How an Australian Centre for Disease Control could prevent chronic disease

It’s a long way to the top if you want to reform the Australian health system. Prime Minister Albanese has promised an Australian Centre for Disease Control, and it’s the subject of our new report The Australian Centre for Disease Control (ACDC): Highway to health.

While the call for an ACDC comes out of the wake of the pandemic, you’d be forgiven for thinking its role is to deal with infection control. But Grattan’s report focusses on the ACDC’s role to prevent chronic diseases.

Report authors Peter Breadon, Program Director, and Lachie Fox, Associate, discuss the broader role of the ACDC with host Kat Clay.

Read the report

Transcript

Kat Clay: It’s a long way to the top if you want to reform the Australian health system. Prime Minister Albanese has promised an Australian Centre for Disease Control and it’s the subject of our new report, ACDC, Highway to Health. While the call for an ACDC comes out of the wake of the pandemic, you’d be forgiven for thinking its role is to deal purely with infection control.

Perhaps that and seeing too many zombie movies. But our report focuses on the ACDC’s role to prevent chronic diseases. There’s a broader role for the ACDC, and here to talk about it are report authors, Peter Breadon, Health Program Director, and Lachie Fox, Associate. Peter, starting with you, why does the report focus on chronic diseases as opposed to infectious diseases that might first come to mind?

Peter Breadon: Despite our, our terror of zombie pandemics, and of course our Current unfolding terrible COVID pandemic and all the harms it has caused, and it is causing. Chronic disease is actually where more of the harms are. So, 85 percent of the disease burden comes from chronic conditions. These are conditions like diabetes, heart disease, cancer, and so on.

And it causes nine in 10 deaths. And the other big problem with chronic disease is it’s growing fast. So, it’s increased by nearly 40 percent in the last 30 years. That’s why we’ve chosen to focus. on chronic disease prevention and in great news that’s also what the government has announced that this new centre for disease control will focus not just on infectious diseases.

like pandemics, it will also focus on chronic disease prevention. And the reason it’s a good idea to focus on chronic disease prevention is because these conditions can be prevented. 40 percent of that massive health burden that causes so much early death, disability, and disease can be reduced. This is by reducing risk factors like obesity, overweight, alcohol, and tobacco.

And if we don’t act now, that rate of chronic disease will just keep on increasing. The rate of obesity, for example, has gone up by, it’s tripled, it’s tripled in the last few decades since, since 1980. So that’s why we have to act now to stop disease before it starts. Otherwise, we’ll just keep getting sicker.

There’ll be pressure put on GPs, on hospitals, on the hospital system, which is already really struggling. and of course, everyone will be sicker than they would otherwise be.

Kat Clay: So, Lachie, I mean, what do you mean when we talk about prevention? Does it actually work?

Lachlan Fox: So, prevention can feel a bit esoteric to discuss.

But when we talk about prevention, we’re really looking at programs and interventions which help reduce these risk factors that Peter mentioned, like alcohol consumption or smoking or obesity. There are some programs which are aimed at stopping these before they start, before someone becomes overweight or obese, and others which look at reducing the amount of alcohol we consume and the risk factors once they’ve already developed.

Prevention can take plenty of different approaches. Some things are population wide, like pricing or regulations. For example, if we put taxes on cigarettes, that affects everyone in Australia. Or if we regulate where people can smoke. For example, saying they can’t smoke in cars if there’s a child in the car.

That affects everyone, but there’s other programs we can also do at a lower level. So, for example, education campaigns that might be to a specific population group or a specific school. And then even below that, there’s sort of one-on-one programs. So, people might be familiar with smoking cessation programs and counselling that they might talk to GP about how best to quit, how best to lose weight and effectively how best to stay healthy.

Kat Clay: Peter, I’m quite lucky because a lot of my career has been in prevention health messaging. And obviously one of the big-ticket things that has been most effective in Australia has, been the taxation of cigarettes. I mean, that Australia does have such a huge history of prevention. How much. Prevention are we actually doing now?

I mean, is it on the rise? Is it on the decline? And what about spending for prevention campaigns? You’re right,

Peter Breadon: Kat. Australia has a pretty proud history of some big triumphs in prevention. You mentioned tobacco and, this is a really good example. So over decades, governments actually brought together a range of different.

