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The Health Wrap: coronavirus news, self-determination matters, primary healthcare and some good news from Tasmania

In this latest edition of The Health Wrap, Associate Professor Lesley Russell raises questions about the roll-out of coronavirus vaccines, reviews some pandemic communications lessons, and reports on developments for Aboriginal and Torres Strait Islander peoples’ health.

She also shares some encouraging news on the health of Tasmanian Devils.


Lesley Russell writes:

The news this past week – and into the future – is centred around the roll-out of coronavirus vaccines. In Australia this will not happen until March next year, and it is not yet clear what vaccine/s this will involve.

However, given that for the foreseeable future there will be constraints around the number of doses available and the infrastructure and personnel needed to deliver them, we should look for much more detail than is currently available about how this will be prioritised and conducted.

The Federal Department of Health website has a section on coronavirus vaccines and the vaccine priority groups are outlined here. If you read the guidance provided on priority groups, it is obvious that much more detail is required, along with explanations for the decisions.

For example, will healthcare workers be prioritised ahead of the frail elderly (the vaccines have not been tested in this population group)? Are carers included with healthcare workers? Which healthcare workers will be vaccinated first?

The Sydney Morning Herald recently reported that the priority list also includes prisoners and those in detention facilities, people with diabetes and those with severe obesity. That’s a lot of people already in the queue for what will likely be limited vaccine supplies initially. “I do worry, if there is great demand and little supply, equity will be one of the things that just slides off to the side,” said one vaccine supply expert.

Academics from RMIT have designed a mathematical model to test different scenarios for coronavirus vaccine distribution in Victoria.

They identified three key factors for success:

  1. Victoria’s 325 medical centres (hospitals) need to have capacity (size and staff) to administer vaccines for the population they serve.
  2. Vaccines must be able to be transhipped between medical centres to address uneven supply needs (assume refrigerated trucks available).
  3. Vaccine packs need to be the right size – larger pack sizes increase the need for transhipments (ie transporting vaccines between medical centres).

The researchers calculate that with guaranteed supplies of 114,000 doses/day (in packs of 12), Victoria could get one shot (and two might be needed, one month apart) to every Victorian within 60 days.

Think how much harder and more resource intensive the task will be to get doses to remote Indigenous communities.

Another mathematical simulation of vaccination from the US finds that factors related to implementation will contribute more to the success of vaccination programs than a vaccine’s efficacy as determined in clinical trials. One of the authors is Dr Rochelle Walensky, Biden’s choice to run the Centers for Disease Control and Prevention.


Long-term impact of coronavirus in the United States

It’s increasingly impossible to say anything optimistic about the pandemic in US. The consequences of the egregious mismanagement by the Trump Administration and some state jurisdictions will be felt for years to come.

This was highlighted by a recent paper that showed that US life expectancy at birth (LEB) will be reduced by COVID-19 by more than a year.

Such an impact on the American LEB is unprecedented since the end of World War II. By comparison, the opioid-overdose crisis has led to a decline in LEB averaging 0.1 year annually, from 78.9 years in 2014 to 78.6 years in 2017.

At its peak, the HIV epidemic reduced the US LEB by 0.3 year in a single year, from 75.8 years in 1992 to 75.5 years in 1993.

This situation could worsen, especially if there are delays in getting sufficient numbers of Americans vaccinated (and research suggests the vaccines will be much less effective at preventing death and illness if they are introduced into a population where the coronavirus is raging — as is now the case in the US).

The expectation is that the US LEB will fall back to the level in 2010 (78.7 years). Thus the impact of COVID-19 on US mortality will cancel a decade of gains against all other causes of mortality combined.


Communication lessons

The importance of effective communication strategies during the coronavirus pandemic was highlighted in a recent paper in Nature Human Behaviour.

It looks at the effectiveness of non-pharmaceutical interventions (NPIs) used by governments to tackle the coronavirus pandemic (this paper was reviewed by Alison Barrett in her recent COVID-19 wrap here.)

The importance of communications is also highlighted in the latest edition of Health Voices from the Consumers Health Forum of Australia.

An article by Professor Helen Skouteris from the School of Public Health and Preventive Medicine at Monash University makes the point that when developing communications for culturally and linguistically diverse (CALD) groups, it is not enough to simply translate the basic messages into other languages. Communication initiatives must be tailored so they are meaningful and relevant to those for whom the messages are meant. This involves co-design and genuine collaboration with consumers and communities.

In an article in The Conversation, Monash researchers led by Skouteris report on what the multicultural community in Melbourne said was needed in the wake of the second coronavirus wave.

