Concerns that more dangerous mutations of SARS-CoV-2 could emerge in unvaccinated nations are highlighted in the latest edition of The Health Wrap.
Associate Professor Lesley Russell also suggests that a new report from the Royal Australian College of General Practitioners suggests the organisation is “stuck somewhere in the last century”, and highlights the need to pressure politicians to address the systemic causes of diabetes and obesity.
Lesley Russell writes:
Earlier this month the End COVID For All campaign released a report A Shot of Hope: Australia’s role in vaccinating the world against COVID-19.
End COVID For All is working to encourage the Australian Government to increase its assistance for the world’s most vulnerable nations and communities. You can read more about the goals and work here.
The report urges Australia to lift its commitment to the global vaccination effort by $250 million and 20 million extra vaccine doses.
There is, of course, an ethical and compassionate underpinning to this call for action but there is also the compelling finding that two-thirds of 77 epidemiologists surveyed in 28 developing countries believe if action is not taken now, it will take less than a year before the virus mutates.
The longer the world allows developing nations to lag in terms of vaccination rates, the more time the virus will have to mutate to something more deadly and spread.
End COVID For All spokesman Tim Costello has urged Australia to “become a vaccine factory for the region” and to donate vaccine doses to lower-income countries across Asia Pacific. I would add that Australia must also include help with testing, supplies, transportation and actual vaccination efforts if these donations are to deliver benefits effectively and efficiently.
Currently the major responsibility for this international work falls to COVAX, an organisation that is now seen by some as “naively ambitious” and failing in its promise to vaccinate the world. It is currently 500 million doses short of its vaccine distribution goal.
Of course it’s not helped by countries like Australia that has committed $130 million to COVAX for poorer countries (has this been paid?) but it appears $123 million of this is for the option to purchase 25 million doses from COVAX for Australian use. At least 500,000 Pfizer doses have been received from this source.
Last week the BBC News reported that six percent of COVID-19 cases in the UK are now a new type of Delta variant AY.4.2, which some are calling “Delta Plus”. It contains mutations that might give the virus survival advantages.
The state of Australian general practice
Last week the RACGP released its annual report General Practice: The Health of the Nation 2021. In the mainstream media, this was reported almost exclusively as GPs calling for more money to cope with the ongoing consequences of the pandemic (see, for example, this article in the Sydney Morning Herald).
With the finalisation of the Morrison Government plans for reform primary care (optimistically) looming (the closing date for submissions on the discussion paper is November 9), I was hoping that the RACGP was looking for more than just increased Medicare rebates and that there was the possibility of some new approaches to funding and delivering primary care, based on what RACGP members had learned over the past 18 months.
There is more of interest in the report than reported by the media, but I was disappointed that the doctors’ organisation seems stuck somewhere in the last century, and I wonder if this is what GPs really think and really want.
A large part of the report is data collated data from various sources. But every year the RACGP conducts a national survey of RACGP Fellows across Australia.
This is a summary of those findings:
- The most common presentations GPs see:
- Psychological conditions (including sleep disturbance and depression) were reported as the most common reason for presentation by 70 percent of GPs, up from 61 percent in 2017. Clearly the high prevalence of mental health concerns is not just due to the pandemic and associated issues.
- Musculoskeletal conditions (back or neck pain, arthritis) were reported as the second most common reason for presentation.
- Respiratory presentations (cough, asthma, sinusitis and suspected COVID-19) remain the third-most commonly reported reason for presentation.
- The age, gender and practice location affect the type of presentations:
- GPs aged 44 years and younger are more likely to report a higher proportion of patients presenting for psychological, respiratory, women’s health, and pregnancy and family planning reasons.
- GPs aged 45 years and older are more likely to report musculoskeletal, endocrine and metabolic, and circulatory issues as reasons for patient presentations.
- Female GPs are more likely to report psychological, women’s health, and pregnancy and family planning as reasons for patient presentations.
- Male GPs are more likely to report musculoskeletal, respiratory, circulatory and skin presentations.
- GPs in rural and regional areas more commonly see endocrine and metabolic, circulatory and skin issues compared to their colleagues in metropolitan areas.
- GPs in areas of greatest socioeconomic disadvantage reported seeing a higher proportion of musculoskeletal, endocrine and metabolic issues, as well as the effects of non-medical issues on health (such as domestic violence, inadequate housing).
- GPs working in Aboriginal medical services are more likely to report endocrine and metabolic issues and the effects of non-medical issues on health, and are less likely to report psychological, musculoskeletal, women’s health, and preventive care than GPs working in other practice types.
- The GP survey asked about issues where respondents would like to see policy action:
- Medicare rebates (26 percent)
- Mental health (12 percent)
- Create new funding models for primary care (9 percent)
- Aged care (6 percent)
- Climate change and health (6 percent)
- Health equity and equality (5 percent)
- Obesity / sugar (5 percent)
- Rural and remote health services (4 percent)
- Social determinants of health (4 percent)
- Telehealth (3 percent)
It’s interesting then that the report chooses only to talk about Medicare rebates, mental health, aged care and telehealth. GPs at the coalface are obviously worried about a range of other issues that impact their patients’ health and care.
