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The Health Wrap: early coronavirus spread, HIV/AIDS matters, health system impacts, and reforming food systems

In her latest edition of The Health Wrap, Dr Lesley Russell reports on the latest developments in coronavirus research, the pandemic’s implications for people with HIV/AIDS and wider global health concerns, as well as digging into some of the issues for Australian healthcare. She also reviews efforts to tackle obesity in Brazil.


Lesley Russell writes:

As usual, I’m trying to keep you up-to-date with the information you might have missed. It’s almost impossible to keep up with what we are learning about the novel coronavirus and COVID-19 and what we still don’t know as new issues arise.

I wrote about this in a piece “What are we learning from the coronavirus” published last week on Inside Story – some of this is already out of date.  

Also along the lines of what are we learning, this look at what is currently known about the host immune response, “How does the coronavirus behave inside a patient”, in The New Yorker, is a great read.

The daily coronavirus tracking data graphs from the Financial Times are a terrific resource (tweeted out with commentary by @jburnmurdoch).

Recently they have added graphs of the excess mortality from a number of countries and regions. When aligned with the reported coronavirus deaths, this gives a measure of the “missing deaths” – an indication of the under-reporting of coronavirus deaths and perhaps other anomalies.

In my article for Inside Story mentioned above, I wrote about how it is now clear that the coronavirus arrived in the United States (on both the west and east coasts) much earlier than originally thought.

Now there is evidence (in a paper published this week) that the virus was also in France at least a month before the first case was reported. That means there were many unnoticed (asymptomatic?) cases and perhaps deaths in the period December 2019 – January 2020 and this contributed to the spread of the virus.

The authors of this paper also write:

Furthermore, since these results change our understanding of the dynamic of the epidemic, it also means that several models used to predict the evolution and outcomes of the SARS-COV-2 propagation might be based on biased data and would need to be adjusted to the actual profile of the epidemic.”


HIV/AIDS

The coronavirus pandemic has highlighted many challenges for the provision of HIV services.

There is currently limited knowledge about the potential effects of COVID-19 on people with HIV.

It does not appear that those with well-controlled HIV are at a greater risk of contracting the new coronavirus. However, there are concerns regarding those who are not currently on anti-retroviral therapy (ART), not virally suppressed, and those who are diagnosed at a late stage of infection

The pandemic raises challenges regarding HIV testing services and care for those newly diagnosed with HIV who require a greater degree of clinical monitoring for both their physical and mental health. There are concerns about national lockdowns discouraging people from seeking out HIV testing and follow-up services, with fewer or no face-to-face consultations for sexual health taking place in many settings. In many cities healthcare systems are overwhelmed by the numbers of COVID-19 patients, which makes getting these services even harder.

In March, US senators, in a letter to the Secretary of Health and Human Services (HHS), warned that the coronavirus “poses a serious health risk” to the estimated 1.1 million Americans who are HIV positive.

The letter says this risk is heightened by barriers to healthcare access exacerbated by the Trump Administration’s policies, stating:

Your agency’s actions to reduce health care discrimination protections for members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community have created additional risks for this population during this national emergency.”

In the developing world, the coronavirus pandemic is making it incredibly difficult to script an endgame for the “Big Three” killer epidemics – HIV/AIDS, tuberculosis and malaria.

In South Africa, the country with the largest number of HIV infections and the largest ART programme globally (approximately four to five million people are on ART but some two million people are not), the vast expertise in tracking and studying viruses is being used to tackle coronavirus.

After South Africa instituted a lockdown on 27 March, its new COVID-19 cases fell quickly and have remained relatively low. South Africa has taken a very proactive approach to actively screening and testing, especially in poor communities. 

As of May 3, South Africa had 7,808 coronavirus infections and 153 deaths.

recent article in the Financial Times (it is behind a paywall but can be accessed by answering some questions) highlights how many African countries, in spite of dreadful budget constraints, have been tackling coronavirus with policies that have been well co-ordinated and, so far at least, surprisingly effective. 

