In this edition of The Health Wrap, Associate Professor Lesley Russell reports on many aspects of COVID-19 vaccine news, telehealth, how poverty may affect children’s brains, New Zealand’s health system revamp, and more.
Lesley Russell writes:
It’s impossible to write an edition of The Health Wrap and not cover the coronavirus pandemic – it has taken over healthcare, science and, in many cases, our lives.
That’s the case also in this edition; however, I try to cover some topics that are not so well covered elsewhere.
As well as a range of COVID-19 related issues in this edition, make sure you don’t miss the regular COVIDWrap from my colleague Alison Barrett; you can read the latest edition here. All of the articles on coronavirus and COVID-19 published by Croakey are collected here.
How vaccines are affecting COVID-19 outbreaks globally
A recent article in The Guardian looks at the impact of vaccination on the pandemic. The analysis, which maps changes in death rates against vaccination rates, shows that, nearly six months after the first COVID-19 vaccines were approved for emergency use, most of the world is yet to see a substantial benefit.
Clear gaps have opened up between the handful of countries where vaccination levels are high (Israel, United Kingdom), those struggling to ramp up their programs (Australia, Canada, New Zealand) and the remainder — mostly poor countries that have received only a trickle of vaccine doses so far.
It’s a sobering picture.
Beyond vaccinations – face masks and social distancing
As The Guardian article above points out, in the absence of adequate vaccine supplies and/or with slow vaccination roll-outs and high levels of vaccine hesitancy, most countries (including Australia) are reliant on face masks, social distancing, onerous lockdowns and other quarantine measures to reduce the extent and severity of virus outbreaks.
An article this month in PLOS ONE from researchers at the University of New South Wales models the power of face masks and social distancing (assuming the isolation of infected cases and the quarantining of close contacts) in controlling the pandemic in the Sydney Greater Metropolitan Area.
The results show that face masks and social distancing can reduce the overall infections by up to 54.4 percent and 24.7 percent respectively – and the findings suggest giving higher priority to face mask usage than social distancing.
While a high proportion of infections happens at home, and the effectiveness of face masks in-home is high, only 21.6 percent of the reductions in population-level infections is due to face mask use in-home.
Wearing a face mask outside home is much more effective at a population level because it reduces the disease spread between households and anyway quarantining of infected cases and contacts reduces the influence of face masks in-home.
The authors conclude that face mask use by at least 60 percent of people provides a feasible strategy for opening the economy, especially as face mask compliance is much easier to enforce than social distancing.
Vaccines don’t protect people with weakened immune systems
In a country like Australia where infection rates have been low and it will be a long time before everyone especially children and adolescents are vaccinated, there is a number of reasons why protections like face masks will be needed for some time to come.
One reason is that the evidence increasingly shows that vaccines will not protect people with weakened immune systems who cannot produce enough antibodies in response to a vaccine or an infection, leaving them unable to fight off the coronavirus. When they do become infected, they may suffer prolonged illness, with death rates as high as 55 percent.
People with weakened immune systems include cancer patients, organ transplant recipients, individuals with HIV, and those with autoimmune or chronic inflammatory conditions such as lupus, multiple sclerosis and rheumatoid arthritis.
Note that the approved coronavirus vaccines are considered safe for people with compromised immune systems – it’s just that some of them may not produce protective antibodies after vaccination, or any antibodies at all.
One recourse for these patients may be to receive regular infusions of monoclonal antibodies. In the United States, the Food and Drug Administration has authorised several monoclonal antibody treatments for COVID-19 but now some are also being tested to prevent infections.
There is a good summary of what is currently known about this issue here.
Can coronavirus research help solve the mysteries of other viruses?
I’m fascinated and frustrated that here in Australia there is little focus on research to better understand, treat and manage “long COVID” and on the long-term burden that this is already imposing on individuals and the healthcare system.
The Victorian Government has stepped in with some funding, but so far I am unaware of anything from the Federal Government. Of course there could be something for this effort in the upcoming Budget – but I’m not holding my breath!
