in tropical health and medicine, James Cook University offers higher degrees designed specifically for health professionals and others involved in public health activities. The Doctor of Philosophy (PhD) and the Master of Public Health (MPH) will equip you with the skills to address the critical challenges facing contemporary health professionals. A defining feature of JCU is its tropical location and its cutting edge research and engagement within South East Asia and the Western Pacific. Our graduates work in public health roles around the globe, with many opting to work in remote Australia or low and middle income settings in tropical regions. Take your career to the next level with a PhD or a Master of Public Health from James Cook University.

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RESEARCH

at teaching institutions would ensure that cutting-edge research results are seamlessly integrated into the curriculum of the next generation of policy makers and public health professionals. The large geographic and temporal scale of some challenges will require public health research to further broaden its methods of inquiry and innovate its risk assessment procedures. Global scale threats defy ‘gold standard’ randomised controlled trials. There can be no real-world counterfactual, only the sort which is modelled, mathematically or through other techniques, some of which still require development. Translating such evidence into compelling risk assessments, much less concrete policy advice, is extremely challenging.

WHERE THE RUBBER HITS THE ROAD Even providing clear policy advice is not enough to enhance health, if the advice is not heeded by policy makers. Lack of knowledge by the right person at the right time and lack of political action will prevent translation of research evidence into policy. Lack of knowledge on the part

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It will also be necessary to make public health a prestige degree, similar to law and economics in some countries, the acquisition of which is a signal of intellectual ability. Achieving this will mean raising the academic standards of public health in most countries, so

of policy-makers is unsurprising in a field as complex and dynamic as public health. This knowledge gap is exacerbated by the fact that many of the most important policy decisions affecting health occur outside of the health portfolio as traditionally

“THE LARGE GEOGRAPHIC AND TEMPORAL SCALE OF SOME CHALLENGES WILL REQUIRE PUBLIC HEALTH RESEARCH TO FURTHER BROADEN ITS METHODS OF INQUIRY AND INNOVATE ITS RISK ASSESSMENT PROCEDURES” conceived. To achieve ‘health in all policies’ will require that the understanding of public health becomes substantially more widespread among policy-makers. Options to make public health knowledge more prevalent include boosting the number of public health university graduates and adding it to general education requirements in undergraduate degrees. On their own, such measures are unlikely to substantially influence the upper echelons of the policy-making hierarchy.

that entry is as competitive as other prestige degrees. Political will is also required to translate public health research into policy. In general, most people expect their governments should keep them healthy and safe. When this ideal is not realised, a lack of accountability to the governed or competing priorities are often to blame. Democratic government enhances accountability to the people. Other methods of increasing accountability include better

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educating a populace about public health and increasing the transparency of governmental decision-making processes. Government elites have policy priorities other than health. Where institutions do not adequately protect against corruption, these can include personal interests. More legitimately, they can include other expectations that people place on their governments, like a functioning economy and rule of law. Those in public health have a role in ensuring that public health policies are prioritised appropriately. Economic language and analytical techniques are an important way of achieving this. Economic analysis which includes the conversion of all things, even human life, into dollars and cents is a powerful technique. It is the language of power spoken by most politicians and senior bureaucrats. It is also intellectually powerful because it reduces the world’s complexity to a relatively simple set of numbers, enabling straightforward comparison of qualitatively different things. The combination of its simplicity and its power give the technique a Siren-like allure, but public health researchers should be wary of putting too much faith in their own hype regarding specific calculations of the return on investment from public health expenditure. Public health relies on smooth

Master of Master of

functioning complex systems, including ecological and social systems. Complex systems are composed of qualitatively different things which cannot be substituted for one another. Modern society requires minimum amounts of energy, food and water. These cannot be substituted for each other regardless of the ratio of financial costs if society is to avoid collapse. Strictly financial analysis fails to account for this. A purely financial analytical approach can also obscure ethical questions. Scholars may be able to assign a value to a human life, but there are legitimate questions about whether they should and what intellectual and ethical safeguards should be put in place if they do. Is the life of a 50 year old banker who earns $200,000 a year for the next 15 years worth more than that of a 1 year old who will never make $5,000 a year across a 50 year working life? Given that the former will earn $3 million in her remaining working life, compared with $250,000 in the latter’s working life, is the banker’s life worth 12 times that of the one year old’s? A strictly financial analysis would conclude that it is. Public health must speak the language of power without being seduced by that language. Compared with most academic disciplines, public health has navigated this difficult course with grace. Efforts to enhance the

Health Health Promotion Promotion

discipline’s influence by improving its capacity to speak the language of power could be rewarded richly (in terms of health), but avoiding self-seduction will be as important as it is difficult.

CONCLUSION Since its inception, public health research has driven real-world change that enhanced human health. The current pace of technological innovation and the globalised economy bring substantial benefits and risks. The set of analytical challenges required to identify and mitigate these risks is historically unprecedented but must be overcome to preserve health. To accomplish this, the resources currently devoted to public health research and research translation will need to be substantially enhanced and restructured. ●

This essay is deliberately provocative, and is designed to stimulate thought and discussion. It is not a comprehensive review of all issues related to public health research or funding, and reflects the personal views of the author. As such, it should not necessarily be read as reflecting the policy position of the Council of Academic Public Health Institutions Australia (CAPHIA). Readers are invited to contact the author with their reactions and observations.

Good health begins in our everyday lives — in how we work, live and play Good in our everyday — in how we work, liveinfluences and play As the health range ofbegins health concerns attributedlives to lifestyle and environmental grows, so does need for dedicated health professionals to target these issues. As the range of the health concerns attributed to lifestyle and environmental influences grows, so doesofthe needPromotion, for dedicated professionals toto target issues. With a Master Health youhealth have the opportunity makethese a broad impact on health throughPromotion, strategy, policy and the education. It’s ato rewarding career that With a Master of Health you have opportunity make a broad will see on youhealth contribute towards safe, stimulating and enjoyable working and living impact through strategy, policy and education. It’s a rewarding career that conditions all. will see youfor contribute towards safe, stimulating and enjoyable working and living conditions for all. The University of the Sunshine Coast program is one of few masters’ programs in Australia to focus on theprogram eld of Health Promotion. You’llprograms learn from The University of theexclusively Sunshine Coast is one of few masters’ leading academics, be involved in active research, and study in an environment that in Australia to focus exclusively on the eld of Health Promotion. You’ll learn from replicates workplace scenarios. leading academics, be involved in active research, and study in an environment that replicates scenarios. You’ll studyworkplace the foundations and principles of public health; how to assess health needs, how to plan, implement evaluateofhealth programs; You’ll study the foundations andand principles publicpromotion health; how to assesssettings health for health epidemiology; researchhealth methods and more. needs, howpromotion; to plan, implement and evaluate promotion programs; settings for health promotion; epidemiology; research methods and more.

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UNHEALTHY CONSUMPTION IS ‘KILLING PEOPLE ON A GRAND SCALE’

The biggest challenge of modern man is unhealthy consumption, from convenience food to alcohol and tobacco, and finding a way to tackle this will have the greatest impact of all on our future health systems. By Dr Anne Marie Thow.

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on-communicable diseases (NCDs) are the major cause of death and disability globally, and the prevalence of these diseases continues to rise. Apart from the preventable human costs of these diseases, the economic costs over the following 20 years could amount to US$ 47 trillion – more than US$2 trillion per year (The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum, 2011). Tobacco, alcohol and unhealthy food consumption are key risk factors for NCDs and for the global disease burden as a whole. Action to reduce unhealthy consumption of food, alcohol and

tobacco is identified as a priority in the 2015 Sustainable Development Goals (SDGs). The United Nations (UN) has set clear targets with respect to unhealthy consumption (Box 1). Achieving these risk factor targets (together with reductions in physical inactivity) would delay or prevent more than 37 million deaths from the main NCDs by 2025, and help to achieve the UN goal of a 25% reduction in premature mortality from NCDs (The Lancet. 2014;384(9941):427-37). The majority of these averted deaths would have occurred in low- and middleincome countries (LMICs). For countries attempting to meet these targets, the first step they need

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to take is to consider what is driving global increases in the consumption of unhealthy commodities. Both personal and environmental factors influence consumption of unhealthy commodities Behavioural psychology research suggests that there is a dynamic relationship between environmental and personal factors. Individual or personallevel drivers of unhealthy consumption include addiction, preference (both innate and learned), habit, taste, UNITED NATIONS TARGETS RELEVANT TO UNHEALTHY CONSUMPTION  Reduce tobacco use by 30%  Reduce alcohol use by 10%  Reduce salt intake by 30%  Halt the rise in diabetes and obesity  Reduce the prevalence of raised blood pressure by 25%. Source: World Health Organization. NCD Global Monitoring Framework. Geneva: World Health Organization, 2012.

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POLICY CHANGE MUST BE PART OF AN EFFECTIVE RESPONSE

“EVEN FOR TOBACCO CONSUMPTION, ENVIRONMENTAL CUES FOR SMOKING HAVE BEEN FOUND TO HAVE AN INDEPENDENT INFLUENCE ON THE DECISION TO SMOKE” income, impulsivity and self-regulation. However, these personal factors are influenced and in some cases mediated by environmental factors. For smoking, food, and alcohol consumption, research consistently shows that exposure to environmental cues influence behavioural outcomes, meaning that so-called ‘personal choices’ are always socially conditioned and located. Food environments, for example, can either exploit or limit people’s ‘biological, psychological, social, and economic vulnerabilities’, affecting the ease with which they can consume unhealthy foods. Exposure to retail alcohol stores is associated with harmful levels of alcohol consumption. Even for tobacco consumption, environmental cues for smoking have been found to have an

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independent influence on the decision to smoke. Public health interventions still tend to focus on individual behaviour change interventions, with people seen as more amenable to change than their environments. However, the interplay between personal and environmental factors means there is a critical role for policy in changing environmental cues. A growing body of research points to the effectiveness of environmental change through public policy as a necessary complement to individual-focussed interventions. Strategic design of policy intervention to consider more personal factors such as impulsivity and habit formation, for example, can support more effective population-level intervention.

