Including health impacts in environmental impact assessments for three Australian coal-mining projects: a documentary analysis.

Notwithstanding the historical benefits of coal in aiding human and economic development, the negative health and environmental impacts of coal extraction and processing are of increasing concern. Environmental impact assessments (EIAs) are a regulated policy mechanism that can be used to predict and consider the health impacts of mining projects to determine if consent is given. The ways in which health is considered within EIA is unclear. This research investigated 'How and to what extent are health, well-being and equity issues considered in Environmental Impact Assessments (EIAs) of major coal mining projects in New South Wales, Australia'. To this end we developed and applied a comprehensive coding framework designed to interrogate the publicly available environmental impact statements (EISs) of three mines in New South Wales (NSW), Australia, for their inclusion of health, well-being and equity issues. Analysis of the three EISs demonstrates that: the possible impacts of each mine on health and well-being were narrowly and inadequately considered; when health and well-being were considered there was a failure to assess the possible impacts specific to the particular mine and the communities potentially affected; the cumulative impacts on human health of multiple mines in the same geographical area were almost completely ignored; the discussions of intragenerational and intergenerational equity did not demonstrate a sound understanding of equity and, it is essential that governments' requirements for the EIA include detailed analysis of the health, well-being, equity and cumulative impacts specific to the proposed mine and relevant communities.

Counting the Cost of Diabetes in the Solomon Islands and Nauru.

AIM: To determine the costs associated with diabetes to governments, people with diabetes and their carers, and its impact on quality of life in two Pacific Island countries--the Solomon Islands and Nauru. MATERIALS AND METHODS: This cross-sectional cost of illness study was conducted on 330 people with type 2 diabetes (197 from the Solomon Islands and 133 from Nauru) using a structured cost of illness survey questionnaire adapted from the Australian DiabCo$t study. Quality of life was measured by the EQ-5D Visual Analogue Scale. RESULTS: There were 330 respondents (50% female; mean duration of diabetes 10.9 years; mean age 52.6 years). The estimated annual national cost of diabetes incurred by the Solomon Islands government was AUD 12.8 million (AUD 281 per person/year) and by Nauru government was AUD 1.2 million (AUD 747 per person/year). The major contribution to the government costs was inpatient services cost (71% in the Solomon Islands and 83% in Nauru). Annual expenditure for diabetes was approximately 20% of the governments' annual health care expenditure. Considerable absenteeism and retirement from work due to diabetes was found. CONCLUSIONS: This study found substantial public and personal costs associated with diabetes. The findings provide objective data on which health policy, funding and planning decisions about the prevention and control of diabetes in the Solomon Islands and Nauru can be reliably based and subsequently evaluated.

Evidence-based medicine: is it a bridge too far?

AIMS: This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. RESULTS: The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context. CONCLUSION: EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

A profile of diabetes in Pacific Island Countries and Territories.

AIM: To examine the available evidence about the epidemiology, health, social, and economic impact of diabetes in Pacific Island Countries and Territories (PICTs). METHODS: We conducted a systematic review of the peer-reviewed literature published in English from January 1990 to January 2014, and relevant technical reports. RESULTS: A total of 1548 articles were identified of which 35 studies of type 2 diabetes met the inclusion criteria. Eighteen technical reports were also included. We found no articles reporting on type 1 diabetes or gestational diabetes that met the inclusion criteria. The prevalence, risk factors and complications of diabetes were substantial. Diabetes prevalence rate of around 40% was common. Physical inactivity, overweight and obesity were leading risk factors. High rates of diabetes complications were reported e.g. up to 69% retinopathy. Poor clinical outcomes were also reported with over 70% not meeting glycaemic control targets and approximately 50% not meeting blood pressure and cholesterol targets. CONCLUSION: This review highlights the burden of diabetes in PICTs and the need for more intensive interventions to improve the quality and outcomes of diabetes care. Overall, further research is needed to monitor secular diabetes trends in PICTs using standardised criteria for diagnosing diabetes and its complications.

The global response to diabetes: action or apathy?

