In this edition of The Health Wrap, Associate Professor Lesley Russell reports on important pandemic publications, extols the benefits of physical activity and high quality primary care, and shares some good news about an explosion of butterfly numbers in north Queensland.
She also reports on a billion dollar investment in public health (spoiler alert, this has nothing to do with the recent Federal Budget), and new research investigating links between obesity, diabetes and dementia.
Lesley Russell writes:
This edition of The Health Wrap will make only passing mentions to the just released Federal 2021-2022 Budget: it has been covered so very well elsewhere in Croakey. You can find the collection of #Budget2021Health stories here.
The Budget briefs from the Australian Parliamentary Library are another great source of information – these are just beginning to be rolled out here.
I wrote a brief assessment of the Budget – with a focus on the big spending areas of aged care and mental health – for The Medical Journal of Australia which you can read here.
This past week saw the release of the final report from the Independent Panel for Pandemic Preparedness and Response set up by the World Health Organization (WHO) to investigate the response to the coronavirus pandemic and co-chaired by Helen Clark and Ellen Johnson Sirleaf.
(Note this is separate from the investigation into the origin of SARS-CoV-2 – you can read more on that in an article I wrote recently for Inside Story. And while on this specific topic: scientists are calling for further inquiry into the origins of the SARS-CoV-2 coronavirus, saying that lack of evidence leaves theories of natural spill over and laboratory leak both still viable.)
The Terms of Reference for the Independent Panel were developed in response to a resolution passed in May 2020 by the World Health Assembly:
…to initiate, at the earliest appropriate moment, and in consultation with Member States a stepwise process of impartial, independent and comprehensive evaluation, including using existing mechanisms as appropriate, to review experience gained and lessons learned from the WHO coordinated international health response to COVID-19 … and to make recommendations to improve capacity for global pandemic prevention, preparedness, and response, including through strengthening, as appropriate, the WHO Health Emergencies Programme.”
The Panel’s report, ‘COVID-19 – Make it the Last Pandemic‘, finds serious failures in the global response from governments and on the part of the WHO.
It called their combined responses a “toxic cocktail” that lead to unnecessary deaths. The report was accompanied by an evidence-based narrative that spelled out thirteen defining moment that have steered the pandemic’s course.
In particular, the Panel found that the WHO’s Emergency Committee should have declared the outbreak in China an international emergency a week earlier than it did, at its first meeting on 22 January 2020 instead of waiting until 30 January.
The month following the WHO’s declaration was “lost” as countries failed to take appropriate measures to halt the spread of the virus (the United States and Europe only acted in early March when their hospitals began to be overwhelmed). And the WHO was hindered by its own regulations that travel restrictions should be a last resort.
To help end the current pandemic, developed countries are urged to quickly share large vaccine quantities. The Panel also called for steps to ease intellectual property restrictions for COVID-19 vaccines, with an automatic waiver if a voluntary agreement can’t be reached through World Trade Organization negotiations.
To better tackle future pandemics, the Panel calls for better processes and structures to spot future threats along with more financial resources and powers for the WHO to make it stronger and give it more teeth.
The report calls for an International Pandemic Financing Facility funded mainly with US$5 – $10 billion from richer countries to support pandemic preparedness. It also recommends the establishment of a Global Health Threats Council to maintain the political commitment for pandemic preparedness and a new global surveillance system that would speed early warnings about outbreaks.
My Croakey colleague Marie McInerney wrote an excellent and detailed summary of the WHO report, which you can read here.
Professor Larry Gostin from Georgtown University wrote this opinion piece in response to the report, claiming that international health regulations were much too slow to curb a fast-moving virus and though the review panel did a great job detailing shortcomings and failures, they didn’t single out any government, agency, or actor.
An editorial in the Sydney Morning Herald calls for Australia to be a leader in endorsing the roadmap for a stronger, better-resourced WHO.
Assessing England’s response to the pandemic
Meanwhile, in England, Prime Minister Boris Johnson, facing calls for an inquiry into the national response to the coronavirus pandemic, has finally announced some details.
Last week Johnson put a loose timeframe on the independent inquiry he had previously promised, saying it would commence by the end of the new parliamentary session, expected to last about a year (ie it would not start until spring 2022).
