BARTONE, Dr Anthony, Federal President, Australian Medical Association

BURNS, Dr Penelope, General Practitioner, Royal Australian College of General Practitioners

DUCKETT, Professor Stephen, Fellow, Australian Academy of Health and Medical Sciences

EWALD, Dr Ben, Member, Public Health Association of Australia

KELLY, Dr Glynn, General Practitioner, Royal Australian College of General Practitioners

TEMPLEMAN, Mr David, President, Public Health Association of Australia

Evidence from Dr Bartone, Dr Burns, Professor Duckett, Dr Ewald and Dr Kelly was taken via teleconference—

[15:29]

CHAIR: I welcome Dr Tony Bartone from the Australian Medical Association, Professor Stephen Duckett from the Australian Academy of Health and Medical Sciences, Dr Penny Burns and Dr Glynn Kelly from the Royal Australian College of General Practitioners, Mr David Templeman from the Public Health Association of Australia and Dr Ben Ewald. On behalf of the committee, I wish to pay tribute to the President of the Royal Australian College of General Practitioners, Dr Harry Nespolon, who sadly passed away this week. We express our deepest condolences to the Dr Nospolon's family, his loved ones and his colleagues at this time. Do you have any comments on the capacity in which you appear?

Mr Templeman : I'm also appearing as a former Director-General of Emergency Management Australia.

CHAIR: Thank you. Dr Bartone, I might start with you because I understand you have some availability challenges this afternoon.

Dr Bartone : Unfortunately I do, yes.

CHAIR: In the AMA's submission you've expressed a desire to see all Australian jurisdictions prepare records for possible disaster response and for a communication protocol in the jurisdictions to contact GPs in an emergency disaster situation. You provided quite a lot of detail in your submission about that. Has the AMA begun lobbying governments about that proposal, and what's the response been?

Dr Bartone : You'll appreciate that obviously there are other pressing matters currently in front of us as a nation, in terms of government, and we have put our submission in. Clearly, we'll be progressing that in fulsome content over the ensuing months ahead. Certainly, we did engage early on with a lot of the initial things—both the task forces that were employed as well as the ongoing responses to those task forces over the ensuing weeks. Unfortunately—or whichever way you want to look at it—COVID-19 rapidly became an entrenched and challenging feature of our landscape over the latter weeks of January and February and then really did overlap the ability to further progress those opportunities.

CHAIR: Thank you, Dr Bartone. I neglected to ask if you would like to make a short opening statement?

Dr Bartone : Yes, I would. Thank you for the opportunity to address this inquiry on behalf of the AMA. In doing so, I acknowledge the traditional owners of the many lands on which we meet by teleconference and video conference today. The summer's fire tragedy has been overshadowed by COVID-19, yet we must not allow COVID-19 to defer action on improving how Australia prepares for future fire seasons. Thirty people were killed in the last fire season, many were injured and thousands were exposed to hazardous smoke pollution. The bushfire toll on Australians' mental health, both those in fire impacted communities and those in smoke covered cities, will have impacts continuing into the next few years and even decades. The bushfire season was a health crisis. We were not prepared for the world's worst air quality levels and we were not prepared for community disruption on such a large scale. I don't seek to attribute blame, particularly when so many firefighter volunteers put their lives on the line, but we can prepare better.

Future preparations can and must better involve general practitioners and the medical workforce more broadly. GPs were not included in local disaster planning, yet it was GPs who the patients went to with respiratory conditions and initial mental health concerns. My key recommendation to this inquiry today is that more effort be applied to involving GPs in both local level fire response plans and to, additionally, better involve medical officers in incident control rooms as appropriate. In its submission to this inquiry, the AMA makes five key recommendations: first, that the Australian government pursue a more ambitious emissions reduction strategy to limit frequency and intensity of the fire season; secondly, that the Australian government commit to developing a national strategy for health and climate change; thirdly, that medical professionals, especially general practitioners, are integrated into disaster and emergency planning; fourthly, that a national centre for disease control be established to educate the public about large scale-disease threats, including poor air and water quality; and, finally, that further research and modelling be conducted into bushfire health impacts, particularly those related to smoke exposure and mental health. I'm happy to leave it there.

Senator SCARR: Dr Bartone, I might ask just one question. I understand you've got limited time available. I note the recommendation that a national centre for disease control be established. My initial reaction is to probe a bit further. What is it in particular that isn't being done today that you think a national centre for disease control could be doing? What is the gap you're seeking to fill by establishing that?

Dr Bartone : A national CDC, as we put it, would be relevant because of many reasons. In particular, it would have a central role in helping to verify and disseminate health information on major disease threats. As we are clearly seeing at the moment, yes, we have a national cabinet being informed by the Chief Medical Officer and AHPPC, but it really is a voluntary and a real-time response to a challenge. By embedding a process and a fabric and a formula in place which would work in between threats, in between challenges, we'd have in place the infrastructure and the ability to utilise and scale up or down as appropriate. In between episodes, in between needs, it could continue that discussion and that research and that information-sharing on a vast range of diseases, including what we're talking about today—the long-term effects of particular substances on the respiratory condition and the health of our ongoing Australian community.

Senator SCARR: We've got a federal system, which is the federal Department of Health, and then we've got all of the state and territory branches with their chief medical officers. At this point in time people in Queensland are receiving directions from the Chief Health Officer in Queensland and the federal health department is issuing guidelines and providing commentary, but at the end of the day the focus seems to be on the state chief medical officers. How do you see the proposed NCDC working with the state chief medical officers to make sure they're on the same page? What's the secret in terms of making sure there's consistency?

