How do presidential contenders Donald Trump and Joe Biden stack up when it comes to COVID-19? How will the pandemic continue to affect us, even if a vaccine is developed? And how are bilbies contributing to healing?
These questions, and more, are addressed in the latest edition of The Health Wrap, by Associate Professor Lesley Russell.
Lesley Russell writes:
So far there has been little substantive focus on policy in the US election campaign (to the extent that the Republican National Committee did not even pass a policy platform this year). However, that will likely change when the debates start.
So here is a brief comparison of the coronavirus policy announcements to date from President Donald Trump and former Vice President Joe Biden.
Every day the news is full of the statements, decisions, interferences and antics of Trump and his administration with respect to the pandemic. Trump has done almost nothing to spell out his agenda for his second term in any area, even on issues that are important to voters like health and the pandemic.
His proposal to “eradicate COVID-19” consists of just four dot points:
- Develop a vaccine by the end of 2020
- Return to normal in 2021
- Make all critical medicines and supplies for healthcare workers in the United States
- Refill stockpiles and prepare for future pandemics.
On the global front, in line with a general foreign policy approach of “America First”, the Administration has chosen not to participate in several high-level international efforts to address COVID-19, has ended funding for the World Health Organization (WHO), and has announced its intent to withdraw from WHO membership – all actions that mark a significant departure from the role the US has historically played, including its major role in tackling the 2014 Ebola outbreak.
Democratic candidate and former Vice President, Joe Biden, has outlined a number of measures for how he would address the coronavirus pandemic. His approach calls for the Federal Government, not the states, to assume primary responsibility for many aspects of the coronavirus response, including for scaling up testing and contact tracing, providing and managing the distribution of critical supplies, and setting strong national standards.
Biden has put forth the following principles in his proposed response to COVID-19:
- Restoring trust, credibility, and common purpose
- Mounting an effective national emergency response that saves lives, protects frontline workers, and minimizes the spread of COVID-19
- Eliminating cost barriers for prevention of and care for COVID-19
- Pursuing decisive economic measures to help hard-hit workers, families, and small businesses and to stabilize the American economy
- Rallying the world to confront this crisis while laying the foundation for the future.
His plans call for the appointment of a “Supply Commander” to oversee a national supply chain of essential equipment, medications, protective gear, directing distribution of critical equipment to the states, and to make more aggressive use of the Defense Production Act to direct companies to produce needed supplies.
He would also establish a “COVID-19 Racial and Ethnic Disparities Task Force”.
Biden proposes measures to further extend fiscal relief to individuals, schools and businesses, to provide enhanced insurance coverage, to support states in providing COVID-19 related services, and to eliminate cost-sharing for COVID-19 treatments. He would further expand paid leave for sick workers and those caring for family members due to COVID-19 and provide additional pay for frontline/essential workers.
On vaccine pricing, he would authorise the Federal Government to approve the price of any COVID-19 vaccine developed with federal resources, in contrast to the Trump Administration, which has said it does not want to pursue price controls.
On the global front, Biden would “re-embrace international engagement” and restore funding to the WHO and reverse the Trump Administration’s decision to withdraw from WHO membership. He would restore the Directorate for Global Health Security and Biodefense at the National Security Council (established by Obama and abolished by Trump) and work to create a Global Health Emergency Board to harmonise the crisis response for vulnerable communities internationally.
It’s worth noting that as Vice President, Biden was part of the Obama Administration’s response to the 2009 H1N1 outbreak, the 2014 Ebola outbreak, and 2016 Zika outbreak.
Croakey is planning some online events around the US election and global health, and I am looking forward to discussing these issues with my Croakey colleague Summer May Finlay and Bruce Wolpe.
Stay tuned for more details, and save the dates: 5pm AEST on Sunday 18 October and 2pm AEST (or later) Wednesday 4 November.
Also, see this recent Covering Climate Now collaboration cross-post at Croakey, by Bill McKibben: On election day, it won’t be just Americans watching.
