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The Health Wrap: fixing poverty, deaths of despair, lessons from Bangladesh and pandemic matters

As the Australian Council of Social Service and other groups highlight the political risks for Government MPs of impending welfare payment cuts, the latest edition of The Health Wrap looks at the health impacts of poverty.

Associate Professor Lesley Russell also reports on a randomised controlled trial in the Californian city of Stockton, where unconditional cash grants were given to randomly selected residents from poorer neighbourhoods.

The findings “highlight how this simple, non-judgemental solution to poverty and inequality can improve job prospects, financial stability and overall health and wellbeing and provide the dignity and agency everyone deserves,” Russell writes below.

The Health Wrap also reports on a range of other recent publications.


Lesley Russell writes:

With World Obesity Day (March 4) just gone (see relevant Croakey article here), this is a timely topic to explore, and a new report finds that most coronavirus deaths have occurred in countries where the majority of adults are overweight.

The report, by the World Obesity Federation (WOF), found that 88 percent of COVID-19 deaths in the first year of the pandemic were in countries where more than half of the population is classified as overweight (a body mass index (BMI) above 25) and obesity (defined as BMI above 30) is associated with particularly severe outcomes. A higher BMI is associated with increased risk of hospitalisation, admission to intensive care, and the need for mechanically assisted ventilation.

The highest death rates are seen in countries like the United Kingdom, Italy, Portugal, Belgium and the United States, where obesity rates are high; the lowest rates are in African and Asian countries where obesity rates are low. An article in The Guardian has some useful data.

The WOF findings were near-uniform around the world and found that increased body weight is the second greatest predictor (after old age) of hospitalisation and higher risk of death. The “dose response” relationship between obesity and severity shown in this study is particularly compelling.

Other research from Johns Hopkins indicates that obesity shifts severe COVID-19 disease and mortality to younger age groups.

A large new study in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report of nearly 150,000 adults at more than 200 hospitals across the United States paints a more detailed picture of the connection between weight and COVID-19 outcomes.

It confirms the findings of the WOF report. Patients with a BMI of 45 or higher, which corresponds to severe obesity, were 33 percent more likely to be hospitalised and 61 percent more likely to die than those who were at a healthy weight.

The connection between obesity and poor outcomes is strongest for patients under 65 but holds even for older adults. At the same time, patients who were underweight, with a BMI below 18.5, were 20 percent more likely to be hospitalised than those who had a healthy weight. The reason is not clear but may relate to the fact that these patients are likely to be malnourished, frail or have other diseases.

The website of the WOF has a lot of interesting information on coronavirus and obesity. It highlights some issues that are not often discussed:

  • People with obesity who become ill present challenges in patient management – they are more difficult to transport, position and intubate and it can be challenging to obtain diagnostic imaging. In general, healthcare systems are not well set up to manage patients with obesity.
  • The measures to control the pandemic might contribute to the obesity problems. The need for self-isolation can restrict many exercise programs and opportunities and is prompting many people to rely more on processed and canned foods instead of fresh produce. The economic impact means that some people have less income to spend on food and exercise.

This article from Bloomberg highlights how the pandemic has exacerbated food poverty in the United Kingdom and the links between food poverty and obesity.

Last year the United Nations Food and Agriculture Organization warned that obesity is a “global pandemic in its own right” and achieving the goal of zero hunger by 2030 was in doubt.

The Director General of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, said the WOF report must act as a wake-up call to governments globally to tackle obesity and the poor health it causes.

He said:

The correlation between obesity and mortality rates from COVID-19 is clear and compelling.

Investment in public health and coordinated, international action to tackle the root causes of obesity is one of the best ways for countries to build resilience in health systems post-pandemic: we urge all countries to seize this moment.”


Pandemic impact on vulnerable Australians

Good Shepherd Australia New Zealand has recently released a report that looks at the impact of the pandemic on vulnerable Australians. It’s comprehensive, well put together and uses data from a variety of sources.

The pandemic has presented a complex economic and social situation and that has meant that the experiences and needs of the people Good Shepherd serves are also complex. There has been a fundamental change in disadvantage in Australia, with large numbers of new cohorts relying on social services for the first time in their lives.

The report sees some positives – the federal Coronavirus Supplement effectively doubled the income of some people, with positive effects on health and wellbeing. But economic wellbeing remains elusive for many, especially as this additional income is now disappearing.