Dr Bartone : Clearly, in the set-up of the CDC there would be involvement and collaboration with the various states and territories. We're not trying to impose or come to a system to undermine federation. Indeed, it's the issue of the heterogeneity of the federation and the members of the federation which requires that we at least have a backbone system to deal with issues in the national interest which then informs and reliably communicates that to the Australian public but also to the various states and territories—a similar song sheet, so to speak. It was really, really powerful when we had the eight—or nine including the Prime Minister—state and territory premiers standing up together and communicating their message to the Australian public at the onset of a challenge of the magnitude of COVID-19. When there is not that ability, when you don't have that consistency of message, you have misinformation. I point you to the fact that, in the very early stages, there was misleading information about the correct use of masks, what kind of masks to use and which ones would be most effective. That's just one example. Of course, our media is a 24/7 national media service, and it's quite as likely that someone in Victoria is seeing a news report that actually originated in Queensland and vice versa. So we really do need to have a single source of truth when it comes to information sharing and communicating with the public.

Senator SCARR: Just teasing this out a little bit more—this is my last question—would that guarantee you the consistency? You can still have individual states taking their own health advice from their own chief medical officers with respect to certain issues and other chief medical officers coming, in good faith, to different conclusions. Are you still going to have that tension, if you like, between the different agencies at the different levels, or do you see this as a mechanism to ensure that there's consistency across all levels, across the whole country, so there's just a single source of truth?

Dr Bartone : Obviously, setting up a CDC is going to require the total buy-in of every member state and territory, otherwise it won't work. In that collaborative framework and set-up, there would be an understanding that this would be the road map, so to speak. There's no point setting up a CDC if you're going to then alienate yourself from that. In the first instance, by allowing it to become the acceptable or the next methodology, you might say, everyone would be needing to give a little bit but also then receive a lot more back. It's in that collaborative framework, the same framework that we saw in the early stages of the COVID-19 pandemic, that we would really see that set-up would benefit everyone in Australia. It's not a guarantee. Obviously anyone can change their mind later on, but, clearly, there would need to be everyone giving a little bit but also working together for a greater good.

Senator SCARR: Okay, thank you very much.

Senator WATT: Others might want to answer these questions later, but if I stick with the AMA for the moment. Dr Bartone, the Medicare rebates were extended for telehealth consultations for people in bushfire affected regions, and there's obviously been a wider extension of telehealth post COVID-19 as well. There are some signs that telehealth availability and rebates are going to be wound back by the government. Could you comment on what effect that would have on people living in bushfire regions, if the availability of telehealth were to be wound back?

Dr Bartone : Certainly the access and equity issues that are intricately involved in the whole issue of telehealth need to be front and centre of any form of continuance of telehealth post 30 September—that's the COVID-19 telehealth item numbers. In terms of the additional bushfire telehealth items, that certainly is another part of the framework. To be very brief but very clear, access and equity need to be hand in hand, and if the distance or the location become a barrier to that person's access that is certainly of enormous concern going forward. By the same token, we really do need to ensure that there is a coordinating framework that involves ensuring that there is a GP, where possible, as part of that ongoing response. We can't allow just a telehealth response to be the only way forward. Clearly, some non-GP specialties can't be provided locally, and there is a tyranny of distance and location, but coordinating all parts of the health system and utilising telehealth as an enabler is a key issue and a key aspect to ongoing, wider spread community access.

Senator WATT: This is my last question to the AMA. I was interested in your opening statement. You made the point that the AMA's position is that we do need to see action on emissions reduction. I think that's a correct way of phrasing it. Some people might be interested that a health organisation like the AMA is taking a public position on that issue. Can you just briefly summarise what exactly the AMA's position is and why you think it is important for a health based organisation like the AMA to be taking such a position?

Dr Bartone : Because I'm constrained with time, I'm going to essentially say that, clearly, the health effects of smoke and the particulate matter underline the long-term issues around emissions and reduction and, clearly, the aspects with the bushfires. The evidence is irrefutable, and we will always look at the evidence in terms of the impacts and the association with health conditions. That's why we've made the comments that we have.

Senator WATT: Thanks.

CHAIR: Senator Rice?

Senator WATT: I think Senator Rice was going to be out of action until about four, Chair.

CHAIR: I see. Thank you. Dr Bartone, you're welcome to stay but free to go when you need to.

Dr Bartone : I appreciate the opportunity. Apologies for having to leave. This was the only time that was offered, and I did want to address the opportunity to speak to our submission because of its importance to the Australian community and its health.

CHAIR: Thank you, Dr Bartone, and thank you for the submission too.

Dr Bartone : Thank you.

CHAIR: I might just turn to the Australian Academy of Health and Medical Sciences. Professor Duckett, I think your submission says:

There was insufficient health advice available to the public in relation to bushfires this season, in some cases because the evidence does not exist and in others, because it has not been collated and synthesised.

Can you give the committee some examples of that, and also point to the research and analysis gaps that need to be filled in order to make sure that that public health advice can be provided?

Prof. Duckett : Do you want me to make my opening statement now?

CHAIR: Yes. I really have had my train of thought derailed. Professor Duckett, you should absolutely go for your life on your opening statement, and then I'll invite everybody else to do the same thing.

Prof. Duckett : Thank you, Chair, and good afternoon, everybody. Thank you for the opportunity to participate in today's hearing. I'm meeting you from lockdown in central Melbourne and on the unceded lands of the Wurundjeri people of the Kulin nation, and I pay my respects to elders past, present and emerging.

