In examining “the silent phase” of the COVID-19 pandemic, Adjunct Associate Professor Lesley Russell diagnoses “a dearth of meaningful national data” and argues that there is no time for surveillance fatigue.
Her latest column also reports on the latest developments in the unending campaign for more equitable access to dental care, progress on HIV/AIDS, the alarming global news on climate change – and brings a good news story from the work of Indigenous rangers.
The quotable:
…consumers and the community have a strong appetite for large, systemic changes to the dental and oral care system which will lead significant improvements to the systems, people’s health experiences and the community’s health outcomes.”
Lesley Russell writes:
There is no expert consensus on where we are in the pandemic. The prevailing view is that we are through the emergency phase and that we are “learning to live with the virus”.
In Australia we have some idea about what this means in terms of hospitalisations and deaths, but – as I have written previously (many times it seems) – we currently have no effective national surveillance, no standardised national collection of epidemiological and genetic data and no-one charged with looking at what is happening internationally (that does not mean that individual researchers are not doing this work).
The absence of these data means we cannot plan for future waves of infection, assess the effectiveness and appropriateness of interventions and treatments, or better target areas of need.
We are in what has been called the “silent phase” of the pandemic.
“This is no time for surveillance fatigue. Laboratories need ongoing funding, and we still require a ‘whole-of-government’ approach. There’s no room for complacency, ” Professor Dominic Dwyer, medical virologist and infectious diseases physician, told the AFR in January.
In an opinion piece for the BMJ in February, ‘Covid-19 in Australia: How did a country that fought so hard for extra time end up so ill prepared?’, Professor Catherine Bennett said this:
In reflecting on what needs to be learnt from the pandemic response in Australia, colleagues and I nominated comprehensive and transparent data collection, reporting, and communication as our top recommendations.
We are not there yet and will struggle as long as essential public health data aren’t routinely collected and released.”
In a separate paper published in The Lancet that same month, Bennett and colleagues reflected on lessons learned from Australia’s public health response: the absence of timely national data, requiring a re-assessment of national surveillance structures, was identified as a key lesson.
The timely collection, analysis and sharing of data is not just an issue about ensuring Australia is monitoring and understands COVID-19 infections and their impact nationally, it should also be part of our international pandemic responsibilities.
There is one additional important factor for the improvement of Australian data (this applies to all health, healthcare, and socio-economic data): it needs more granularity with respect to race and ethnicity.
As outlined in a recent publication from Professor Andre Renzaho from the University of Western Sydney: “There is an urgent need for the collection of customised, culturally competent racial and ethnicity data that can be consistently integrated into all policy interventions, service delivery and research funding across all levels of governance in Australia.”
Currently, Australia is falling behind other OECD countries in tracking and addressing racial and ethnic inequities in health and social determinant factors.
Earlier this year my Croakey colleague Alison Barrett reported that the Health Minister Mark Butler had promised that Australia’s future COVID-19 policies will be evidence-led.
Sadly, we’ve yet to see any policies – maybe that’s because there are no data to indicate what need to be done?
It’s hard to see how, with the current dearth of meaningful national data, any policies to come will be evidence-based.
Croakey is currently running a series on COVID (with more articles to come). Published to date:
- How governments are (still) failing the public on COVID control by Alison Barrett.
- Changing Australia’s approach to managing COVID-19 pandemic may help reduce burden on health system by Andrew Hewat.
Better access to dental care for all Australians – if not now, when?
The good thing is that people are (still/once again) talking about improving access to affordable dental care and oral health for all Australians.
I’m somewhat embarrassed to look back at everything I have written on this topic over the years – to date, with little effect.
There has also been a substantial pile of reports adding to the evidence of Australia’s growing “dental divide” and the impact this has on healthcare costs, health outcomes and people’s productivity and quality of life.
A few poorly designed programs have come and gone, while state-run public dental services receive the same levels of federal funding as a decade ago. The only major changes are that waiting lists and wait times for public services have blown out and out-of-pocket costs for those who can afford treatment in the private sector have grown.