Coronavirus vaccines – building a bulwark against politics
It is now widely acknowledged that – regardless of the availability of needed data – President Trump will make politically motivated announcements about coronavirus vaccine success ahead of the election on November 3.
This has combined with some strong anti-vaxxer sentiments in the US to undermine public confidence in vaccines. A recent survey found that only 51 percent of adult Americans now say they would definitely or probably get a vaccine to prevent COVID-19 if it were available today (down from 72 percent in May). Nearly as many (49 percent) say they definitely or probably would not get vaccinated at this time.
On the heels of a pledge from nine pharmaceutical companies to ensure that a potential vaccine would meet rigorous standards, some of these companies have also moved to reveal their study designs and evaluation procedures in attempts to boost public trust and counter the confusion sown by Trump. AstraZeneca – Oxford University, Modern and Pfizer and, most recently, Johnson & Johnson, have all made their vaccine trial blueprints public.
Meanwhile a group of African American doctors, organised by the National Medical Association (NMA), has created an expert task force to independently assess regulators’ decisions about coronavirus drugs and vaccines as well as government recommendations for curbing the pandemic.
“It’s necessary to provide a trusted messenger of vetted information to the African American community,” said the NMA president.
The task force will also evaluate how well the clinical trial participants represent the demographic breakdown of the American population, as well as the fairness of federal plans to distribute a vaccine — both of which are especially important given the disproportionate impact the pandemic has had on African American, Latino, and Native American communities.
The Commissioner of the Food and Drug Administration (FDA) used an opinion piece in The Washington Post to try to reassure the public, stating that “only a safe and effective vaccine will get our approval”. But after last week’s debacle over the censoring of information provided by the Centers for Disease Control and Prevention (CDC), who could believe that?
The FDA is set to release new guidance that would raise safety and efficacy requirements for a vaccine emergency use authorisation – with standards it says will be above earlier guidance and above the criteria used for convalescent plasma or hydroxychloroquine.
However, on September 15 the Secretary of Health and Human Services (HHS), Alex Azar, assumed all final authority in deciding new rules from HHS agencies, including the FDA. This will make it more difficult for FDA to issue stronger rules and regulations.
Trump followed this up with comments to the media that the White House “may or may not” approve the new FDA guidelines, saying that this “sounds like a political move”.
It is appropriate that a number of public health officials and medical commentators are pointing out that the advent of a safe and effective vaccine signals the beginning of a real coronavirus response, not the end (see, for example, this article by Aaron Carroll in The New York Times).
Even assuming the vaccine can be distributed widely and quickly, that most people will get it, and that distribution will be prioritised so that those most at risk will get it first (this might happen it Australia, but it is unlikely in the US, especially under a Trump Administration) – the approval of a vaccine marks only the beginning of a new stage in the response to coronavirus, not the end.
Until there is convincing evidence that a vaccine has a large and lasting population-level effect, there will still be a need to wear a mask, to distance and socially isolate.
The advent of a vaccine does not mean life will return to pre-pandemic normal.
Links between mental illness and COVID-19
The Lancet has just published a study from South Korea showing that a diagnosis of a mental illness is not associated with increased likelihood of testing positive for SARS-CoV-2. Patients with a severe mental illness had a slightly higher risk for severe clinical outcomes of COVID-19 than patients without a history of mental illness – presumably reflecting that fact with people with mental illness are more likely to have co-morbidities and these are less likely to be well managed.
These findings are what you would intuitively expect and are in line with the evidence that people with a mental illness have a higher mortality and a poorer prognosis than the general population when they are diagnosed with any disease.
But another recent paper published in The BMJ, which used UK Biobank data, found that pre-pandemic psychiatric disorders were associated with an increased risk of coronavirus infection and especially with severe and fatal COVID-19.
The excess risk was observed across all levels of somatic comorbidities and subtypes of pre-pandemic psychiatric disorders. The authors propose that altered immune responses might be involved.