Policy can address environmental cues associated with unhealthy consumption, and can affect population level change by making healthier lifestyles more accessible for all. The World Health Organization’s Global Action Plan for the Prevention and Control of NCDs identifies a range of policy interventions focussed on reducing environmental cues for consumption of tobacco, alcohol and unhealthy food. This is not new – more than 30 years ago, the Ottawa Charter for Health Promotion identified Healthy Public Policy as the cornerstone of effective health promotion interventions. Global action towards implementation of the Framework Convention on Tobacco Control (FCTC) has demonstrated that policy can effectively reduce consumption of tobacco through targeting environmental cues such as price, advertising and availability. Such policies are similarly effective in reducing consumption of unhealthy foods and alcohol. The FCTC has also shown the benefits of a clear, step-wise framework in enshrining global policy norms that support health. For example, challenges to tobacco control legislation at the World Trade Organization (WTO) have increasingly referenced the FCTC as a global health norm. The monitoring framework for NCDs emphasises the importance of implementing taxation and pricing policies, restrictions on advertising, and clear, understandable labelling of unhealthy commodities policies to achieve the UN NCD targets. However, countries are making patchy progress towards the UN NCD targets, and implementation of recommended policies remains slow (The Lancet. 2015;385(9985):2400-9). While the monitoring framework identifies unquestionably important strategies, they nonetheless fall into the ‘necessary but not sufficient’ category. Specifically, increased trade and investment in the unhealthy commodities these strategies intend

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to regulate are a direct reflection of current trade, investment and agricultural policies. Agricultural policies that subsidise inputs such as corn and soy can drive reformulation of food products to achieve higher profit margins. Further reduction of trade barriers and supply-chain integration may drive the need for increased transportability and shelf life duration. Collectively, these policies may incentivise the global food industry to put more high-fat, high-sugar, high-sodium processed food products on market shelves around the world, with trade and investment agreements already identified as having significant potential to undermine achievement of the nutrition and health-related sustainable development goals. With respect to tobacco, trade and investment policies in many low-income countries foster tobacco production and manufacturing in the name of economic development and protection of small-hold farmer livelihoods. This situation exists despite many of these countries having ratified the FCTC (which calls for reductions in supply as well as demand), and evidence that tobacco production does not yield the economic returns (either to farmers or to countries) that are often assumed and cited as the rationale. Similarly, the WHO recommends minimum pricing policies to reduce the harmful consumption of alcohol. Scotland attempted to do this by regulating a minimum price per unit of alcohol, to make high-alcohol content beverages more expensive and less likely to be consumed. The European court ruled that this policy would violate EU free-trade rules unless its pricing was more proportionate and effective than other less traderestrictive taxation measures, and referred the matter back to the Scottish courts. Four years after introducing the legislation, Scotland’s top judge finally ruled in favour of the policy. The delay represents an example of ‘regulatory chill’ where government efforts to regulate unhealthy commodities

(in this case, to reduce unhealthy consumption levels) are challenged using trade or investment treaties.

EVIDENCE: NECESSARY BUT NOT SUFFICIENT FOR POLICY CHANGE Public health researchers and practitioners have a well-deserved reputation for generating evidence on the nature of health problems, as well as on the potential impact of different solutions. To a large extent, we know what causes NCDs and what we could do to prevent them. This gets to the heart of the challenge: evidence is necessary but not sufficient for policy change. There are three critical issues that also need to be considered in seeking to change policy with respect to unhealthy consumption: politics, economics, and globalisation.

POLICY IS POLITICAL The design of policy is nuanced by the complex socio-political environment in which it is made: policy is politics.

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While evidence can (and in many cases should) inform policy content, the processes, contexts and actors that surround the making of policy are equally if not more influential. Research from political science on agenda setting processes – what determines which ‘problems’ receive attention from policy makers – tells us that policy making is influenced by ideas, framing, advocacy, political cycles, and perceptions of whether an issue is amenable to a policy solution. Similarly, key factors that shape policy design are ideas, practical administrative considerations, political context, and beliefs (about both the nature of the problem and potential solutions). For example, analysis of submissions to trade negotiating bodies by the food industry during negotiation of the Trans-Pacific Partnership (TPP) demonstrated consistent framing of food as a commodity, focusing on types and quantities of food traded and what this meant for revenue generation, with no connection to nutritional health.

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Although US withdrawal from the TPP has effectively killed this agreement, its various trade and investment measures are likely to recur in other regional or bilateral treaties, within similar policy frames. Framing the policy problem as barriers affecting the cross-border flow of food commodities sets up solutions focused on further reducing tariffs and harmonising regulatory standards. Addressing cheap and prevalent unhealthy foods will thus require reframing the issue of global food trade from a system driven by a need for quantity (the trade imperative) to one driven by a need for nutritional quality (the health imperative).

POLICY IS AN ECONOMIC CONCERN Regulation designed to reduce the consumption of tobacco, alcohol and unhealthy food targets profitable and highly traded or foreign-invested commodities. At the heart of regulation of unhealthy commodities is an implicit tension within government between creating a conducive environment for economic growth and development (albeit increasingly giving attention to issues of environmental sustainability) and preventing long term negative outcomes from market failures or unhealthy externalities. In this case, the evident negative outcomes from

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“SINCE ADDRESSING UNHEALTHY COMMODITIES REQUIRES POLICY TOOLS FROM ACROSS SECTORS, POLICY MAKING IS ALSO INFLUENCED BY GLOBAL COMMITMENTS IN OTHER SECTORS – FINANCE, TRADE AND AGRICULTURE, IN PARTICULAR” an economic point of view include escalating (preventable) health care costs – either borne publicly or potentially resulting in personal bankruptcy – and reduced labour force productivity due to morbidity and premature mortality. Feeding this governance tension is the general opposition to policy interventions that would reduce consumption of unhealthy commodities by companies whose profits derive from these products. The food, tobacco and alcohol industries have considerable influence in the framing and shaping of public policy options, resulting in their concerns having disproportionate impact on decision making. Industry resistance to public health policy measures regarding unhealthy consumption is one reason that such measures have been slow to move forward. For example, during the period of negotiations of the TPP, food industry spent over US$265 million lobbying the US government and

made over US$78 million in political campaign contributions (Data provided by OpenSecrets.org, originally sourced from the United States Senate Office of Public Records). Food industry representatives from companies including Cargill, Archer Daniels Midland, Kraft Food, The Hershey Company, Kentucky Fried Chicken, and many others, all had access to TPP negotiators and negotiating texts throughout the process. Public health research seeking to support policy change thus needs to consider how to counter such influence, including the dominance of the economic arguments of concern to governments and readily invoked by industry.

POLICY IS MADE IN A GLOBALISED WORLD Global health policy has strengthened national policy making with norms and reference points over the past 60 years. However, since addressing unhealthy commodities requires policy tools from across sectors, policy making is also influenced by global commitments in other sectors – finance, trade and agriculture, in particular. International trade and investment agreements are one of the key avenues through which economic globalisation has occurred. These agreements are binding and increasingly apply to ‘behind the border’ (i.e. national) policy making that affects traded goods or foreign investment. Agreements that restrict the use of technical measures, expand recognition of intellectual property rights, place limitations on public procurement, or offer special protections to foreign investors, create limitations on the

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King Saud bin Abdulaziz University for Health Sciences

COLLEGE OF PUBLIC HEALTH & HEALTH INFORMATICS College of Public Health & Health Informatics (CPHHI) at King Saud bin Abdulaziz University for Health Science (KSAU-HS) is one of its kind in Kingdom of Saudi Arabia (KSA). It was established in 2005 and has had a number of associations and collaborations with well known international schools of public health. CPHHI attracts well qualified western trained faculty and scholars from USA, UK, Australia, Canada and other countries. CPHHI, currently, provides four postgraduates programs (Master Degrees) and two undergraduates and there is a plan to expand. In addition to teaching and learning, CPHHI is active in research and community services. Our vision is to be a regional hub for Public Health. CONTACT: College of Public Health & Health Informatics King Saud Bin Abdulaziz University for Health Sciences P.O. Box 22490 Riyadh 11426 Internal Mail Code 2350 Tel. +966-11-4299999 Ext: 95441 Email: CPHHI@ksau-hs.edu.sa http://cphhi.ksau-hs.edu.sa

CPHHI.indd 1

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The National Centre for Immunisation Research and Surveillance is funded by the Australian Government Department of Health and the NSW Ministry of Health to provide a range of technical services for immunisation programs. The Centre sits within The Children’s Hospital at Westmead, and is aďŹƒliated with the University of Sydney. NCIRS also receives substantial independent research funding and provides training for higher degree and professional students. Vaccine Safety

NCIRS plays a lead role in a range of important vaccine safety initiatives including the multi-state AusVaxSafety active surveillance network and are responsible for analysis and reporting of national passive surveillance data

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Research & Evaluation

NCIRS evaluate all new national immunisation programs. We operate funded research programs in clinical, social and epidemiological sciences and manage the multi-state Paediatric Active Enhanced Disease Surveillance hospital network

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Evidence for Policy Development

NCIRS provides technical support for the Australian Technical Advisory Group on Immunisation, including production of the Australian Immunisation Handbook. We identify and synthesise published evidence, and analyse routinely collected data on diseases and vaccine coverage, to inform policy and planning for national immunisation services

ncirs.schn@health.nsw.gov.au www.ncirs.edu.au


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“LEARNING FROM SUCCESS STORIES OF POLICY CHANGE WILL BE CRITICAL TO EXPAND IMPLEMENTATION OF POLICIES TO ADDRESS UNHEALTHY CONSUMPTION” policy space that countries have to regulate unhealthy commodities. A recent example of the impact on regulation of unhealthy commoditie has been the challenges to public health labelling interventions at the WTO. These include tobacco plain packaging and interpretive labels for alcohol and nutrition, which have been shown to be effective in increasing consumer understanding of the nature of the product, and associated with reduced consumption. All of these measures have been formally challenged at the WTO. Changing policy to tackle NCDs requires strong leadership for

multisectoral approaches. What does this mean for the practise of public health researchers and practitioners in their daily work? Two recent reviews have identified applied strategies for influencing policy from political science research on obesity prevention policies (see Public Health Nutrition 19(11):2070 and BMC Public Health 16(1):1084). Both reviews highlighted the importance of taking research findings to the next level by engaging with politics. They found that successful policy change had involved coalitions and networks of actors in influencing policy processes, leadership from policy entrepreneurs

(individuals with the knowledge, expertise, power, and perseverance who are able to exploit policy ‘windows of opportunity’), and strategic use of narratives and framing as well as evidence. This aligns with a recent summary of policy change from the political science literature, which found that developing deep knowledge about an issue, building networks among relevant actors and engaging with them for extended periods of time were the key factors in influencing policy. Learning from success stories of policy change will be critical to expand implementation of policies to address unhealthy consumption. Recent commentaries have highlighted the potential to learn from LMICs about how to tackle NCDs. In many of these countries, the dual burden of disease – persistent high rates of acute infectious illness coexisting with a growing incidence of NCDs – means that health care systems are pushed

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REASONS WHY YOU SHOULD JOIN THE PUBLIC HEALTH ASSOCIATION OF AUSTRALIA

• Discounts on national and international Conferences • Access to academic publications • Be part of the voice advocating on good public health for all • Access to public health job vacancies • Input to develop and update public health policies The Public Health Association of Australia, a non party-political organisation representing more than 40 public health related disciplines.


