Chapter 2Provisional mortality data and contributing factors to excess mortality

2.1Over the course of the inquiry, the evidence presented to the committee overwhelmingly pointed to COVID-19 as the key contributing factor to excess mortality during 2021–2023. This included deaths both directly and indirectly caused by the virus.

2.2The nature of the Australian Government’s response to COVID-19 meant that 2020 experienced ‘negative excess mortality’, as fewer people died than expected, while excess mortality was experienced in the following years. This phenomenon is known as ‘mortality displacement.’

2.3This chapter first discusses the breakdown of Australian Bureau of Statistics (ABS) data from 2020–2023, as well as addressing international comparisons and future demographic considerations. It then discusses the various ways COVID-19 drove excess mortality within this timeframe, as well as other drivers raised throughout the inquiry.

Provisional mortality data

2.4As discussed in Chapter 1, the primary source of provisional mortality data is that offered by the ABS. In its submission, the ABS outlined the discrepancy between expected and observed deaths, as shown in the table below.

Source: Australian Bureau of Statistics, Submission 2, p. 5.

2.5Additionally, the Actuaries Institute has a Mortality Working Group (MWG), which provides its own mortality estimates. Its calculations are presented below, including comparisons to other bodies which made calculations of excess mortality across the same timeframe (i.e., The Economist and Kobak & Karlinsky):

Source: [Actuaries Institute, Submission 3, p. 4]

2.6As shown above, these different groups present slightly different figures, but all indicate the same trend: Australia experienced negative excess mortality in 2020, a slight increase in 2021, and an increase of more than ten per cent in 2022.

2.7In regard to excess mortality data, the Actuaries Institute emphasised the inexact nature of such estimates:

The predicted number of deaths used in excess mortality calculations is an estimate based on certain assumptions, and therefore the calculated excess mortality is also an estimate. Excess mortality can only ever be an estimate – it is not, and cannot be, a known quantity.[1]

Mortality displacement

2.8A key term used in submissions and evidence in the inquiry is ‘mortality displacement’. In its submission, the Department of Health and Aged Care (the Department) defines mortality displacement as follows:

… delayed deaths from existing underlying health problems due to reduced circulation of many respiratory and other diseases in 2020 and 2021, which would have otherwise contributed to deaths in those years.[2]

2.9The ABS links this phenomenon to excess mortality numbers in Australia in recent years:

As Australia had lower than expected mortality in 2020, it is likely some reverse mortality displacement was experienced. This means deaths that may have occurred in 2020 had 2020 followed usual patterns of mortality, may have instead occurred in later years.[3]

International comparisons

2.10As excess mortality was a global phenomenon in the years following the COVID-19 pandemic, the committee heard evidence which detailed international comparisons of excess deaths.

2.11In its submission, the Department cited an Australian Institute of Health and Welfare report which found that ‘[e]xcess mortality in Australia was 4.4% in this period, compared to an average excess mortality of 14% across 30 countries, including the USA and UK’.[4] In addition, the Department referred 2023 OECD report which ‘found in 2020-21, Australia had one of the lowest global excess death rates, with the excess mortality rate ranking as 5th lowest of thirty-five studied countries’.[5]

2.12Furthermore, the Actuaries Institute stated in its submission that:

Globally, countries with low (or negative) excess mortality in 2020 (like Australia) have generally had lower excess mortality over the period 2020 to 2023 than those with high excess mortality in 2020 (such as the United Kingdom). This is despite the impact of mortality displacement, which makes Australia’s excess mortality in 2022 and 2023 look relatively high.[6]

2.13The Actuaries Institute also provided a table (below) illustrating the relatively low rate of excess mortality in Australia:

Source: [Actuaries Institute, Submission 3, p. 4]

2.14The Actuaries Institute explained the broad trend:

This pattern (negative excess in 2020, increasing to a large excess in 2022 and a lower excess in 2023) is similar to that experienced in Denmark, Germany, Japan, New Zealand, Singapore, South Korea and Taiwan. A few other countries also reached a peak of excess mortality in 2022.[7]

2.15The Actuaries Institute gave further context, describing different trends to those found in Australia:

In contrast, many other countries experienced very high or extremely high excess mortality in 2020 and 2021, with the latter generally being the peak, before excess mortality declined in 2022 and 2023. The total excess over the four years 2020–2023 was generally far higher in these countries than in Australia and most other countries with low excess mortality in 2020.[8]

Data gaps

2.16Some submitters addressed perceived shortcomings in the existing data, namely a lack of geographic data and First Nations data.[9] These are explored below.

