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The Health Wrap: diverse public health matters, as well as some troubling news and glorious views from the United States

Introduction by Croakey: A new wave of COVID-19 infections, driven by the BA.4 and BA.5 Omicron subvariants, is expected to lead to a substantial increase in hospitalisations and deaths, at a time when our communities and health systems are already under strain, the Australian Health Protection Principal Committee (AHPPC) warned today.

The committee, comprised of all state and territory Chief Health Officers and chaired by the Australian Chief Medical Officer, also said that we are likely to see reinfection rates rise among those who have previously been infected with an earlier COVID-19 variant and those who are up to date with vaccinations.

In a statement, the AHPPC urged Australians to stay up to date with vaccinations, wear a mask outside home when in crowded, indoor environments including on public transport, ensure indoor spaces are well ventilated, and to stay home if symptomatic.

It also urged employers to review occupational health and safety risks and mitigations, and business continuity plans, and to consider the feasibility of some employees working from home and to support employees to take leave when sick.

As Associate Professor Lesley Russell writes below, reducing the overall burden of death and disease due to SARS-CoV-2 will require strategies for prevention of reinfection. Her latest edition of The Health Wrap also covers preparation for the next public health emergency, Birthing on Country and worrying news from the United States.


Lesley Russell writes:

You only have to look at the daily numbers from Australia (where we hit 10,000 deaths on 1 July), the United Kingdom (where last week COVID-19 cases were up 32 percent on the previous week) and Europe (where cases have tripled in the past month) to know that the pandemic still rages, fuelled by new Omicron variants BA.4 and BA.5 and the casting aside of public health mandates like masks and vaccinations.

This Twitter thread from Professor Bob Wachter at the University of California, San Francisco, is a good explainer of what is looming.

It’s called “living with COVID” but the reality is that many are sick with COVID, or living with long COVID, or – dreadfully – dying with COVID.

As Federal Health and Aged Care Minister Mark Butler said this week, “we are in the early stages of a building third Omicron wave… and it’s becoming a very serious pressure on our health and hospital system”.

This at a time when around a third of the population has yet to have the essential third vaccine jab, and there is a general reluctance to reinstate mask mandates, despite pressure from some public health officials.

What we are now seeing is people catching the virus multiple times. The data from several studies suggest the Omicron subvariants are more antibody resistant than previous strains and could “pose additional problems for vaccinated and/or infected people”.

People who are infected more than once face additional health risks. A recent study suggests people who catch COVID-19 at least twice have double the risk of dying from any cause and are three times as likely to be hospitalised in the next six months, compared with people who test positive just once.

They also had higher risks for lung and heart problems, fatigue, digestive and kidney disorders, diabetes and neurologic problems. The original paper, based on a large study using Veterans Affairs data, is here.

Minister Butler says that Long COVID is “a major health challenge” but we are yet to see any significant action from the Albanese Government on this front.

The situation is such that experts like Dr Anthony Fauci now believe that, unlike infectious diseases such as measles, polio and smallpox, herd immunity is unattainable for COVID-19.

“The big stumbling block with COVID is that history has already shown us we’ve had five separate variants with five separate surges, and the immunity to coronaviruses is very self-limited and fleeting,” Fauci said.

Reducing the overall burden of death and disease due to SARS-CoV-2 will require strategies for prevention of reinfection.

See more on the importance of vaccines-plus strategies in these recent Croakey articles:


Emergence of diphtheria in New South Wales

One of the lessons of the pandemic is that all the other healthcare issues don’t just disappear while everyone is focused on the crisis of the moment.

There was shocking news this month of two cases of diphtheria in unvaccinated children living in northern New South Wales, the first cases reported this century. This is a disease that is hard to treat, is often fatal, and is completely preventable by vaccination.

The causal bacteria, Corynebacterium diphtheriae, has no animal host, so infection is passed from individual to individual. In the non-toxigenic form the bacteria live on the skin and in nasal passages; the toxin is encoded on a corynebacteriophage and its expression is regulated by iron. (As an aside, this was the area of my post-doctoral studies – many years ago.)

There are two public health questions to be answered around these reports: where did the toxigenic bacteria come from, and why were these children (and perhaps others they were in contact with) unvaccinated?

While it’s unlikely to happen here, there are lessons from the major outbreaks of diphtheria in the 1990s in the former Soviet Union states that highlight how important herd immunity delivered via vaccination is in controlling this disease.

As if to emphasise this point, we are now seeing outbreaks of diphtheria again in the Ukraine.

Read more on the NSW situation here.


Preparing for the next public health emergency

It’s a short segue from COVID and diphtheria to now focus on what is being done in Australia and internationally to prepare to prepare for the next public health emergency.

We need, for example, to be preparing for more monkeypox cases.