The complications of COVID-19 like loss of smell, heart inflammation, lung and nerve damage, and blood clots are not unique to coronavirus infection, but also occur in some patients who have had other respiratory and viral infections. These patients can also have their own version of “long COVID”.
A recent article in The New York Times outlines how the coronavirus pandemic may help scientists understand why some people with common viral infections develop these complications. Previously funding for such studies has been hard to come by because they occur so infrequently.
Since COVID-19, there is much more interest in loss of smell and other more serious complications of viral infections such as myocarditis — an inflammation of the heart muscle. This affects as many as 1.5 million people worldwide each year, most of whom had a prior respiratory virus infection.
Does vaccination cure long COVID?
There is growing evidence that people with long COVID (somewhere between 10 and 30 percent of those who recover from infection) seem to recover, at least in the short-term, after they have been vaccinated.
To date much of this evidence is anecdotal. However a recent study (quite small, involving only 66 patients) from the United Kingdom found that about 23 percent of vaccinated patients reported that their long COVID symptoms improve. The researchers saw no difference in response between people who received the Pfizer-BioNTech or the Oxford-AstraZeneca vaccines.
An article in The Atlantic explores possible mechanisms for this.
COVID-19 impacts on Medicare and the PBS
The Australian Institute of Health and Welfare has just released the most recent in a series of quarterly reports tracking the impact of the pandemic on utilisation of Medicare and the Pharmaceutical Benefits Scheme.
Unfortunately these just report comparative numbers of services and scripts with little or no interpretation of what they indicate or predict.
Key findings:
- Lockdown measures in April 2020 and the temporary ban on elective surgeries led to large falls in Medicare claims for pathology, optometry, operations and anaesthetics.
- The introduction of temporary telehealth consultation items in March 2020 led to a drop in face-to-face consultations, particularly for general practitioner consultations in Victoria during its second COVID wave (July to September 2020).
- There was an increase in Medicare benefits paid for incentive items during the period April 2020 to September 2020, when the fees associated with the temporary COVID-19 bulk-billing incentives items were doubled.
- The pandemic had little impact on the volume of PBS scripts dispensed in 2020 compared to 2019.
- There was a decrease in the number of prescriptions dispensed for antibiotics and antivirals likely associated with measures such as physical distancing and improved hand hygiene practices and a decrease in influenza cases compared to previous years.
Telehealth: in the news and in the Budget
Health Minister Greg Hunt has announced that the telehealth items added to the Medicare Benefits Schedule (MBS) during the pandemic and due to expire on June 30, will be extended for another six months, to the end of the year.
“The government continues to work with peak bodies to co-design permanent post pandemic telehealth as part of broader primary care reforms to modernise Medicare and provide flexibility of access to primary and allied healthcare services,” he said.
This Just-In-Time approach to extending these MBS items has been a feature of the Government’s approach to them from the very beginning: they were first introduced as temporary items in March 2020; on September 18, just days before they were due to expire on September 30, they were extended until March 31, 2021; and then on March 14 they were further extended until the end of the 2020-21 financial year.
The requirements for billing these items have also been changed a number of times, seemingly more to meet the demands of the medical profession rather than the needs of patients.
As long ago as November, Hunt said he was “pleased to announce that, for the long term, telehealth will become a permanent part of the Medicare system”. But it seems permanency is at least 12 months away.
Along with other health organisations, the Australian Healthcare and Hospitals Association (AHHA) and the Australian Medical Association have called for permanency.
I belong in the camp that sees telehealth and digital technology as both facilitating and disrupting healthcare, with the benefits, disadvantages and challenges of virtual care yet to be fully evaluated.
I have written previously about the need to collect and use evidence to ensure that these MBS items are effectively targeted and appropriately financed so that they improve access and health outcomes and deliver value for money and patient satisfaction.
As it currently stands, the Morrison Government simply refers only to the numbers of services delivered and the cost to Medicare when talking about why such items are important.
In The Health Wrap from June 9, 2020 I looked at these issues and referenced an article from Deakin University academic Dr Anna Peeters where she makes the case that the shift to telehealth requires more than a few new Medicare items and the associated financial incentives.
