Worrying news on the infectious diseases front just keeps on coming, reports Associate Professor Lesley Russell in her latest column, covering the latest on monkeypox and other diseases hitting the headlines (or not).
This latest edition of The Health Wrap also reports on health policy news from the United States, including efforts to tackle racism in health, and brings some good news on life expectancy increases in the African region.
Lesley Russell writes:
The global outbreak of human monkeypox has now spread to more than 31,700 cases – with about a third of those in the United States.
In the wake of criticisms that the Biden Administration has been slow to act on the spread of the disease, on August 4 the Secretary of Health and Human Services, Xavier Becerra declared monkeypox a public health emergency. The announcement came just two days after the appointments of a White House National Monkeypox Response Coordinator and Deputy Coordinator.
The Administration strategy to combat monkeypox includes the production and distribution of vaccines, expanding access to testing and treatments, and empowering communities affected by or at risk of contracting the virus.
The emergency designation provides immediate funding and lifts some bureaucratic hurdles, but many experts fear the slow start means containment may no longer be possible.
As of August 5, the Centres for Disease Control and Prevention had confirmed 7,510 cases spread across all but two states. But, as an article in The Nation states, to date vaccines are limited, communication is poor, and conspiracy theories abound.
Although it is not the case in Africa, in the United States monkeypox is mostly diagnosed in men who have sex with men and it is behaving like a sexually transmitted disease. This has led to fears of homophobia but also concerns that, as was for so long the case with HIV/AIDS, other at-risk populations are being ignored.
The right wing media’s aggressive stigmatisation of Americans with monkeypox poses a serious challenge to public health advocates and community leaders trying to have honest conversations about the disease with the gay and bisexual men who are most at risk during the current outbreak.
The parallels between the two infections are limited but clear. Many who work in HIV/AIDS are pushing for public health authorities to use the well-established and trusted HIV/AIDS networks for relaying information and services to the population most at risk.
Last month The New Yorker published an interesting article on the need for a global fight to tackle this disease.
In an opinion piece for the BMJ on why the monkeypox outbreak constitutes a public health emergency of international concern, Dr Tedros Adhanom Ghebreyesus, Director General of the World Health Organization, said:
This outbreak is another demonstration that breaking the cycle of ‘panic and neglect’ that for decades has been the hallmark of the global response to epidemics and pandemics requires a paradigm shift in global health.
The world ignores at its peril pathogens that spread “only” in low-income countries; most are one flight away from sparking a global public health emergency.
Protecting the health of any population relies ultimately on protecting the health of every population, through stronger public health functions and health systems, based on robust primary health care and a commitment to universal health coverage. Global health security depends on local health security in every country.”
In Australia (with 57 confirmed cases as of August 4), monkeypox was declared a Communicable Disease Incident of National Significance by the Chief Medical Officer Dr Paul Kelly on July 28. The Federal Government has secured 450,000 vaccine doses and states have begun an immunisation campaign.
An article published last week in The Washington Post outlines how warnings about the threat of monkeypox, including signs that it was spreading more rapidly by sexual transmission, were ignored for over a decade.
In 2010, researchers reported the rate of monkeypox cases in the Democratic Republic of Congo (DRC) had increased twenty-fold from the 1980s to the mid-2000s. In their paper, published in the Proceedings of the National Academy of Sciences, the authors (epidemiologists from the US and the DRC) wrote that, if the growth went unaddressed, it could cost the world a chance “to combat [the virus] while its geographic range is limited”.
A second alert came in 2019 in a paper that analysed an outbreak of monkeypox in Nigeria in 2017, the first cases in the country in almost 40 years. The authors concluded that the virus was spreading from person to person, not just from animals to humans, and appeared to be transmitted through sexual contact.
The WHO had also noted, in its own report about the Nigerian outbreak in 2017, that: “The nature of person-to-person contact leading to transmission needs to be studied; some suspect sexual transmission may be one route.”
Scientists’ now fear that – despite all the warnings and emergency declarations – monkeypox may establish a permanent foothold in developed countries like the United States and Australia, joining viruses such as HIV and influenza.
Origin of COVID-19 back in the news (again)
Two papers just published in Science argue that the coronavirus pandemic began in separate viral spill overs – at least two but perhaps many more – from live animals sold and butchered in late 2019 at the Huanan Seafood Market in Wuhan, China. You can read the articles here and here.
The papers, which were subject to months of peer review and revisions, are unlikely to quell the rancorous debate about how the pandemic began and whether the virus emerged from a Chinese laboratory.
