In her latest column, Adjunct Associate Professor Lesley Russell investigates the trauma of gun violence in the United States, where it is easier to buy a gun than to adopt a dog in at least one state.
Health technology assessment, the ongoing COVID toll, an under-discussed complication of pregnancy, and treatment of drug overdoses are also covered. Watch for the eye-rolling.
Lesley Russell writes:
In the wake of last week’s shooting in Nashville, which killed three primary school student and three adults, the United States is yet again going through a period where gun opponents are angry and sad and demanding action, while gun proponents offer thoughts and prayers and indicate that nothing more can be done, because gun ownership is a constitutionally given right and part of American “freedom”.
President Joe Biden has described gun violence in the US as an epidemic and an international embarrassment. In April 2021 he announced some modest but significant efforts to address gun violence but partisan politics at both the federal and state levels is hindering progress on these.
An opinion piece in The New York Times summed up the situation:
We should judge a nation by a simple metric: the number of weeping parents it allows, the small coffins it tolerates. The debate around gun control is not new, of course, and each tragedy brings a fresh wave of calls for common-sense gun regulation.
The adversaries of reform will rebuke us for turning a tragedy, the deaths of six innocent people, into an occasion to debate politics. We will be urged to offer prayers for the victims and their families while we await the appropriate time to discuss the more difficult issues. But too often it seems that rather than waiting for the right time, politicians are simply trying to wait out the news cycle.”
So, inevitably in the face of inaction, mass shootings continue to rise across the nation. Data from the Gun Violence Archive show that in the first three months of 2023 there were 131 mass shootings and 10,325 gun-related deaths, of which 417 were children and teenagers.
Mass shootings are so common that survivors of one are now sometimes finding themselves impacted by another, offering a devastating portrait of compounding trauma.
American children and teens are more likely to die by guns than any other cause.
In Australia, motor vehicles are the primary cause of death for this age group, although it is somewhat disturbing to see firearms as the 11th cause of death.
An analysis published in 2018 showed that there were more privately-owned guns in the United States than people; 393 million guns which equates to 120 guns for every 100 people. Gun-owning households (42 percent of all households) had an average of eight guns each.
What makes the situation worse is that gun-buyers are increasingly purchasing AR-15 style weapons that inflict dreadful damage on the human body, especially that of a child. The doctors who treat the victims of mass shootings say they are haunted by their experiences confronting injuries so dire they struggle to find words to describe them.
New York Times journalist Nick Kristoff makes the point that it is far too easy for people seeking to do harm to others or themselves to purchase guns.
He compares the process for adopting a dog in Mississippi (a 64-question form; in-person meeting with entire family; approval from landlord if renting; property inspection; a trial sleep-over) with what is required to buy a gun (not obviously under-age or drunk; a brief background check – you can access the form here).
And he asks the obvious question: why is it easier to buy a gun than to adopt a dog?
Australia is often held up as an exemplar for national gun control, but my investigation of actual numbers of firearms makes me concerned: the country has 14.5 guns per 100 people. That means Australian civilians now own more than 3.5 million registered firearms, an average of four for each licensed gun owner. Most guns used in crimes are stolen and/or illegally purchased.
The good news is that the proportion of Australians who hold a gun licence has fallen by 48 percent since 1997 and the proportion of Australian households with a firearm has fallen by 75 percent. These data indicate that people who already own guns have bought more rather than an increase in new gun owners.
End of the COVID-19 pandemic – or not?
Like gun violence and Donald Trump, there is one other topic that shows no signs of disappearing – despite what some politicians would have us believe – and that is the impact of the COVID-19 pandemic.
As the most recent data on COVID-19 deaths makes plain, the pandemic is continuing to claim too many Australian lives (see tweets below from Professor Adrian Esterman and Professor Kathy Eagar).
See also these recent articles in Croakey Health Media:
In an article published recently in the BMJ, my Croakey colleague Alison Barrett reported that Health Minister Mark Butler says Australia needs to “learn the lessons” of the latest COVID-19 wave, which has lasted longer than expected (it began in late October 2022 and is now thought to be nearing its end).