Negative impacts include not just those on employment and financial security but also concerns about women’s safety and an increase in coercive control tactics, long-lasting mental health effects, and eroding worker protections.

While negative economic impacts from the pandemic have been felt across the board, the data clearly demonstrate lower-income households are over-represented among those experiencing new vulnerabilities.

The findings of this report highlight how readily some segments of Australian society might slip into the “deaths of despair” situation reported below.

The community services sector is bracing for an emerging “tsunami of need”. The Good Shephard report calls on Australian governments to ensure that those households most impacted by the economic downturn will be supported to re-join the economy as it adapts to new realities. It also calls for budgets and economic policies that are gender-responsive and consider the wellbeing needs of priority cohorts.

Infographic from report

These are timely issues as the Federal Budget looms and a number of reports on International Women’s Day have highlighted the disproportionate impact of the pandemic on women.

See for example:

ACTU report: IWD2021 – Reality Check for Australian Working Women

Grattan Institute report: Women’s Work: the impact of the COVID crisis on Australian women.


America’s epidemic of despair

I’m using beach time to catch up on that pile of New Yorkers that always sits on my bedside table; one good thing about this magazine is that even when read a year later there is always something relevant.

Last week I found a piece from Atul Gawande on the epidemic of despair that is consuming the United States. It aligns well with my recent article for Inside Story on declining life expectancy in some of the world’s richest countries.

The term “deaths of despair” was coined by two economists Anne Case and Angus Deaton (they just happen to be a married couple) in a paper that they initially struggled to get published. (Ironically, just a few weeks before it was eventually published in Proceedings of the National Academy of Sciences in November 2015, Deaton was awarded the Nobel Prize for economics.)

Their research linked declines in self-reported health (including mental health) and the ability to work, together with growing numbers of suicides and increased reports of pain, with a  marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women between 1999 and 2013.

The paper put numbers to the sense that for many Americans, something had gone profoundly wrong with the American Dream, and once it was published, it drew the sort of public response seldom seen for economic research.

It’s interesting that it was around this time (late 2015) that Donald Trump started to cut though in his presidential campaign which was so appealing to the population most likely to experience these deaths. A county-by-county analysis of death rates, causes of death and voting patterns shows that the death rate was nearly 8 percent higher between 2000 and 2015 in counties where Trump won the majority in 2016.

Gawande’s article takes us through how Case and Deaton, in their book “Deaths of Despair and the Future of Capitalism”(out last year), looked for explanations.

Here’s what they find:

  • The oversupply of opioids did not create the conditions for despair but rather played havoc with the lives of white, less educated Americans who were already adrift.
  • These deaths are not related to obesity, which causes an increase in chronic illness and joint pain.
  • It’s tempting to see a connection with poverty, but Black and Hispanic populations are poorer and less affected. California and New York have among the highest income inequality levels in the country and the lowest mortality rates.
  • A consistently strong economic correlate is the percentage of the population that is employed – this holds true even when suicide rates, drug overdoses and alcohol-related liver disease are taken into account. Employment rates have been in long decline and wages have stayed flat for years, and those hardest hit are white Americans with no college education.

Too often the conservative response to this is that people are lazy and choosing alcohol, drugs, welfare and disability support over work and so lawmakers look to restrict benefits and impose work requirements on programs like Medicaid – as happened during the Trump Administration.

Case and Deaton identify the factors that make the steep rise in “deaths of despair” uniquely American (although something similar has been seen in Russia after the collapse of the former Soviet Union).

These include what Gawande sees as “unusually casual access to the means of death” – references to the opioid crisis; the loss of jobs from automation and globalisation with few supports for displaced workers; and the complicated and costly healthcare system, where access to affordable healthcare insurance often depends on employment.

To date the American federal response has been to pour resources into addiction treatment and suicide prevention programs – something Gawande describes as “using pressure dressings on a bullet wound to the chest instead of getting to the source of the bleeding”.

Gawande sees American culture as a harsh judge of those whose lives aren’t going well, with intimations that somehow it’s their fault. We see this approach too often in Australia. It’s important to realise that poverty is not a personal choice but a reflection of society.