My day job is director of the health program at the Grattan Institute, and I'm a fellow of the academy, the organisation I'm representing today. The academy is one of Australia's learned academies. It is an independent, interdisciplinary body of 398 fellows, who are elected by their peers for their outstanding achievements and contributions to health and medical science in Australia. The academy's goal is to advance health and medical research in Australia and its translation into benefits for all. I'd first like to take the opportunity to express our deepest sympathy for the lives lost during the last bushfire season and the communities that were impacted and are still recovering from devastation in those difficult times.

Our response to the inquiry was informed by interdisciplinary expertise from fellows and other experts in areas such as: respiratory medicine; mental health; environmental health; health economics, which is my own discipline; and many other disciplines. The extent and duration of the 'black summer' bushfires had a major impact on physical and mental health in Australia on an unprecedented scale. Clearly, we need to address the ongoing impacts. We also need to prepare to mitigate and adapt in response to future events, given that the frequency and severity of such events is predicted to rise during the coming decades. Our response and future preparedness depend on how well we understand these impacts. At present, we do not always have an accurate picture of the scale of these problems, the mechanisms through which they occur or the most effective strategies for managing them. It is important, therefore, to address these gaps in our knowledge through research.

In our submission, we highlighted several areas. For example, concerns around the potential impact of bushfire smoke on the respiratory health of first responders, volunteers and the broader population were well documented during the bushfires. However, we do not fully understand the underlying biological mechanisms for how air pollution from bushfire smoke causes or exacerbates respiratory problems, particularly in the Australian context. We also have only a limited understanding of the health impacts of prolonged exposure to bushfire smoke. These sorts of questions need to be addressed. Likewise, there are similar gaps in our knowledge of the impacts on mental health; vulnerable groups, such as pregnant women and Indigenous communities; eye health; food and water safety; burns; and heat stress.

There is an opportunity now, following the devastating black summer bushfires to undertake research to fill these knowledge gaps. This sort of research will need to be prioritised alongside other areas, especially at this time with research to help tackle the pandemic. Going forward, evidence will allow for more targeted advice, especially for vulnerable population groups. Most importantly, this public health advice needs to be clear and evidence based to avoid confusion. Thank you very much. And, in answer to your question—

CHAIR: Just so I'm consistent and get back on top of this process, before I let you answer what is, I accept, my question, I'll welcome Dr Kelly to the video conference and see if Dr Burns or Dr Kelly want to make an opening statement in addition to their submissions.

Dr Burns : Yes. I'm going to make that opening statement. I would also like to very quickly acknowledge the untimely passing of Dr Harry Nespolon, who was an amazing GP, an exceptional person to those who knew him well and a very strong advocate for GPs. So we do express our condolences to his young family. I'd also like to acknowledge the traditional custodians of the land on which we're meeting and pay my respects to their elders.

The college of GPs thanks the committee for the opportunity to give evidence in relation to the Senate inquiry on the lessons to be learned in relation to the Australian bushfire season 2019-20. The college is our largest general practice organisation, representing more than 40,000 members working in or towards a career in specialist general practice. GPs are front line in Australia's healthcare system. Nine out of 10 people visit a GP every year and GPs provide more than two million consultations to Australians every single week.

In times of natural disaster and emergencies, the health impact on people and communities is significant. GPs are essential members of the healthcare team in supporting individuals and communities in natural disasters and are not yet well included. The RACGP provided a written submission to this inquiry in May this year and I'm just going to summarise the main points and recommendations from our submission.

GPs have continuous relationships with their communities before, during and after disasters and emergencies, and they have opportunistic encounters with patients due to the high demand for primary care during disasters. This can continue for many years and many decades afterwards. We would say that to maximise the role of GPs as frontline health providers, they must be formally embedded in disaster preparedness, response, recovery, planning and decision-making. Efforts to achieve this have been compromised in the past, partly due to the divide of state and territory government management of emergency planning and federal government responsibility for general practice. But it's essential that these cross-jurisdictional and interagency connections are better coordinated.

The RACGP would like to see a representative or adviser on the Australian Health Protection Principal Committee to ensure that GPs are involved at the governance and strategic levels for disaster responses before they occur. Similarly, we would like to see formal and permanent GP representation on state and territory disaster management committees to ensure that the GP voice or input into plans, responses and solutions is included and that GPs are involved at governance and strategic levels for statewide responses.

I'd also like to mention the PHNs and the need for a national, uniform approach to the PHN network engagement with general practitioners during disasters. I would also emphasise the role that GPs play in health coordination during disasters, not only in the immediate situation but in the long-term aftermath. Often, these roles are not recognised or integrated into the broader framework, and we believe that this affects the overall effectiveness of the response and impacts on the support provided to the community.

A key focus of healthcare recovery efforts need to be on mental health—and I applaud what was said in the recent discussion—and chronic disease as well. We know they are a huge burden of care in the aftermath of disasters. GPs in practices operating in areas affected by disasters also need to be afforded greater financial support to deliver the care to their communities and to ensure business sustainability following disasters in particular.

Finally, I'd like to suggest that we would support the increase in research into healthcare effects of natural disasters to show what is actually happening, in primary care, in disasters. There are a number of points, here, but a couple of them are longitudinal review of presentations to general practice for physical and mental health related conditions in recently disaster affected areas, and the impact of natural disasters on chronic disease management and patient outcomes in general health as well as the long-term health affects of bushfire smoke.

CHAIR: Thanks, Dr Burns and Dr Kelly. Do Mr Templeman or Dr Ewald wish to—Mr Templeman.

Mr Templeman : Good afternoon everybody. Firstly, let me say thank you very much for inviting the Public Health Association to present today in the context of our submission. May I also say that I acknowledge the traditional owners of all the lands on which we meet today and we pay our respects to elders past and present. May I also say that we feel for all those communities that are affected by the fires, including our First Nations people, very sadly.

