In the latest edition of The Health Wrap, Dr Lesley Russell reports on critical aged care concerns, the latest developments in climate health, recent dementia research and other new reports and research.
Lesley Russell writes:
Like many, I have been following the hearings of the Royal Commission into Aged Care Quality and Safety, which has been taking testimony about the dreadful toll of coronavirus infections in residential aged care facilities (RACFs).
The Victorian data highlight the important of having formalised staff/resident ratios in RACFs – this is the case for public facilities run by the state but not for private facilities overseen by the Federal Government. Early last week, one in every 23 residents in private facilities had COVID-19, compared to only one in every 900 patients in public facilities.
These empirical findings are borne out by those in a recent paper published in JAMA. It looked at the situation in the US, where approximately 27 percent of deaths due to COVID-19 have occurred among residents of nursing homes (that’s about the same as in Australia). It too asked why some facilities have been more successful at limiting the spread of infection than others.
The study found that RACFs with higher nurse staffing had fewer COVID-19 cases than those with lower levels. In contrast, there was no significant difference in the burden of COVID-19 cases between high- vs low-performing RACFs for health inspections or quality measure ratings. The authors conclude that policies providing immediate staffing support may be most effective at mitigating the spread of COVID-19.
This does not mean that other issues are unimportant. What has clearly emerged from the Royal Commission hearings is that the Federal Government had done little or nothing to ensure that RACFs were as well prepared as possible for a coronavirus outbreak.
Peter Rozen QC, senior counsel assisting the Royal Commission, has warned the buck must stop with the Morrison Government, which is responsible for aged care. He said:
Tragically not all that could be done was done.
The sector was not properly prepared in March before the Dorothy Henderson Lodge and Newmarch House outbreaks.
The lessons of those two outbreaks were not properly conveyed to the sector and as a result the sector was not properly prepared in June 2020 when we witnessed high levels of community transmission of the virus in Melbourne and based on the evidence that you’ve heard, the sector is not properly prepared now.”
Rozens went further in his criticisms, saying there was “reason to think that in the crucial months between the Newmarch House outbreak in April and mid-June a degree of self-congratulation and even hubris was displayed by the Commonwealth”.
That’s pretty damning stuff – will it generate the appropriate response from the Morrison Government and the Department of Health?
There’s a media report that aged care preparedness will on the agenda for discussion at National Cabinet this week – so clearly no mad rush, and it’s not on the agenda of Federal Cabinet so I guess Morrison is looking to shunt the blame and responsibility to the states. (Yes, I’m angry and cynical but much more interested in getting this dreadful mess sorted and aged care residents protected that I am in sheeting home the blame – there’s plenty to go round).
Further reading:
Jennifer Doggett’s report for Croakey: “Senate Committee on COVID-19 – what we learnt about aged care issues”.
Professor Kathy Eager’s piece in Pearls & Irritations: “Aged care homes: the weakest COVID-19 link”.
Dr Sarah Russell writing in Michael West Media: “Passing the buck: why Victoria’s Covid is raging in private aged care homes”.
Rick Morton in the Saturday Paper: “Covid-19 outbreaks in aged care” (sadly this excellent article is behind a paywall).
Katherine Murphy in The Guardian: “Scott Morrison’s coronavirus mea culpa was barely disguised score settling with Daniel Andrews”.
Medicos demand climate action
Australia’s peak medical bodies, representing around 75 percent of the nation’s doctors, have written a joint letter to Scott Morrison on the dual crises of COVID-19 and climate change and the need to act on both. You can read the letter here.
The letter highlights the costs to Australians’ health and the cost to the economy of climate change and its consequences such as last summer’s bushfires. It calls for a health-centred economic approach to pandemic recovery that would support a transition away from fossil fuels to renewable energy as a way to address human-caused impacts on global warming.
It emphasises the summer fires, which torched the eastern coast, and its immediate and longer-term effects are a result of human-caused impacts and we must stop further warming for the sake of our health.
The key point of the letter is this sentence: “As we continue efforts to limit the spread of the COVID-19 virus, we must ensure that we also have a whole-of-government approach towards addressing climate change, which also has potentially catastrophic health impacts.”
There are lots of links between climate change and the coronavirus pandemic, and these two huge problems (and a whole raft of others) will be with us for the foreseeable future. Governments must learn to “walk and chew gum”.
On this point it was sad (maybe even disturbing?) to hear the statement of the Secretary of Health, Dr Brendan Murphy, to the bushfires Royal Commission that hundreds of important health policy reforms and research projects have been delayed due to COVID-19, including research on the long-term impact of bushfire smoke.
And recently the Great Barrier Reef Special Envoy Warren Entsch has warned the Morrison Government, of which he is a member, that it can’t allow the coronavirus pandemic to reduce its climate change and environment action, as the reef can’t cope with funding cuts.