The authors acknowledge there are many unknowns requiring further investigation – most notably, which animals were involved.
The papers are nicely summarised in this article in The Washington Post.
In an article in The Age, Professor Dominic Dwyer, director of public health pathology in NSW and a member of the World Health Organization (WHO) team that travelled to Wuhan last year to investigate the origins of the virus, agrees with one of the co-authors who states that: “In terms of what we can reasonably do, with the available science and the science we’ll get in the foreseeable future, I think we’re at the end of the road frankly. There’s not a lot more to mine.”
That’s unlikely to stop the conspiracy theories. As an example, Republican members of the intriguingly named Subcommittee on Emerging Threats and Spending Oversight of the US Senate Committee on Homeland Security and Government Affairs recently held a hearing on gain of function research.
You can watch the hearing here, but be warned, it is led by Senator Rand Paul (not known for his scientific expertise) and, mysteriously, no Democrats are present.
Meanwhile there are two warning signs of growing disease threats that should keep public health officials on the alert:
- A new animal virus, named Langya henipavirus (LayV), that can infect people has been identified in eastern China. It causes respiratory symptoms and is closely related to two other henipaviruses known to infect people — Hendra virus and Nipah virus. Researchers think LayV is carried by shrews, which might infect people directly or through an intermediate animal. The original paper in the New England Journal of Medicine is here; there is a good summary in Nature here.
- A recent WHO analysis finds that Africa is facing a growing risk of outbreaks caused by zoonotic pathogens (such as monkeypox) which originate in animals and then switch species and infect humans. There has been a 63 percent increase in the number of zoonotic outbreaks in the region in the decade from 2012-2022 compared to 2001-2011.
As I was writing this, an article appeared at ABC News, headed “COVID-19 lab-leak theory debunked by Australian professor who has been dubbed ‘the virus hunter’”. You can read more here.
Polio threat in New York
The bad news on the infectious disease front just keeps coming.
Some three weeks ago there was a report that a man in Rockland County, north of New York City, was diagnosed with polio. Polio vaccination rates in the area are shockingly low, about 60 percent compared with 93 percent nationwide.
The last case of polio in the United States was in 2013, in someone who brought the disease in from abroad. There has not been a case originating in the United States since 1979, according to the Centers for Disease Control and Prevention.
It appears this most recent case was infected by someone who received the oral polio vaccine, which is no longer used in the United States.
Public health officials now find that the polio virus has been circulating in the wastewater of Rockland County and New York City and fear that it is being spread by people who are not displaying serious symptoms of infection.
People who have been vaccinated may still carry and shed the virus, even if they do not experience infection or symptoms. Epidemiologists say that means the virus will be difficult to eradicate quickly.
A major public awareness and polio vaccination campaign is now underway.
The “forgotten epidemic”
The 24th International HIV/AIDS Meeting was held in Montreal from 29 July to 2 August.
It began with an unpleasant (and arguably totally unnecessary) controversy around visa denials by the Canadian Government for some delegates. This was seen by participants as highlighting the broader problem of global inequity and systemic racism that significantly impacts global health and HIV/AIDS in particular.
But that aside, the substance of the conference received little attention from the mainstream media, even as the organisers expressed concern that, in the face of dualling pandemics, the world is losing ground against HIV prevention and treatment and in cure research.
“We live in a world where HIV is the forgotten epidemic,” the conference program stated.
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 79 million people have become infected with HIV. Only 28 million of the 38 million people living with HIV today are on life-saving antiretroviral therapy.
A number of protests at the conference highlighted the need to expand access to anti-viral therapy.
I attended the 5th International HIV/AIDS Meeting in Montreal in 1989. At that time research had just validated the use of AZT to postpone the onset of symptoms of disease secondary to HIV.
Friendships and economic mobility
Several recent articles in The New York Times have explored the implications of a major new study published in Nature that looks at the links between social capital and economic mobility.
Social capital – the strength of an individual’s social network and community – has been identified as a potential determinant of outcomes ranging from education to health, but efforts to understand what types of social capital matter for these outcomes have been hindered by a lack of social network data.
The paper uses data on 21 billion friendships from Facebook. The authors measured and analysed three types of social capital by ZIP (postal) code in the United States: (1) connectedness between different types of people, such as those with low versus high socioeconomic status (SES); (2) social cohesion, such as the extent of cliques in friendship networks; and (3) civic engagement, such as rates of volunteering.
