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The Health Wrap: health workforce under pressure, global health concerns, and democracy matters

As the pandemic puts healthcare workers and systems under relentless pressure, Associate Professor Lesley Russell delves into related research, as well as reporting on wide-ranging global health matters.

Leonard Cohen makes a guest appearance, as do some macropod friends from Kangaroo Island.


Lesley Russell writes:

A paper from Professor Marie Bismark and colleagues, just published in the Australian & New Zealand Journal of Psychiatry, looks at the prevalence and predictors of thoughts of suicide and self-harm among healthcare workers during the pandemic.

A summary of the paper can be accessed here, but the full paper is behind a paywall.

The research found that one in ten healthcare workers in Australia had thoughts of suicide or self-harm in a two week period durng the second wave of the pandemic between August and October 2020. Even among those who did not have such thoughts, high levels of burnout, anxiety, depression, and trauma symptoms were observed.

Although there is no comparative baseline data, it is recognised that, even before the emergence of COVID-19, Australian health workers had higher rates of suicide than those in other occupations.

Certain groups were more vulnerable, including those who had friends or family infected with COVID-19, were living alone, had poor physical health or prior mental illness, and increased income worries.

Regrettably, most healthcare workers with thoughts of suicide or self-harm did not seek professional help.

Source: Tweet by Professor Marie Bismark https://twitter.com/mbismark/status/1491250547877289989

In an interview with Sally Sara on ABC World Today, Professor Bismark said, “As the results started to come in, it gave me chills down my spine. To see my colleagues … doing everything they could to help patients in the hospital, and to know from this study that one in ten of them was struggling.”

Like so many others, she called for more attention and more care for healthcare workers.

In return, healthcare workers are desperate for the public to know and understand what’s been happening in public hospitals.

The ABC News website has their stories in their words, which highlight the very tough conditions so many are working under. Nurses and midwives from 150 public hospitals and health services across New South Wales went on strike yesterday to protest conditions including understaffing, lack of nurse-to-patient ratios, and an increased workload during the pandemic.

See some of the responses to the new study, via Twitter:


Medical training

Concerns about the wellbeing of health workers are also raised in the annual report on the 2021 Medical Training Survey from the Medical Board of the Australian Health Practitioner Regulation Agency (APHRA).

The Medical Training Survey (MTS) is a national, annual, profession-wide survey of all doctors in training in Australia. It asks about their experience of medical training across curriculum, workplace environment and culture, workload, training and educational opportunities and overall satisfaction.

Last year questions about the impact of COVID-19 on training were also included. Not surprisingly, the pandemic was seen as adversely impacting both training and personal lives.

More disturbingly, the findings highlight that there has been little improvement since previous surveys in issues around bullying, workplace harassment and discrimination:

  • There was no improvement in the percentage of trainees (35 percent) reporting that they had experienced and/or witnessed bullying, harassment and/or discrimination (including racism) in training. The most common sources of this behaviour were senior staff.
  • The majority (67 percent) of trainees who experienced bullying, harassment and/or discrimination did not report the incident. Of those who did, only 58 percent were satisfied with the follow-up.
  • There is a clear link between unprofessional behaviours and medical training, with 38 percent of trainees who experienced bullying, discrimination and/or harassment reporting moderate or major adverse impacts on their training.
  • Racism is rife with 52 percent of Aboriginal and Torres Strait Islander trainees who reported experiencing and/or witnessing bullying, harassment and/or discrimination.


Racism and health

Meanwhile, the February edition of the United States journal Health Affairs has ‘Racism and Health’ as its theme. While some articles consider how structural and other forms of racism affect health workers and workplaces, the edition’s focus is far broader. 

The issues covered relate to those around the health of minority groups in the US. The edition makes thought-provoking reading, and the statement that “Racism must be explored as a key driver of health outcomes and health disparities” clearly also applies in Australia.

In particular, I commend to you the overview paper that explains the path from systemic racism to poor health and provides examples of dismantling racist systems. A variety of excellent Health Affairs resources on racism and health is available here.

See also this Twitter thread by Croakey’s Dr Melissa Sweet summarising the Health Affairs articles, and this article just published at The Conversation by Professor Chelsea Watego and Associate Professor Lisa Whop: Racism is a public health crisis – but Black death tolls aren’t the answer.