Geographic data

2.17In its submission, the National Rural Health Alliance (NRHA) pointed to existing shortcomings in ABS data in relation to geographic gaps, stating that:

despite the breadth and depth of data analysis provided by the ABS, there is no indicator for the impact of excess mortality on rural people ie. excess mortality data is not broken down by a geographic measure such as the Australian Statistical Geography Standard – Remoteness Areas.[10]

2.18The NRHA also stated that there has been ‘a lack of research’[11] in pandemic management strategies for rural Australians, emphasising the importance of this part of the population:

As a demographic that represents approximately one third of the Australian population, this research and data is incredibly important.[12]

2.19In order to address this gap, the NRHA urged that ‘the ABS analyse and publish data on excess mortality by geography’.[13] Ms Susanne Tegen, Chief Executive Officer of the NRHA, explained in her testimony before the committee the need for such data:

By increasing the amount of data that is available, by increasing an understanding of health care, not only the healthcare system but also your own health, you are more likely to be able to deal with your own health issues because you have an increased health literacy level. … We need to make sure that [rural people] are not forgotten, and that we have a social contract to do something about this, rather than having reforms and inquiries, and nothing happening with them.[14]

2.20The Stroke Foundation, in its submission, made a recommendation for the government to ensure, during times of national emergency, that:

hospitals maintain geographically defined stroke units staffed by specialised medical, nursing, and allied health professionals, to provide evidence-based, best-practice acute stroke care.[15]

2.21The AIHW stated, in response to a Question on Notice, that it is currently progressing analyses for the Health outcomes following a COVID-19 diagnosis by population groups and vaccination status report, which is due to be released in December 2024. This population will include, among other demographic characteristics, ‘geographical areas (state/territory, remoteness area)’.[16]

First Nations data

2.22The lack of specific breakdown of excess mortality according to First Nations status was also an issue which drew commentary over the course of the inquiry.[17]

2.23In its submission, the National Aboriginal Community Controlled Health Organisation (NACCHO) commented specifically on this issue, stating that:

Reporting of ABS provisional mortality data used to show excess deaths, does not include Indigenous status. It is therefore not possible to assess whether excess deaths seen at the whole-of-population level affect Aboriginal and Torres Strait Islander communities at a comparable level.[18]

2.24NACCHO went on to say that the lack of this data meant the impact of excess mortality on First Nations communities could not be entirely understood:

Avoidable and preventable deaths already represent a considerable burden on Aboriginal and Torres Strait Islander communities. To date, limited reporting has been available to demonstrate whether (or how) this changed during the COVID-19 pandemic. However, it is critical to highlight the importance of looking beyond the impact of COVID-19 infections to the impacts on preventative health actions (such as the reduction in sexual health screening during the pandemic) and environmental health issues (such as the subsequent increase in overcrowding which does not support good health outcomes).[19]

2.25In addition, NACCHO asked for already-existing data to be released, which would help gain a clearer picture of this issue on these particular communities:

However, while gaps exist, robust data is available on excess mortality for Aboriginal and Torres Strait Islander people in a majority of jurisdictions, and steps must be taken toward public reporting of this data, despite its limitations.[20]

2.26The NRHA also recommended that the ABS engage with researchers from the First Nations community in order to explore the factors driving this disproportionate rate of excess deaths in relation to COVID-19, and ultimately provide funding and support in order for recommendations.

