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The Health Wrap: pandemic of inequity, vaccine news, and hospitals in strife. Plus pandas

In her latest edition of The Health Wrap, Dr Lesley Russell looks at the pandemic’s intersections with wider determinants of health inequity, the latest news in vaccine development, a shocking survey of hospitals in the United States, democratic rights, and new reports from the Australian Institute of Health and Welfare. Also, pandas.


Lesley Russell writes:

Every day there is increasing evidence of the toll coronavirus is exacting on people of colour in the United States.

Data from several states and cities show that the coronavirus is infecting and killing African Americans, Hispanics and Native Americans at disproportionately high rates, highlighting entrenched inequalities in resources, health and access to care. One analysis shows that counties that are majority-black have three times the rate of infections and almost six times the rate of deaths as counties where white residents are in the majority.

The disproportionate impact appears to be attributable to pre-existing conditions — high blood pressure, heart disease, diabetes and inadequate access to health care — that make these population groups more vulnerable to the disease. 

For African Americans, the pandemic has arrived at a time when distrust about racial bias in the allocation of limited medical resources is already high. Lack of clean water, over-crowding and poor medical facilities leave the Navajo Nation and other reservations open to a perfect storm of health and economic crises. Hispanic communities are vulnerable because they are more likely to be un- or under-insured and less than one in five workers can work from home. They have been hardest hit by pay cuts and job losses.

For unexplained reasons, the Centers for Disease Control and Prevention (CDC) is not providing nationwide data about COVID-19’s impact broken down by racial and ethnic groups – it does customarily report such data, and presumably is collecting it.


Aboriginal and Torres Strait Islander communities

As Celeste Liddle pointed out in a recent article, if ever proof was needed that the health gap between Indigenous and non-Indigenous communities is disastrous, the Prime Minister’s advice that Aboriginal and Torres Strait Islander people over the age 50 should avoid leaving the house – highlighting a 15 to 20-year gap in the advice provided to other Australians – is it.

Issues such as over-crowded housing, limited access to medical care, and the increasing unavailability of food and household supplies highlight the problems remote communities are facing in managing the pandemic (as has been covered recently at Croakey here and here).

There are very real concerns that an outbreak in these communities that have disproportionate numbers of people with serious health issues could be catastrophic. A recent media story highlights how fearful Indigenous elders are retreating to out-stations in the bush in Western Australia as coronavirus creeps closer to remote communities. 

Information about government aid to Indigenous businesses and communities is available here and on the National Indigenous Australians Agency website – although better, more comprehensive information is found on the NACCHO website.


High risk communities

Internationally about a billion people live in slums — defined by the United Nations (UN) as human settlements with inadequate access to safe water and sanitation, poor housing quality, overcrowding and insecure residential status.

As a recent article in The New York Times reminds us, neglect of these marginalised populations will be an important factor in enabling the spread of this pandemic. A UN report estimates that the pandemic will push another half a billion people into dire poverty.  

This tweet should make us see how privileged we are to be able to self-isolate and even wash our hands multiple times a day.

Meawnhile, in an analysis of 3,080 counties in the United States, researchers at the Harvard University School of Public Health found that long-term exposure to air pollution (specifically the tiny, dangerous PM 2.5 particles) is associated with higher death rates from COVID-19.  Such links had previously been postulated for countries like China, Italy and Iran.

The good news? The shutting down of industrial activity and transport as a consequence of the coronavirus pandemic is leading to a huge drop in air pollution around the globe.


Vaccine development at pandemic speed

The New England Journal of Medicine recently published an article by the Coalition for Epidemic Preparedness Innovation, an international nongovernmental organisation funded by the Wellcome Trust, the Bill and Melinda Gates Foundation, the European Commission, and eight countries (Australia, Belgium, Canada, Ethiopia, Germany, Japan, Norway, and the United Kingdom), which outlines how vaccines against coronavirus might be developed at what is called “pandemic speed”.

The paper outlines the challenges involved in SARS-CoV-2 vaccine development and some promising approaches. Among those with the greatest potential for speed are DNA- and RNA-based platforms because RNA and DNA vaccines (which require no culture or fermentation) can be made quickly.  