As a commentary in The Lancet Psychiatry in April said:
Few voices of this large but vulnerable population of people with mental health disorders have been heard during this epidemic.
Epidemics never affect all populations equally and inequalities can always drive the spread of infections.
As mental health and public health professionals, we call for adequate and necessary attention to people with mental health disorders in the COVID-19 epidemic.”
Mental health in the 2020-21 Federal Budget
We are all waiting expectantly (but perhaps not very optimistically) to see what is in the Morrison Government’s 2020 – 21 Budget, to be delivered October 6, for health and healthcare. The coronavirus pandemic has exposed some huge needs, especially as far as mental health services are concerned.
This month a group of a group of Melbourne GPs wrote to Victorian Premier Daniel Andrews reporting up to fivefold increases in the number of cases of people with mental health problems they see daily, including young teenagers at risk of suicide.
Failure to address these needs effectively now will mean huge costs (economic and social) for individuals and the nation in the future.
Modelling done by the University of Sydney’s Brain and Mind Institute (BMI) shows that the mental health bill for the nation due to COVID-19 lockdowns and unemployment could be as high as $114 billion over the next five years. The total costs might be even higher: The Canberra Times reports that the Productivity Commission estimates mental ill-health and suicide are costing Australia up to $180 billion per year.
The BMI report calls for an “urgent” $2.2 billion boost to community-based mental health services to address the current shortage of mental health services that will see more people turning to hospital emergency departments (EDs) as the only available help.
The tsunami of ED presentations predicted is already being reported – and the ED is not a good place for people in mental health crisis to get the care they need.
A recent report from the Australasian College for Emergency Medicine (ACEM) looks at why Australia’s mental health system is failing people who present to the emergency department in mental health crisis, and the urgent reforms that are needed.
It makes the case that more needs to be done in the community to avoid the types of crises that precipitate a visit to the ED, and that more appropriate, timely treatment options are needed to minimise ED waiting times for people seeking mental health care.
Dr Simon Judkins, the Immediate Past President of ACEM, wrote an article about this report for Croakey, calling Emergency Departments “the canary in the coalmine for mental healthcare system failure”.
There’s been a lot of focus on telehealth services for mental health and they have certainly helped improve access.
But recent research highlights that these services are not always suitable. A pre-print of an Australian study, published in early September, found that telehealth is less effective for mental health services, most commonly because communication was perceived to be less effective. Such findings indicate that simply expanding telehealth mental health services will not be sufficient to meet the needs of those who seek care.
In an opinion piece on telehealth published in the Medical Republic, Dr Helen Schultz, a consultant psychiatrist, writes that in these pandemic times “telehealth has been a blessing and a curse”.
Dr Sebastian Rosenberg wrote an article for Croakey, based on the Budget submission made by BMI and the Australian National University, about the big budget boost that is needed for mental health in order to address both the needs exposed by the pandemic and the longer-term reforms.
I am not optimistic that we will see anything to do with longer-term reforms because Health Minister Greg Hunt has, to date, failed to release the Productivity Commission’s mental health report, which was handed to the Government on 30 June.
You can read the Spring update from the Royal Commission into Victoria’s mental health system here.
As my Croakey colleague Marie McInerney reminds us, it’s not only the health portfolio that matters when it comes to health impacts of the budget: #AusterityKills.
Please join the Croakey team in using the hashtag #Budget2020Health to share on Twitter health-related budget news.
More on the health impacts of bushfires
If you are a regular reader of The Health Wrap or follow me on Twitter, then you know that I have often argued the need for continuing research on the long-term effects of bushfires.
Here is the case I made in January: Why it is imperative to start now to study and research the long-term health effects from bushfires.
And here is the case made by my colleague Jennifer Doggett in June: Summer’s legacy.
This month has seen new data and research that adds to the case. A paper from Australian academics with expertise in this area, published in in Nature Sustainability (sadly behind a paywall), compared the health costs of the past 20 fire seasons across Australia. It finds that the healthcare costs of the 2019-2020 bushfire season were unprecedented, with a cascade of hospital admissions and premature deaths.
