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Dingell, the gap, dope, disease, discrimination and determinants

Lesley Russell writes:

My Colorado #skibumsojourn continues (great snow, cold weather, sunshine most days) so the focus of The Health Wrap continues to be on things American.

It’s easy to be overwhelmed, day after day, with Trump stories, and now there is also a focus on Democrats who are putting up their hands to run for the presidential nomination in 2020.

Of course, the big story is the declaration of a national emergency by Trump so that he can use money already committed to areas like defence infrastructure and drug interdiction to build The Wall on the border with Mexico. You might find this explainerby my skiing partner Bruce Wolpe helpful as the issue plays out.

The end of an era with the death of Congressman John Dingell

Many who work or have worked in politics in Washington over the past 60 years are mourning the death of former Michigan congressman, John Dingell. He was the longest-serving member of Congress ever, elected in 1955 to replace his father who died in office and then re-elected every two years until his retirement in 2015, when his seat was taken by his wife Debbie. Only someone who had never met Dingell and knew nothing of his legacy would raise their eyebrows at this apparent family sinecure.

For seven years (1984-1991) I was his senior health policy advisor on the powerful Energy and Commerce Committee which he chaired for 28 years. I was a short-timer by Dingell staffer standards, but it was one of the most important experiences of my life.

Dingell has a legislative record that might never be matched across a spectrum of issues that was even wider than the jurisdiction of the committee he chaired (we used to say if it moved it was energy and if it didn’t move it was commerce). He was perhaps best known for championing national health insurance – a cause his father had adopted after World War II. Every congress he resubmitted his bill, updated as needed (and that was part of my responsibilities in the time I worked for him).

John Dingell, seated, as Barack Obama signs the Affordable Care Act

One of my fondest memories is of him sitting, beaming, as Obama signed the Affordable Care Act into law. It was not his bill, indeed it was a long way from what he envisioned, but he always told us to “never let the perfect be the enemy of the good”. Many times he sent me out to negotiate on tough issues with that mantra in mind, telling me to come back only when I had improved the status quo. He required that his staff mastered both policy substance and political process, and always reminded us that without the latter the former was nothing.

Dingell understood that congressional service is the act of coming together for the betterment of the nation and its people. He never forgot where his power came from – the people who voted him into office. He was at once fierce, tough, imposing, tenacious and intolerant of those who did not have the good of the nation at heart. But he was also gentle and thoughtful, a wonderful friend and mentor who loved music and ballet. It was such a pleasure to sit with him late in the night on the House floor and hear his retelling of Civil War stories. He didn’t demand loyalty from his staff, he created it.

The Dingell team today is a strong, cohesive group that bands together in times such as these. I was luckily able to go back to Washington DC to attend Dingell’s funeral and catch up with friends and colleagues. There were so many stories to tell and retell, and moments of great laughter over his tweeting mastery and especially around the fact that, in typical fashion, he had left a manifesto for us and those who come after. Our only sadness was that in these Trumpian days we desperately need another John Dingell.

You might enjoy these stories about him:

His Washington Post obituary: John Dingell, longest-serving member of Congress in U.S. history, dies at 92.

Norm Ornstein: John Dingell Was a Gift to America.

Washington Post on Dingell’s funeral: Dingell remembered as a larger-than-life lawmaker deeply respected by colleagues from both parties.

Dingell’s wicked mastery of twitter: John Dingell was a Twitter superstar. Here are his greatest hits.

Dingell’s last words to the nation: John Dingell: My last words for America.

Closing the Gap report

On 14 February, Prime Minister Scott Morrison delivered to the House of Representatives his statement on Closing the Gap, 2019. This was the eleventh report from the fifth Prime Minister – but the news has not improved. The report itself seems to get glossier each year, but lots of photos cannot hide the fact that progress has not been made.

There are however some reasons for optimism. This is the final report against the framework established in 2008 – a framework Morrison rightly called “doomed to fail” because it did not sufficiently share “objective and process” with Indigenous Australians and did not hold different levels of government to account. Let’s hope these insights accurately inform the Australian Government’s approach to the next phase of Closing the Gap.

In December COAG committed to a genuine formal partnership with Indigenous people to finalise the Closing the Gap Refresh by mid-2019 and to providing a forum for continuing engagement throughout implementation of the new agenda and new targets.

There have been lots of interesting and valuable papers written recently, so it is my intention to collect up some of them here for your reading and filing.

Nicholas Biddle. Four lessons from 11 years of Closing the Gap reports. The Conversation, 13 February, 2019.

Calla Wahlquist. Indigenous groups call for greater share of Closing the Gap funding. The Guardian, 13 February, 2019.