She highlighted the work done in Denmark to build a telehealth strategy that recognises the need for integrated, person-centred care, and writes: “Working well includes positive health outcomes, positive patient experience and positive health professional wellbeing. We must also actively monitor the impact on health inequalities and health professionals themselves.”
These issues are also being discussed in the US where telehealth claims for the privately insured population (ie does not include Medicare and Medicaid) increased 2,817 percent nationally from December 2019 to December 2020.
The Trump Administration finalised permanent Medicare billing items for telehealth in December 2020 – there is a good description of the policy here. The Medicaid telehealth policies vary by state – there is a recent summary here.
I found this article “The promise and the peril of virtual health care” in the 9 June 2020 edition of The New Yorker interesting, and also the comments in a later edition of the magazine.
More recently, Health Affairs published an excellent article on “Establishing a value-based ‘new normal’ for telehealth”. It makes a number of points that are relevant for Australia.
They include:
- The pressing need to clarify the infrastructure needs such as broadband that are needed to support and sustain equitable delivery of telehealth services.
- Establishment of platforms to measure access, clinical outcomes, patient satisfaction, continuity of care and expenditure.
- Recognising and bridging the digital divide in access for under-served, vulnerable and elderly patients.
- Aligning expanded use of telehealth with payment reform initiatives.
- Leveraging principles of value-based care.
- Incentivising telehealth utilisation to support population health and geographic dispersion of care and workforce.
The Australian Healthcare and Hospitals Association has produced a supplementary paper “Effective and Sustainable Adoption of Virtual Health Care” to the organisation’s Healthy People, Healthy Systems blueprint for health reform that reaches similar conclusions.
This paper was developed through substantial consultation with AHHA’s membership and stakeholders across the hospital, primary and community health sectors.
The Morrison Government would do well to draw upon its findings and address the areas outlined as needing attention. Along with patient-centredness and equity, these include the need for a digitally capable workforce providing team-based care.
How poverty affects young brains
The impact of poverty on health and wellbeing is well-understood and hard to ignore. Poverty affects children’s health not only when they are young, but also later in their lives as adults with impacts on both physical and mental health.
The Smith Family finds one in six Australian children and young people are living in poverty. The coronavirus pandemic has served to highlight that.
An emerging branch of neuroscience looks at how poverty affects the developing brain.
Recent studies show that children raised in poverty have subtle brain differences compared with children from families of higher means. On average, the surface area of the brain’s outer layer of cells is smaller, especially in areas relating to language and impulse control, as is the volume of the hippocampus, which is responsible for learning and memory.
Researchers speculate that specific aspects of poverty — poor nutrition, elevated stress levels, low-quality education — might influence brain and cognitive development.
In the US a research project called Baby’s First Years is examining the effects of giving poor families cash payments in amounts that wound up being comparable to those the Biden Administration will distribute as part of an expanded child tax credit.
The Baby’s First Years initiative is seen as an audacious effort to prove, through a randomised trial, a causal link between poverty reduction and brain development.
That said, there are also those who are sceptical about this approach – and there are clearly some other factors involved.
Some point to the research on brain and cognitive development in children who grew up in Romanian orphanages from the mid-1960s into the 1990s. Those studies demonstrated that deprivation and neglect diminish IQ and hinder psychological development and that and that institutionalisation profoundly affects brain development.
Whatever the causal mechanism, more needs to be done to help families with young children and protect them from the exigencies of poverty.
In Australia this approach is being pushed by a number of organisations. These include:
- First 1000 Days Australia – this is a First Nations model aimed at strengthening all families so they can give their children the best start in life. It is headed by former chair of Indigenous Health at the University of Melbourne Professor Kerry Arabena. You can read more here.
- The Strong Foundations: Getting it Right in the First 1000 Days Partnership – Australian Research Alliance for Children and Youth.
Is the Morrison Government listening?
The Department of Social Services website states: “To help us all navigate through the waters of raising children in the early years, the Australian Government is partnering with experts to provide a range of resources to help.”
It references the Australian Parenting Network’s website which is funded by the Department of Social Services but operated by several academic and hospital research groups.