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to breaking points and governments cannot afford the lost productivity that untreated NCDs entail. Necessity means that these governments are often leading policy innovation for NCD prevention. Public health researchers will be pivotal in sharing success stories of policy change that consider politics and process as well as impact. For example, in Thailand, research into the successful engagement between trade and health sectors regarding access to medicines identified the importance of networks and advocacy in supporting policy change. In this situation, health actors were able to translate their understanding of the effects of trade on health into coordinated advocacy for consideration of health within trade negotiations. However, often over-stretched government ministries in LMICs have less capacity to successfully circumvent the influence of powerful transnational industries, especially

when such industries used economic growth or development arguments to gain the ears of, if not actual support from, governments. Creating and sustaining meaningful policy change regarding unhealthy commodities will require the development of multinational, multi-sectoral coalitions with dedicated leadership and clear messaging. Constructive engagement between public health researchers and practitioners, and policy makers – particularly those in other sectors – can also be fostered by developing global norms that guide and support countries to innovate. Research from tobacco control has found that the FCTC has been a helpful basis for identifying opportunities to integrate global economic norms and health promoting norms. To successfully influence the policy process, public health coalitions must strategically frame and reframe policy problems, such as economic

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and health consequences of increased trade in unhealthy commodities. This engagement will benefit from the support of robust evidence; however, policies that deliver inequitable opportunities for healthier lifestyles, often to the world’s most vulnerable populations, cannot wait for irrefutable evidence of causal effects before action is taken. Most important may be a sustained willingness by a critical mass to challenge the structures and vested interests behind the manufacturing and marketing of unhealthy commodities, and demand that global policies achieve not just economic development but sustainable and equitable development. No longer can we accept policies that trade away lives to achieve a balance of trade. ● For a version of this article with full referencing, please contact Dr Anne Marie Thow (annemarie.thow@sydney.edu.au).


R U R A L H E A LT H

FLYING DOCTOR

PROVIDING VITAL HEALTH SERVICES TO RURAL AND REMOTE AUSTRALIA

Chief Executive Officer of the Royal Flying Doctor Service Martin Laverty reflects on the unique work his organisation does in delivering health to the most remote places in Australia.

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ustralians are proud of the vast brown land that they call home, and whilst two thirds of our population live along the metro and coastal regions, the remaining third live across rural and remote areas. The Royal Flying Doctor Service has been servicing people who live, work and travel in country Australia for almost 90 years – with the world’s largest waiting room of 7.15 million square kilometres. Providing both primary health and emergency medical services through a fleet of 68 planes and 87 road health service vehicles, last year the Flying Doctor had some 280,000 patient contacts and flew the equivalent of 36 times to the moon and back. There is no typical day as a flight nurse. Life is never boring. Every day

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varies significantly and in a week a flight nurse may work a variety of nights and days, with a range of people. They may land on a road, a remote dirt strip, fly out to an isolated community to deliver a baby, or transport a sick neonate or intubated patient from one hospital to another. They may be mid-flight transporting a patient and get diverted to a serious quad bike accident, motor vehicle accident or station accident that requires immediate treatment. Every day is different. One nurse reflected that she has been exposed to everything from minor cases through to some very serious accidents and injuries. She has experienced road landings, dirt strip landings, headlight and flare landings and even been involved with birthing babies on the tarmac. What has surprised her the most in working for the Flying Doctor has been experiencing how large Australia actually is, how long it takes to get to people in need, and most of all how resilient people in outback communities are. Someone in a remote community may sustain a serious life threatening injury that due to location takes two hours for the Flying Doctor to reach them, but despite this the communities band together with knowledge, skills

and a friendly attitude to all help, comfort, support and keep them alive until assistance arrives. Working as a pilot for the Flying Doctor is also a unique role and brings challenges unknown to many regular commercial pilots. One of our many pilots commented that he has seen Sturt Desert Peas flowering on Tarcoola airstrip, he has flown over a mother emu followed by a line of chicks crossing a runway, and he has watched the whales whilst flying along the coast to Cook on the Nullarbor Plain. Once he had to land on Lake Gairdner salt lake when it was being used as a track for an American who had been injured attempting a world speed record on a motorbike. And for those late night emergency evacuations, he has often had to explain to station owners how to light up their airstrips using Milo cans filled with sand-soaked kerosene and petrol as flares, or toilet rolls soaked in diesel. On one occasion he enlisted truckies in the area to light up a dirt strip near the Stuart Highway at Marla. It’s normally the medical teams that are involved in emergency retrievals by the RFDS, but a unique outback mission in the Northern Territory required engineers, not doctors and nurses.

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In what is a surprisingly rare incident given the bush locations regularly flown to, a RFDS aircraft from the Alice Springs Base struck a kangaroo during a night landing on the remote Mt Allen strip, which serves the Yuelamu community 300 kilometres north-west of Alice Springs. Fortunately the RFDS crew on board were not injured, but the aircraft was automatically declared ‘unserviceable’ as a safety precaution. A second aeromedical crew was immediately activated to complete the patient evacuation from Mt Allen to Alice Springs Hospital. When the RFDS Senior Engineer was flown out to inspect the damage the next morning he realised it was going to require some mind-bending logistics to get the plane back in the air. The collision damaged the four-blade propeller of the Pilatus PC-12 aircraft and the propeller had to be replaced and engine repaired. The first challenge was getting all the spare parts to the

site as whilst some parts could be flown in, the propeller was too big to fit in an aircraft and had to be trucked to site. The equipment list was long and included a gantry, crane, hydraulic frame and various slings to lift the heavy components. They also had to take extra aircraft fuel and a generator. After working all day through

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temperatures that were high enough to ‘melt their snake lollies’, the engineers climbed into swags laid out on the edge of the airstrip under the wings of the aircraft. The next morning they ran tests to ensure all was safe and good to go and less than 24 hours after they started, the plane was ready to fly and return to Alice Springs. It is challenges such as these that result in resilience, initiative, team-work and professionalism by the Flying Doctor staff teams. And this is reflected in the Royal Flying Doctor Service’s award as ‘Australia’s Most Reputable Charity’ for the past six years running. But if you ask any of the RFDS staff why they do what they do, they routinely will answer ‘because we are helping and making a difference in rural and remote Australia’ and it is the very nature of the work and the harsh landscapes and vast distances that make the work that much more rewarding. ●


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ACROSS THE GLOBE, WORK IS NEEDED TO CLOSE THE GAP Across the globe, significant disparities exist in the health status of indigenous people compared to that of non-indigenous, calling for a revised global partnership to improve the health outcomes of our First People. By Leanne Philpott.

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ast year (April 2016) Australian indigenous health research body the Lowitja Institute and British medical publication The Lancet revealed the findings of a collaborative global study into indigenous and tribal peoples’ health. The study, involving 65 experts and covering almost 50% of the global indigenous population, found that the health of indigenous people is not intrinsically linked to the wealth of the

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country in which they live. Chief Investigator Professor Ian Anderson, Pro-Vice Chancellor (Engagement), and Chair of Indigenous Education, at the University of Melbourne, says, “The important thing to note is that the poorer outcomes are not by virtue of someone being indigenous; it’s not necessarily the case. What we need to do is work with local data. This is a precondition to making any analysis;

we need to understand those local and historical circumstances. “There’s a very different circumstance to an ethnic indigenous population living in the South East Asian state of Myanmar (Burma), which is a very large multi-ethnic state, compared to Canada, which has a particular type of colonial history.” Relative to benchmark populations, the study showed that the Mon people of Myanmar fared better in educational attainment. Likewise, the gap in life expectancy between indigenous and non-indigenous Australians is similar to the gap in the African Cameroon for the Makaa people, despite the fact that Australia is a far wealthier country. Anderson says that gaps in data across the globe made it impossible to identify the root causes of indigenous

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health inequality but that poverty, poor employment opportunities, a lack of educational opportunities and exposure to racism and social exclusion are critical factors.