I want to briefly mention some key issues which we addressed in our submission, not necessarily go through it in a great deal of detail. I think the critical point, which you also covered in a specific issue raised a minute ago, about being the key driver of a worsening fire situation, is the climate change issue leading to a worsening bushfire circumstance. That, of course, is having a devastating impact on health and wellbeing and it continues, in many communities, in the six-month period since the bushfires, and it's quite evident that will go on for quite a significant period of time.

Some of those health impacts include death and harm, which have been mentioned. It's not just to firefighters but also to other responders. I include all responders, in this situation, the many who work in various NGOs in other support areas that work hand in hand with first responders. They're all professionals and they need to be regarded in that particular light. The mental health and wellbeing issue has also been covered, already, extensively by others.

There are some issues I think important to bring out to this committee, in relation to lessons in bushfires but also for the future, things that I describe as the silent killers of disaster. One is the issue related to heat, which is very significant. In a study that was done from 2001 to 2005 there were 1,100 heat related deaths in Melbourne alone, 750 in Sydney, 550 in Adelaide, 530 in Perth and 220 Brisbane. Think of that, and we've got to keep that front and centre because, so often, it's a forgotten issue around disasters in Australia. We've also seen, in the last bushfire season, the issue about air pollution and smoke, which has been touched on. There have been 430 deaths and 3,400 hospitalisations. They are very significant issues, which need to be front and centre, with regard to future planning and understanding, and picking up the issues that have been raised already about integration of the health areas within the disaster management planning arrangements is critically important.

We're going to see a situation where the fire season will be longer. That's the prediction. If you look at the Bureau of Meteorology's recent report into the bushfire inquiry or the national disasters inquiry, in which they predicted what was going to occur last year, they've given evidence along those lines. I think it's important, in the context of mentioning the bushfire inquiry, that we appreciate the Prime Minister calling for a royal commission and acknowledge that climate change was a driving force for hot and dangerous conditions, but that didn't also address the root cause and bringing down emissions, in terms of coal, oil and gas.

If you look at that further, the royal commission's terms of reference, it highlights that fires are getting longer and getting hotter—lasting longer and drier—necessitating practical action. My question, really, is: what is that? What is the practical action being suggested here? Is it a case of our leadership saying, 'Get used to it,' while ignoring the science and advice of many experts? The science and the experts are there to assist in this process and they want to be engaged. I think it's important that we take climate change issues far more seriously than what we've seen to date. We need to better resource mental health services and make them local, flexible, reliable and ongoing.

As an aside to this, I've seen work already undertaken in this area down on the south coast of New South Wales in communities such as Conjola. It's a community led operation in terms of community liaison and wanting to have those sorts of situations put in place. So it's community led and community managed, and so long as there's resourcing there to cover that particular aspect, I think it's probably a good omen for the future.

I will get Dr Ewald to talk a bit more about resourcing an air smart facility, which is about educating the community about air pollution and, more importantly, what that might mean and what steps they might need to take.

The last comment I would make is relation to the COVID impact. COVID has had an impact in relation to the aftermath of the unfortunate, dreadful, worst natural disaster we've had in Australia in terms of overall cost and impact. I think it's diverted government's attention and support. The facts on the ground from the last season remain. It's hindered some aspects of community recovery, and I've touched on that a little bit. I think it also will hinder our ongoing firefighting effort in terms of 2021. I think you've already had evidence from the former commissioner of Fire and Rescue New South Wales, Greg Mullins, in relation to discussions that he would have mentioned around that. So we are dealing with a situation with possibly ongoing community concerns about safety and further loss and so forth, but another aspect of this is the capacity of the firefighting resource to pick up and do what it did last year, and whether we will draw on international assistance in the same way we called on it previously because of COVID restrictions. It's something to really seriously think about. International firefighting exchange may be a particular issue.

I'll leave it at that. Dr Ewald is available for expert comment on air pollution threats and responses and, more importantly, to talk about the air smart facility. Thank you.

CHAIR: Dr Ewald, did you want to go to those issues as part of an opening statement?

Dr Ewald : I just have a few brief insights. The first thing I want to say is that there is a journal article published estimating the number of deaths and hospital admissions due to the acute air exposures over the summer. So there is an estimate of that that's probably as close as we can get. There's also a chronic disease burden from smoke exposure. You can think of this: on a bad air day, we know people will have more heart attacks or need more hospital admissions. The air exposure is also a risk factor, just like bad diet or high cholesterol or never getting any exercise, for the development of chronic diseases like heart disease. Some of those people who are having heart disease due to bad air exposure won't necessarily have their heart attack on a bad air day; this is a chronic effect that will play out over subsequent years or decades, as well as the acute effect that we have the better estimate of. When the chronic effects are compared, the chronic effects are about four or five times bigger than the acute effects for same amount of air pollution. So there's the estimate of 417 deaths expected during the summer, and there's a much larger number that will play out over subsequent years. We're less certain of the timing, but the epidemiology points to that effect certainly being there.

CHAIR: Thanks, Dr Ewald. Professor Duckett, what may appear to the untrained eye looking into this process as being my procedural bungling is actually an effort by me to make sure you have sufficient time to consider your answer to my question. If I can direct you back to that, if you can remember what it was, that will be excellent.