Marie McInerney. Hopes on strong, timely Closing the Gap partnership, after targets remain out of reach. Croakey, 14 February, 2019

Melitta Hogarth. There’s little reason for optimism about Closing the Gap, despite changes to education targets. The Conversation, 15 February, 2019

Pat Turner. Closing the Gap 2019: opinion piece. NACCHO, 18 February, 2019.

There is one more reason for optimism: and that was the Prime Minister’s recognition that, to date, too much focus has been on deficits and failures in Indigenous programs and not enough on gains and opportunities.

In this vein, perhaps we should make the 2017 report from the Lowitja Institute Deficit Discourse and Indigenous Health – how narrative framings of Indigenous people are reproduced in policy – compulsory reading for all bureaucrats and Ministers involved in Closing the Gap policy making?

Marijuana use in Colorado

It is almost six years since voters approved Colorado’s first-in-the-nation experiment to legalise marijuana (Colorado approved the sale and use of marijuana for medicinal purposes in 2000). Since then, 29 states and the District of Columbia have legalised medical and/or recreational marijuana. But Colorado is the canary in the coal mine that other states look to as they decide on whether and how to legalise.

Financially, marijuana has been a boon to the state; in 2018, marijuana tax, licence and fee revenue was US$266.5 million. On issues such as the impact on crime, accidents and the healthcare system, Colorado has led the way with a series of reports.

I wrote about this for Croakey this time last year. Here’s an update, based on some recent reports.

Photo by Michael Fischer from Pexels

Health effects

The Colorado Department of Public Health and Environment mandates a biannual report that provides insights into marijuana usage patterns, research into the drug’s effects, and data about health effects associated with its use. The most recent report Monitoring Health Concerns Related to Marijuana in Colorado: 2018, which uses data from six separate data sources, indicates the following:

Usage rates among adults continue to rise: in 2017 15.5 percent of adults reported using marijuana in the last 30 days, up from 13.6 percent in 2016 and considerably higher than the national average of 9.5 percent. Usage is highest for adults ages 18-15 (29.2 percent) and it is considerably higher in men (19.8 percent) than women (11.2 percent). The LGBTQ community has very high rates of use (34.7 percent).

Daily or near daily usage among adults increased from 6.4 percent in 2016 to 7.6 percent in 2017. More than 84 percent of users reported smoking marijuana, but 50 percent of users reported multiple methods of use including taking edibles, vapourising and dabbing. (If, like me, you don’t know what dabbing is, here is a primer!)

In contrast to adults, schoolchildren’s usage (about 19 percent of high school students and 5.2 percent of middle school students reported usage in the past 30 days) is steady and consistent with the national average.

There are serious concerns about marijuana in homes with children, including whether the products are stored safely and the fact that about 5.5 percent of such homes have secondhand smoke. More than 65 percent of unintentional exposures in children were caused by edibles. There is evidence that younger women with less than 12 years of education have a high rate of usage during pregnancy (13.3 percent of pregnant women aged 15-19 reported using marijuana).

There was a small increase in emergency department visits related to marijuana from 2016 to 2017, but hospitalisations decreased.

Criminal justice

A recent report from the Colorado Department of Criminal Justice Impacts on Marijuana Legalization in Colorado confirms that young people are not smoking more pot but does show that the involvement of organised crime in marijuana black market activities is increasing and there is some concern about whether legalisation has led to more dangerous driving.

The percentage of Driving Under the Influence (DUI) citation with marijuana-only impairment has not increased since legalisation, although the number of fatalities where a driver tested positive for any cannabinoid increased from 55 (11 percent) in 2013 to 139 (21 percent) in 2017.

Meanwhile there was a report this week in the Washington Post that lawmakers in Maryland are considering a bill that would explicitly legalise the use of marijuana to treat opioid-abuse disorder, following decisions already made by Pennsylvania, New York and New Jersey.

Following a lengthy review process, the World Health Organisation has proposed removing cannabis from its placement in the drug category reserved for the most dangerous substances. Currently, marijuana and cannabis resin are considered schedule IV substances (a category shared by heroin and cocaine), indicating that any medical uses for the substance are outweighed by their potential for abuse.

Disease hotspots – this week it’s Venezuela

There are so many places around the world where disease and malnutrition are rampant (Yemen, Syria, the Rohingya refugees in several countries, and the Democratic Republic of the Congo) and sadly, in developed countries we find these crisis so easy to ignore.

Reports this week show the number of new Ebola cases has dropped slightly in the DRC, but experts warn that doesn’t mean the world’s second-largest Ebola outbreak on record is yet under control, and it could simply be moving to new areas of the sprawling country.

