As governments press ahead with plans to “live with the virus”, the latest edition of The Health Wrap stresses the importance of balancing freedom with protection, especially for those who are at greatest risk.
Associate Professor Lesley Russell also investigates the push for global climate action, the place of physical activity and creativity in healthy ageing, and some pharmaceutical industry news that you may not have heard about.
Following the recent Dementia Action Week, Russell calls for the needs of people with dementia to be “at the centre of primary care and aged care reforms, research on prevention, treatment and management, and planning for the needed care workforce”.
Lesley Russell writes:
Concerns are growing that government proposals to open up and “learn to live with the virus” in the weeks and months ahead do not sufficiently take into account the need to ensure that everyone in every community is assured both maximum protection and equal freedoms.
These concerns arise from the lagging effort to ensure that the most vulnerable are vaccinated (for example, people with disability are being left behind), from the inequitable levels of lockdowns imposed on different communities (for example, Sydney’s eastern suburbs versus western and south western Sydney), and from the ongoing failures to address predictable problems in a timely fashion (for example, COVID-19 outbreaks in prisons).
The opening up plans developed to date continue to ignore the socioeconomic divides that have been so dreadfully highlighted by COVID-19.
Recommended reading
Croakey Health Media has published a number of articles on these issues. Here are some of the most recent:
- Nicole MacKee: Back-to-school plans must address issues of educational inequity, say experts.
- Melissa Sweet: Aboriginal health alarm over NSW Government’s “freedom” plans.
- Stephen Duckett and Anika Stobart: Concerns mount over NSW’s COVID opening plan.
- Nicole MacKee: Aboriginal and Torres Strait Islander people’s voices must be heard in NSW COVID response.
- Elysia Thornton-Benko: Raising some pointed questions about back-to-school plans in NSW.
- Susan Green: COVID in Wilcannia: a national disgrace we all saw coming.
And here’s a selection from other sources on this topic:
- The Conversation: Vaccinations need to reach 90% of First Nations adults and teens to protect vulnerable communities.
- The Conversation: Australia was a model for protecting people from COVID-19 – and then we dumped half a million people back into poverty.
- The Guardian: Ending restrictions with 80% vaccinated could cause 25,000 Australian deaths, new modelling suggests .
- Last month ACOSS sent an open letter to National Cabinet urging it to develop vaccination targets that are specific to population groups and locations in line with its Community Sector Vaccination Principles.
- There was a similar letter from a diverse range of organisations representing the interests of people with disability, their families, carers and support persons.
The case made in these communications is further strengthened as new modelling and new data have become available and effectively supersede the work done by the Doherty Institute which forms the basis of National Cabinet’s four-stage reopening plan.
See, for example:
- ANU researchers: Modelling highlights risks in national COVID plan.
- The Burnet Institute: Modelling the Victorian Roadmap.
- University of Mebourne researchers: COVID-19 pandemic tradeoffs modelling.
- OzSAGE: Independent expert advice on opening safely in the COVID-19 pandemic.
(As an aside – how fabulous that Australia has all this expertise! And what are we doing to ensure it is there for the next pandemic?)
It will be interesting to see if Prime Minister Scott Morrison and NSW will revisit the reopening plans in the days ahead, especially given the data from Canada that shows the Delta strain of the virus is significantly more deadly than was assumed when the national plan was adopted.
A recent article in The Sydney Morning Herald provides some useful background: The Doherty reopening report: all your questions answered (hopefully).
Beyond paternalism
In line with the need to protect at-risk population groups while respecting their autonomy, a recent paper in the Australian and New Zealand Journal of Public Health from researchers at the Indigenous Education and Research Centre at James Cook University found that unilateral government policy responses to the pandemic in Indigenous communities have perpetuated an ongoing paternalistic discourse, “informed by notions of Indigeneity as deficient”.
Too often they have failed to build on the strengths of, and work done by, Aboriginal and Torres Strait Islander families, leaders, and communities and the work of community-controlled health organisations.
In particular, the paper cites how Indigenous mobility was seen as a problem to be addressed with law-and-order solutions while other health risks – more serious, more long-standing, and clearly within government control – such as overcrowding, poor standards of housing, affordable nutrition, health education, and limited medical infrastructure were ignored.
The pandemic has highlighted too many occasions when government policies and programs have ignored Indigenous advice and expertise and taken a “deficit discourse” approach that places responsibility for dysfunction with the affected individuals or communities, while overlooking the complex socioeconomic environment they confront and ignoring their capabilities and strengths.
