THEO MURPHY (AUSTRALIA) HIGH FLYERS THINK TANK

Preventative health: Science and technology in the prevention and early detection of disease

University of Sydney (Eastern Avenue Complex), Thursday 6 November 2008

Professor John Chalmers FAA

John Chalmers is a graduate of the University of Sydney, with a PhD from the University of New South Wales. John was foundation professor of medicine at Flinders Medical Centre in Adelaide (from 1975 to 1996). He is now senior director at the George Institute, emeritus professor of medicine at the University of Sydney and at Flinders University, and consultant physician at the Royal Prince Alfred Hospital.

John's research has focussed on brain mechanisms regulating blood pressure and on clinical trials of blood pressure lowering. He was elected to the Australian Academy of Science in 1987 and has published over 450 papers. He has received many awards including the Volhard Medal of the International Society of Hypertension for 1998 and the Zanchetti Lifetime Award of the European Society of Hypertension for 2008. He was appointed a Companion in the Order of Australia (AC) in 1991.

Thank you very much Phil, Kurt and the Academy, for the opportunity to play a role in this Think Tank. I guess the starting point is that we are looking at preventative health and science and technology, in prevention and early diagnosis. We chose four areas: mental health, cancer, metabolic syndrome or disorders, and infectious diseases. The metabolic syndrome was meant to encompass cardiovascular disease and diabetes and to cover both the diseases and the risk factors, such as obesity.

I guess one of the most striking features for me today from everything we have heard is the commonality of risk factors across the whole panoply of the diseases that we have talked about and many of the ones that we have not talked about. The same things came up in all presentations.

The second big thing for me was what we know in relation to the interaction of genes and the environment. It keeps coming back to the need to strike the right balance in the research to get both of these into a meaningful framework. Also, the interaction between the various topic areas we were covering: for example, mental health has huge interaction with physical health – as you called it, Ian – and with the other three of today. Mental health predisposes and exacerbates all of the other diseases we talked about. Each of those is markedly affected by the presence of mental health in terms of recovery outcome.

So the outcomes of cancer, cardiovascular disease and infectious disease are integrally involved with mental health. I think the co-morbidity of mental and physical is one of the most important areas that we have to look at when talking about prevention. They helped to reinforce for me the meaningfulness of the term 'chronic diseases', which is gradually spreading through bureaucracies, health systems and planners to say: 'Don't think in silos of cardiovascular, cancer, respiratory or rheumatological conditions; think of them as chronic diseases which have a series of common antecedents, which also have problems that can be dealt with in a systematic manner through a health system with similar features.' Someone who has a chronic disease which is going to bring them into contact with the health system time and again has certain problems in coping with the health system which we need to address. Today it reinforced for me that the term 'chronic disease' really does mean quite a bit because there is so much in common between the ones that we have talked about, let alone the others that we have not talked about. Many of those raise similar issues; we could readily talk about obesity and think of arthritis – again, huge commonality.

The overwhelming importance of diet and nutrition came through across all areas today: exercise and inactivity or activity and alcohol, tobacco and obesity, whether we are talking about cancer, metabolic diseases, cardiovascular diseases, diabetes, mental health or drug and alcohol. Even the outcomes and impacts of infectious diseases are dependent on the physical and nutritional wellbeing and health of the individual patient who is suffering from an infection.

So I think I can understand the taskforce choosing obesity, alcohol and tobacco for phase 1 – and I understand it is to report in June 2009 – and giving a special focus to primary prevention and disadvantaged communities. I can see that makes a lot of sense. I would hope that many other things will get a place at the table as they progress to phases 2, 3 and 4 over years 2 and 3, as the taskforce continues; especially mental health and child health. Child health and obesity are incredibly important and will be, I am sure, a big part of the attention of the taskforce in relation to the obesity side.

And then there is indigenous health: obesity, alcohol and tobacco are incredibly important for indigenous health. I hope that at some time it gets to the point where it's a target in itself rather than through obesity, alcohol and tobacco, because I think it is so important in terms of the national agenda. Maybe it's being dealt with in other ways. There are taskforces on indigenous matters and indigenous health that perhaps will look at prevention in a serious way.  It is a matter of balance; the government has so many taskforces going that maybe we have to be aware of who is addressing what.