Public health and healthcare resources have been seriously strained by the ongoing pandemic and the winter influenza season, and that will make it more difficult to manage the next emergency.

In the United States there has been considerable activity from the Biden Administration in this space – they learned the hard way from the failures of the previous administration.

The Biomedical Advanced Research and Development Authority (BARDA), which has responsibility for the health security of the nation and the development of medical countermeasures (tests, treatments, vaccines) that are safe, effective, and widely accessible, has recently released its 2022-2026 Strategic Plan.

It is focussed on four goals:

  1. Enhancing preparedness by investing in the development of a robust pipeline of innovative medical countermeasures to protect people during public health emergencies from threats such as chemical, biological, radiological, and nuclear incidents and emerging infectious diseases.
  2. Embracing a role as an agile response organisation.
  3. Expanding and sustaining public-private partnerships
  4. Continuing to invest in the needed workforce.

The Commonwealth Fund recently released the report from its Commission on a National Public Health System with recommendations for building a nation-wide public health system that can address ongoing and future health crises.

The report finds:

  • Public health efforts are not organised for success. Despite dozens of federal health agencies and nearly 3,000 state, local, tribal, and territorial health departments, there is no single person or office at the US Department of Health and Human Services to lead and coordinate the nation’s public health efforts.
  • Public health funding is not sufficient or reliable. Chronic underfunding means a weak infrastructure, antiquated data systems, an overworked and stressed workforce, laboratories in disrepair, and other major gaps.
  • Expectations for health agencies are minimal. Funding is not tied to a set of basic standards for the capabilities of state, local, tribal, and territorial health departments.
  • The health care system is missing opportunities to support health improvement. It is difficult to convert collaboration with public health agencies during emergencies into sustainable work to address day-today health challenges.
  • The public health enterprise is facing a crisis in trust. This crisis relates to experiences with racism and discrimination, ideological opposition, and misinformation.

Australians working in public health reading this will be in vigorous agreement that these same findings hold true in our country.

The Commission provides a detailed set of recommendations to achieve its vision, with specific tasks for the Congress, the Administration and state, local and tribal governments.

I was enthusiastic to see that it recommended the reconvening of the National Prevention and Public Health Council to guide an all-of-government approach to the drivers of health (I worked on this during my 2009-2012 stint in Washington DC).

This statement in the summary should also speak to Australians in public health: “Modernizing public health … is not a simple task, but it cannot be ignored. The window for change is open, and the moment of opportunity is now.”

As a final note on the American perspective, the Commonwealth Fund’s 2022 Scorecard on State Health System Performance is just out.

It finds that states that have historically performed well on the annual State Scorecard also performed well as the pandemic unfolded, both on the usual set of health system measures and the new COVID-19-specific measures.

Looking across all measures of performance – health care access, quality, and spending, as well as health outcomes and equity – Hawaii and Massachusetts top this year’s rankings. These two states’ overall performance separates them from other states, even other top performers. Both were consistently among the top three states across each of the seven dimensions of performance the State Scorecard evaluates.

Connecticut, Washington, and Vermont rounded out the five top-performing states. Mississippi, Oklahoma, and West Virginia ranked lowest overall.

I will note (because the Commonwealth Fund didn’t) that you can predict with almost complete accuracy whether a state is red (Republican) or blue (Democratic) by the performance rankings.So where is Australia on this task?  A long way to go, and with a lot of competing priorities.

The current pandemic preparedness plans (mostly focused on influenza) are here. I think it’s fair to say they all need updating in the light of what has been learned since COVID-19 arrived.

It’s not clear that the findings from the Review of Australia’s health sector response to pandemic (H1N1) 2009 have ever been incorporated into more recent planning. This despite a strong critique, “Is Australia prepared for the next pandemic?” published in the Medical Journal of Australia in 2017 (and which included the current Secretary of Health as an author).

While it is likely that much of the responsibility for this work would fall to the promised Australian Centre for Disease Control, tomorrow is not too early to be starting on this work.

Alongside this is the need to reform, resource and coordinate nationally public health efforts.

My colleague Melissa Sweet recently reminded us (and the Albanese Government) of the value of another look at the recommendations of the 2009 National Health and Hospitals Reform Commission.

But that very valuable report and the reform agenda of the Rudd Government that it triggered was criticised (by Professor Raina MacIntyre among others) due to insufficient attention to public health.

While we worry about addressing the crises in general practice, acute care and aged care, we should not forget the need for the essential work done in public health laboratories and services that help keep us healthy and out of the healthcare system. Consideration of the public health workforce needs to be central to wider health workforce policy development.


Birthing on Country for the best start in life

The latest edition of the Medical Journal of Australia has an excellent paper that outlines the value to First Nations mothers and babies when birthing services are available on country.

The background to this work is that a disproportionate number of First Nations women experience adverse outcomes in pregnancy and birth and there has been little improvement in perinatal indicators over the past ten years. This includes the rate of preterm births, the largest contributor to infant and child mortality.