Arauca River by Dansar CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=582130

However, the smug developed countries are not immune. There are measles outbreaks in Canada, the United States, Europe, Ireland and Australia – and more serious problems in the Philippines and Latin America.

[By the way, did you read “Everyone can be an effective advocate for vaccination: here’s how” in Croakey?]

While Trump is ranting about the evils of socialism in the US, using Venezuela as an example, this poverty-stricken South American country is in the midst of a dreadful health crisis – including a measles outbreak that began to erupt in 2017, just one year after the World Health Organization triumphantly declared the Americas to be the first region on the globe to eradicate measles.This outbreak is now spreading throughout Latin America.

Venezuela used to have one of the best health systems on the continent. Now it has the most problematic. The ongoing political and economic crisis has caused major shortages of food and medicine, hyper-inflation and millions of refugees are flowing out of the country.

In this environment, other diseases are also making a comeback.Venezuela officially eradicated malaria in 1961, but the erosion of the mosquito control program has seen the disease explode. There were over half a million cases of malaria in 2018.

Three million Venezuelans have now left the country, taking diseases (including measles, malaria and HIV/AIDS) with them. Patients say Venezuela’s public health care system ran out of the lifesaving anti-AIDS drugs months ago.

It’s not just people in need of health care who are fleeing Venezuela – healthcare professionals are leaving too. In December, when Chile gave its national exam to certify doctors to work in its public health system, just over 5,000 applicants sat down to take the test. Almost half of them, 2,300, were from Venezuela.

Discrimination against people with intellectual disabilities

Healthcare gaps, disparities and discriminations are not borne solely by Indigenous Australians but are burdens for many other population groups, perhaps none more so than Australians with an intellectual disability. How rarely are their voices heard in the debates, despite the evidence of dreadful health outcomes.

This past week, the Council for Intellectual Disability hosted @wepublichealth under the rubric #OurHealthCounts and did a great job in highlighted why we must all do more to tackle #deadlydisabilitydiscrimination in the healthcare system.

People with intellectual disabilities make up about 3 percent of the population. Finding up-to-date information on numbers of people affected is difficult: the most recent data I found was from the Australian Bureau of Statistics and dated to 2012. (There’s a story just here!) Many of these people have severe or profound disabilities leading to limitations in all three core activities of daily living – self care, mobility, and communications.

Here’s a brief summary highlighting the healthcare needs of this population group.

A 2017 article found that in NSW 38 percent of deaths of people with an intellectual disability were potentially avoidable (compared to 17 percent for the general population). This delivers a 27-year gap in life expectancy.

The situation might actually be getting worse: in 2008 the National Health and Hospitals Reform Commission looked at these “stark health inequalities” and found that life expectancy for people with intellectual disabilities was 20 years lower than that for the general population (the NHHRC noted that this is comparable to, or perhaps even worse than, that for Indigenous Australians).

This population group has a huge burden of undiagnosed physical and mental illness. Only 29 percent of health conditions are diagnosed and treated appropriately, and dental disease and psychiatric disorders are particular problems. As far back as 1993 the Burdekin Report stated ”there is an urgent need for academic research, increased clinical expertise and increased resources” for the mental health of people with intellectual disabilities.

In 2007 an annual health assessment for people with intellectual disabilities was introduced into Medicare. However, while there is a list of components that must be part of such an assessment, since 2014 these assessments are billed with a range of other health assessments under MBS items 701-707 and so it is not possible to know how many are delivered annually.

People with intellectual disabilities have problems communicating, with schooling and community participation. Their chances of employment are low, and they are more likely to experience bullying and violence.

There is a huge unmet need for services and assistance. Hopefully these people will be fully included in the current calls for a Royal Commission on Disabilities.

As an aside, it’s a pleasure to see a reasonable number of people with intellectual disabilities employed in the eating places on the ski slopes here in Colorado (a recent move). They are fun, often charming, always eager to help. I hope their benefits include a ski pass!

This week’s good news story

At George Washington University in Washington DC, third- and fourth-year medical students can receive hands-on training through a culinary medicine clinical elective that was introduced in 2017. The classes give students the tools to teach patients real-world skills to alter their diets, shopping habits, and meal preparation to help them feel better, prevent disease, and treat disease.

Actually GWU is not alone is doing this: the university is part of a consortium of 31 medical schools, two nursing schools and five residency programs that are adapting a curriculum developed by Tulane University.

GW is partnering with a local food bank which works to solve hunger alongside undernutrition, heart disease, and obesity for the elective. This links in with GWU’s Clinical Public Health curriculum which integrates public health and population health throughout students’ medical education.

Definitely worth copying!


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow Lesley on Twitter at @LRussellWolpe

Previous editions of The Health Wrap can be read here.

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