The list included:

  • Involve communities in developing strategies
  • Tailor messages to community values
  • Use trusted messengers
  • Use channels that the audience can access
  • Establish a national peak body for multicultural health issues.

One role of the national peak body would be to advise authorities on public health messaging and interventions across CALD communities.

See also this earlier article “Rethinking the COVID message for multicultural communities” from Dr Abby Wild at the Monash Sustainable Development Institute.

With a slightly different focus, a great article in The Washington Post quotes Professor Larry Gostin of Georgetown University (he is well-known to many Australians) about the need for effective communications around vaccination.

He says: “

The science of education is no less important than the science of vaccine development or the science of epidemiology.

It’s no good having a 95 percent effective vaccine if you don’t have at least 70 percent of the population willing and able and do get the jabs in their arm.”


Early treatment options needed

I recently read an article where Dr Anthony Fauci, the top infectious diseases expert in the US, shared a day in his life. He’s 79-years-old, but it’s exhausting just reading about his work ethic.

That probably explains why he has time to think about what else is needed to tackle coronavirus and to co-author a JAMA paper on the need for more research to develop early therapies for COVID-19.

While treatment options for patients with severe disease requiring hospitalisation are now available, with corticosteroids emerging as the treatment of choice for critically ill patients, interventions that can be administered early during the course of infection to prevent disease progression and longer-term complications are urgently needed.

The paper outlines several current and possible approaches. These include:

  • Looking at the repurposing of antivirals for infections such as HIV, hepatitis C and Ebola. These investigations have not yet yielded clinically actionable results; however, many trials are ongoing.
  • Earlier use of the immune-modulating drugs that are being developed for the treatment of moderate to severe COVID-19.
  • SARS-CoV-2–specific approaches, such as antiviral antibodies. Convalescent plasma, hyperimmune γ-globulin, and polyclonal antibody products are being tested in a wide range of studies including in participants with mild to moderate disease.

The authors make the case that, given the duration and severity of the COVID-19 pandemic, investments in targeted de novo drug design approaches for early treatment are also warranted.

They also argue that for early interventions to provide the greatest benefit, treatments will need to be administered easily and made available widely at low cost.


Tracking progress in Indigenous affairs

  1. Productivity Commission report in Overcoming Indigenous Disadvantage

Earlier this month the Productivity Commission released its Overcoming Indigenous Disadvantage: Key Indicators 2020 report. This is a report card, produced every four years, against 52 indicators across a range of areas including governance, leadership and culture, early childhood, education, economic participation, health, home environment, and safe and supportive communities.

The report was produced in consultation with Australian governments, the Coalition of Aboriginal and Torres Strait Islander Peak Organisations and other Aboriginal and Torres Strait Islander people and organisations.

The findings are a mixed bag, with progress in some areas (early childhood development, economic participation and some aspects of health and education), while in other areas (justice and mental health) it seems things are going backwards, with increases in the rates of imprisonment, suicide and self-harm.

The report finds that, “If change is to occur these outcomes need to be understood in context; recognising the strengths of Aboriginal and Torres Strait Islander people that contribute to their wellbeing, as well as the structural and systemic barriers that can undermine or erode their wellbeing.”

I appreciated that the report looked at the common characteristics of approaches that appear to be successful in improving outcomes for Aboriginal and Torres Strait Islander people. None of these are surprising or new. They include:

  • Enabling Aboriginal and Torres Strait Islander people to share in decision‑making on things that affect them
  • Addressing laws, policies, and practices that operate to the detriment of Aboriginal and Torres Strait Islander people
  • Ongoing government investment, collaboration and coordination
  • Ensuring access to effective culturally safe services, at the right time and suited to the local context
  • Addressing racism and discrimination in the Australian community, through structural changes, and building knowledge and education.

See also Croakey’s coverage of the report, by Dr Summer May Finlay and Dr Amy Coopes (3 December).

  1. AIHW Report on progress in implementation of the Aboriginal and Torres Strait Islander Health Plan

This month also saw the release of the Australian Institute of Health and Welfare report Tracking Progress Against the Implementation Plan Goals for the Aboriginal and Torres Strait Islander Health Plan 2013-2023.

The Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan was introduced in October 2015. There are goals to be achieves by 2023 for 20 indicators, developed to complement the existing COAG Closing the Gap targets, and focussed on prevention and early intervention across the life course.

Again, it’s a mixed story with eleven goals on track to be met, and nine not on track.

All the goals relating to smoking and maternal health – except, unfortunately, the rate of pregnant women smoking – are on track.

Most of the unmet goals relate to health checks; perhaps this is a sign that access to primary care is not optimal?

  1. Food costs in remote Indigenous communities

The Standing Committee on Indigenous Affairs in the House of Representatives has brought down the report on its inquiry into food pricing and food security in remote Indigenous communities.

