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The Health Wrap: on the pandemic, primary care and wellbeing

*** See the Prime Minister’s statement tonight on compulsory vaccination for residential aged care workers, a professional indemnity scheme for healthcare professionals and changes to quarantine arrangements ***


As millions of Australians grapple with lockdowns and other restrictions on daily life as well as anxiety about COVID outbreaks across multiple jurisdictions, The Health Wrap investigates some lesser-discussed aspects of the pandemic, including the importance of addressing food insecurity and poverty.

Associate Professor Lesley Russell also offers an 11-point plan for primary care reform, and shares some good news from the United States as well as some timely tips for de-stressing.


Lesley Russell writes:

I recently came across a paper summarising a study from the United States that showed food insecurity caused by the pandemic is associated with increased risk of mental illness. It found that food insecurity is associated with almost a 250 percent higher risk of anxiety and depression compared to an increase of around 30 percent from losing a job during the pandemic.

These findings highlight the value of President Biden’s work to increase access to food stamps and nutritional programs and reduce childhood poverty.

They also sent me on a hunt to learn more about these links, with a focus on problems in high-income countries. Here’s a summary of what I found.

Food insecurity encompasses food availability, affordability, the cultural norms that dictate acceptable means of acquiring food, and individual food utilisation. It is associated with a diversity of nutrition-related health outcomes including dietary inadequacies, obesity, poor physical health, low educational achievement, and faltering early childhood growth and developmental deficits in children.

There are other health consequences that are not directly linked to nutrition; these include poorer mental health, greater mental distress, lower cognitive function, depression, poor sleep patterns and behavioural problems in children.

Food insecurity may contribute to common mental disorders through several different mechanisms. First, by generating uncertainty over the ability to maintain food supplies, or to acquire sufficient food in the future, thus provoking a stress response that contributes to anxiety and depression.

Secondly, acquiring foods in ways that are seen as socially undesirable (such as relying on food banks and charity) can induce feelings of alienation, powerlessness, shame, and guilt that are associated with depression.

Food insecurity may also magnify socioeconomic disparities that increase cultural sensitivities and influence overall mental well-being.

Not surprisingly the mental health consequences of food insecurity are a particular problem for women, especially those with children, and there are associations between prenatal and postpartum depression and food insecurity.

The relationship between food insecurity and poor health is cyclical; food insecurity increases the likelihood of trade-offs in food choices and the management of health conditions in those on low incomes with spiralling consequences.

The pandemic has put the spotlight on food insecurity in Australia – a fact I suspect many Australians (including politicians) struggle to recognise despite reports from organisations at the coalface like Foodbank.

It’s shocking to realise that although Australia is a food secure nation that exports 60 percent of its total production, there are pockets of food shortages; in some disadvantaged communities these are quite severe.

These have been made worse by the restrictions on transportation in response to the pandemic and the subsequent disruption of food supply chains. Along with the apparent food shortages have come rising prices of staple foods, which creates additional anxiety amongst disadvantaged communities.

Rising rates of unemployment during the coronavirus pandemic, combined with drought and the recent bush fires, mean regional and rural areas have been hit hard. Small, remote Aboriginal and Torres Strait Islander communities have been heavily affected.

In 2014 Professor Sharon Friel and colleagues published data showing the links between drought, food shortages and mental health in Australia and pointed out how this would increase due to climate change.

The 2020 Foodbank report found more than half of food insecure Australians (53 percent) say they have experienced a decline in their mental health since COVID-19 was declared a pandemic. The most common emotions experienced as a result of not having enough food include stress (49 percent), depression (46 percent), anxiety (41 percent) and sadness (39 percent).

There has been a massive expansion of the food banking industry in Australia but these supports are not effectively reducing food insecurity and may in fact be maintaining it.

That is why governments at all levels – national, state and local – have critical roles to play. Poverty is one of the main factors for a household being food insecure, so Australian government policies that improve household financial resources will enable people to feed themselves in culturally appropriate ways.

Catch up on other articles around the topic of food insecurity here and here.


Whither primary care reforms?

If you are a regular reader of Croakey Health Media, then you are aware that the discussion paper from the Primary Health Reform Steering Group that will form the basis for the Primary Health Care 10-Year Plan has finally made an appearance. It was due in September 2020 but was reportedly delayed by the coronavirus pandemic.

I’ve called it a chameleon document because the very valid criticisms of the current primary care system (including a conclusion that it is not fit for purpose) are not matched by the recommendations which are very medically focussed and will not deliver the transformative reforms needed. You can read my analysis here.

As the paper states: “[Reform] will require standing against underlying resistance structurally embedded in the health system through its fragmented, siloed and hierarchical nature, promoted largely through funding that incentivises through put and episodic treatment of sickness.”

I do hope the discussion paper generates some informative and passionate discussion and goals and that leaders will emerge who will stand against underlying resistance.

I’m acutely aware that criticisms of current systems and proposals should also be accompanied by alternatives, so I have drawn up a list of recommendations (and questions) in response to those in the paper.