The report does also discuss the issues in managing multimorbidity in patients across the age spectrum – in rural and regional areas, three-quarters of GPs report that 79 percent of their patients have multimorbidity issues. But again, the discussion is in terms of long consultations and there is no mention of a team approach.
On mental health:
GPs provide the vast majority (82 percent) of MBS-subsidised mental health services, and attendances are rapidly increasing (a trend that existed well before the pandemic).
The figure below shows that there is so much to unpack around this issue – workforce, access, affordability, appropriateness, what this means for GP education, training and support. This is a topic I might return to at another time.
A 2019 paper from Dr Sebastian Rosenberg and Professor Ian Hickie looked at the need for urgent reform of the Better Access program under which most mental health services are delivered.
Telehealth is cited as “one of the ongoing success stories emerging from the pandemic” and while I would like to believe that, I wonder what it really means for most patients. I suspect a lot of it is referrals and prescription renewals over the phone.
The RACGP report states that in May 2021, 17 percent of GP attendances were by phone (a decline of around one-third from April 2020) and 0.29 percent of GP attendances were video calls (down from 1.3 percent in April 2020).
While the rest of us are exhausted from Zoom meetings, why are GPs so reluctant to use them (or Skype or Facetime)? Here’s what the RACGP survey showed:
- 25 percent do not have the hardware / software to enable video.
- 15 percent say patients do not want to use video.
- 9 percent are not confident using video platforms
- 7 percent have poor internet connections that do not support video platforms.
On out-of-pocket costs:
The RACGP report makes no mention of patients’ out-of-pocket (OOP) costs, but they are covered in the summary document. Although there is not much detail here, it is useful information because it looks beyond the bulk billing rate for non-referred services (also includes pathology and some diagnostic services – it’s the one Health Minister Greg Hunt is always keen on quoting).
Only 22 percent of GPs surveyed work at a practice that bulk bills all patients.
The average OOP cost for a level B (MBS item 23) 15-minute GP consult that is not bulk billed is $38.80. So, some patients are paying a lot more than that.
As the figure below shows, the growth in bulk billing of general practice services has been in steady decline since at least 2013-14.
Earlier this month I wrote an article for the Pearls and Irritations blog, about what I saw as the inadequacy and lack of vision of the responses from the AMA and the RACGP to the discussion paper on primary care reform. Sadly, my assessment then is not changed by this latest report.
Countdown on health and climate change
Climate change is (literally, figuratively and rightly) a hot topic these days. It is too often seen only in economic and environmental terms, but it is also the greatest global health threat.
The Lancet Countdown on health and climate change has been published annually since 2015 (since the Paris Agreement to limit the harms caused by climate change). It tracks 44 indicators across five key domains: climate change impacts, exposures, and vulnerability; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement.
The 2021 Countdown has just been released: it calls code red on a healthy future.
This Twitter thread is a useful summary.
There are also a series of resources and individual country analyses to accompany the 2021 Countdown report. This includes a policy briefing for Australia under the logos of the Australian Indigenous Doctors Association, the Public Health Association, the Australian College of Nursing, the Australian Medical Association, the Australian Medical Students Association and the Royal Australasian College of Physicians.
The briefing report was facilitated by The Medical Journal of Australia. I’m intrigued as to why just these few organisations signed on to it.
The brief finds that:
- Australia has no national plan for climate change and health and is “increasingly out on a limb”.
- Australia remains one of the world’s largest coal and gas exporters and has carbon-intensive energy and transport systems.
- There has been minimal engagement with climate change as a health issue by the federal Department of Health.
Three recommendations – described as practical, tried-and-tested policy measures – are put forward to help set Australia’s healthcare system on a more sustainable emissions pathway, and foster national climate change resilience.
- Beat the heat. Develop a national heat-health strategy to coordinate extreme heat preparation, response, and recovery measures across jurisdictions.
- Empower First Peoples. Provide funding and support to ensure Aboriginal and Torres Strait Islander Peoples are at the centre of climate change and health policymaking and implementation. Aboriginal and Torres Strait Islander knowledge and practices will be critical to enabling an effective national climate change response.
- Sustainable healthcare. Establish a target of net-zero healthcare in Australia by 2040, and a national sustainable healthcare unit to work towards this goal. This model is being successfully implemented in England and has resulted in significant healthcare emissions reductions over the past decade.
The video of the launch of the report, co-hosted by Monash University and the University of Melbourne, is available here.
Some additional reading on this topic from Croakey Health Media:
- Ying Zhang and Paul Beggs: Climate health experts declare code red for the world, while Australia is stuck on limb.
- Melissa Sweet: “Listen to us”: Aboriginal and Torres Strait Islander leadership on climate and health.
- Mark Burdack: On net zero and rural health, an open letter to rural and regional MPs.