GLOBAL SNAPSHOT Late last year the United Nations (UN) released its 2016 report into Indigenous Peoples’ Access to Health Services; It too recognised that ‘Indigenous peoples’ health status is severely affected by their living conditions, income levels, employment rates, access to safe water, sanitation, health services and food availability.’ The report looked at seven sociocultural regions across the globe and identified some of the key health inequalities and challenges. In Asia, indigenous people compared to non-indigenous people have a lower rate of life expectancy, higher infant and child mortality, poorer maternal health outcomes and lower levels of access to health services provided by the government. The Minority Rights Group International (MRG) Report 2013 showed that Baluchistan in Pakistan experienced one of the highest levels of maternal mortality ratios with 758 per 100,000 live births. This alarming figure is emphasised by the fact that the national maternal mortality rate declined from 400 per 100,000 in 2004-2005 to 276 in 2006-2007. Similarly, in Myanmar (Burma) research indicates that the maternal mortality rate for the indigenous people is triple that of the country as a whole even though approximately a third a these deaths is due to postpartum haemorrhage, a condition that could be prevented through the provision of basic healthcare services. While child nutrition in Asian countries has seen improvement over the last 20 years, this has been notably slower amongst indigenous people. Similarly, steps have been made to provide vaccinations for ethnic minorities yet there remains inequality in access between the

broader Asian child population and indigenous children. The health of indigenous people in Asia partly dates back to the era of colonisation, with many traditional sources and methods of food collection being destroyed, leading to increased nutritional deficiencies. The poor health of the Sami living in Norway, Sweden and Finland has also been attributed to colonisation as it prohibited the Sami language

linguistic needs. In fact, Norway funded the first outpatient psychiatric clinic with Sami-speaking therapists in the Sami-centric area of Karasjok. From the start of the 1990s several countries have included an intercultural approach to their healthcare plans. In Guatemala, the Inclusive Health Model was introduced to recognise the cultural diversity in health practices and promote intercultural processes. In Mexico, the National Program

WHILE CHILD NUTRITION IN ASIAN COUNTRIES HAS SEEN IMPROVEMENT OVER THE LAST 20 YEARS, THIS HAS BEEN NOTABLY SLOWER AMONGST INDIGENOUS PEOPLE. from Norwegian schools, which led to discrimination and negative impact on health. Despite life expectancy and mortality rates for Norwegian and Swedish Sami being similar to that of the nonindigenous population, higher suicide levels are reported amongst Sami men in Norway and Finland, with discrimination and marginalisation seen as a root cause of the Sami’s health problems. For the indigenous people of Central America, South America and the Caribbean, their experiences are much the same with poorer social conditions, higher rates of morbidity and mortality and the least access to health services compared to the rest of the population. As a result, substance abuse, depression and other mental disorders are more prevalent amongst the indigenous, as are HIV/AIDS and other STDs.

ATTEMPTS TO ‘CLOSE THE GAP’ While health inequality amongst indigenous people is widespread, the UN report noted some positive steps have been implemented to address the health gaps. Since the 1980s Norway has focused on a Sami-specific healthcare network that meets the Sami’s cultural and

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for Action has focused on making its health services culturally adequate with the incorporation of indigenous traditional medicine and medical staff with knowledge of ancestral healing practices. In Peru, the Ministry of Health (MINSA) offered culturally adapted birthing services to women resulting in more indigenous women seeking birth care and a decrease in maternal deaths, mainly amongst the indigenous population. In Ecuador, the MAISFCI – Integral Care Model for Family, Community and Intercultural Health allows different cultural views and approaches to healthcare. It straddles conventional health systems and ancestral wisdoms. Yet while these policies and models of care are a positive step, they can be further strengthened through research and increased knowledge of traditional wisdom and practices. A recurrent theme throughout the report is the need to first and foremost recognise the existence of indigenous people. In Asia, for example, despite improvements in the level of poverty and social development, poor indigenous health remains a persistent problem in part due to the complex issue of ‘Asian controversy’–

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“WE KNOW THAT THE EVIDENCE ON THE SOCIAL DETERMINANTS OF HEALTH INCLUDES POWERFUL CON RMATION THAT DISEMPOWERMENT, SOCIAL EXCLUSION AND RACISM HAVE NEGATIVE EFFECTS ON HEALTH. THIS EVIDENCE CANNOT BE IGNORED. the contested concept over who is indigenous and who is not. In other cases indigenous peoples are lumped together as a single marginalised group, devaluing their different social and cultural beliefs. This inability to identify indigenous people also severely impacts data collection.

HOMEGROWN HEALTH INEQUALITIES Despite Australia being ahead of many other countries in terms of data collection, it has the highest recorded gap in life expectancy (20 years)

between indigenous and non-indigenous people, with chronic disease identified as a major factor. 50% of Aboriginal and Torres Strait Islander people have a chronic condition or disability. Conditions such as heart disease (22%), diabetes (12%) and liver disease (11%) account for 80% of the mortality gap between Aboriginal and Torres Strait Islander and other Australians. Indigenous compared to nonindigenous people are also more likely to smoke and suffer from alcohol abuse. As is the case in most countries across the globe, colonization is in part to blame.

According to the UN’s State of the World’s Indigenous Peoples report, ‘Prior to arrival of the British colonisers in 1788, indigenous peoples were able to define their own sense of being through control over all aspects of their lives, including ceremonies, spiritual practices, medicine, social relationships, management of land, law and economic activities’. With colonisation came disease, conflict, loss of land and independence. It also signalled the beginning of a cycle of ‘dispossession, demoralisation and poor health’. In a speech a couple of years ago, Pat Anderson AO, Chairperson, Lowitja Institute, referred to the definition of health put forward in the landmark 1989 National Aboriginal Health Strategy: ‘[Health is] not just the physical wellbeing of an individual but the social, emotional and cultural well-being of the whole community’. She says that the theory of the social determinants of health, how social,

The National Aboriginal Community Controlled Health Organisation (NACCHO) is a living embodiment of the aspirations of Aboriginal communities and their struggles for self-determination. NACCHO’s vision: Aboriginal people enjoy quality of life through whole-of-community self-determination and individual spiritual, cultural, physical, social and emotional wellbeing. Aboriginal health in Aboriginal hands.

NACCHO is the Peak national body for Aboriginal health in Australia representing a membership of over 150 Aboriginal Community Controlled Health Services (ACCHS). These organisations have over 45 years of cultural experience, knowledge and capability in the delivery of comprehensive primary health care. The services are delivered through fixed, outreach and mobile clinics in urban, rural and remote settings across Australia. NACCHO supports the local ACCHOS and the State/Territory Peak Bodies to improve coordination and collaboration towards Closing the Gap in health outcomes.

Our members continue to demonstrate that they are the leading provider of culturally appropriate, comprehensive, primary health care to Aboriginal people across the nation, exceeding Government or private providers. NACCHO will maintain and strengthen its position as the National Peak body for Aboriginal health and wellbeing in Australia as it continues to champion and support the expansion of ACCHS to properly meet the health needs of Aboriginal people.

A Level 3, 221 London Circuit Canberra City P 02 6246 9300 E admin@naccho.org.au NACCHO Aboriginal Health

@NACCHOAustralia


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emotional and political issues affect health, offers a powerful argument about how to improve the health of our indigenous communities. ‘We know that the evidence on the social determinants of health includes powerful confirmation that disempowerment, social exclusion and racism have negative effects on health. This evidence cannot be ignored.’ Chief Executive Officer of The Lowitja Institute Romlie Mokak, speaking at the Medicine & Society Oration in Melbourne last August, said, ‘In order to achieve significant, measurable, positive change in the health and wellbeing of Aboriginal and Torres Strait Islander peoples we need to expand the idea of value.’ ‘Aboriginal and Torres Strait Islander values, beliefs and knowledges must be at the centre of any decisions and policymaking because their wellbeing is located in those values, beliefs and knowledges.’ Despite the challenges, work is

being done to help bring positive social and health benefits to the indigenous population in Australia. For example, there’s The National Health Leadership Forum (NHLF) – a partnership between multiple Aboriginal and Torres Strait Islander health leadership organisations that has been established to work with the Government and facilitate change. Other successes are the Aboriginal community controlled health services. Established in Redfern in 1971, there are now 150 services delivering holistic, comprehensive, and culturally appropriate health care to the communities that control them. Mokak says, “Another example of Aboriginal and Torres Strait Islander organisations delivering significant results for their people is the Institute of Urban Indigenous Health. The Institute leads the planning, development and delivery of comprehensive primary health care

services to the Indigenous population of South East Queensland.” Since it was established in 2009 its network has expanded to 18 multidisciplinary primary health clinics and has delivered increases in the number of new patients (300%), health checks (1000%) and GP Management Plans (360%). Yet Mokak says the real transformative change will only occur when we understand and value Aboriginal and Torres Strait Islander health as a paradigm that places our First People in leadership positions, and at the centre of policy making. Ultimately we need to continue to address the deep-rooted issues of recognition and empowerment, take a cohesive approach to the social determinants of health and give power (at a policy and decision-making level) to those for whom the policy is intended — our First People. ●


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COMPLEMENTARY MEDICINE Traditional and complementary medicine (TCAM) is an increasingly important – yet often underestimated – part of health care systems globally. By Professor Jon Adams and Dr Jon Wardle, University of Technology Sydney.

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CAM is present in every country and its use is growing internationally. In some countries, TCAM forms the mainstay of health care delivery, particularly where conventional health services may not be well-established. However, even where conventional health systems are well-established, utilisation of TCAM can still be significant. In Australia, for example, even with the presence of a comprehensive universal health care system the utilisation of TCAM is among

the highest observed in any developed nation, with over 70% of the population estimated to use some form of TCAM. Most TCAM research and education in Australia and internationally to date has focused on clinical and experimental medicine (safety, efficacy, and mechanism of action) and regulatory issues, to the general neglect of public health dimensions. Whilst these questions are undeniably important, public health research must consider social, cultural, political, and

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economic contexts to maximise the contribution of TCAM to health care systems globally. For example, the World Health Organization’s (WHO) Traditional Medicine Strategy outlines a broad research agenda for CAM which looks beyond issues of clinical efficacy and safety, with development of an evidence base for CAM only one of over 20 issues identified as requiring action. The public health TCAM research agenda therefore needs to be extended to include research on health services utilisation, social and cultural factors related to TCAM use, economic research and priority disease management in TCAM.