I think one of the more difficult things for us – and remember that we have talked a lot about policy engagement – is that this is a bunch of early- and middle-career researchers. The bigger problem is: how do we provide better research and evidence for the people who are putting it into policy and practice? Looking at that, what are the important elements of research agendas that we need to focus on?

One thing that came out time and again was interactions between genes and environment and doing more in that area. So many of us work either on the environment or on the genes, and never the twain shall meet. We all talk at these meetings about how important it is to meet, but we don't do it. That was one message I got: the importance of it and our failure to do it sufficiently well.

A second is making physiological sense of genetic research, and Chris Goodnow talked eloquently about that. He and Paul Korner had a discussion on the need for integrated models; the need to put the genetic, environmental and physiological into an integrated model where we talk about genes and the environment, the animal model and the human disease, the individual patient and the population health aspect. We must go all the way to epidemiology through pathogenesis and pathology and through 'omics and genetics to health problems and health systems delivery – all the way through – because, if you do not get into the health system delivery, the evidence never gets translated.

I think that is one of the biggest messages I have: we have to break down the silos. I think that is a huge challenge for us as researchers, in that we are comfortable in the little boxes that we are in. Progressively, over the last 10 years, we have done more multidisciplinary work; but it is difficult. I think that one of the biggest challenges for us as researchers is to cross those silos and meet all the other halves that are here, because we understand our half but not the other half. So multidisciplinary, integrated research which we have been moving towards and which is starting to develop – but which we need to do much more of – is one of the big challenges for us as researchers.

We have another big challenge. We talk about translation into policy and into practice. One of the problems is that we are not very good with our messages. If you look at the public interpretation of our messages – read newspapers and listen to TV and radio – it is the little bites that get through time and again. Sometimes it is our fault and sometimes it is the media's. You hear about this or that little gene, or about this or that clinical trial. You hear little disjointed messages. One of the things we ourselves have to try to progress towards, is helping to develop an integrated message which can be used in a more effective way by the media. If we give them a single segmented message on a little agenda, that is all they will have. We have to put it in a context and maybe work together towards integrated messages which a patient, member of the public or a health professional can understand. We have a hell of a problem in communicating with health professionals.

There are two very different things. One is translation into policy, which has been discussed a lot this afternoon – and I think most of the interventions were very valuable – but the other is translation into clinical practice, which again is very, very difficult. If you look at the gap between evidence and practice, it is huge almost everywhere. It is not enough to produce the evidence. It requires us probably to do more research on effective means of translation into practice. It is a different sort of research. It is not just as simple as drawing up good guidelines. Good guidelines probably are implemented for about 20 to 30 per cent of the population, if you look at stats across the board in almost any area of medicine. But that gap, that failure to reach the other 70 to 80 per cent, is there because we are not very good at communicating either with patients – that is, the public at large – or with the health professions.

Think of the poor general practitioner, that poor individual. We'll talk about cancer. There are about probably 10 or 15 common cancers, let alone all of the others. Talk cardiovascular diseases and they have to be across all of that. Then there are dermatological diseases – which we got nowhere near – psychological diseases, mental health diseases and childhood diseases. It is a huge problem. They have guidelines but the fact is that many of these poor people have little chance to read all the longwinded guidelines, let alone observe and implement them. How do we get past that, when we write guidelines that are 40 pages long? The International Diabetes Federation guidelines make up a booklet of about 80 to 100 pages. If we could give them one page on something, they might just read it. As for getting as far as implementing it, we have a hell of a problem.

Within special fields, it is hard enough. If you are talking about cardiologists implementing the messages of cardiological research or cancer specialists or oncologists, it is hard enough to get good observation and compliance with recommendations within those fields but, in general practice, it's a hell of a problem. As researchers, we have to do a bit more research on what would help translation and how to do it, because it is plain that just putting guidelines out does not work. We need interactive programs with the health practitioners.

I think the age of IT is one of the things which can really help us – people have talked about that already – because we can probably reach directly to the patient. One thing that is most effective is a patient asking their doctor about this or that bit of information. It may be a recommendation about how you should treat hypertension or diabetes or whether or not you should have a certain screening program. To have the patient asking the doctor about it is a very powerful way of getting implementation.

