In her column this week, the well-travelled Dr Lesley Russell takes readers from Colorado to Chicago, and from Africa to Sweden and lutruwita/Tasmania.
Russell shares observations of the “joyous and inclusive” Democratic National Convention, and brings updates on a raft of infectious diseases, raises questions about cost effectiveness studies, reports on an innovative wildlife study, and brings the latest news on mental health reform.
The quotable?
…somehow, despite all the policies and plans listed on the [Department of Health and Aged Care] site, and the huge number of inquiries and reports, Australia’s mental health prevention and treatment and care system is endlessly failing to deliver needed services to the Australians that need them, especially to the Australians who most need them.”
Lesley Russell writes:
This is the last edition of The Health Wrap from our (northern) summer sojourn at our Colorado home. It’s been a wonderful time for hiking and working.
We have been coming to Keystone for 35 years, and we never tire of the magnificent mountain scenery and the outdoor lifestyle. We will be back in early 2025 for the ski season.
Presidential politics
This year our attention – and our work – has been focused on the up-coming US presidential campaign. It’s been quite an exciting time as the nomination of Kamala Harris as the Democratic presidential candidate and her selection of Tim Walz as her running mate has regalvanised the campaign.
The Democratic National Convention was in Chicago last week. All the former Democratic presidents (except Jimmy Carter who is in hospice care) spoke. It is hoped that the Harris–Walz team will get a big polling boost from this; it really was a joyous and inclusive convention.
I went to the 2008 DNC in Denver, when Obama was nominated. It was an exciting and exhausting time! These conventions are about so much more than what happens on the convention floor: there are seminars and discussions on the side, cultural events and concerts, and lots of funny costumes and partying.
My latest article for Inside Story Magazine looks at what Trump and Harris might mean for health and healthcare, particularly as healthcare costs are an important component of the rising cost-of-living issues that are top of voters’ concerns.
And you might enjoy this article from my husband Bruce Wolpe, which looks at what Harris must do to win – starting with a masterful, uplifting convention acceptance speech.
And even better, especially for West Wing fans, is this speech from President Josiah Bartlet (also known as Martin Sheen).
The next pandemic
At the same time as COVID-19 infections are surging around the world, fears are growing about the threats from other pathogens.
Earlier this month the World Health Organization (WHO) added H5N1 bird flu, mpox (formerly monkey pox) and Black Death plague to a watchlist that now has 24 pathogens that could trigger the next pandemic.
This list, known as the R&D Blueprint for Epidemics, was first published in 2017. It points out the most dangerous diseases for which there are no vaccines, diagnostics or treatments as a way to prioritise research.
At the Global Pandemic Preparedness Summit 2024 held in Rio de Janeiro at the end of July, the WHO R&D Blueprint for Epidemics issued a report urging a broader-based approach by researchers and countries aimed at speeding up surveillance and research to understand how pathogens transmit and infect humans and how the immune system responds to them.
This was followed by a call from WHO and the Coalition for Epidemic Preparedness Innovations (CEPI) for governments and researchers around the globe to strengthen and accelerate this research in preparation for the next pandemic.
To date, not enough has been done at the international or national level to build on what was learned from the COVID-19 pandemic.
Much has been written (including by me) about the failure of the World Health Assembly in May to reach a treaty on pandemic preparedness. See The Health Wrap, 10 April 2024.
In June 2024 the Independent Panel for Pandemic Preparedness and Response, co-chaired by Helen Clark and Ellen Johnson Sirleaf, released its report No Time to Gamble, outlining how world leaders are “gambling with their children’s and grandchildren’s health and wellbeing” by failing to prepare for future pandemics.
The co-chairs have spoken out strongly about how lessons from Ebola and COVID-19 have not been learned and how lack of preparation leaves the world vulnerable to “devastation”.
What is Australia doing? And are these efforts sufficient?
The Department of Health and Aged Care website has a page devoted to Australia’s efforts at the global level. It looks pretty pro forma. My googling did not turn up any national information on the DoHAC website with regard to updated plans for pandemic preparedness.
This may be because the expectation is that this work will be the responsibility of the Australian Centre for Disease Control (CDC). The interim CDC has a list of responsibilities here, including “increase and productively use resources to support preparedness and response across all Commonwealth, state, and territory governments, including nationally”.
Under a heading “Into the Future” on the interim CDC page, there is this statement: To protect Australians from health threats, the CDC will: prepare and plan for potential public health emergencies, such as pandemics.
Other organisations have done more work. In 2022, the CSIRO released a report Strengthening Australia’s Pandemic Preparedness, which looked at science and technology-based solutions.
At the end of 2023 the Grattan Institute released How to Prepare for the Next Pandemic, its submission to the Federal Government’s COVID-19 Response Inquiry.