Who knows if he will still be in office when the findings are brought down?
The Prime Minister said the inquiry would be fully independent and have “the ability to compel the production of all relevant materials and take oral evidence in public, under oath”.
A full month earlier The Kings Fund – acting independently – brought out its framework for assessing the response and called for the Government to immediately start work to establish a public inquiry into England’s response to COVID-19.
Primary care during the pandemic
The coronavirus pandemic has highlighted the value of primary care in Australia and internationally.
Lack of access to primary care during the pandemic, especially for people with pre-existing chronic conditions, is considered to be a significant factor in “excess deaths” associated with the pandemic. Current estimates are there have been seven to thirteen million excess deaths worldwide during the pandemic.
A US-based consortium of the Center for Primary Care at Harvard Medical School, the Milbank Memorial Fund and the CareQuest Institute for Oral Health (how great to see oral health in the primary care arena!) has just released a report “Primary Care in the COVID-19 Pandemic” that takes an international look at how primary care systems have responded internationally.
It does this under three major headings:
- Challenges to primary care access and quality – this looks at healthcare systems in the United States, the United Kingdom, Europe and Asia Pacific (including Australia). There is a particular focus on chronic care management, reproductive health, oral health and food insecurity.
- Practice transitions in payment and deliver – the focus here is mainly on the United States but there are lessons here applicable in Australia.
- Strategies to advance primary care equity – this looks at community engaged primary care, addressing racism in healthcare services, telehealth equity and improving communication for health practitioners.
The report’s key findings can be grouped under two major headings:
The key role of primary care
International responses to COVID-19 were diverse but effective responses did not just rely on tertiary care and intensive care units; they involved a more proactive approach through community-based primary care and population health centres.
These primary care providers were able to reach vulnerable and often isolated populations, engaging people through community health workers, on-site services nearing sites of employment or housing, or expanded technology access to telemedicine services. The very effective use of Aboriginal Controlled Community Health Organisations in Australia highlights that point perfectly.
The failure of fee-for-service funding
COVID-19 brought into sharp relief the contrast between capitation-based health care financing and the traditional fee-for-service approach.
Primary care practices reliant on fee-for-service medicine were adversely financially impacted despite rapid efforts by payers to pay for telemedicine services. Many practices lacked technical capabilities to reliably deliver telemedicine, and destitute patients were unable to reliably gain access in some locales.
By contrast, capitation-based financing clearly enabled primary care practices to pivot toward new forms of comprehensive care using multidisciplinary teams and breaching divides between primary and specialty care, virtual and in-person care, and community- or home-based and clinic- or hospital-based care.
These finding, drawn from the US experience, are completely applicable in Australia.
The authors of this report have put forward specific strategies to improve access to high-quality primary care, including adoption of a diverse mobile workforce and telehealth technologies with greater accessibility features. They emphasise that patient management and financial challenges can be addressed through alternative financing arrangements for primary care practices.
The pandemic highlights how important the primary care provider community is for the mitigation of disparities and inequalities.
The introduction to the report states:
Primary care provides greater increases in life expectancy and health equity than any other health care services and its supply continues to be diminished”.
That is certainly true in Australia!
How exercise habits influence our sense of purpose in life
I am totally convinced that, along with the benefits of being personally fit, there are huge benefits mentally and for my work efficiency (and sometimes it’s just an excuse to ignore housework or to walk to a new café for coffee).
So you can imagine how quickly I picked up a recent Sydney Morning Herald article about how our exercise habits may influence our sense of purpose in life and our sense of purpose may affect how much we exercise.
As the SMH article highlights, science offers plenty of evidence that being active bolsters our mental and physical health. And additional research indicates that the reverse can be true, and people who feel depressed tend not to work out.
A recent longitudinal study, published in the Journal of Behavioral Medicine, looked at the links between positive emotions and physical activity in middle-aged and older adults (that’s me!).
The research showed that a sense of purpose in life predicted greater levels of self-reported engagement in physical activity over a substantial period of time (four years) in a large, representative sample of 18,000 older adults. The reverse was also found to be the case – that self-reported exercise predicted a greater sense of purpose in life.
