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My presentation today is being done within the framework of Setting the Agenda, the vision and action manifesto recently released by the ACT Minister for Health and Community Care, Michael Moore. Setting the Agenda is an exciting blueprint for action, a major change agenda. It establishes a clear vision for a healthy community in the ACT, and emphasises a series of community principles which will guide the future development of the health and community care system.
If you take the opportunity to read it and it's available on our web page.Äs you will see that having established the vision and principles it then tells a very logical story about the actions we need to take and explore to achieve our goals, and about the interdependencies between thoseactions.
This includes: building on the World Health Organisation's concept of Health for All putting in place the partnerships and processes to establish Canberra as a healthy city and Greg Goldstein and Pat Mowbray are travelling to Canberra today to assist us in our endeavours informing, empowering, partnering and involving consumers, both in self care and as active partners in the formal health system strengthening the role of primary health care to take on more integrated and increasingly specialised service roles developing new integrated care models supported by pooled funding mechanisms reforming the acute hospital system to reflect both trends in health care and this changed philosophical approach harvesting the opportunities provided by communications and information technology, and maximising the benefits of both science and consumer choice in relation to outcomes, evidence, and best clinical practice.
The philosophical shift outlined in Setting the Agenda is in accord with the WHO vision of Health for All. For the Public Health Association, this is of course preaching to the converted. The approach is well versed.
However it is an ambitious agenda, and implementation moving from ideas to application is a huge challenge.
Where we have dared to be different is in establishing a commitment to action which I believe puts us at the forefront of contemporary health policy in Australia. While not underestimating the challenge, the ACT has chosen to paint a lofty vision because we believe we can make a difference, that we can help set the agenda for the type of health system we want for ourselves, for our families, for our society.
As a small boutique State, we exhibit a whole range of factors which give us the potential to be more agile and creative than many other Australian health systems. We can use flexibility, speed, and innovation to pilot and trial new ways of doing thingsto be a model of care for the rest of the country.
I am confident we can make a real difference through the directions we will be pursuing over the years ahead. In fact, we will not achieve the full potential of our approach unless we develop the type of health system where, instead of focusing on funding, program, and professional boundaries, we focus on the future opportunities and outcomes for individual consumers and population groups as the overriding driver of our decisions and interventions.
Of course, daring to be different, to be at the forefront of change, is not new to us, and my topic here today is one where already we have established something of a reputation in this way that of drug abuse and innovative approaches to harm minimisation.
Given the eminence of my Minister, Michael Moore, in relation to drug reform, I expect that reputation to grow rather than diminish.
Indeed it is highly appropriate for me on behalf of the ACT to speak at a session which deals with `Future Opportunities' in public health because the approach we have taken has consistently been about future opportunities for all of those affected by drug abuse, whether directly or indirectly.
It would be whimsical of me to revisit the notion of our heroin trial while in this forum. In the highly charged atmosphere of a Federal election, it would serve little point.
I simply observe that we had adopted an evidence-based approach for the trial and that it was proposed as a part of our much broader approach to harm minimisation. And despite its current demise, we need to be optimistic about what the proposed heroin trial has achieved.
Certainly it successfully increased the level of community debate about heroin use as a health problem. This included an increased focus on alternative maintenance and treatment options. In that way I think it was an important element in triggering the range of trials which are either under way or under development in Australia trials which in fact provide the first significant new pharmacotherapy treatment and maintenance alternatives since methadone was introduced so many years ago.
Following the Commonwealth's decision not to support the ACT heroin trial, we have joined with NSW and Victoria to investigate two alternative treatments for opioid addiction.
We are involved in and funding two pilot studies, due to commence shortly in the ACT:
The first trial involves an examination of the use of bupremorphine for the management of heroin withdrawal in an inpatient setting, followed by naltrexone for maintenance.
The second trial will investigate accelerated detoxification from methadone using naltrexone.
However my focus today is on two other significant drug related public health initiatives as examples of the ACT's harm minimisation approach to drug use, contrasting both a legal drug and an illegal drug. These are smoke free areas legislation and safe injecting facilities.
We are all aware of the fact that tobacco smoking is known to be the single greatest cause of death or disease by licit or illicit drugs.
And the links between `active' smoking and the effects on other members of the community and children through `passive' smoking also are well established.