Last year my Croakey colleague Charles Maskell-Knight compiled the sad history of the Australian Government’s efforts in funding dental services. He described “more twists and turns than an episode of Midsomer Murders”. (Frankly I think you need Vera or Silent Witness on the case!)
Most recently my article for The Conversation explored whether it was time for including dental care within Medicare or a Medicare-style “Denticare” scheme. In short – the answer to that is “not yet”, but we should already be moving down the road towards the goal of universal access to basic dental and oral healthcare.
I am willing to be uncharacteristically optimistic that the final report from the Senate Select Committee on the Provision of and Access to Dental Services in Australia will be the report that finally drives action.
The Committee’s interim report was delivered last month. The Committee is still taking submissions and has hearings planned for the next three months. The final report is due at the end of November.
The interim report has been well received, although it has received little public and media attention. It found widespread support from experts and the community for broadening Medicare to include more dental and oral health care subsidies (although it’s not clear if there is widespread support for an increased Medicare levy or increased taxes to pay for this).
The usual loudest voices in the room on these issues – the Australian Dental Association (ADA) and Private Healthcare Australia (PHA) – have spoken out on the issues they see as “theirs” but have largely ignored the needs and preferences of the most important stakeholders – Australians, especially those who suffer from limited access to dental and oral health services.
The Australian Medical Association (AMA), while a player on this turf, has chosen to restrict its focus solely to the oral health needs of Aboriginal and Torres Strait Islander people.
Media releases on interim report’s findings:
- ADA backs Senate interim report on dentistry in Australia
- Australian Health Funds best placed to deliver access to much needed dental care.
I couldn’t find a media release from AMA on this specific issue, but there was an opinion piece in the MJA’s Insight+ column: Medicare with teeth: Senate call for public dentistry
I also could not find any media releases from Consumers Health Forum (CHF) and the Australian Council on Social Services (ACOSS).
To date there has been well over one hundred submissions to the Senate Inquiry. I took the time to read some of them.
The AMA’s submission focuses solely on the needs of Aboriginal and Torres Strait Islander people and says nothing about the needs of other population groups who experience dental health inequities. It is perhaps telling that there was no mention of how expanded dental services should be paid for.
It was good to see the Australian Dental Association submission speaking about the fact that dental caries is a preventable disease and making suggestions for how to address this. However, the submission offered little in how to address dental workforce issues outside of a suggestion that vouchers from the public system could be used to access care in the private system.
The Private Healthcare Australia submission was spruiked by a media release claiming, “Australian health funds are ideally placed to deliver a future government scheme to increase access to dental services for the most vulnerable in the community, given health funds are the major funding source for dental care and have an unequalled track record keeping out of pockets costs under control”.
Charles Maskell-Knight bravely undertook to fact-check the submission (this was much-needed; let’s hope the Senate Select Committee also reads his article carefully – available here).
The ACOSS submission was surprisingly perfunctionary and made only two recommendations – to increase investment in public dental services and to transition to universal dental healthcare, provided through Medicare – with no indication about the best way to get there.
The CHF submission provides some great recommendations for immediate and longer term actions. It also includes the results of a survey of Australian health consumers about their experiences with and views about oral and dental healthcare in Australia.
There are some pretty shocking survey findings:
- Nearly one third (31 percent) of participants had not seen an oral health provider in over five years;
- 17 percent had to wait more than a year for an appointment with a public dental service;
- Only 15 percent of participants reported that they had organised dental or oral care for children within the last 12 months.
The survey found that “consumers and the community have a strong appetite for large, systemic changes to the dental and oral care system which will lead significant improvements to the systems, people’s health experiences and the community’s health outcomes”.
Meanwhile, some more food for thought on the costs of so many Australians missing out on dental care:
An article in The Sydney Morning Herald on gum disease (the “quiet disease”) says some 30 percent of Australian adults have severe gum disease, known as periodontitis. This is linked to other health conditions, such as dementia, diabetes and heart disease.