Prof. Duckett : Thank you, Senator. I'm most grateful for the careful way in which you orchestrated that I could have that extra time. I think there are two things I want to mention about areas where research is needed. One is about this issue of the impact of the particulate matter. Importantly, our guidelines are all about threshold levels, for example, of so called PM 2.5—the level of small particles in the air. They only talk about the levels, and they don't talk about, for example, the composition, and whether the composition of the different particles has different effects. For example, we don't know whether bushfire pollution is different from traffic pollution. It's, of course, a peculiarly Australian issue that our bushfires will create different types of particulate matter from others. The second thing is that, again, our guidelines and our thresholds for alerts and so on are calibrated quite low, and in the 'black summer' period we have seen extremely high levels of particulate matter for a reasonable period of time. Those of you who live in Canberra will be acutely aware, but also those of you who live in Sydney. So we're unsure what the public health implications are of moving from moderate levels—even though they're above the threshold—to extremely high levels. Is there a different impact? That is unknown.

Secondly, taking a somewhat different approach, there is impact of bushfire pollution on a vulnerable group. If I use the example of pregnant women, we again don't know whether, for example, bushfire pollution and the very small particulates impact on breast milk. So we can't give sensible advice—or evidence based advice—about what women in those circumstance should do. So there are lots of areas where the evidence that should underpin public health advice is not well known.

CHAIR: It sounds like the research that would be required to start to deliver answers to those questions in public health terms—it's a very broad-ranging set of questions, isn't it?

Prof. Duckett : Indeed, it is. As other witnesses have said, the likelihood of bushfires and the length of the season are both increasing, so this is becoming more and more important in Australia. So, obviously, the better evidence we have to inform public health advice the better. It's becoming more of an important issue, and there are lots of areas where we're still unclear about what the best evidence is.

CHAIR: Dr Ewald, the Public Health Association submission also touches on issues of air quality, air quality monitoring and the provision of protective services and advice. Did you want to add anything?

Dr Ewald : I noticed that one of the things that came out during the fire season was that people didn't know much about the protective behaviours they can use. On a really bad air day, what can people do to protect themselves? The health department advice was to stay indoors and shut the windows and, if you've got an air conditioner, make sure it's filtering properly. That's a good way of dealing with one or two bad-air days, but in Canberra it went on for 56 days. We can't really expect people to stay indoors for that long. People need to get out and exercise for their general health and their mental health, and those people walking or cycling to work need good advice about how to protect themselves with a mask so they can get some exercise despite the bad-air day. There are some good masks designed for this, largely available as things for cyclists in bad-air countries. They have particle filters that do a good job and can be worn in heavy exercise. They're not very well-known, but one future approach would be better advice informing the public on which masks are available and which masks do the job of protecting people. This comes up as an issue. It would be important, for instance, for schools and schoolchildren. If they're going to be doing their usual school sports days during a bad-air emergency, they could have a system where they could have masks available—in the same way as having a hat available to protect them from UV radiation. They could well have some masks available so they can do their sports, despite the air being poor quality. That hasn't been done in the past, but that would be a logical step to take if we're going to have repeats of these bad air months that happened over the last summer.

That's part of a bigger program I see of informing the public. There are two steps to this. One is online. There's a phone app called AirRater, which is run by the University of Tasmania and operates for Tasmania, Victoria and the ACT. Basically, the phone knows where you are and gives you information about the air quality at that location. It is a way of alerting people who might be sensitive to air quality due to conditions like asthma when the air is bad and they need to take other measures to protect themselves. The New South Wales EPA runs a system that sends out an SMS alert. If you sign up to it, you'll get an alert when there's poor air quality at your nearest air monitor. Systems like that do a great deal to raise community awareness and let people take health-protective behaviours when they're needed due to the poor air.

We also have a proposal of an air smart public education program, modelled on the idea of SunSmart, which teaches people to protect themselves from UV radiation. It would be getting the public a bit more clued up on how to respond to bad air days. Certainly the Asthma Foundation was very keen on this idea of developing community education on how people should respond to days of high air pollution.

CHAIR: Thanks, Dr Ewald. I'm very conscious of the amount of time that's left, and I will shift to Senator Scarr in a moment, but I would like just a very brief comment from the College of General Practitioners. Your organisation leads the state health disaster response roundtable in New South Wales. Are you able to say anything about when that was established and how that works and contributes to the overall health effort in disaster response?

Dr Burns : I can talk to that, being from New South Wales. That was established essentially following the 2013 bushfires, when we were, as GPs, feeling very disconnected. So we brought together the state PHNs, mental health, public health and some of the disaster managers, including the director of the Health Emergency Management Unit at the time, predominantly in order to provide planning and support for general practice and in an attempt to work out how we could link in and improve communications through that group. During a couple of the last disasters, we've had a GP liaison person in the New South Wales State Emergency Operations Centre, which has worked very well, but it's not a standing position and it only occurs when people know each other, I guess, and people understand the value of general practitioners. So that is a nascent group that we hope will become stronger. It's also got a subcommittee of GPs who went through the bushfires in the south-east of New South Wales over the summer. We originally established that to give us some surveillance of what was happening on the ground because, again, general practice is often invisible in these events. We know that people will present to their general practitioners for mental health support and for physical health support, but we don't really have any quantitative data, if you like, of the number of cases that people are presenting with and what they're presenting with. So there's a hidden burden of health care presenting there. The aim of this group was predominantly to try to support assimilation of general practice into various levels of planning and preparedness,

CHAIR: Thank you Dr Burns. Senator Scarr, do you have questions?

Senator SCARR: Thank you, Chair. I do have some questions. The first question I want to put to each of the witnesses—perhaps we can start with the Royal Australian College of General Practitioners—is in relation to this concept that was raised by the AMA of establishing a national centre for disease control. I'm just wondering what the position of each of the witnesses on that proposition is and what your thoughts are. I will ask the Royal Australian College of General Practitioners first.