Engage with First Nations researchers to explore the drivers behind the disproportionate rate of death related to COVID-19 and provide funded support to address recommendations.[21]

2.27NACCHO recommended that data collection should align with the four Priority Reform Areas under the National Agreement on Closing the Gap.[22]

Future mortality predictions

2.28While in the ABS statistics to date, ‘[p]andemic years were intentionally excluded from the baseline,’[23] the ABS stated that it will, in future, ‘produce estimates of expected mortality with COVID-19 included in the baseline’.[24]

2.29Accordingly, the ABS outlined in its submission its rationale for changing future baselines for excess mortality:

Firstly, this will provide new insights into mortality expectations accounting for the virus and may be used for policy and planning purposes. The second reason is that the further we are from the start of the pandemic the more factors we have influencing our current mortality profile which should be considered. For example, influenza and other respiratory diseases are again circulating and contributing to deaths in Australia. Thirdly, the older the data used to model a current year of expected mortality, the less robust the estimate will be.[25]

COVID-19 as a driver of excess mortality

2.30Many submitters expressed the view that excess mortality was driven both directly and indirectly by COVID-19.[26]

Deaths caused directly by COVID-19

2.31In its testimony before the committee, the ABS stated that ‘COVID-19 was the main cause of excess deaths in 2021, 2022 and up to August 2023’,[27] adding that:

In 2020, COVID-19 ranked as the 38th leading cause of death in Australia; in 2021, it moved up to the 34th position; and, by 2022, COVID-19 was the third leading cause of death, marking the first time in over 50 years that an infectious disease was in the top five causes of death in Australia.[28]

2.32The Actuaries Institute also provided its own analysis of COVID-19 in relation to excess mortality, as seen in the table below:

Source: [Actuaries Institute, Submission 3, p. 5]

2.33As indicated in the table above, COVID-19 represented either the plurality or majority of all identified causes of excess deaths between 2021 and 2023.

2.34The Actuaries Institute explained the data as follows:

Unsurprisingly, deaths from COVID-19 have been the major contributor to excess mortality, particularly in 2022 and 2023, once the vast majority of the population was vaccinated and Australia was no longer pursuing a suppression/elimination strategy. Across the four years shown, we estimate that the total deaths from COVID-19 of 17,200 make up almost two-thirds of the total estimated excess mortality of 27,200. Pleasingly, COVID-19 waves have shown an encouraging trend of reducing mortality impact since early 2022, with each successive wave resulting in fewer deaths than the previous wave.[29]

2.35In its submission, the Department stated that ‘COVID-19 was the main contributor to excess mortality in 2022’, citing the Measuring Australia’s excess mortality during the COVID-19 pandemic until August 2023 from the ABS.[30]

Cardiovascular disease and strokes

2.36The committee also heard about the increased rates of deaths from cardiovascular disease and strokes which contributed to excess mortality.

2.37In its testimony before the committee, the Heart Foundation clarified the link between COVID-19 and cardiovascular disease, stating that the virus had ‘devastating effects on the cardiovascular system’.[31]

2.38The ABS also stated in its testimony that ‘there is an increase of myocarditis in 2022 as an associated cause of death’, which is ‘generally attributed to COVID‑19’.[32]

2.39In its submission, AIHW also spoke to the rise in deaths associated with cardiovascular disease in the years following the onset of the pandemic:

[Coronary heart disease] continued its historical decline in 2020, the first year of the pandemic with 16,800 deaths, however this decline stalled in 2021 with 17,400 deaths and then increased to around 18,600 deaths in 2022. After adjusting for age, the [coronary heart disease] death rate (as the underlying cause) increased by 4.3% between 2021 and 2022 (from 50 to 52 per 100,000 population).[33]

2.40The AIHW stated that this data ‘should be interpreted in the context of higher overall mortality in 2022’,[34] linking it to the broader picture of excess deaths associated with COVID-19.According to the AIHW’s submission, chronic heart conditions represented the most common category of pre-existing among those who died from COVID-19, and the virus itself ‘was an associated cause of death for 729 deaths due to circulatory system diseases in 2022’.[35]

2.41In its testimony before the committee, the Stroke Foundation also spoke to the relationship between COVID-19 and strokes:

A person who has had a stroke is more likely to get severe COVID symptoms, more likely to get complications and five times more likely to die. That comes out in the statistics around people with comorbidity. The other thing that we know is that if you have COVID you are also more likely to have a stroke.[36]

