OzSAGE Independent Expert Panel

OzSAGE has convened an independent expert panel to produce a report on an Australian Centre for Disease Prevention and Control by July 1 2022. The panel has expertise in public and occupational health and prevention, and includes past chief health officers and others with substantial depth of knowledge on the history of public health in Australia and recurrent deliberations about establishing a Centre for Disease Prevention and Control. This report is made by the panel as independent experts.  Panel members were selected on the basis of being independent (not being potential recipients of funding for a new Centre for Disease Prevention and Control). In addition to producing a report, the panel is available to government and opposition as an independent expert resource.

The development of an Australian Centre for Disease Prevention and Control (CDPC) has been debated intermittently for over 30 years without resolution [1-4]. Australia has a number of mechanisms to respond to pandemics and epidemics of communicable diseases, including The Communicable Diseases Network of Australia (CDNA), The Australian Health Protection Principal Committee (AHPPC), both of which have representatives of states and territories. Pandemic response committees which existed at the time of the 2009 influenza pandemic no longer exist, and The Australian Technical Advisory Group on Immunisation provides advice on vaccine programs. However, there is no national operational response capacity for global or cross-border epidemics of either communicable or non-communicable, including occupational, diseases.

Australia’s response to COVID-19 has revealed significant gaps in the way we manage public health problems. We did not succeed in having a harmonized approach to COVID and this led to a less than optimal degree of control, with outbreaks crossing state and territory borders [5]. The pandemic was worse in communities already disadvantaged by social and economic drivers of poor health [6, 7].  Our immunization programme was not well organized, resulting in important gaps in protection [5]. There was a considerable amount of reinventing the wheel.

Effective responses to public health problems require leadership informed by a sound, scientifically based, understanding of the issues [8]. Our view is that current processes and structures do not provide the best basis for achieving this at a national level and that this is true both for emergent public health threats and for ongoing threats to health. We consider that a national resource, in the form of a National Centre for Disease Prevention and Control, will strengthen Australia’s ability to respond to public health problems.

Public health is defined as an organised response to protecting the health and wellbeing of populations [9] and comprises three pillars:

• Health protection (for example, legislation such as for seatbelt use, smoking or mask mandates)
• Prevention (such as immunization programmes, masks, testing, tracing and surveillance)
• Health promotion (enabling people and communities to increase control over, and to improve, their health)

Public health in Australia is primarily a state and territory responsibility. In the past, this has often led to fragmentation of responses, when coordinated action would have been more effective. However, there are examples of national collaboration, which have been highly successful. Unfortunately, most of these examples have been short-lived.

Our health care system needs to focus on prevention as well as on the treatment of established diseases. A national resource is needed to enhance the focus on a long-term view of public health, by engaging in the science, understanding and practice of health protection, prevention and promotion. A national Centre would support governments; state, territory and Commonwealth, by providing high quality analysis and advice, by providing staff and services as needed and by providing operational response capacity. These services would be provided for both emergent and ongoing public health issues. It would also coordinate multidisciplinary workforce training and capacity building in public health and public health preparedness.

A national Centre needs to serve both national and state and territory interests.  Although public health is primarily a state and territory responsibility, a national approach can bring effectiveness and efficiencies, especially when faced with threats that cross domestic and international borders. It would need to be responsive to these different interests, but be able to resolve divergent approaches if this is necessary to achieve public health objectives. The governance of a national centre will bring many challenges. There are several possible models, but in principle it should support governments; state, territory and Commonwealth, and this requires a management system in which state, territory and Commonwealth governments have confidence.

A centre also could be a focal point for international response and collaboration.

 

 

A national Centre for Disease Prevention and Control

On average, the Australian population enjoys very good, and generally improving, health [10-12]. By several measures we are among the healthiest people in the world, with long life expectancy [10, 12]. However, the death toll of COVID-19 has reduced life expectancy in countries like the US [13, 14], and effects in Australia may be seen in the next few years, with a lag corresponding to the period of closure of international borders and low COVID-19 incidence. Australians generally state they have excellent or very good health. However, there is still room for improvement, and almost 50% of Australians live with chronic disease [12, 15]. While average health is very good, some subpopulations have much worse health; Aboriginal and Torres Strait Islander people have markedly worse health than the rest of the population [12, 16]. Similarly, people living with a disability have a shorter life expectancy compared to other Australians [12, 17, 18]. This is both unjust and economically inefficient.