This is a perennial issue that no-one in government seems committed to addressing. This is the third time this matter has been examined in recent years and none of these inquiries has resolved the concerns about food prices and security that have been expressed.

The supply of quality and affordable food is often unstable due to poor infrastructure, seasonal changes and the high costs of living and operating stores remotely. However, complaints about food pricing need to be examined by a body that is equipped to do the thorough, forensic examination that will satisfy the public.

The Committee is recommending these matters be investigated with the ACCC undertaking an enhanced market study in remote communities, along with real time price monitoring, inspection of remote community stores, and better governance training at the local level. This could increase competition and improve public confidence that there is no price gouging.

There is a good news story here arising out of the coronavirus pandemic. When the remote communities took control of the response to the pandemic, they realised that the restrictions imposed could limit supplies and access to foods. So worked with industry, NGOs, governments and stores to ensure food supply was maintained.

This was done through the Supermarket Taskforce established by National Cabinet and the Food Security Working Group which was established in April. The parliamentary report recommends building on this cooperative momentum to improve the food security and health outcomes experienced by people in remote Indigenous communities.

  1. AHRC report on First Nations women and girls

The Australian Human Rights Commission, under the guidance of Aboriginal and Torres Strait Islander Social Justice Commissioner Dr June Oscar has released a landmark report that surveyed Indigenous women and girls across the nation. The report, titled Wiyi Yani U Thangani (women’s voices in the language of the remote Western Australian region where she was raised) is the first engagement of this type since 1986.

The feedback Dr Oscar received showed that Indigenous women and girls have an overwhelming need for more support to break cycles of crisis in many areas of their lives. The report makes five major findings and seven recommendations.

The report finds:

  • First Nations women and girls have diverse strengths that support all aspects of life.
  • Investing in First Nations women and girls is an investment in society.
  • It is structural forces, not individual behaviours alone, which overwhelmingly determine life outcomes.
  • First Nations women and girls want systems and services to be preventative, place-based, culturally safe, healing-oriented and trauma-informed.
  • We must support First Nations women and girls’ leadership and participation in all decisions that impact their lives.

The report recommends:

  • A National Action Plan on advancing the wellbeing of Aboriginal and Torres Strait Islander women and girls.
  • Conducting a National Summit and establishing a National Aboriginal and Torres Strait Islander Women and Girls Advisory Body.
  • Empowering women’s leadership on the ground.
  • Protecting, supporting and reviving Aboriginal and Torres Strait Islander cultural practices and knowledge systems.
  • An urgent focus on healing from intergenerational trauma.
  • National action to eradicate racism.
  • Local and regional focused engagement.

See also Croakey’s coverage of the report by Dr Tess Ryan (14 December).

Undermining self-determination

Sadly, I always seem to find something to offset the good news and to remind us of the continuing obstacles to self-determination for Aboriginal and Torres Strait Islander people. Some recent examples follow below.

  1. Alcohol conflicts – profits over Indigenous health and welfare

Even as the National Health and Medical Research Council was announcing updated alcohol guidelines, lowering the threshold for harmful drinking, Indigenous leaders are pleading with the chairman of Woolworths to abandon plans to construct a mega-sized Dan Murphy alcohol outlet in Darwin near dry Indigenous communities. This has been done without proper community consultation.

This issue has been going on for some time (by my assessment, since March) without a satisfactory resolution. An article in Croakey in May outlined the elders’ concerns.

You can read Professor Kate Conigrave’s analysis of the updated NHMRC guidelines here. My Croakey colleague Dr Amy Coopes wrote about Indigenous protests to Woolworths here.

  1. Paying lip service to Indigenous self-determination and choice

This past week the Aboriginal community-controlled health sector was formally recognised for its acclaimed pandemic response this week with the award of the Australian Health and Hospitals Association’s Sidney Sax medal to NACCHO CEO Pat Turner.

But at the same time the Morrison Government was seeking to undermine Indigenous autonomy and choice by pushing legislation to expand and make permanent the cashless welfare card.

While the original legislation could not pass and was eventually watered down, the scheme has been extended for another two years. It is clear the Government is looking for ways to further embed it in disadvantaged communities, despite opposition from most Indigenous groups and lack of evidence that it improves people’s lives.

Aboriginal and Torres Strait Islander groups and advocates have condemned this push by the Morrison government, calling the cashless debit scheme “punitive, discriminatory and harmful” and a regressive step in efforts to close the gap.

Pat Turner’s speech at the AHHA award ceremony with her reflections on Aboriginal community successes in COVID-19 (“We have lost not one Elder”) is published in Croakey.