“Cutting funding would be a very, very foolish thing to do. I understand we are in all sorts of problems economically, but we need to maintain a priority for climate change and for the environment,” he said.
The world-wide global pandemic and associated shutdowns and lockdowns have led to a major decline in greenhouse gas emissions – described by Official Monetary and Financial Institutions Forum as the “first significant decline since modern records began”. However, shutting down the economy is not a sustainable solution for the future – hence the pleas for action.
Other climate concerns
Many experts have wondered if the coronavirus will be a seasonal pandemic as is seen for some other viruses (and President Trump has opined on this matter). There’s a growing body of evidence that this is not the case and recently this was confirmed by experts at the World Health Organization.
However, there is evidence that increasingly hot summers are impacting the ability to control coronavirus, especially in countries like India and in sub-Saharan Africa.
In India, where summer temperatures are now sometimes rising to 50C, coronavirus restrictions and water shortages have compounded the miseries of the current heatwave. Water is a precious commodity and supplies are inadequate for drinking, let along for hand hygiene, especially for the 100 million people living in urban slums. In Delhi, a city of 20 million people, demand for water outstrips supply by an estimated 760 million litres (200 million gallons) per day.
The daily wait for water trucks in the capital has become even worse since the pandemic hit the city. People living in the slums must line up for hours with plastic buckets and bottles, standing a suitable distance apart, waiting for the government water truck that often never comes.
In West Africa, where the outbreak of coronavirus is most severe, the regions faces a three-pronged threat of surging jihadi attacks, climate change harming vital food supply chains, and now the pandemic. More than 43 million people are seen as in need of urgent food assistance.
And the climate change/coronavirus problems are not confined only to less developed countries. In Japan, which has been experiencing a very hot August, there has been a sudden increase in heatstroke cases. In the week of 5-11 August, 12,751 people suffering from heatstroke were taken to hospital by ambulance – a decrease compared to the 18,347 heatstroke victims the previous week (July 29 to August 4).
But, as Melanie Brock, an Australian who is a long-time resident in Japan, points out, the ambulances must first take patients to a hospital where PCR tests can be done (apparently this is not done at every medical facility); only when cleared for coronavirus can patients then be admitted or go to other hospitals.
This ability to control hospital infections is important, but it also means that the (mostly elderly) heatstroke patients face substantial delays in getting treatment.
BTW – Make sure you read the recent piece by Deborah Di Natale for Croakey that looks at why climate change is a critical health issue for people in the Northern Territory, where an election is coming up on August 22. These issues should be on the campaign agenda.
This is the perfect segue into the next section……
Election policies – Aotearoa/New Zealand
You may have noticed that New Zealand has an election coming up! The date has just been changed to 17 October.
If you are interested in the health policies that are on the table from the various parties, here are several useful links:
Election 2020 – Party Policies – Health (although I note as I write this that this site has not been updated since July 25)
COVID-19 policies at Stuff.nz
I can’t access the NZ Doctor magazine, but in case some readers can, it also has a summary of the parties’ health policies.
Election policies – United States
You can’t help but notice the United States has an election coming up! It will be held on Tuesday November 3. Yes, President Trump would like to delay it, but the date is written into the Constitution and he can’t.
The US Studies Centre at the University of Sydney will be closely following the issues, and has compiled a playbook of the issues – as things currently stand – for a Biden Administration and a second term of the Trump Administration. I was responsible for the section on health.
Health care is always a key issue for voters and in 2020 this is magnified by the coronavirus pandemic and the erosion of affordable health insurance under Trump’s first term. A June survey conducted by Pew Research showed that affordability of health care and the coronavirus outbreak ranked as key issues for all voters, well ahead of crime, terrorism and illegal immigration.
The contrast between the policies of the two presidential candidates on health issues could not be starker. Currently no policies of any kind are to be found on the Trump campaign website; his second term election policies must be inferred from his public statements, tweets and executive orders.
Biden’s campaign website has a wealth of policies and position statements on a wide range of issues, including many related to health and healthcare. He would come to the presidency burdened with enormous voter expectations that he will improve access to healthcare and address the Trump failures on the coronavirus pandemic quickly and equitably.
Expect more from me on these issues in the weeks ahead. Please let me know anything you are particularly interested in as we head into what is likely the most important US election ever.
There are also ramifications for global health if Trump stays in power, not least because of his withdrawal of the US from the World Health Organization.
Dementia update
Dementia has been in the news recently. Here’s my summary of what I’ve been reading.
Rates falling in the US and Europe
We are used to warnings about the coming tsunami of dementia, and more people than ever now have dementia – but that is because there are more and more older people in the population.
In fact, new research shows that rates of dementia have steadily fallen in the US and Europe over the past 25 years, although increases are seen in Asia, South America and Africa.