Linking health and social services – payments mechanisms matter

Many who work in public health, myself included, have long been pushing for the transformation of general practice into primary health care. We have a long way to go on that journey, although Aboriginal Community Controlled Health Organisations are leading the way.

In the United States, Community Health Centers have been delivering primary health care services that include a range of social services for over fifty years (there’s lots more information on CHCs here). Now some of the Accountable Care Organisations (ACOs) that were set up under Obamacare are also trying to do this.

In an edition looking at Innovations in Care Delivery, The New England Journal of Medicine examines the integration of the social determinants of health into healthcare services.

The NEJM edition includes a fascinating paper that examines a program in Massachusetts that allows the state’s Medicaid ACOs to pilot evidence-based initiatives that address members’ health-related social needs in an effort to improve health outcomes and reduce total costs of care. The main focus of the social services was on provision of housing and nutrition services.

Just imagine what such an approach could deliver in address health inequities and disparities in Australia!

You can read the summary here; unfortunately the paper is behind a paywall.

Measuring the impact of these partnerships and the sharing of patient data were cited as the most common major challenges due to limited data infrastructure.

Referring patients to social service organisations was another major challenge, as integrating social needs support requires a large cultural shift in healthcare settings on the part of both providers and patients.

In particular, the Massachusetts study focussed on payment mechanisms.

Four payment mechanisms were used across the partnerships: (1) fee-for-service; (2) prospective payments; (3) retrospective payments; and (4) hybrid models of these payment methods.

Since 2018 Massachusetts has moved away from a fee-for-service approach for Medicaid, but this is still perpetuated in the payment system for social services, and there are concerns that this will not ensure value for money.

Despite this, the ACOs strongly agree that partnerships between ACOs and social service organisations offer significant potential to improve patient experience, assist with management of chronic health conditions, and reduce health disparities.

For those looking for more information on this, the May 2021 report on the MassHealth Accountable Care Organisation Program is useful reading and would provide some guidance for those policy wonks keen to institute similar programs in Australia.


Questions about the new National Medicines Policy

I return yet again to this topic, having previously addressed it in The Health Wrap edition of 8 November 2021

It seems that – once again – things are not on track and the Morrison Government is pushing to forego due process in order to meet its own (election-driven) timetable.

To review progress on the National Medicines Policy (NMP) review to date:

The Review, the first since 2000, was announced by Minister for Health Greg Hunt in 2019, although the Terms of Reference were not released until August 2021. It is led by an Expert Advisory Committee that includes a consumer representative.

A discussion paper was released in September 2021. This paper suggests that the Government (and the pharmaceutical industry stakeholders) believe the current NMP is basically fine – the word “refresh” is used multiple times.

Fortunately, a second document, detailing the key themes to come out of a consultation workshop held in January 2020 (but not released until September 2021!) states that participants “emphasised the need for a patient-centric focus within the NMP to empower consumers to make informed choices about the quality use of medicines”. It also emphasised the importance of health literacy.

Initially submissions made in response to the discussion paper were not made public, although after protests, that decision was reversed and they are now available here.

The draft final report was released, without any announcement, on 2 February, 2022.

Despite the importance of the policy, and the level of public interest in the review, the comment period was just two weeks, until 16 February. In the face of public outcry, the comment period was extended until 2 March.

It is described as a “refreshed draft” and a “high-level policy framework”. It has no vision statement, but a series of pillars, principles and policy enablers are listed (see figure).

The substance of the four pillars has not changed from the 2000 version. However the new draft policy contains considerably more detail as to the components of each pillar.

There is now an emphasis on equity and reliability of access to medicines, the use of digital technologies, improving health literacy of consumers, responsible media behaviour in reporting health information, and the importance of industry research.  It also says the digital platforms should protect individuals against harm from online disinformation and misinformation.

It is proposed that the scope of the NMP is broadened to include biologic medicines, including gene therapies, cell and tissue engineered products, and vaccines.

The new draft NMP sets out with greater specificity the responsibilities of partners to advance each of the pillars, as well as expectations regarding evaluation and reporting against these responsibilities, including the publication of results. See this diagram giving an overview.