The Africa Centres for Disease Control and Prevention, which only came into being in 2017 in the wake of Ebola, has been instrumental in driving this.


Impact on Australian healthcare

A friend sent me this report from a consulting company that focuses primarily on the impact of coronavirus (directly and indirectly) on pharmaceuticals in Australia. It has some interesting statistics.

Here are my take-outs from the report’s findings:

  • There has been an unprecedented surge in demand for prescription medicines (March 2020 saw a 21 percent increase in prescriptions filled over March 2019). This has been particularly the case for respiratory, cardiovascular and lipid modifying medicines and also untested drugs with potential benefits for the treatment of COVID-19 such as hydroxychloroquine.
  • Many of these prescriptions have been supplied under regulation 24 (which enables the supply of all repeats at once).
  • Interestingly (and positively) it seems that fear of coronavirus has driven many relapsed patients (those who had stopped taking their medicines for chronic health conditions for at least six months) to get their prescriptions filled.
  • The demand on some medicines (for asthma and chronic obstruction pulmonary disease, insulin and oral diabetes drugs, anti-epileptics) was such that restrictions were introduced on March 19.
  • There has also been an unprecedented demand for consumer health products with sales of over-the-counter pain relief up 190 percent and over-the-counter asthma medicines up 272 percent in March over March 2019.
  • In March, while specialist doctors saw only a very small increase in patient presentations (even that is a surprise!), GPs saw their case load double.
  • Pharmacists are most worried about shortages affecting their ability to supply medications. GPs are most worried about the supply of personal protective equipment (PPE).
  • Their ability to provide ongoing care through the coronavirus crisis to patients with chronic conditions is a significant concern for almost all clinicians.
  • Clinicians are aligned in their belief that coronavirus will radically change the current model of healthcare in Australia (although there was no reference to needed changes in financing mechanisms). The changes include an increased emphasis on telehealth, hospital in the home and hospital substitute treatments, and an expanded role for practice nurses.
  • There is evidence that ongoing clinical and research studies in Australia have been adversely impacted by the pandemic and that planned new studies are being delayed.

Primary care in pandemic times

As the piece above highlights, thoughts are turning to the healthcare system will look like in a post-coronavirus world, and what positive changes the pandemic has driven.  

To that end, a “Report from the Covid Front Lines of Value-Based Primary Care” published in Innovations in Care Delivery in the NEJM Catalyst on the impact of coronavirus on primary care caught my eye.

It looks at how Oak Street Health, an American network of 56 primary care centres in eight states that provides what is described as “high-touch, value-based” medical care for some 80,000 adults on Medicare, is facing up to a significant challenge from the coronavirus crisis in the US.

Image from Oak Street website

First, a little about Oak Street Health, which is one of those remarkable ventures I suspect you could only find in the US (and which goes to prove that US can lead in innovative primary care).

It was started by investors with a pretty strong “do good” streak and operates under a full-risk, fully globally capitated model taking care mostly of patients on both Medicare and Medicaid (such dually eligible patients are poor and tend to be sicker), but also some patients on Medicare Advantage (the privatised part of US Medicare) and traditional Medicare. You can read more about the Accountable Care Organisation finance model here.

It claims to have achieved a 50 percent reduction in hospital admissions, a 52 percent reduction in emergency department visits, and a 35 percent reduction in the 30-day readmission rate to hospitals through what is described as stepping up the “dosage of primary care” that patients receive.

The NEJM article outlines how, in response to the coronavirus pandemic, Oak Street Health has moved most patients to a remote care model (currently 93 percent of the 2200 daily patient visits are done remotely via telehealth – one quarter via video and the remainder by phone) and the precautionary measures that have been put in place to ensure that this means patients with chronic and complex conditions get the care they need.