Principles of operation

In order to make further gains we believe that a national Centre for Disease Prevention and Control should be established. It should operate under the following principles

• It should take prevention of ill health and promotion of good health and wellbeing as its primary goals, and public health control of disease where this is not possible.
• It should have 24/7 operational functions and have responsibility for responses on the ground, actions that enhance and support state and territory functions. These should include support for and enhancement of continuing programmes, such as immunization, screening, disease surveillance and anti-tobacco measures, as well as short term responses to emerging threats including response to cross-border or international emergencies. It should also have advisory functions and help to build a well-trained public health workforce.
• It should be evidence based, using the best available scientific knowledge to inform its actions, and assist states and territories in evidence-based public health responses. In the absence of evidence it may need to create knowledge through sponsorship of appropriate applied research. The Centre should be scientifically independent to enable it to work from the best available scientific knowledge. Legislation should be considered to ensure independence.
• It should be socially and politically responsive, taking account of social values, and should be subject to political oversight. A major issue is the question of public trust. The Centre should be established and operated in a way that builds public trust. Trust is essential for effective public health outcomes [19-21].
• It should cover a broad range of public health functions, ranging from interventions against specific problems, such as communicable diseases outbreaks, through determinants of health such as tobacco smoking and diet, to the broader upstream social determinants of health. The COVID experience has shown that there is a strong interrelationship between chronic and communicable diseases; people with pre-existing chronic diseases had poorer outcomes after contracting COVID [22-25]. For several populations, particularly Indigenous peoples, progress in improving health will not happen unless there are real changes to the social conditions borne by these people. A national Centre should address a broad range of public health issues.
• It should be national and bring together efforts made by the Commonwealth and the states and territories, and the private and health research sectors. It should have the capacity to provide support to states and territories, which may be quite considerable in the event of a major pandemic.

Functions of a Centre for Disease Prevention and Control

Essential functions of a CDPC are

• In conjunction with the Australian Institute of Health and Welfare, and the states and territories, monitoring and evaluating the health status of the population.
• Detecting, investigating, and responding to emergent threats to health.
• Contributing to the creation of the conditions that prevent ill health and promote good health, including addressing behavioural risk factors such as smoking, high blood pressure, diet, and broader risks such as social determinants, environmental risks, occupational risks and consequences of climate change.
• Developing a national strategic plan to improve and promote equity in health of the population. It is particularly important that it has a major focus on improving the health of Aboriginal and Torres Strait Islander populations.
• Developing template regulatory instruments to improve health, enforcing and monitoring the application of regulations to improve health, and evaluating the effectiveness of regulatory instruments.
• Evaluating and promoting equity of access to preventive health services.
• Assessing health risks arising from climate change
• Contributing to public health workforce training, at all levels including surge workforce capacity.
• Contributing to pandemic, emergency and disaster responses.
• Sponsoring, where needed, applied public health research.
• Contributing to quality and safety in clinical health care, for example in the control of health care associated infections, and preventing the emergence of and spread of antimicrobial resistance.

These functions should be exercised either through, or with the cooperation of, states and territories.

Attributes of a Centre for Disease Prevention and Control

Attributes of a CDPC include

• National recognition. This requires high levels of expertise and high levels of confidence and trust by society, including the public, experts, and political leaders. The Centre should have the ability to instigate responses to threats to health on its own motion, except for disasters or major health emergencies, where the Centre should be the main source of expertise and advice and contribute to responding staff to assist political leaders and other agencies in responding to crises.
• National scope. This requires governance arrangements that allow for Commonwealth, state and territory and non-government sectors to work effectively together.
• Independence and scientific credibility. The Centre’s operations should be driven by evidence, supported adequate resourcing and infrastructure. The Centre should have adequate staffing, facilities and funding to achieve its objectives
• A high level of collaboration with other health sectors, including clinicians, researchers, non-government organizations and the private health sector.
• National accountability, through a respected governance process.