Diabetes and related non-communicable diseases (NCDs) account for over 60% of the world's annual deaths, untold personal suffering, and an economically crippling burden of lost productivity. Despite the body of evidence and various calls to action, historically, the global response has bordered on apathy. Although diabetes and related NCDs remain disproportionately underfunded, the United Nations now recognises them as a major challenge to human and economic development, resulting in an action-oriented policy, frameworks and monitoring requirements that are being driven by the UN and the World Health Organization. Australia is at the forefront of many of these initiatives and is currently developing a new national diabetes strategy.

Health care frames - from Virchow to Obama and beyond: the changing frames in health care and their implications for patient care.

RATIONALE, AIMS, OBJECTIVES AND METHODS: Framing allows us to highlight some aspects of an issue, thereby bringing them to the forefront of our thinking, talking and acting. As a consequence, framing also distracts our attention away from other issues. Over time, health care has used various frames to explain its activities. This paper traces the emergence of various health care frames since the 1850s to better understand how we reached current ways of thinking and practicing. RESULTS AND CONCLUSIONS: The succession of the most prominent frames can be summarized as: medicine as a social science; the germ theory of disease; health care as a battleground (or the war metaphor); managing health care resources (or the market metaphor); Health for All (the social justice model); evidence-based medicine; and Obama Care. The focus of these frames is causal, instrumental, political/economic or social in nature. All remain relevant; however, recycling individual past frames in response to current problems will not achieve the outcomes we seek. Placing the individual and his/her needs at the centre (the attractor for the health system) of our thinking, as emphasized by the World Health Organization's International Classification of Function framework and the European Society of Person Centered Health Care, may provide the frame to refocus health and health care as interdependent experiences across individual, community and societal domains. Shifting beyond the entrenched instrumental and economic thinking will be challenging but necessary for the sake of patients, health professionals, society and the economy.

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts.

Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.

The cost of diabetes in adults in Australia.

AIMS: To assess and compare costs associated with diabetes and lesser degrees of glucose intolerance in Australia. METHODS: The Australian Diabetes, Obesity and Lifestyle study collected data on the use of health services and health related expenditure in 2004-2005. Complications data were collected through physical examination and biochemical tests or questionnaire. Data were available on 6101 participants. Age- and sex-adjusted direct healthcare costs, direct non-healthcare costs and government subsidies were estimated according to glucose tolerance status. RESULTS: Annual direct per person costs were A$1898 for those with normal glucose tolerance to A$4390 for those with known diabetes. Costs were substantially higher in people with diabetes and both micro- and macrovascular complications. The total annual cost of diabetes in 2005 for Australians aged ≥30 years was A$10.6 billion (A$4.4 billion in direct costs; A$6.2 billion in government subsidies) which equates to A$14.6 billion in 2010 dollars. Total annual excess cost associated with diabetes in 2005 was A$4.5 billion (A$2.2 billion in direct costs; A$2.3 billion in government subsidies). CONCLUSION: The excess cost of diabetes to individuals and government is substantial and is greater in those with complications. Costs could potentially be reduced by preventing the development of diabetes or its complications.

Coal mining, social injustice and health: a universal conflict of power and priorities.

Given the current insatiable demand for coal to build and fuel the world's burgeoning cities the debate about mining-related social, environmental and health injustices remains eminently salient. Furthermore, the core issues appear universally consistent. This paper combines the theoretical base for defining these injustices with reports in the international health literature about the impact of coal mining on local communities. It explores and analyses mechanisms of coal mining related injustice, conflicting priorities and power asymmetries between political and industry interests versus inhabitants of mining communities, and asks what would be required for considerations of health to take precedence over wealth.

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

The cost of overweight and obesity in Australia.