“It is my intention to make sure that we learn the lessons of the past few months and constantly make sure that the response that all governments, including the Commonwealth, put in place to deal with what inevitably will be the next wave of COVID sometime over the course of 2023 is aligned with the best understanding and the best evidence,” he said.
I fear too many of us, driven to cynicism by experience, are rolling our eyes at that statement.
However, on 30 March the Commonwealth Chief Medical Officer, Professor Paul Kelly, released his report, Lessons from the Fourth Omicron COVID-19 wave.
This is a modest six-page document that strikes me as a fairly complacent take on where Australia currently finds itself and what the future might bring.
It does say this about what 2023 might bring:
The Australian community will continue to experience waves of COVID-19 infection, which may put pressure on health systems and result in deaths. The next wave may coincide with the winter season, and while COVID-19 is not a seasonable disease there is a risk that co-circulation with other seasonal respiratory viruses such as influenza and respiratory syncytial virus (RSV) might occur, as has been seen in the recent Northern Hemisphere winter.
This makes winter a much more dangerous time, especially for older Australians and people with complex health conditions. Preparations are underway ahead of the Australian winter to ensure our system is well prepared to manage such an eventuality, building on the substantial work from 2022.”
I think many public health experts wonder just what these “preparations” and “substantial work” encompass.
In the United States, the Biden Administration acted in January to renew the COVID-19 public health emergency because “there’s still a lot of COVID out there, and the public health emergency and his determination gives us tools to fight this.” This emergency declaration is expected to end on 11 May 2023.
However, several major relief measures are now decoupled from the public health emergency. This includes the requirement that prevents states from disenrolling Medicaid recipients as long as the public health emergency is in effect (in exchange for an enhanced federal match) and enhanced food stamp benefits. These changes are expected to cause confusion and hardship for many.
One of the areas where the United States is leading the way is in the analyses and critiques of pandemic management and in efforts to improve readiness for the nest pandemic – which many fear will be a strain of H5N1 bird flu.
A very substantial observational analysis just published in The Lancet, Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from January 1, 2020 to July 31, 2022, looks at why the United States struggled in responding to the COVID-19 pandemic, and why not all states struggled equally.
The findings of this paper are well summarised in an article in Axios, Why America was uniquely vulnerable to COVID.
The policy mandates and protective behaviours adopted were effective in reducing SARS-CoV-2 infections but might have been associated with employment and educational trade-offs.
The more robust a health system, the better a state performed in the pandemic, but only in states where the public was willing to make use of healthcare services for vaccination or to get early treatment for their conditions.
States with more mandates (such as mask use, mobility restrictions and vaccination), and which kept them longer, experienced lower infection rates.
Only vaccine coverage had a strong association with the state-by-state variation in COVID death rates.
“Ultimately our public health policies seem capable of preventing transmission, but other societal factors like poverty, education attainment, and access to high-quality healthcare might have muddled the response and led to death rates being highest in some states that didn’t have tremendously high infection rates,” the authors wrote.
This is exemplified in my US home state of Colorado (which ranked #3 in healthcare in 2022), which recorded the fifth-most COVID-19 deaths in the nation when adjusted for age and comorbidities at 473 per 100,000 people. The state trails only Arizona, Washington, DC, New Mexico and Mississippi.
Australian public health experts would surely agree with these findings, despite the stark differences between how Australia and the United States handled the pandemic.
There was one recommendation in the paper – that there should be further study of how the impact of trade-offs (like disruptions to employment and education) could inform future protective measures – that I thought should be examined in the Australian context.
The March 2023 edition of Health Affairs is devoted to papers that focus on lessons learned regarding public health during the COVID-19 pandemic. Articles include an examination of the relationship between public health and medical care, the legal framework for public health interventions, and infrastructure needs.
Two papers particularly caught my interest for their applicability to Australia.
The first argued that chronic under-investment in the public health system can only be addressed if we do a better job identifying how much is spent and what the returns are on this investment. The authors note that “with greater funding follow, naturally and appropriately, calls for greater accountability.”The second paper proposed that future pandemics should be addressed through the use of a Community-based Outbreak Investigation and Response (COIR) framework.
COIR is a local public health strategy that integrates effective surveillance and a coordinated response by community partners with emphases on building trust and achieving equity.