Dr Kelly : I'm not aware that the college has an official position on a CDC for Australia. I can give my own view. I think a CDC has got some value, but what would have more value in disasters and emergencies would be a national disaster committee that has overall responsibility for national disasters. That would be able to cut through state and federal boundaries and deliver effective responses and planning, and we don't have that. I think we heard earlier that there was inconsistent messaging, inconsistent communication, when disasters occurred.

The AMA supports greater GP involvement in planning, preparation, responding and long-term recovery. I think it has been pointed out that GPs are there for the long term. We do tend to think of disasters and acute injuries at the time, whether they be physical or mental, but, on the other hand, there are long-term [inaudible] physical, whether it be lungs, heart or so on, or mental, such as ongoing depression. I think one of the submissions mentioned that the University of Melbourne found that after the 2009 bushfires one in five patients had psychological issues five years after the event, but not always directly involved.

I just want to make the comment, if I may, that in Australia we have more than 29,800 full-time equivalent GPs—there are a lot more GPs because not every GP works full-time—and 8,000 practices. I think at the national and state levels we need to focus on general practice as being a system, a significant health resource that can be used in responding and planning for disasters. I'd say that it's akin to using Australian Defence Force Reservists, as they're doing in Melbourne in this disaster.

We are a significant resource and we are not used. Health departments, state governments and maybe even federal governments sometimes think they can cope with disasters. Sooner or later find that they can't and then they call on general practice. General practice rises to the occasion, and I applaud all my colleagues [inaudible] to the occasion. But it has not always been in a fully coordinated way and it doesn't always achieve all of the outputs and outcomes that it should.

I think the way to resolve this is to have general practice as a system involved in local, state and national disaster committees and roundtables. That has to be planning, exercising, responding, recovering and regrouping. That will require support. I don't think we can expect GPs to give up days to be involved in this, although many will, and I am sure Dr Burns and I would. I think there has to be some resourcing and support for this. I applaud New South Wales for its roundtable that it has set up. That is a very proactive state. They've done it. I'm not aware that any other states have done that. Again, I think we need support to be able to do that.

Senator SCARR: Professor Duckett, what are your views on the proposed Australian national centre for disease control?

Prof. Duckett : The academy hasn't got a view on that. My own personal view is that I am really unsure about that. At Grattan we are preparing a report on bushfires. We also did a report on COVID and we did not recommend a centre for disease control, partly because in the Australian context it's really unclear how that would work vis-a-vis the role of the states under the Constitution and also because the US experience with a CDC is that it doesn't necessarily fix the problems they've got there obviously. That's where people usually like to look. The CDC in the US has done some fantastic work, but at the moment the US is not covering itself in glory in its handling of the pandemic.

Senator SCARR: Mr Templeman from the Public Health Association of Australia, does your association have a view? Do you have any personal views based on your experience that you would like to offer?

Mr Templeman : I want to hark back a little bit to the comments made earlier by Dr Bartone. Maybe this is a crawl-before-you-walk situation. I respect the constitutional responsibilities in terms of protecting life and property. We have a very well-established AHPPC arrangement, and mention has been made about us perhaps doing something in that space, integrating aspects around this and those thought processes. I think that would be an initial step, otherwise we'll get push-back from jurisdictions and things like this in the first instance.

I will also say that the comments that have been made in answer to this particular question about the national disaster committee arrangements and things like this are very relevant. Since 2001, the principal focus around this whole area has been singularly focused, particularly around terrorism and around dealing with these events, not in an all-hazards context, and I think that some recent events that we've dealt with in Australia have been a real wake-up call as far as the capacity to respond and recover. This also stems from the issue about thinking big. It also stems from the issue about having realistic planning and involving the right experts in that planning. The point has been raised of actually having health at the table, in terms of jurisdictional and also national disaster planning and things like this, because recovery, as we're seeing here, is the long-haul stuff and it'll go on and on and on. It has to be actually front of mind. It also has to be tested and be very realistic in terms of testing, and it will also have a cost attached to it.

But the whole national coordination arrangements around these sorts of things are very significant, in terms of being front and centre as far as the Royal Commission into National Natural Disaster Arrangements in Australia. There's an opportunity through this royal commission to actually hit up and do something about these sorts of things, rather than having to go back and have repeated inquiries, of which we've had so many since the 1939 fires. We don't need to have to go through this. We've got to adopt and be able to adapt and have flexibility arrangements and actually do this, in a multihazard arrangement, taking into account our federated structure that we have to work with. I often say to people: 'Think big. Think of the situation that happened at Mallacoota. There were 4,000 people on a beach. What would you do if you didn't have a beach, if you couldn't actually get aircraft in there and do anything to extract those people?' These are serious issues that we need to think about for the future in terms of the communities involved. They are also having significant, long-term, devastating effects on the anxiety, the uncertainty and the mental health of those people affected, not just in Mallacoota but right through that whole area.

Senator SCARR: Dr Burns, firstly, do you have anything to add in relation to this concept of a national centre for disease control? Then, could you perhaps provide a bit more insight about the view that I think Professor Kelly put passionately about the greater role GPs should have in these arrangements and this planning et cetera? I'm interested to know of some practical examples where you could look at a situation and at the way we've done things, in relation to either bushfires or elsewhere, and say, 'Gee, if we'd had a GP in the original planning stages, we would have done X, Y or Z differently because of A, B or C.' Are there practical examples of that particular insight that GPs can bring to the table?