The risk for a person to develop dementia over a lifetime is now 13 percent lower in the US and Europe than it was in 2010. The data also include a separate assessment of Alzheimer’s disease. Its incidence, too, has steadily fallen, at a rate of 16 percent per decade.
This new incidence data are described as “hopeful” and “[suggesting] that the risk is modifiable.” One leading hypothesis for the decline in the US and Europe is improved control of cardiovascular risk factors, especially blood pressure and cholesterol.
The decline in disease was not seen in Asia, South America or, from limited data, in Africa and there are reports of increasing dementia rates in Japan, China and Nigeria. This might be related to higher rates of smoking.
You can read the original study in Neurology here and there is an excellent summary in the New York Times here.
Evidence for dementia prevention
A tweet from Associate Professor Genevieve Steiner who works in this space at the University of Western Sydney alerted me to this evidence and I’m reprinting her slides here. I’ll let her work make the case. 
Socioeconomic factors
There is a growing body of evidence around the role played by socioeconomic factors as risk factors for dementia. See, for example, a UK study here.
Thus, public health strategies for dementia prevention should target socioeconomic gaps to reduce health disparities and protect those who are particularly disadvantaged in addition to addressing vascular risk factors such as hypertension, diabetes mellitus, smoking, and heart disease.
But there are confounding factors. A recent study published in JAMA investigated the associations of birth cohort and early-life environment with dementia incidence.
Interestingly, it found that that dementia incidence is lower for individuals born after the mid-1920s compared with those born earlier and that the association between birth cohort and dementia incidence remained after accounting for early-life socioeconomic environment, educational level, and late-life vascular risk factors. This lower incidence applies to those born during the Great Depression and during World War 2.
Addressing homelessness?
A little recognised positive aspect of the coronavirus pandemic is that state and territory governments have stepped up to address the need for crisis accommodation for people who are homeless, especially those who have been sleeping rough.
There’s growing evidence that the coronavirus pandemic has proved that homelessness is a problem that can be solved – and led to support for action to do this.
ABC News: Has the coronavirus pandemic proved that homelessness is solvable?
The Guardian: Homelessness: can the Covid-19 crisis help end rough sleeping in Australia for good?
SBS Insight: COVID-19 gave these homeless people housing, here’s how they could keep it.
But what happens next? Will these people be sent back on to the streets?
A recent article in Inside Story from Peter Mares looks at this issue through the “Housing First” ethos: that when people are homeless, you first provide them with housing and only tackle their other challenges – health, employment, substance abuse – when they are secure in their homes.
This approach is in contrast to the entrenched “Preparation First” model where people must overcome their challenges while living in temporary, transitional accommodation to prove they are “housing ready” and capable of independent living.
You can read more about the Housing First model here.
Mares looks at the implementation of Housing First in three similarly sized countries – Finland where it is eminently successful, Denmark where there has been marginal progress, and Ireland where it must be considered a failure.
He and concludes that government resolve is crucial for the effective implementation of this model. There must be a system-wide approach with the focus on the right to a decent home rather than merely the right to shelter.
Finland has reduced homelessness to a “rare, short-lived and non-recurrent” phenomenon – the only country to do so. You can read more here, in another article, written in 2018 by Peter Mares, in which he asks if this approach could work in Australia.
In 2017 I wrote a similar piece for Inside Story in which I outlined how in Australia Housing First has, to date, taken second place to housing affordability for home owners, and how the promise of this program has dissipated for lack of funding and political will.
Mares makes the case that the Federal Government has a unique opportunity to begin reshaping Australia’s housing landscape in the October budget by committing to a large-scale investment in social housing as part of a COVID-10 stimulus package.
I like the point he makes to support this:
There are many paths into homelessness … but the only route out of homelessness is secure, affordable, decent housing.”
There’s a good up-to-date summary of the issues of homelessness in Australia – something that is increasingly affecting older women – here.
Measles, coronavirus and vaccine “hesitancy”
Here’s yet another example of why governments must learn to manage more than one problem at a time and not let the coronavirus pandemic take the focus away from other important issues – especially other infectious diseases.
Decreasing vaccination rates, combined with an increase in measles outbreaks abroad and high volumes of international travel, places countries like the US and Australia at increased risk of measles introduction and local outbreaks.
Last year saw a reversal in decades of progress towards measles elimination in many countries. In the US, 1,282 cases of measles were reported in 2019 across 31 states and 94 counties, the most since 1992. The majority of these were in unvaccinated populations in New York.
In 2019, Australia had 285 confirmed measles cases, the highest number reported since 2014, when Australia was declared measles-free.
The World Health Organization called this a “global health crisis”. This year the lockdowns and border closures for the coronavirus pandemic are expected to protect against some measles infections, but there is concern that there is also likely to be a fall in vaccination rates.