Governance

Governance arrangements for a CDPC will need to be carefully crafted. A CDPC will need to respond to the social and political concerns of the day, yet it needs also to be scientifically independent, focus on long-term health, and be able to pursue agendas on their scientific merits. In the Australian context, it will need to recognize the constitutional reality that public health is primarily a state and territory matter, and some form of delegation and/or control by states and territories will be required. It needs to recognize and promote the benefits of a national, consistent, and cost-effective response to issues. It needs to recognize the role of the Commonwealth and national agencies. These considerations also mean that the CDPC will need to be some form of public sector agency.

Some possible arrangements include

• A Commonwealth line agency, responsible to a Commonwealth minister. This is not our preferred option as it is unlikely to ensure the ongoing support of states and territories.
• A Commonwealth statutory authority, with a board and ultimate responsibility to a Commonwealth minister. The board should include state and territory appointed representatives under an arrangement with National Cabinet.
• A Commonwealth business enterprise, with a board, including state and territory representation, and looser responsibility to a Commonwealth minister.
• There could be an arrangement that the CDPC operates under a “national law” enacted by each state and territory, which delegates some functions to the national agency. Such a model currently exists for health professional registration [26].

There are agencies overseas which operate in federated nations, or groupings of nations, which have addressed complex issues of governance, and it would be worth examining their governance structures (see the appendix on international examples below). The final model should be developed in consultation with all governments and relevant stakeholders.

Most public health functions will remain the responsibility of states and territories. The CPDC should be a resource that all states and territories (and the Commonwealth) can draw on to assist in the exercise of their functions. The CPDC should be required to be transparent in the advice it offers, and public health actions it undertakes, including being clear about the evidence base.

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View the full report here at the OzSAGE website.

 

Panel members

Prof Bill Bowtell (Adjunct professor at UNSW and a strategic health policy consultant. Involved in Australia’s response to HIV/Aids and global response to HIV and other infectious diseases. OzSAGE member)

Ms Kate Cole (occupational hygienist, OzSAGE member).

Prof Stephen Duckett (health economist, Honorary Enterprise Professor, University of Melbourne. OzSAGE member)

Dr Kalinda Griffith (UNSW Scientia Lecturer, Centre for Big Data in Health, expert in measurement of health disparities, with a particular focus on cancer and Indigenous Data Governance)

Dr Robert Hall, Chair (former Chief Health Officer, Victoria, a founder of the Communicable Disease Network of Australia).

Prof Lisa Jackson Pulver (deputy vice chancellor, University of Sydney)

A/Prof Marion Kainer (infectious diseases physician and medical epidemiologist, Western Health, past US CDC employee and trainee).

A/Prof Kamalini Lokuge (ANU, public health physician who has worked for Médecins Sans Frontières, WHO and the International Committee of the Red Cross in a range of humanitarian emergencies. OzSAGE member)

Dr Cathy Mead (former Chief Health Officer, ACT, a founder of the Communicable Disease Network of Australia).

Prof Michael Moore (Past CEO of the Public Health Association of Australia and former ACT Minister of Health).

Dr Karina Powers (Occupational Physician, MPH,  OzSAGE member.

Prof George Rubin (former Chief Health Officer, NSW, past US CDC employee and trainee).

A/Prof Linda Selvey, (A/Prof public health UQ and former Executive Director, Population Health Queensland).

Prof Tony Stewart (Director of the ANU Master of Applied Epidemiology, Australia’s field epidemiology training program, and previously, WHO’s Health Emergencies Program and the Global Outbreak Alert and Response Network).

A/Prof Lisa Whop (Torres Strait Islander epidemiologist, Senior Fellow at ANU and NHMRC EL2 Fellow)

 

References

1.       Douglas, R.M., Does Australia need a centre for disease control? Med J Aust, 1987. 147(10): p. 493-6.

2.       Kelly, P.M., et al., Australia needs a national centre for disease control. Medical Journal of Australia, 2010. 193(10): p. 623-624.

3.       Australian Medical Association Limited. AMA Position Statement: Australian National Centre for Disease Control (CDC) 2017; Available from: https://www.ama.com.au/position-statement/australian-national-centre-disease-control-cdc-2017#:~:text=Australia%20must%20play%20a%20global,by%20establishing%20a%20national%20CDC.

4.       Australian House of Representatives Standing Committee on Health and Ageing, Diseases have no borders, Chapter 6: Does Australia need a national centre for communicable disease control? 2013.