Past research has found a positive link between a sense of purpose in life and health outcomes and longevity. For example, a 2019 study of people older than fifty from the US Health and Retirement Study found that life purpose is significantly associated with all-cause mortality and that a sense of purpose can not only prolong life but improve the quality of those final years.
These current findings suggest that sustained activity could at least partly explain this link. So, my new status as a gym rat (even seen using the weight machines) is justified!
Biden tackles public health
President Joe Biden has made a concerted, multi-focused effort to boost America’s healthcare and restore and rebuild Obamacare a major focus of his Build Back Better plans. I outlined what he has been doing in the past one hundred plus days in a recent article for Inside Story.
It’s exciting to see the extent to which Biden and his Administration see the importance of the social determinants of health and are simultaneously pushing for mechanisms to address poverty, to make childcare and education more affordable to more families, to provide housing, public transport, clean water and broadband access.
And to rebuild public health. The announcement last week that the Biden Administration will spend US$7.4 billion on public health has Australian public health experts green with envy (on a population basis, the equivalent in Australian dollars would be around $750 million: when was the last time Australian public health saw that sort of spend?).
Of this, $4.4 billion will go toward boosting states’ overstretched public health departments, allowing them to hire disease specialists to do contact tracing, case management, and support outbreak investigations and school nurses to help schools reopen. Some of these funds will also go to expanding the Epidemic Intelligence Service at the Centers for Disease Control and Prevention.
The remaining $3 billion will be used to create a new grant program to train and update the nation’s public health workforce. Applicants for those grants will be required to prioritise recruitment from the communities they serve, especially those from under-represented backgrounds.
Given the erosion of public health in the United States, this funding will be stretched thin. A new report published this month by the Trust for America’s Health found that the underfunding of US public health played an outsized role in the country’s disastrous response.
A majority of Americans support such funding, according to a poll released Thursday by the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health. The poll found 71 percent of the public favours substantially increasing federal spending on improving the nation’s public health programs. In addition, 72 percent said they believe the activities of public health agencies in the United States are extremely or very important.
Is the obesity crisis driving the dementia crisis?
A recent paper in JAMA looks at the link between the age at which type 2 diabetes is diagnosed and subsequent dementia risk (unfortunately the paper is behind a pay wall but the abstract is quite informative).
The prospective cohort study, with 10,095 participants followed over a median time of 31.7 years, found that younger age at onset of type 2 diabetes was significantly associated with higher risk for incident dementia; each five-year earlier onset of diabetes was associated with a 24 percent increased risk of dementia. So someone diagnosed with type 2 at ages 55 to 59 had more than twice the risk of dementia in old age compared with a person in the same age group without diabetes.
The study and its implications are examined in a New York Times article.
The findings highlight the link between obesity and diabetes and now Alzheimer’s Disease and other forms of dementia. The conclusion is that these associations between the timing of onset of diabetes and development of dementia show the importance of a life-course approach to preventing degenerative disease.
How diabetes is linked to dementia is unknown. One of the study’s authors speculates that “Living a long time with diabetes and having hypoglycaemic events is harmful, and there are neurotoxic effects of diabetes as well. The brain uses enormous amounts of glucose, so with insulin resistance, the way the brain uses glucose might be altered” in people with type 2 diabetes.
In Australia, 35 percent of adults are overweight and 28 percent are obese. These statistics are projected to increase to 41 percent and 34 percent respectively by 2025.
Some Australian statistics to put this in perspective:
At least one in twenty Australians has diabetes and the majority of these (86 percent) have type 2 diabetes.
Diabetes is the fastest growing chronic condition in Australia; increasing at a faster rate than other chronic diseases such as heart disease and cancer.
The number of Australians with dementia is expected to increase to between 550,000 and 590,000 by 2030. Each week there are 1,800 new cases of dementia in Australia, and this is expected to increase to 7,400 new cases each week by 20508
I don’t think there was a single mention of obesity in last week’s Budget. The focus was strongly on aged care. What if there was a connection?
The best of Croakey
The good news story
There’s a butterfly boom in northern Queensland thanks to weather conditions that have enabled butterfly-attracting plants to thrive.
You can read more, with some lovely photos, here.
If you’re interested in butterfly migrations, there’s a good summary of three of the biggest here. The abstract of a global overview of butterfly migration, which is under serious threat in some areas, is 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.
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