Dr Burns : Regarding the CDC suggestion, I'm not really qualified to answer that, and I would probably tend to agree with the last speaker about the fact that we probably need to focus more on the structure that we have. It's a reasonable structure, but it's just missing a whole-of-health and, I agree, an all-hazards approach. I don't think we have the luxury of creating different systems for terrorism and for natural disasters and having separate responses. It needs to be all hazard, and it needs to be very much an all-of-health response. In a normal environment in health, we have a very strong primary care system. Ninety-five per cent of the health encounters are seen in general practice on a day-to-day, week-to-week basis, and there's a huge burden of chronic care that's managed. If you take that away or disconnect it, at the moment you've got a risk of a huge increase in chronic disease issues, which then ripples into the longer term. At the moment, we don't have that part of the health system connected to the rest of it during disasters.

I'd also agree with the idea that this is a four-phase—we talk about the four phases of disasters: the before, the during and the after, really, and then the prevention. But it begins with understanding exactly what different groups within that holistic response to health would be doing.

That's why we feel that having a GP representative to help inform at the very high level—at the AHPPC, then also at a state level, into the state planning, and then at a local level. At a local level, we've already seen some really good planning going on after the 2013 bushfires. The New South Wales state planning GP group that we were talking about was very involved with the Nepean Blue Mountains PHN, and we ended up putting together a response, an emergency plan, which was actually rolled out during the last bushfires and worked very well. That's the feedback that we received from GPs and from the CEO of that group. They pulled it together themselves. They were supported by us, and it was a really good linkage of the PHN through the LHD information conduit out to GPs—GPs ready and trained in disaster mental health and in what was going to be needed in the evacuation centre, if that's where they were sent. That was, I think, a good example, and that has subsequently been disseminated to PHNs at least within New South Wales that I'm aware of.

In terms of a really practical point about what GPs could be doing, we are basically on the ground, we're the eyes and ears of the community and we're part of a healthcare system in the community that will continue in the longer term. I have colleagues in New Zealand who went through the Christchurch earthquakes. Ten years later, they are still seeing certain patients who are triggered every time there's an earthquake. We see triggering with all sorts of disasters. When you have one disaster in one spot, it's not just that local area that's affected. It's the area outside that local area where they see the inundation of people coming through, but there is also that bigger ripple effect that goes through everybody who has ever been affected by that sort of disaster. So we need to think very holistically about what the person's experience of a disaster is. They have mental health effects, physical health effects, social effects, financial effects and work-related effects, and we need to think very holistically. As GPs, we have a really strong role to play there. I know that, five or six years after the Victorian bushfires, doctors were very busy doing insurance claims in certain areas, and that's part of that holistic care.

This is an area of PhD that I'm doing, so I must confess to that, and I have done a literature review on the health consequences of disasters. One of the things that becomes very clear is that there's an acute burden of care but then the chronic burden of care over the months and years afterwards is quite substantial. As Ben was saying, there are effects that occur immediately and there are effects that then go on and on and on, and chronic disease is a huge part of that. I hope that answers the question.

Senator SCARR: That's excellent. Thank you very much.

Senator RICE: I might start where we just finished off, Dr Burns, with the chronic burden of care and the link with people's fears and climate anxiety and being triggered by every fire event. If these fire events are going to become more and more frequent and more and more intense, what effect does that have on the chronic burden of care?

Dr Burns : One of the things that I like about general practice is that you actually have an opportunity to prevent things. We also have studies that show us that, for example, after the Hull floods in England, there was a deterioration in diabetic care at three months and at six months that was then corrected by having the health services there and available to manage that. When we look at the studies from Hurricane Katrina, 18 months following that, where the health services have been severely disrupted, you still have rising levels of haemoglobin A1c or diabetic care markers and also high blood pressure and lipid levels. I think you're right that the way the acute event and the early days are managed can have a profound effect on how that health care goes on further. There are even some studies out of Hurricane Katrina suggesting that disasters should be declared a social determinant of health because there are some changes seen in some of the chronobiology of the disease that's presenting—heart disease presenting in different ways—and the characteristics of people who are in those communities and disease presenting.

One of the things around mental health that I'm very aware of is that people come flooding in—and anecdotally we know this. After bushfires I've talked to many GPs who've said, 'People turn up at the doorstep on the day after the event; they're distressed, they're very upset and they're looking for their GP waiting room, which is where they're gathering because they just don't know where to go and what to do.' One of the key roles in primary care at that early stage is psychological, de-escalating that distress, which we believe then has a positive effect on decreasing that longer term event. There are a couple of things there. Firstly, if we intervene early, we can hopefully decrease that ripple effect or that recurrence. I have a colleague who works with people who experienced the Bali bombing, and, again, it's the same sort of thing—when there's a terrorist event somewhere, there's an increased surge in those presentations or that need.

Senator RICE: But is it possible to de-escalate that level of stress if there's an ongoing fear, if they see that our climate crisis isn't being addressed and if people are looking at the prospect of the sorts of extreme, more frequent bushfires such as we heard about this morning?

Dr Burns : I'm probably not an expert in this area, but the way I would approach it—and the way I would generally approach someone in distress like that; and I agree that it is a serious issue—is that I would look at agency and small steps and look at how that person could then begin to start addressing small steps themselves. That's what we do when we see someone who comes into general practice, for example, in acute distress. We would look at what efforts that individual can make and then how that individual can contribute to some sort of agency. But I'm not really the expert in this area.

Senator RICE: Thank you. I would like to move to Mr Templeman, from the Public Health Association, along similar lines. Mr Templeman, you mentioned in your opening statement that the message from government was almost, 'Just get used to it'. You talked about the anxiety that the people on the beach at Mallacoota would have felt. Can you tell us more about what's known about the anxieties regarding climate change and the prospect of ongoing climate disasters and more frequent fires and how this is compounding the mental health impacts?

