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The Health Wrap: prescriptions for loneliness, la-belle-indifference on cashless welfare & heading outdoors to offset the Trump effect

Lesley Russell writes:

This week I am in Washington DC, so inevitably there is a Trumpian focus to much of The Health Wrap. None of it is good news!

Loneliness is a health issue – and compassion starts with you and your neighbourhood

Several weeks ago I heard Hugh Mackay talk about his new book Australia Reimagined: Towards a more compassionate, less anxious society. Several aspects of his underlying thesis got my attention, especially his hypothesis that “social cohesion, grounded on compassion and mutual respect, is the key to true greatness for any society.”

He makes the case that the state of the nation starts in your neighbourhood, on your street, in recognising and greeting your neighbours.

There is growing awareness that although technology and devices seemingly promote connectivity, for many people they have had the opposite effect of fostering social isolation and loneliness. The internet and social media engagement can exacerbate feelings of loneliness, depression and anxiety.

Mackay picks up on this, highlighting that Australia is an increasingly fragmented society that is experiencing an epidemic of anxiety and depression.

Loneliness and social isolation have major impacts on health, estimated to match those of obesity, alcohol abuse and smoking 15 cigarettes a day, and these factors play “an outsized role” in preventable deaths by suicide.

Young people aged 18-24 have the  highest incidence of loneliness, but the rate of persistent loneliness is also high among older adults, especially those whose lives are limited by chronic illness, mobility issues, lack of transportation, and untreated hearing loss.

Experts from the Harvard TH Chan School of Public Health have urged that social relationships be considered a national public health priority “to roll back those heartbreaking, preventable deaths of despair.”

Loneliness also has an impact on health utilisation among older adults; there is evidence that the doctor-patient relationship may be providing not just medical treatment but also social support.

It was pleasing to see a small initiative in this year’s federal budget for a pilot of services led by mental health nurses to target the mental health of older Australians in the community, particularly those at risk from isolation. But there is much more than can be, must be done.

The United Kingdom has recently appointed a Minister for Loneliness, based on the recommendations of the Commission on Loneliness that was set up by Member of Parliament Jo Cox just before she was so brutally murdered. The Commission called for tackling loneliness “one conversation at a time.”

The Mary Foundation in Denmark is also tackling loneliness.

Below are two international projects that I find particularly appealing:

The Compassionate Frome Project

Frome is a small town in Somerset, UK. The Compassionate Frome project was launched in 2013 by a local GP who recognised that loneliness was a health issue. It uses volunteer “Community Connectors” to help isolated people, especially those with chronic conditions, find the support they need.

This might be something as simple as joining a club or it might involve the management of housing problems or debt. Over three years, it was found that emergency hospital admissions in Frome dropped by 17 percent, while those in the rest of Somerset rose by 29 percent.

French La Poste “Watch over my parents” service

French postal workers check in on and chat to elderly people living alone and then inform their children or other relatives if there are any problems. The “Veiller sur mes parents” (“Watch over my parents”) service formalises something that has happened in rural France for some time.

The postmen and women pop in to have a chat for between five and ten minutes while on their daily rounds. They have a list of questions such as “Are you well?”, “Do you need any shopping?” and “Do you need a doctor?”.

Once they have the answers, the elderly person signs that the information is correct and the replies are sent by text or email to the relative via an app, and to a pre-decided list of other people who have agreed to be contacted if necessary. There must always be someone on the list who lives locally, and can react if there is a problem.

And a caution:

Dr Susan Pinkler, an expert in this area, in her book The Village Effect, highlights how important face-to-face contact is for learning, happiness, resilience and longevity. But she also cautions that we must be careful not to turn the natural and enjoyable process of sociability into yet another health obligation.

It’s impossible to know if the cashless debit card system is working – but the Government doesn’t care

This week the Australian National Audit Office (ANAO) released a report on the 12-month cashless debit card trial in Ceduna, South Australia and the East Kimberley in Western Australia run by the Department of Social Services.

The trial started in 2016 and cost some $18 million. The report finds that it is impossible to say whether this controversial initiative has improved lives, reduced social harm or saved money because the monitoring and evaluation has been inadequate.

Indeed, some of this work, including the planned cost-benefit analysis and post-implementation review was not just inadequate, it was not completed.

These trials are expensive: they cost about $12,000 a participant.  The Government’s evaluation was also expensive: the cost of the private firm contracted for this work blew out to $1.6m – more than twice the amount originally agreed.

On the positive side, the report does note that there was an extensive consultation process with stakeholders in the trial sites and that the communications strategy was “largely effective”.

Despite the fact that the Minister for Social Services, Dan Tehan was advised that much of the evaluation data were unreliable, he was all positive spin in response to the ANAO report, arguing that it “had confirmed the trials are on track”.

He continued to promulgate the Turnbull Government ideology on this;

“The cashless debit card trial is an important element of the government’s work to reduce welfare-funded social harm, and to help Australians escape welfare dependency. The cashless debit card is making a real difference in the communities where it operates.”

The ANAO report also notes that the initial trial was “not designed to test the scalability of the (cashless debit card) and there was no plan in place to undertake further evaluation”. Nevertheless the Government has moved to continue the trial in the two existing sites and expand the program to the Western Australian Goldfields area.