This recent Croakey summary from a round table at the World Congress of Epidemiology 2021 explores this approach further: Research against racism: why strength-based approaches are crucial in Indigenous health research.
And also read Dr Dawn Casey’s presentation to the recent Australian Public Health Conference, after receiving the Public Health Association of Australia’s Sidney Sax medal.
Longevity, exercise and creativity
Readers of The Health Wrap know that these are issues that I return to frequently. These days, like many, I am obsessively walking every route in my Local Government Area while missing the gym (whoever would have thought I would say that?) and planning the long hikes I want to do when travel finally begins.
Science has not established whether and to what extent the physical decline that comes to most of us as we age is inevitable or is at least partially a by-product of modern lifestyles and thus amenable to change.
Recent studies have found that older athletes have healthier muscles, brains, immune systems and hearts than people of the same age who are sedentary. But most of these studies have concentrated on competitive athletes, rather than people who exercise recreationally, and few have included many women.
A study published several years ago in the Journal of Applied Physiology compared the cardiovascular systems and muscles of three groups – people in their seventies who had been physically active (running, swimming, cycling) over the past fifty years but had rarely or never competed; age-matched older people who had not exercised during adulthood; and active young people in their twenties.
They found the muscles of the older exercisers resembled those of the young people, with as many capillaries and enzymes, and far more than in the muscles of the sedentary elderly. The active elderly group did have lower aerobic capacities than the young people, but their capacities were about 40 percent higher than those of their inactive peers.
The researchers calculated that the aged, active group had the cardiovascular health of people 30 years younger. These findings suggest that exercise could help to build a reserve of good health now that might slow the onset of physical frailty.
“The new 40”
It seems 70 really is the new 40! That might persuade you to keep up the exercise regime. How much exercise should you be doing?
A retrospective study published this month in JAMA Network Open shows a strong association with step counts and mortality. Those men and women accumulating at least 7,000 daily steps were about 50 percent less likely to have died than those who took fewer than 7000 steps. Mortality risk continued to drop as step totals rose, levelling off at 10,000 steps.
So my Fitbit obsession is justified, but probably overdone!
A second retrospective study published in August in Mayo Clinic Proceedings involved data from the decades-long Copenhagen City Heart Study (there’s lots of great information about health and exercise on the Study’s website).
It found that people who reported exercising in some way (walking cycling, badminton, swimming) between 2.6 and 4.5 hours per week were 40 percent less likely to die during the period studied than less active people.
The researchers translated the hours of exercise into step counts. This is not an exact science but they estimate people exercising for 2.6 hours a week, or about 30 minutes most days, would accumulate around 7,000 to 8,000 steps on those days; those working out for 4.5 hours a week would reach the 10,000-steps a day threshold.
And at that point, as in the previous study, benefits plateaued. But there was also a surprising decline in benefits among the relatively few people who worked out for 10 hours or more per week.
My take-out: do whatever physical activity you enjoy, do it regularly, but don’t over-do it.
And if physical activity is just not your thing, then there’s this: research suggests that creativity may be key to healthy aging.
Studies (such as this) show that participating in activities such as singing, theatre performance and art supports the well-being of older adults, and that creativity, which is related to the personality trait of openness, can lead to greater longevity. Moreover, travel can boost creativity.
You can read more on this delightful, inspiring topic here.
The push for climate action grows
As world leaders gathered in New York for the 2021 General Assembly of the United Nations, climate change and the need for climate action was a top issue. You can see what else was on the UN agenda here.
At the start of the week there was an Informal Climate Leaders Roundtable on Climate Action, convened by UK Prime Minister Boris Johnston, which took place behind closed doors at UN Headquarters (it’s not clear if Prime Minister Morrison was an attendee).
Ahead of the roundtable, UN Secretary-General Antonio Guterres called for “decisive action now to avert climate catastrophe”.
He pushed for leadership from the G20 nations on three actions:
- Keep the 1.5-degree goal within reach.
- Deliver on the promised $100 billion dollars a year for climate action in developing countries.
- Scale up funding for adaptation to at least 50 percent of total public climate finance expenditure.
The United Nations Framework Convention on Climate Change has issued a report on the Nationally Determined Contributions (NDCs) of all parties to the Paris Agreement saying the world is on a catastrophic pathway to 2.7 degrees of heating. According to the report, to limit temperature rise to 1.5 degrees, a 45 percent cut in emissions is needed by 2030.
