Research Paper no. 3 2004–05
Critical, but stable
Australia's capacity to respond to an infectious disease
outbreak
Nigel Brew
Foreign Affairs, Defence and Trade Section
Kate Burton
Social Policy Section
16 November 2004
Contents
Executive summary
Introduction
Responsibility for public health: the historical
context
The evolution of Commonwealth quarantine powers
A national health department
Infectious disease control today
National co-ordination and control
Commonwealth-state relations in health
Practitioners and policy-makers
An Australian national disease control centre?
Stove-piping
Surveillance
External surveillanceInternal surveillanceSyndromic
surveillance
Medical response capacity
Hospital surge capacityAvailability of hospital bedsCreating
additional capacity Workforce issues
Mass casualty and outbreak preparedness
National exercisesBali bombingHospital preparedness
Vaccines and anti-virals
Conclusions
Endnotes
Appendix
Infectious disease control has always been central to public
health in Australia, and it was largely concern about infectious
disease that led to the establishment of the Commonwealth
Department of Health in 1921. The Commonwealth today retains a
strong interest in infectious disease, even as its interest and
involvement in public health has broadened well beyond this
issue.
After a period of apparent complacency about Australia s
vulnerability to communicable diseases, which some say ended only
as recently as the 1990s, Australia s systems for disease
surveillance, detection and reporting have recently been
reinvigorated, as has planning for mass casualty and outbreak
preparedness. For example, measures announced in the 2004 05
Federal Budget included $40.2 million for initiatives to strengthen
national health security, preparedness and response capability in
the event of a terrorist attack or a national health emergency.
Many of the improvements being undertaken build on existing
influenza pandemic planning.
Even as little as five or six years ago, issues such as a
national emergency stockpile of vaccines and medications, mass
casualty preparedness and real-time disease surveillance did not
receive routine or ongoing attention. Much of the recent boost to
this sort of planning has occurred as part of the current national
security agenda, which, according to some, is as much a hindrance
to successful planning as an advantage. It has also been argued
that Commonwealth/state health responsibilities are ill-defined and
that policy-makers with limited public health content knowledge are
making decisions on critical public health matters, with little or
no consultation with clinical health professionals.
Existing research and comments from respondents interviewed for
this paper highlight major deficiencies in the emergency health
response to infectious disease in humans. Few respondents felt, for
example, that routine reporting through current surveillance
systems was sufficient for early notification of a serious disease
outbreak, whether it is naturally-occurring or deliberately
introduced. Furthermore, despite the experience and commitment of
the people working in the health system nationally, many of
Australia s hospitals appear to be underprepared for dealing with
mass casualty incidents particularly one involving an infectious
disease or are only now beginning to address the issue.
Most respondents were confident that in the event of a national
infectious disease emergency the system would work , but also
readily admitted that the system is largely untested. Most
respondents agreed that Australia s current surveillance networks
are sufficiently robust to deal with routine disease threats, but
felt that detection and reporting mechanisms need to be more
streamlined in order to deal with a major infectious disease
crisis. There is a general sense that the emergency health response
labours under difficulties arising from limited resources,
inadequate training exercises and a lack of integration, and that
perhaps the system works despite the structures in place
rather than because of them.
Summary of key issues
- the Commonwealth Government has become increasingly involved in
public health matters traditionally left to the states/territories,
with little, if any, decrease in state involvement
- as recently as the late 1990s, there appears to have been a
distinct complacency within government about Australia s
vulnerability to infectious disease SARS and avian flu in
particular have driven a renewed interest in the detection and
control of infectious disease
- overlapping Commonwealth/state responsibilities and divisions
between clinical health practitioners and public health
policy-makers were identified as two broad problem areas in
Australia s national arrangements for responding to an infectious
disease outbreak
- respondents were confident the emergency health system would
work in the event of a national infectious disease crisis, but
admit that it is still largely untested
- the securitisation of health appears to be as much a hindrance
as an advantage to planning
- there appears to be some resistance amongst the medical
community to an all-hazards approach in dealing with an infectious
disease outbreak
- Australia s external and border disease surveillance mechanisms
were generally thought to be good, but Australia s internal
surveillance systems attracted considerable criticism
- the success of Australia s infectious disease control system
appears to rely more on unofficial networks and personal contacts
than on bureaucratic structures respondents nominated the calibre
of the people in the system ahead of the structures in which they
operate as the primary strength of the health care system
- there is very little slack or surge capacity in the hospital
system to deal with a mass casualty incident, particularly an
infectious disease outbreak
- several respondents felt that medical workforce issues have not
received enough attention in contingency planning
- many of Australia s hospitals appear to be underprepared for
dealing with mass casualty incidents and administrators appear
reluctant to devote time and resources to exercising their
response
- there does not appear to have ever been a national exercise,
the focus of which has been a human health crisis, particularly one
which involves an infectious disease outbreak at most, mass
casualty response is sometimes included as one aspect of
counter-terrorism exercises which are primarily designed to test
the national security apparatus
- most respondents were critical of the way in which the Bali
bombing has been held out to have been a successful test of
Australia s mass casualty preparedness, arguing that the scale of
the incident was relatively modest and the impact on resources
short-lived and easily absorbed, and
- Australia has been steadily expanding its National Medicines
Stockpile in case of an emergency need for vaccines, antibiotics or
anti-virals, but unlike some other countries, it is envisaged that
medication would only be made available to first responders and
other essential personnel rather than the entire population.
Somewhat reluctantly, countries such as New Zealand and
Australia now recognise that national security in a globalised
world involves facing a wide range of threats which transcend
simple considerations of military power and national borders.
Both countries have been slow to recognise that infectious
diseases are a direct threat to their population; that they are
likely to aggravate and, in some circumstances provoke, social
fragmentation, threaten trade and commerce and undermine national
confidence.(1)
Despite the oft-cited success of eradicating smallpox globally,
serious infectious diseases have not gone away, as the advent of
new and re-emerging disease threats such as Severe Acute
Respiratory Syndrome (SARS), multi-drug resistance and the ongoing
outbreak of avian influenza ( flu ) across much of Asia clearly
demonstrates. The existence of such threats, combined with the
spectre of bioterrorism, has prompted countries around the world to
examine closely their capacity to prevent, detect and respond to
serious infectious diseases. Australia is no exception, despite the
fact that it has so far been spared infection from the likes of
SARS and the recent avian flu. Indeed, the fact that Australia has
been spared appears to have provided added impetus to ensuring that
Australia keeps such diseases out of the country and can act
promptly and effectively if an outbreak does occur.
The bulk of the research for this paper was conducted through
interviews with a range of Australian experts in public health
policy and practice between March and May 2004. (See list at
Appendix). Interviews were conducted in the form of an open
discussion, either by telephone or in person, with respondents
invited to comment as appropriate on specific issues such as
disease surveillance, the influenza pandemic plan, disaster
planning and hospital preparedness, the Commonwealth state
relationship and the Bali bombing in 2002. The information obtained
from these interviews has been supplemented with other research
based on academic literature, government information and media
reports.
As such, the aim of this paper is to raise issues for discussion
and highlight both the positive and negative aspects of Australia s
current emergency health response arrangements. Therefore, given
the vast and complex nature of the national health system, it is
not the intention of this paper to provide much more than a basic
analysis of the issues or to offer recommendations. Similarly,
given that health is predominantly a state/territory government
responsibility, it is important to note that while the paper
attempts to cover the major aspects of the health response to a
national emergency, which may involve all states and territories,
enquiries with state health authorities and professionals were
limited to the ACT, NSW and Victoria. This was due mainly to time
and resource constraints, and NSW and Victoria were chosen because
they are the two most populous Australian states.
Although all respondents who contributed to the research for
this paper agreed to be identified, none of the comments made by
respondents cited in the paper are attributed to specific
individuals, due to the sensitive nature of many of the issues and
the confidential basis on which some of the respondents offered
comments.
Infectious disease control has always been central to public
health in Australia so much so that concern about infectious
diseases drove the development of a national response to public
health matters, culminating in the establishment of the
Commonwealth Department of Health in 1921. This movement was
propelled by a number of factors.
In the second half of the nineteenth century, and continuing
into the early twentieth century, scientific and medical knowledge
about the origins of disease made considerable advances. Disease
and its spread were no longer believed to be due to pollution of
the air from insanitary conditions (for example, malaria was
thought to be a result of bad air ), but rather caused by bacteria.
Moreover, these living agents were found to be identifiable and
controllable.(2) As a former (and the founding)
Commonwealth Director-General of Health explained:
The current belief that disease was the result of insanitary
conditions had now become completely superseded by exact knowledge
of the true relationship of insanitary conditions to the occurrence
of disease, which, in turn, indicated the directions for rational
administrative procedure.(3)
In addition, in the early years of the twentieth century there
was a growing acceptance that the proper role of government was
more than the prevention and control of disease it was also to
promote health, both of the community and the
individual:
These advances in medical knowledge steadily induced an
ever-expanding adaptation of governmental policy to the fundamental
truth that public health as a responsibility of government could
not exclude private health the health of the individual human
unit.(4)
The movement towards federation also facilitated the emergence
of a national approach to public health. In the lead-up to
federation, one of the matters raised regularly as one for which a
national government should have the power to make laws was
quarantine.(5) The reason given was that quarantine was
essential to the health and prosperity of Australia, which this
statement from 1884 reflects: Quarantine is a means only to the end
sought: which last is the preservation of the public health in
Australasia .(6) Quarantine became one of the few
functions of government at the time for which the new Commonwealth
Parliament had power to make laws.(7)
However, it took outbreaks of disease around the country, such
as bubonic plague which ran from 1900 to 1909, to prompt the
Commonwealth Government to give legislative effect to its
Constitutional quarantine powers. After a conference of state
premiers in 1906 passed a resolution that quarantine administration
should be taken over by the Commonwealth, the Commonwealth
Government introduced a Quarantine Bill in 1907 which took effect
from 1 July 1909, as the Quarantine Act 1908 ( the Act
).(8)
The Act deals with the Commonwealth power over human, animal and
plant quarantine, section 4 of which states:
(1) In this Act, quarantine includes, but
is not limited to, measures:
(a) for, or in relation to:
(i) the examination, exclusion, detention,
observation, segregation, isolation, protection, treatment and
regulation of vessels, installations, human beings, animals, plants
or other goods or things; or
(ii) the seizure and destruction of animals,
plants, or other goods or things; or
(iii) the destruction of premises comprising
buildings or other structures when treatment of these premises is
not practicable; and
(b) having as their object the prevention or
control of the introduction, establishment or spread of diseases or
pests that will or could cause significant damage to human beings,
animals, plants, other aspects of the environment or economic
activities. (9)
Under section 51(ix) of the Constitution, the Commonwealth has
power over the states regarding quarantine. Where state and
Commonwealth laws are inconsistent, the Commonwealth law
prevails.(10) However, this principle proved less
clear-cut than its drafters probably intended. Between 1910 and
1919 a number of incidents showed that the delimitation of relative
spheres of co-existent Commonwealth and State authority must be
achieved by experience and adjustment through either repeated
conflict or mutual goodwill .(11)
For example:
- During the smallpox outbreak in Sydney in 1913, the
Commonwealth Director of Quarantine declared a quarantine area
within a 15 mile radius of Sydney. New South Wales protested
strongly, arguing the move hurt commerce, but it did comply with
conditions for lifting the quarantine ban after 18 months;
- Before an amendment to the Act in 1912 the Commonwealth did not
have the power to act in response to a number of diseases, such as
a measles epidemic aboard a ship. The states had the power, but no
resources, to take quarantine measures;
- Emergency internal quarantine measures taken by the
Commonwealth during the influenza pandemic of 1918 19 were accepted
by the states. But when the first cases appeared in Sydney and
Melbourne, the states imposed their own internal quarantine
restrictions by closing state borders. The abject failure of these
measures (no state escaped infection) saw the states once again
cede control over quarantine to the Commonwealth.(12)
(See Box 1 for further detail on the 1918 19 pandemic).
In 1920 the Act was amended to address these constitutional and
administrative problems. Section 2A(3) was inserted to give the
Commonwealth power to override state legislation by proclamation in
an emergency.(13)
The epidemic scares, combined with concerns about diseases
imported by soldiers returning from World War I and burgeoning
ideas about state planning and intervention, created impetus for
further centralisation of health responsibilities:
Medical and population policy as the means to
national renewal dominated thinking amongst public health doctors
and a wide section of the medical profession. Stimulated by wartime
experiments in medical control, this new public health lobby urged
that the power of the state be harnessed to the wider project of
health education and preventive medicine.(14)
[T]he growth of the Department has been an orderly
process in response to the growth of scientific knowledge, to
urgent national needs arising from recurrent national emergencies,
and to more intelligent and exacting demands by the public as a
natural result of the rapid development of educated public
opinion.(15)
At a Premiers Conference in 1919, the acting Prime Minister, W.
A. Watt, proposed that the states consider either transferring
powers over health to the Commonwealth or accepting Commonwealth
co-ordination. Watt asked the premiers to consider the following
arrangements:
A system in which the Commonwealth Department of
Public Health would, in addition to its quarantine functions,
concern itself with the investigation of causes of disease and
death, methods of prevention of disease, the collection of sanitary
data, the education of the public in matters of public health. In
addition to this, the Commonwealth Government would subsidize any
well directed effort made by any State towards the eradication or
control of any disease; conduct campaigns of prevention on which
more than one State is interested, and generally as is done in the
United States of America inspire and co-ordinate public health
measures generally without infringement or transfer of sovereign
powers to the States.(16)
The influenza debacle of 1919 was not sufficient to secure the
states agreement to the proposal. The issue was settled only after
public support of the proposal by the British Medical Council in
Australia and the Australian Medical Congress in 1919 and 1920
respectively, and an offer of funding from the International Health
Board of the Rockefeller Foundation.(17) The Government
accepted the offer and on 3 March 1921, the Commonwealth
Gazette announced the new Department of
Health.(18)
The central function of the new department was not to operate as
a national public health service per se, but rather to
focus on quarantine matters.(19) These included
administration of the Act, establishment and control of
laboratories for the investigation of disease, conducting campaigns
for prevention of disease, and control of sanitary
data.(20)
Increasing Commonwealth involvement in public health was
propelled by its interest in controlling infectious disease (and in
regulating the entry of immigrants who might be carrying disease),
although its expansionary moves waned somewhat following World War
II.(21) Commonwealth measures in this regard expanded in
response to new knowledge and practices in medicine and government
and specific issues and emergencies, such as disease outbreaks. For
their part, the states accepted or rebelled against encroaching
Commonwealth powers usually according to the level of crisis each
faced.
The Commonwealth today retains a strong interest in infectious
disease, even as its interest and involvement in public health has
broadened well beyond this issue. As many of the respondents
interviewed for this paper highlighted, the historical tensions
between the Commonwealth and states continue with regard to
responsibility for infectious disease, as does the Commonwealth s
expansionary impulse in response to what it perceives as national
security issues in health.
