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The Health Wrap: addressing ‘intractable’ issues, dementia & COVID19, science in the White House, mental health crisis responses, and more

The Health Wrap by Associate Professor Lesley Russell looks this fortnight at how COVID-19 has led to better approaches for homelessness and poverty, the importance of civic trust, the return of science in the US, dementia and COVID-19, and a host of other important reports and insights.


Lesley Russell writes:

You may have noticed the proliferation of papers and reports about what we have learnt/are learning from the coronavirus pandemic, along with lots of suggestions for how to build back better (to borrow a phrase from a politician or two).

I addressed some of these in the last edition of The Health Wrap. At that time, I missed this commentary in Nature Reviews Immunology from Professor Peter Doherty which I would particularly commend to you.

Addressing other ‘intractable’ problems

As I say endlessly about policies – writing them is the easy bit, implementing them is harder.

A sentence in a recent article at The Mandarin caught my eye – “Governments’ lightning-fast responses to the pandemic have shown that many apparently intractable policy problems are in fact failures of will.”

Like me, you may not be able to read all the article because it’s behind a paywall, but that is almost unnecessary – it’s an excellent point and there are examples of how this is the case in Australia. Probably the two best are homelessness (the topic in The Mandarin) and poverty.

Homelessness

In several states, homeless hotel programs instituted as a consequence of the pandemic have given many people the ability to begin to turn their lives around. State governments are learning what public health people always knew —  housing the homeless is a cheaper model of social welfare than leaving people on the street.

Research conducted for the Australian Homelessness Monitor 2020 revealed at least 33,000 rough sleepers and other homeless people were booked into hotels and other temporary accommodation. during the crisis period of the pandemic.

Suddenly governments were able to provide shelter to those who needed it most. Will they continue to do so? Already there is evidence that only a minority of those housed in emergency accommodation will gain permanent housing.

Several states, including Victoria and New South Wales, have pledged funds and support to move beyond the short-term fix and ensure former rough sleepers find long-term housing, but much more is needed.

The homelessness problem is much larger than rough sleeping: it includes those who are living in short-term and inappropriate accommodation, such as couch surfing and living in cars.

Greater challenges lie ahead. The existing extreme shortage of social and affordable housing has been aggravated as the pandemic affects people’s employment and incomes. In the months ahead, increasing numbers of Australians will struggle to find affordable housing.

Landlords unwilling to reduce rent during the pandemic have left tens of thousands of Australians at risk of becoming homeless, as those who received deferred payments find they are now unable to repay the money.

A new report from the UNSW-ACOSS Poverty and Inequality Partnership has found at least 75,000 Australians face mounting debts due to deferred mortgage payments during the pandemic.

From the ACOSS-UNSW Poverty and Inequality Partnership report

Poverty

An important policy response to the pandemic and the resultant lockdowns was to increase government payments to individuals and households. These include the temporary COVID-19 supplementary payment, which substantially increased JobSeeker and other payments, and the JobKeeper payment, both of which are about to cease.

The ANU Centre for Social Research and Methods finds that these changes reduced poverty and housing stress to levels below what they were prior to the pandemic.

There have been many stories in the media about how, as a result of temporary supplemental payments, people were able to pay off debts, access dental treatment and eat more healthily.

Experts say the supplement has been vital in raising many Australians, including children, out of poverty for the first time. Moreover it is positive for the economy as most of this funding goes straight back into the economy.

Analysis done for ACOSS shows that the Government’s planned cuts to the Coronavirus Supplement for people on JobSeeker, Youth Allowance and parenting payments would see the economy lose $31.3 billion and 145,000 full-time jobs over the next two years.

Despite this, and the fact that most Australians are opposed to reducing the payment, the Morrison Government plans to eliminate this, primarily on ideological grounds, claiming it is a disincentive to work. It is a lost opportunity to begin to address the socio-economic divides that contribute to health inequalities.

Importance of social capital in a crisis

A growing body of research has suggested that, in times of crisis, higher levels of social capital and trust enhance the ability of individuals and communities to prepare for, respond to, and recover from such crises.

I think that community capital explains the resilience and cooperative spirit that we see again and again in Australia when communities are hit with natural disasters. And I think the willingness of Australians and New Zealanders to comply so well with the pandemic lockdowns and other requirements can be explained by these social factors.

This past week there was a paper published in PLOS One that looked at the role social capital might have played in the pandemic responses of communities in the United States. Not surprisingly it found that American communities with high levels of interconnectedness, trust in institutions and neighbours, with strong community networks and communal trust experienced less severe coronavirus outbreaks in 2020. You can see it mapped out here.

Research shows that in places with low social capital, people tend to be distrustful of the government, making them less likely to comply with social distancing and mask mandates.