These include:

  • Using a team-based approach to telehealth care that mimics face-to-face appointments
  • Providing patients with items like digital thermometers and pulse oximeters
  • Drivers and vehicles normally used to transport patients have been turned into a delivery fleet for medical supplies, groceries and other necessities
  • During the transition to remote care, Oak Health teams made more than 5000 daily wellness checks to understand patients’ physical, mental and emotional needs an to screen for adverse social determinants of health
  • The healthcare service is also providing COVID-19 specific care that simulates a hospital stay and incorporates remote monitoring, daily rounds, and supportive care such as food delivery and social services.

Two final quotes from this report:

By picking up the phone and calling a patient you can practice a remarkable amount of medicine.

We are all seeing what happens when you let a fee-for-service healthcare system try to take care of everybody in a pandemic.”


Obesity – are there lessons from Brazil?

A study just published in the journal PLOS One shows a strong dose-response association between the intake of ultra-processed foods (UPFs) and obesity in the UK adult population. This dose response relationship was observed in both sexes; a 10 percent increase in the consumption of ultra-processed foods was associated with an 18 percent increase in the prevalence of obesity in men and a 17 percent increase in women.

The link between obesity and UPFs is not new, but as this paper points out, these findings contradict those of an earlier study using the same data sources but different food classifications, which found obesity was not associated with UPFs but with processed ingredients (defined as extracted and purified components of single whole foods – such as sugar, whey protein, lard).  Studies like this earlier one have been used by food manufacturers to help make their case that their products are not implicated in the obesity epidemic.

The PLOS One study was funded by a Brazilian foundation and Brazil has been a real pioneer in tackling obesity. (This is in stark contrast to what is currently happening in Brazil under President Jair Bolsonaro with coronavirus. And I’m not sure what Bolsonaro’s tenure means for obesity policies.)

You can read about the pioneer work of a Brazilian scientist Dr Carlos Monteiro on obesity and UPFs here. This article also discusses the multinational food industry’s efforts to dismiss Monteiro’s ideas about his food classification system (called Nova) and how UPFs are detrimental to our health. 

A Brazilian study published in April looks at the association between the price of UPFs and obesity. It finds that the price of UPFs is inversely associated with the prevalence of overweight and obesity in Brazil, mainly in the lowest socioeconomic status population. Such findings support the use of  taxation of UPFs as a prominent tool in the control of obesity.

In 2014, the Brazilian government, concerned about rising rates of obesity and associated chronic diseases, took the radical step of advising its citizens to avoid UPFs.  In radical new guidelines Brazilians were to avoid snacking, eat regular meals (in company when possible), learn how to cook and teach children to be “wary of all forms of food advertising”. The guidelines took the approach that whether a food is unhealthy is more about the degree to which it is processed than the fats, sugars and carbohydrates it contains.

In 2018 the Brazilian Ministry of Health has implemented a ban on the advertisement and sales promotion of UPFs. The ban was one part of a broader ordinance seeking to improve workers’ health, it also included offering only unprocessed or minimally processed foods in all establishments located within the premises of the Ministry of Health and related entities. 

At the same time, Brazil was also focused on eliminating hunger and malnutrition and addressing food security. A 2018 report from the UK-Brazil Learning Exchange on Food and Nutrition Security Policy project is here.

Are these policies working? I can’t find the data to say one way or the other, but I suspect the answer is “not well enough”. 

A 2018 survey found that although obesity appears to have plateaued, overweight continues to rise and the goals of reducing regular consumption of sodas and increasing consumption of fruits and vegetables had not been met.


On private health reforms, don’t hold your breath

Those of us who are optimistic that positive things may come out of this terrible time hope there will be a rethink and then a rework of the healthcare system/s. Many will argue this should involve scrutiny of the private healthcare system and private health insurance (PHI).

For example, my colleagues Professor Adam Elshaug and Professor Stephen Duckett have asked whether all those procedures that didn’t happen as a result of the ban on non-urgent surgery were even necessary. They believe Australia’s elective procedure system after the pandemic should be different from before the pandemic – and that there will be increased evidence to help dramatically reduce the number of low- or no-value procedures.

Recent news helps make the case for this sort of review of the private healthcare system. How optimistic do I dare to be?