Mr Templeman : I harken back to my time as director-general of Emergency Management Australia. Dr Burns just mentioned Bali a minute ago. I always remember the date—12 October 2002—when we lost 88 Australians and there were 66 critically injured people. Every year that 12 October time comes around and we see a resurgence of Bali anger in those people in the community. It may not necessarily be people who have been directly affected or personally impacted, but this sort of thing has these issues and unfortunately brings some things to a really sad head. We see similar circumstances that happen as a result of the fires in Canberra in January 2003. They are things that we have got to be very conscious of and we have to take into consideration and plan around those sorts of issues. From my time in public health, in the area of alcohol and other drug use, we see substance use leading to all sorts of other issues around domestic and family violence and homelessness, unfortunately leading to loss of life through suicide and stuff like this. I can only see circumstances now where the evidence is there, as Professor Duckett said before, in terms of climate change—we need people to embrace this issue, that we are going to deal with severe and worsening bushfire situations for a longer period of time.

I can hark back to the days of the Macedon fires in 1983, the Victorian Ash Wednesday fires. You still have people who actually, unfortunately, have gone back and built and live in the same areas, and the day they see smoke in those particular areas, they think, 'Oh my God, it's all going to come back again.' People want to stay where they are; they want to rebuild and go back into these particular areas. So I think there are some very significant things that we need to be able to work with and deal with across a whole range of issues that impact on people who have been affected by some form of disaster and how they actually come to the fray. That's why I said in my opening remarks that what I'm troubled about is that we're not tackling this root cause.

We've got an inquiry underway now which is taking significant evidence. It's taking significant evidence, say, from the Bureau of Meteorology, where it's actually talked about the advice that it gave to government in relation to the predicted threat of what we saw happen, particularly in the December-January period. I think it's a case of making sure, let's hope, that this royal commission addresses this issue so the community can start to feel a bit more confident that they are desperately doing something. We can never prevent these bushfires from occurring, but we can do certain things in relation to addressing some of the things that are the root cause of them to prevent them from being a worse circumstance. At the same time, that would send a very powerful message to the community, with their anxiety and fear around this, that they need to trust and work with organisations at the grassroots level to help communities rebuild and regroup.

Senator RICE: What impact does it have if people see their governments refusing to act at the speed and scale required? What impact does that powerlessness have—the 'not wanting to think about climate change', because it just brings on despair, the 'not having agency', as Dr Burns said—on people's mental health?

Mr Templeman : I think it would be to other very unfortunate consequences. You would see the impact primarily being on families and children, and it wouldn't be a very comfortable thing to be responsible for. I think we have to keep reminding leadership that these are very significant and serious issues and they will be there for the long-term; they will not be fixed with a short-term bandaid approach. But that's what worries me: that we will end up with some short-term bandaid approach. If the fire season this year is not of the same severity that we had last year—people forget about these things and they move on. We've been very lucky—up to a point. When you look at disasters in Australia, the most recent event is the most significant natural disaster that has ever happened in terms of the loss and in terms of the costs—homes, infrastructure and the like. In the 2009 fires in Victoria, 175 people lost their lives. But we need to keep in the minds of people the area that was affected and the ferocity of this year's fires. I think there will be some very significant questions asked of leadership if action isn't taken in that particular area.

Senator RICE: I want to finish with a question for all of you about the flip side of that. We heard in the last session about the importance of giving people hope and a sense that things are going to be better. How do you think governments can do that in relation to climate anxiety and anxiety about more intense, more frequent and more extreme fire seasons?

Dr Burns : I think it is all about building local capacity and ability to do things, and engaging the locals in doing stuff. I remember that, following the Victorian bushfires, there were two communities I was involved with. One of them did have that—they pulled together and did stuff. They created their own response, they came up with their own ideas and enacted them, and they were supported to do that. There was another group that couldn't quite get that together. The difference in terms of resilience was phenomenal. I think it goes to all areas of that community, but to me it is about building local capacity for the next bushfire.

Senator RICE: Mr Templeman?

Mr Templeman : We've seen a very good example in terms of the way COVID has been managed; we've had the leadership listen to the science, accept it and act on it. I ask the question: why can't that happen in this particular space? That's a fundamental issue. The importance of the science has been reflected, through the AHPPC, to the leadership and has been communicated in a simple, consistent message to the community. That has added enormous store to the way in which Australia has dealt with this particular event. I ask the question: why can't it be done in relation to other events? And we are dealing with other events here today—significant and worsening bushfires.

Senator RICE: Professor Duckett?

Prof. Duckett : I would just make a couple of comments. First of all, there has been a literature on the psychological impacts of climate change for more than a decade now. So this is not a new issue, and obviously it is one where we have to work at a number of different levels. Dr Burns talked about building local resilience. That's important, but I think it's also about working at a national level to address some of those climate change issues. I also do work with the World Health Organization, and I despair sometimes about the fate of some of the Pacific island nations. I hear stories from them about how they are not worrying much about some of the public health issues into the long term—malnutrition among mothers and so on—because their whole island will not exist. The despair you hear in their voices, and the fatalism, makes me weep. We are not at that stage yet in metropolitan Melbourne but, as we've heard, the number and intensity of bushfires is increasing and the length of the bushfire season is increasing. So we really need to think about what we are doing about that.

Senator RICE: And at the speed and scale that is required to address our climate emergency. Thank you.

CHAIR: I thank all of the witnesses who have given evidence to the committee today. In particular, I thank all of you here for your submissions and the discussion today. The submissions have been of a very high quality and we have had a very stimulating and important set of evidence for the committee's deliberations over the coming weeks and months.

Committee adjourned at 16:47