Perhaps we should assume that the work of developing a national pandemic preparedness plan is awaiting the completion of this inquiry; the final report is due at the end of September.
There is also the work of two infectious disease research organisations:
- The Australian Partnership for Preparedness Research on Infectious Disease Emergencies (APPRISE), a national network of experts involved in medical, scientific, public health and ethics research. It’s encouraging to see that APPRISE has a particular focus on First Nations’ needs.
- The Australian Institute for Infectious Disease, established by the Victorian Government specifically to respond to current and future pandemics. While building the new infrastructure is underway, it is not clear how the proposed collaborative partnerships are operating.
Australia currently faces imminent threats from H5N1, bird flu, and mpox – and many in public health would argue that, while the threats from COVID-19 may have diminished, with new strains regularly emerging, they have never gone away.
Imminent threat from mpox
On 14 August the WHO declared mpox virus a public health emergency of international concern.
Mpox cases have been spreading throughout many countries in Africa, particularly the Democratic Republic of the Congo and neighbouring Burundi, Kenya, Rwanda and Uganda.
This year the Africa Centres for Disease Control reports central and eastern Africa have had over 17,000 infections and more than 500 people have died from mpox, primarily in DRC. The disease has been reported in 13 African countries and has quickly spread internationally.
Mpox virus spread is mapped here.
There are two types of mpox – clade I and clade II. Clade I is endemic in central Africa, while clade II is endemic in West Africa.
The clade II variant was responsible for the global outbreak of 2022 which was also declared an international public health emergency. It swept quickly across the globe The clade IIb strain swept quickly around the world and, to date, has caused nearly 96,000 documented cases and at least 184 deaths in 116 countries.
A new variant of clade I, called Ib, appears be significantly more lethal, especially to children, and to spread more easily, mainly through close contact, including sexual networks. In the past month some 90 cases of Clade Ib were reported in countries neighbouring the DRC which had not previously reported mpox cases.
There has already been a confirmed case of clade Ib in Sweden which most likely means dozens of undetected cases in Europe.
In Australia mpox infections are surging, with 206 cases reported in the period 1 April to 1 August. This is compared to the 26 cases reported nationwide in 2023. It is only a matter of time until the new variant arrives.
There is a good briefing paper on mpox in Australia from the UNSW Kirby Institute here. Bookmark this link to follow Croakey’s coverage of mpox.
As pointed out in an opinion piece in PLOS Global Public Health, there are consistent global health failures when it comes to addressing infectious diseases in Africa.
While countries like the United States have donated vaccines to address the mpox outbreak, millions of doses are needed. If there are outbreaks in Europe and the United States, then all vaccine manufacturing and sales will be directed to these wealthy countries at the expense of the poorer countries with the greatest need.
On 26 August, The World Health Organization launched a global Strategic Preparedness and Response Plan to stop outbreaks of human-to-human transmission of mpox through coordinated global, regional, and national efforts. The plan covers the six-month period of September 2024-February 2025.
Growing concerns over H5N1 bird flu
A recent article in The Sydney Morning Herald asked “Are we ready for a bird flu pandemic – and how can we cut the risk?”
Another article in The Guardian warned that H5N1 bird flu could reach Australia this spring, with experts saying it was a matter of when, not if.
H5N1 bird flu is now widespread in wild birds worldwide and in the United States is causing outbreaks in poultry and dairy cows. A big concern is that there have been a number of human cases in American dairy and poultry workers.
The consensus among experts is that bird flu poses only a low risk to human health. And we are assured that the Government has a stockpile of appropriate vaccines and CSL could have the first batches of a vaccine rolling off the production line within 100 days of a pandemic being declared. (Past experience suggests we might be sceptical of both these claims.)
But it is almost inevitable that the virus will cause significant infections among Australia’s birds. It has been pointed out that birdlife in places like Lord Howe Island and Antarctica are particularly vulnerable.
COVID-19 pandemic is far from over
The SARS-CoV-2 virus is continually evolving and the number of infections has been rising, despite the fact it is summer in the northern hemisphere.
The United States is experiencing its largest summer COVID-19 wave in at least two years and a number of European countries have also reported a summer wave.
As usual, it’s very difficult to get Australian data but it does seem that infections are declining from a high point earlier in the winter.
Just as difficult is the task of following the variants of concern. The latest seems to be an strain called KP.3.1.1 which is part of the Omicron family and descended from JN.1. This is now the predominant strain in the United States.
In the United States, the Food and Drug Administration has just approved updated Pfizer-BioNTech and Moderna vaccines to better protect against currently circulating variants. These are both m-RNA vaccines. There is also a new Novavax vaccine which is protein-based but it is not clear when this will be approved.
The two new m-RNA vaccines are apparently also being reviewed by the TGA for use in Australia.