Diabetes

2.42Evidence presented before the committee indicated that diabetes reflected one of the largest proportions of excess deaths for any cause, apart from COVID-19.[37] In its submission, the AIHW explained:

Diabetes remains one of the 10 leading causes of death in Australia contributing to around 22,000 deaths in 2022 (11% of all deaths). Diabetes was the underlying cause of death in 6,000 deaths (28% of diabetes deaths). It was an associated cause of death in a further 16,000 deaths (72% of diabetes deaths).[38]

2.43In order to illustrate these trends, the AIHW also provided the graph below (N.B. COD refers to ‘Cause of Death’):

Figure 2.6AIHW – Diabetes Death Rates

Source: [Australian Institute of Health and Welfare, Submission 4, [p. 7].]

2.44The AIHW went on to give historical context to this data:

While diabetes death rates (underlying and/or associated cause) remained relatively stable between 2000 and 2020, increases were recorded in both 2021 and 2022. After adjusting for age, the diabetes death rate increased from 54 per 100,000 population in 2000 to 56 and then 62 deaths per 100,000 population in 2021 and 2022, respectively. Like CHD, diabetes is a commonly reported comorbidity in deaths associated with COVID-19 (24% in 2021, 15% in 2022 and 13% in 2023). COVID-19 was an associated cause of death for 121 deaths due to diabetes in 2022. Type 2 diabetes is also the second most commonly diagnosed comorbid chronic condition recorded in hospitalisations that involve a COVID-19 diagnosis behind chronic cardiac conditions (21% in 2022–23).[39]

2.45As described above, diabetes represented a significant proportion of excess deaths from 2021 to 2023. In its submission, Diabetes Australia recommended that the Australian Government increase investment into diabetes research and strengthen the Australian health system’s response to diabetes.[40]

2.46The Department pointed out that an ageing population, such as Australia’s, means an increased risk of diseases including diabetes.[41]

2.47In addition, the ABS noted that deaths from diabetes were higher during periods of general high mortality during the pandemic, that diabetes was commonly recorded as a co-morbidity among deaths associated with COVID-19.[42]

Dementia

2.48Dementia also represented a notable factor associated with deaths between 2021 and 2023, as the AIHW outlined in their submission:

Dementia including Alzheimer’s disease was the leading cause of death in females and the second leading cause of death in males in 2022. Age-standardised mortality rates for dementia including Alzheimer’s disease increased from 36 per 100,000 in 2012 to 44 per 100,000 in 2019. The rates recorded in 2020, 2021 and 2022 were 41.5, 43,5 and 45.3 per 100,000 respectively.[43]

2.49AIHW offered further detail on this trend and its relation to COVID-19:

When interpreting these trends, it should be noted that people with dementia have a greater risk of developing severe illness from COVID-19 and higher risk of dying from acute respiratory infections including influenza and pneumonia. …. Fatal COVID-19 outbreaks have involved many people with dementia.[44]

2.50In its submission, the ABS also related the increased incidence of deaths from dementia to COVID-19:

Death rates for doctor-certified deaths for ischaemic heart diseases, diabetes and dementia have been higher during times of high mortality during the pandemic. These are all causes commonly recorded as co-morbidities among deaths associated with COVID-19.[45]

2.51Further, the Department noted more generally that Australia’s ageing population was a contributing factor to excess mortality, as this shift in demographics ‘raises the risks associated with dementia, cardiovascular disease, chronic kidney disease, respiratory disease, and diabetes’.[46]

Other issues raised

2.52In addition to these factors, a number of submitters raised concerns about other issues which were thought to be contributing to excess mortality. These issues, and their potential impacts, are discussed below.