The World Health Organization keeps an updated list of COVID-19 candidate vaccines; I counted 44. You can keep up with clinical trials for vaccines on Hilda Bastian’s blog

This article in Nature (9 April), The COVID-19 vaccine development landscape, said the global COVID-19 vaccine R&D landscape includes 115 vaccine candidates, of which 78 are confirmed as active and 37 are unconfirmed (development status cannot be determined from publicly available or proprietary information sources). Of the 78 confirmed active projects, 73 are currently at exploratory or preclinical stages. The most advanced candidates have recently moved into clinical development, and numerous other vaccine developers have indicated plans to initiate human testing in 2020.

In Australia several groups are working to develop a vaccine. CSL is working with the University of Queensland and the CSIRO on a potential COVID-19 vaccine, which is on track to go into clinical testing in June, but it will be more than a year before this could be made publicly available.


Shocking new report

A report released last week by the office of the Inspector General for the US Department of Health and Human Services, which surveyed 323 hospitals across the nation, delivered some shocking news – so shocking that President Trump blasted the report, saying: “It’s just wrong” (while providing no evidence to support that assertion).

Now Trump appears to be engaged in a power play against the semi-independent inspectors general across the government, driven by his fury with voices within the government that he considers disloyal. 

The report found that insufficient supplies of key testing components and long waits for virus test results have compounded deficits of personal protective resources, staff and hospital beds. Hospitals also reported shortages of ventilators, IV poles, bed sheets, toilet paper, cleaning supplies and other basic equipment. Some hospitals lacked enough thermometers to monitor the temperatures of their own staff.  

Hospitals have not been able to count on shipments from the federal strategic stockpile, which have been not only few and far between but often contain defective, outdated and unusable gear.


Protecting democratic rights

If you follow American politics then you will be aware of the dreadful fiasco in Wisconsin where the Republican legislature, supported by both the state Supreme Court and (shockingly) the US Supreme Court, refused to allow mail-in votes for the state’s primary elections.

This meant people were faced with a dreadful choice – to risk coronavirus infection and stand in long queues for hours (the number of voting places in Milwaukee was cut from 180 to 5 and it was raining), or forgo their democratic right to vote. 

For the political junkies, I wrote about how the coronavirus pandemic is affecting the presidential elections, and whether Trump is allowing the “invisible enemy” he and the rest of the nation are battling to erode democratic rights for Inside Story.

There are also issues about what is happening elsewhere around the world as leaders are invoking executive powers, emergency decrees and legislation to expand their authorities. This is happening across a broad range of political systems — in authoritarian states like Jordan, faltering democracies like Hungary, and traditional democracies like Britain and Australia.

Governments and rights groups agree that these extraordinary times call for extraordinary measures.

But will these new powers ever be relinquished? Civil rights groups have warned that societies should not “sleepwalk” into permanent surveillance in the coronavirus pandemic’s aftermath, that digital surveillance rolled out to curb the virus should be limited in time and scope.

Similar cautions have been issued in Australia. See for example this article for ABC News.


Missing out on care Versus recognising low-value care

Over the past several weeks I’ve had some brief but interesting tweet exchanges about the bad and good health outcomes unrelated to infection with the virus that might result from the management of the coronavirus pandemic.

One concern is that in hospitals stretched beyond capacity, coronavirus patients will crowd out other patients whose needs are also urgent, as is demonstrably happening in New York City.

For the moment there’s no evidence this is the case in Australia, although non-urgent surgery has been cancelled, along with some organ transplants.

It’s impossible to know how long this pandemic will last. Longer term there are reasons to fear that there will be consequences from people going without or delaying needed community-based care.

Here in Australia there is anecdotal evidence that cancer patients are fearful of hospital visits and doctors, especially specialists like cardiologists, are seeing fewer patients in their clinics. Breast screening programs are suspended, dentists are closed or providing only emergency services, and rural pharmacies are experiencing “massive” shortages of essential medicines.

The Australian Government’s Chief Medical Officer Professor Brendan Murphy has pleaded with patients to stop cancelling face-to-face consultations with their GP, saying, “Don’t stop going to your GP”. 

On the other hand, the Centre for Evidence Based Medicine at the University of Oxford finds that all-cause mortality in England and Wales for the period 31 January (when coronavirus was first confirmed in the United Kingdom) to 20 March is three percent less for 2020 than the average for 2015-19. It is postulated that this reduction in deaths is due to public health measures impacting on all respiratory deaths.

Reduced social activities may also mean decreased trauma-related deaths due to decreased traffic accidents. Some additional evidence for this comes from San Francisco, which has seen a recent reduction in moderate trauma cases as a result of accidents.