Hyperemesis gravidarum finally gets some attention
A recent article in The New York Times on how her own pregnancy experiences drove a Californian clinician and researcher to coordinate an effort to understand hyperemesis gravidarum (a condition whose hallmark symptoms include nausea and vomiting so severe and relentless that it can cause dehydration, weight loss, electrolyte imbalances, hospitalisation and pregnancy loss) made me realise how little this topic is discussed in the medical literature – and I’m pretty certain it has never been mentioned in Croakey Health Media.
This complication affects about two percent of pregnancies and its consequences can be devastating. In surveys, women have described their experiences with the condition in harrowing terms.
But doctors are often slow to treat it, sometimes dismissing it as a temporary discomfort or even a psychological disorder. It is suggested that one reason hyperemesis is under-researched and insufficiently recognised is because about 70 percent of pregnancies come with some degree of nausea and vomiting.
Before IV fluids became routinely available in the 1900s, hyperemesis often killed pregnant women. It is postulated that it may have caused the death of the pregnant Charlotte Bronte.
Electrolyte imbalances caused by excessive vomiting and dehydration can bring about heart arrhythmias and cardiac arrest. Hyperemesis is also linked with a higher risk of pregnancy complications including preterm birth, pre-eclampsia and blood clots. A 2022 study found that hyperemesis is one of the main predictors for postpartum depression.
Most babies born from hyperemesis pregnancies are healthy, but there is a small risk of low birth weight and developmental delays likely due to malnutrition and stress in the womb.
In 2011, the work of the California researcher mentioned above showed that there was a genetic link for this condition: women who had sisters with hyperemesis had a 17-fold higher risk of developing the condition than those who didn’t. In 2018, these same researchers discovered two genes, both known to be involved in placentation, appetite, and cachexia, that were associated with hyperemesis.
Just last year, a further study showed that variants in one of these two genes, known as GDF15, were strongly linked to the condition.
Improving the diet of Indigenous Australians to help manage type 2 diabetes
A new study will test whether diets that closely resemble those consumed by First Nations people in pre-colonisation times can help drive type 2 diabetes remission in Indigenous people.
The research, led by Ngarrindjeri elders in South Australia’s Coorong, along with Flinders University and the Riverland Mallee Coorong Local Health Network (RMCLHN), will use a ketogenic diet to boost health outcomes.
Ketogenic diets call for fewer carbohydrates so that fats become the primary source of energy. You can read more about this study and how local communities are involved here.
This is an area that Professor Kerin O’Dea (now Emeritus Professor at the University of Australia) has spent many years researching, beginning in the 1980s. You can read a 2012 article about her work here.
One of her early studies involved working with a group of largely diabetic or pre-diabetic Indigenous Australians to encourage them to adopt a so-called hunter-gatherer lifestyle, where three foods – kangaroo, freshwater fish and yams – made up 80 percent or more of their diet.
She was able to show marked improvements in the carbohydrate and lipid metabolisms that are linked to insulin resistance in the participants after just a seven week period.
In remote regions of Australia, where traditional foods are widely available, Aboriginal and Torres Strait Islander people are recognised as being most at risk of food insecurity. The association between food security in these regions and the access, availability and use of traditional food by Indigenous people and their food preferences needs better exploration and understanding.
Many First Nations scholars, community members and businesses are working to promote traditional foods, which are an important aspect of the cultural determinants of health, as noted by a Lowitja Institute report on the cultural determinants of health in 2020. Researchers have found that connection to culture, particularly via traditional foods, is associated with positive health and wellbeing.
Improving the diet of African Americans to help reduce colon cancer rates
Now a nifty segue to an interesting study, reported in Nature, that highlights the benefit of persuading African Americans and rural South Africans to switch diets.
Rates of colon cancer are much higher in African Americans (65:100,000) than in rural South Africans (<5:100,000). The higher rates are associated with higher animal protein and fat, and lower fibre consumption.
The research involved two-week food exchanges, where African Americans were fed a high-fibre, low-fat African-style diet and rural Africans a high-fat, low-fibre western-style diet, under close supervision.