  1. Spell out what a primary care team and a primary healthcare team should each look like and how the various members could be remunerated/reimbursed and by whom.
  2. When is fee-for-service appropriate and when should another payment mechanism be used? Can these two financing mechanisms operate side-by-side? How to prevent unintended consequences?
  3. How to manage patients’ out-of-pocket costs alongside the financial viability of primary care practices?
  4. Spell out how to transition from general practice to primary care and then to primary healthcare.
  5. It is imperative to link community-based specialist care with primary care. Is there a role here for outpatient clinics? How to make this more affordable, accessible, and better integrated with primary care?
  6. What can be learned from ACCHOs? What can be learned from Australia’s history with Community Health Centres? What can be learned from US history with Community Health Centres? What can be learned from Health Care Homes?
  7. How to get a culture of innovation in primary care – and ensure that this is more than just short-term pilots? How can this innovation involve both commonwealth and state/territory governments and bridge community/hospital divides?
  8. Primary care research, data collection, evaluation, and feedback need specific funding and capacity. To be done well, this needs to go beyond academia to the coalface. How can busy GPs and other healthcare workers be encouraged/rewarded to be involved?
  9. Workforce is the key issue here – the right people in the right place at the right time (for the right price). This means moving beyond the doctor – nurse paradigm. It is essential to break the control medical colleges and states have over training places. Supports for rural and remote healthcare workers and their families are important. Restoration of an independent health workforce agency is imperative.
  10. Need more sustainable funding for prevention, tackling health disparities, and innovation and a way to protect this from the political vagrancies and election cycles.
  11. Need to identify and work with vanguard Primary Health Networks, GPs and practices to understand what works, barriers to success, and what can be translated elsewhere.

I would argue that stakeholders need to get started on some of this work now, ahead of the yet-to-be written strategy, implementation plan, and evaluation plan (a task that could delay reforms by several years).

The recent publication from the Central and Eastern Sydney PHN, entitled “COVID-19 challenges and opportunities for primary care” exemplifies the sort of innovative approaches to primary care that might be used elsewhere (at least for other metropolitan areas).

The document outlines short- and long-term action plans for delivering on the six broad strategic implications of the pandemic, as depicted below.

There is also much to learn from the success of the First Nations-led response that has shown the effectiveness (and cost-effectiveness) of leadership by Indigenous leaders and communities.

The primary care discussion paper calls for greater recognition of the role of the primary care sector in disaster management at both the local and national levels – as exemplified by fires, floods and the pandemic. This task of boosting emergency preparedness and ensuring “surge capacity” will likely fall to PHNs.

A survey of general practices done last year highlights how much work there is to be done here. Only 57 percent of practices which responded to the survey had a pandemic plan in place when coronavirus arrived in Australia; generally these were repurposed disaster, swine flu or influenza plans.

No surprise then that half of the practices with a plan rated its applicability to the needed coronavirus response as less than 50 out of 100. Most practices (77 percent) then turned to PHNs for assistance.


Coronavirus and the brain

Some people who are infected with the coronavirus develop neurological symptoms. Patients report visual and auditory disturbances, vertigo and tingling sensations, some lose their sense of smell, or their vision became distorted. Weeks or months after the initial onset of symptoms, even in mild cases, some have a persistent “brain fog.”

Others have more serious problems. A paper published in April of a large study found the estimated incidence of a neurological or psychiatric diagnosis in the six months following a COVID-19 diagnosis was 33.62 percent. The diagnoses included intracranial haemorrhage, stroke, parkinsonism, Guillain-Barré syndrome, and psychotic, mood, and anxiety disorders. The incidence of these is linked to the seriousness of the COVID-19 disease.

But neurological symptoms can show up even in mild cases. A paper just out in Nature Medicine shows that young, home-isolated adults with mild COVID-19 are at risk of long-lasting cognitive symptoms.

Scientists are slowly starting to understand what the SARS-CoV-2 virus does to the brain, although many questions remain.

Autopsies of the sickest COVID patients have revealed clotting in the brain and other signs of acute damage although there is little evidence the virus attacks the brain directly.

One hypothesis is that the coronavirus acts like herpes simplex, which in rare cases causes encephalitis – a swelling of the brain that triggers an autoimmune attack. COVID-19 results in “an immune system on steroids” and this hyper-reaction can include the release of autoantibodies that damage tissues. Autoantibodies have been found in the brains and cerebrospinal fluid of COVID-19 patients.

An article in The Conversation last April outlines the long-term impact of these neurological problems.

It concludes:

COVID-19 remains and will continue to be one of the largest socioeconomic problems across the world as we begin to recognize the true long-term impacts of the disease.

Both the scientific and research communities should continue to be diligent in the fight long after the acute infections are gone. It appears that the chronic effects of the disease will be with us for some time to come.”


Reshaping collaboration – and competition – in science

A recent article in Stat News (always a good read) reported on a discussion held as part the Milken Institute’s Future of Health Summit, where a panel of experts was asked how the pandemic has reshaped the cultural landscape in science. You can watch the video of the event here.