5.       Stobart, A. and S. Duckett, Australia’s Response to COVID-19. Health Economics, Policy and Law, 2022. 17(1): p. 95-106.

6.       Australian Institute of Health and Welfare. The first year of COVID-19 in Australia: direct and indirect health effects. 2021; Available from: https://www.aihw.gov.au/reports/burden-of-disease/the-first-year-of-covid-19-in-australia/summary.

7.       Australian Bureau of Statistics. COVID-19 Mortality in Australia, Deaths registered to 31 January 2022. 2022; Available from: https://www.abs.gov.au/articles/covid-19-mortality-australia-deaths-registered-31-january-2022.

8.       Koh, H.K. and M. Jacobson, Fostering public health leadership. Journal of Public Health, 2009. 31(2): p. 199-201.

9.       Public Health Association of Australia. What is Public Health? 2018; Available from: https://www.phaa.net.au/documents/item/2757.

10.     Australian Institute of Health and Welfare. International comparisons of health data. 2020; Available from: https://www.aihw.gov.au/reports/australias-health/international-comparisons-of-health-data.

11.     Australian Institute of Health and Welfare. How healthy are Australians? 2020; Available from: https://www.aihw.gov.au/reports/australias-health/how-healthy-are-australians.

12.     Australian Institute of Health and Welfare, Australia’s health 2020 data insights, in Australia’s health series no. 17. Cat. no. AUS 231. 2020, AIHW: Canberra.

13.     Islam, N., et al., Effects of covid-19 pandemic on life expectancy and premature mortality in 2020: time series analysis in 37 countries. BMJ, 2021. 375: p. e066768.

14.     Andrasfay, T. and N. Goldman, Reductions in US life expectancy from COVID-19 by Race and Ethnicity: Is 2021 a repetition of 2020? medRxiv : the preprint server for health sciences, 2022: p. 2021.10.17.21265117.

15.     Australian Bureau of Statistics. Chronic Conditions. 2018; Available from: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/chronic-conditions/latest-release#:~:text=Endnotes-,Key%20statistics,57%25%20compared%20to%2051%25).

16.     Australian Institute of Health and Welfare. Indigenous health and wellbeing. 2020; Available from: https://www.aihw.gov.au/reports/australias-health/indigenous-health-and-wellbeing.

17.     Australian Institute of Health and Welfare. Health of people with disability. 2020; Available from: https://www.aihw.gov.au/reports/australias-health/health-of-people-with-disability.

18.     Trollor, J., et al., Cause of death and potentially avoidable deaths in Australian adults with intellectual disability using retrospective linked data. BMJ Open, 2017. 7(2): p. e013489.

19.     Bargain, O. and U. Aminjonov, Trust and compliance to public health policies in times of COVID-19. J Public Econ, 2020. 192: p. 104316.

20.     Sopory, P., et al., Trust and Public Health Emergency Events: A Mixed-Methods Systematic Review. Disaster Medicine and Public Health Preparedness, 2021: p. 1-21.

21.     Organisation for Economic Co-operation and Development. Enhancing public trust in COVID-19 vaccination: The role of governments. 2021; Available from: https://read.oecd-ilibrary.org/view/?ref=1094_1094290-a0n03doefx&title=Enhancing-public-trust-in-COVID-19-vaccination-The-role-of-governments.

22.     Liu, B., et al., High risk groups for severe COVID-19 in a whole of population cohort in Australia. BMC Infectious Diseases, 2021. 21(1): p. 685.

23.     Kompaniyets, L., et al., Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020-March 2021. Prev Chronic Dis, 2021. 18: p. E66.

24.     Dessie, Z.G. and T. Zewotir, Mortality-related risk factors of COVID-19: a systematic review and meta-analysis of 42 studies and 423,117 patients. BMC Infectious Diseases, 2021. 21(1): p. 855.

25.     Horton, R., Offline: COVID-19 is not a pandemic. The Lancet, 2020. 396(10255): p. 874.

26.     Australian Health Practitioner Regulation Agency (Ahpra). Legislation. 2022; Available from: https://www.ahpra.gov.au/About-Ahpra/What-We-Do/Legislation.aspx.