WHAT IS TCAM? TCAM includes a vast range of selfdirected and practitioner-led health

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practices (e.g. meditation, yoga, chiropractic, naturopathy) and products (e.g. herbal medicine, nutritional supplements, and homeopathy) that are not traditionally considered part of conventional care or the medical curriculum. This broad definition brings with it one of the key challenges in researching and evaluating TCAM. TCAM is somewhat unique among recognised health specialisations in that its definition is based solely on exclusion, rather than on a set of unified professional, cultural or physical traits. TCAM’s definition therefore is not focused on what it is – as occurs in almost all other elements of the health system – but rather centres on what it is not (i.e. it is not “conventional” medicine). The World Health Organization defines complementary medicine as a ‘broad set of health care practices that are not part of that country’s own

tradition and are not integrated into the dominant health system’. The WHO uses a separate definition for traditional medicine, defining it as ‘the sum of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether inexplicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness’. In some countries the terms traditional medicine and complementary medicine are used interchangeably. These definitions are often complicated by the fact that in many cases traditional medicines are considered complementary medicines when removed from their country of origin. For example, Ayurveda is quite popular outside of India but is rarely officially sanctioned as a recognised form of medicine outside that country. These differences can even occur within

countries. Australia – an immigrant nation with a rich indigenous history – proffers several examples of this phenomenon. For instance, whilst indigenous medicines and traditional healing are commonly employed in indigenous health programs, they are not utilised significantly outside this context. Additionally, numerous culturally and linguistically diverse communities throughout Australia commonly enlist medical traditions from their countries of origin to complement their access to conventional care. Such variability in definition results in both relatively well-accepted treatments and fringe therapies being included in TCAM’s definition, for no other reason than they are not part of established conventional practice. Further complicating this definition is the fact that many ideological, social and cultural drivers for (and against) TCAM influences its use. For example, numerous therapies from a TCAM origin remain less utilised and more controversial than conventional-origin medications, even once equal or greater efficacy has been established (the herbal medicines St John’s Wort for mid-to-moderate depression and Kava for anxiety offer two examples). The ‘alternative’ nature of TCAM’s definition can also often mean that those attracted to oppositional stances toward conventional medicine can often become TCAM advocates, blurring the line between TCAM and inappropriate health practices (the links between the anti-vaccination movement and TCAM is an example).

HOW CAN TCAM AFFECT PUBLIC HEALTH? In addition to public health research and methodological expertise being essential to properly evaluate TCAM and the role it should play in health care systems, the significant use of TCAM itself is a public

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health issue worth exploring in its own right. For example, TCAM may now form up to half the health care sector in Australia – in terms of number of practitioner consultations, practitioner numbers and out-of-pocket health spending. Today patients attending a general practitioner consultation in Australia are more likely than not to be using a TCAM supplement, are more likely than not to be seeing a TCAM practitioner and are more likely

ad-hoc, highly variable, and often tokenistic (for example, many cancer centres in Australia offer TCAM for palliative care or non-ingestible treatments, as these are more politically acceptable than ingestible treatments with a higher evidence-base). In most instances TCAM forms an informal ‘black market’ of health care. For this reason the impact of TCAM is often under-acknowledged or underestimated. Moreover, TCAM’s largely

“SUCH VARIABILITY IN DEFINITION RESULTS IN BOTH RELATIVELY WELL-ACCEPTED TREATMENTS AND FRINGE THERAPIES BEING INCLUDED IN TCAM’S DEFINITION” than not to avoid disclosing this to their medical practitioner. However, TCAM use by patient is generally unregulated and unmonitored in its use, and there is often inadequate or absent legislative and regulatory infrastructure to deal with public health issues associated with TCAM use. While some integration does occur in most countries, this is often

unregulated nature can itself attract those practitioners or marketers primarily concerned with avoiding oversight or accountability of their practice, resulting in dangerous fringe and unorthodox practices being promoted by unqualified or unsuitable practitioners. Public health discussion and analyses of issues of safety and risk around

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TCAM have traditionally revolved around issues of direct risk, usually including adverse events (such as potential hepatotoxicity of complementary products or potential TCAM-drug interactions) and the monitoring of these events (e.g. pharmacovigilance), or the direct clinical risks associated with specific TCAM disciplines, modalities or practices (e.g. arterial dissection in chiropractic). However, direct clinical risks and adverse events form only part of the risk profile of any medical treatment. Indirect and non-health risks may in some instances pose more of a danger to patients than direct clinical risks – and can occur at both the individual patient level and the systems level – and as such usually require public health solutions. Indirect health risks associated with TCAM include acts of omission such as the opportunity costs caused by underuse of medical services and quality issues such as delayed diagnosis, failure to provide indicated treatments (e.g. alternative cancer treatments in lieu of chemotherapy) or sub-therapeutic doses of medicines. Non-health risks are defined as risks of using health services that harm

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the patient or consumer in ways not related to health – most commonly manifesting as economic harm as the result of health care costs or financial exploitation of patients. These risks require appropriate regulatory and legislative infrastructure (as also recommended by the WHO Traditional Medicine Strategy) that are informed by public health research perspectives.

WHAT CAN RESEARCH AND EVALUATION IN TCAM TEACH US? Despite high levels of TCAM utilisation, there are enormous information gaps that remain. We still know little about who uses TCAM, how or why they use it – or even in many instances what TCAM they are using. We know little about what TCAM providers actually do in clinical practice – and in some cases we can’t even identify how many or what kind of TCAM practitioners are delivering care). Exploring these issues can offer insights

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not only into how it is affecting health, but may also offer insights to broader health care questions. For example, one of the key defining features of TCAM is that, rather uniquely and by virtue of its definition of exclusion, it is the world’s major form of almost entirely demand driven healthcare. TCAM exhibits extraordinarily high utilisation rates even when there is little institutional or official support, has usually been developed over time from the bottomup rather than imposed top down, and remains popular even when freely available conventional care options exists. Various ‘push’ and ‘pull’ factors, defined as the positive or negative motivations regarding TCAM use respectively, have also been identified as influential in driving TCAM use. Examples of ‘pull factors’ may include dissatisfaction with conventional care and concerns about the safety of pharmaceutical medication whilst

“IN NATIONS SUCH AS AUSTRALIA PATIENTS ARE ACTIVELY DRAWN TOWARDS TCAM AND DO SO THROUGH INDIVIDUAL INITIATIVE AND AT THEIR OWN EXPENSE, OFTEN AGAINST THE ADVICE OF CONVENTIONAL PROVIDERS” ‘push factors’ include alignment with personal beliefs or traditions, attraction of the holistic principles of TCAM or desire for greater personal control of their wellbeing. In nations such as Australia patients are actively drawn towards TCAM and do so through individual initiative and at their own expense, often against the advice of conventional providers and irrespective of options that do not incur out-of-pocket expense. Understanding and exploring the drivers for such use can help develop more attractive and culturally relevant health care services

– of a conventional or complementary nature – that are not only effective but also encourage compliance among contemporary patients. The more we know about patients and their motivations, expectations, decisionmaking and evaluation, the better equipped we are to deal with their general health and health care needs. Researching and evaluating TCAM may also offer insights into new therapeutic approaches that may be useful for addressing public health priorities. The awarding of the 2015 Nobel Prize in Medicine to Youyou


SELF HELP, SUPER HEALTH AND SUPER SAVINGS

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o achieve sustainability, our current disease-oriented health systems requires gentle, pursuasive, firm and strategic reform. The informed public are rapidly becoming mindful consumers of complete foods, complementary medicines and safe health practices. These safe and effective options are being introduced to their medical carers contributing to an awareness among all health professionals of the potential power of natural health care. Grassroots organisation will inevitably bring about the necessary changes to medical systems that will ensure sustainability in Health. Education of all aspects of health also needs reform. Despite our best efforts in the field of complementary medicine, current health practice in Australia still focuses on the treatment of disease as opposed to the prevention of disease and optimisation of health. The ‘drug and disease’ paradigm is costly, not only in monetary terms but also the human toll of pain and suffering, iatrogenic death and the impact on productivity and quality of life. Despite an increasing awareness of the importance of lifestyle factors and prevention, mainstream medical professionals are trained to think and act in terms of disease and its pharmacological end points and interventions. To date prevention has largely been something of a secondary consideration in most medical schools and practices, and true health optimisation in this context is still in the minority. Whilst governments have made investments in prevention a priority, the key emphasis of prevention has been the drive to reduce preventable death and disease by addressing the risk factors of tobacco use and harmful consumption of alcohol. This is clearly inadequate when nutritional factors play a role, and are frequently a primary cause, in all medical conditions. Nevertheless, to ensure natural health care plays a major role in health optimisation, government health policies must be inclusive of natural healthcare services and products. What this means it that our government needs to embrace a ‘Wellness Model’ approach to health, encouraging people to seek natural healthcare products and services. The ‘Wellness Model’ of health requires that people are given the necessary tools and encouragement to maximise their health status and prevent illness. The objective is the achievement of

Super Physical and Psychological Health for every individual. Some of the keys to achieving Super Health are the judicious use of foods, nutrition and nutritional supplements, regular physical exercise, the avoidance of pollutants (chemical, electromagnetic, biological) and the practice of positive mindfulness through simple techniques such as meditation. Studies have shown that expanding the use of natural health care and complementary medicines could save many hundreds of millions of dollars a year in direct healthcare costs, whilst maintaining consistency in patient outcomes. The longterm benefits are profound. Better informed choices for individual self-care will be an absolute necessity for sustainable health care systems to be successful. Governments should also look more closely at what implications this might have in the context of national health reform. Hospital admissions and adverse drug events can be reduced significantly $3 billion could be wiped off the total Australian PBS expenditure and these savings could be used to promote better nutrition, physical fitness and the application of safe and effective natural therapies. Thus, the very people who choose to look after their own health by using natural healthcare products are the ones being penalised by current taxes. Governments must incentivise individuals to achieve their optimal health and fitness. The rapidly changing attitudes among the general populace also necessitates a change of training and attitudes among the orthodox medical establishment. In the words of the American author, spokesperson and activist for healthcare reform, Dr Andrew Weil, ‘Its just astonishing that something (nutrition) that is so central to health is given such short shrift’. As long as this attitude prevails in medicine, the adoption of a true ‘wellness model’ of healthcare in our society would seem much less likely. Fortunately there are many GPs and academics who are now becoming open to use of nutrients in diet, nutritional supplements and dietary modification as viable options and even alternatives to pharmacological interventions. Certainly there will always be a degree of ambivalence, stubbornness, even hostility from the biomedical diehards and the academic power brokers, but eventually the system will change to be in accord with the robust published evidence. Research in the field of nutritional medicine is growing at a phenomenal rate, and now that the human genome has been unravelled, the science supporting it is more impressive than ever. Serious, considered and moderate and continuing long-term reform is needed at every level of the health care system; governments, policy makers, universities, medical schools, postgraduate colleges and the professions. Resistence to change will be high as it always has been to technological advancement. This is not caused by ignorance or prejudice but the irrational fear of loss. Loss of power, of income, of self-worth and position in society. To achieve sustainability, our current disease oriented health system requires gentle, pursuasive, firm and strategic reform. Failure to reform is not an option.