Suicide and mental health

2.53Some submitters suggested that the government response to COVID-19, in particular the imposition of lockdowns, had a negative impact on mental health outcomes, inferring that excess mortality was driven to an extent by an increase in suicides.[47]

2.54For example, Father David Smith, an Anglican priest in Sydney who managed a youth drop-in centre targeting local at-risk teenagers, stated in his submission that ‘during the lockdowns I became very aware of the stress being experienced by some of the people I was working with.’[48] Father Smith expressed the view that ‘the lockdowns had the effect of pushing people who were on the edge over the edge,’ and that the lockdowns ‘cost numerous lives amongst the more vulnerable members of the community’.[49]

2.55The committee did receive evidence from the ABS that COVID-19 and the government response negatively impacted Australians’ mental health.[50]However, in its testimony before the committee, the Black Dog Institute stated that:

I'll comment first on the suicide deaths comparing 2015 to 2020 with 2021 to 2022. There were no significant changes from the earlier period to the late period. There were no increases in suicide deaths during the peak of the pandemic. The 2023 national data are not yet available, but we do have preliminary data from New South Wales, Victoria and Queensland also showing no increase from 2020. So that's one way to look at mortality.[51]

2.56The ABS described suicides as part of a broader class of ‘preventable disease from trauma’, which in fact decreased during the pandemic.[52] Providing context, the ABS explained that this broad category ‘includes road traffic accidents, suicides and also drug-induced deaths’.[53]

2.57The ABS added, in its testimony, that:

That's certainly not to say that, for something such as suicide, for example, the pandemic didn't affect people. We know that the pandemic did have an effect on people's mental health but, overall, there was a reduction in those. We did see a slight increase in 2022, but for the moment it doesn't look like that's statistically significant excess deaths. It looks more like it's a return to the usual patterns of excess mortality that we would see.[54]

2.58In addition, the AIHW provided data in its submission which showed that ‘the pattern of no clear trend has remained for the pandemic years with age‑standardised rates reported for 2020, 2021 and 2022 ranging between 12.1 and 12.3 per 100,000’.[55]

Vaccinations

2.59The committee received both submissions and correspondence which suggested that COVID-19 vaccination injuries were a potential driver of excess mortality.[56] For example, Coverse, in its submission stated:

While our organisation does not have statistical evidence that the COVID-19 vaccines have definitely contributed to excess mortality during 2021-2023, we do have evidence of widespread and significant downplaying of vaccine-caused harms, which has concerning implications for current understanding of drivers of excess mortality in Australia.[57]

2.60However, the Actuaries Institute placed such injuries in a broader health context:

The available evidence does not support a significant contribution to excess mortality by the adverse side-effects of COVID-19 vaccines. Indeed, the reverse is true: while every such death is regrettable, it seems clear that the small number of deaths triggered by COVID-19 vaccines is a tiny fraction of the number of COVID-19 deaths that they have prevented.[58]

2.61The committee heard evidence that, while there are 16 cases confirmed by the Department of deaths as a result of vaccine injury, this represents a relatively small proportion of the 69, 788, 192 vaccine doses administered between the years 2021 and 2023, as well as the total number of excess deaths in Australia.[59]

2.62The Actuaries Institute stated in its submission that vaccinations helped to prevent higher rates of excess mortality:

Many studies around the world have shown that COVID-19 vaccines reduce the severity of the disease. For example, a recent study “Assessing the impact of Australia’s mass vaccination campaigns over the Delta and Omicron outbreaks” presented a conservative estimate that deaths from COVID-19 would have been six times as high with no vaccinations. This meant that almost 18,000 deaths were averted between August 2021 and July 2022 in people aged over 50 by the COVID-19 vaccines in NSW alone. Extrapolating this nationally, more than 50,000 deaths were averted in this 28-week period. In other words, COVID-19 vaccines have significantly reduced excess mortality. [Emphasis in original][60]

Healthcare access

2.63Some submitters also expressed concern about reduced access to healthcare during the pandemic.[61]

2.64In an answer to a question on notice, the Stroke Foundation stated the following:

The National Heart Foundation of Australia has estimated that 27,000 fewer Heart Health Checks were conducted due to COVID-19.

Specifically, between March 2020 to March 2021, 92,380 heart health checks were undertaken.

The number of heart health checks undertaken has increased steadily since then, and between March 2023 to March 2024, 207,919 heart health checks were undertaken, the highest number since the Medicare Benefits Schedule item numbers were introduced in early 2019.