In a recent conversation, paediatric dentist Professor Richard Widmer told me that very often he and colleagues are called upon to treat urgent dental problems before children in hospital for major cardiac surgery can have surgery. These children, along with those who have had rheumatic heart disease, are particularly vulnerable to infective endocarditis as a result of dental problems and procedures.
Australian progress on HIV/AIDS
Australia has always been an exemplar in the management of the HIV/AIDS pandemic.
By decriminalising sex work, providing free needle exchange, and bringing together researchers, politicians, doctors, and those most at risk, Australia has been able to manage the spread of the virus. If only we could echo this success with the SARS-CoV-2 virus!
This past week brought more good news.
As reported on the ABC 7:30 program, Sydney’s gay neighbourhoods – the eastern and inner west suburbs – are poised to be the first place in the world to end community transmission of HIV (effective elimination is defined in the NSW HIV Strategy 2021 – 2025 as a 90 percent reduction in new HIV cases over a decade).
It’s obvious from the way this is worded that “effective elimination” does not mean no new infections.
Australia must better communicate with people at risk of HIV who live outside of metropolitan areas and men who have sex with men who come to Australia from overseas. The HIV notification rate is also higher in Aboriginal and Torres Strait Islander people (2.3 per 100,000 in 2021 compared to 1.7 per 100,000 among non-Indigenous people).
Data from Health Equity Matters (formerly the Australian Federation of AIDS Organisations) show that in 2021 it was estimated that there were 29,460 people with HIV in Australia; 92 percent of people diagnosed were receiving HIV treatment, and of those on treatment, 98 percent had an undetectable viral load.
In 2021, 60 percent of HIV notifications were attributed to sexual contact between men, 27 percent of cases were attributed to heterosexual sex, 8 percent to a combination of sexual contact between men and injecting drug use, 2 percent to injecting drug use alone, and 3 percent to other/unspecified. Most HIV transmission today occurs where one partner has HIV but does not know it.
The reductions in new HIV diagnoses among Australian-born gay, bisexual, and other men who have sex with men over the past five years reflect advances in biomedical prevention in the past decade, namely rapid HIV tests, treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). More than 38,000 people were accessing PrEP in Australia in 2021, the highest number per capita in the world.
However, HIV diagnoses are not declining among overseas born gay, bisexual and other men who have sex with men, particularly those born in Asia and the Americas.
While the HIV notification rate across the nation remains lower than in preceding years, the effects of COVID-19 mean we must be mindful of trends over time.
Understanding and addressing the structural and social factors that influence emerging difference in HIV incidence among population groups and providing culturally appropriate and scaled up prevention programs in partnership with community stakeholders must be provided for all who are at risk.
In an article in the Star Observer, the CEO of Health Equity Matters Darryl O’Donnell said, “Sydney’s progress with HIV reflects decades of enlightened political leadership but just as importantly an unceasing community commitment to fight stigma, amplify empathy and put people at the centre of the treatment and prevention effort. This unique alchemy is a world-leading model.”
Because of that inspired collective audacity and hard work, the community is able to think about the future.
I found the discussion paper from ACON, “Imagining HIV in 2030”, to be quite inspiring. It asks important questions like how to ensure that no one gets left behind and, as the HIV positive population is getting older, how to make sure the best treatment, care and support are provided in aged care settings.
Climate change and health – the issue heats up
For the past few weeks, media around the world have been full of climate change stories. For example, on July 13, these articles from Australia and the United States:
- Weather extremes are thrashing the world, and it’s just a taste of what’s to come. Sydney Morning Herald.
- Floods, fires and deadly heat are the alarm bells of a planet on the brink. Massive floods. Record heat. Extreme ocean temperatures. Forest fires burning out of control. Climate alarm bells are ringing all over the planet. Washington Post.
Much of Europe and Northern America is suffering an ongoing and massive summer heatwave. On top of climate change, the Earth has entered a natural El Niño weather pattern for the first time in four years, bringing about conditions that will turn up the heat in many parts of the world. The season is already shattering various global temperature records.