Also on the positive side of the ledger, the current restrictions on non-urgent surgery that can be done in the private sector has led some to speculate that this might be a way to drive treatment away from low-value care to high-value care. An Australian study has identified over 150 low-value health care practices.

So this article, The coronavirus ban on elective surgeries might show us many people can avoid going under the knife, in The Conversation caught my attention. It’s written from the point of view of orthopaedic surgery, where there is considerable evidence that surgery isn’t always the best option.

For further background you might find these two articles useful: How knee replacement surgery highlights issues of access, affordability and best practice in Australia’s two-tiered healthcare system: Part 1 & Part 2

Research by my colleagues at the Menzies Centre for Health Policy, using 2014 PHI data, shows that 20.8 – 32 percent of hospital admissions were for procedures of low-value. Admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value. This varies greatly by hospital.

In a report for the Grattan Institute, Professor Stephen Duckett, claims that private hospitals provide more care than public hospitals that is of little or no value to the patient. He finds that private health insurers could save about $1 billion a year if they no longer had to play for low-value or no-value care.

Meanwhile, for the policy wonks and economists: you might be interested in this article on The Economics of Infectious Disease – and I would be interested in your thoughts.

I have now read this several times. It has some really interesting points and information, but I’m not sure what the final take-out is for economists, epidemiologists and public health officials (!).


New reports

While so many of us are consumed with coronavirus news, other parts of the health world continue on with their work (thank goodness). That includes the Australian Institute of Health and Welfare, which last month released several new health reports you might have missed.

GEN: Residential aged care quality indicators

This report has data for the last quarter of 2019 from the Quality Indicator Program, which has been mandatory for residential aged care services (RACS) since July 2019, and consumer experience surveys for residents of RACSs.

The quality data is around pressure injuries, use of physical restraints and unplanned weight loss. However all of the data are presented in terms of 100 care recipient days, and frankly, I don’t know how to interpret this.

GEN: People’s care needs in aged care

This report has data to June 2019.  It shows:

  • 31 percent of people in permanent residential care had high care needs in all three care domains (activities of daily living, cognition and behaviour, complex health care). High care need ratings are increasing over time. They are higher for women than men and for people from CALD backgrounds.
  • 49 percent had a diagnosis of depression.
  • 53 percent had a diagnosis of dementia.

GEN: People using aged care

This report provides data for all aged care services (residential, home care and home support) through to June 2019. The data are mapped at the national level and by state and territory, Aged Care Planning Region, and Primary Health Network.

  • Around 2 in 3 people using aged care services were women.
  • Aboriginal and Torres Strait Islander Australians accounted for around 1 percent of people living in residential aged care, 3 percent of people using home support, and 4 percent of people using home care.

Incidence of insulin-treated diabetes in Australia

This web report presents the latest available data on new cases of type 1 diabetes and insulin-treated type 2 diabetes. It is part of the ongoing national reporting using the National (insulin-treated) Diabetes Register (NDR).

In 2018, about 31,300 people registered on the NDR began using insulin to treat their diabetes. Of these:

  • Just over 2,800 (9.0 percent  people were diagnosed with type 1 diabetes, and began using insulin to treat it.
  • 17,000 (54 percent) people began using insulin to treat type 2 diabetes.
  • 10,800 (34 percent) females began using insulin to treat gestational diabetes.
  • About 600 (2.0 percent) people began using insulin to treat other forms of diabetes.

National Opioid Pharmacotherapy Statistics Annual Data collection 2019

In Australia, three medications are registered for long-term maintenance treatment for opioid-dependent people: methadone, buprenorphine, buprenorphine-naloxone.

On a snapshot day in 2019, over 50,000 clients received pharmacotherapy treatment for their opioid dependence at 2,940 dosing points across Australia. There were 3,395 authorised prescribers of opioid pharmacotherapy drugs. Of the dosing points, 2,627 were pharmacies, 56 were public clinics and 20 were private clinics (most of these clinics were in NSW and Queensland) and 38 were in correctional facilities.


The good news story

Here’s a silver lining to coronavirus isolation! In the peace and quiet of a closed zoo in Hong Kong, and after thirteen years of playing hard to get, two giant pandas have finally mated.

Maybe Le Le and Ying Ying may have just needed some privacy from the usual slew of visitors in order to kindle a romance. There’s more information here about whether this might lead to the birth of a panda cub.

(You can follow this link to see video and hear audio of the act, but be warned, you know exactly what you are getting into.)


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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