The Intergovernmental Panel on Climate Change finds the 1.5-degree goal is still in reach, but a dramatic improvement is needed in the NDCs from most countries.
On September 4 The Lancet Planetary Health published an editorial from editors of health journals world-wide, ahead of the UN Climate Change Conference of the Parties (COP26) in Glasgow. It calls urgent action to keep average global temperature increases below 1·5°C, halt the destruction of nature, and protect health.
They write:
Many governments met the threat of the COVID-19 pandemic with unprecedented funding. The environmental crisis demands a similar emergency response.
Huge investment will be needed, beyond what is being considered or delivered anywhere in the world.
But such investments will produce huge positive health and economic outcomes. These include high quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.”
#HealthyCOP26
Croakey will be actively tracking and reporting on the latest new on climate and health in the countdown to COP26. Follow the news using the hashtag #HealthyCOP26.
The United States is expected to play a leadership role in COP26 and President Joe Biden has made climate action, at home and internationally, a key aspect of his presidency.
In his speech to the UN, he called climate change a “borderless” crisis and said all nations need to bring “their highest possible ambitions” to the climate summit in Glasgow in November.”
Biden likely also put pressure on Morrison during their one-on-one meeting where he said: “The United States and Australia are working in lockstep on the challenges that I laid out today in my speech to the United Nations: ending COVID, addressing the climate crisis…”.
The Morrison Government is clearly out of step with most Australians on climate change, as a recent poll shows. A clear majority (60 percent) of Australians want the Federal Government to cut greenhouse gas emissions to net zero by 2050. A more ambitious target for 2030 also has slim majority support (52 percent).
The United States has endured a dreadful summer of wildfires and, as Croakey recently reported, Biden has just announced steps to combat extreme heat linked to climate change, now America’s leading weather-related cause of death.
Six federal agencies will coordinate to protect vulnerable populations – including outdoor workers, children and the elderly – from heat-related illnesses and other public health risks linked to rising global temperatures.
This will include the development of new federal labour standards to protect outdoor workers, including agricultural, construction, and delivery workers, as well as indoor workers, including those in warehouses, factories, and kitchens from heat exposure.
Biden did not mention the health impacts of wildfires – which is also a major issue in Australia. The September 1 issue of The Lancet Planetary Health is focussed on the health risks associated with climate change and air pollution linked to wildfires.
The papers included illustrate some of the health challenges associated with what are called “landscape fires” and the smoke they produce.
Dementia – the major chronic disease of this century
Last week was Dementia Action Week and September 21 was World Alzheimers Day.
Nearly half a million Australians are living with dementia, with almost 1.6 million people involved in their care. The forecasts from Dementia Australia are that by 2058, 1.1 million people will be living with dementia.
A report from the Australian Institute of Health and Welfare (AIHW) released to coincide with this Action Week shows that dementia is the leading cause of death for women, the second leading cause of death for all Australians after heart disease, and the third leading cause of disease burden.
This is the first comprehensive report on dementia since 2012. It finds that the direct cost of dementia to the nation is about $3 billion. This includes $1.7 billion on residential aged care, with about 132,000 of 244,000 residents nationwide living with dementia.
A report from Dementia Australia describes dementia as one of the major chronic diseases of this century and outlines how people with dementia face discrimination, do not feel included in society, and often have their rights ignored.
Too often they are shunned by family, friends and colleagues and denied needed services. This discrimination can extend to their carers. It leads to social isolations, loneliness, poor mental health and financial stress. COVID-19 has intensified these experiences.
What is sometimes referred to as the dementia tsunami must be at the centre of primary care and aged care reforms, research on prevention, treatment and management, and planning for the needed care workforce.
As I was researching this, I came across an opinion piece I wrote about these needs in 2015. Sigh – so little has changed!
In that piece I bemoaned the cuts to preventive health programs that were made to fund the Medical Research Future Fund (MRFF). When the MRFF was announced, then-Treasurer Joe Hockey offered the tantalising prospect it might produce a cure for dementia and Alzheimer’s Disease.
I’ve been analysing how the MRFF funds are spent. $167.5 million has been allocated to the Dementia, Ageing and Aged Care Research Mission to 2021-28. As of last week, only 12 projects, totally $27 million, had been funded (including one grant of $10 million to the University of Queensland) and the roadmap to guide priorities for funding remained in draft form.