There are lots of grand words but very little detail. I am uncertain of the extent to which the input from patients and consumers was incorporated and I could find no mention of the role that out-of-pocket costs play in thwarting to desired outcomes of “equitable, safe, timely and affordable” access to needed medicines (did I miss it?).

After such a slow start, the Morrison Government is now in a mad rush to conclude the review and release it ahead of the election.

But all the stakeholders think this is too important to be rushed. See, for example, this letter from Better Access Australia to the Shadow Minister for Health, Mark Butler.

A media release from Medicines Australia on 10 February said this:

“The NMP affects all Australians. It is central to the health of the nation – now and into the future. It is far too important to be rushed. We have examined the Draft NMP closely and it is lacking in many vital areas.

“The aim is focused on processes rather than on desired outcomes. This misses the point. Governance, accountability and evaluation proposals are ambiguous and there is no framework for regular review with the stakeholders and partners.

“While there is intent to modernise the policy, the draft document fails to reflect stakeholders’ inputs, particularly the voice of consumers – the patients whose lives are most directly impacted by medicines policy and access to medicines.

“We cannot let the first review of the NMP in 20 years to be a missed opportunity. Too much is at stake.”


Growing global burden of antimicrobial resistance

A study published in The Lancet in January provides a comprehensive assessment of the global burden of antimicrobial resistance (AMR) and an evaluation of the availability of data.

AMR is a leading cause of death around the world, with the highest burdens in low-resource settings.

The paper is nicely summarised in Stat and Croakey has also covered the findings, together with a call from infectious diseases physician Dr Trent Yarwood for more effective communications strategies around AMR.

Here are the key findings:

  • It is estimated that in 2019 there were 4.95 million deaths associated with bacterial AMR, including 1.27 million deaths attributable to bacterial AMR. This is more than the deaths attributed to malaria or HIV/AIDS.
  • The death rate is highest in western sub-Saharan Africa (2.3 deaths per 100,000) and lowest in Australasia (6.5 deaths per 100,000).
  • The seven leading pathogens for deaths associated with resistance are Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, Mycobacterium tuberculosis, and Pseudomonas aeruginosa.
  • One pathogen–drug combination, meticillin-resistant Staph aureus, caused more than 100,000 deaths attributable to AMR in 2019.
  • There are serious data gaps in many low-income settings and a need to expand microbiology laboratory capacity and data collection systems.

Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions about infection prevention and control programs, access to antibiotics, and the research and development of new vaccines and antibiotics.

Antimicrobial resistance has been a growing threat for decades. Although all of the seven pathogens have been identified as priority pathogens by the World Health Organization (WHO), only two have been a focus of major global health intervention programs — Streptococcus pneumoniae, primarily through pneumococcal vaccination, and Mycobacterium tuberculosis.

In an accompanying editorial, The Lancet noted that innovation to address these problems – described elsewhere as potentially the next pandemic – has been extremely slow and “the clinical pipeline for antibiotics is too small to tackle the increasing emergence and spread of AMR”.

“National leaders now have an obligation to move AMR to a higher position in their political agendas. Research efforts should be accelerated to address knowledge and innovation gaps and to inform policy and practices.”

The Australian Government website describes AMR as “one of the biggest threats to human and animal health today”.

Australia’s National Antimicrobial Resistance Strategy – 2020 and Beyond was endorsed by the Council of Australian Governments in March 2020. The 2020-21 Federal Budget provided $22.5 million over four to implement it.

But with COAG gone, and the AMR Strategy involving both Health and Agriculture Departments across federal and state and territory governments, who is in charge of delivering it?

The fourth Australian report on antimicrobial use and resistance in human health (AURA 2021), released by the Australian Commission on Safety and Quality in Health Care in August 2021, highlights the ongoing public health and safety threat posed by AMR.

It finds that while antibiotic use in the community is decreasing, overprescribing and inappropriate prescribing continues to be a problem, and antimicrobial resistance to commonly prescribed antibiotics remains an ongoing threat.

Most concerning is that antibiotics continue to be prescribed for conditions for which there is no evidence of benefit (more than 80 percent of patients with acute bronchitis and acute sinusitis get a prescription).