There is growing evidence that vaccination lowers the risk of developing Long COVID (see, for example, this summary).
The value of this protection to individuals and society is highlighted by a recent study from Professor Raina MacIntyre and colleagues that looks at the health and economic costs of Long COVID in Australia.
Questions about cost-effectiveness studies
Cost effectiveness studies are routinely used to inform healthcare and public health policy decisions. But, as a recent paper in Health Affairs points out, such studies also carry the potential of perpetuating health disparities.
The authors discuss how competing risks, baseline healthcare costs, and indirect costs are different for different populations – their focus is on racial and ethnic minority populations in the United States.
For example, higher rates of health insurance in white American communities (as opposed to communities of colour) means that a health intervention that averts disease will deliver higher healthcare cost savings for this population.
In a podcast, one of the researchers discusses their findings and the implications.
As a comment on the paper points out, this work “aligns with calls to conduct sex-disaggregated economic analyses for cancer, to account for the many differences in access, services, and outcomes between men and women”.
There is an interesting paper from 2017 on using cost-effectiveness analysis to address health equity concerns here.
And, on a slightly different issue, I found a 2023 paper that looks at how the selection of an outcome for a clinical study can have implications for equity.
It states: “When intervention scientists plan a clinical trial of an intervention, they select an outcome metric that operationalizes their definition of intervention success.
“The outcome metric that is selected has important implications for which interventions are eventually supported for implementation at scale and, therefore, what health benefits (including how much benefit and for whom) are experienced in a population. Particularly when an intervention is to be implemented in a population that experiences a health disparity, the outcome metric that is selected can also have implications for equity.”
On mental health, it’s time to move from talk to action
As the Department of Health and Aged Care website states: “Almost half of all Australian adults will face mental ill-health at some point in their lives. Making sure people can access care when they need it is critical.”
But somehow, despite all the policies and plans listed on the site, and the huge number of inquiries and reports, Australia’s mental health prevention and treatment and care system is endlessly failing to deliver needed services to the Australians that need them, especially to the Australians who most need them.
On Friday 16 August there was a meeting of Health Ministers, as well as a joint meeting of Health and Mental Health Ministers. It’s interesting to compare the reports of these meetings from my Croakey colleague Charles Maskell-Knight, writing in The Zap, and from the CEO of Mental Health Australia, Carolyn Nikoloski, writing in her weekly update.
The communique from the meeting has a commitment to Ministers working together “to improve access to mental health services across Australia through a re-affirmed commitment to delivering on the National Mental Health and Suicide Prevention Agreement”, and to working with “mental health stakeholders, including lived experience and First Nations, to develop a robust plan for future psychosocial support arrangements”.
Nikoloski is optimistic about that this means for needed reforms; I agree with Maskell-Knight’s succinct comment: “I don’t think this amounts to the ‘serious action’ the sector is seeking”.
For too long, Australian mental health services have depended too much on general practice which is not well supported with training, mental health staff and Medicare financing; have provided limited crisis services with even more limited step-down, follow-up services (that should be considered essential); and have patients’ access limited by geography and burgeoning out-of-pocket costs.
The Federal Government’s responses (regardless of which party is in power) seem to be limited to the problematic Better Access program, an increasing reliance on telehealth services and IT, and community-based, headspace-type programs. That leaves a lot of holes in the safety net (if indeed it really exists) for people to fall through, especially those who have serious mental health diagnoses.
Several recent reports highlight the issues that demand urgent attention:
A world-first review into youth mental health from The Lancet Psychiatry Review, led by Australian Professor Patrick McGorry, shows an alarming rise in mental ill-health among young people driven by the COVID-19 pandemic, the measures taken to contain it, and its aftermath. In Australia youth mental health has declined since the pandemic and climate change is also triggering anxiety.
The public release of the national Analysis of Unmet Need for Psychosocial Support Outside the NDIS has underscored the staggering reality of unmet need: 230,500 people with severe mental illness and 263,100 people with moderate mental illness are not receiving the psychosocial support they need.
The Albanese Government’s response to the Better Access program evaluation was finally released. Given that the evaluation was undertaken in 2021-2022 and the final report was delivered to the Government in December 2022, we might query how relevant the assessment is to current times and how timely the Government’s response is. For the most part, it appears that the Government believes its commitment in the 2024-2025 Budget of an additional $888.1 million over 10 years for mental health is sufficient response.
There’s an analysis of what the RACGP thought of the evaluation report and its recommendations here.
Dr Sebastian Rosenberg wrote about the (in)adequacy of the 2024-2025 Budget commitment in an article for Croakey here.
A recently published article suggests that the Budget funding is not well targeted at the greatest need and is funding unproven initiatives.
See this recent Croakey Health Media article: Time to bridge gap for nearly 500,000 Australians missing out on needed psychosocial support.