Despite the Constitutional limitations on its power over public
health matters, the Commonwealth today is a significant player.
This is partly by virtue of the funding it provides to the states
through health agreements and other arrangements, and the
accountability these entail. In the area of disease surveillance
and control, however, the Commonwealth plays an increasingly
hands-on role against a national security backdrop.
This renewed activism in infectious disease control has only
developed in the last decade, after a period of complacency about
Australia s vulnerability to communicable diseases.(22)
One respondent claimed that as recently as the late 1990s, the
predominant thinking in the Commonwealth Government was that
Australia was free from communicable diseases, with the Government
pointing to successes such as the global eradication of smallpox
and the ongoing campaign to eliminate polio. Indeed, the Department
of Prime Minister and Cabinet s (PM&C) 1977 review of
quarantine arrangements concluded that, the disease threat to
people has reduced to almost insignificant proportions,
notwithstanding enormous increases in personal mobility since World
War II .(23) The Nairn Review of quarantine in 1996 also
noted a long-standing disinterest in human
quarantine.(24) The 1977 PM&C review did, however,
recommend that the Commonwealth establish access to infectious
disease facilities in state hospitals in the event of an outbreak
of diseases not yet known .
Indeed, it has been new or re-emerging public health threats
such as HIV/AIDS, multi-drug resistant tuberculosis, hepatitis C,
Severe Acute Respiratory Syndrome (SARS), and more recently, avian
flu, which have all since helped precipitate renewed national
action.(25) See Box 1 below for a summary of the threat
posed to Australia by the recent outbreak of avian flu in Asia and
Australia s response to it.
Box 1: Australia and the avian flu
Although avian flu viruses usually only cause mild symptoms in
wild birds, some (most notably the H5 and H7 strains) cause
widespread, highly contagious and fatal disease (referred to as
highly pathogenic avian influenza (HPAI), or avian flu ) in
domestic poultry. It was the H5N1 which recently swept across much
of Asia. Human infection with H5N1 was first noted in Hong Kong in
1997. Pigs are also susceptible to both avian and human flu
viruses. If avian flu and human flu were to mix in an infected pig
or person to create a new flu virus to which people have no
immunity, and human-to-human transmission occurred, a human flu
pandemic could occur.
The most infamous pandemic was the Spanish Flu of 1918 19, which
is estimated to have killed 40 50 million people worldwide,
including 11 500 in Australia, in an age before mass
commercial air travel. Although a different strain from the recent
outbreak of avian flu, it is also thought to have originated in
birds. According to figures in the Commonwealth Government document
A Framework for an Australian Influenza Pandemic
Plan (June 1999), if Australia was struck by a flu pandemic
today like the Spanish Flu, it could expect at least 42 000
deaths per year, representing a 30 per cent increase in overall
mortality rates.
A significant outbreak of the current avian
flu in Australia could threaten the agricultural industry
(particularly poultry meat and eggs), trade, tourism and the
economy generally. It would result in significant loss of income
for operators and could lead to job losses on farms and in related
industries. There are costs associated with every aspect of an
outbreak loss of revenue, dealing with the disease, compensating
farmers and re-establishing markets. In Australia at least, the
costs associated with an outbreak of avian flu in poultry (without
human infections), would be shared equally by government and
industry under the pre-existing Emergency Animal Diseases Response
Agreement. A total of five outbreaks of HPAI (due to H7 viruses)
have occurred in Australia, with the last occurring in NSW in 1997.
Each outbreak was quickly eradicated, but in each case, there was
evidence of contact between the farmed poultry and waterfowl.
Sampling of wild birds for avian flu is part
of the Australian Quarantine and Inspection Service s (AQIS)
disease surveillance programs, and surveys have confirmed various
strains of avian flu do circulate among wild birds. Australia s
strict farm biosecurity aims to prevent contact between commercial
poultry and wild birds by protecting feed and water supplies,
limiting entry to farms, and physically isolating the poultry. The
Australian Veterinary Emergency Plan (AUSVETPLAN) deals with a
variety of animal health crises, including avian flu. The section
on HPAI provides detailed information on mounting a response to any
outbreak of the disease. Although it notes that the risk of a major
HPAI outbreak in Australia remains low due to the strength of the
biosecurity provisions in the poultry industry, AQIS conducted 100
per cent baggage screening with passengers arriving from Asia, and
seized all poultry products such as meat, eggs and feathers.
International mail was also screened and poultry from ships stores
confiscated. Even under normal circumstances, Australia does not
import live poultry, eggs or raw poultry products, and any cooked
product must be cooked well enough to kill the flu and other
viruses before it is imported.
Although the recent HPAI outbreak affected
some of Australia s nearest neighbours, and the threat to Australia
was considered high, the actual risk of it spreading to Australia
while it predominantly affected only birds appeared to be low. The
consensus seems to be that Australia s strict farm biosecurity
measures, routine disease surveillance and increased quarantine
screening should act together to substantially mitigate the
risk.
(Adapted from Nigel Brew, Avian
Influenza is Australia a Sitting Duck? , Research Note No.
40, Parliamentary Library, 2003 2004)
|
However, various problems with the current national arrangements
for preventing and controlling infectious disease in Australia are
mentioned in the academic literature and were identified by many of
the respondents interviewed for this paper.
National preparedness for an infectious disease outbreak begins
with the development of policies and strategies. At the national
level, these are formulated in a number of agencies and with the
input of various experts (see Box 2 below).
Box 2: National-level bodies involved in outbreak response
- Commonwealth Chief Medical
Officer (CMO). The CMO provides support to the Minister
and the Department of Health and Ageing across the full range of
professional health issues, including health and medical research,
public health, medical workforce, quality of care, evidence-based
medicine and an outcomes-focused health system. The CMO does not
have an executive or operational role in relation to managing
health issues, and contrary to how the role is sometimes
understood, the Office does not appear to be entirely independent
from the Commonwealth Government. Several respondents had the
impression that the CMO is expected to support government policy
the CMO himself said in evidence to the Senate Standing Committee
on Community Affairs on 3 June 2004, when questioned about the
decision to purchase a particular anti-viral drug for Australia s
National Medicines Stockpile: I will have to seek some technical
advice as to who makes decisions. I do not think CMOs make any
decisions (p. 54).
- Australian Health Disaster Management
Policy Committee (AHD MPC). This high level
inter-jurisdictional committee was formed in the wake of the Bali
bombing to help improve national health disaster preparedness. Its
membership includes a senior health official from each Australian
state and territory and experts in public health, mental health,
and clinical and emergency care. The Australian Defence Force,
Emergency Management Australia and a senior health officer from New
Zealand are also members of the Committee.
- Communicable Diseases
Australia. As a branch of the Department of Health
and Ageing, it coordinates the national surveillance of notifiable
and other communicable diseases, manages and liaises with specific
communicable disease surveillance programs and fosters
collaboration on national strategies to improve communicable
disease surveillance.
- Emergency Management
Australia (EMA). Although primary responsibility
for the protection of life, property and the environment rests with
the states and territories, EMA provides Commonwealth Government
support to develop the states capacity to deal with emergencies and
disasters. EMA also provides physical assistance when the
states/territories cannot reasonably cope during an emergency.
- Communicable Diseases Network
Australia (CDNA). The CDNA provides national
public health leadership and co-ordination on communicable disease
surveillance, prevention and control. It offers strategic advice to
governments and other key bodies on public health measures to
minimise the impact of communicable diseases in Australia and the
region. The CDNA also oversees the National Communicable Diseases
Surveillance Strategy, which aims to develop the infrastructure and
systems for effective national surveillance, preparedness and
responses to communicable disease risks.
- National Influenza Pandemic Action
Committee (NIPAC). NIPAC was formed in 2003 to plan for
pandemics and monitor avian influenza. NIPAC s plans address,
amongst other things, border protection, immunisation, anti-viral
agents, laboratory diagnosis, respiratory hygiene, communication
with the public, and infection control measures to limit the spread
of the disease.
|
The respondents interviewed for this paper consistently raised
two main issues with regard to the national arrangements for
responding to an infectious disease outbreak, both of which are
also reflected in the literature. The first issue is the
overlapping Commonwealth state responsibilities for different
aspects of health a broad issue which regularly kindles heated
debate.(26) Communicable disease control is no
exception, particularly in the wake of SARS, avian flu and the
perceived increased threat of bioterrorism, although it does not
always attract the same degree of public debate as other aspects of
health policy. The second issue is the division in involvement and
function between public health practitioners and health
policy-makers.
The relationship between the Commonwealth Health
Department and the State organizations is increasingly good,
although some elements of suspicion persist. Co-ordination could be
better if we had a greater community of interest: we can all admit
that co-ordination will be better when we recognize that the cause
we are serving is greater than our personal interests.
(27)
Commonwealth
Director-General of Health, 1925
All respondents noted that the Commonwealth had increased its
involvement in public health in the last few years after
effectively leaving responsibility for it to the states for
decades. Not all respondents see this as a favourable development,
although as some of them suggest, some aspects of Commonwealth
involvement are more about divisions between practitioners and
bureaucrats than Commonwealth state relations per se.
According to some respondents, the invention of new Commonwealth
structures in the wake of terrorist attacks, SARS and avian flu
(such as the Australian Health Disaster Management Policy
Committee: AHD MPC) has added to an already heavy public health
bureaucracy dealing with infectious diseases.(28)
Respondents were also concerned about duplication of effort, noting
new Commonwealth involvement but no decrease in state involvement.
The existence and alleged overlap of numerous committees and
working groups was described by one respondent as messy and as a
shambles by another.(29)
Such comments reflect an element of distrust between the states
and the Commonwealth (or, perhaps more accurately, the distrust
which the states have towards the Commonwealth). Neither side
appears to wholly trust the other s motives. States see a federal
grab for control over what remains essentially a state
responsibility, while from the perspective of the federal
bureaucracy s new can-do attitude to infectious diseases, the
states are stubbornly resisting ceding power. This was described by
one respondent as a tug-of-war between the Commonwealth and
states.
Nevertheless, several respondents (including some at state
level) acknowledged that the new Commonwealth activity in
infectious disease has brought benefits. For example, measures
announced in the 2004 05 Federal Budget included $40.2 million for
initiatives to strengthen national health security, preparedness
and response capability in the event of a terrorist attack or a
national health emergency.(30) The bringing together of
expert groups, facilitated by the Commonwealth in recent years was
also seen as a positive step towards greater and more effective
collaboration.
Furthermore, despite the concerns expressed above, most
respondents believe that the system retains its decentralised
essence and works well. Advice and goodwill (from other states or
the Commonwealth) are said to be available when needed, and health
resources are reportedly infinite if the case is properly made.
Despite underlying tensions, Commonwealth state relations were
described as quite cordial in practice. Most respondents were
confident that in the event of a national infectious disease
emergency, the system would work . The response to SARS was often
cited as an example of Commonwealth state co-operation and
goodwill. It was also noted as an example of where duplication in
structures is not necessarily wasted effort.
All respondents considered state-state relations and
communication to be excellent, and it was claimed that help
required in any jurisdiction would be quickly forthcoming (the
Canberra bushfires in 2003 were mentioned as an example). It
appears that due to the first-response role of the states, the link
between public health practitioners and state governments is
generally much stronger than that between practitioners and the
Commonwealth Government.
The Commonwealth doesn t make enough use of the
expertise available to it.(31)
A common refrain from many respondents was that managerialism
has had a detrimental effect on Australia s ability to plan and act
strategically for infectious disease outbreaks. Respondents used
the term managerialism in the context of the Department of Health
and Ageing governing through a deliberate division between public
health policy-makers and clinical health
professionals.(32)
These respondents argued that policy-makers with limited public
health content knowledge make decisions on critical public health
matters, with little or no consultation with experts or
practitioners in the field. Some were frustrated by recent
decisions of the Commonwealth on the distribution of resources in
public health. An example cited was the allocation of money to
infrastructure or equipment, without any real assessment of the
need for it, that could have been spent more usefully. Staff and
training were both frequently suggested as the two areas in need of
more funding.
Another source of frustration was the Communicable Diseases
Network Australia. Whilst it was acknowledged as an important asset
in Australia s disease monitoring system, some respondents felt it
is not always well connected to strategic policy-making on
communicable diseases. Comments by respondents suggest that part of
the reason for this appears to be the Commonwealth s tendency in
the last two to three years to maintain a tight policy grip on
health matters deemed to be also matters of national security,
which, it is claimed, often sidelines practitioners and other
experts in the process.
Although most respondents felt that the introduction of a
security consciousness into health policy and planning was
generally beneficial, mainly because it gave health issues a little
more weight , many were critical of the way in which this had been
implemented. Some commented that the securitisation of health had
become a barrier to proper planning and that there was a reluctance
by police and intelligence agencies to accept or share planning
with any other professional who was not a spook . A number of
respondents noted that this lack of integration has given rise to a
strong sense of distrust and suspicion, to the extent that medical
experts are ironically becoming further removed from aspects of
public health planning at a time when, it could be argued, they are
needed most. As one respondent pointed out, addressing the threat
of bioterrorism, for example, is clearly a national security issue,
but one to which medical experts have a clear contribution to
make.
It is important to note, however, that some respondents felt
that in some areas content people are beginning to provide
strategic leadership. For example, one person commented that the
AHD MPC is helping to connect health experts more closely with
executive decisions, but felt that there is a long way to go .
Change is generally felt to be slow and there is a sense that top
levels of the Commonwealth bureaucracy are resistant to allowing
such experts to have more influence.
A number of reasons were suggested for this resistance, both by
the practitioners and the policy-makers among the respondents
interviewed for this paper. Policy-makers seem to view
practitioners as having too many vested interests, such as a narrow
focus on obtaining research funding or extravagant new equipment.
Practitioners are also accused of having a poor understanding of
the process by which policy is developed and implemented,
particularly on Commonwealth issues. Policy-makers, on the other
hand, are seen by practitioners as being driven more by politics
and bureaucratic goals than by genuine concern for good public
health outcomes. As one respondent said, you end up with
non-sensible decisions made for political purposes .
This historical mutual distrust is being fuelled currently by an
environment in which health has become a national security issue.
Medical experts feel they have been further sidelined and not
trusted with sensitive security planning. One respondent described
a chasm that exists between content/expert knowledge and
management/strategic planning. The concern amongst many respondents
is that an infectious disease outbreak is likely to quickly become
a political issue, where bureaucrats micro-manage what is
essentially a public health matter one with which health
professionals are better positioned to deal.
It is clear that the policy-practitioner divide is overlaid by
Commonwealth-state tensions, particularly in the area of health
funding. However, it was evident from comments by respondents that
all parties feel that relations are cordial in practice. Perhaps
more importantly, despite the ongoing bureaucratic tensions, the
broad feeling amongst respondents is that in the event of an
infectious disease outbreak, the application of the
Commonwealth-state structures would result in an adequate practical
response.