So I think information technology has a huge role to play in helping us, not just as researchers, but with the implementation of the fruits of research with information and communication. Probably electronic decision support systems for doctors and patients will need to be very different. But, if you want to do something about inactivity or activity in the general population or nutrition, the internet and IT give us an enormously powerful tool which wasn't around 10 or 15 years ago. Probably over the next decade we will have to learn how to use that.

Data linkage: I completely agree that that is terribly important. As Bruce Armstrong said, we are starting to get to the point where we have sufficiently good databases we can access and link. There are things like that '45 and Up' cohort study in New South Wales, which is now linked to databases in New South Wales hospitals and at Medicare and with the Pharmaceutical Benefits Scheme. That will enable us to do things that this cohort study could not have done 10 years ago.

Another aspect of education which I think the Academy is on and which is really worthwhile thinking about, is schools. If we want the public to be well informed, there is nothing better than starting at school. I think the Academy has a very active program of taking science into schools, and maybe health science and prevention and so on could be an important specific element of that program which the Academy is running.

There are a few take-home messages that I got out of today. Number one is that we are all mutants – I loved that – and our cells are mutating away at a very fast rate. Thank God that it doesn't happen all at once in the whole body. The second thing I got from Chris Goodnow is that Darwin got it wrong: it's not selection of the fittest but selection of the fattest. That was wonderful. There is no evidence that there has ever been selection for being thinner. All the genetic selection models seem to have been for those with good flesh on them.

While talking about that, I loved some of the eating messages. Number one is to eat more broccoli; just remember that. Buy broccoli on the way home tonight. Number two is the Mediterranean diet – and I loved it when Kerin O'Dea talked about this. She said that you can stay fat, provided that your fat is in the right place. I am going to keep eating Mediterranean and stay nice and fat.

The screening side: interesting discussion and brought out by a number of groups – the importance of good evidence before implementing a screening program.  Some have been incredibly valuable and others wasted a large amount of resources and some have actually done harm.  That needs to be well considered.

The mental health group talked about the importance of more science and technology to help inform mental health. I think we need more scientific technologies – as I have spoken already – to bridge into translation.

One of the problems with indigenous health – and I am very pleased that we gave that a good focus – is that we're not quite as good at knowing what to do. We know there is a gap between evidence and practice in the broad populations of the world. The gap in indigenous health is partly there because of lack of resources and attention; but it is also there because we don't know what the strategy ought to be to deal with implementing the fruits of research in disadvantaged groups. I suspect that it is not the same as dealing with it in the broader situation (where we are bad enough) in the general population. Maybe we need more evidence about what works well in different social situations, in which we have disadvantaged indigenous people in urban situations and in rural situations. Quite different strategies are needed in different situations.

I liked two or three of the specific recommendations. For example, that we ought to make sure that we have a five-yearly national health survey and that maybe we need a CDC [Centre for Disease Control]. They were two very specific things that came up in different parts of the day. Also, there was this business about biobanks and biorepositories. We have a huge number of biobanks and tissue banks across the country, which are, as someone said, 'small, disjointed and not linked'. It is a challenge to get an effective set of samples which have sufficient commonality of data. Whether it is a breast tissue bank, a blood bank, a brain bank or whatever, the different elements can be combined into something meaningful. We had a working group on clinical research in Australia that reported to the NHMRC and it suggested that the NHMRC should take the leadership role – maybe the Academy or the NHMRC – in doing something to put these biobanks together.

Let me just finish by saying that I think it is an important agenda for Australia and for our government in difficult economic times. I hope that maybe the Academy can work with government to help to make sure that prevention does not fall off the radar. There are so many priorities that the government must address. The current state of the world's economy and the budgets, let alone the Commonwealth–state set-up that we have in our country, leads me to think that maybe two years ago was a more propitious time, when the economy seemed to be booming. So maybe there is a real challenge for the Academy to get this on the agenda and keep it on the agenda. I hope, Kurt, that you and the Academy will pursue it relentlessly on our behalf. Thank you.