OBJECTIVE: To assess and compare health care costs for normal-weight, overweight and obese Australians. DESIGN, SETTING AND PARTICIPANTS: Analysis of 5-year follow-up data from the Australian Diabetes, Obesity and Lifestyle study, collected in 2004-2005. Data were available for 6140 participants aged >or= 25 years at baseline. MAIN OUTCOME MEASURES: Direct health care cost, direct non-health care cost and government subsidies associated with overweight and obesity, defined by both body mass index (BMI) and waist circumference (WC). RESULTS: The annual total direct cost (health care and non-health care) per person increased from $1472 (95% CI, $1204-$1740) for those of normal weight to $2788 (95% CI, $2542-$3035) for the obese, however defined (by BMI, WC or both). In 2005, the total direct cost for Australians aged >or= 30 years was $6.5 billion (95% CI, $5.8-$7.3 billion) for overweight and $14.5 billion (95% CI, $13.2-$15.7 billion) for obesity. The total excess annual direct cost due to overweight and obesity (above the cost for normal-weight individuals) was $10.7 billion. Overweight and obese individuals also received $35.6 billion (95% CI, $33.4-$38.0 billion) in government subsidies. Comparing costs by weight change since 1999-2000, those who remained obese in 2004-2005 had the highest annual total direct cost. Cost was lower in overweight or obese people who lost weight or reduced WC compared with those who progressed to becoming, or remained, obese. CONCLUSION: The total annual direct cost of overweight and obesity in Australia in 2005 was $21 billion, substantially higher than previous estimates. There is financial incentive at both individual and societal levels for overweight and obese people to lose weight and/or reduce WC.

Counting the cost of type 2 diabetes in Vanuatu.

AIM: To determine the health system costs, cost to people with diabetes and their carers, and impact on quality of life associated with type 2 diabetes in Vanuatu. METHODS: A cross-sectional paper based survey was administered to 199 people with type 2 diabetes as part of a larger diabetes project. RESULTS: There were 172 respondents (86% response rate) with a mean age of 56 years (mean duration of diabetes 8 years, 106 females; 67 unemployed). Over the preceding year there were 2352 outpatient visits for health care totalling 442,400 vatu ($4020 USD); 140 overnight hospital stays totalling 1,383,620 vatu ($12,580 USD); and prescription medications costing 3220 vatu/person ($29.20 USD). Major out-of-pocket costs for individuals were the over-the-counter medications totalling 6600 vatu/person/year ($60 USD) for 31 people (18%); transport at 1980 vatu/person/year ($18.00 USD) for 110 people (64%) and special diets for 38 people (22%) costing 36,480 vatu/person ($332 USD). Quality of life was 91/100 on the EQ-5D visual analogue scale. CONCLUSIONS: Given that diabetes in Vanuatu is likely to be significantly under-diagnosed and under-treated the current costs, while substantial are artificially low but are set to rise sharply with increased awareness of diabetes and growing rates of obesity.

Do socio-economic factors influence supermarket content and shoppers' purchases?

ISSUE ADDRESSED: Obesity is at crisis proportions. Individuals of low socio-economic status (SES) are more likely to consume higher energy dense diets than their high socio-economic status counterparts. The contribution of supermarket purchases of energy dense, nutrient poor foods has not been well-researched and has largely depended on unverified self-report. METHODS: We estimated the proportion of supermarket shelf space dedicated to non-core foods in nine supermarkets (in five high and four low SES areas) in metropolitan Sydney. We analysed 204 shoppers' dockets (102 from high and 102 from low SES areas) for purchases of confectionery; sugar sweetened, carbonated beverages and cordials, sweet biscuits and cakes, and crisps and popcorn. RESULTS: After adjusting for the number of people shopped for, low SES shoppers purchased significantly more non-core foods than high SES shoppers (p=0.039), especially chips and sugar sweetened, carbonated beverages and cordials. There was no difference in the shelf space dedicated to non-core foods, or between non-core foods purchased and the proportion of shelf space occupied by them in either low or high SES areas. CONCLUSIONS: Increased purchase of non-core foods by low SES shoppers who are already at higher risk of obesity than high SES shoppers is cause for concern. Further research is required to explore underlying reasons for this association.

The answer to diabetes prevention: science, surgery, service delivery, or social policy?

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.