The coronavirus pandemic has pushed many other important public health issues off the table. Among these issues – the Zika virus epidemic and the fate of the children born with congenital Zika syndrome.
Beginning around 2013, outbreaks of mosquito-borne Zika virus in Southeast Asia, the Pacific and South America raised concerns because of a spike in microcephaly in newborns in the affected areas. The outbreaks appear to have peaked around 2016 when the World Health Organization declared a global public health emergency because of an increase in microcephaly and neurological complications linked to the virus.
The epicentre of the outbreak was in Brazil, but to date, a total of 86 countries and territories have reported evidence of mosquito-transmitted Zika infection.
A large observational study conducted in Brazil in 2019 found that women infected with Zika virus during early pregnancy were 17 times more likely to have a child with microcephaly. Another study published that same year found that one-third of children aged three or younger who were exposed to Zika virus in utero had below-average neuro-development and / or eye abnormalities or hearing problems.
A recent program produced by US-based National Public Radio highlights how those children, that scientists were once so keen to study, and their families and carers, are now too often forgotten and ignored.
“We feel diminished,” said one parent. “It’s like we were lab rats. They come in nicely, collect information, collect exams on the child, and in the end, we don’t know of any results. It’s like we are being used without even knowing why that is being done.”
It’s a classic example of how, despite all the ethical guidelines, not communicating results to participants is seen by some researchers as business as usual.
The situation is made worse because – as the coronavirus pandemic rages – the Zika virus has become an under-the-radar epidemic. At the same time the pandemic has been dreadfully mismanaged in Brazil and more than half a million Brazilians have died with COVID-19, the second highest death toll worldwide, behind only the United States.
There are concerns that rising temperatures due to climate change may lead to the spread of the mosquitos carrying Zika virus to currently cooler regions. Under the most drastic model of global warming, the risk of Zika transmission will increase over southern and eastern Europe, the northern US, northern China and southern Japan by 2080.
As yet there are no antivirals or vaccines available for the treatment or prevention of Zika virus infection. We should all hope that at least some epidemiologists, infectious disease experts and vaccine developers are focussed on this potential problem area that will surely plague the world again.
In case you missed it
October is Health Literacy Month
As the month ends, just a reminder that health literacy is critical to informed decisions, patient-centred care, care navigation, and access to services. It’s an essential part of healthcare, not just a nice add-on. And it’s an effective way to deal with misinformation around the pandemic.
A survey reported last June looked at measures of health literacy in Australia. It found that 60 percent of Australians appear to lack the capacity to access, understand, appraise and use crucial information to make health-related decisions.
Health Literacy Month seems to have escaped the Health Minister’s attention this year. Last year he launched the Mitchell Institute’s Self-care for health: a national policy blueprint which called for a national health literacy strategy.
(Note to Minister: a media opportunity does not constitute action in a needed policy area.)
The importance of continuity of care
A new research paper from Norway informs us (again) about the benefits of continuity of care.
It shows that patients who stayed registered with the same GP over many years had fewer out-of-hours appointments and acute hospital admissions, as well as a reduced risk of death.
These benefits were significant, and they increased the longer the relationship continued. People who kept the same GP for more than 15 years had a 25 percent lower chance of dying than those with a GP relationship lasting a year or less.
As the editorial that accompanies the paper states: few, if any, medicines produce benefits this dramatic. And the benefits work for both doctor and patient.
New international public health journal
A team of 360 editors from more than 60 countries last week delivered the inaugural PLOS Global Public Health.
This journal clearly promises to be essential reading and – thank goodness – it’s open access. You can read the editors’ vision for the journal here.
These two articles at Croakey have generated intense interest and concern among the health community in Australia and globally.
Read the articles here:
What does this mean for the future of academic research and teaching in Australia?
The good news story
I’m actually getting a little ahead of myself here, pushing an issue as a good news story when we don’t actually know the outcome. But I think that the mere fact it is happening is good news, and I’m very optimistic.
I’m talking about the war on diabetes that Dr Michael Mosley is waging on SBS TV along with proud Gomeroi man and exercise physiologist Ray Kelly and some very courageous participants.
What I love is that while there is emphasis on personal responsibility and personal agency, part of Dr Mosley’s mission is to tackle systemic change.
To demonstrate this, he follows an average Australian diet and in just two weeks, his blood sugar levels become pre-diabetic and his blood pressure becomes worryingly high. Mosley thus highlights the root of Australia’s obesity and type 2 diabetes epidemic – no wonder almost 200 Australians are diagnosed with type 2 diabetes every day.
“There’s a whole host of things that you can do,” Mosley says. “Advertising. Subsidies. A sugar tax. I see it as a bit like smoking. The war on people smoking was not won by telling people to stop smoking. It was won by taxation, by making it much harder to smoke, by banning smoking in pubs and clubs. I absolutely believe there are lots of things governments could and should be doing. That’s why putting pressure on politicians is so important.”
Tune in – and maybe there are some changes you can make towards being healthier!
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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