In her latest edition of The Health Wrap, Dr Lesley Russell investigates the latest pandemic news with a focus on health literacy and public health communications, the alcohol harm paradox, and also raises issues of concern around research, for COVID-19 and more broadly.
Lesley Russell writes:
It’s been a worrying two weeks on the pandemic front, with the outbreak in Melbourne proving difficult to address and the continuing conflagration of infections and deaths in the United States and countries like Brazil, Russia and India. But pandemic control is not about finger pointing and sheeting the blame to others.
The Melbourne outbreak shows how difficult it is to contain this virus and highlights how containment efforts demand attention to ensuring that information is properly targeted at all Australians, especially those whose first language is not English. Sadly, it also highlights how sceptical many people are of expert public health advice, how persuasive misinformation can be, and how ready some people with a public voice are to scapegoat others in society.
Despite the obvious success of the Australian public health education and information campaigns around the coronavirus pandemic, they are hindered by an “infodemic”. The World Health Organization (WHO) describes this as “an over-abundance of information – some accurate and some not – that makes it hard for people to find trustworthy sources and reliable guidance when they need it”.
For many this is not what the experts agree is best practice (and sorting through this as it changes over time and varies by state and territory can be confusing enough) but a cacophony of conspiracy theories, exaggerated facts and the promulgation of false prevention methods and cures.
Worse, the blame for coronavirus and its consequences is often sheeted to certain minority population groups and to certain public gatherings (Black Lives Matter marches) but not others (football games). To me this has dreadful echoes of what is happening in the US where, in some states, wearing a mask has become a political statement.
To date, despite acknowledging some of these problems, there is currently little obvious effort on the part of the Victorian Department of Health and Human Services and the Victorian Government to understand and address them.
If 10,000 people have refused testing, we need to know why.
Did they really understand what was being offered and why, had they heard that the test was painful, are they afraid of the consequences, do they fear authority, were they thinking of themselves, their family or their community?
The warnings of police patrols and postcode checks might seem particularly frightening to those who have previously lived under authoritarian regimes or who are without permanent residency, especially as it was a lack of procedure in a hotel that sparked the news virus outbreak.
My Croakey colleagues have posted some up-to-date commentary around the Melbourne lockdowns and how they highlight the growing gaps in social and health inequities.
Health literacy vital
The need for health literacy, and better understanding of what underpins it, has never been more important. The coronavirus infodemic has highlighted that poor health literacy is an underestimated public health problem globally.
An individual’s health literacy is influenced by their cultural beliefs, language, disability, education, income and health status.
Data from the Australian Bureau of Statistics reported by the Australian Institute of Health and Welfare (this is from the 2008 survey on health literacy as these aspects of the 2018 survey have not yet been released as far as I can determine) showed that health literacy is lower in people who speak English as a second language (26 percent) and higher in people who have completed a Bachelor degree or higher (70 percent).
Health literacy is higher among people with high incomes (63 percent) compared to people on low incomes (21 percent).
These findings are not unexpected. However, despite acknowledgements of the importance of health literacy, there is limited Australian data on this and some of it is conflicting.
The National Health Survey: Health Literacy, 2018 shows that most Australians assess their health literacy positively: one-third of Australians (33 percent) said they found it always easy to discuss health concerns and actively engage with their healthcare providers, 56 percent found this usually easy, while 12 percent found it difficult.
On the other hand, a 2019 paper that reviewed publications on health literacy in Australia found low levels of health literacy in consumers which affects health-related behaviours, utilisation of health services and navigation of the health system. It also showed a dearth of sound measurement tools for assessing health literacy.
The importance of organisational health literacy was also highlighted during the Centre for Primary Health Care and Equity (CPHCE)s’ Annual Forum in 2018, which focused on health literacy (See the Croakey Conference News Service coverage). Health literate organisations were described as those that reduce the health literacy demands placed on patients through service design and patient engagement.
It’s good that some Australian researchers have been quick off the mark to explore variation in understanding, attitudes and uptake of COVID-19 health advice.