2.65Moreover, the Heart Foundation, in its appearance before the committee, emphasised the potential long-term consequences of this change:

We saw a testing and management of risk factors out in primary care drop significantly, with about a 40 per cent drop in pathology testing for things like cholesterol and diabetes. We saw people delaying attendance at health facilities. As far as severe events like myocardial infarction, we saw much higher acuity and fewer procedures being done to deal with those. There will be a price, and there is a price, that we're paying in the long term for that, because people with more significant damage at the time of their event are going to have long-term chronic illness.[62]

2.66Diabetes Australia, in its submission, also expressed concern about access during the pandemic:

… in Australia reduced access to primary care, diagnostic and hospital services for diabetes, combined with fear of exposure to the virus in these settings, led to a significant drop in access to usual diabetes care. From the diabetes care perspective, there was a significant and concerted diversion of hospital resources and staff to COVID-19 specific activities, and there was a reduction in HbA1c testing (the main biomarker used to assess long-term glycaemic control) amongst people with type 2 diabetes.[63]

2.67The Actuaries Institute also listed, among others, the following possible causes of excess mortality:

delays in patients receiving emergency medical care, supported by statistics on ambulance response times and emergency department treatment times; and

delays in patients receiving routine medical care, supported by statistics on elective surgery wait times.[64]

2.68This issue is further considered in Chapter 3 within the context of addressing preventable drivers of excess mortality from 2021–2023.

Footnotes

[1]Actuaries Institute, Submission 3, p. 2. Emphasis in original.

[2]Department of Health and Aged Care, Submission 1, [p. 5].

[3]Australian Bureau of Statistics, Submission 2, p. 12.

[4]Department of Health and Aged Care, Submission 1, [p. 8].

[5]Department of Health and Aged Care, Submission 1, [p. 8].

[6]Actuaries Institute, Submission 3, [p. 2].

[7]Actuaries Institute, Submission 3, [p. 4].

[8]Actuaries Institute, Submission 3, [p. 4].

[9]See, for example, Royal Australian College of General Practitioners, Submission 8, [p. 1]; Associate Professor Tim Adair, Associate Professor Brian Houle and Professor Vladimir Canudas-Romo, Submission 32, pp. 7–8.

[10]National Rural Health Alliance, Submission 9, p. 6. Citations omitted.

[11]National Rural Health Alliance, Submission 9, p. 6.

[12]National Rural Health Alliance, Submission 9, p. 6.

[13]National Rural Health Alliance, Submission 9, p. 7.

[14]Ms Susanne Tegen, Chief Executive, National Rural Health Alliance, Committee Hansard, p. 21.

[15]Stroke Foundation, Submission 6, p. 3.

[16]Australian Institute of Health and Welfare, answer to question on notice, 13 June 2024, (received 4 July 2024).

[17]See National Rural Health Alliance, Submission 9, p. 3.

[18]NACCHO, Submission 7, p. 4.

[19]NACCHO, Submission 7, p. 5. Citation omitted.

[20]NACCHO, Submission 7, p. 4.

[21]See National Rural Health Alliance, Submission 9, p. 4.

[22]NACCHO, Submission 7, p. 4. Note that the four Priority Reform Areas are ‘1. Formal partnerships and shared decision-making, 2. Building the community-controlled sector, 3. Transformation of mainstream institutions, and 4. Sharing data and information to support decision making.’ pp. 3–5.

[23]Australian Bureau of Statistics, Submission 2, p. 4.

[24]Australian Bureau of Statistics, Submission 2, p. 12.

[25]Australian Bureau of Statistics, Submission 2, p. 12.

[26]See, for example, Actuaries Institute, Submission 3, [p. 1]; Associate Professor Tim Adair, Associate Professor Brian Houle and Professor Vladimir Canudas-Romo, Submission 32, p. 6; Australian Bureau of Statistics, Submission 2, p. 9; Department of Health and Aged Care, Submission1, [p. 5]; Centre for Population, Department of the Treasury, Submission 35, pp. 1–3; Heart Foundation, Submission 25, p. 2.

[27]Ms Bindi Kindermann, General Manager, People and Place Statistics Division, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 1.

[28]Ms Bindi Kindermann, General Manager, People and Place Statistics Division, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 1.

[29]Actuaries Institute, Submission 3, p. 5. Emphasis in original.