The MJA paper describes the Caring for Mum on Country project that has been working with Yolŋu women in North East Arnhem Land to address the region’s entrenched perinatal inequities.

The local women, working alongside researchers from the Molly Wardaguga Research Centre at Charles Darwin University, are speaking up to reclaim the control and return of childbirth services to their community.

They aim to achieve this by establishing a national very remote exemplar demonstration Birthing on Country maternity service. This will provide evidence‐based Western medical maternity care (earlier in pregnancy and more frequently than currently occurs) integrated with cultural caring practices delivered by a workforce of skilled Yolŋu djäkamirr.

The djäkamirr are doulas who have undergone government-recognised vocational educational training alongside a Yolŋu knowledge curriculum. This combination provides clinically and culturally safe care, with referral pathways to manage medical and sociocultural complications, using both knowledge systems and both workforces.

The paper concludes thus:

For too long Yolŋu women and families have been excluded from maternity service design and delivery in their own community — biomedical services have been imposed upon them and multiple consultations undertaken but ignored.

As Yolŋu woman Associate Professor Maypilama states in the documentary describing the journey so far: ‘If you listen carefully and hear what is coming in, it will come into your heart and then you can help. We need your hand please’.”

The documentary mentioned in this quote is available here. The media release from Charles Sturt University that accompanied the publication of this paper is available here.

In March this year, The Conversation published a good summary of where the Birthing on Country movement currently stands in Australia, written by some of the researchers at Charles Darwin University. There is more information about the Molly Wardaguga Research Centre here.

See also previous Croakey articles on Birthing on Country:


More on Indigenous health

The July 4 issue of the Medical Journal of Australia has a number of interesting articles on Indigenous health that are open access (so good to see).

As well as the Birthing on Country paper discussed above, these include:

Climate, housing, energy and Indigenous health: a call to action. The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels in remote communities in Australia.

The need for a roadmap to guide actions for Aboriginal and Torres Strait Islander adolescent health: youth governance as an essential foundation.  There is no national strategy for Indigenous adolescent health and it’s a glaring policy gap for an important population group.

Improved life expectancy for Indigenous and non‐Indigenous people in the Northern Territory, 1999–2018: overall and by underlying cause of death. In the Northern Territory, life expectancy increased more rapidly for Indigenous than non-Indigenous people during 1999 – 2018, but the gap in life expectancy between the two groups remains considerable (15.4 years for both men and women).

SISTAQUIT: training health care providers to help pregnant Aboriginal and Torres Strait Islander women quit smoking. A cluster randomised controlled trial. About 44 percent of Indigenous women smoke during pregnancy. This trial will train healthcare workers to deliver culturally appropriate interventions. (See also Croakey’s previous article from those involved with the program.)

High prevalence of hearing loss in urban Aboriginal infants: the Djaalinj Waakinj cohort study. This study found that 69 percent of urban Aboriginal infants had hearing loss at about twelve months of age. Such findings support early monitoring of otitis media and hearing loss in Indigenous children, with prompt referral for audiological assessment as recommended by Australian otitis media guidelines.

Interrogating the intentions for Aboriginal and Torres Strait Islander health: a narrative review of research outputs since the introduction of Closing the Gap. I analysed this paper in the June 17 edition of The Health Wrap.

Editorial. Life expectancy for Indigenous people is improving, but closing the gap remains unacceptably slow. Progress has been sluggish, and social factors and access to major health service schemes need much more attention.

Editorial. Strengthening the presence of Aboriginal and Torres Strait Islander voices in the Medical Journal of Australia. The editorial staff at MJA recognise that the journal has failed to sufficiently address the inclusion of Aboriginal and Torres Strait Islander voices. They aspire to do better and here lay out the groundwork for continuous dialogue towards a more inclusive journal. I hope this initiative will bear fruit in terms of acknowledging the expertise of Indigenous researchers and the value of co-design and partnership with Indigenous communities on research.


The case for more comprehensive ethnicity data

Given that the Australian Bureau of Statistics has been releasing lots of data from the 2021 census, including data highlighting the cultural diversity of Australian society, this issue is very topical.

Last year Dr Liz Allen (known to many readers of The Health Wrap by her Twitter handle @DrDemography) from the Australian National University published a paper making the case for more comprehensive ethnicity data in Australia.

The paper outlines how gaps in data can lead to and further entrench disempowerment and poor representation. It demonstrates that what is counted matters for equality and lays out what is necessary to help promote ethnic diversity through data collection.

Allen is among many who are very pleased that the Albanese Government has announced it will begin collecting ethnicity data as part of measuring diversity in Australia, a move long called for by experts and multicultural community groups.