The 2019-2020 bushfire season had a health cost of $1.95 billion – about three and a half times the next highest estimate of $566 million for 2002-2003. NSW bore the brunt of the cost ($1.07 billion), followed by Victoria ($493 million) and Queensland ($224 million).
According to the researchers, “relatively few studies” have looked at the health costs of bushfire smoke exposure and this work needs to be included when considering future investments in fire management.
There are news media summaries of this research from the Sydney Morning Herald here and from RenewEconomy here.
A recent Insight article for The Medical Journal of Australia on what is known about the long-term impacts of bushfire smoke is headed “yesterday was the time to talk about it”. It highlights what is known about the impact on pregnant women and their babies, and this recent Croakey article by Rebecca Green brings a personal focus to these issues, ‘The summer everything changed’.
While some research is underway, funded by the Medical Research Future Fund, much more needs to be done.
Given the dreadful impact the Morrison Government’s policies are having on university staffing and research, one might ask how, where and when this will be funded and conducted, especially now that the focus has shifted to coronavirus.
Social prescribing
A number of issues coalesced this past week and got me researching the potential role of social prescribing links workers in primary care, sub-acute care and even aged care in Australia.
First, there was this piece on “Home based and community health care” by Professor Mary Chiarella, which looks at the healthcare teams and funding models that would support increased used of home-based and community health care.
In the context of the Royal Commission on Aged Care Quality and Safety there is the debate about staffing levels and the related issue of how to ensure people get both the medical care and the social attention they need (whether they are living at home or in a residential aged care facility). Read the review of innovative aged care models prepared for the Royal Commission here.
And then there is the perennial issue of how to help people with chronic illness (both physical and mental) to better manage their conditions.
In the UK, a workforce is especially charged with helping patients manage the intersection between medical care and social care – the social prescribing links worker. This is a role that is not unlike that of case manager or care navigator, but they operate in primary care with a focus beyond the healthcare system.
It is interesting to note an emphasis on addressing loneliness and isolation. In the UK it is estimated that one in five people who visit a GP surgery do not have a medical problem but could benefit from a healthier lifestyle or greater social interaction – that is likely similar in Australia.
Here’s how NHS England describes social prescribing and the role of links workers:
Social prescribing is a key component of Universal Personalised Care.
Social prescribing is a way for local agencies to refer people to a link worker. Link workers give people time, focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support.”
NHS England says social prescribing works for a wide range of people, including those:
- with one or more long-term conditions
- who need support with their mental health
- who are lonely or isolated
- who have complex social needs which affect their wellbeing.
It says:
When social prescribing works well, people can be easily referred to link workers from a wide range of local agencies, including general practice, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations. Self-referral is also encouraged.”
Social prescribing links workers have been in place in some parts of the UK for a while (there are currently about 1,500 links workers) and recently there have been efforts to boost this.
There is neither time nor space to explore this approach in greater detail. This paper “Link Worker social prescribing to improve health and well-being for people with long-term conditions: qualitative study of service user perceptions” found that most program participants surveyed experienced multimorbidity combined with mental health problems, low self-confidence and social isolation. All were adversely affected physically, emotionally and socially by their health problems.
The intervention of social links workers engendered feelings of control and self-confidence, reduced social isolation and had a positive impact on health-related behaviours including weight loss, healthier eating and increased physical activity. Thus the value of a holistic approach to health is highlighted – no surprise!
Clearly this an approach worth exploring as part of needed primary care reforms in Australia, especially if doctors’ organisations were more willing to think beyond general practice and fee-for-service models of primary care and alternative financing mechanisms for the primary care team.
Social prescribing has been considered and discussed by a number of organisations and groups (see for example, this report from a roundtable on social prescribing held by the Royal Australian College of General Practitioners and Consumers; Health Forum in November 2019). There are also at least a few pilot programs – for example, Plus Social which is operated by the Gold Coast Primary Health Network, whose website also has some useful links to evidence and references.