Now, in acknowledgement of Dementia Action week, Health Minister Greg Hunt has announced an additional $25.5 million under the Dementia, Ageing and Aged Care Mission for dementia research and release and finalisation of the Mission’s roadmap. Given the burden of disease, this level of research spending is still really inadequate.
Also announced was $13 million for the AIHW to establish the National Centre for Monitoring Dementia to routinely monitor dementia care in Australia.
See the resources mentioned in the tweet above here.
New agreements with pharmaceutical industry
I spend a lot of time complaining about the work that the Morrison Government doesn’t do – and then there’s the work they do and don’t tell us.
New agreements between the Federal Government and Medicines Australia (MA) and the generic Biosimilar Medicines Association (GBMA) that will have significant consequences for the Pharmaceutical Benefits Scheme (PBS) fall into this latter category.
I sometimes think that we don’t pay enough attention to the issues around the PBS; keeping up with what is happening is not easy as much of the insider reporting is in online newsletters that are not publicly available.
I have limited access to these – here’s what I’ve been able to gather about these new agreements.
The new agreements replace one signed in 2017 (you notice that while issues like the National Preventative Health Strategy take forever to be finalised, this is done smartly ahead of time – the current agreement does not expire until July 2022). You can access the 2017 agreement here.
These agreements are couched in language that proclaims their role in ensuring that patients will be able to access new medicines and therapies when they need them, but really they are about providing economic surety and the ability to get products listed on the PBS in a timely fashion for the pharmaceutical industry. There are billions of dollars involved.
That said, there are some initiatives in the new agreement that will benefit Australians. Most notably, there are provisions to ensure there is robust and uninterrupted supply of prescription medicines.
As most prescription medicines are now manufactured overseas, Australia has regularly encountered supply problems for some essential products and these have e become more serious as the coronavirus pandemic has led to disruptions to supply chains globally. The Therapeutic Goods Administration has a website that reports and monitors these shortages.
Here are the key measures in the new agreements (taken from the Health Minister’s media release):
- An expected investment of approximately $5 billion in PBS medicines listings over the life of the agreement; through the PBS New Medicines Funding Guarantee. This was established in the 2020-21 Budget and originally funded at $2.8 billion over four years.
- A new statutory pricing system for medicines with efficiencies from price reductions (estimated at $1.9 billion over five years) agreed with the pharmaceutical industry to be reinvested in PBS listings.
- An Enhanced Consumer Engagement Process to better capture the patient voice early in the medicines assessment process. This has been welcomed by Consumers Health Forum.
- A Medicines Supply Security Guarantee to include a commitment by pharmaceutical companies to hold additional onshore stocks of critical medicines, of at least four to six months, to better protect patients against supply chain volatility.
- A review and what is described as “enhancements” to Health Technology Assessment (HTA) policy and methods.
- A Horizon Scanning Forum to provide early access to breakthrough treatments.
- Commitments to policy stability and predictability for the industry and Government.
Note that the $5 billion for investing in new medicines is contingent on “efficiencies” of $1.9 million being reached.
The industry groups have welcomed these new agreements. The MA response is here. The GBMA response is here.
Reading between the lines, I would say that they are placing a lot of optimism for the future on the outcome of the Health Technology Assessment (HTA) Policy and Methods Review. This will involve the TGA and the Pharmaceutical Benefits Advisory Committee and may also include the Medical Services Advisory Committee.
This is stated to cover “methods for evaluating medicines for rare diseases, emerging technologies such as cell and gene therapies, and other precision-based medicines, the use of real-world evidence in decision making, and the feasibility of international work-sharing for reimbursement submissions, amongst other issues.”
The last HTA review was in 2009. The (archived) HTA Framework website from 2011 is here.
The best of Croakey
The Croakey Conference News Service has been very busy in recent weeks – don’t miss these reports from the Youth Health Forum summit.
And by the way – don’t miss Croakey’s new occasional columnist Professor Kathy Eagar and COVID Snaps – her news and views, knowledge and insights, and sometimes scathing wit on COVID-19 issues.
First two columns are here; I’m eagerly awaiting the next one.
The good news story
Dr Jamal Rifi is a local hero – and for good reason. He has been working tirelessly throughout the pandemic to serve his community and ensure they get the information, testing, vaccinations and care they need, from someone they trust.
Listen to him speaking with Croakey’s Cate Carrigan.
There’s more here, from the ABC.
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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