On the website of the Australian Institute of Family Studies (a statutory agency of the Australian Government) I found this essay entitled “Children in poverty: can public policy alleviate the consequences?” and got quite excited – until I realised it was dated 2011 – a hangover from a previous (Labor) Government!
New Zealand health care system reorganisation
Our Kiwi cousins show an admirable level of innovative policy development in the health area. In the previous edition of The Health Wrap I wrote about their wellness approach to budgeting.
Now comes news of some major changes in the structure of their healthcare system. What’s going on and why?
A 2016 overview (paywalled) of the New Zealand healthcare system described it as “in a continual process of restructuring and change”. At that point there had been several major system-wide changes in recent decades, although more recent change has been incremental and evolutionary.
The article outlines the problems then facing the system and proposed solutions. These included the need for team care, providing services closer to patients’ homes, focusing on a population of interest, connecting up the system, and engaging patients more closely in care design and delivery.
Last month came the announcement of a new round of major changes – the New Zealand healthcare system will now look much more like the British National Health Service.
- Graphic from the New Zealand Government announcement
- The 20 District Health Boards which run services for individual areas around the country will be replaced by one new body, Health NZ, which will instead plan services for the whole population. Health NZ will delegate authority to local levels.
- There will also be a new Māori Health Authority, sitting alongside Health NZ, to both set policies for Māori health and to decide and fund those who will deliver services. This Authority will have the power to directly commission services.
- The 30 Primary Health Organisations — large regional networks of GPs and primary care — will be ditched.
- In the wake of the coronavirus pandemic, there will be a new Public Health Agency which will focus on prevention, tackling widespread health problems like smoking, and infectious diseases.
As you can imagine, there has been a very mixed response. You can read some of them here.
The changes go further than those proposed in the recent Health and Disability System Review. The Health Minister says they have been made to stop what’s called the ‘postcode lottery of care’, where people get different care — or have different changes of survival — depending on which DHB area they live in.
The aim is to get hospital and specialist care into a coherent network and to increase the focus on and funding for primary care.
The Māori Health Authority is aimed at overcoming the huge health disparities for Māori as a whole and their distrust of mainstream services.
The new system is expected to come into effect in July 2022. Legislation will be needed to implement the proposal. You can read the documents that accompanied the announcement of the reforms here.
We should watch this effort and the outcomes closely.
When doctors and their families don’t follow the guidelines
A Swedish study shows that patients with personal access to medical expertise (ie doctors and their close relatives) are less likely to adhere to medication-related clinical guidelines.
Patients with access to expertise are likely to be better informed, better able to make decisions, and better able to communicate with their medical providers. If ignorance, complexity, and patient-provider communication or trust are important barriers to adherence, then it is reasonable to expect that patients with access to medical expertise will tend to be more adherent.
However, this research found the opposite. The authors suggest that access to expertise gives patients superior information or confidence which can lead them to disregard guidelines that they do not perceive to be in their clinical interest.
The best of Croakey
Croakey’s ‘The Road to Aged Care Reform’ series, particularly two articles by Charles Maskell-Knight:
Aged care reform: how to improve funding systems to support quality care
Aged care reform: improving the transparency and accountability of funding
Good news story
Some really good news this week with the announcement from the Woolworths Group that, on the basis of the findings of the Gilbert Review, it will not proceed with the development of a large Dan Murphy liquor outlet near Darwin Airport.
This had been opposed by a wide range of groups, in particular the nearby dry Aboriginal communities.
The Woolworth’s decision is an acknowledgement of the significant harm the store would cause these communities and the lack of appropriate consultation.
“The Gilbert review has made it clear that we did not do enough in this community to live up to the best practice engagement to which we hold ourselves accountable,” said Woolworths chairman Gordon Cairns. “In particular, we did not do enough stakeholder engagement with a range of Aboriginal and Torres Strait Islander communities and organisations.”
You can read the background and the issues in this article which Jeff McMullin and I wrote in January here.
Croakey colleague Marie McInerney collated the responses from Indigenous leaders here. A number of organisations which worked hard to oppose the liquor outlet put out a media release welcoming this news.
However, just one cautionary note: there are concerns in some quarters that this may not be the end of the saga.
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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