[30]Department of Health and Aged Care, Submission 1, [p. 5].

[31]Professor Garry Jennings, Chief Medical Adviser, National Heart Foundation of Australia, Committee Hansard, 13 June 2024, p. 46.

[32]Ms Lauren Moran, Director, Health and Vital Statistics Section, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 2.

[33]Australian Institute of Health and Welfare, Submission 4, [p. 6]. Citations omitted.

[34]Australian Institute of Health and Welfare, Submission 4, [p. 6]. Citations omitted.

[35]Australian Institute of Health and Welfare, Submission 4, [p. 6]. Citations omitted.

[36]Dr Lisa Murphy, Chief Executive Officer, Stroke Foundation, Committee Hansard, 13 June 2024, p.27.

[37]See, for example, Australian Institute of Health and Welfare, Submission 4, [p. 7]; Diabetes Australia, Submission 10, [p. 1]; and Department of Health and Aged Care, Submission 1, [p. 5].

[38]Australian Institute of Health and Welfare, Submission 4, [p. 7].

[39]Australian Institute of Health and Welfare, Submission 4, [p. 7]. Citations omitted.

[40]Diabetes Australia, Submission 10, [p. 1].

[41]Department of Health and Aged Care, Submission 1, [p. 5].

[42]Australian Bureau of Statistics, Submission 2, p. 12.

[43]Australian Institute of Health and Welfare, Submission 4, [p. 5]. Citations omitted.

[44]Australian Institute of Health and Welfare, Submission 4, [p. 5]. Citations omitted.

[45]Australian Bureau of Statistics, Submission 2, p. 12.

[46]Department of Health and Aged Care, Submission 1, [p. 5].

[47]See, for example, Father David Smith, Submission 22, [p. 1]; The World of Wellness International, Submission 12, [p. 5]; Dr Monique O’Connor, Submission 18, pp. 36–38.

[48]Father David Smith, Submission 22, [p. 1].

[49]Father David Smith, Submission 22, [p. 1].

[50]Ms Lauren Moran, Director, Health and Vital Statistics Section, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 3.

[51]Dr Fiona Shand, Associate Professor and Head of Suicide Prevention Research, Black Dog Institute, University of New South Wales, Committee Hansard, 13 June 2024, p. 46.

[52]Ms Lauren Moran, Director, Health and Vital Statistics Section, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 3.

[53]Ms Lauren Moran, Director, Health and Vital Statistics Section, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 3.

[54]Ms Lauren Moran, Director, Health and Vital Statistics Section, Australian Bureau of Statistics, Committee Hansard, 13 June 2024, p. 3.

[55]Australian Institute of Health and Welfare, Submission 4, [p. 4].

[56]See, for example, Dr Martin P. Stewart, Submission 26, [pp. 7–8]; Ms Xin Yin Ooi, Submission 20, [p.2]; Mr Martin Hicking, Submission 29, p. 6; Dr Jeyanthi Kunadhasan, Treasurer, Australian Medical Professionals Society, Committee Hansard, 13 June 2024, p. 36.

[57]Coverse, Submission 13, p. 1.

[58]Actuaries Institute, Submission 3, p. 2.

[59]Department of Health and Aged Care, answer to written question on notice, 13 June 2024 (received 26 June 2024); Dr Philip Gould, First Assistant Secretary and Chief Data Officer, Health, Economics and Research Division, Department of Health and Aged Care, Committee Hansard,13 June 2024, p.57. See also Australian Bureau of Statistics, Submission 2, p. 14; Actuaries Institute, Submission 3, p. 2.

[60]Actuaries Institute, Submission 3, p. 2.

[61]See, for example, National Rural Health Alliance, Submission 9, p. 12; Diabetes Australia, Submission 10, [p. 3]; Stroke Foundation, Submission 6, pp. 1–2.

[62]Professor Garry Jennings, Chief Medical Adviser, National Heart Foundation of Australia, Committee Hansard, 13 June 2024, p. 45.

[63]Diabetes Australia, Submission 10, [p. 3]. Citations Omitted.

[64]Actuaries Institute, Submission 3, p. 7.