Policy tools to drive down rates of smoking. You mentioned taxation, which was gradually ramped up over time. There’s also really powerful and sustained mass media marketing campaigns to educate people about the consequences of smoking. There were regulatory measures about where you could smoke and then there were those smoking cessation programs and supports for individuals that Lockie talked about.

So multi-pronged approach sustained over time. We’ve had similar, efforts in skin cancer in sun smart behaviour. Again, over decades, building shades in schools, slip, slop, slap campaigns to tell people how to be sun smart. and over time that’s changed behaviours and the results are really big.

So, you know, smoking came down from being about 40 percent of the population in the eighties down to about 10 percent today. skin cancer rates have fallen for people under 30, they’ve halved just since 1995. So, these are massive, massive gains with many, many lives saved. So, we know this works, but you also asked the question.

So, we’ve had success, but what are we doing now? Well, we’ve really fallen behind these huge campaigns and big successes really are stories from the past. Today, we spend less than 2 percent of health spending on prevention. That is well below the average for rich countries and it’s, its far below leading countries, about half of what is spent per capita in the UK, about a third below Canada.

And we’ve also abolished the Preventive Health Agency years ago, and the National Funding Agreement for prevention funding was, was axed. And you can also see in many areas where we’ve fallen behind in taking action through regulation and other measures. So, a few examples. Salt, excess salt consumption leads to a stomach cancer.

It leads to stroke. and Australia has about twice the recommended intake of salt. Other countries have done a lot to limit salt intake through mandatory policies to reduce the amount of salt put in manufactured food, through labelling, through consumer education and other measures. About 80 of 96 countries that a recent study looked at have taken measures like that, but Australia only has really weak voluntary targets, for reducing.

So, in manufactured foods, there are taxes on sugar, sweetened beverages, and sugar in about 85 other countries, nothing in Australia. And while many countries around the world are moving to reduce harmful trans fatty acids in foods. That lead to cardiovascular disease. Again, Australia is doing very little.

And the WHO, who ranked and looked at countries around the world, didn’t even score Australia on their list because our measures are so weak. So, really looking across all these things in food, we can see that for the new, really big risk factor of obesity, we’re just not achieving what we achieved in those past campaigns.

Kat Clay: Attacks on sugary drinks is something that we’ve advocated for in previous Grattan reports and alongside other preventative, bodies. And I mean, I, I reflect on, you know, there’s a certain generation of us that will remember Sid the Seagull and Slip Slop Slap and, you know, life being at cartoons and, you know, it’s almost like we don’t, you know, necessarily have a lot of those iconic health prevention campaigns at the moment.

Why are we so bad at prevention at the moment? And why is it so challenging?

Lachlan Fox: So, prevention is challenging for a number of reasons. And one of these is because it is such a long-term game for governments to play. We all know the governments tend to focus on the political cycle more than some other very long-term cycles.

And for prevention interventions, this means that a government may not consider it to be as politically important as other things. So, then they could introduce stronger regulations on smoking or other harms, but they know that they may not see the benefit for 10 or 15 years. And even when that benefit does come, it can be very hard to identify someone that didn’t get heart disease or didn’t get lung cancer because of a government action.

So, it’s hard to claim credit for is one reason. Vested interests also have a really strong role in creating challenges. There’s a lot of industries that serve to benefit from selling ultra processed foods, tobacco, alcohol. And evidently for-profit reasons, these companies don’t want to see those products being consumed at a lower level.

And so, they can actively lobby against government regulation or government interventions which can help reduce consumption. And the third reason is that is a bit more sort of specific to Australia and it is how hard prevention is to coordinate. So, in Australia, obviously there’s the different levels of government with different responsibilities and prevention falls across all levels of government, as well as the non-government sector.

The federal government holds some levers like some regulations and taxes. The state government is responsible for spending about 50 percent of the budget allocated to public health and tends to implement lots of programs. And then local governments do enforce some bylaws, for example, around food safety.

And so, getting all three levels of government, as well as different portfolios within each level of government to work together, to implement sort of coordinated packages, of solutions that can help reinforce each other and really encourage healthy behaviours is a big challenge in Australia.

Kat Clay: We’ve talked about, you know, how Australia’s not doing so well on the prevention side of things at the moment.

What I do wanna move on to is what the A CDC can and should do to help spur on better prevention.

Lachlan Fox: So, the ACDC is a really big opportunity to do be chronic disease prevention in Australia. A lot of other countries have CDCs, which have a range of roles. One role CDCs play overseas is to be an independent technical advisory group to government.