The 1997 National Health and Medical Research Council review of scientific evidence concluded that exposure to environmental tobacco smoke causes lung cancer in adults, respiratory illnessin children, contributes to the symptoms of asthma in children and also may cause coronary heart disease in adults.
Many jurisdictions have taken the view that non-legislative means will suffice to provide smoke-free enclosed public places. We have not. In the ACT, we have led the way on legislating to minimise the harm to members of the community with the Smoke-free Areas (Enclosed Public Places) Act 1994. This Act aims to minimise people's exposure to environmental tobacco smoke in public places and is supported in employee-only areas by the Code of Practice for Smokefree Workplaces, which has evidentiary status under the ACT's Occupational Health and Safety Act.
The underlying principle of the Act is that people should be able to carry out their normal daily activities and participate fully in the life of the community without risks to their health from exposure to environmental tobacco smoke.
In implementing the legislation an incremental approach was adopted because community support and social norms are very important in supporting legislation which essentially relies on self-enforcement.
First, smoking was prohibited in most enclosed public places. These included theatres, health care facilities, shopping centres, taxis, public transport, hairdressers, showrooms, sporting centres and retail outlets.
Second, two months after gazettal of the legislation, restaurants were required to go at least 50% smoke-free, and then totally smoke-free after 12 months.
However, restaurants can apply for an exemption which permits smoking in up to 25% of the dining area, on condition that they meet certain criteria.
Interestingly, even with an exemptionprovision, only 11 restaurants have obtained an exemption out of more than 400 restaurants in the ACT.
Clearly smoke-free dining is thepreferred option of the community.
The last phase at least in the current legislation involves licensed premises, the pubs and clubs which are the traditional hangout of many smokers. Quite understandably, tackling this area is the toughest of the lot.
Again, we have phased the arrangements in. Currently licensed premises can use transitional arrangements which permit smoking in up to one-third of the public floor area.
However from 10 November in less than two months smoking will be prohibited in licensed premises unless they have obtained an exemption. A licensed premises exemption permits smoking in up to fifty percent of the public floor area but once again specific requirements have to be met and these are not without cost, for example in relation to air conditioning and smokeextraction standards.
Thus in the ACT, non-smoking within most enclosed public places is now becoming the norm. There has been no evaluation of this change in expectations; however, many ACT residents are shocked and surprised when they go interstate and are exposed to tobacco smoke in restaurants, shopping centres and other enclosed public places.
The Smoke-free Areas Act has been a success in minimising people's exposure to tobacco smoke and changing smoking behaviour in most enclosed public places. The final phase of the Act will be the greatest challenge for us to implement as there is of course a strong smoking culture in licensed premises.
While we have been undertaking an education program throughout the transitional stage and this will intensify leading up to 10 November, I do not expect the final phase to pass without comment and I am sure everyone will watch with interest.
Likewise I think everyone is watching with interest the various initiatives being undertaken to deal with the increasing problem of heroin dependence in Australia.
With our proximity to Sydney, this is as much the case for the ACT as anywhere else, and one approach we are developing involves safe injecting
facilities.
Building on the excellent albeit unconsummated work of the NSW Parliamentary inquiry and, following consultation with both Government and non-Government service providers in the ACT, a model is being developed for a facility for injecting drug users incorporating a safe injecting area.
I qualify the following remarks on the basis that there are several hurdles to overcome before such a facility becomes a reality. However it is proposed that such a facility provide a safe and stable environment where clients may access a range of services including health promotion, counselling and medical treatment as well as referral to appropriate services such as housing or sexual assault services for furtherassistance.
I was able to visit safe injecting rooms, or consumer rooms as they were interpreted to me, when I was in Frankfurt in Germany recently.
I must admit it was a somewhat sobering experience to stand in a room while a dozen people legally inject themselves with heroin. However after the first time it is probably less disturbing than the experience of having people inject with dirty needles and mop-up with bloodied tissues in doorsteps or on curbs as you walk by.
Frankfurt (like Berne and other places which have introduced such facilities) of course has a different history to ours. They had a very open drug culture, with thousands of people a day publicly injecting themselves, particularly in a park in the centre of the city.
In Australia we need to develop our own solutions to meet local problems.