A publication from University of Sydney researchers has found that people with inadequate health literacy had poorer understanding of COVID-19 symptoms, were less able to identify behaviours to prevent infection, and experienced more difficulty finding information and understanding government messaging about COVID-19 than people with adequate health literacy.
Importantly they were more likely to endorse misinformation about COVID-19. Similar results were observed among people who primarily speak a language other than English at home.
The researchers’ earlier analyses (published in Croakey) show that the readability of health information on government websites is higher than the level (Grade 8) recommended for the average Australian and considerably higher than that (Grade 5) recommended for communities with low literacy and English as a second language.
Taken together, it is obvious that – as a priority – health messages must be tailored to meet the needs of these population groups. Failure to do so means that important knowledge and attitude gaps threaten efforts to reduce viral transmission and protect Australian lives.
As others have pointed out, health literacy helps people to grasp the reasons behind the recommendations and reflect on the outcomes of their various possible actions. But taking social responsibility, thinking beyond personal interests, and understanding how people make choices should also be considered within the toolbox of health literacy.
What do the data say about large public gatherings?
In both Australia and the United States, epidemiologists have braced for a surge of coronavirus infections as a consequence of the Black Live Matter marches. But this has not happened in either country.
In Australia only four people who attended the Melbourne protest have tested positive to coronavirus and experts say it is unlikely they spread it to other demonstrators. In New York City, where Black Lives Matter protests have continued for weeks, the rate of infections is continuing to decline.
This is probably because protests are outdoor events, tend to involve younger people, and in most cases attendees have been careful about wearing masks.
Epidemiology data show the virus spreads far more easily indoors than outdoors, and close contact indoors is believed to be the main driver of transmission.
One study, based on a review of 110 cases in Japan, found that the odds of transmission were 18.7 times higher in closed environments than in open-air environments. Another study involving a review of thousands of cases in China found only a single instance of outdoor transmission.
Meanwhile, the Prime Minister has announced that sport stadiums with fewer than 40,000 seats will be allowed to reopen to crowds this month, with venues allowed to sell 10,000 ticketed seats per event.
Let’s see what happens with yelling, beer-drinking spectators. So far, I don’t hear any protests about this.
Public health funding during a pandemic
One of the lessons learned from the coronavirus pandemic is the importance of public health preparedness and services.
We have seen how the efforts of so many countries and jurisdictions have been hamstrung because public health funding (always a minor part of healthcare budgets) and expertise has been allowed to erode.
A report from Kaiser Health News and The Associated Press looks at the US public health system (which is described as “hollowed out”– under-funded and under threat) as the nation faces the worst health crisis in a century.
Since 2010, spending for state public health departments has dropped by 16 percent per capita and spending for local health departments has fallen by 18 percent.
At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.
Less than a third of local health departments have an epidemiologist or statistician on staff.
Most local governments spend more on policing than on health.
So when coronavirus arrived — and the Trump Administration bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.
It’s somewhat ironic that Dr Robert Redfield, the director of the Centers for Disease Control and Prevention (CDC) and part of the Trump Administration, has now said that his “biggest regret” is “that our nation failed over decades to effectively invest in public health”.
It’s a universal problem – when public health is done well, you don’t notice the returns on the investment and so it’s easy to cut resources.
There’s an interesting discussion about “return on investment in public health” from the Kings Fund here.
Clinical trial data – another sobering story
An analysis, published June 22, 2020, in the Journal of the American College of Cardiology (the paper is behind a paywall and available only in part here, but there is a great summary here), examined clinical trials for heart failure treatments before and after the passage of the US Food and Drug Administration Amendments Act of 2007 (FDAAA).
This mandated that trials involving FDA-regulated interventions (Devices and drugs) must register and report their results to ClinicalTrials.gov, an online global database under the direction of the US National Library of Medicine.
It found that while there was a bump in the registration of heart failure trials after passage of the FDAAA, only 56 percent of the more than 1,400 studies registered were ever published in a journal. Of those that were terminated or incomplete, only 20 percent ever reported their results, and of those that were completed but never published, only 12 percent ever reported their results anywhere (for example at a conference).