I suspect there are a series of arguments about the widespread applicability of using data from Facebook, but the results are topical, interesting, and thought-provoking. The findings are available on a website that presents economic connectiveness, cohesiveness and civic engagement for neighbourhoods, high schools and colleges across the United States. It’s pretty impressive in its detail.
The key finding is that poor children who grow up in a community connected across class lines are more likely to rise out of poverty. These cross-class friendships (economic connectedness) had a stronger impact than school quality, family structure, job availability or a community’s racial composition.
The analysis did not directly measure the role of race, which was not provided in the Facebook data. But in more racially diverse places, the study found fewer cross-class relationships. You can read more about this research here.
Some of the implications of these findings are: there should be more subsidised housing in well-off areas; more diverse schools and colleges; and specific efforts — like public parks that draw a diverse mix of families — to encourage interactions among richer and poorer people. Churches and other religious organisations that have lower levels of what the researchers call socioeconomic “friending bias” may also help here.
An opinion piece in The New York Times by David Brookes asks one of the authors of this study “what is so (economically) powerful about friendships?” – you read the response he got here.
Health news from the United States
As many readers of The Health Wrap know, I have spent the past few weeks in the United States, so American news and the chance to catch up with public health friends from my days working in Washington DC mean that lots of interesting issues have been on my radar.
I see many initiatives in the US to tackle the healthcare issues of the day – issues that are in many cases common to both countries – that I wish Australia was also doing.
Enactment of the Inflation Reduction Act
President Biden has scored a big legislative win with passage through both the Senate and the House of the Inflation Reduction Act. This was done totally along party lines, without a single Republican vote.
The bill is a pared-back version of the Build Back Better package which last year failed to gain enough votes to pass in the Senate but it still represents some major achievements in deficit reduction, climate change and energy, health and tax reforms.
You can read the details of the bill’s provisions here. A more detailed analysis of the climate change and energy provisions is here. Note that there is nothing in this bill to address the impact of climate change on health.
There are several important healthcare provisions in the bill.
These include empowering the Secretary of Health and Human Services to negotiate prices for the top-selling drugs covered in Medicare. It also requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries. (Until now, the United States stood alone among high-income countries with no government control – outside of Medicaid and the Veterans Health Administration – over drug prices.)
The bill caps out-of-pocket drug spending for beneficiaries in Medicare Part D (drug coverage) at US$2,000 annually and limits the cost of insulin for people with diabetes who are on Medicare to US$35 per month.
The bill also extends for three years the enhanced Affordable Care Act (Obamacare) subsidies that Congress passed last year as part of the American Rescue Plan Act. That temporary boost increased the amount of financial help available to people already eligible to buy subsidised health plans in the ACA Marketplaces, and expanded subsidies to more middle-income people, many of whom were previously priced out of coverage.
More details are available in a briefing paper from the Kaiser Family Foundation here.
The legislation was passed under the provisions of budget reconciliation (which meant only 51 votes and not 60 were needed for passage in the Senate) and under the arcane rules that apply to this procedure, an extension of the drug price negotiation provision and the cap on insulin costs that would also apply to private health insurance was ruled out of order.
Despite this adverse ruling from the senate parliamentarian, Democrats opted to keep the full price cap provision in the bill anyway. Republicans challenged this on the Senate floor, and Democrats (with just 51 votes, including that of the Vice President) were unable to find the 60 votes needed to reject this effort.
In a sign of how toxic and partisan congressional politics has become, just seven Republicans were willing to support the inclusion of a limit on insulin costs, despite the benefit to millions of Americans. The fight was a policy loss for Democrats, but it was also a political win, as lowering the price of drugs like insulin is popular with voters.
This will surely be an issue that will be in play in the midterm elections in November. Over seven million Americans with diabetes require some form of insulin, and insulin prices have tripled in the United States in the last decade.
Even in this pared-down form, the changes to the cost of drugs in the US healthcare system in the Inflation Reduction Act are tightly described as momentous, politically and for the many patients struggling with drug costs.
This is the biggest health reform initiative since passage of the Affordable Care Act, more than a decade ago. And the fact that this new legislation passed despite the vehement opposition of the pharmaceutical industry makes it a statement about what’s still politically possible in the politically divided Congress in terms of healthcare reform.
Biden signs executive order to protect abortion rights
Republican state legislatures continue actions to limit access to abortions and reproductive care. Last week Indiana became the first state to pass an abortion ban (except in cases of rape, incest, fatal foetal anomaly, or a serious risk to the health or life of the pregnant patient) since the Supreme Court overturned Roe v Wade in June.