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Tu for the discovery of artemisinin very publicly highlighted the public health potential ‘hidden away’ in TCAM, and countries such as India, Nigeria and the Philippines have begun systematically documenting traditional practices to assist efforts to uncover new treatments based on China’s success (though initiatives to protect the intellectual property rights of cultural owners of traditional medicines has some way to go). Some TCAM approaches are being slowly absorbed into conventional medicine: although considered ‘alternative’, acknowledgement of the effects of the microbiome on health occurred for nearly a century in naturopathic practice before its acceptance in mainstream medicine; and scientists in the United Kingdom have found ‘lost’ traditional remedies to be effective in antibiotic resistant Staph infection. Beyond individual therapies, TCAM approaches may themselves offer insights that can help improve delivery of health care. For example, current research evidence indicates that homeopathic medicines do not work beyond placebo but cohort studies of homeopathic patients show that patients who use homeopathic care do see better results than those using conventional care – a phenomenon attributed to ‘non-specific factors’ employed in homeopathic consultations. Examining what these factors are, and why they are effective, and how they can be extended to other areas may offer insights that can improve the delivery of primary health care. However, the extraordinary variability and heterogeneity of TCAM means that critical, rigorous and systematic approach to evaluation is required in order to identify appropriate areas for integration. Public health and health services research is increasingly identified as a core component of an effective TCAM research agenda. Despite this, relatively little work has been completed, and there remain many

“PUBLIC HEALTH AND HEALTH SERVICES RESEARCH IS INCREASINGLY IDENTIFIED AS A CORE COMPONENT OF AN EFFECTIVE TCAM RESEARCH AGENDA. DESPITE THIS, RELATIVELY LITTLE WORK HAS BEEN COMPLETED” gaps in the empirical understanding of TCAM practice and consumption and the effects of such practice and consumption ‘on the ground’. TCAM is now a significant part of the health care sector – indeed one that is ostensibly too large to ignore any longer. Further public health research and evaluation of TCAM is required to maximise the potential benefits TCAM may offer and minimise the public health risks it can pose. In order to fully understand TCAM and its impact and interface with public health goals and objectives we must broaden our approach beyond simply asking questions of clinical

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effectiveness, to include methods and research perspectives from public health (encouraging a research focus upon community self-care, TCAM use and wider population based health issues) and health services research (encouraging a research focus upon investigating CAM and integrative services and the systems in which they are provided). It is essential that we examine the economic, political, social and cultural contexts of contemporary TCAM in order to help inform and direct consumers, practitioners (both TCAM and conventional), health care managers, governments and health policy-makers in their decision-making, behaviours and interventions. ●

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A SMOKE-FREE AUSTRALIA

CAN WE GET THERE? Australia has taken great strides in recent years against the consumption of tobacco, but it’s important to recognise that the fight has been going on for more than 65 years. There remains more to be done. Professor Mike Daube AO explains.

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ustralia has been mournfully described by one of the largest global tobacco companies as ‘the darkest tobacco market in the world’. This is not simply the result of developments over recent years, such as plain packaging. They have indeed made a great contribution, but Australia’s tobacco control successes are the outcome of decades of campaigning, policy development, and implementation to ensure action and ultimately trends concomitant with the overwhelming evidence of the magnitude of the problem. Amazingly, it is more than two thirds of a century since the seminal 1950 papers by Doll and Hill (BMJ) and Wynder and Graham (JAMA) showing beyond doubt the lethal nature of smoking, and more than half a century since the first blockbuster reports of the UK Royal College of Physicians in 1962 and the US Surgeon General in

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1964. During that time there has been a vast amount of further evidence on the extraordinary range of harms caused by smoking, confirming its role as the world’s largest preventable cause of death and disease. There is equally overwhelming evidence on the comprehensive approach needed to reduce smoking, and of course the global tobacco industry’s ruthless determination to continue selling and promoting its lethal products and to oppose and undermine any efforts by governments, medical authorities and health organisations to reduce the tobacco death toll. That is why Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC), which is legally binding in 180 countries, specifically commits governments to ensuring that tobacco companies play no role in policy development and implementation. Globally smoking causes six million

deaths each year. WHO and the US National Cancer Institute predict that this will rise to eight million by 2030, and that already the economic costs of smoking exceed one trillion US dollars annually. Even more disturbingly, 80% of cigarettes are now smoked in Low and Middle Income Countries (LMICs), overtly identified by the tobacco industry as its major growth market. But Australia, along with other countries, is showing that there is light at the end of the tunnel. Not only can the tobacco industry be defeated, but a nation’s approach and perspective on smoking can be dramatically changed over time. Half a century ago, smoking was the norm, accepted and acceptable in public and in private, around children, and even in health institutions. Now, not only is smoking down to around 12% in adults, but less than 3% of our 12 to 15-year-olds are smokers. Smokers are literally dying out, and the new markets so crucial to the tobacco industry are no longer there. And yet it would be a mistake to declare victory. Such is the extent of the problem that more than 2 million Australians are still smokers; and while the numbers are of course much lower than they were, children are still starting to smoke. Notwithstanding those 67

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years since the early evidence, smoking still causes the deaths of more than 15,000 Australians every year. The three dangers facing us are still the global tobacco industry; complacency; and governmental reluctance to attach serious priority to prevention, which attracts less than 2% of all Australian health expenditure. The tobacco industry is fiercely competitive, but united and well organised in opposing effective action, using all its old strategies while stepping up newer approaches such as indirect lobbying, litigation against governments and health agencies, and working through front groups. As WHO Director General Dr. Margaret Chan has pointed out, “The tobacco industry can be trusted in one area only. The vigour of its opposition to a control measure is good evidence of the effectiveness of that measure”. But the recipe for action is clear. If our governments act on the basis of best evidence and expert advice – and implement those measures opposed by the tobacco industry – there is every reason that Australia should become effectively smoke-free by 2025 (defined as less than 5% adult prevalence), and even reach 3% by 2030. So what does this need? The evidence is there. We need a combination of continuing tax increases; properly funded, hard-hitting mass media programs; strong health warnings and packaging restrictions that build on Australia’s world leading plain packaging; more smoke-free measures to protect children and other non-smokers from exposure to passive smoking; further controls on tobacco products themselves – especially flavourings such as menthol; and special programs for vulnerable groups where smoking is high, such as Aboriginal communities and people with mental health problems. Governments may also wish to contemplate litigation against the tobacco companies whose activities have resulted in such massive costs to the community as well as to the public health, and new approaches such as limiting the number of sales outlets, perhaps engaging with the major retailers

that sell some two thirds of the cigarettes smoked in Australia. Australia is indeed on track to lead the world in becoming smoke-free – but it is vital to recognise that this will only happen if governments take the action they should – and this in turn will

“AUSTRALIA IS ON TRACK TO LEAD THE WORLD IN BECOMING SMOKE-FREE – BUT THIS WILL ONLY HAPPEN IF GOVERNMENTS TAKE THE ACTION THEY SHOULD” only happen if health organisations keep playing their part, and keep the pressure up. We also have an important international role in showing that the tobacco industry can be defeated over time if governments stand firm, and in providing assistance and support to LMICs which are being so heavily and ruthlessly targeted. But if LMICs are

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to fight off the targeting, promotion, lobbying, lies, cynicism and corruption associated with Big Tobacco, they need strong exemplars and support from other countries too. There are many countries that would be seen internationally as being just as developed as Australia and other countries where smoking is clearly in decline, just as sophisticated, just as well-informed, just as well served by their health systems – but where smoking prevalence remains high, and governments have failed to take significant action. This is largely because of the power of the tobacco lobby, but may also be because health organisations have not been sufficiently active and forceful. So the challenge for Australia is to avoid complacency, to press as hard as ever for a focus on prevention and evidence-based action, to keep shining a light on the activities of the world’s most lethal industry, to steer clear of distractions, and to show the world that with continuing pressure from public health organisations a smoke-free society can indeed be achieved. That would have seemed unthinkable even two or three decades ago: now it is within our reach. ●

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INJURY PREVENTION

PREVENTING INJURIES

SUCCESSES AND FUTURE CHALLENGES Preventing injuries is an evolving field. Take, for example, the increased pedestrian accidents that have occured since the rise of mobile phones. By Dr Richard Franklin.