I found this Scottish evaluation from 2017, which I think does a good job of highlighting the implementation problems.
This year Croakey has published these articles on social prescribing:
February 11, 2020: Primary care push for a social prescribing scheme
May 13, 2020: ‘Iso’ – a spur to think about social prescribing
June 19, 2020: How social prescribing can improve health and wellbeing
Dementia Action week
It didn’t get much attention, but this past week (September 21 – 27) was Dementia Action Week. There’s been some interesting news around dementia – some good, some not.
An article published in JAMA Global Health this month looks at what is known about preventing, or at least delaying, dementia. Recently international experts have expanded the list of risk factors that, if reduced or eliminated, could prevent or delay 40 percent of dementia cases worldwide.
In a 2017 report, The Lancet Commission on Dementia Prevention, Intervention, and Care identified nine preventable risk factors for dementia: having little or no education, hypertension, untreated hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, and low social contact.
Since then, the Commission has reported there are three additional preventable dementia risk factors: head injuries, excessive alcohol consumption in midlife, and air pollution exposure in later life (is this last one a link to bushfire smoke?)
To prevent or delay dementia, the Commission recommends the following actions:
- Provide primary and elementary education for all children
- Prevent obesity and diabetes
- Reduce air pollution and exposure to second-hand smoke
- Prevent smoking initiation and encourage smoking cessation
- Prevent hearing loss and encourage hearing aid use
- Prevent head injuries
- Maintain systolic blood pressure of 130 mm Hg or lower in midlife, limit alcohol to fewer than 21 servings per week, and maintain an active lifestyle.
Also in the news is the huge increase seen in the United States in the number of deaths attributed to Alzheimer’s disease and dementia; deaths from these causes rose more than 20 percent over normal during the American summer.
An analysis of CDC data by The Washington Post shows that more than 134,200 people have died from Alzheimer’s and other forms of dementia since March. That is 13,200 more deaths from these causes than expected, compared with previous years. A similar analysis by Politico delivered similar findings.
These deaths are seen as linked to the true toll of the coronavirus pandemic and among the sources of excess deaths, dementia has produced by far the most — more than the next two categories, diabetes and heart disease, combined.
Some of the reasons are that people with dementia have not had the medical treatment, the daily care or the social interactions they need during the pandemic. It sadly is a case of “out of sight, out of mind” or, worse, that the lives of these people are not considered valuable.
Do we have any idea what is happening in Australian aged care facilities?
Data from the Australian Bureau of Statistics show that deaths from pneumonia, diabetes and dementia did spike above longer-term averages through the early stages of the coronavirus pandemic (to the end of May). No more recent data are available.
Source: The ABS
The pandemic has not only significantly affected the care of people with dementia – it has also adversely impacted research, especially behavioural research.
Alzheimer Europe has called for urgent action to address the impact of COVID-19 on dementia research and outlined the effect on existing projects.
The best of Croakey
Check out the #FreeHer campaign, as reported by Debbie Kilroy, Tabitha Lean and Vickie Roach.
And please follow the #JusticeCOVID Twitter festival on Tuesday 29th from 11am AEST-1pm AEST. It will be moderated by Dr Tess Ryan, and I will be presenting on the global picture on prisons and the pandemic.
Good news story – the bilby revival
More than 100 years ago the bilby – Australia’s cute marsupial version of the Easter bunny – was declared extinct in the wild in New South Wales. But now that has changed. In 2019, 50 bilbies were released into Mallee Cliffs national park (now predator-free) in the south-east of the state, and now ecologists have reported these bilbies are breeding and there are bilby joeys.
To add to the good news, this month ten bilbies have been released into Stuart national park in the north-western corner of NSW.
For the local Wongkumara people, the region’s Traditional Owners, the return of the bilby to these lands is seen as a healing process for the land.
There are just 9,000 bilbies in Australia and the reintroduction of the small marsupial into these special enclosures aims to increase that number by 17 percent.
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.
