Whether discussing the impacts of housing insecurity or restrictions on reproductive healthcare, it is women’s health and wellbeing that is often at most risk, reports Adjunct Associate Professor Lesley Russell.
In her latest column, Russell also investigates other structural inequalities including racism, and moves towards universal healthcare in South Africa.
And she shares details of new publications on antimicrobial resistance, nature therapy, COVID’s origins, the health impacts of austerity policies, and much more too.
The quotable?
Previous studies have demonstrated how experiencing homelessness or living in unsafe housing can impact patient health.
But this paper highlights that moving because the rent gets too high is linked to increased psychological distress, higher likelihood for emergency department visits, and lower likelihood of having preventive care visits.”
Lesley Russell writes:
The June 22 edition of The Lancet has a series that looks at global inequalities in diabetes. The accompanying editorial calls diabetes “a defining disease of the 21st century” and says: “The world has failed to understand the social nature of diabetes and underestimated the true scale and threat the disease poses.”
New estimates indicate that, worldwide, more than 1.31 billion people could be living with diabetes (primarily Type 2 diabetes) by 2050; that’s double the number in 2021 (529 million). By 2050, it is projected that between one in seven and one in eight people will be living with diabetes.
Most of this growing burden is attributable to a rise in obesity that is linked to our obesogenic environments, and the inequitable way resources and societies are organised and distributed.
Diabetes causes life-altering morbidity, high rates of mortality, and interacts with and exacerbates many other diseases. But Type 2 diabetes is largely preventable and, in some cases, potentially reversible if identified and managed early.
Follow this Twitter thread from Professor Tom Astell-Burt for a summary of The Lancet findings:
One of the papers in The Lancet series outlines the role of structural racism and geographical inequity in diabetes.
Sadly, it’s far too easy to see how this applies in Australia.
According to a report from the Australian Institute of Health and Welfare (AIHW), an estimated 1.3 million Australians were living with diabetes in 2020. Hospitalisation rates for diabetes in 2019-20 were almost three times higher for people living in remote Australia compared to those in major cities, and diabetes death rates were twice as high for people living in remote and very remote areas.
The diabetes prevalence rate in 2018-19 was 2.9 times as high among Indigenous Australians as non–Indigenous Australians. An excellent paper from 2021 outlines how racism has implications for health inequity for Aboriginal and Torres Strait Islander peoples.
Amidst these gloomy facts there is some good news. The Lancet series, in looking at best practice approaches to achieve equity in diabetes care and outcomes, chose Diabetes across the Lifecourse: Northern Australian Partnership as the case study to show how to effectively “change the ecosystem”.
The international diabetes “pandemic” is set to worse as research increasingly highlights the link between diabetes and COVID-19.
A German study has found a 28 percent increase in Type 2 diabetes in adults after COVID-19 infection. This research was supported by the results of a large study from Canada, published this year in JAMA Network Open.
More than a dozen studies have looked at the link between COVID-19 and diabetes, and a majority have reported an increase in diagnosis following infection, as well as higher risks for men and those with severe disease.
An American study involving data from 14 nations finds that children and adolescents have a 72 percent increased risk of developing Type 1 diabetes in the first six months after COVID-19 infection. These findings are supported by an observational nationwide study of 1.2 million Norwegian children in the first 2 years of the pandemic.
However, the causative links between COVID-19 infection and diabetes have yet to be determined. Experts said it was possible, for instance, that patients recovering from COVID were more likely to be diagnosed with diabetes simply because they were receiving more regular care.
Ongoing fight for US abortion rights
June 24 marked the one-year anniversary of the US Supreme Court’s Dobbs decision, which had the effect of denying American women the federal right to abortion that was believed to be enshrined in the Constitution under the 50-year old Roe v Wade decision.
See my Croakey article from June 2022: “As the United States Supreme Court inflicts a ‘catastrophic blow’ on women’s rights, what are the wider implications?”
The decision has had dramatic and heart-breaking ramifications for women and their healthcare providers. A patchwork of abortion policies has emerged across the country: where women live now dictates the medical advice and care they can receive.
Fifteen states have completely banned abortions or at six weeks of pregnancy, an additional five states have enacted bans at 12 to 18 weeks of pregnancy, and bans in other states are working their way through the courts or scheduled to go into effect soon.
An article in The Guardian, “A year ago Roe v Wade was overturned. Grieve for the new America”, describes what is happening as “a generational tragedy”.
In Scientific American, doctors discussed how abortion bans are impacting healthcare well beyond abortion; “One year after Dobbs, abortion bans are harming reproductive care, Ob-Gyns say”.
JAMA published an opinion piece on mounting obstacles to the care of pregnant women.