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t would be hard to cover off on all of the successes and challenges of injury prevention, so I present for you an abridged version of some of the successes and challenges for injury prevention as I see them. I am sure others will argue that I have missed something and to them I agree, this paper is not a compendium but a few thoughts to get you thinking about preventing injury. Injury is normally caused by an exchange of energy causing damage to the body, however it does also include psychological trauma and deprivation

such as is the case with drowning or hanging. To prevent injuries from occurring either the exchange of energy is prevented or reduced such as is the case with a helmet or seat belt. Injury prevention is a multi-disciplinary field containing people from public health, psychology, engineering, medicine, nursing, occupational therapy, physiotherapy, policy & government, information technology, law, and education to name a few. Injury is a common cause of death particularly for those aged 1 to 50 years of age. In 2015 there were five injury

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causes in the top 30 leading causes of global years of life lost (YLL), these were road injuries in 8th position, self-harm was 14th, interpersonal violence was 19th, drowning 23rd and falls 28th. It should however be noted that there is variation in these ranking by country. In 2013 it was estimated that there were between 895 and 951 million people seeking medical care for an injury and between 4.5 and 5.1 million deaths from injuries. Common causes of deaths included road injuries, falls, drowning, fire, heat and hot substances, self-harm, interpersonal violence, exposure to mechanical forces. Injury is not evenly distributed with different countries having higher rates than others as well as different age groups having higher rates and sustaining differing injuries. There is some good

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“WHILE PREVENTION REQUIRES TARGETING OF THE HAZARDS AND RISK FACTORS REQUIRING GOOD EPIDEMIOLOGICAL EVIDENCE THERE ARE SEVERAL KEY PREVENTION STRATEGIES USED TO UNDERSTAND AND PREVENT INJURIES FROM OCCURRING” news with the incidence rate for all injuries dropping by 20% between 1990 and 2013, with the biggest gains being made in drowning, poisoning and contact with animals. Injury is common and part of the human condition, with many sustaining an injury making a full recovery. Coverage of injury events are common with newspapers daily abounding with news about those who have been injured from road crashes or during a sporting match or the death of a young child in a swimming pool. Often these events could have been prevented or minimised with some prior preparation. Success in preventing injury continues to grow as the field of injury prevention develops and greater understanding of how injuries occur is garnered. Preventing injuries is not a new concept, however its modern tradition can be traced back to the late

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1700s when interested started to grow in prevention deaths which previously had been considered an act of God. Some formative prevention activities include: in 1767 the formation of the organisation ‘Maatschappij tot Redding van Drenkelingen’ in Amsterdam to promote awareness of immersion incidents and prevent drowning; in 1815 the invention of the ‘Davy Lamp’ by Sir Humphry Davy, used by miners in coal mines with flammable gases to reduce the danger of explosions and to indicate a lack of oxygen; and the ‘Waterline’ – the line markings on the hull of a ship indicating the maximum load to ensure the buoyancy of the ship which was introduced in 1835 by Lloyd’s Register of British and Foreign Shipping, subsequently called the ‘Plimsoll Line’ after the British MP Samuel Plimsoll who in the 1860s took up the cause to make it mandatory

for all British ships and foreign ships visiting British ports to have a load line. Often with modern prevention of injuries our minds move to the more technological advances that we have seen such as airbags in cars which self-inflate during a crash, or heaters which automatically switch off if they fall over, or smoke detectors, however many prevention activities still require an element of human intervention to be effective. While prevention of injury requires appropriate targeting of the hazards and risk factors requiring good epidemiological evidence, there are several key prevention strategies used to both understand and prevent injuries from occurring. Unlike other areas in medicine where a randomised double blind control trial is able to be used to establish the evidence for its effectiveness, other types of evidence for the effectiveness of preventing injuries are required including good ongoing data collections of injury events. Think about how you may show that a parachute is an effective measure to prevent an injury from jumping out of a plane. There are numerous theories and approaches to the prevention of injuries. I will showcase three of what I would consider common, this includes Haddon’s Matrix, the hierarchy of control, and the three E’s. Haddon’s Matrix is a table consisting of 4 columns and 3 rows, each of the rows represents a phase in the event (pre / event / post), the columns represent the factors related to the event and include human, vehicle or equipment, social environment and physical environment. Each of the cells then are used to unpack the injury event and used to develop prevention strategies based on each cell. For example a child who drowns in a swimming pool without a fence, in the physical environment pre-event cell would have the strategy of ensuring there is a pool fence. The hierarchy of control is a system of concepts used to help with

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INJURY PREVENTION

establishing the effectiveness of a prevention activity. There are five levels to the hierarchy of control from what is considered most effective to least effective: elimination – removing the hazard (e.g. banning baby walkers); substitution – swapping for something that does not create the hazard or is a lesser hazard (e.g. pen lids for pen lids with a hole in them to prevent choking); engineering controls – this includes isolating the person from the hazard (e.g. covers over power-take-offs on tractors); administrative controls – this includes training, procedures, warning labels and signs; and personal protective equipment – this include pieces of equipment such as gloves used to protect the worker. The third approach is that of the 3 E’s, engineering, education and enforcement, although these have been expanded over the years to cover more E’s will quickly elucidate these three. Education refers to ensuring those who may be vulnerable (or their carers) have appropriate information to enable them to undertake prevention activities e.g. ‘don’t drink and drive’. Engineering refers to modify the environment (such as guarding or blister packs for drugs) and enforcement as is stated refers to the need to ensure that the prevention measures are in place, ie there is no point having a speed restriction if no one enforces that people stick to the speed limit. While there are many area where injury prevention needs to be focused I will quickly explore two, these are road traffic injuries and drowning. On the 11th May 2011 the 20112020 decade on road safety was launched. The decade is mandated by the United Nations General Assembly, aimed at preventing loss of life on roads. A global plan was developed following consultation and focused on building road safety management capacity, improving the safety of road infrastructure and transport networks, developing safer vehicles, enhancing road user safety behaviour and improving post-crash response. It is

however also worth noting the success in the area of road safety; these include seat belts and the wearing of them, tackling the issue of drink driving, air bags, road and car design. You will note that some of the strategies require a behaviour element (or active element) requiring the person to do something each time, ie the wearing of seat belts, and while there has been much success, a range of campaigns has been required targeting a range of road users from children to adults, linked to legislative requirements and enforcement. Helmets for all cyclists (motorised and human powered) are recommend as they can and do prevent deaths and reduce the impact of injury and sit in the area of secondary prevention or mitigating the exchange of energy. WHO in their 2014 Global report on Drowning identified it as ‘a serious and neglected public health threat’. While deaths due to drowning have seen a steady decline over the years, partly due to development and removal of water sources close to the home, there has been at the same time an increase in leisure related aquatic activities and the building of home swimming pools. Increasing leisure use of aquatic location particularly

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beaches and public swimming pools has seen the development of rescue organisations which train lifeguards and provide standards for the supervision of these areas. Drowning in locations with lifeguards is significantly lower than those without. Both the technological development and increase in household wealth has seen an increase in the installation of home swimming pools and with it child drowning deaths. One of the most successful measures to prevent children from drowning has been placing a barrier (fence) around the pool, with 4-sided fencing being the most effective. Lifejackets and their use are also important in the prevention of drowning deaths, as are swimming skills, supervision and cardiopulmonary resuscitation. Injuries are preventable and many of the deaths today can be prevented with our current understanding, however there is still a long way to go before we understand and are able to prevent all injuries which cause death or serious ongoing harm. New challenges will be created as we have seen recently with people talking on their mobile phones while driving or drowning in home swimming pools requiring new solutions. ●

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O R A L H E A LT H

ORAL HEALTH

AN ESSENTIAL COMPONENT IN HEALTH CARE DESIGN A look into the development of oral health care and the issues that remain today. By Dr Hyewon Lee and Professor Raman Bedi.

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ral health has been historically separated from general health in various aspects. Differences in curricula and training modules between medicine and dentistry, separate insurance systems, lack of interoperability between medical and dental records, and a divided care delivery system are some examples. Worldwide, 60–90% of school children and nearly almost all adults in the world have dental caries based on the World Health Organization (WHO) data. However, oral disease still remains a silent epidemic disproportionately affecting overall health and well-being of the poor and disadvantaged populations. Mounting evidence shows the bi-directional impacts of oral health complications and other systemic diseases. Periodontal disease is a chronic inflammation in tissues and bones that support the teeth. People with poorly controlled diabetes are significantly more likely to have severe periodontitis, and unmanaged periodontitis can also adversely affect glycemic control in patients with diabetes. Considering the increasing prevalence of diabetes and the fact that 15% of middle-aged (35-44 years) adults worldwide have severe periodontal disease as indicated by WHO data, it is important to include oral health into care management of diabetes. Consequences of poor oral health may negatively influence children’s speech, nutrition, growth and function, social development, and academic performance. All evidence shows that oral health is an integral part of overall health. Public health entities and health care systems should consider oral health as an essential component of primary health system and design.

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O R A L H E A LT H

Current challenges in oral health care can be categorised into three areas: financing, workforce, and public communication. Fluoridated toothpaste is the simplest form of primary prevention for dental caries that does not involve trained health professionals or specific equipment other than a toothbrush. However, people in poor and marginalised communities, especially in low-income countries, may not be able to purchase these hygiene items due to the cost. Goldman et al. (2008) reported that toothpaste is still classified as a cosmetic product with various taxations, while other essential prevention products such as insecticide treated mosquito nets, vaccines, contraceptives and oral rehydration salts are tax exempted. In African countries like Kenya and Zambia, the poorest 30% of population may need to work several days to buy one annual dose of toothpaste at the lowest price. The World Health Organization calls to reduce or remove taxation on fluoridated toothpaste and increase taxation for high sugar beverages and foods. Policymakers and corporates need to work together to make preventive interventions for dental caries available and affordable for people from all income levels. The second challenge is the capacity of a dental workforce who can deliver oral health messages and care. A traditional dental team that provides direct clinical services consists of dentists, dental hygienists, and dental assistants. In many countries, dental therapists and dental nurses are also included in a dental care team providing critical preventive and restorative care, especially for underserved populations. To form an efficient dental workforce composition, policymakers and health care leaders should know the needs and characteristics of the population to be served, including the socio-economic status, specific barriers to access oral health care, and health literacy levels of the population. If community outreach is a key success factor for a given dental program, community dental health coordinators will serve as core

members of the dental team. Regardless of various dental team models, all team members should clearly understand that oral health is an integral part of overall health, and know how to link oral health and other health issues, including dietary counselling, diabetes and periodontal health, and oral health for pregnant women. Recently and globally, non-dental professionals such as pediatricians, family medicine doctors, nurses, and

The U.S. Department of Health and Human Services and the National Institute of Dental and Craniofacial Research defines oral health literacy as ‘the degree to which individuals have the capacity to obtain, process and understand basic oral and craniofacial health information and services needed to make appropriate health decisions.’ True changes in healthy behaviour are influenced by an individual’s value placed on

“POLICYMAKERS AND CORPORATES NEED TO WORK TOGETHER TO MAKE PREVENTIVE INTERVENTIONS FOR DENTAL CARIES AVAILABLE AND AFFORDABLE FOR PEOPLE FROM ALL INCOME LEVELS” pharmacists are also being considered as important players in a larger oral health team both at the training level and practice level. This interprofessional team approach includes development of oral health training modules for non-dental health care providers and projects and research studies with different integration models. The role of primary care providers in improving oral health is critically important in the context of limited resources and access to dental personnel. This situation is found not only in many developing countries which can have dentist to population ratios of 1:150,000 as WHO data shows; but also across the globe in communities with limited access to dental care due to poverty, geographical, and language barriers. In communities where access to both doctors and dentists are limited by various factors, public health workers, such as pharmacists, community health care workers, care navigators, health educators and social workers, play a vital role to prevent potential oral health problems and promote oral health of all members of the community. Lastly, effective and evidencebased oral health communication and campaigns for public are essential.