The food changes resulted in remarkable changes in mucosal biomarkers of cancer risk such as inflammation and in aspects of the microbiota and metabolome known to affect cancer risk.
While clearly more longitudinal studies are needed, these results provide some evidence that an increase in fibre consumption, together with a moderation in fat intake, may reduce the disproportionately high incidence of colon cancer in African Americans and indeed in most westernised communities.
What’s happening with the Health Technology Assessment Review?
The Government is supporting and resourcing a HTA Policy and Methods Review that was part of the 2022-2027 Strategic Agreement between the Commonwealth and Medicines Australia (this was done under the Morrison Government).
The terms of reference are here. The review was originally supposed to be completed by June 2023 with implementation of the findings by July 2024, but the HTA Review Reference Committee webpage appears to indicate that this work will now run until 31 December, 2023.
The last such review was done in 2009.
This new review potentially has some major consequences for industry, government regulations and financing, and the cost and availability of medicines, vaccines and medical devices. But there is little to tell us what is happening.
The HTA Review Reference Committee webpage has meeting agendas and communiques for 2023, but nothing for earlier work. There is also a Probity Plan, which was released (apparently unheralded) on 9 March 2023. The aim of this is to ensure the integrity of the Review, given that there are many commercial interests involved.
This does seem to indicate that the Review is making slow progress (perhaps there were no meetings before 2023?) – or that the Probity Plan has come rather late in the proceedings.
FDA approves over-the-counter sales of medicine to reverse drug overdoses
The US Food and Drug Administration has approved over-the-counter sale of naloxone, used to reverse opioid and fentanyl overdoses, in a nasal spray formulation (brand name Narcan).
In announcing the decision, the FDA said in a statement, “Today’s action paves the way for the life-saving medication to be sold directly to consumers in places like drug stores, convenience stores, grocery stores, and gas stations, as well as online.”
This move has been welcomed as a way to address America’s worsening opioid crisis.
Nationally, nearly 107,000 Americans died after overdosing on some kind of drug in 2021, up from about 92,000 in 2020 and 70,600 in 2019. The majority of those overdoses involved opioids and specifically fentanyl, the synthetic opioid that is much more potent than heroin.
Naloxone is remarkably effective at stopping overdoses. It does this within minutes of administration by blocking the receptors in the brain that are targeted by opioids, thus reversing the dramatic slowdown in respiration that can lead to sudden death.
There is a good explainer (from the American point of view) here.
Australia is ahead of the United States on this issue. The national Take Home Naloxone program began in July 2022, with funding of $19.6 million over four years, provided in the 2022-2023 Federal Budget. It is available for free, without a prescription, for anyone who may experience, or witness, an opioid overdose or adverse reaction.
The first trial of a Take Home Naloxone program began in 2012 in the Australian Capital Territory.
A pilot program funded by the Federal Government ran in NSW, South Australia and Western Australia from 1 December 2019 until 30 June 2021. The evaluation of the pilot program is available here. It showed that the program saved an estimated three lives per day, which includes both improvement in prognosis and reductions in mortality.
Best of Croakey
The Lancet has recently published a landmark series of papers on the relationships between commercial entities and society – the so-called commercial determinants of health.
The series provides recommendations and frameworks to foster a better understanding of the diversity of the commercial world, potential pathways to health harms or benefits, and the need for regulatory action and investment in enterprises that advance health, wellbeing, equity, and society.
My Croakey colleague Dr Melissa Sweet has done a sterling job in summarising this work and the commentary around it.
These are issues that must remain at the forefront of public health policy development.
The good news story
An article in Science has announced that natural history museums around the world are joining forces to produce a global digital inventory of their collections to facilitate international sharing of information.
This new effort, which includes 73 museums in 28 countries (including six in Australia), is unparalleled in its scope. Most objects in natural history museums have yet to be scanned and uploaded to the cloud — or even recorded in an online catalogue. So there is a huge task ahead.
The next edition of The Health Wrap will be written back in Australia.This week we are headed home after a wonderful stay in our Colorado home. Lots of physical exercise with skiing and snowshoeing and plenty of US political issues to keep us busy and bemused and very glad to live in Australia.
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.