Another article, “A year later, doctors feel impact of Dobbs decision ‘every single day’”, quotes a doctor as saying “sometimes I feel that I am not able to fulfill the Hippocratic Oath”.
A recent report from doctors documented 50 cases of poor-quality medical care due to these bans.
There is also some good news here: a number of states have moved to protect abortion rights in various ways.
Eleven states have passed so-called “shield laws,” which can safeguard providers and patients against prosecution from other states. And at least 15 municipalities and six state governments allocated nearly $208 million to pay for contraception, abortion and support services.
In the 20 March, 2023 edition of The Health Wrap I wrote about the dreadful maternal and infant mortality statistics in the United States and how these will be further adversely impacted by the push to ban abortions and restrict access to reproductive health services. Most of this burden is borne by women of colour and poor families.
My articles for Inside Story provide some background to the June 2022 US Supreme Court decision:
Abolishing abortion has long been a litmus test for conservative politicians in the United States and the overturning of Roe v Wade has galvanised anti-abortion activists who want to go further in restricting (or even denying) abortion access and setting up new battles over abortion pills and contraception.
But the Dobbs decision also amped up the abortion rights movement and abortion is now part of the national political conversation like never before. This will be one of a handful of key issues in the 2024 elections.
President Biden and Vice-President Kamala Harris have held several recent events calling attention to the issue and tapping into the simmering rage. Biden warns that Republicans are not done with efforts to deny abortions.
Last week, in his latest executive action in response to the Dobbs decision, he issued a wide-ranging executive order aimed at ensuring and expanding access to birth control.
“Contraception is an essential component of reproductive health care that has only become more important in the wake of [the Supreme Court decision] and the ensuing crisis in women’s access to healthcare,” the White House said in a press release.
Homelessness and health
Our media outlets are daily concerned with the Australian housing crisis. Safe, stable, affordable housing is a key social (and economic) determinant of health.
Housing is a human right and a key social determinant of health and housing‐focused interventions have long been effective in protecting and improving population health and reducing health inequalities.
I recently spent some time looking at the health impacts of the burgeoning problem of finding affordable housing.
Housing is considered to be “affordable” when less than 30 percent of a family’s income is spent on renting or buying a residence.
Unaffordable housing creates financial strain for families, forcing them to choose between food, heating, medical care and other basic needs.
Habitat for Humanity Australia reports that the wellbeing of renters is below the normal range across Australian demographics, particular for older renters between 45-55 years old and single parents.
There is a raft of recent data on how the current housing crisis is affecting the mental health of Australians. This issue is highlighted in a recent report from the National Mental Health Commission, well summarised by my Croakey colleague Alison Barrett.
See also “Housing stress and the mental health and wellbeing of families” from the Australian Institute of Family Studies.
The 2021 Census (results released in March 2023) shows that young adults aged 19 to 24 years have the highest rate of homelessness of any age group, with 91 people of every 10,000 Australians aged 19–24 being homeless. Nearly one in four of all people experiencing homelessness (23 percent) is aged 12 to 24 years.
The Australian Housing and Urban Research Institute reports that while expensive housing costs have an impact on all segments of Australian society, younger adults and teenagers are affected particularly badly as they have fewer economic resources.
Females accounted for 81.7 percent of the 6,067 increase of people experiencing homelessness in 2021. Older women were more likely than men to be in supported accommodation for the homeless, staying temporarily with other households or living in severely crowded dwellings.
Housing is well-recognised (if not well addressed) as a major issue for Aboriginal and Torres Strait Islander people. But although the majority of Indigenous Australians live in urban areas, most of the focus on housing and its relationship with health has on remote communities.
A 2016 paper explored the views of Aboriginal people living in Western Sydney about their housing circumstances and the relationships they perceived between housing and health. Sadly, we can be certain that the situation has not improved since then.
In a paper on the commercial determinants of health recently published in The Medical Journal of Australia, the authors posed the question about Australia’s vision for housing: should it be a wealth creation tool or a social benefit?
With their support for the latter, they called for social housing and minimum standards in the rental sector to be part of a public health prevention strategy to improve people’s health.
In an accompanying interview with InSight+, co-author Professor Rebecca Bentley, Director of the National Health and Medical Research Council Centre of Research Excellence in Healthy Housing, said that the scale of wealth generation linked to Australian housing makes it a critical commercial determinant of health.
An American study, published in JAMA Network Open, highlights a very particular element of housing instability as a social determinant of health.
Previous studies have demonstrated how experiencing homelessness or living in unsafe housing can impact patient health. But this paper highlights that moving because the rent gets too high is linked to increased psychological distress, higher likelihood for emergency department visits, and lower likelihood of having preventive care visits.
(Also see Croakey’s extensive archives on housing and health).
Universal healthcare for South Africa – maybe?
After many years of discussion and effort, the South African parliament has passed a National Health Insurance Bill.