A number of respondents commented on the desirability of
Australia establishing a body equivalent to the US Centers for
Disease Control and Prevention (CDC). It was argued that while
Australia has expertise in disease control, this expertise is too
diffuse, spread as it is amongst a multitude of working groups and
committees. An Australian equivalent of the CDC might, for example,
through better resourcing, improve the ability of health
professionals around Australia to identify a new virus.
However, other respondents rejected this idea, partly because
Australia may not have the physical and human resources required to
equip and staff such a centre. Some also felt that, whereas the CDC
was established with the public health agenda of fighting
communicable diseases (although its mission was later broadened to
preventive health generally), the establishment of a similar body
in Australia would probably be driven more by political goals, than
by a genuine belief that public health would benefit. For example,
an Australian body might be used to make it appear that
Commonwealth state problems of co-ordination and responsibility for
infectious disease were being resolved.
Most respondents agreed that Australia should practise an
all-hazards approach in dealing with any infectious disease
outbreak that is, emergency procedures should be the same
regardless of the source or nature of the crisis. Emergency
Management Australia generally takes an all-hazards approach in its
planning, but such an approach does not appear to be universally
accepted or practised.
Many respondents noted that existing emergency plans are
stove-piped that is, separate plans exist for a response to a
terrorist attack, fire, flood, influenza pandemic and so on. One
respondent described this delineation as man as terrorist versus
nature as terrorist , and another believed that in terms of dealing
with terrorism, governments would do well to consider that
terrorism is just another disaster . Overall, the all-hazards
approach was felt to be stronger in rhetoric than in practice.
According to some respondents, this was not due to poor
implementation, but to resistance in some areas to such an
approach, especially in health bureaucracies and amongst the
medical community. The reason for this resistance is not entirely
clear, but may stem from an underlying perception that terrorism is
not just simply another disaster , and is somehow qualitatively
different perhaps because a terrorist attack would be likely to be
a far more political and emotive issue than other disasters.
Re-emerging and new infectious diseases have
caught governments by surprise (33)
The World Health Organization (WHO) defines surveillance as the
continuing scrutiny of all aspects of the occurrence and spread of
disease that are pertinent to effective control . It is
characterised by methods distinguished by their practicability,
uniformity, and frequently by their rapidity, rather than complete
accuracy .(34) In other words, while surveillance is
central and essential to infectious disease control, the protection
it offers is not foolproof. Effective surveillance relies on a
combination of laboratory-based diagnoses, timely reporting systems
(including from general practitioners and emergency departments)
and the human capacity to analyse and interpret data.
The SARS outbreak has highlighted the importance
of border protection measures against the transmission of disease
as an essential first line of defence.(35)
In some ways Australia s surveillance systems begin beyond its
borders. Identifying diseases before they reach Australia is
perhaps the best strategy for keeping 
them out of the country.
That is, Australia s health security is dependent on its continued
involvement in international surveillance networks, such as the WHO
Global Influenza Surveillance Network, and good security in the
region Australia s avoidance of SARS and avian flu are good
examples.(36) However, it was suggested by several
respondents that Australia is too introspective when it comes to
disease prevention and control in the region. This is partly
because of new and re-emerging disease threats, but also because
many Asian and Pacific neighbours need more help with their disease
control systems.(37) Many regional countries, for
example, do not have anti-virals and vaccines. One respondent
argued that, just as Australia is taking a proactive role in
preventing the political and economic collapse of near neighbours
such as PNG and Nauru, Australia should take greater responsibility
for influenza pandemic preparedness in the immediate region.
Surveillance at the border is the next step in Australia s
preparedness. Health surveillance at the border has long been a
small but effective permanent presence which is boosted as needed,
such as during the SARS outbreak.(38) Most respondents
felt that Australia managed this aspect very well:
Australia s capacity to protect its population at
the border is as good, if not better, as anywhere
else.(39)
The term border in this context was taken to mean controlled
entry points rather than Australia s largely unprotected
36 000 km of coastline. Australia s internal surveillance
arrangements attracted more criticism from respondents, as well as
in the literature.
We re in reasonable shape to spot an [infectious]
agent and respond to it.(40)
National co-ordination of surveillance activities occurs through
the Communicable Diseases Network Australia (CDNA). Established in
1989, its membership includes Commonwealth and state government
representatives, representatives from other countries in the region
as observers, members of key organisations in the communicable
diseases field and others with relevant expertise. Members convene
fortnightly to exchange information about communicable diseases in
Australia and the region. See Box 3 for a summary of communicable
disease surveillance activities co-ordinated by the CDNA.
Box 3: Communicable disease surveillance
- National Notifiable Disease Surveillance
System. Established in 1990 under the auspices of the
Communicable Diseases Network Australia (CDNA), the system
coordinates the national surveillance of more than 50 communicable
diseases or disease groups endorsed by the CDNA. Public health
legislation requires that notifiable diseases are reported to
health agencies within each state or territory. Computerised,
de-identified unit records of notifications are also supplied to
the Australian Government Department of Health and Ageing for
collation, analysis and reporting. This allows for the detection of
national trends, outbreaks of diseases crossing borders and enables
co-operative national action.
- National Influenza Surveillance
Scheme. This is based on several schemes collecting a
range of data that can be used to measure influenza activity. The
schemes include:
-
- laboratory-confirmed influenza, which is a notifiable disease
in all Australian states and territories, reported through the
National Notifiable Diseases Surveillance System,
- sentinel general practitioner schemes that report incidents of
influenza-type illness, and
- the Virology and Serology Laboratory Reporting Scheme
laboratory reports of influenza diagnoses.
- Public Health Laboratory
Network. The PHLN was established to complement the
Communicable Diseases Network Australia (CDNA) and consists of a
collaborative group of laboratory representatives. The Network
provides strategic advice and shares expertise nationally to
enhance the capacity for the laboratory-based detection and
surveillance of communicable diseases in Australia.
|
Most respondents agreed that Australia s current surveillance
networks are sufficiently robust to deal with routine and some
emerging infectious diseases, due to a combination of factors, one
of the most important of which was referred to as rumour
surveillance . This was described as the often informal personal
networks through which current information is exchanged between
professionals. According to many respondents, these networks are a
real strength of the day-to-day functioning of the overall
system.
Such networks form the basis of a system of decentralised
assistance, where states ask for and offer advice and resources to
each other when needed without the Commonwealth acting as mediator
or co-ordinator. A common refrain was that the system comprises a
lot of goodwill and expertise . In other words, the success of
Australia s infectious disease control system is felt to be largely
due to unofficial networks, decentralised assistance and personal
contacts between agencies.
It was clear, however, from repeated comments that this reliance
on informal arrangements is also a weakness. Respondents felt that
it reflects the lack of workable structures through which states
can communicate with each other and with the Commonwealth.
Respondents appeared less convinced that Australia s surveillance
networks would be sufficiently robust to handle a major infectious
disease crisis.
Lack of timely reporting was identified as a serious problem by
several respondents. One respondent claimed that official
notification of the SARS outbreak took six weeks to reach general
practitioners in some states. This is a long delay when health
authorities are attempting to control a serious disease outbreak.
It was also claimed that the time taken for reports to pass from
local hospitals or other health care facilities, to state health
departments and on to the Commonwealth means that a cross-border
outbreak (with the potential to become a national health emergency)
could potentially take weeks to identify. Although this was
believed to be partially mitigated by the fact that alerts about
unusual diseases or symptoms would pass quickly through informal
channels, there was, however, a strong view that detection and
reporting mechanisms need to be more streamlined.
Another aspect of Australia s surveillance network that
attracted some criticism is laboratory capacity. It was felt that
there are not enough laboratories around Australia to be useful in
the rapid identification of a disease, and many are not equipped to
detect SARS, one of the latest threats to public
health.(41)
However, even with better facilities, many of our respondents
commented that outbreaks are unlikely to be detected in a
laboratory. Clinicians, such as doctors and nurses, are more likely
to raise the alarm about a new infection, and laboratories would
then be used to confirm the case. In other words, few respondents
felt that routine reporting through current surveillance systems
was sufficient for early detection of a disease outbreak, whether
it is naturally-occurring or deliberately introduced.
Outbreaks are not detected in labs, but by
clinicians in the field noticing something different or
odd.(43)
Syndromic, or real-time, surveillance differs from the
surveillance systems described above in that it involves collecting
and analysing data on symptoms and other indicators of health (such
as fever or cough), rather than relying on particular disease
diagnoses. Syndromic surveillance aims to identify in real-time
abnormal occurrences of groups of symptoms and signs, and to alert
health authorities well before an individual clinician could
identify an evolving event. For this reason, syndromic surveillance
aims to detect outbreaks earlier than traditional disease
surveillance systems. (44)
The threat of bioterrorism has fuelled interest in developing
syndromic surveillance systems.(45) Given that
bioterrorist agents such as anthrax, plague and smallpox can result
in initial flu-like symptoms, a sudden increase in reports of
headache, fever or muscle pain could indicate a bioterrorist
attack.(46) However, the problem for any detection
system is that such symptoms could also simply indicate the onset
of normal seasonal influenza.
It is clear that views differ on the usefulness of real-time
disease surveillance systems. Some respondents argued that because
such systems expand the range and volume of data that can be
collected, they increase the chances of identifying and managing
disease outbreaks when they occur (see Box 4 below for a
description of a NSW trial).
Box 4: NSW biosurveillance system
The NSW Department of Health is developing a biosurveillance
system which aims to produce near real-time public health
surveillance . Currently being trialled in hospital emergency
departments, the system uses a combination of specific diagnoses
from individual cases and categories based on symptoms. Captured
data includes age, sex, time and date of arrival in the emergency
department, and country of origin.
Triage entries are accessible to users of the NSW Health
database. Data messages are instantly transmitted from emergency
departments to the surveillance database. Human communication
protocols are also in place for updating the national Communicable
Diseases Network Australia (CDNA), allowing any communicable
disease issues to be followed up at a national level if
necessary.
Limitations of the system, according to those working closely
with it, include the fact that reliance on hospital emergency
department data means that only conditions related to the clinical
case are recorded. Emergency department data needs to be enhanced
with other hospital data, such as pathology, ambulance and absentee
data from schools and the workforce to provide a fuller
picture.
Significantly, the system is not built to distinguish between
natural and intentional outbreaks of disease. However, the NSW
system is currently designed to provide both early warning of
outbreaks and to monitor the progress of an outbreak once it is
recognised.
|
Others argued that even the best real-time surveillance system
still needs human skill to read and interpret the data once it is
collected, so Australia s disease prevention systems need more
human resources rather than technological advances to boost their
capacities. Several people pointed to US trials of such systems,
which highlighted the need to boost staff numbers and training to
deal with the volume of information produced by the automated
collection system. In New York City, for example, real-time
surveillance did not detect anthrax cases that clinicians reported
informally from the community.(47)
A RAND Corporation study agrees:
No matter how well a syndromic surveillance system
performs, its benefits ultimately depend on how effectively it is
integrated into the broader public health system. Syndromic
surveillance only sets off alarms. A process for investigating such
alarms and responding effectively must be in place beforehand.
(48)
Another US study of the cost-effectiveness of syndromic
surveillance makes a similar point:
The optimal approach to using the establishment of
syndromic surveillance to strengthen the state and local public
health infrastructure would be permanently to increase state and
local funding to hire and equip well-trained public health
professionals (e.g. epidemiologists, biostatisticians, programmers,
etc.) working in these agencies to establish, conduct, and analyse
the results of the surveillance However with most cities, counties,
and states facing budget deficits, it is hiring freezes,
elimination of unfilled positions, and reductions in staffing that
are the order of the day, not the hiring of new staff into locally
funded permanent positions.(49)
It was also argued that syndromic surveillance needs laboratory
support to identify influenza types and to differentiate normal
seasonal influenza from exotic (and potentially dangerous) variants
like the one associated with the recent avian flu outbreak. As
noted above, the belief is widespread that Australia lacks capacity
in this regard.
Real-time data is also of limited use when some hospitals,
including major hospitals in capital cities such as Canberra, do
not have the resources to conduct a test for viruses such as SARS.
Samples are typically sent interstate with a minimum 2 3 day
turn-around. Several respondents suggested that Australia needs a
number of adequately-resourced and staffed laboratories throughout
the country equipped to test for viruses such as SARS.
These points are echoed in the findings of a recent assessment
of a New York City syndromic surveillance system:
Syndromic surveillance systems are essentially
smoke detectors and call for prompt investigation and response if
they are to provide early warning of outbreaks. Syndromic
surveillance should be viewed as an adjunct to, not a replacement
of, traditional disease surveillance.(50)
Better use of information technology, such as through real-time
computerised systems, may help the response to some diseases, but
not necessarily all. This is partly because public health
surveillance relies heavily on investigations, which means that,
while data and electronic surveillance are helpful, interviews and
investigations are of more value from an epidemiological
perspective. Clinicians, hospitals and public health professionals
are the main vehicles for this. As much as electronic data and
equipment are useful, most respondents felt that more people are
needed on the ground .
Another possible limitation of the usefulness of syndromic-type
systems is the extent to which they assist health departments to
respond to a report suggesting an outbreak. As one study notes:
it is difficult to envision a health department
taking any substantive action, such as distributing prophylactic
anti-microbial agents, vaccination, imposing quarantine, or even
issuing an alert to the public, based solely on an increased number
of clinical illnesses.(51)
None of this is to argue that development of syndromic systems
should be abandoned. They are an important public health resource.
As the comment below suggests, even if syndromic data does not
necessarily improve the chances of identifying and fully
controlling an outbreak, once detected, the data helps to trace the
epidemiology of the outbreak and track its progress. It could also
be used to assess the effectiveness of prevention and control
measures.(52)
Even if bioterrorism is first detected by an
astute clinician, syndromic surveillance can help delineate the
size, location, and tempo of the epidemic or provide reassurance
that a large outbreak is not occurring when a single case or a
small, localized cluster of an unusual illness is
detected.(53)
Part of the problem is that we are trying to
imagine that which is beyond the imagination of most
Australians.(54)
The ability of hospitals to deal with a sudden influx of
multiple casualties, often referred to as a surge capacity , is a
critical part of the response to a major incident. Most of the
respondents interviewed for this paper expressed serious doubts
about the ability of any hospital to deal with such a crisis, with
many noting in particular the lack of sufficient intensive care
facilities. Several respondents also expressed concern that
workforce issues were not given enough consideration in devising
emergency plans for dealing with multiple casualties, particularly
if those casualties are the victims of an infectious disease
outbreak. Other research suggests that many of Australia s
hospitals are underprepared for dealing with mass casualty
incidents or are only now beginning to address the issue.