Indiana is the state where a 10-year old girl, pregnant after rape, was taken for an abortion last month when it was too late for her to be treated in her home state of Ohio.
On August 3 President Biden signed an Executive Order to protect reproductive rights.
The EO will:
- Increase access for patients who travel out of state for abortions. The executive order calls for the Secretary of HHS to “consider action to advance access” to reproductive healthcare services, including for Medicaid patients who travel out of state for abortions.
- Ensure that healthcare providers follow federal non-discrimination laws.
- Promote research and data collection on maternal health outcomes and how this is affected by diminished access to reproductive care.
Government reports on Long COVID
In compliance with a Memorandum on Addressing the Long-Term Effects of COVID-19 issued by President Biden in April, the Department of Health and Human Services (HHS), leading a whole-of-government response, has released two reports that provide actionable pathways to address Long COVID and associated conditions.
The National Research Action Plan on Long COVID, created in coordination with 14 government departments and agencies, provides a government–wide national research agenda focused on advancing prevention, diagnosis, treatment, and provision of services and supports for individuals and families experiencing Long COVID.
The Research Plan stresses four guiding principles to govern federal government data analysis work: health equity, accelerating and expanding current research, orienting the research effort to improve patient care, and partner engagement.
The Services and Supports for Longer-Term Impacts of COVID-19 Report provides information in three key areas:
- Federal supports and services available for people experiencing Long COVID. These include health care coverage, community services, financial assistance, nutrition, educational issues and rights.
- Resources for health care personnel treating patients with Long COVID, as well as support for health care personnel experiencing stress and trauma related to COVID-19.
- Services for individuals confronting challenges related to mental health, substance use, and bereavement.
Moves to tackle racism in health
A decade after it was first established as part of the Affordable Care Act (Obamacare) and in the wake of the disparate impact of the COVID-19 pandemic on Americans based on factors such as race, ethnicity, geography, and income, the Centers for Medicare and Medicaid Services (CMS) Innovation Center has articulated a new vision: “Achieve equitable outcomes through high quality, affordable, person-centered care.”
To realise this vision, the Innovation Center has developed a new strategic plan organised around five objectives, one of which is to advance health equity.
In a bold move, the Innovation Center then examined three established models of care it is currently promulgating (the Kidney Care Choices Model, the Comprehensive Care for Joint Replacement Model, and the Million Hearts® Cardiovascular Risk Reduction Model) to identify potential sources of bias.
All these models were found to have design flaws that lead to the exclusion of some potential beneficiaries. Work has now begun to develop a step-by-step guide to screen for and mitigate bias in Innovation Center models.
You can read more about this effort in a recent article in Health Affairs.
Recent studies on the intersection of health equity and patient safety have revealed race differences in patient safety incidence and reporting in the United States.
Applying an equity lens to patient safety could address avoidable harm to certain race/ethnicities that would otherwise remain hidden. But for this to happen, the appropriate data need to be collected.
An article in the February edition of Health Affairs outlines three policy changes to improve the collection of race / ethnicity information relates to patient safety and outlines some of the challenges, opportunities and impacts in implementing these changes.
- Require collection of patient perceptions of racial/ethnic bias and patient safety, using existing surveys of patient satisfaction.
- Require health care facilities to collect patient race/ethnicity information as part of their safety improvement efforts.
- Encourage patient safety organisations to collect, analyse, and disseminate information on race/ethnicity and patient safety.
The PSO program, established by an act of Congress, operates under the oversight of the Agency for Healthcare Research and Quality.
Australia currently collects very little data that addresses race/ethnicity and other factors that lead to health disparities, although the Minister for Health, Mark Butler, has recently indicated that more will be done in this space.
A recent segment on the PBS News Hour program looked at systemic racism and its impact on health in the United States. The transcript is here and it’s well worthwhile reading.
In case you missed it
South Australian model breaks the homelessness cycle
The majority of the 575 people in South Australia with a history of chronic homelessness have found stable housing and are well on the way to a better life after three years of intensive support under the ‘Aspire’ program – Australia’s first social impact bond targeting homelessness.
The final evaluation report found:
- Three years into the program, by June 2021, 369 Aspire participants had secured a tenancy, mostly in public housing, and among those participants, 93 percent were maintaining their tenancies.
- Participants accessing Specialist Homelessness Services was down 78 percent; hospital emergency department visits were down 27 percent; inpatient stays were down 26