And so, this is what we are pitching the ACDC’s role in chronic disease. It would be very beneficial in Australia if we had a body such as the ACDC, whose role was to look at the evidence about prevention, to assess the evidence of different interventions, see what works and advise governments on what works best.

Then governments could make decisions about implementing certain programs. funding certain campaigns or taking regulatory action that would be aligned with this best evidence. We think that this evaluation function of the ACDC should go towards what we’re calling the prevention schedule. And this is no different to schedules used in other areas of medicine.

We in Australia have the pharmaceutical benefits schedule. there’s a technical group which assesses all different medicines. effective creates a schedule and then government funds them because they’ve been decided to be worth it. We think it should be no different for prevention and that should be a role of the CDC.

We think the CDC should advise governments on different regulatory settings. One thing which the government has actually done in recent years that has been quite promising is put together the national prevention strategy. this was a joint effort with the States and has been quite welcomed by public health bodies across the board. We think governments should continue to update that and the ACDC should have some input and advice when they update that every five years and another function of the ACDC, we think, should be to advise existing research bodies. on future areas of research. So, for example, there are a few research bodies that give out grant funding, some of which is to public health and prevention each year.

And we think the CDC could play a strong role helping them to direct funds into the best places.

Kat Clay: Peter, you’ve looked at CDC equivalents in many other countries while you’ve been preparing this report. What have you learned from these about how the ACDC should be best set up for success?

Peter Breadon: We think it’s important that the ACDC be independent. And some CDCs around the world, you remember when Lockheed was talking about, you know, why is prevention so hard? It’s because it’s about gains in the future, not today, because there are vested interests out there, harmful industries that will lobby and have lobbied and blocked government action in prevention, and because it requires this coordination role.

And for all those reasons, being, a bit outside. and being independent, a strong independent voice is, is really important. and we do that in other areas. We have a climate change authority to really push government about the long term. impact of climate change. We have a Reserve Bank of Australia, which is independent to set monetary policy interest rates so that we keep inflation under control a pretty unpopular entity, maybe as this podcast goes out, but probably over the long term beneficial not having those kinds of long-term decisions.

with short term pain completely controlled by politicians, and we’re not saying that the CDC should make the funding decisions or follow through and take the action like the Reserve Bank does, but we think we need that really strong independent voice out there to counterbalance, the, the kind of sometimes misinformation, and strong pushback on action that you get from some industries.

It also needs to be adequately funded and have the right skills. Lockheed mentioned that really good prevention often requires working across different functions of government. It might be about transport and planning, it might be about taxation and consumer protection, or it might be about health services.

And so having it again, independent, outside maybe the health portfolio, helps to take that broader view. and look at all the drivers of preventing chronic disease. But the other thing that comes out of the functions Lockie was talking about is that we don’t really have the system for prevention policymaking the way we do in other areas of policymaking and investment in health.

Lockie mentioned, you know, drugs and medical treatments. We have a schedule. We have ongoing recurrent sources of revenue. This is what we really need for, Prevention. So, we argue that the government also has to step up and create a national funding agreement with the states where they share the cost of increasing investment in prevention over time.

But importantly, that that investment is tied back to those interventions on the ACDC’s schedule, the cost-effective interventions that they recommend. And this will put that kind of rigor and as well as the funding into rolling out more prevention investment. The final thing I’ll add. Is that it’s very important that the states are a core part of this new entity and our report details, how to involve them in decision making, and make sure that this is a real national effort under the ACDC.

Kat Clay: Lockie, the ACDC would provide technical advice, but how do you picture governments using this advice? I mean, we can only look at the pandemic internationally to see the variety of opinions on the CDC in the U S would governments need to follow the ACDC’s advice, or could they choose to ignore it?

Lachlan Fox: Yeah. So as Peter mentioned, the ACDC would provide technical advice to governments, but unlike other bodies like the Reserve Bank, they wouldn’t make the final decision. The final decision on whether or not to implement certain regulations or fund certain campaigns would lie with government. We think that for a body, we think that a body like the ACDC shouldn’t necessarily have the power to spend lots of grant money or make regulatory decisions.

Because they cannot really be held to account in the same way as politicians by the Australian public. And when chronic disease prevention is such sort of an unbound, large, area, giving them the ability to fund different interventions is, is quite broad ranging and we can’t define it with a strict set of criteria, which is usually what we do for funding bodies and the like.