Just how extensive a surge capacity the health
sector has, or may need, to deal with the consequences of a major
terrorist attack here in Australia is under active consideration at
the moment.(55)
Professor Richard Smallwood, Chief
Medical Officer (Commonwealth) November 2002
During the worldwide outbreak of SARS in mid-2003, an Australian
professor of emergency medicine working in Hong Kong, Dr Peter
Cameron, claimed that Australia s health care system lacked
sufficient intensive care unit (ICU) beds, ventilators and trained
staff to adequately deal with an outbreak such as SARS. He claimed
that the biggest concern was the acute lack of ICU beds, and that
if there were just 200 cases of a disease such as SARS in Sydney or
Melbourne, 20 30 per cent of which required intensive care, there
would be little likelihood of finding 50 ICU beds at short notice
.(56) The director of the Infectious Diseases Unit and
the Department of Microbiology at Canberra Hospital, Dr Peter
Collignon, agreed that there was not much spare capacity in the
health care system, and was quoted as saying at the time that,
there is not even the planning in our hospitals to cope with the
increase in influenza cases every winter .(57) Indeed,
it has been estimated that an influenza pandemic could, within a
six to eight week period, result in up to 20 000 people
requiring hospitalisation in Victoria alone(58)
One respondent related a case in which a major public hospital
in a capital city struggled to deal with a coach-load of tourists
who presented together at the emergency department with diarrhoea.
Most of the respondents interviewed for this paper were unsurprised
by this story, commenting that most hospitals consistently
run
at near capacity and that the majority of all admissions are
emergency admissions (but not necessarily ICU admissions). A recent
performance audit conducted by the NSW Auditor-General into the
transport and treatment of emergency patients in NSW supports this
observation when it reported that on average 60 per cent of all
overnight patients admitted to an inpatient bed do so via the
emergency department .(59) The fact that most hospitals
operate at near capacity obviously leaves little flexibility or
slack in the system generally, and even less in terms of ICU
facilities. More than one respondent believed that Sydney or
Melbourne hospitals would not currently cope with a mass casualty
incident or an extensive infectious disease outbreak. It was also
claimed that most hospitals would on average only ever have one or
two ventilated ICU beds spare at any given time.
Admittedly, such problems do not appear to be unique to
Australia. In February 2004, the BBC reported that a survey of over
half of the UK s intensive care units revealed that approximately
10 per cent of doctors interviewed claimed that bed shortage had
cost lives and a further 31 per cent said that delays in finding a
bed had compromised patients health .(60)
The results of a survey conducted during 2001 02 by the
Australian and New Zealand Intensive Care Society (ANZICS) reveal
that Australia has a total of 171 hospitals with ICU facilities and
that, of those ICUs which participated in the survey (92 per cent
response rate), 65 per cent are located in capital
cities.(61) The survey also indicated that Australia has
an average of around 7.4 ICU beds per 100 000
population.(62) The following table provides some
indication of how this compares to other major industrialised
nations:(63)
Table 1:
International comparison of ICU bed numbers per 100 000
population
|
Country
|
Publication
Year
|
Number of ICU
Beds
|
|
England
|
2003(64)
|
6.3
|
|
Australia
|
2001
02
|
7.4
|
|
Germany
|
1999(65)
|
8.3
|
|
Italy
|
|
9.0
|
|
Holland
|
|
10.2
|
|
Canada (Alberta)
|
|
16.0
|
|
United States
(Massachusetts)
|
|
24.0
|
In the recently released report by the Joint Standing Committee
on Foreign Affairs, Defence and Trade titled Watching Brief on
the War on Terrorism, the Deputy Secretary of the Department
of Health and Ageing, Mary Murnane, is quoted in evidence to the
Committee describing a national audit of acute hospital beds,
ventilators, isolation beds and mortuary facilities currently being
undertaken.(66) In remarks to a June 2004 Senate
Estimates hearing on the results of this survey (the first of its
kind), Ms Murnane described Australia s capacity to respond to
incidents similar to the Bali bombing as reasonable and adequate
.(67) A month earlier, in May 2004, the current Chief
Medical Officer, Professor John Horvath, had described Australia s
emergency medical response as excellent , adding that I m not
concerned at the present time that any credible threat will not be
able to be appropriately met with our current level of preparedness
.(68)
In an apparent effort to deal with increased demand for hospital
services over winter, the NSW Government, for example, announced in
early June 2004 that it would open nearly 1000 extra beds
throughout Sydney hospitals, approximately only half of which would
be permanent. South Australia took a similar approach in
2003.(69) However, figures provided by the Australian
Private Hospital Association indicate that in the two years to
October 2003, the NSW Government closed 359 public hospital beds
(and the Victorian Government, 526 beds, the most of any State), so
the sustainability of this approach as a long-term strategy is
questionable.(70) The NSW Nurses Association was
cautious in its support for the announcement, saying that nurses
were always under pressure to open up extra
beds.(71)
This approach does not appear to have done much to ease the
problem of ambulances in Sydney being forced to ferry patients from
one emergency department to another in order to find a bed, or
queuing outside hospitals, a situation which the Health Services
Union claims occurs every winter with no long-term strategies to
prevent it.(72) The NSW Auditor-General reports that the
main cause of so-called access block , which occurred at an average
rate of 36 per cent in NSW metropolitan hospitals in the 12 months
to March 2004, is the inability to find ward beds into which
existing emergency patients can be transferred.(73) This
problem is not unique to NSW, with the ACT Government recently
moving to ease pressure on hospital emergency
departments.(74)
Simply opening additional beds as a solution to increasing bed
capacity was criticised by many of those interviewed for this paper
as short-sighted and temporary, and a number shared the concerns of
the NSW Nurses Association that permanent extra beds require an
ongoing commitment of additional, suitably qualified staff. Several
respondents emphasised that it is not so much creating bed capacity
that is the problem, but rather adequately staffing those beds.
This view is supported by the NSW Auditor-General:
increasing bed numbers necessitates an increase in
nursing staff numbers. As current shortages indicate, it would be
difficult for hospitals to find sufficient staff to provide this
many extra beds.(75)
This issue is of acute importance when planning for the creation
of extra beds in an emergency, because patients require ongoing
monitoring. Workforce issues are covered in more detail in the next
section.
She [Diana Horvath, chief executive officer of the
Central Sydney Area Health Service] confirmed Royal Prince Alfred
hospital would close about 32 elective surgery beds by merging
wards such as vascular with cardiovascular, and head and neck
cancer surgery with general cancer surgery.
But she said the beds would be reopened for
patients being admitted by the emergency department. She said the
hospital was 97 per cent full when it should be running at an 85
per cent occupancy rate.
It makes a situation where you just can't deal
with the slightest surge in demand, and we know we have a peak
during winter, she said.
We want to ensure the beds we have got can take
the emergencies rather than the electives. (76)
The standard approach to creating additional bed capacity in a
medical crisis appears to be the cancellation of elective surgery.
A 2001 report by the Australian and New Zealand Intensive Care
Society (ANZICS) evaluating the availability of intensive care
resources for influenza pandemic planning indicated that the
cancellation of elective surgery could potentially provide an extra
68 252 ICU bed days each year in addition to the total
249 306 ICU bed days reported in Australia for
1998.(77) The report also noted that just over 1400
extra ventilated beds could be created in health care facilities
around Australia if required, but warned that the effect on other
areas of the hospital system of co-opting resources had not been
assessed.(78) Significantly, in assessing the potential
requirement for ICU beds in the event of a pandemic, the report
concluded that even the most conservative estimates suggest that
the current system would be overwhelmed .(79)
Comments by respondents for this research would suggest that the
situation has not changed since 2001, and the NSW Auditor-General
has noted that the cancellation of elective surgery has become
normal practice for dealing with the 
increasing numbers of routine
emergency patients. This perhaps suggests that the value and impact
of cancelling elective surgery as an emergency measure in times of
crisis might now be somewhat diminished. While all respondents who
commented on this issue agreed that cancellation of elective
surgery is one of the quickest ways to create additional beds, it
was suggested by one respondent that the capacity for routine
elective surgery first needed to be expanded in order to create
greater potential slack in the system that could be drawn on in an
emergency. As the respondent put it, you can t cancel what you don
t have . The findings of the NSW Auditor-General s report would
seem to provide some basis for this view:
Mr Sendt [Auditor-General of NSW] found hospitals
had experienced a 23 per cent increase in attendances since 1997
and were increasingly unable to get through their booked surgery
lists. The number of people waiting more than a year for surgery
doubled in the 12 months to March 2003, and had risen by another 10
per cent since then.(80)
Another respondent suggested that in order to ensure a true
overflow capacity, each state would need to maintain two fully
equipped wards on permanent standby, sealed for emergency use only
although it was also acknowledged that this is highly impractical.
It was also noted that China built a new hospital in approximately
two weeks to deal with the increased need for beds during the SARS
outbreak in 2003. Other more practical options being examined
include adopting the Israeli approach of setting up general wards
such that they can be quickly converted to ICU wards in a crisis
and lining the walls of hospital corridors with oxygen and
electrical outlets to connect up extra patients as required.
It was suggested that much could be learnt from how Israel deals
with mass casualties, given that it experiences bombings and other
violent attacks on a fairly regular basis. The Federal Government
at least appears to recognise that surge capacity is a national
issue, requiring national coordination to address it effectively.
The Deputy Secretary of the Department of Health Ageing stated in
evidence to the Joint Standing Committee on Foreign Affairs,
Defence and Trade in March 2004 that:
Coordination is the key. You can plan for certain
incidents but, generally speaking, surge is something that requires
a national solution.(81)
One respondent suggested that bed shortages will always be a
problem because health is predominantly a state responsibility and,
because hospitals are costly to run, they are perpetually
short-staffed. It was also noted by some respondents that the
states are usually left to cope with an imposition on resources
when their hospitals are expected to enforce measures of national
significance, as was the case with SARS. This point is also made in
a recent review of SARS surveillance in Australia, which concludes
that an influenza pandemic could be expected to have a far greater
impact than SARS:
The rapid and extensive allocation of resources
required for the SARS response has also highlighted a need to
examine surge capacity at primary care, jurisdictional and national
levels. Most stakeholders needed to make a substantial and
prolonged response to SARS at the expense of other investigations,
programs and routine activities. An assessment to estimate the
impact of the response may assist in a more efficient future
response to an influenza pandemic which would most likely be far
greater in magnitude.(82)
The Alfred Hospital in Melbourne was apparently designated by
the Victorian State Government as a SARS hospital, but it was
claimed that in the absence of any back-up support for dealing with
day-to-day emergency cases, the admission of just one SARS patient
would have necessitated closure of the entire state-wide trauma
service provided by The Alfred. As it was, The Alfred did not end
up taking any SARS patients. However, despite these and other
complaints, suggestions earlier this year that the Commonwealth
Government might consider taking over responsibility for running
the public hospitals were not viewed very favourably by any of the
respondents who commented on the issue.(83)
A number of respondents pointed out that it is widely
acknowledged that very little slack currently exists in the health
system, and expressed doubts as to how successful any of the
current approaches to increasing bed capacity would be in reality.
There is the possibility too that supply actually creates demand
meaning that additional beds will always be filled and that this
might always deter governments from dramatically expanding the
numbers of hospital beds, even in emergency wards. It was noted
generally that surge capacity is a problem faced all over the
world, and with the exception perhaps of Israel, one that so far
has very few real solutions.
Several respondents commented that the staffing of hospitals and
ICU facilities in particular is an issue not given nearly enough
consideration in contingency planning. 
Indeed, the ANZICS 2001
report on influenza pandemic planning stated that in Australia at
the present time, the ability to admit patients to the ICU is
frequently constrained by inadequate number of qualified nursing
staff and claims that several studies have indicated ICU mortality
rates are higher during periods of increased workload and when
fewer trained staff are available.(84) Although
respondents saw merit in proposals to use hotels, patients homes,
community halls, and other similar places as a means of creating
additional bed capacity during a pandemic, several suggested that
such an emergency measure would be of only limited value because
there would still not be enough staff to attend to such
patients.(85)
Absenteeism would also be likely to impact significantly on the
availability of health care workers during an infectious disease
outbreak. It has been estimated that between 40 70 per cent of the
workforce might not be able to attend work due to illness during an
influenza pandemic.(86) This does not account for the
people who may choose to stay at home to avoid infection in the
first place. One respondent suggested that despite the likelihood
that health care workers would receive vaccinations and other
prophylactic treatments as a priority, perhaps up to 50 per cent of
medical staff may not turn up for work due to the higher risk of
exposure they potentially face. Some respondents questioned their
own willingness to attend for work if there was an outbreak of a
deadly infectious disease, commenting to the effect that doctors
have families too. Indeed, it has been reported that a group of
thirty Canadian nurses who contracted SARS during the global
outbreak in 2003 are suing the Ontario Government for failing to
implement and enforce adequate workplace safety
measures.(87)
Some respondents also claimed that few current disaster plans
adequately account for hospital staffing issues. Indeed, a review
of The Canberra Hospital s response to the January 2003 Canberra
bushfires one of the largest responses to a disaster ever by a
single Australian hospital noted that many staff were unable to
attend work because of fire in or around their homes and that:
The fires occurred during school holidays and the
hospital s medical changeover period, when junior staff move to new
positions, often interstate. Many regular staff were out of the
city, and many of the previous year s staff had already
left.(88)
Despite this, the review notes that the emergency department s
workforce was sufficiently boosted with the assistance of staff
from other areas of the hospital and that overall, medical outcomes
were excellent, and the hospital system coped well .(89)
Although the emergency department dealt with 252 presentations in a
single day (139 of them in six hours) compared with a daily mean of
137 for the preceding five years, only 15 per cent of patients
required admission.(90)
Respondents also made the point that a hospital s work continues
long after the initial clean-up of an incident scene is over, and
that disaster plans generally do not consider the need for numerous
patients to stay in hospital for potentially six to eight weeks
following admission. One respondent believed that the current level
of resources means that the capacity really only exists to care for
patients for a maximum of two weeks. Other areas of concern
regarding staffing related to the difficulty of rotating limited
numbers of staff to avoid exhaustion and psychological trauma, and
the possible reluctance or inability of hospitals to accept
transfers of patients infected with a contagious deadly
disease.
One comment repeatedly made was that the real strength of
Australia s health care system lies with the experience and
commitment of the people working within it. The success of the
system was described as relying on informal networks, decentralised
assistance between regions and the maintenance of personal contacts
between agencies. It is perhaps significant that all the
respondents interviewed for this paper nominated the calibre of the
people in the system ahead of the structures in which they operate
as the primary strength of the health care system. Perhaps this
indicates a general belief that the system works despite the
bureaucratic structures in place, not because of them and that but
for the people involved, the system might not work at all. Just how
well Australia s health care system would deal with a major
infectious disease outbreak if large numbers of its staff were
unable or unwilling to work appears to be open to question.