Case and Deaton go further, writing that capitalism has failed less educated workers for decades. Gawande’s conclusion is that the blighted prospects of the less educated are a public health crisis and an unfairness measured in dollars and deaths.

Coincidentally, the US National Academies of Sciences, Engineering and Medicine has just released a report that looks at rising death rates among middle-aged and younger Americans (25-64 years) using data from 1990-2017. It finds that this population has been dying at higher rates since 2010, and that deaths of working-age Americans from drug overdoses and hypertensive heart disease have been climbing since the 1990s.

The report documents what it calls “a public health crisis” sweeping the American workforce, with profound implications for families, employers, and the economy. It calls for an urgent national response and outlines the elements of this response.


Getting people out of poverty

In both Australia and the United States there are current political debates about addressing the increase in poverty and inequality highlighted by the coronavirus pandemic.

The Morrison Government has announced a permanent increase in JobSeeker payments of $50 per fortnight – just $3.57 per day – when the coronavirus supplement expires at the end of March. However, recipients will now face additional “mutual obligations”, including additional job searches, face-to-face appointments with employment services, intensive training after six months on welfare, and more paperwork for some recipients.

It’s worthwhile pointing out that Senator Anne Rushton, the minister responsible for families, welfare and the unemployed, has previously stated that that raising the Newstart allowance (forerunner of JobSeeker) would do “absolutely nothing” but likely give more money to pubs and drug dealers. Has she now changed her opinion on this?

In the United States, President Biden has just had his first major legislative success with the enactment of the American Rescue Plan Act of 2021 – done without a single Republican vote despite the fact that 76 percent of Americans (including 60 percent of people who identify as Republican) think this is a good idea.

This US$ 1.9 trillion Covid-19 relief and stimulus package will provide $300 a week in jobless aid through to September and provide cash infusions of several thousand dollars for families.

But it does not include a provision that Biden wants that would see the minimum wage increase to US$15 per hour. That will be separate legislative fight. The current minimum wage, which was set in 2009, is US$7.25 per hour.

In light of the debates yet to come around the issue of helping the poorest citizens in some of the wealthiest countries, it’s interesting to look at the impact of a program that just gave them money, with no strings attached.

The Stockton Economic Empowerment Demonstration (SEED) was established in 2019 by the Stockton mayor who, with support from donors, gave 125 randomly selected residents US$500 a month for two years. The cash was completely unconditional, with no requirements of the recipients.

The findings from the first year have just been released and they highlight how this simple, non-judgemental solution to poverty and inequality can improve job prospects, financial stability and overall health and wellbeing and provide the dignity and agency everyone deserves.

Among the key findings of the first year (to February 2020, just before the pandemic hit California) are that the unconditional cash reduced the month-to-month income fluctuations that poor households face, increased recipients’ full-time employment by 12 percentage points and decreased their anxiety and depression, compared to the control-group.

Individuals spent most of the money on basic needs, including food, utilities and transport costs, with less than one percent going to alcohol and tobacco. It furthered recipients’ ability to cover unexpected expenses.

The study also found that the guaranteed income created increased opportunities for self-determination, choice, goal-setting, and risk-taking. Its effect was felt across family networks and relationships.

Critics of such programs worry they eliminate the incentive to work. But there is no evidence to support this. There are a number of other such pilot programs underway in American cities, many sponsored by a group called Mayors for a Guaranteed Income.

The value of such programs is increased during these pandemic times so the final report from SEED will be even more interesting. Also critical will be assessing what happens to recipients now SEED has concluded.

By the way – Mayor Tubbs who introduced this program in Stockton lost his re-election bid last November to a Republican. Critics say voters rejected him because of problems in the city including poverty and homelessness and a sense that Tubbs was more interested in national affairs than local ones. A reminder that no good deed goes unpunished – at least in politics!

Image via Stockton Economic Empowerment Demonstration (SEED) website

Lessons from Bangladesh

As I was writing this edition of The Health Wrap, I happened to read a column in the New York Times from Nicholas Kristof (always worth reading).

He starts out by noting that the most important and historic provision in Biden’s American Rescue Plan is the effort to address child poverty (what Kristof calls “one of the great moral stains” on the United States) with an expansion of the child tax credit to provide up to US$3,600 to families for each young child.

A Columbia University study suggests that if these measures were made permanent – a long-overdue recognition that all of society has a stake in investing in poor children – child poverty in the United States could fall by half.