However there are two important principles which emerged for me from my visit to Frankfurt:
1. The strength of bipartisan support, including political support, and support from the various agencies involved such as health and drug workers, police and prosecutors.
The changes in Frankfurt initially were triggered by the public nuisance aspects of public injecting, with demand from the community and from the business sector to get people off the streets. It was not until later that dependency was broadly accepted as a health problem.
2. The emphasis on safe injecting facilities as being only one small part of a broad harm minimisation approach.
To focus on safe injecting facilities as other than an element of a broadly based approach would over-emphasise their importance. They have proven to be useful and indeed essential elements to the approaches being taken elsewhere, but they are only one of the many elements we need to have in place in a properly planned harm minimisationprogram.
In Frankfurt, safe injecting facilities developed as a part of a much larger harm minimisation approach. This included massive expansion of needle exchange and methadone programs.
The safe injecting facilities were introduced in association with the development of crisis centres established to enable contact with heroin addicts who were at their lowest threshold.
The crisis centres were set up to provide basic support for people in desperate need, including services such as accommodation, food, and laundry.
However of course the people using these facilities were still addicted and so continued to shoot up, in showers, rooms, or other nearby places.
So the safe injecting places were established to provide clean injecting equipment in a hassle free and safe environment.
Overall the harm minimisation approach has been highly successful, with a significant reduction in public injecting, and in the spread of blood borne diseases.
To quote some statistics from Frankfurt: the number of deaths from overdose has dropped from 147 in 1991 to 22 last year; and the number of emergency overdoses has dropped from 100 a week in 1992 to two a week now.
I reinforce the point that this is due to a whole range of harm minimisation strategies rather than simply to the safe injecting rooms. However the authorities in Frankfurt do regard the safe injecting rooms as a fundamental part of their strategy.
They also have not used either the crisis centres or the injecting rooms as a way of forcing people into assistance programs, but rather have made counselling and other services available for those who want to seek that help. This is, as I said, lowest threshold contact.
Perhaps one of the most impressive results has been the turnaround in attitudes: there is broad community support for the approach the police and prosecutors were sceptical at first, but knew that what they were doing was not working, and now are highly supportive; and the police and people working with heroin users are now working in collaboration: instead of the police being seen as the enemy a level of trust has developed and they are now pulling on the same side.
In the ACT we also are emphasising the point that a safe injecting room would be only one element of a broader community based approach for injecting drug users.
This service would be developed as an entry point for injecting drug users to
access services and support, including detoxification services, methadone or
other treatment programs.
Clients would be able to access clean injecting equipment, to inject in a clean, safe environment and to dispose of equipment safely.
The provision of supervised, safe injecting facilities would also provide more immediate and reliable medical attention for those who overdose as well as provide a safer work environment for ambulance officers attending an overdose.
The public safety implications of injecting drug use also would be improved.
By reshaping the circumstances under which a person injects, a safe injecting facility not only has the potential to improve the health of the person but reduce the criminal and public nuisanceimpact of intravenous drug use. The provision of safe disposal facilities would reduce the risk associated with injury
from poorly disposed of injecting equipment.
There are of course a range of legal and associated issues to overcome, including ensuring public debate and transparency of what is proposed. However within those parameters our Minister, Michael Moore, is committed to pursuing this approach as a priority, and I would venture that again we are likely to be the leader in this area.
Heroin and tobacco may be two very different drugs, but in concluding I want to stress two common features of the approaches I have outlined today:
they are based on an overall philosophy of harm minimisation; and they are not necessarily easy or popular choices.
Smoke free places tackles some of our most basic norms having a beer and a smoke at the pub while the establishment of a safe injecting facility confronts community attitudes and values about a safe society.
In one, we are restricting use of a legal drug, and in the other we are recognising the reality of the problems of use of an illegal drug.
But these approaches are in fact compatible, they are based on common principles of minimising harm, and the difficulties of winning that argument in public debate are not a reason to stop pursuing these types of solutions.
The ACT is committed to looking at a range of flexible, pragmatic options for all drug dependent people, with the aim of reducing the harm to them and the
general community. We remain prepared to dare to be different.
When we do, when we are out in front, and when controversy does inevitably arise, I just trust that organisations such as the Public Health Association, and the many individuals and agencies which make it up, are very publicly out there behind us.
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