If there were multiple outbreaks of say, smallpox,
in capital cities around Australia, we d be in
trouble.(91)
It is striking that there does not appear to have ever been a
national medical or anti-terrorist exercise aimed solely at testing
Australia s ability to respond to an infectious disease outbreak.
As many respondents noted, even the Australian Action Plan for
Pandemic Influenza has never been exercised at a national
level, leading most to agree that it is more of a health policy
document than an operational plan. Most respondents noted this
deficiency with some concern and were critical of the way in which
the Bali bombing has been held out to have been a successful test
of Australia s mass casualty preparedness. Many respondents also
deplored the lack of local exercises within individual hospitals.
Each of these issues is addressed in turn.
Although the Minister for Defence, Senator the Hon. Robert Hill,
stated in May 2004 in a speech on Australia s response to
terrorism, that we have exercised the capability of the Australian
health system to cope with attacks , the respondents interviewed
for this paper were unable to identify any such exercises conducted
by the Commonwealth at a national level.(92) They
certainly were not aware of any national exercise in which issues
such as disease surveillance, quarantine and the emergency
distribution of medication or vaccinations had been tested, which
was of great concern to those who commented on the issue.
Although a number of exercises appear to have involved testing
the management of casualties, there does not appear to have ever
been a national exercise the focus of which has been a health
crisis, particularly one which involves an infectious disease
outbreak. It has been claimed by some respondents and others that
even the largest national exercise to date, Mercury 04 , announced
and conducted with much fanfare, did little to test the emergency
health response properly:
There has been a major exercise recently Mercury 4
as I m sure you ll remember, but that involved very little of the
hospital side of things, more security and police.
That is a significant problem, the modern currency of terrorism is
in morbidity or injury and mortality or death and we really need to
look at how our hospitals can deal with that and if they can t
start planning for changes to that.(93)
Medical experts appear to be increasingly concerned that
Australia s capacity to deal with a major infectious disease
outbreak, in particular, remains largely untested.(94)
Evidence to the Joint Standing Committee on Foreign Affairs,
Defence and Trade in April 2003 indicated that New Zealand
conducted a very large exercise across the country as far back as
2001 called Operation Virex , which simulated the impact of an
aberrant influenza .(95) A number of respondents said
there was now a pressing need for a national exercise with a health
focus to be conducted in Australia.
As one respondent pointed out, national anti-terrorism exercises
typically involve a siege-hostage scenario or the investigation of
some threat of violence which is almost always successfully
resolved by police or army counter-terrorism units. However, as
Derek Woolner from the Australian Defence Studies Centre noted in
an interview in 2003, siege-hostage situations are now only about 1
per cent of terrorists worldwide .(96) The respondent
expressed concern that incidents are perhaps not properly regarded
as terrorism or treated as such unless the response calls for guns
and bullet-proof vests , and claimed that as a result, Australia s
bioterrorist response is vastly underprepared .
Exercise Fastball in Brisbane in 2003, which dealt with a mock
radiological dispersal incident, has perhaps been the only
exception at the Commonwealth level, but as one respondent
remarked, even this exercise focussed more on testing the national
security apparatus rather than the emergency health response. While
Exercise Explorer , staged in Sydney in May 2004, was
designed to focus partly on mass casualty management , it revolved
solely around the mock bombing and collapse of a building in the
CBD.(97) Similarly, Exercise Heavy Metal , which took
place in Melbourne in early September 2004, in part assessed the
emergency response to a mass casualty situation , but a rigorous
test of the emergency health response does not appear to have been
the focus of the exercise.(98)
Although some respondents believed it is potentially dangerous
to try and impose rigid, structured plans like the Australian
Action Plan for Pandemic Influenza in a dynamic public health
setting, the same respondents were also of the opinion that as a
minimum, any test of Australia s emergency health response should
rigorously test the influenza pandemic plan. As one respondent put
it, plans made in peace need to be tested in war . The respondents
also believed that the pandemic plan would be best implemented by
health professionals, rather than bureaucrats , and that the
various state plans need to be integrated more fully with the
federal plan.
In what was claimed to be the first ever test of an influenza
pandemic plan anywhere in Australia, the NSW Health Department
conducted a statewide exercise called Warning Shot in October 2003,
the first statewide disaster exercise involving all eighteen NSW
Area Health Services. The objective of the exercise was to activate
and evaluate the NSW Influenza Pandemic Action Plan and test
operational response under local Area Health Service Emergency
Plans.
Most respondents interviewed for this paper believed that there
was an overwhelming need for a multi-jurisdictional approach to
emergency health response planning 
and that the only way to
maintain vigilance and responsiveness in the health system is to
practice and rehearse emergency arrangements continually. Some
respondents were especially critical of the tendency they believed
existed to regard a one-off exercise as a sufficient test of
emergency procedures.
Despite national exercises
focussing on animal health having been conducted, such as Minotaur
, there still appear to be no plans at the Commonwealth level for
an exercise like Warning Shot which deals with a human health
emergency.(99) Emergency Management Australia (EMA) is,
however, planning to hold a pilot senior management training
programme in November 2004 which uses an influenza pandemic
scenario. This desk-top training is aimed at the Secretary/Deputy
Secretary level within the state and Commonwealth public services
and is designed to improve decision-making processes and strategic
thinking in responding to a national emergency. Those designing the
programme hope that such training might also foster the development
of closer ties between agencies so that in the event of an
emergency, those making critical decisions are not meeting and
dealing with each other for the first time.
Recent comments on the importance
of routine communication between hospitals by the visiting
director-general of Jerusalem s Hadassah Hospital, Professor Shlomo
Mor-Yosef, underscore the significance of this point:
Having spent the past three-and-a-half years
dealing with the devastation caused by Palestinian suicide bombers,
Mr Mor-Yosef told a forum at the Royal Prince Alfred Hospital in
Sydney that communication between hospitals was essential to
handling the victims of a major terror attack.
The main idea is to build communication on a daily
basis, he said.
If you don t work on (the communication) then don
t expect that when you need it, it will be there.
(100)
The training might also go some way to addressing the perception
of some of the respondents for this paper that a lack of
integration of state and federal resources is undermining Australia
s capacity to respond to an infectious disease outbreak.
Respondents frequently expressed the sentiment that as there is
only so much money to go around, state and federal health bodies
cannot afford to conduct emergency planning and exercises
independently of each other. They were also keen to point out that
despite the fact that counter-terrorism and national security
planning is a federal responsibility, the responsibility for the
initial and frontline emergency health response rests with the
states because it is the states which run the country s hospitals
and health services.
Bali
bombing
If Bali had happened on Australian soil, we d have
been in trouble.(101)
Without wishing to detract from the admirable effort by the
Australian Defence Force (ADF) and various medical authorities
across Australia in successfully evacuating and treating surviving
victims of the Bali bombing (see Box 5 for a brief summary), all
respondents who commented on the issue agreed that the Bali bombing
was not a significant or real test of Australia s ability to deal
with a mass casualty incident, and was even less of a test of
Australia s capacity to respond to an infectious disease
outbreak.
Respondents noted that whilst Australia s response was good, in
terms of the impact on the emergency health system nationally, the
scale of the incident was relatively modest and the impact on
resources short-lived and easily absorbed a rather different view
from the Federal Government s claim that the Bali bombings were the
gravest single medical crisis that Australia has ever confronted
.(102) Some respondents suggested that the response
might not be so good if hospitals were faced with hundreds or
thousands of casualties, particularly if those casualties were
infectious. The difference between the impact on resources of a
bombing and an infectious disease outbreak was succinctly explained
by Dr William Beresford, Director of Clinical Services at Royal
Perth Hospital and metropolitan hospitals services director of
disaster planning in Perth, in testimony to the Joint Standing
Committee on Foreign Affairs, Defence and Trade in April 2003:
The concern with [a] biological [incident] is that
it starts small, is imported and then spreads, and each successive
wave of outbreak puts more and more strain on the system. A
chemical or bomb explosion is a once-only: you pick up the pieces,
recover and move on; you have an end point. With biological, you
are potentially into a control situation where it remains
endemic.(103)
It was claimed by respondents that hospitals around the country
coped easily with a number of extra patients in the immediate
aftermath of the Bali bombing, but that any one hospital in
Australia would have been seriously stretched dealing with all the
casualties alone. As Dr Beresford explained to the Joint Standing
Committee:
We have planned to take up to 150 [burns victims].
We have the capability to do so. Prior to
Bali, we had nine severe burns patients. We took 32 in the space of
48 hours, and we also took another 11 over the next two weeks. We
were capable of coping with that.(104)
Box 5: Australia s emergency medical response to the Bali
bombing 12 October 2002
In what was the largest Australian aeromedical evacuation since
the Vietnam War, ADF operation Bali Assist undertook the triage,
stabilisation and evacuation of 66 critical (and mostly young)
patients suffering a variety of burn, blast and shrapnel injuries
from Bali to Darwin over a period of 21 hours in an operation
involving 34 military medical staff and five Hercules C-130
aircraft. The first C-130 arrived in Bali at 1930 hrs on 13 October
2002.
- 13 October 2002 (2230 hrs) the
first C-130 left Denpasar Airport with 15 patients, one of whom
died en route to Darwin, despite aggressive attempts at
resuscitation;
- 14 October 2002 (0430 hrs) the
second C-130 departed with 22 patients on board, two of whom were
in intensive care and another six of whom were in a serious
condition;
- 14 October 2002 (0830 hrs)
the third C-130 left for Darwin with 16 patients, closely followed
by the fourth aircraft carrying 11 patients;
- 14 October 2002 (1400 hrs) the last C-130 left
Denpasar Airport carrying all the medical personnel, two patients
and several uninjured Australians.
With the assistance of civilian medical retrieval teams, such as
the Royal Flying Doctor Service, the Royal Australian Air Force
transferred 35 patients from Darwin to four different capital
cities over a period of 16 hours on 15 October 2002. Every effort
was made to ensure that patients would be treated in their home
state and many of the military medical staff involved had been
working for an average of 34 hours straight. Significantly, it was
noted by those involved that no single agency could have conducted
the whole operation and that military and civilian personnel worked
seamlessly to meet the challenge.
(Photo and text derived
from Gregory V Hampson, Steven P Cook and Steven R Frederiksen,
Operation Bali Assist The Australian Defence Force response to the
Bali bombing, 12 October 2002 , The Medical Journal of
Australia, 177(2), 16 December 2002, pp. 620 623)
|
One respondent reasoned that the response to the Bali bombing
involved a staggered evacuation to a number of hospitals around the
country, and claimed that the Royal Darwin Hospital, which
initially received all the casualties before they were transferred,
could not have continued to cope on its own with dozens of patients
arriving and requiring treatment all at once. Indeed, although the
Royal Darwin Hospital apparently dealt in 36 hours with more
casualties than any single hospital dealt with after either 9/11 or
the Oklahoma bombing , its emergency facilities were seriously
challenged, as Dr Malcolm Johnston-Leek from the hospital s
emergency department explains:
We had 61 patients come through and at one stage
we had 18 simultaneous resuscitations going on, so the space was
just we were packed.(105)
Media reports at the time reported that patients were
transferred to hospitals in Sydney, Melbourne, Brisbane, Perth and
Adelaide.
If there were an outbreak of an infectious disease, either
naturally or as a result of a deliberate release, hospitals (and
indeed governments) in areas not yet affected might be less
inclined to accept infectious (or potentially infectious) patients
and the sharing of casualties around the country might possibly not
be so easy to achieve. As one respondent familiar with emergency
department procedures said, infectious disease only adds another
layer of complexity . This issue does not appear to have been taken
into account by the Department of Health and Ageing, if the Deputy
Secretary s comments are anything to go by. The Deputy Secretary,
Mary Murnane, explained to a Senate Estimates Committee in June
2004 that Australia s response to an incident on the scale of the
Bali bombing would require a national response , involving a
transfer of patients, expertise, resources across borders
.(106)
Commenting on the fact that the majority of emergency patients
during the 2003 Canberra bushfires arrived at hospital by private
vehicle, a review of The Canberra Hospital s response to the
disaster had this to say on the problems for hospitals posed by
biological or other contamination:
The high use of private transport during this
disaster is an important lesson for the national capital, where
exposure to chemical, biological or radiological weapons is
considered a real threat. As there appears to be no realistic
prospect of containing an exposed population, services must plan
around patients presenting by private transport and requiring
decontamination at hospitals.(107)
This comment echoes the concerns of several respondents that
Australia s ability to respond to a biological incident is both
untested and underprepared. Critical questions remain unanswered
quarantine, as the comment above alludes, could well be a
logistical nightmare. Would people submit to it and what degree of
curtailment of personal rights and freedoms would people accept
during an outbreak?(108) Would compulsory detention for
the sake of public health be viewed any differently from
imprisonment?(109) On the prospect of a biological
terrorist attack, Dr Beresford said that it scares me silly
.(110)
One of the initiatives to have
arisen out of the lessons learnt from the emergency health response
to the Bali bombing was the development of a National Burns Plan,
which was proposed by doctors in Perth. This, in turn, has led to
calls for a national trauma plan for dealing with mass
casualties.(111) It should also be noted that in May
2004, citing the fact that there were important lessons to be
learnt from the Bali bombing, the Western Australian Government
announced the formation of a Disaster Preparedness and Management
Unit, which, it was reported, would develop plans for a coordinated
health response to a chemical explosion, a biological or
radiological incident, or the outbreak of a pandemic and would be
able to assist local hospitals deal with up to 1000
casualties.(112) Western Australia s Health Minister,
the Hon. Jim McGinty, said that diseases such as SARS, avian flu
and AIDS have challenged medical knowledge and the possibility of a
human pandemic must be taken seriously we are not immune and we
have to ensure our hospital and health services are well-prepared
.(113)
The Federal Government also
announced, as part of its 2004 election platform, a promise to
commit $49.5 million towards establishing the Royal Darwin Hospital
as a National Critical Care and Trauma Response Centre to receive
and treat as many casualties as possible in the event of another
crisis in the region similar to the Bali
bombing.(114)
Central Sydney Area Health Services director Dr
Peter Kennedy said central Sydney hospitals were prepared for
tragedies like bushfires or train derailments, but not the sort of
devastation caused by a terrorist attack.(115)
The view that major hospitals in Australia s capital cities are
not adequately prepared for a terrorist attack was common amongst
the majority of respondents interviewed for this paper, and one
which is also supported by research.
In June 2002, Dr Peter Aitken, an emergency physician at The
Townsville Hospital and a Senior Lecturer at James Cook University
in Queensland, conducted a survey of 61 Australian emergency
departments to ascertain their level of disaster
preparedness.(116) The results indicate that whilst 98
per cent of emergency departments had a disaster plan, half had not
undertaken any sort of risk assessment or tested staff call-in
procedures. Furthermore, only just over half (52 per cent) of those
emergency departments surveyed had a contingency plan for dealing
with loss of power supply and had tested it.