However, we do think that. If the ACDC provides public advice and regulatory advice, for example, which we recommend is tabled in parliament and the minister has to respond to, this will help to really build the presence of prevention and also give the public the information they need. To make decisions about whether or not they think the government is doing the right job.

If it’s more public that the government isn’t following evidence provided by the ACDC, it would be up to ministers to justify why they’ve deviated from that advice. And this isn’t too dissimilar from some of the new regulations. Some of the new legislative measures which are in place around pandemic advice, which some of the states have taken as well.

Kat Clay: Given NGOs have played a significant role in health prevention campaigns, and we’ve talked about Cancer Council’s Slip, Slop, Slap and Quit campaigns today. Wouldn’t we actually be better off funding already existing bodies than creating an entirely new one?

Lachlan Fox: NGOs like Cancer Council obviously have a very important role to play in the broader ecosystem.

of Australian prevention. Those bodies receiving funding and running campaigns like Slip Slop Slap has definitely benefited all Australians, but there are some things which a non-government body simply don’t have the power to do that we think the ACDC can do. Could do and would really benefit the Australian public.

And one of these real benefits is the fact that we can try and link the A CDC into government decision making. So, as we mentioned before, things like having a requirement in legislation that the ACD C’S regulatory advice should be tabled in parliament and politicians should be required to respond to it.

Is something that we can’t really set up with an NGO, for example, but we think is quite important. And another function is the coordination function. So having an ACDC that is part of, but also independent from government gives them a real strength in trying to bring together the states and the federal government and different departments in a way that might be more difficult for an NGO that doesn’t necessarily have a legislated authority to do any of those things.

So, while NGOs play a really important role, and we think their ongoing work is really doing wonders for Australians. There are a few things that the CDC should tackle, which is probably a bit hard for NGOs.

Kat Clay: Peter, I imagine that it could be quite powerful, the CDC working in concert with more specialized NGOs to deliver these, prevention programs.

Peter Breadon: That’s right, Kat. We don’t suggest that the CDC directly fund or deliver These prevention interventions instead, they would really do the hard-nosed, rigorous work about what is most effective and then government would fund that and then that money would cascade through our existing prevention ecosystem.

And that might be through state departments and state government services or government services, but equally. Through really important prevention NGOs that make such a big contribution, like the Cancer Council or the Heart Foundation, and also state based, independent prevention bodies. But having this national approach, having this national, list of what works, which currently we don’t have, and there’s all these scattered approaches to try and work that out, and then linking that back to the national strategy, focusing on those things that make the biggest contribution to existing national goals.

and then pushing that out through the system through a big new funding deal, that’s the way we get more coherence. but all those specialist players would still be able to play their part.

Kat Clay: Peter, what would you see the CDC looking at and evaluating first up? Well,

Peter Breadon: Kat, in our brief discussion today, we’ve touched on a lot of areas where Australia’s fallen behind.

We used to be a bit of a world leader in tobacco, where we had the plain packaging regulation, but recently we’ve seen some really exciting reforms overseas. New Zealand has passed a new law referred to as the tobacco end game, where people born after a certain year won’t be allowed to even purchase tobacco.

The U. S. is reducing the amount of nicotine in tobacco products is a really interesting thing they’re looking at. And we also talked about how in food, there’s lots of really well proven stuff about, you know, sugar and salt, et cetera, that we should really get on top of. The ACDC will also have a really important role in looking ahead and getting Australia back on track.

To that leadership position by starting to tackle emerging risks. You know, vaping is, is really spiking amongst young people. We’re seeing a really alarming rise in mental health concerns and conditions among young people. And some of this may be associated with new technologies and social media. Some of it might be mitigated through prevention efforts around social connection and use of technology and also indoor air quality.

it is now, you know, we know linked to a lot of chronic respiratory conditions. So, the evidence is emerging about all these new things as well. So, as well as catching up on a lot of particularly things about food and obesity, there is so much more that the, the ACDC can do over time. And it’s a really exciting opportunity to both catch up with best practice.

And start to forge, a new path leading on these new risks.

Kat Clay: To read the report we’ve been discussing, to find out our love of akka dakka puns, do check out the report at grattan.edu.au. It’s all there for free. We’d love to hear your opinions on this work. If you’d like to talk to us on social media, please do find us on Twitter at Grattaninst, and all other social media networks at Grattan Institute.

As always, please do take care, and thanks so much for listening.