It made the point that a global health crisis is no time for guarding secrets and highlighted how, in the fight to tackle the coronavirus pandemic, we have seen what’s possible when scientists put collaboration ahead of personal glory.

In particular the panel hailed the widespread adoption of preprints for accelerating the exchange of information and ideas (despite the obvious vetting problems). But they also pushed for a rethink of long-standing incentive structures in science that have favoured the individual and rewarded people for staying “in their own lanes”.

And they saw political separations as a clear and present danger to international cooperation, citing the deteriorating relationships with China, which is emerging as a powerful force in basic science.

A paper in Nature on this topic highlighted that, while many scientists have strengthened existing connections and collaborations and forged new ones, the pandemic has interrupted projects and curtailed travel.

It also makes the point that it has intensified the challenges to international cooperation arising from long-standing political tensions, particularly between the United States and China – and now Australia and China. Note than China is Australia’s biggest research partner and this has included studies on coronaviruses.

This paper was part of a whole issue of Nature dedicated to research collaborations generated by the pandemic.

This includes an examination of how industry scientists have been collaborating with academic colleagues on vaccine development – part of the reason for the speed and scale of achievement with vaccines.

These pandemic collaborations have highlighted problems that have long existed in industry-academic relationships, especially those around ownership of data and intellectual property.


The impact of COVID-19 on life expectancy

Back in February I wrote an article for Inside Story on how COVID-19 is impacting life expectancy in developed countries. It attracted some attention and I was even asked to give a talk to the University of the Third Age about it.

I’ve been following this issue closely.

A paper just out in BMJ updates the work that has been done on this topic, looking at the United States (broken down by race) and sixteen other high-income countries.

The paper highlights how bad the situation was in the United States even before the pandemic, which has only served to make the disparities worse. Life expectancy across the United States plummeted by nearly two years from 2018 to 2020: white Americans lost 1.36 years, Black Americans lost 3.25 years and Hispanic Americans lost 3.88 years. These are the biggest declines in life expectancy since World War 2.

A number of other studies on life expectancy have come to similar conclusions (see, for example, a recent study published in JAMA.)  None of these factor in how the long-term complications of COVID-19 will affect US life expectancy in the coming years.

In an analysis of the paper, Kaiser Health News wrote: “The ripple effects of the pandemic will affect babies born in this year not only because of the immediate effects…but because the economic and social upheaval that the pandemic is leaving in its wake will influence child development and health trajectories.”

To date Australia has largely escaped any impact on life expectancy because infection rates have been low and mostly confined to older people and there have not been (recognised) excess deaths as a consequence of people not receiving adequate care.

However, as the Australia’s Health 2020 report from the Australian Institute of Health and Welfare highlighted, Australians who died of COVID-19 lost more years of their expected lifespan on average than those who died of our three leading causes of death: coronary heart disease, dementia and stroke. This is explained well in an article in The Guardian here.


Getting the most from exercise

Everyone who follows me on Twitter knows I’m addicted to walking and more recently I’ve become a bit of a gym rat, enjoying some weightlifting, pilates and yoga – and seeing some good results.

So of course I was interested in a recent article in The New York Times reporting on a study that looks to explain why some people respond better than others to different exercise regimes. (The research paper was published in Nature Metabolism; you can read the abstract here, but unfortunately the rest of the paper is behind a paywall).

The hypothesis being tested was that exercise alters the molecular environment inside the body, and this shows up in the blood. It seems that perhaps a blood test could indicate the best types of exercise for each of us – suggesting that “molecular profiling tools might help to tailor” exercise plans. I must confess that even if this becomes reality, for me this approach would be just too boring, no matter how beneficial.

This article outlining how the wilder the nature you walk in, the greater the benefit, is much more to my taste. It is based on a study published several years ago in Behavioral Sciences that attempts to unravel the factors that are most crucial to nature’s restorative benefits.

The study compared three different “levels of nature”- a wilderness setting, an urban park and an indoor exercise club – to see how they affect levels of stress. The results suggest that visiting natural environments is most beneficial in reducing both physical and psychological stress levels. This “levels of nature” response is further explained here.

As many people across Australia face restrictions on their daily lives, I’m revisiting some pre-pandemic hiking photos as a substitute for “forest bathing” (which I wrote about for The Health Wrap in July 2018).


The best of Croakey

Don’t miss the three-part series reporting on the recent #CroakeyREAD Twitter festival that shared diverse global perspectives on #CommunicatingCOVID:

Part one
Part two
Part three.


The good news story

The good news story this week, this month, and even this year has to be the US Supreme Court decision, released  on 17 June, that upheld the Affordable Care Act (Obamacare).

You can read the decision here and a good outline of what is means here.

Tweets from both former President Barack Obama and President Joe Biden highlight their pleasure and relief at this decision. I’m sure Biden repeated in private what he said sotto voce when Obamacare was first signed.

To celebrate, I pulled out this photo from 2010, when I was working in Washington DC on the enactment of Obamacare (which passed and was signed into law just a few weeks after this rally). Those were heady days!


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.


See Croakey’s archive of stories on healthcare and health reform.

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