Kristof thinks Biden’s efforts could ultimately do for child poverty something like what FDR’s Social Security plan did for poverty among senior citizens.

And then he pivots to Bangladesh, a country born 50 years ago this month amid genocide, squalor and starvation. Life expectancy in Bangladesh is now 72 years. That’s longer than in quite a few places in the United States, including, for example, 10 counties in Mississippi.

He sees much that Bangladesh can teach the world – including the United States (and perhaps Australia?) – about how to engineer progress. He makes the case that the secret to Bangladesh’s progress is education of girls (and maybe micro-financing for women).

In the early 1980s, fewer than one-third of Bangladeshis completed elementary school and girls were rarely educated. Today, 98 percent of children in Bangladesh complete elementary school.

Still more astonishing for a country with a history of gender gaps, there are now more girls in high school than boys. This has transformed the status of women in the country and helped lift 25 million Bangladeshis out of poverty over 15 years.

Kristof’s point in that Bangladesh invested in its most under-utilised assets – its poor, with a focus on the most marginalised and least productive, because that’s where the highest returns would be. And he says that the same could be true in America (where one in seven children don’t graduate from high school).

I like to think that this approach – investing in the poorest and most marginalised groups – would also deliver Australia huge returns on that investment and make us much more genuinely a society of the “fair go”.


Edging closer to a National Preventive Health Strategy

In the “good news” category – the draft National Preventive Health Strategy has been released for comment. My Croakey colleague Melissa Sweet has done a great job of summarising it here.

Some of the gaps are also summarised here by Fiona Armstrong, executive director of the Climate and Health Alliance.

As I told Melissa, my concern now goes to the implementation and funding of the strategy, particularly so because Health Minister Greg Hunt has yet to show any interest in advocacy around this (I can find nothing in his media portfolio about the release of the draft and the short time frame provided for comments).

When I worked for the US Surgeon General during the Obama Administration, our office, together with the CDC, was responsible for convening the National Prevention Council set up under the Affordable Care Act (Obamacare) and overseeing the implementation of and reporting on the Action Plans that were part of the National Prevention Strategy (NPS).

This of course disappeared under the Trump Administration, but it offers a great example of a whole-of-government led approach to prevention, the establishment and development of partnership across government, business and community sectors, and annual reporting of progress and outcomes.

You can read the 2015 progress report (the last one) here and earlier progress reports are available here.

Almost certainly this is not the way Australia wants to proceed, but it does highlight what can be done and the key roles that government departments with responsibilities as diverse as health, defence and labour can play in prevention.

There is a good summary of the work of the NPS in leveraging multiple sectors to improve population health, written by former colleagues in the Office of the US Surgeon General and at CDC, in a paper published in the American Journal of Public Health in 2015. In 2018 the Annual Review of Public Health published a summary of prevention efforts under Obamacare.

In February, former CDC Director Dr Tom Frieden, summarised on his blog a paper he wrote some years ago where he outlined the six components of effective public health implementation.

He sees these as:

  1. Innovation
  2. Proven interventions
  3. Management, tracking performance
  4. Partnerships
  5. Communication
  6. Political commitment.

He summarises it this way:

To implement public health programs effectively, it’s essential to get the science right – this leads to having an appropriate technical package and innovating to improve that package continuously.

And it’s also essential to manage well, including communicating effectively and creating coalitions. But unless the politics is aligned, even the best designed and best managed public health programs will fail.”


In case you missed it

The Lancet reflects on 50 years of the Inverse Care Law here.

John Menadue writes in Pearls and Irritations on why dental care was originally excluded from Medicare – and why it should now be included.

The Lancet Global Health Commission on eye health: vision beyond 2020 here.


The best of Croakey

The experiences of people with hearing loss are informing efforts to drive wide-ranging societal changes, reports journalist Cate Carrigan for the Croakey Conference News Service from the recent launch of Soundfair’s HearMe Project report.


The good news story

I wanted to share a recent story in The Guardian about how, after  two decades walking an “ethical tightrope” in banking, Kate Woods retrained to become a pharmacist and moved to the remote East Kimberley.

She says “the people of the Kimberley – both patients and healthcare team – make it such a rich and rewarding experience”.

Never too late: ‘I had to throw out everything I knew and start again’ | The Guardian


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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