Some 90 per cent of the emergency departments surveyed reported
holding training exercises, but the majority of those (82 per cent)
were desk-top exercises only. Approximately only 40 per cent of all
exercises conducted were triage or casualty-based . Fewer still
were conducted in real time. The factor most impacting on an
emergency department s ability to conduct exercises was the ongoing
need to maintain delivery of normal services. The next two factors
reported were lack of time and lack of staff. Nearly 90 per cent of
all emergency departments surveyed reported having no specific
funding in place for disaster preparedness and response.
The survey concluded that there was large variation in disaster
preparedness amongst emergency departments, 
but that
emergency departments in NSW/ACT and Victoria were the best
prepared. Dr Aitken noted that although the majority of emergency
departments had a reasonable level of planning , the existence of
training and exercises was limited. Dr Aitken has since conducted
an updated survey with colleagues in other states, the results of
which are due to be released later this year. Preliminary results
apparently indicate that the level of disaster preparedness in
emergency departments has not improved much in the two years since
the original survey.(117)
Several respondents interviewed for this paper reported that in
their own experience, most hospitals had rarely, if ever, conducted
disaster response exercises involving mass casualties. The main
reason for this, they claimed, was that hospital administrators and
health authorities believed the exercises to be too disruptive . As
one respondent said, exercises are warranted, but you can t do them
all the time. Reflecting the apparent view that mass casualty
exercises are too disruptive, the current Chief Medical Officer,
Professor John Horvath has said:
I know there s a debate out there that maybe we
should do an exercise that involves 2000 potentials, but that means
closing down hospitals, that means stopping elective surgery for
periods of time and seriously disrupting the normal working of our
health system.(118)
Most of the respondents interviewed for this paper were of the
view that adequately testing the emergency health response
justified some degree of temporary disruption to services. The
Canberra Hospital, for example, conducted a desk-top exercise of
its regularly reviewed external disaster plan just two months
before the 2003 Canberra bushfires, but it was only the response to
the actual fires that revealed practical problems with the
plan.(119) The inability or reluctance of hospitals to
conduct full practical training has also been highlighted publicly
by others in the field, with one Sydney emergency doctor pointing
out that although most emergency department staff are encouraged to
undertake the three-day Major Incident Medical Management and
Support Course (MIMMS), the course is sometimes compressed into one
day.(120) It was also claimed by one respondent that
some doctors working in major hospitals would be largely unaware of
what plans existed in their own hospitals for dealing with mass
casualties in a disaster situation.
One of the few hospitals to have conducted an actual mass
casualty exercise is the Royal Adelaide Hospital which conducted
the exercise Supreme Truth in May 2003. Supreme Truth was designed
to test South Australia s readiness for a
chemical/biological/radiological (CBR) terrorist attack, and was
billed at the time by the State Government as the largest of its
type ever held in Australia .(121) The exercise involved
a mock CBR attack on a racecourse, in which 160 people were exposed
to an agent, and in response, the Royal Adelaide Hospital enacted
its Major Incident Plan. The exercise quickly revealed that health
authorities were unable to deal with the incident, with the
hospital admitting that their CBR response plan fell over within
the first 15 minutes .(122) According to the hospital,
the major problems were crowd control, staff exposure,
decontamination and communications despite the Royal Adelaide
Hospital being probably the best prepared hospital in the country
.(123)
Dr David Caldicott, a doctor in the emergency department at the
Royal Adelaide Hospital involved in the exercise, believes
Australia is underprepared and said of the exercise in an interview
in May 2004:
We shut our hospital doors and people very
concerned, very upset about not having immediate access to medical
care tried to break into the hospital
One of the good reasons for talking about this
openly is to prepare the Australian public for what is likely to
happen.
If they expect immediate care straight away,
they're going to be sorely disappointed and probably very angry
We need to plan for worst-case scenarios and the
Australian public needs to ask how many of us are going to survive
this event because doctors are short-staffed or underprepared for
this event.(124)
Even with the best planning and training that a hospital can
manage, in the event of a mass casualty incident or a major
outbreak of an infectious disease (such as an influenza pandemic),
it is possible that limited resources combined with fear and panic
in the community would mean that hospitals might have to take
drastic measures to regulate the likely surge in the influx of
patients. A respondent noted that hospital emergency departments
would quickly become the primary chokepoint in the system, with an
increasing number of patients attending off the street and
expecting medical attention. Indeed, during the 2003 Canberra
bushfires, 60 per cent of disaster patients and 30 per cent of
patients requiring admission arrived at The Canberra Hospital by
private vehicle, including the two most critically
ill.(125)
Echoing Dr Caldicott s views, several respondents claimed that
many 
sick people would be left to cope on their own, and that
not everyone would get the treatment they needed. Furthermore, as
more than one respondent explained, the unpalatable truth is that
people may well be left to die as limited resources would possibly
not be expended on victims with little probability of survival.
This was referred to by one respondent as military triage , and
described in general terms as a standard approach to triage for a
mass casualty situation in which the need for treatment outstrips
the ability to provide it.
Indeed, this approach is written into the Australian Emergency
Manual Series (AEMS), published by Emergency Management Australia,
which is a guide to the management and delivery of support services
in a disaster context .(126) It states that the guiding
principle of triage is to achieve the greatest good for the greater
number of casualties , and that in the event of a disaster,
available health resources should only be directed to those who
will receive the greatest benefit .(127) According to
the manual, in addition to the standard triage categories, there is
the option of also creating an expectant death category, which
would comprise those casualties whose injuries are so severe that
they either will not survive, or they will drain excessive
resources to the detriment of large numbers of other casualties
.(128) As the manual explains, the decision to establish
this triage category should be made by the senior ambulance/medical
officers on site, and will depend on factors such as the level of
resources available at the scene, evacuation resources and the
resources available in hospital .(129)
A number of respondents agreed that most hospitals would
probably be forced to lock their doors and, according to very
strict triage processes, restrict entry only to those selected for
treatment. However, the same respondents indicated that decisions
about triage and how resources were utilised would rest with
individual doctors and hospitals and that doctors would make every
effort to save lives where possible.
Some respondents also believed mortuary facilities would be
over-stretched, particularly if bodies needed to be stored for
coronial or pathology purposes, and that few hospitals could meet
this need alone. To this end, the manual recommends that prior
consideration must be given to the disposal or medium to long-term
storage of bodies that may require further pathological testing or
may be highly contaminated , and suggests that interim storage
facilities should be considered, including the utilisation of large
refrigerated or freezing facilities .(130) In order to
assist with the storage of bodies following the Bali bombing, the
Australian Defence Force provided five refrigeration units on site
in Bali which are normally used to store perishable food during
military deployments, but which are capable of storing 12 17
bodies.(131) The manual also recommends that authorities
plan for mass burial with the ability to identify specific graves .
It is also interesting to note that state coroners have apparently
advocated a new federal coronial jurisdiction to deal with national
disasters.(132)
It s prudent to believe an epidemic of flu will
occur.(133)
In November 2002, the then Commonwealth Chief Medical Officer
stated publicly that Australia would have 100 000 doses of
smallpox vaccine by early 2003.(134) In March 2002,
Parliament amended the Therapeutic Goods Act 1989 to allow
the Minister to import and stockpile unregistered compounds , like
the smallpox vaccine, for use in an emergency. It was imported to
meet the demands of an emergency response in the event that
smallpox was introduced into Australia, and is reportedly stored in
several locations around the country, from where it can be
distributed to any Australian city within hours.
Australia s National Medicines Stockpile, comprising of
antibiotics, anti-virals and vaccines is, however, limited although
it has been recently reported that the size of the stockpile is to
be expanded.(135) In mid-2004, the Government apparently
utilised emergency regulations to fast-track the importation of
200 000 doses of new smallpox vaccine from the US and to
enable the local manufacture of about 400 000 packets of
antibiotics to prevent and treat anthrax infection in
humans.(136) By comparison, the US has sufficient
supplies of smallpox vaccine, for example, to vaccinate its entire
population, Canada has enough to cover a large percentage of its
population, and the UK has reportedly ordered enough vaccine for at
least 30 million people.(137)
The reason for the limited stockpile, according to some
respondents, is that the Commonwealth has not made up its mind
about whether it would vaccinate or provide treatment to the entire
population in the event of an influenza pandemic, for example.
Evidence to Senate Estimates hearings in June 2004 by the
Department of Health and Ageing would seem to suggest that the
provision of medication to the entire population is, in fact, not
envisaged:
So the primary purpose of the expenditure is to
stockpile anti-viral drugs which would help to keep essential
services operating, under conditions of a pandemic flu we would
want to be protecting health workers, people transporting essential
supplies of food and medication, police and essential utilities
like power and water, to make sure that people keep turning up for
work under conditions of a pandemic flu.(138)
Another reason suggested by some is the sense that the risk of a
bioterrorist attack in Australia is not as great as in the US, and
that if such an attack did occur in Australia, the Government would
rely on close US ties to obtain the required additional
vaccines.
In the case of smallpox, despite the fact that the majority of
the Australian community would have no remaining immunity to
smallpox, Australia has decided against mass vaccination for now,
in line with WHO recommendations. This is primarily because the
smallpox vaccine can have serious side effects, ranging from
encephalitis and ulceration of muscle and bone, to death for
example, if the US was to vaccinate its entire population, it could
expect several hundred deaths due to the vaccine
itself.(139) This has led some to believe that the
vaccine is more problematic than the disease itself, particularly
given that powerful and effective anti-viral treatments now exist
which could potentially be used to treat smallpox.(140)
Whilst the exact use of smallpox vaccine in Australia is still
being determined, it would be likely to only be used in the event
of an outbreak, and involve only vaccinating relevant
medical/emergency personnel and those who may have had close
contact with an infected person.
Australia is fortunate enough to have a local vaccine
manufacturer (CSL Limited), and is in fact one of the few countries
in the world with this resource. However, there was concern among
some respondents that, according to their recollections, little or
no consultation had occurred between the Commonwealth and CSL on
influenza pandemic planning. They believed this was because other
manufacturers had not been invited to tender, and this would be in
breach of the Commonwealth s commitment to competitive tendering.
This, however, did not stop the Federal Government recently
purchasing anti-viral influenza medication worth over $120 million
without a tender process, in the form of a direct purchase from the
supplier of the product that the department has determined is the
best fit for the purpose .(141)
Several respondents argued that it is important that Australia
maintains the capacity to make its own vaccines, partly because it
is unrealistic to expect that, during a global pandemic, Australia
could rely on the US, or any other country similarly under threat,
to supply vaccines. Indeed, one respondent pointed out that during
the SARS outbreak in North America, Canada did not receive the
vaccines it had been promised from the US.
However, it was also suggested that it is perhaps unwise to rely
on vaccines because they typically take months or even years to
develop and produce in sufficient quantities a reliable SARS
vaccine is still two to three years away, according to many
scientists.(142) It was also claimed by one respondent
that acquiring adequate supplies of vaccine is further complicated
by patents over drug and vaccine developments, and that this is a
major issue that is yet to be resolved.
Some respondents also questioned the value of influenza
anti-virals. Although they are generally regarded as an important
interim measure , it was claimed that they are only a stop-gap ,
essentially for treating early cases and protecting essential
staff. Respondents who commented on the issue emphasised that
anti-virals should have prophylactic and treatment power, not just
one or the other. The Department of Health and Ageing has since
confirmed that the anti-viral influenza drug it has purchased is a
wonderfully flexible drug which is useful both for prevention and
for cure .(143) Incidentally, despite the Department
refusing to name the drug that had been chosen on the grounds that
such information falls into the category of security
(144) and could assist those who do not wish us well
,(145) the Minister for Health, the Hon. Tony Abbott,
had already previously confirmed that the drug purchased was
Tamiflu(146) comments the Deputy Secretary of the
Department described as not useful .(147) This perhaps
serves to highlight the inconsistencies and problems associated
with the securitisation of health.
Ultimately, given that full national protection through vaccines
and anti-virals would cost many hundreds of millions of dollars,
Australia s response plan is perhaps best described as a
risk-management approach to infectious disease control. That is, it
is a system which uses a combination of robust surveillance systems
(both off-shore and within Australia) and vaccines and anti-virals
for vulnerable groups and first responders (frontline health
workers and others involved in emergency response).
It is clear that there are a number of problems with the current
national arrangements for preventing and controlling infectious
disease in Australia. Existing research and comments from
respondents interviewed for this paper have highlighted major
deficiencies in the emergency health response to infectious
disease.
Despite the experience and ongoing commitment of the people
working in the health system nationally, many of Australia s
hospitals appear to be underprepared for dealing with mass casualty
incidents, particularly one involving an infectious disease, or are
only just now beginning to address the issue. To be fair, however,
even as little as five or six years ago, issues such as a national
emergency stockpile of vaccines and medications, mass casualty
preparedness and real-time disease surveillance did not receive
routine or ongoing attention.
It is perhaps reassuring that in the event of a national
infectious disease emergency, most respondents were confident
overall that the system would work . However, Australia s ability
to respond to a serious infectious disease outbreak remains largely
untested. Whilst the majority of respondents agreed that Australia
s current surveillance networks are sufficiently robust to deal
with routine infectious disease threats, they were less convinced
of the ability of the networks to respond effectively to a major
infectious disease crisis. Given that not even the national
influenza pandemic plan has been exercised, there appears to be an
urgent need for the emergency health response to infectious disease
to be exercised nationally in such a way as to test the whole of
the emergency health care system rather than just aspects of it as
an adjunct to tests of the national security apparatus.
There is an overwhelming sense that the emergency health
response currently labours under difficulties arising from
constantly limited resources, inadequate training exercises and a
distinct lack of integration, and that perhaps the system works
despite the structures in place rather than
because of them. Australia s response to a national
infectious disease emergency might well be adequate initially or
for a short duration, but serious questions remain as to Australia
s capacity to manage concurrent crises or crises over an extended
period of time.