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health status, and not merely from accessibility or affordability for of care. To empower each individual to be a decision-maker for healthier choices for better oral health, the message needs to be based on science with appealing communication vehicles so that it leads to meaningful behaviour change. To respond to this urgent need of improved oral health, the World Federations of Public Health Association Oral Health Workgroup has put forward a resolution to the 2017 General Assembly at the World Public Health Congress, calling for better integration between oral and general health. If passed all national public health associations are encouraged to take this issue forward in their own countries. The time is prime for health policymakers to create a platform for affordable and accessible oral health care with innovative workforce and health communications models. By recognising oral health as an integral part of overall health and emphasising oral health issues as primary health problems, we will be able to lessen the impacts of the current oral disease epidemic and secure future oral health parity worldwide. ●

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EXERCISE

TIME TO INVEST IN HEALTHIER LIFESTYLES

Modern lifestyles are seriously impacting health, especially in children. Coupled with ageing population, action is needed to help promote the varied benefits of even moderate activity. By Professor Rachel Davey.

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n Australia, as in many other nations across the world, modern living has not been good for many of our children. Recent research from the University of Canberra, involving measurements of almost 22,000 primary school children from the Australian Capital Territory, who participated in the SmartStart for Kids healthy exercise eating and lifestyle after school programme, demonstrated that 69% of children were of low

general fitness and a quarter were either overweight or obese. These data are backed up by the findings from the Canberra-based Lifestyle of our Kids (LOOK) study that examined the influence of specialist physical education on physical activity and many other factors in 853 Canberra school children followed up between the ages of 8 and 12 years. This study showed that, overall, 31% of boys and just 16% of girls met the national guideline of

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60 minutes of moderate to vigorous physical activity per day. As if these data were not bad enough, the situation is even worse when one considers the adult population, where two thirds of people are overweight or obese, making being overweight the accepted norm, and a significant proportion of the population (38% for Australia) consider themselves to be inactive. Indeed, synthesis and modelling from the most recent Global Burden of Disease study 2013 for Australia shows that behavioural risk factors make the dominant contribution to years of life lost through death and disability. The top seven established risk factors, all related to lifestyle choices, are estimated to contribute over 45%

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of the total burden of disease. Social factors, environmental exposures and behaviours together are responsible for 60% of early deaths and a similar proportion of ill health. The risk factors reflect individual choices that are shaped by our life circumstances such as the living environment, housing, employment, education, income, social networks and relationships. These risk factors have been driving up health care costs steadily as a proportion of GDP. In Australia, for example, health care expenditure as a proportion of GDP rose from 6.7% to 9.8% over the 25 year period between 1989-90 and 2013-14. Over this same period the cost per capita rose from around AU$ 3000 to AU$ 6560. In most other nations, the figures may differ but the trends are ubiquitous and, probably, not sustainable. England’s National Health Service, once the paragon of health care delivery models, is close to breaking point trying to reconcile the increasing demand for health care with a government struggling to justify the budget to meet the added costs. As a nation, they are not alone there. Perhaps the time is right to focus public health attention more assiduously on the wider social and behavioural determinants of health and to look for ways to invest in healthier lifestyles so as to prevent many of the behaviours that are most detrimental to health from arising in the first place.

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“PERHAPS THE TIME IS RIGHT TO FOCUS PUBLIC HEALTH ATTENTION ON THE WIDER SOCIAL DETERMINANTS OF HEALTH TO LOOK TO PREVENT MANY BEHAVIOURS THAT ARE DETRIMENTAL TO HEALTH FROM ARISING IN THE FIRST PLACE” One stand-out example of such potential for prevention comes from better individual and community education. For example, closer analysis of the data gathered in the SmartStart for Kids programme referred to above showed that the majority of overweight children could potentially achieve normal weight with just an extra 15 minutes of physical activity a day and dietary intake restriction equivalent to around 2 squares of chocolate per day. In addition, general fitness levels could be improved through a wide range of physical activities such as those that might be gained through active play at school and active travel to or from school. School policies, communities and environments that teach and practise maintaining body weight about right (for gender, stature, metabolism and habitual physical activity levels) as a lifestyle norm

would add considerably to the preventive potential. Alongside these improvements in physical abilities and reductions in excess body weight, children’s social skills and psychological resilience would be improved, since these are known to develop well through structured active play. This should in turn contribute to reducing the prevalence of mental health issues that have been on the rise in both children and adults. Behaviours learned and established in childhood often carry through into adulthood. In Japan, for example, where over 98% of school children use active transport to school, the proportion of the population that is overweight or obese is around 19%, whereas most similarly developed nations have proportions approaching two thirds of the adult population.

CHALLENGE TO PARENTS AND COMMUNITIES These findings throw down a challenge to us as a society to do better for our children. In essence, this means that we need to reconfigure our environments and lifestyles for children such that there are adequate opportunities for all children to be physically active daily, to interact socially more often and with fewer opportunities to consume excess calories. Increasingly, the demands of the workforce on parents and carers have made the challenge of providing active and social opportunities for children more challenging. A greater proportion of children’s time today is spent in sedentary, often solitary, activities, usually in front

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EXERCISE

TOP 7 RISK FACTORS - GBD 2013 (AUSTRALIA) % of total burden of disease 0

2

4

6

8

10

12

Dietary

Risk Factor

High BMI Smoking High BP Cancer Circulatory ENM Musculoskeletal Respiratory

Physical inactivity High FPG High TC

Figure The top 7 risk factors contributing to the total burden of in 2013. BMI – body mass index, BP – blood pressure, FPG – fasting plasma glucose, TC – total cholesterol. Colour key: ENM – endocine, nutritional and metabolic diseases.

of a TV screen or using a mobile or gaming device. The natural consequences of this change in lifestyle are: loss of social and psychological skills; decline in general fitness; and gradual increase in excess body weight. Parents, carers and communities should become more engaged with these challenges, advocate for and, where feasible, support change to embed healthier lifestyle norms and reset the detrimental drift of recent decades.

PUBLIC HEALTH CHALLENGES OF THE 21ST CENTURY Looking at the seven dominant drivers of disease burden (and health care expenditure) more closely, six are related to excess, inadequate or unnecessary consumption and the seventh, physical inactivity, relates to the loss of opportunity or time or a disinclination for physical activity. These are the dominant public health challenges as we progress into the 21st century. To tackle these challenges we need a better mix of policy,

provision and incentive than is the case currently. A fairer distribution of wealth or, at least the basic needs for good health, within nations and globally would be a good start. Undesirable behaviours either by commercial companies or individuals should be de-incentivised or paid for by taxation, as has been the case in the past for tobacco consumption and has begun in some countries for sugar consumption. Healthier lifestyles can be developed through better education, re-balancing of the time or opportunity to be physically active or to consume too many calories or incentivised by lower premiums for health care insurance.

BETTER PUBLIC HEALTH INTELLIGENCE At the same time, there is a need to bring our analyses and public health epidemiology much closer to where our people live, work and play – to where the real exposures or behaviours occur – and to determine how best to restrict or eliminate such exposures or behaviours.

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This necessitates gathering as much pertinent data at high spatial resolution as feasible, multi-level analysis of the relationships and interplay between these factors, and high spatial resolution mapping that allows identification of the threats to health and effective targeting of resources to eliminate or reduce those threats. In short, we need to switch attention to the opposite end of the public health conveyor belt, i.e. to a local level rather than at the national or regional scale. This will require changing highly restrictive mind-sets and improving systems for gathering, linking and analysing data. The challenge for public health research will be to develop new ways of unravelling the causes or causal relationships between behaviours and health outcomes such that prevention initiatives will be founded on strong evidence. Special focus should be given to populations where there are clear health inequalities that, despite some progress, remain resistant to change. ●

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ADVERTISER INDEX Aboriginal Medical Services Alliance Northern Territory (AMSANT)..........................................83

Public Health Association Australia (PHAA)..............................................................................76

Australian Diabetes Educators Association.................100

RDNS................................................................................16

Australian National University........................................33

Sanitarium.......................................................................14

Bond University................................................................40

Sax Institute.....................................................................27

CSIRO ..............................................................................04

Swinburne University of Technology............................OBC

CUNY School of Public Health.........................................34

Teesside University..........................................................33

Deakin University.............................................................77

The University of Hong Kong...........................................66

Endeavour College of Natural Health..............................84

Torrens University............................................................88

Griffith University.............................................................02

Transport Accident Commission.....................................94

Instituto Nacional de Salud PĂşblica................................08

University of Technology Sydney (UTS).................................................................................89

James Cook University....................................................67

University of Canberra.....................................................12

King Saud bin Abdulaziz University for Health Sciences.........................................................75

University of Tasmania....................................................79

Massey University............................................................10

University of the Sunshine Coast....................................69

Monash University...........................................................06

University of Wollongong............................................... IBC

NACCHO............................................................................82

UNSW Australia................................................................52

National Centre for Immunisation Research and Surveillance (NCIRS)................................75

Victoria University...........................................................70

Northern Territory Government.......................................19

Walter and Eliza Hall Institute of Medical Research........................................................54

Nutrition Care Pharmaceuticals.................................... IFC

Western Sydney University..............................................18



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