Trials funded by the National Institutes of Health (NIH) had a higher likelihood of being published than trials funded from other sources (71 percent versus 55 percent). Interventional trials that were funded by the NIH had a publication rate at one year of 30 percent, compared with 20 percent for industry-funded trials and 19 percent for those with other sources of funding.
The authors wrote: “By not releasing results, particularly for trials that do not meet their primary endpoint, we are depriving society of that investment that patients have made.”
The real issues here – and the reason why I am including this in The Health Wrap – are outlined in an accompanying editorial comment. It states that the under-reporting of clinical trial data has persisted into the contemporary era as “a sin of omission” despite the ability today to compute data with high efficiency, rapidly disseminate information via the Internet, and have simultaneous publications released in conjunction with meeting presentations.
As for what needs to be done?
The editorial suggests that under-reporting results should possibly be considered scientific misconduct as well as “a public health matter because it is an impediment to medical discovery and poses plausible threats to patient safety”.
The global research response to the coronavirus pandemic
In the five months since the novel coronavirus appeared in our lives there has been an unprecedented response from the global medical research community.
At the same time, concerns have been raised about the rapid publication of studies that are misleading, biased or just lacking in proper scrutiny. In addition, for clinical studies, I worry about the threats to patient safety and many of the issues outlined in the section above.
A paper just out in The Medical Journal of Australia looks at this research response in terms of methodological quality and impact, and compares it with responses to SARS, MERS and the 2009 H1N1 pandemic. It analyses studies registered on five international clinical trial registries.
It found 1,694 registered studies, 41 percent of which were randomised controlled trials, mostly to evaluate interventions for infected patients. In contrast, six months after their declaration as a pandemic there were no registered studies for SARS and MERS and 99 for H1N1. However, there was a high discontinuation rate of trials.
The huge coronavirus response is postulated as due to the size and impact of the outbreak, the absence of proven therapies and the improved ability to access and communicate data internationally.
The authors make some sobering conclusions:
Many studies of interventions may not lead to high-quality evidence to guide treatment of COVID-19, due to methodological insufficiencies.
There was significant duplication with multiple trials of several interventions. The impact on non-COVID-19 research has been substantial.”
The alcohol harm paradox
In high income countries like Australia, individuals with low socioeconomic status (SES) are two to five times more likely to die from alcohol attributable causes than individuals with high SES, even though alcohol consumption overall is lower for low SES groups. This is called the alcohol harm paradox.
Other risk factors such as smoking, poor diet, obesity and physical inactivity also cluster in low SES drinkers, which help explain why they experience higher alcohol-related mortality and morbidity. However, increasingly it seems that a major explanation for the alcohol harm paradox is that low SES groups are more likely to drink at extreme levels.
A recent systematic literature review in The Lancet supports this. It found that up to 27 percent of the socioeconomic inequalities in mortality are explained by alcohol, and that drinking patterns (especially heavy episodic drinking) are more explanatory of these inequalities rather than simply alcohol use.
An accompanying editorial makes the point that the substantial variability in alcohol-related harms between SES groups cannot be explained by drinking patterns alone and that “eco-social perspectives” are needed to achieve a better understanding of contemporary determinants of health.
For example, it has been shown that increases in alcohol availability is associated with increases in consumption and alcohol-related harm and that alcohol outlet density and alcohol harm correlate positively with neighbourhood deprivation.
The editorial concludes: “A deeper understanding of the potentially complex mechanisms behind the [alcohol] paradox should be the next challenge for alcohol epidemiology and public health research in general.”
The best of Croakey
This story, Health and medical experts sound the alarm on university funding changes, generated widespread interest with its focus on the importance of the humanities for health and healthcare, as per the comment below by Professor Julie Leask from the University of Sydney.
The good news story
As mentioned during the recent #CroakeyREAD event, many people have found comfort in reading and writing poetry during these pandemic times. I thought I would share some sources of poetry.
Some reflections on coronavirus life in The New York Times here.
Poetry in the time of coronavirus here.
I particularly love Sir Patrick Stewart (@SirPatStew) who daily reads a sonnet on Twitter – #ASonnetADay. He has just the voice for this – and I’m from the generation that was required to learn many such sonnets. 
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.