A number of issues arise for possible policy consideration from
the discussion in this paper. They include whether:
- the roles of health policy-makers and public health
practitioners should be better integrated
- the overlapping of Commonwealth state responsibilities with
respect to infectious diseases should be assessed and continually
monitored
- there is a need for more workable structures in the health
system through which states can communicate with each other and
with the Commonwealth
- more funding is required to enable the provision of additional
medical staff and training and whether Australia s disease
prevention systems need more human, rather than technological,
resources
- the opening of additional hospital beds requires an ongoing
commitment of additional suitably qualified staff to attend to
them
- the Communicable Diseases Network Australia should be better
connected to strategic policy-making on communicable diseases
- the top levels of the Commonwealth bureaucracy should allow
medical experts to have more influence in national security
planning for bioterrorism and the national emergency health
response
- Australia s expertise in infectious disease control should
perhaps be consolidated and more fully utilised by the Commonwealth
a national disease control centre has been suggested as a possible
solution
- an all-hazards approach to infectious disease planning and
terrorism generally should be emphasised
- Australia should take greater responsibility for influenza
pandemic preparedness in the immediate region
- disease detection and reporting mechanisms need to be
streamlined and more adequately-resourced laboratories around
Australia should be established to allow the rapid detection and
identification of diseases such as SARS
- Australia needs to increase the number of intensive care unit
beds it has per 100 000 population and whether Australian
hospitals need to implement permanent measures to cope with
increased routine admissions
- the cancellation of elective surgery as a means of creating
additional hospital beds in a crisis should be reviewed as it has
now become normal practice for dealing with increasing numbers of
routine emergency patients
- the capacity for routine elective surgery needs to be expanded
in order to create greater potential slack in the system that can
be drawn on in a crisis
- Australia s hospitals should be better prepared for dealing
with a mass casualty incident or a major infectious disease
outbreak and whether hospitals should conduct full-scale practical
emergency response exercises
- medical workforce issues should be given greater consideration
in crisis contingency planning
- Australia s national emergency health response urgently needs
to be properly tested starting with the national influenza pandemic
plan as a minimum and whether there is now a pressing need for a
national exercise with a health focus to be conducted in Australia,
and
- a greater multi-jurisdictional approach to emergency health
response planning is needed.
- Peter Curson, We need to prepare for war of bugs , The New
Zealand Herald, 2 June 2004,
http://www.nzherald.co.nz/storydisplay.cfm?storyID=3569922&
thesection=news&thesubsection=dialogue&thesecondsubsection=
(2 June 2004).
- J. Cumpston, The Health of the People: A Study in
Federalism, 1978, pp. 1 6.
- ibid., p. 16.
- ibid.
- H. Kelsall, P. Robinson and G. Howse, Public health law and
quarantine in a federal system , Journal of Law and
Medicine, vol. 7, August 1999, pp. 89 90. Quarantine was also
closely linked to immigration. The Immigration Restriction Act
1901 (section 3d) named as a prohibited immigrant any person
suffering from an infectious or contagious disease of a loathsome
or dangerous character . Meanwhile, the Quarantine Act
refers to immigration and entry regulation (see for example section
35AA). According to Cumpston, quarantine was the strict prohibition
against the entrance into our country of certain races of aliens
whose uncleanly customs and absolute lack of sanitary conscience
form a standing menace to the health of any community , cited in A.
Bashford, At the border: contagion, immigration, nation ,
Australian Historical Studies, vol. 120, 2002, p. 349; See
also D. Walker, Anxious Nation: Australia and the Rise of Asia
1850-1939, 1999; P. Curson, Times of Crisis: Epidemics in
Sydney 1788-1900, 1985; M. Roe, The establishment of the
Australian Department of Health , Historical Studies, vol.
17, no. 67, 1976, pp. 183 90. For a more contemporary perspective
see J. Singer, Bugs, boats and bigotry, Herald Sun, 25
April 2003, p. 18; M. Barton, Illegals a disease risk: claim,
The West Australian, 5 March 2001; J. Sommerfield,
Hanson wants action on boat people, The Courier Mail, 23
April 2001; G. Roberts, Diseased, suicidal and angry: Iraqis
suffer in PNG detention camp, Sydney Morning Herald, 5
February 2002.
- Report of the Proceedings of the Australasian Sanitary
Conference, 1884, cited in J. Cumpston, op. cit., p. 11.
- After a referendum on 28 September 1946, the Constitution
Alteration (Social Services) Act 1946 (enacted on 19 December
1946) altered the Constitutional powers of the Parliament by adding
paragraph xxiiiA to section 51. This addition of paragraph xxxiiiA
to section 51, introduced by the Chifley Labor Government, gave the
Commonwealth Parliament the power to make laws for the provision of
a much wider range of social services child endowment, benefits to
students, unemployment benefits, medical and dental services,
maternity allowances, family allowances, sickness and hospital
benefits, widows pensions as the Constitution had only referred to
pensions for invalid and aged people. This more prominent role was
reflected in the establishment of the Commonwealth Department of
Social Security in 1939, the Department of Immigration in 1944, and
the Commonwealth Employment Service and the Commonwealth Office of
Education in 1945.
- Cumpston, op. cit., pp. 16 20.
- Quarantine Act 1908, section 4.
- When a law of a State is inconsistent with a law of the
Commonwealth, the latter shall prevail, and the former shall, to
the extent of the inconsistency, be invalid : The
Commonwealth of Australia Constitution
Act 1900, section 109.
- Cumpston, op. cit., p. 24.
- Kelsall et al., op. cit., p. 91. See also Cumpston op. cit.,
pp. 24 39 for a more detailed account of these and other
incidents.
- A further amendment, in 1947, enables the Governor-General to
declare that an epidemic caused by a quarantinable disease or pest
exists or that there is a danger of such an epidemic. Section 2B
empowers the Minister to take whatever quarantine measures s/he
deems necessary to control or eradicate the epidemic. This section
was inserted into the Quarantine Act in 1947 because of concerns
that outbreaks of communicable diseases in Europe, Africa and Asia
after World War II, and the increasing volume and speed of air
travel to Australia, required that the Minister be given more power
to deal with an emergency resulting from an outbreak of disease in
Australia.
- J. Gillespie, The Price of Health: Australian Governments
and Medical Politics 1910-1960, 1991, p. 31.
- Cumpston, op. cit., p. vii.
- Watt, cited in M. Roe, The establishment of the Australian
Department of Health , Historical Studies, 17 (67), 1976,
p. 179.
- The funding offer was made contingent upon the establishment of
a Ministry of Health and a Commonwealth Department of Health. See
Cumpston, op. cit., p. 45.
- M. Roe, The establishment of the Australian Department of
Health , Historical Studies, 17 (67), 1976, p.
180.
- M. Roe, Nine Australian Progressives, 1984, p.
134.
- Cumpston, op. cit., p. 46.
- There is a growing literature on the way that fear of
contagion, from disease or alien races , has seen Australian health
and immigration policies develop in mutually supportive directions.
See endnote 5 above.
- M. Metherell, Beware: the untreatable epidemic is on its way ,
Sydney Morning Herald, 28 June, 2003. This claim was
also made by respondents interviewed for this paper.
- Department of Prime Minister and Cabinet, Review of
Australian Quarantine Arrangements, Australian Government
Publishing Service, Canberra, 1977, p. 132.
- M. E. Nairn, Australian Quarantine: a Shared
Responsibility, Department of Primary Industries and Energy,
Canberra, 1996.
- For example, the first National HIV Strategy began in 1989, a
National Hepatitis C Action Plan was initiated in 1994 and SARS was
declared a quarantinable disease in April 2003, giving the
Commonwealth powers to implement a range of control measures.
- For example, see Surgeons call for federal health funding
control , Canberra Times, 31 May 2004, p. 4; M. Metherell,
National health merger moves one step closer , Sydney Morning
Herald, 24 April 2004, p. 5; M. van der Weyden, Australian
healthcare reform: in need of political courage and champions ,
The Medical Journal of Australia, 179 (6), pp.
280 281.
- Commonwealth Director-General of Health, 1925, cited in
Cumpston, op. cit., p. 60.
- Micro-economic reform is also believed to have been behind an
increase in the Commonwealth s involvement and to have spawned a
plethora of new bodies such as the National Blood Authority, Food
Standards Australia New Zealand, etc.
- In addition to the multitude of bodies established to monitor
and respond to infectious disease outbreaks, numerous documents and
plans are devoted to providing information and guidelines to public
health professionals and the general public about Australia s
capacity to respond to an infectious disease outbreak.
- Addressing emerging or potential health risks, Fact Sheet 1,
Budget 2004 05.
- Comment by a respondent interviewed for this paper.
- The concept of managerialism appears to reflect a devaluing of
expertise in specific policy areas across the public service
generally and perhaps a suspicion of professionals with special and
particular interests. For a wider discussion of managerialism and
public health see F. Baum, The New Public Health,
2nd Edition, 2002, pp. 75 85; J. Germov, Medi-fraud,
managerialism and the decline of medical autonomy:
deprofessionalisation and proletarianisation reconsidered ,
Australia New Zealand Journal of Sociology, 31 (3),
November 1995, pp. 51 66; A. Davis, Managerialised health care , in
S. Rees and G. Rodley eds, The Human Costs of Managerialism:
Advocating the Recovery of Humanity, 1995, pp. 121
135.
- Alison Bashford, quoted in Linda Vergnani, A historic take on
the contagions , The Australian, 30 June 2004, p. 44.
- J.M. Last, A Dictionary of Epidemiology, Oxford
University Press, New York, 1988.
- Senator the Hon. Robert Hill, Minister for Defence, Second
reading speech: Quarantine Amendment (Health) Bill 2003 , Senate,
Debates, 21 August 2003.
- According to the WHO website: The WHO Global Influenza
Surveillance Network was established in 1952. The network comprises
4 WHO Collaborating Centres (WHO CCs) and 112 institutions in 83
countries, which are recognized by WHO as WHO National Influenza
Centres (NICs). These NICs collect specimens in their country,
perform primary virus isolation and preliminary antigenic
characterization The WHO Influenza Surveillance Network serves also
as a global alert mechanism for the emergence of influenza viruses
with pandemic potential. Australia has three NICs in Melbourne,
Perth and Sydney and is home to one WHO Collaborating Centre (in
Melbourne), http://www.who.int/csr/disease/influenza/influenzanetwork/en/
(21 September 2004).
- See, for example, J. S. Mackenzie et. al, Emerging viral
diseases of Southeast Asia and the Western pacific , Emerging
Infectious Diseases, 7 (3), Supplement, June 2001, pp. 497
504.
- S. Labi, Quarantine holding up against spread of deadly virus ,
Canberra Times, 27 April 2003, p. 5. For a slightly more
qualified assessment see G. Samaan, M. Patel, J. Spencer and L.
Roberts, Border screening for SARS in Australia: what has been
learnt? in The Medical Journal of Australia, 180
(5), 2004, pp. 220 223.
- Comment by a respondent interviewed for this paper.
- Comment by a respondent interviewed for this paper.
- The Canberra Hospital is one of these. A. Plant and L. Adams,
Australia and infectious diseases: a challenge to our biosecurity?
in Daring to Dream: The Future of Australian Health Care,
2001, pp. 154 155; M. Nairn, An overview of Australia s biosecurity
record and future operating environment , in Biosecurity: A
Future Imperative, Australian Academy of Technological
Sciences and Engineering, 2001, p. 3.
- Syndromic surveillance is an imprecise term. Its medical
meaning usually refers to the lack of a distinct diagnosis. A
medical syndrome is a collection of a group of symptoms and signs
known to occur in certain conditions, but that do not necessarily
add up to a single definable diagnosis. Syndromic systems can also
refer to non-specific indicators of health, such as a patient with
a complaint of cough , or the sale of over-the-counter cold
medication. Other possible terms include biosurveillance, which, as
indicated below, is used by the NSW Health Department epidemiology
section. F. Mostashari and J. Hartman, Syndromic surveillance: a
local perspective , Journal of Urban Health, 80 (2),
Supplement 1, 2003, pp. i1 i7.
- Comment by a respondent interviewed for this paper.
- R. Hellstern, Bioterrorism early warning syndromic surveillance
, Healthcare Information Solutions, www.health-infosys-dir.com/wphcemg1.htm
(2 September 2004).
- The proliferation of electronic technologies in healthcare
settings is also fuelling the development of these systems.
- RAND, Syndromic surveillance: an effective tool for detecting
bioterrorism? , RAND Research Highlights, 2004, p. 1.
- D. Heyman, Lessons from the anthrax attacks: implications
for bioterrorism preparedness, Centre for Strategic and
International Studies, 2002, pp. 14 15: The most effective and
fastest method of detection today relies on astute clinicians.
Alert practitioners have been the key for detecting recent unusual
outbreaks, including anthrax, hanta virus, and West Nile virus.
Until adequate detection technology is available and perhaps even
after it is medical and public health professionals and private
citizens will play a critical role in bioterrorism detection and
defense , p. 15.
- RAND, op. cit., p. 2.
- Reingold, If syndromic surveillance is the answer, what is the
question? , Biosecurity and Bioterrorism: Biodefense Strategy,
Practice, and Science, 1 (2), 2003, p. 80.
- R. Heffernan et. al, Syndromic surveillance in public health
practice, New York City, Emerging Infectious Diseases
[serial on the Internet], 10 (5), 2004. Available from www.cdc.gov/ncidod/EID/vol10no5/03-0646.htm
(2 September 2004).
- Reingold, op. cit., p. 79.
- A useful critical discussion of the costs versus benefits of
syndromic surveillance can be found in ibid, pp. 77 81.
- F. Mostashari and J. Hartman, op. cit., p. i6.
- Dr David Caldicott (Royal Adelaide Hospital), quoted in
Domestic security under the spotlight , Lateline, ABC TV,
20 May 2004, http://www.abc.net.au/lateline/content/2004/s1112666.htm
(26 August 2004).
- Professor Richard Smallwood, Vaccines to Combat Bioterrorism ,
World Vaccine Congress, 27 November 2002,
http://www.health.gov.au/pubhlth/strateg/communic/factsheets/vaccine_statement.htm
(25 August 2004).
- Ruth Pollard, Hospitals not ready for SARS, expert warns ,
The Age, 22 April 2003, p. 4.
- ibid.
- Standing Committee on Infection Control, An Influenza
Pandemic Contingency Plan for Health Care Institutions (Draft 18
May 1999), Department of Human Services, Victoria, 1999, p. 1
included as an appendix in Department of Health and Aged Care,
A Framework for an Australian Influenza Pandemic Plan,
June 1999.
- The Audit Office of New South Wales, Auditor-General s
Report: Performance Audit Transporting and Treating Emergency
Patients, NSW, July 2004, p. 5.
- Lack of beds killing patients , BBC News online, 24
February 2004, http://news.bbc.co.uk/1/hi/health/3514065.stm
(14 July 2004).
- Tracey Higlett, Therese Anderson and Graeme K Hart, Review
of Intensive Care Resources & Activity 2001/2002,
Australian and New Zealand Intensive Care Society, Melbourne, 2004,
p. 2.
- ibid. Calculated as the average number of beds across available
and ventilator beds per 100 000 population.
- Due to the different definitions and composition of ICU beds
around the world, international comparisons should be treated with
caution and as an indication only. It should also be noted that
Australian ICU data includes both adult and paediatric intensive
care services.
- cited in Higlett, et al., op. cit., p. 120.
- cited in Therese Anderson and Graeme K Hart, Review of
Intensive Care Activity 1999/2000, Australian and New Zealand
Intensive Care Society, Melbourne, 2001, p. 19.
- Joint Standing Committee on Foreign Affairs, Defence and Trade,
Watching Brief on the War on Terrorism, Commonwealth of
Australia, Canberra, June 2004, p. 105.