In the US, as of June 5, there were 12 confirmed cases of measles for 2020. In Australia, as of July 31, there were 32 reported cases.
A recent article in The Lancet identified multiple regions in California, New York, Washington, Texas, and Florida as continuing to be at high risk of measles outbreaks. It’s notable that these are the very areas experiencing the worst of the coronavirus pandemic in the US.
As highlighted in The Lancet paper, US counties shown to be at high risk for measles due to low vaccination rates will likely also be counties most likely to refuse vaccination against COVID-19 when this becomes available.
Meanwhile, an article in The Medical Journal of Australia describes Australia as “an island in a sea of measles”. The authors warn that combatting the resurgence of measles in Australia and Pacific Island nations requires “vigilant clinicians and sustained, high level vaccination coverage”.
New reports and plans
Victorian Action Plan to Prevent Oral Disease 2020-30
VicHealth has released the Victoria Action Plan to Prevent Oral Disease 2020-30, which can be accessed here.
The action plan sets out a vision to achieve good oral health for all Victorians by 2030, with a focus on reducing the gap in oral health for people that are at higher risk of oral disease.
There is an emphasis on preventive strategies and oral health promotion in schools, including healthy eating and drinking via the School Dental Program – Smile Squad. It includes priority actions in key settings including early childhood centres, residential aged care and disability care.
The Victorian Government’s key priorities for the prevention of oral disease are to:
- build partnerships and environments that support good oral health
- improve oral health literacy
- strengthen prevention and early intervention programs
- improve oral health promotion skills within the workforce
- improve population data on oral health status and enhance oral health promotion research.
The plan includes four targets for 2030:
- proportion of children entering primary school without dental cavities will be 85 percent
- proportion of adults with moderate or severe gum disease will be 23 percent
- proportion of Regional Victorians accessing fluoridated drinking water will be 95 percent
- relative five year survival rate for Victorians with oral cancer will be 75 percent
New South Wales is currently preparing its 2030 Oral Health Strategy, but apparently this has been put on hold because of the coronavirus pandemic. This will replace the current strategy which was developed in 2013.
Australian Burden of Disease Study 2015 – interactive data
The Australian Institute of Health and Welfare has just released interactive data on risk factor burden and new analyses of the key drivers of change over time in the burden of disease due to selected risk factors. You can access this information here.
The usefulness of this data is undermined because it is from 2015. Alison Verhoeven, CEO of the Australian Healthcare and Hospitals Association, and I (and others) have recently bemoaned the length of time it takes to collate and report health and healthcare data in Australia.
In this digital age we just have to get better if this work is to have value in terms of evaluation of current programs and evidence-based planning for future programs.
It is possible to compare the 2015 data with that from 2003 and 2011.
The figure below from the report’s section on Drivers of change in risk factor attributable burden shows how the factors included in the drivers of change over time analyses (population growth, population ageing, risk exposure and linked disease burden) may cause the attributable burden from a risk factor to rise (indicated by a positive percent change) or fall (a negative percentage change) over time. The sum of the effect of all factors represents the overall actual change in attributable burden between 2003 and 2015.
The five risk factors looked at are: tobacco and alcohol use, overweight and obesity, high blood pressure and dietary risk factors. It shows that in 2015, 38 percent of the disease burden in Australia was preventable and due to these modifiable risk factors.
A framework and indicators to monitor inequalities in health and the social determinants of health for Australians with disability
The Australian and New Zealand Journal of Public Health recently published “The Disability and Wellbeing Monitoring Framework: data, data gaps, and policy implications”.
The Disability and Wellbeing Monitoring Framework will be used to report baseline data for people with and without disability and to monitor inequalities over time in Australia across 19 domains (see below).
It will also be used to locate policy priorities and focus efforts to address data gaps. Australian national data are available currently only for 73 percent of the 128 indicators of the domains. 
The best of Croakey
Jade Bradford, a proud Ballardong Noongar freelance journalist in Perth, contributed this report on an artwork included in the Aboriginal Health Council of Western Australia’s submission to the WA Department of Health’s Climate Health Inquiry.
Thanks also to those supporting Croakey’s crowdfunding campaign at Patreon to enable more coverage of climate and health matters.
Such community support is vital with public interest journalism under such pressure globally, as my colleague Melissa Sweet reported recently.
Good news story
Like many Australians, in this strange year I find great comfort and enjoyment in the arts. And I marvel at what so many groups have been able to do on line – although I worry about the financial future of the arts.
The Queensland Symphony Orchestra has done a series of musical offerings called “Orchestra Over the Fence”- although not every backyard has an array of musicians.
Here to whet your appetite is a fantastic rendition of Rossini’s “Le rendez-vous de chasse” with horn players and chooks. What a treat!
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.