An article in the Medical Republic looks at the Government’s response to the Better Access evaluation. It argues that better coordination is needed, and – controversially for some – that there’s no point in GPs being the gatekeepers for mental health services if there is nothing to refer patients to.
Whatever you think about the issues taken up in the Medical Republic article, there is no doubt that a key issue for mental health reform, or even mental health tinkering at the margins, is workforce.
The decision of Health and Mental Health Ministers to initiate a national workforce data and information monitoring project, inclusive of community-managed and peer mental health workforces, is therefore a critical next step.
News from Science Week
The week 10-18 August was National Science Week – always one of my favourite weeks of the year.
A list of grant recipients highlights the many and varied activities around the nation.
To mark the week, the Federal Department of Industry, Science and Resources released Australia’s National Science Statement and a list of revitalised National Science and Research Priorities to guide Australian science and research efforts.
The National Science Statement provides a framework to shape science policy and leadership across governments, in our labs, in research institutions and in boardrooms, to 2034. It is very economically and commercially focused.
“Australia’s future prosperity, security and wellbeing rely on our capacity to use our scientific strengths. The government recognises that great ideas emerging from science and research become great products. They become profitable, enduring companies and create new jobs.”
The work of updating the science and research priorities began in 2022: the previous priorities were set in 2015 (for some reason, these are no longer publicly available on the DISR website; I did find a government paper which discusses the 2015 priorities here). There’s an outline of the consultation process towards the 2024 priorities here.
The DISR website states: “The priorities will help the Australian Government align its effort and investments in the science, research, technology, innovation and commercialisation system. The priorities will also help to shape investment and efforts across the university and private sectors. They provide focal points towards which researchers from across research and innovation can concentrate their combined efforts to help solve Australia’s greatest challenges.”
The priorities are:
- transitioning to a net zero future
- supporting healthy and thriving communities
- elevating Aboriginal and Torres Strait Islander knowledge systems
- protecting and restoring Australia’s environment
- building a secure and resilient nation.
In a statement on these documents, the Australian Academy of Science applauded the Government on having the discipline to identify science and research priorities, but added that these will be ineffective without an implementation plan to drive action across government portfolios, industry and the research sector.
“Previous science and research priorities were ineffective because they lacked implementation, monitoring and evaluation and therefore did little to focus and scale up science and research in the identified areas.”
It is wonderful to see that Aboriginal and Torres Strait Islander knowledge systems are now a national priority, creating an opportunity to improve research outcomes.
See a recent article by Professor Tristan Kennedy and Professor Melissa Miles that describes some of the benefits of elevating First Nations’ knowledge systems.
There are some expert reactions, generally positive, to the new statement and priorities here.
A good news story
This is not a health story – at least not in the traditional sense. But it’s a story about a wonderful First Nations artist who was recently announced as the top prizewinner of the 2024 Telstra National Aboriginal and Torres Strait Islander Art Awards (NATSIAA].
Noli Rictor is a Pitjantjatjara man and artist from Tjuntjuntjara in Western Australia. He won for his large and remarkable and very beautiful painting that depicts the significant site of Kamanti, situated in the north of traditional Spinifex Lands.
This site is home to the Wati Kutjara Tjukurpa (Two Men Creation Line), an epic narrative that follows the journey of a father and son water serpent across the Spinifex Lands on ceremonial business.
You can watch Noli Rictor talk about his art and its meaning here.
The best of Croakey
It’s wonderful to see Croakey Health Media amplifying the voices of those who are concerned about gambling and gambling advertising in Australia. This is an important social welfare and public health issue.
- In the face of a powerful web of commercial interests, a public health advocate calls halt on gambling advertising
- Gambling is a public health issue, and must be treated like one
- A call to civil society: it’s time to reframe media policy.
Bookmark this link to follow Croakey’s coverage of gambling as a public health concern.
And finally…
This is a good news story about a bad news situation.
Devil Facial Tumour 2 (DFT2) was discovered in Tasmanian devils ten years ago near Cygnet on the D’Entrecasteaux Peninsula of lutruwita/Tasmania. This second transmissible cancer found in the animals has steadily spread across southeastern Tasmania.
Now the University of Tasmania is leading a trial of artificial intelligence to monitor the spread of DFT2, in an approach that is hoped may one day revolutionise wildlife disease management around the world.
Using a combination of cameras located in remote parts of Tasmania, a research team from the UTas School of Natural Sciences has deployed AI software to process thousands of images of devils to identify diseased animals.
The university has also leveraged a community-based monitoring network of citizens, land owners, local councils, government and non-government organisations, in a bid to record more responsive detections of animals with the tumour.
You can read more 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.
Hoping this leads to positive and sustained action across the world. The threat of climate change seems greater globally over the past few months and should be added to the list of public health priorities for disease control.