- Mary Murnane, Deputy Secretary, Department of Health and
Ageing, Senate Community Affairs Legislation Committee, Estimates
Official Committee Hansard, 3 June 2004, p. 57, http://www.aph.gov.au/hansard/senate/commttee/S7637.pdf
(3 September 2004).
- Quoted in Domestic security under the spotlight ,
Lateline, ABC TV, 20 May 2004, http://www.abc.net.au/lateline/content/2004/s1112666.htm
(26 August 2004).
- The Hon. Lea Stevens, MP, More Hospital Beds Open to Ease Flu
Outbreak , news release, 26 August 2003,
http://www.ministers.sa.gov.au/Minister/MediaFrame.asp?
premier=n&article=1776&MinisterID=8 (1 September
2004).
- Public hospitals poaching private patients , Private
Hospital, October 2003, http://www.apha.org.au/media_files/2375386101
(13 July 2004).
- New hospital beds on way for winter , Sydney Morning
Herald, 7 June 2004,
http://www.smh.com.au/articles/2004/06/07/1086460219667.html?from=storylhs
(14 July 2004).
- See, for example, Hospitals see red over crisis in beds ,
National Nine News, 31 August 2004, http://news.ninemsn.com.au/article.aspx?id=15484
(31 August 2004) and Ambos see red on hospital crisis , The
Australian, 31 May 2004,
http://www.theaustralian.news.com.au/printpage/0,5942,9700397,00.html
(31 May 2004).
- The Audit Office of New South Wales, op. cit., p. 19.
- Simon Corbell, ACT Minister for Health and Planning, Minister
announces options to address , media statement, 24 August
2004, http://www.act.alp.org.au/media/0804/20001944.html
(31 August 2004). See also ACT moves to ease pressure on hospitals
, 666 ABC Canberra, 24 August 2004, http://www.abc.net.au/act/news/200408/s1184127.htm
(31 August 2004).
- The Audit Office of New South Wales, op. cit., p. 27.
- Nick O Malley, Elective surgery axed to free up beds for flu
season , Sydney Morning Herald, 24 March 2004,
http://www.smh.com.au/articles/2004/03/23/1079939646542.html?from=storyrhs
(6 September 2004).
- Bed days are defined in Tracey Higlett, Therese Anderson and
Graeme K Hart as the total number of days for all patients who were
admitted to the ICU for an episode of care calculated as the
difference between the separation date and admission date (op.
cit., p. 129). Therese Anderson, Graeme K Hart, Marion A Kainer and
Kevin Moon, Influenza Pandemic Planning for Intensive
Care, Australian and New Zealand Intensive Care Society,
Melbourne, 2001, p. 12.
- Therese Anderson, et al., ibid, p. 17 and p. 20.
- ibid.
- Nick O Malley, Medical inattention , Sydney Morning
Herald, 29 July 2004, http://www.smh.com.au/articles/2004/07/28/1090694029576.html#
(29 July 2004).
- Joint Standing Committee on Foreign Affairs, Defence and Trade,
op. cit., p. 104.
- James E Fielding, Keflemariam Yohannes, Hassan Vally &
Jenean D Spencer, Severe acute respiratory syndrome surveillance in
Australia , Communicable Diseases Intelligence, 28 (2),
June 2004, pp.181 186, http://www.cda.gov.au/pubs/cdi/2004/cdi2802/pdf/cdi2802f.pdf
(16 August 2004).
- See, for example, Mark Metherell, There s still life in
hospital takeover plan: Abbott , Sydney Morning Herald, 24
March 2004,
http://www.smh.com.au/articles/2004/03/23/1079939646380.html?from=storyrhs
(6 September 2004).
- Therese Anderson, Graeme K Hart, Marion A Kainer and Kevin
Moon, op. cit., pp. 7 8.
- See, for example, Standing Committee on Infection Control, op.
cit., for discussion of this option.
- Standing Committee on Infection Control, op. cit., p. 1.
- SARS nurses sue Canadian govt , The Courier Mail, 26
March 2004,
http://www.couriermail.news.com.au/common/story_page/0,5936,9080758%5E1702,00.html
(29 July 2004).
- Drew B Richardson and Sashi Kumar, Emergency response to the
Canberra bushfires , The Medical Journal of Australia,
181(1), 5 July 2004, p. 41.
- ibid., p. 40.
- ibid., p. 40 and 42.
- Comment by a respondent interviewed for this paper.
- Senator the Hon. Robert Hill, Minister for Defence,
Australia s Response to Terrorism, Question and Answer
Session, Menzies Research Centre, 25 May 2004,
http://www.minister.defence.gov.au/HillTranscripttpl.cfm?CurrentId=3846
(30 July 2004).
- Dr David Caldicott, op. cit.
- See, for example, Pandemic capabilities untested , National
Nine News, 19 July 2004, http://news.ninemsn.com.au/article.aspx?id=12723
(26 July 2004).
- Dr William Beresford, Director of Clinical Services Royal Perth
Hospital, Joint Standing Committee on Foreign Affairs, Defence and
Trade, Watching brief on the war on terrorism , Official Committee
Hansard, 2 April 2003, p. 14, http://www.aph.gov.au/hansard/joint/commttee/J6341.pdf
(27 August 2004).
- Home security inadequate: experts , Lateline, ABC TV,
12 March 2003, http://www.abc.net.au/lateline/content/2003/s805620.htm
(18 May 2004).
- See the Hon. Philip Ruddock, MP, Attorney-General, NSW Exercise
to Test Terrorism Response Capability , media release
083/2004, 28 May 2004,
http://www.ag.gov.au/www/MinisterRuddockHome.nsf/Web+Pages/
0A7E3550C84DB033CA256EA2001CCC10?OpenDocument (1 September
2004).
- See the Hon. Philip Ruddock, MP, Attorney-General, Victoria to
Host Next Counter-terrorism Exercise , news release
162/2004, 1 September 2004.
- Exercise Minotaur was conducted by the Department of
Agriculture, Fisheries and Forestry in September 2002 as a desk-top
exercise focusing on a national foot and mouth disease outbreak.
Involving over 1100 people, it was the largest exercise of its type
ever held in Australia http://www.affa.gov.au/exerciseminotaur
(11 October 2004).
- Hospitals must prepare for terrorism , The Age, 10
August 2004, http://www.theage.com.au/articles/2004/08/10/1092102444398.html
(11 August 2004).
- Comment by a respondent interviewed for this paper.
- The Howard Government Election 2004 Policy, Royal Darwin
Hospital: Equipped, Prepared and Ready , undated released 20
September 2004, p. 1,
http://www.liberal.org.au/documents/royal_darwin_hospital_final.pdf
(21 September 2004).
- Joint Standing Committee on Foreign Affairs, Defence and Trade,
Watching brief on the war on terrorism , Official Committee
Hansard, 2 April 2003, p. 14, http://www.aph.gov.au/hansard/joint/commttee/J6341.pdf
(27 August 2004).
- Joint Standing Committee on Foreign Affairs, Defence and Trade,
Watching Brief on the War on Terrorism, Commonwealth of
Australia, Canberra, June 2004, p. 25.
- Hospital staff look back on Bali bombing aftermath , 7.30
Report, ABC TV, 12 October 2004, http://www.abc.net.au/7.30/content/2004/s1218623.htm
(13 October 2004).
- Mary Murnane, op. cit., p. 57.
- Drew B Richardson and Sashi Kumar, op. cit., p. 41.
- Peter Curson, op. cit.
- Alison Bashford, op. cit.
- Joint Standing Committee on Foreign Affairs, Defence and Trade,
Watching brief on the war on terrorism , Official Committee
Hansard, op. cit., p. 14.
- Health system not ready for disaster , The Age, 29
July 2004,
http://www.theage.com.au/articles/2004/07/29/1091080370760.html?oneclick=true
(27 August 2004).
- New disaster preparedness unit , news.com.au, 24 May
2004,
http://www.news.com.au/common/story_page/0,4057,9647190%5E2761,00.html
(8 September 2004).
- The Hon. Jim McGinty, MLA, New unit for victims of disasters
and terrorist attacks , media statement, 21 May 2004,
http://www.mediastatements.wa.gov.au/media/media.nsf/
9dbd10dc05971ee348256a76000cc002/649bc2a54e57550f48256e9b001af6bc?OpenDocument
(8 September 2004).
- The Howard Government Election 2004 Policy, op. cit., p.
2.
- Hospitals must prepare for terrorism , op. cit.
- Dr Peter Aitken, A review of disaster preparedness of emergency
departments in Australia , unpublished summary provided by the
author.
- Dr Aitken, telephone and email communication, 20 May 2004 cited
with permission.
- Domestic security under the spotlight , op. cit.
- Drew B Richardson and Sashi Kumar, op. cit., pp. 40 42.
- Steve Dow, Preparing for terror , Sydney Morning
Herald, 15 May 2003, http://www.smh.com.au/articles/2003/05/15/1052885324586.html
(25 August 2004).
- The Hon. Lea Stevens, MP (South Australia), An Exercise to Deal
with a Terrorist Attack on Adelaide , news release, 18 May
2003,
http://www.ministers.sa.gov.au/Minister/MediaFrame.asp?
premier=n&article=1347&MinisterID=8, (6 September
2004).
- Judy Skatssoon, Hospital terror plan fell apart in minutes ,
The Advertiser, 15 September 2003, p. 4.
- ibid.
- Domestic security under the spotlight , op. cit.
- Drew B Richardson and Sashi Kumar, op. cit., p. 41.
- The Australian Emergency Manual Series has been developed to
assist in the management and delivery of support services in a
disaster context. It comprises principles, strategies and
actions, compiled by practitioners with management and service
delivery experience in a range of disaster events. The series
has been developed by a national consultative committee,
representing a range of State and Territory agencies involved in
the delivery of support services and sponsored by Emergency
Management Australia (EMA) ,
http://www.ema.gov.au/ema/emaInternet.nsf/AllDocs/
RWP11758B11BF799092CA256C8200796A28?OpenDocument (30 August
2004).
- Emergency Management Australia, The Australian Emergency
Manual Series, Part III Emergency Management Practice, Volume
2 Specific Issues, Manual 3 Health Aspects of Chemical, Biological
and Radiological Hazards, Chapter 6 Triage,
http://www.ema.gov.au/ema/rwpattach.nsf/viewasattachmentPersonal/
FA53E03F13A3C6B7CA256C8A0011FB77/$file/TRIAGE.PDF (27 August
2004).
- ibid.
- ibid.
- Emergency Management Australia, The Australian Emergency
Manual Series, Part III Emergency Management Practice, Volume
2 Specific Issues, Manual 3 Health Aspects of Chemical, Biological
and Radiological Hazards, Chapter 12 Public Health Aspects of CBR
Incidents,
http://www.ema.gov.au/ema/rwpattach.nsf/viewasattachmentPersonal/
21BDD25D6364D7A6CA256CB200278EDE/$file/Public_Health_Aspects_of_CBR.pdf
(27 August 2004).
- Woman dies from burns , Sydney Morning Herald, 15
October 2002, http://smh.com.au/articles/2002/10/15/1034561144452.html
(30 August 2004).
- Australian Public Service Commission Management Advisory
Committee, Connecting Government: Whole of Government Responses
to Australia s Priority Challenges, Commonwealth of Australia,
Canberra, 2004, p. 193, http://www.apsc.gov.au/mac/connectinggovernment.pdf
(30 August 2004).
- Comment by a respondent interviewed for this paper.
- Professor Richard Smallwood, op. cit.
- Lesley Podesta, Assistant Secretary, Communicable Diseases
Branch, Department of Health and Ageing, Senate Community Affairs
Legislation Committee, Estimates Official Committee Hansard, 3 June
2004, p. 56, http://www.aph.gov.au/hansard/senate/commttee/S7637.pdf
(3 September 2004).
- Mark Davis, Bioterrorism drugs put on fast track ,
Australian Financial Review, 15 June 2004, p. 3.
- Professor Richard Smallwood, op. cit.
- Andrew Stuart, First Assistant Secretary, Population Health
Division, Department of Health and Ageing, Senate Community Affairs
Legislation Committee, Estimates Official Committee Hansard, 3 June
2004, p. 10, http://www.aph.gov.au/hansard/senate/commttee/S7637.pdf
(3 September 2004).
- Professor Richard Smallwood, op. cit.
- ibid.
- Andrew Stuart, op. cit.
- Vaccine for SARS a few years away: scientists , Canberra
Times, 12 May 2004, p. 8.
- Andrew Stuart, op. cit., p. 56.
- Mary Murnane, op. cit., p. 10.
- ibid, p. 53.
- Richard Gluyas, Drug tender stays a state secret , The
Australian, 4 June 2004, p. 21.
- Mary Murnane, op. cit., p. 53.
The authors would like to thank the following people who agreed
to be interviewed for this paper, and without whose input this
paper would not have been possible:
|
Ms Mary Beers-Deeble
|
Senior Lecturer, National Centre for Epidemiology and Population
Health, Australian National University.
|
|
Mr Robert Cameron
|
Director, Planning and Operations, Emergency Management
Australia.
|
|
Dr Scott Cameron
|
Senior Lecturer, National Centre for Epidemiology and Population
Health, Australian National University.
|
|
Dr Tim Churches
|
Manager, Population Health Information Branch, Centre for
Epidemiology and Research, NSW Health.
|
|
Dr Peter Collignon
|
Director, Infectious Diseases Unit and Department of
Microbiology, The Canberra Hospital.
|
|
Dr Charles Guest
|
Deputy Chief Health Officer, ACT.
|
|
Dr Alan Hampson
|
Deputy Director, World Health Organization Collaborating Centre
for Reference and Research on Influenza.
|
|
Prof. Thomas Kossmann
|
Director, Department of Trauma Surgery and Director, National
Trauma Research Institute, The Alfred Hospital.
|
|
Dr Mahomed Patel
|
Senior Lecturer, National Centre for Epidemiology and Population
Health, Australian National University.
|
|
Ms Trish Mannes
|
Population Health Information Branch, Centre for Epidemiology
and Research, NSW Health.
|
|
Prof. John Mathews
|
Deputy Chief Medical
Officer, Commonwealth (as at March 2004).
|
|
Dr Jeremy McAnulty
|
Director, Communicable Diseases Branch, Centre for Health
Protection, NSW Health.
|
|
Mr Dudley McArdle
|
Director, Emergency Management Australia Institute.
|
|
Mr David Muscatello
|
Population Health Information Branch Centre for Epidemiology and
Research, NSW Health.
|
|
Prof. Richard Smallwood
|
Chief Medical Officer, Commonwealth, 1999 2003.
|
|
Ms Margery Webster
|
Assistant Director, Education Development, Emergency Management
Australia Institute.
|
|
Ms Wei Zheng
|
Population Health Information Branch, Centre for Epidemiology
and Research, NSW Health.
|
A number of others, both in and out
of government, were approached for this study but in the event were
unable to participate
For copyright reasons some linked items are only
available to members of Parliament.