It’s easy to see how this all links in with the distrust and confusion sown by the Trump Administration.

More coronavirus analyses

Make sure you catch the latest edition to the COVID-19 Wrap from my colleague Alison Barrett. She has some excellent summaries of the preliminary findings from the WHO team that investigated the origins of coronavirus; the factors that might predicts national responses to the coronavirus pandemic; the importance of trust in government; and telehealth lessons.

I recently reviewed the essay on healthcare issues needing attention written by Professor Paul Torzillo that is included  in Upturn: A Better Normal After COVID-19, a collection of essays edited by Tanya Plibersek.

You might also be interested in my latest article for Inside Story Magazine that looks at the impact of COVID-19 on life expectancy.

Science is back in the US

Scientists and thinking people everywhere breathed a sigh of relief when, in one of the most significant departures from the Trump Administration, President Joe Biden vowed to make science a central theme of his administration and to enlist scientists to solve problems at home and across the globe. He demonstrated this by making the head of the Office of Science and Technology Policy (essentially the chief scientist of the United States) a Cabinet-level position.

His nominee to be the new head of OSTP is Professor Eric Lander, a geneticist who helped map the human genome (he is yet to be confirmed by the Senate). Alondra Nelson, the president of the Social Science Research Council and a professor at the Institute for Advanced Study, will serve as the OSTP’s deputy director for science and society, focusing on issues of science, policy and social inequality.

Biden has also named Maria Zuber, a planetary scientist who led efforts to map the surfaces of the moon and Mars, and Nobel chemistry laureate Frances Arnold, a pioneer in synthesizing artificial proteins, to head the President’s Council of Advisors on Science and Technology. They will be the first women to co-chair the council.

Biden’s questions for his science advisors

 In a letter to Lander (echoing the letter FDR sent to his science advisor Dr Vannevar Bush in 1944), Biden outlined five questions he sees as needing urgent attention.

  • What can we earn from the pandemic about what is possible – or what ought to be possible – to address the widest range of needs related to our public health?
  • How can breakthroughs in science and technology create powerful new solutions to address climate change?
  • How can the United States ensure that it is the world leader in the technologies and industries of the future?
  • How can we guarantee that the fruits of science and technology are fully shared across America and among Americans?
  • How can we ensure the long-term health of science and technology in our nation?

Oh to see these issues on the table for discussion in Australia!


Some science and public health issues to consider

An article this month in JAMA looks how the pandemic offers opportunities to ensure a more successful future for science and public health. It poses a series of questions (and some recommendations) for deliberation. Some of them are quite challenging.

The authors outline how the pandemic has unveiled vulnerabilities in society and in the scientific independence of public health institutions. There have been escalating attacks on science and expert opinion, an intrusion of partisan politics into public agencies, and absence of national coordination.

They see the pandemic as “a clarion call for a thoughtful examination of ways to bolster and modernize systems that support and guide science, technology, and public health” and effective governance and communications as the cornerstones for delivering the promise of science and technology for enhancing public health.

Some of the issues they raise include:

  • It is essential that what is learned from science is understood and respected by the public. How can education be improved to promote deeper societal understanding and knowledge of science and scientific principles to enhance public trust in science?
  • Science is an iterative process – there can be limitations even in the best of scientific studies and uncertainty. How can the public appreciate that knowledge is ever changing and new questions can emerge?
  • Science, per se, has no innate moral compass, and yet many contemporary challenges require the culture and mindset to meld the sciences and humanities with a sense of larger purpose and a moral compass. What is needed for public policy and society to embrace this scientific temperament, and for science and humanities to constructively embrace one another?
  • What model of funding streams and governance structure can help to insulate public health institutions from near-term political concerns and position them to generate and disseminate data and science to best serve the public, including anticipating and responding to public health emergencies?
  • How to protect the quality and integrity of science and public health and the independence of national science agencies while at the same time ensuring appropriate oversight?
  • Can emboldened fail-safe mechanisms such as strong whistleblower protections ensure that public health agencies such as the United States’ Centers for Disease Control and Prevention and the Food and Drug Administration serve the people by providing up-to-date evidence-based recommendations and thwarting the disrupting influence of politics?
  • How to improve international engagement and cooperation?

Dementia and COVID-19

The coronavirus pandemic poses unique risks to people with Alzheimer disease and dementia. Research has shown that these people have a relatively high risk of contracting severe COVID-19, and are also at risk of neuropsychiatric disturbances as a result of lockdown measures and social isolation.