My article, “It’s impossible to know if the cashless debit card system is working – but the Government doesn’t care” written for The Health Wrap back in July 2018, outlines how the Australian National Audit Office found that it is impossible to say whether this controversial initiative has improved lives, reduced social harm or saved money because the monitoring and evaluation have been inadequate.

Indeed, some of this work, including the planned cost-benefit analysis and post-implementation review was not just inadequate, it was not completed.

Amy Coopes wrote a biting analysis of the issues, with comments from stakeholders, here.

  1. The mining industry – putting profits ahead of priceless cultural heritage

The letter from community leaders to Woolworths (mentioned above) urged the business not to put profits ahead of people and to work in consultation with the community.

This in-balance in the way Australian businesses balance their books is highlighted in extremis in the findings and recommendations of the interim report from the parliamentary Standing Committee on Northern Australia on the destruction of the Juukan Gorge cultural sites.

The report, titled “Never Again” finds that: “The blast devastated a place of personal, community, national and international significance. Rio Tinto’s role in this tragedy is inexcusable. Rio knew the value of what they were destroying but blew it up anyway.”

It was good to see the passion from Warren Entsch, the committee’s chair, at the report’s release: “Never again can we allow the destruction, the devastation and the vandalism of cultural sites as has occurred with the Juukan Gorge—never again!” he said.

The report calls actions from Rio Tinto, the West Australian Government, the Commonwealth and all other mining companies.

While Rio Tinto has issued a public apology, and says it is “working to progress a remedy” the fact is they allowed profits to over-ride priceless cultural heritage. Rio Tinto and the mining industry in general fails to see that their corporate and ethical responsibilities entail more than mere compliance with the law.

An article in The Conversation highlights that many mining companies have not kept pace with their social policy commitments and too often the work of community relations and Indigenous affairs units is peripheral to mine planning and production processes.

  1. To offset the bad news ….

On an uplifting note and for your Christmas reading and re-reading – Croakey Professional Services has published a raft of Community Control success stories, sponsored by the Aboriginal Health & Medical Research Council of NSW. You can access them here.


Marking International UHC Day

December 12 was International Universal Health Coverage Day.

In a timely paper in the International Journal of Health Policy and Management, Australian researchers, including Professor Sharon Friel and Professor Fran Baum, look at what can be learned from Australian primary healthcare (PHC) about universal coverage for non-communicable diseases (NCDs) and health equity.

They do a good job of outlining the principle ideas/issues in what they call “primary healthcare” but which (as they acknowledge) is mostly GP care. These include:

  • the dominance of biomedical and behavioural views of health and subsequently the models of care
  • the contestation between social democratic and neoliberal values seen in the combination of public or private insurance structures
  • the GP-centric PHC system is failing to properly manage NCDs and to prevent avoidable hospitalisations, and
  • that recent conservative governments view risk factors for NCDs such as diet, exercise and alcohol consumption as matters of individual responsibility.

The authors identify concerns with Health Care Homes and effective chronic disease management. They find that the policy focus for Primary Health Networks (PHNs) is too narrow and there is little leeway for them to address inequalities. And they make the case for better funding, increased capacity and greater flexibility for community health centres and Aboriginal Community Controlled Healthcare Organisations. (This is a song sheet I can sing from!)

Making needed reforms is difficult because of the power of vested interests such as private health insurance, the Australian Medical Association and the Pharmacy Guild.

Their conclusion?

“Although Australian PHC policy has major features favourable to equity of access, other features detract from the capacities of the system to take preventive action on, and better manage NCDs, deliver equity of access according to need, and support equity in health outcomes.”

I’m pretty certain the authors would agree that improving Australian health requires much more than access to healthcare.

In doing some background reading I found this paper from El Salvador that does a great job of reflecting the need for a more comprehensive, multi-sectorial approach to preventing and managing NCDs. I’ve no idea how, or even if, this is reflected in the El Salvador health system, but I like the principles.


The best of Croakey

Read the article on the new WHO guidelines.


The good news story

I grew up in Tasmania and a little of my heart always belongs there. So of course I loved this good news story about how the Tasmanian Devil has flattened the curve of the spread of the transmissible cancer that has threatened it with extinction.

Using similar sophisticated methods of genomic analysis used to trace the evolution and spread of COVID-19 through human populations, scientists have established that the reproduction number of the disease has significantly reduced.

Photo via Wikimedia Commons: https://commons.wikimedia.org/wiki/File:AZ_Tasmanian_Devil-2_(4630664592).jpg

This is the last The Health Wrap for 2020, so I am sending readers best wishes for the holiday season – and I am looking forward optimistically to 2021.


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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