This is already done in comparable countries like the United States, Canada and New Zealand. To date Australia has simply collected information about country of birth and language spoken at home.

Last year, the Morrison Government committed to using ethnicity data about COVID-19 testing and vaccination, but this was not done.

Yet analysis by the Australian Bureau of Statistics shows those who were born in North Africa and the Middle East were about ten times more likely to die from COVID-19 than those born in Australia, while people who came from South-East Asia and Southern and Central Asia recorded twice as many COVID-19 deaths.


Views from the United States

I am currently spending time in the United States, so I thought a report back on what I am seeing and hearing might be interesting.

There is no escaping that this is a troubled and divided nation. It’s in the news reports, the banner, stickers and posters that are everywhere, and comes up in every conversation I have.

Nothing highlighted the issues more than the wide-ranging responses to the gun massacre at the July 4 parade in Highland Park, an affluent Chicago suburb known for its picturesque homes and tree-lined streets.

The tweet below is an example of just how awful the language, lies and blame shifting about the July 4 shooting has become.Vanity Fair described the massacre as “a stark symbol of a uniquely American crisis”.

Perhaps a starker symbol is the findings of a June Gallup poll: only 38 percent of adults are “extremely proud” to be American – a record low. And an overwhelming and growing majority of Americans (85 percent) say the United States is heading in the wrong direction.

The failure to act on gun violence is just one reason why most Americans are worried. The issues (and the dreadful statistics) are summed up in perspective in the New England Journal of Medicine: Nineteen Days in America:

People often call these killings senseless, but tragically, they do make sense: we are seeing exactly the results the system is designed to achieve. We know that most countries have vastly lower rates of firearm-related violence and deaths. And yet we in the United States choose to give ready access to weapons of war to people who will use them to hurt themselves and destroy others.

As physicians, we know that prevention is better than treatment. We advise patients and families about lifestyle and dietary changes to prevent or ameliorate obesity, diabetes, and heart disease. We prescribe drugs to control serum lipid and glucose levels. We ask about many aspects of safety in the home, but clinicians often don’t talk with patients, even those at increased risk of hurting themselves or others, about guns. Shouldn’t limiting access to deadly weapons be part of preventive care?”

For many, their concerns have been stoked by the inability of the Biden Administration to get anything much done through the partisan Congress and, most recently, by a series of legal decisions handed down by the US Supreme Court (SCOTUS), now dominated by conservatives determined to implement the conservative agenda.

In the space of a few short weeks, SCOTUS has made the following decisions:

The overturning of the federal right to abortion has reverberated throughout the world and will have dreadful ramifications for reproductive rights and women’s health here in the United States. See, for example, this article about the profound impact on the provision of prenatal care in general and prenatal genetic screening and testing.

The basis on which Roe v Wade was repealed is that abortion is not specifically mentioned in the constitution. This approach of strict originality makes people nervous that important rights for today’s society, like the unconstitutionality of separating children by race in public schools (the ruling known as Brown v Board of Education), gay marriage, and health insurance cover for contraception are now at risk.

Now SCOTUS has indicated that next term it will hear a case from North Carolina that could upend federal elections by eliminating virtually all oversight of those elections by state courts. The case will argue that only the legislature has the power to regulate federal elections, without interference from state courts.

Many see this as a Republican bid to set new election rules that could have implications not just for North Carolina but nationally as it would affect the outcome of the 2024 presidential election.

As the sitting year ends for SCOTUS, a number of other, less controversial, decisions have also been released, and some of these relate to health issues. Health Affairs has produced two excellent articles that summarise the health-related decisions:

The testimonies rolling out from the Congressional Select Committee to Investigate the January 6th Attack on the United States Capitol deliver increasingly levels of evidence that former President Trump planned a political coup. Fortunately, it did not succeed.

But his judicial coup – his selection of Gorsuch, Kavanaugh and Comey Barrett for the Supreme Court – is now succeeding in systematically rolling back laws that provide crucial protections for all Americans, regardless of race, colour, creed or sexuality.

People I talk to here – friends, family, colleagues from my days in Washington, young and old – are concerned about the potential for political violence.

Some historians have compared the current rate of civil unrest to the pre-Civil War era. The proportion of Americans who say political violence is acceptable appears to be on the rise, especially on the right.

One historian said this: “The point to make is that supporters of each party in the US now see the other side as an existential threat to their vision of the future of America.”


The best of Croakey

I commend these two recent articles by Charles Maskell-Knight:


The good news story

Some weeks I really scratch for a good news story. This is one such week. It’s not that I’m personally glum, but it seems as if the world is.

However, we are currently at our home in Colorado and every day nature delivers the most beautiful scenes and flora for us to contemplate.

So here is a double rainbow over the lake outside the window where I work, at the end of a  thunderstorm, at the end of the day on July 4.

I hope it’s a sign of optimism and better things to come.


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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