Dementia as a significant risk factor

Research from the United States out this past week shows that people with dementia have a significantly higher risk of contracting coronavirus and they are much more likely to be hospitalised and die from it than people without dementia. Black Americans are at even greater risk. In US nursing homes, residents living with dementia were 52 percent of COVID-19 cases and 72 percent of all deaths.

The increased risk cannot be entirely explained by the known risk factors for COVID-19 that are common to people with dementia: old age, living in a nursing home and having other chronic conditions.

After researchers adjusted for those factors, Americans with dementia were still twice as likely to get COVID-19. The researchers think the reasons for this vulnerability might include cognitive and physiological factors, including the difficulties in wearing a mask, socially isolating, maintaining hygiene measures and lack of mobility and muscle tone.

In the United Kingdom there are similar findings. A paper published in the BMJ finds that, from March to June 2020, 27.5 percent of all COVID-19 deaths had Alzheimer’s disease and other types of dementia were the most common underlying conditions.

Delirium as an early sign of infection

 During the coronavirus pandemic, older adults with dementia are likely to develop behavioural changes as their routines are upset and their family contacts limited.

An Italian study found that delirium occurred as the initial presentation of COVID-19 in about 38.7 percent of nursing home patients and those with delirium-onset COVID-19 had higher mortality than those who did not.

This delirium is not well recognised in these patients, especially among those who do not have respiratory failure. But if unrecognised, these cases can contribute to the spread of the infection in nursing homes, already high-risk facilities, and such failure also means delays in treatment and increased mortality.

Previous studies have reported neurological manifestations among patients infected with the SARS-CoV-2 virus in both the acute phase of infection and long-term. However in ICU care there is often little emphasis on neuropsychiatric presentations in critically ill patients.

The human rights aspect

In an opinion piece in the MJA penned by members of the National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia, the authors make the case that Australia “does not currently meet the human rights of people with dementia to timely and accessible health services of appropriate quality or to participation in healthcare decisions”.

Professor Dimity Pond, a GP with a special interest in aged care, agreed with this assessment.  “There is a really strong argument to say that that’s true. We’ve got a very fragmented system. At every step along the way, there are difficulties.”

These issues are among the growing pile that must be addressed in response to the final report from the Royal Commission on Aged Care. That report is due on February 26. It will need urgent action.


Replacing police for urgent incidents

Normally at this time of the year I am in Colorado, and there is always an interesting local health-related story to report. Sadly, there’s no skiing this year, but there is a Denver story.

In 2020 Denver police began implementing a program called Support Team Assisted Response (STAR) that replaces police officers with health care workers when responding to incidents involving issues with mental health, poverty, homelessness or substance abuse. STAR providers only respond to incidents in which there is no evidence of criminal activity, disturbance, weapons, threats, violence, injuries or “serious” medical needs.

STAR is modelled on the Crisis Assistance Helping Out On The Streets (CAHOOTS) program in Eugene, Oregon, which also uses unarmed intervention members to respond to mental health calls without police backup.

An evaluation report shows that the Denver program is working; the city’s police chief believes it saves lives. During the first six months of the program (June – November 2020) health professionals responded to 748 calls, including trespassing, welfare checks, narcotic incidents, and mental health episodes. None of those cases required help from Denver police and no individuals were arrested.


Recent reports and papers

Coping with COVID-19: Rethinking Australia. University of Melbourne / Melbourne Institute. 2020 See in particular Chapter 9 – The Future of Healthcare After COVID-19

J Desborough et al. Reflecting on Australia’s five principles for pandemic response in primary care through the lens of early international experiences of COVID-19. Australian Journal of General Practice. 2021. Available at https://www1.racgp.org.au/getattachment/413a13a9-db2f-48da-8379-0ce0bc093d0a/Reflecting-on-Australias-five-principles-for-pande.aspx

K Ludlow et al. Aged care residents’ prioritization of care: A mixed‐methods study. Health Expectations. 2021. Available at https://onlinelibrary.wiley.com/doi/10.1111/hex.13195

Women’s Health Survey 2020 Report. Jean Hailes Foundation.

2020 deceased organ donation and transplantation report. Organ and Tissue Authority.

Alcohol retail during COVID-19. FARE Australia. February 2021.

Report from The Lancet Commission on Public Policy and Health in the Trump Era. February 2021. (Note that the lead authors of this report are strongly aligned with Senator Bernie Sanders)


The best of Croakey

Two important pieces from Jennifer Doggett: health sector perspectives on political donations and on Health Minister Greg Hunt’s politicisation of COVID vaccine program.


Good news story

This week a French nun in Toulon celebrated her 117th birthday. She is the oldest living person in Europe, and the second oldest living person in the world. She has survived the Spanish flu, two world wars and, most recently, infection with coronavirus.

You can read more about Sister Andre 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.


 

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