Delivering affordable healthcare for all his people was a key item on the late President Nelson Mandela’s to-do list; it has taken some 30 years to achieve this.
I was once told (but have been unable to verify this) that Mandela thought universal access to education should come before universal access to healthcare – although I’m not sure even the former has been achieved.
It has been a long and difficult road to the enactment of this enabling legislation and the task is far from complete.
Healthcare reforms and increased affordability are sorely needed. South Africa has a relentless burden of infectious and noncommunicable diseases, persisting social disparities, and inadequate human resources to provide care for a growing population with a rising tide of refugees and economic migrants.
South Africa (0.7 percent of the world population) has 17 percent of the global burden of HIV/AIDS and human immunodeficiency virus (HIV) infection and one of the highest tuberculosis burdens in the world. Diabetes is the leading killer of women in South Africa and second highest for men. There are severe mental health and suicide problems, and alcohol abuse is rife.
South Africa currently has a two-tiered and highly unequal healthcare system: the state-funded public sector caters to the majority of the population but is under-resourced and severely strained; the expensive private healthcare system is largely funded through individual contributions to private health insurance.
The Bill will provide universal healthcare by buying services from health professionals through a National Health Insurance fund that will then be delivered at private and public facilities. The details of financing and the benefits package for the Bill are yet to be determined and the tax increases to support this are likely to be high.
You can read more about how the new health insurance mechanisms will work in this article in The Lancet.
There seems to be a fair amount of scepticism (or is opposition a better word?) about this effort, as this media article indicates.
It states: “In a way it’s a win for reducing inequality in both directions: the poor get better healthcare, and the rich get worse.” And see the tweet below.
In case you missed it
• The World Health Organization (WHO) has published its first global research agenda to combat antimicrobial resistance (AMR). The agenda outlines 40 research priorities. (Note that tackling AMR is one of 13 Medical Research Future Fund priorities for 2022-2024.)
• The US Office of the Director of National Intelligence has released a declassified version of its report “Potential Links Between the Wuhan Institute of Virology and the Origin of the COVID-19 Pandemic”. The report finds no clear evidence that COVID-19 originated from the Wuhan laboratory.
• In The Guardian: Nature prescriptions: how reconnecting with the landscape healed a bushfire-ravaged community. This article describes how, three years after the black summer fires, Snowy Valleys council launched a nature trail to help residents work through their grief.
• A recent report, published in Nature, from the Non-Communicable Diseases Risk Factor Collaboration has collated national height measurement data for children in 200 countries at the ages of five and 19 between 1990 and 2020.
There are two key take outs from this report:
- The average height of urban children and adolescents in wealthy countries such as the US and France is now slightly shorter than that of their peers in rural areas. Read more here.
- British children are slipping down the global rankings. The most pronounced decline is among children born since David Cameron’s Conservative-Liberal Democrat coalition government launched its austerity programme in 2010.
Experts have said a poor national diet and cuts to the National Health Service are to blame. But they have also pointed out that height is a strong indicator of general living conditions, including illness and infection, stress, poverty and sleep quality.
• A systematic review and meta-analysis of 90 cohort studies of social isolation, loneliness and mortality. Published in Nature Human Behaviour. This paper found that social isolation and loneliness is significantly associated with an increased risk of all-cause mortality.
• Communication and engagement of community members from ethnic minorities during COVID-19: a scoping review. Published in BMJ Open. This review examines the factors influencing communication and engagement with ethnic and racial minority groups in Australia during the COVID-19 pandemic.
The papers reviewed highlighted the key role of community organisations in providing local support and community leaders as trusted spokespersons.
Key recommendations to reduce inequity and strengthen future pandemic responses focused on the need for collaborations and consultations, increasing the number of bilingual workers, and supporting community-led communication efforts.
• And finally, definitely linked to the previous paper, an ABC News story about how Victoria Police has been accused of racial profiling, with newly released data revealing people of African or Middle Eastern appearance received a disproportionate number of COVID-19 fines in the first year of the pandemic. Read the full story.
Best of Croakey
These recent articles highlight the wide-ranging ways that the commercial determinants of health operate and shape our environments.
Read: Critical pandemic lessons: prioritise public good over private profits 
Read: Concerns raised about KPMG conducting National Health and Climate Strategy consultation
The good news story
My choice this week, about the efforts over a decade to extract and understand an Indigenous language from the Peruvian Amazon from its last lucid speaker, is best classified as a sad good news story.
Linguist Roberto Zariquiey has been meeting with Nelita Campos for more than a decade to record all she knows of the Iskonawa language. I was alerted to this effort by a story in the Washington Post.
There is some background to this work here.
The University of Texas has an interesting on-line Iskonawa cultural collection you can access 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.