Last week Canada saw blistering temperatures that reached into the North Western Territories and these dangerously hot and dry conditions, together with lightning storm, generated new wildfires that intensified the country’s historically severe fire season.
For weeks now these wildfires have caused dreadful air pollution across Canada and in the northern and eastern states of the United States.
Recent stories in the American media speak to people needing medical treatment for burns from hot pavements and scalding water from garden hoses (see this Washington Post article).
People are dying from the heat even in cities like Laredo, Texas, where summer temperatures have always been high – but the current unending wave of punishing heat and stifling humidity killed ten people past week.
Much of Europe is experiencing a “heat dome” and southern European countries like Spain and Portugal are reeling under temperatures higher than ever previously recorded. On July 11, Land Surface Temperature exceeded 60°C in Extremadura, in the central-western part of the Iberian peninsula.
People in Europe struggle to deal with temperatures that most Australians would find manageable and there are severe health consequences.
A study just published in Nature Medicine found that more than 61,000 people died because of last year’s brutal summer heatwaves across Europe. This year’s toll could be worse.
Most of the people who died were women, especially those older than 80. Among younger people, men died at higher rates, especially if they worked outdoors. Italy, Spain and Portugal had the highest heat-related mortality rates.
Many European governments had “heat action plans” developed in response to a deadly heatwave in 2003, but those adaptations weren’t enough to prevent mass casualties.
Countries like India have been dealing with increasing mortality rates from high temperatures for some years.
This (northern) summer in northern India, the heat has been hovering around the critical “wet-bulb temperature,” the threshold beyond which the human body cannot cool itself to a survivable point by perspiration, defined as 35 degrees Celsius (95 degrees Fahrenheit), adjusted for 100 percent humidity. Already heat-stressed regions are experiencing a growing number of days in near-unliveable temperatures.
It is expected that more older and infirm patients than usual will die in heatwaves like this one, which climate change has made more common across India’s historically scorching plains.
A study just published in PLOS Climate shows that climate change-induced heatwaves in India in 2022 left almost 90 percent of people more vulnerable to public health issues, shortages of food staples and increased risks of death.
The authors argue that the full extent of the damage from India’s sizzling heat that’s causing more deaths, illnesses, school shutdowns and crop failures is underestimated by Indian lawmakers and officials and is slowing the nation’s development and progress towards the Sustainable Development Goals.
The impact of climate change does not stop at severe summer temperatures. In the past few weeks there have been raging floods in Vermont and northeastern United States, in the state of Alagoas, Brazil, and in Japan.
Rising temperatures make this problem worse because they allow the air to hold more moisture, leading to more intense and sudden rainfall, seemingly out of nowhere.
“It’s getting harder and harder to adapt to these changing conditions,” said Rachel Cleetus, policy director for the climate and energy program at the Union of Concerned Scientists. “It’s just everywhere, all the time.”
As Doctors for the Environment Australian point out, Australia is not immune from these disasters and must do more to prepare for them.
Croakey has a number of recent articles on what can and should be done:
- Sharing some bright ideas for the National Health and Climate Strategy.
- As climate emergency escalates, medical leader call urgently for an end to “business as usual”.
- Health sector urged to engage and empower young people in climate advocacy and activism.
The best of Croakey
READ: On the Robodebt – some reflections for the health sector
The good news story
A team of female Indigenous rangers is working to keep a threatened species – golden bandicoots – alive by helping with its translocation from the Kimberley to the Northern Territory.
In June the Wilinggin Aboriginal Corporation’s Darran.gu Wulagura women’s ranger team worked alongside the Australian Wildlife Conservancy on the first-ever golden bandicoot population survey on Wilinggin country.
Golden bandicoots were once widespread in Western and Central Australia, but now their only mainland population is in the Kimberley region.
There’s a great article about the increasingly important work that women’s rangers do on the World Wildlife Federation Australia website here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