It appears that some private hospitals and specialist doctors have not been in compliance with the Government’s orders that non-urgent (Category 3) surgeries should not be undertaken (a requirement imposed on March 25 and eased somewhat on April 26).

The Australian Health Practitioner Regulation Agency and state-based healthcare complaint bodies are investigating multiple reports of surgeons in private hospitals allegedly carrying out category 3 procedures after the ban came into effect.

This is pretty egregious given that private hospitals given a $2.6 billion lifeline to help them survive the elective surgery ban (money that some hospitals might now be forced to pay back) and the doctors involved would have billed Medicare and PHI funds for these services. The Federal Department of Health is using Medicare data-matching to detect any such suspicious activity at private hospitals. 

The president of the Royal Australasian College of Surgeons said any surgeons found to have breached the elective surgery ban by state or federal regulators would face sanctions under the college’s code of conduct. The president of the Australian Orthopaedic Association said he was concerned about surgeons within the specialty failing to exercise “restraint” under the restrictions. The issue has been referred to the association’s ethics committee.

It will be interesting to see if any actions are brought by federal and state and professional regulatory bodies. Don’t hold your breath!

Meanwhile, research from the Australia Institute finds that PHI funds stand to reap a windfall of between $3.5 billion and $5.5 billion due to a dramatic fall in elective surgery and other medical, dental and allied health procedures during the coronavirus crisis. The report also said that if premiums were cut in line with the downturn in services, the Federal Government would save $1-1.5 billion on the PHI rebate.

Health funds have given a commitment that any funds resulting from the cancellation of elective surgery and some allied health services will be returned to members.

Again, don’t hold your breath!

A study from Western Australia published in the Medical Journal of Australia highlights the considerable levels of, and marked variation in, out-of-pocket expenses for cancer patients in that state. It looked at the OOP costs for patients from outer metropolitan and rural areas with a range of cancers.

Ninety-eight percent of outer metropolitan patients and 95 percent of rural patients had OOP costs associated with their treatment. It is interesting to note that patients from outer metropolitan areas had higher OOP costs (ranging from $51 – $106,140, average $2,510)  than those from rural areas ($13 – $20,842, average $1,103).

This is  something that has been noted previously – despite the distance issues that confront rural patients. (Is there a link here with socioeconomic status? This was not explored by the authors.)

All patients with PHI had considerable higher OOP costs – on average, double of those who did not ($2510 vs $4670 for outer metropolitan patients; $1103 vs $2455 for rural patients).

As the paper points out, these findings once again highlight the need for easily accessible information about services, medical costs, and gap payments for all healthcare services and for new approaches to funding the range of treatments and care all cancer patients need.

The authors said:

The Informed Financial Consent website coordinated by the Australian Medical Association, consumer organisation fact sheets, and professional body initiatives are steps in the right direction, but their impact is yet to be determined.

Problems that still need attention in the unregulated private fee‐setting environment in Australia include price discrimination in some specialist sectors.

Bundles of care for cancer treatment that would allow patients and their families to better understand and plan for expenses should be explored.”

Once more: don’t hold your breath waiting on this!


The good news story

Many people around the world, but especially in the UK, have been following the fund-raising efforts of Captain Tom Moore. The war veteran has raised a phenomenal sum of money (32 million pounds and counting) for the National Health Service by walking laps of his garden.

For his recent 100th birthday, he was made an honorary colonel. The occasion was also marked with an RAF flypast and birthday greetings from the Queen and the prime minister.

“Reaching 100 is quite something. Reaching 100 with such interest in me and huge generosity from the public is very overwhelming,” he said. “People keep saying what I have done is remarkable, however it’s actually what you have done for me which is remarkable. “Please always remember, tomorrow will be a good day.”

A version of You’ll Never Walk Alone featuring Colonel Moore singing with theatre star Michael Ball and the NHS Voices of Care Choir quickly topped the music charts. You can listen here.

You can see his emotional interview on the BBC this week 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.

Previous editions of The Health Wrap can be read here.

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