Also antibiotic use has increased in hospitals, and the rate of overall appropriateness of prescribing has been static for some time.

A 2020 report from ACSQHC that tracked antibiotic use in Australia over a five-year period found that Australia’s antibiotic prescribing rates were comparatively high; 22.7 defined daily doses per 1000 people in 2017–18 more than double the equivalent figures in the Netherlands (8.9) and Sweden (10.8).

Also there was a pattern of high use in some of the most disadvantaged areas of major cities across the country.

Clearly this is an issue needing more resources and more focus.


Mosquito nets do prevent malaria

It’s well recognised that increased use of mosquito bed nets will decrease the incidence of malaria. Insecticide-treated nets are now widely distributed in sub-Saharan Africa which accounts for approximately 93 percent of all malaria cases and 94 percent of deaths.

The nets are estimated to have prevented more than 663 million malaria cases between 2000 and 2015.

But still many die: in 2020 there were some 602,000 deaths from malaria, with about 80 percent of those deaths in children less than five years of age.

There has always been a concern that controlling malaria in children under five simply shifts deaths to older children by delaying functional immunity.

Now a recent paper published in The New England Journal of Medicine shows these fears are unfounded.

The paper reports on the results of a 22-year prospective longitudinal cohort study in rural southern Tanzania which found that the more time children slept under bed nets, the less likely they were to acquire malaria.

The findings also found that this protective efficacy persisted into adulthood.  Of the participants who always used a treated net, 91 percent survived to adulthood, versus 80 percent of those who did not.

This means a healthier early life for these children which makes them more resilient against other infections as they grow up.

The authors noted that it is remarkable that they were able to find information on nearly all the children after 20 years. “It’s a testament to the deep social connections the interviewers had in the study communities, as well as making the most of mobile phone coverage.”

You can read more about this study here.


International concerns about pandemic medical waste

It’s impossible not to realise that discarded masks are the new waste problem – they litter the streets and waterways and are an increasing danger to wildlife. A paper published last November in PNAS highlighted the problems with pandemic- associated plastic waste in the world’s oceans.

A report from the World Health Organization (WHO), published this month and covered recently at Croakey, finds serious shortfalls in COVID-19 healthcare waste practices.

It found that supplies of personal protective equipment (PPE) and diagnostic equipment provided by the United Nations to assist (low income) countries in tackling the pandemic in the period between March, 2020, and November, 2021, generated 2600 tonnes of general waste (mainly plastic), and 731,000 L of chemical waste.

It also noted that over eight billion doses of vaccine have been administered globally, producing 144,000 tonnes of additional waste.

“Evidence on the amount of health care waste generated, the lack of resourcing to safely manage waste, and the incomplete attention to environmental and climate impacts demonstrates that a more holistic approach is needed” the report concluded.

The report’s findings are also summarised in The Lancet.

This is an issue in Australia, where the healthcare sector has been battling its environmental footprint for years.


Federal budget and election looming

I tackled these issues head-on in my first edition of The Health Wrap for 2022, which you can read here.

Croakey Health Media will be actively reporting on the issues that readers care about in the lead-up to the budget and election – and how the two are inevitably linked.

So far, Croakey has published these two articles – and there are more to come:

Pre-Budget submissions on priorities for the 2022-23 Budget were called for on 6 December and closed on 28 January. They can be accessed here.


The best of Croakey Health Media

Don’t miss this comprehensive investigation by Jennifer Doggett: How to stop dirty money ruining our health and democracy.

See also this related Twitter thread, which finishes with a timely song:


The good news story

If you follow me on Twitter, then you will know that I have just returned from a wonderful second visit to Kangaroo Island where the good news is the continuing recovery of the island’s flora and fauna from the dreadful bushfires that engulfed most of the island in January 2019.

The Kangaroo Island Community Recovery Plan 2020-2022 is here.

You can read the Kangaroo Island Fire Recovery Newsletters here.

There’s a report from the South Australian National Parks and Wildlife Service here.

And a December report from the Australian Wildlife Conservancy here.

Remarkable Rocks looking towards Cape du Couedic. This area, in the western part of the island, was the most severely damaged by the fires and is now green and lush with new growth.


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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