Linda Burney, Acting Shadow Social Services Minister, said there were now questions to answer about whether the card does help people. “We simply don’t know. We have testimony from communities that are part of the trial sites and there is a variety of views in the community about the value of the card.”

ACOSS has called on the Government to cease the trial based on the findings of what it called “this damning report”.

The communities in which these trials are taking place are themselves divided in the success or otherwise. Most of the affected people are Indigenous and many say they  feel disempowered and voiceless.

Clearly it’s time for some evidence-based policy making, transparency and more consultation. My hopes for this are not high, especially after I read in The Mandarin that former top public servant Terry Moran says the Commonwealth is “all thumbs” on social policy, and that the ability of the Australian Public Service is so diminished, that he wouldn’t trust the Commonwealth “with organising a collection of funds to build the local church”. (Yikes!)

The Trump Administration upsets the international applecart on breast feeding

The Trump Administration’s refusal to address the inappropriate marketing of infant formula (ie promotion of foods in contravention of the International Code of Conduct of Breast-milk Substitutes) has been widely reported and analysed in the US, in Australia and internationally.

The genesis of this issue came in May when Ecuador put forward a resolution at the World Health Assembly calling on governments to “protect, promote and support breast-feeding”.

The New York Times reported that American officials threatened to unleash trade sanctions and withdraw military aid from Ecuador unless it withdrew the resolution. The driver for this nastiness was American support for the large corporate manufacturers of breast-milk substitutes.

Then Russia stepped in, and the intimidation apparently stopped. As Professor Roger Magnussun pointed out in his recent article for the Sydney Health Law blog, “so many ironies here” (and even more after the Helsinki meeting debacle this week).

The resolution that eventually passed no longer has language that calls on the World Health Organisation to provide “technical support to member states seeking to halt inappropriate promotion of foods for infants and young children.”

The United States has a complicated history of infant feeding and promotion of infant formula over breast feeding and this has extended to their international policies and positions. The producers of these products (it’s a $70 billion industry) have been major players in policy development (or, perhaps more accurately, in hindering policy development) from the beginning.

A 1973 WHO report  found that baby formula was contributing to infant malnutrition and deaths in the developing world because too often the expensive formula was watered down and because of the lack of clean water to mix it.

Such reports led to a multi-year boycott of Nestlé, beginning in 1977. In 1981, the WHO voted 118 to 1 to adopt a (non-binding) code restricting the promotion of infant formula, with the US as the lone dissenting vote. Elliott Abrams, a Reagan Administration official, said it was a free speech issue.

Trump tweeted in response to the New York Times story, “The U.S. strongly supports breast feeding but we don’t believe women should be denied access to formula. Many women need this option because of malnutrition and poverty.”

However medical experts have responded by stating that,  “Malnutrition and poverty are the precise settings where you absolutely do need to breast-feed, because that’s the setting where access to safe and clean water for reconstituting powdered formula is often impossible to find.”

Australia’s record on breast feeding is not great; a new report card on Australia’s breastfeeding support and policy gives us a “mediocre” rating. You can read more in this recent Croakey article here.

Another Trump atrocity – the National Guideline Clearing House is gone.

While the world reels from the outcome of the Trump-Putin meeting, there was a disaster of a different kind taking place below the radar in Washington DC.  On July 16, what has been called “perhaps the most important repository of evidence-based research” disappeared from the internet.

Citing budget cuts, the Agency of Health Research and Quality (an agency of the Department of Health and Human Services ) has stopped supporting and maintaining the 20-year old National Guideline Clearinghouse; not even an archived version of the website remains.

The National Guidelines Clearinghouse has played an important role as the promulgator and gatekeeper of quality, for clinical guidelines that are produced by a wide array of organisations and used by the medical community, healthcare professionals and health policy makers both nationally and internationally. Last year it cost just $1.2 million to operate.

The National Guidelines Clearinghouse has been a perennial target for Republicans. Earlier this year it drew the ire of the former Secretary of Health and Human Services, Tom Price (he was forced to resign because, among other sins, he wasted $341,000 on inappropriate air charters) when it published a study critical of a drug manufactured by one of his campaign donors. There were a number of emails from his aides requesting the removal of this study from the website.

“Forest bathing” and time outdoors for your health and wellbeing

My friend and Croakey colleague Ruth Armstrong – a keen traveller and hiker – introduced me to the Japanese idea of “forest bathing” or immersing yourself in nature. Now it’s being embraced by healthcare professionals as a way to combat stress and improve health.

The wilderness as a health tonic for the troubles of civilisation was prescribed by Henry David Thoreau in his 1854 classic essay Walden: Or, Life in the Woods. Forest bathing works on the zen principle of just being with trees. No hiking, or counting steps on a Fitbit required – the point is to relax rather than to accomplish anything.

It became part of the national health program in Japan in 1982 and in a country where nature appreciation is a national pastime, it quickly took off.

From 2004 to 2012, Japanese studies of the physiological and psychological effects of forest bathing led to the designation of 48 therapy trails based on the results. Forest environments have been found to promote lower concentrations of cortisol, lower pulse rate, lower blood pressure, greater parasympathetic nerve activity, and lower sympathetic nerve activity than city environments. A study of the psychological effects found reduced hostility and depression scores and decreased stress levels.

However a recent Australian systematic review found that while forest therapy might play an important role in health promotion and disease prevention, the lack of high-quality studies limits the strength of results and means there is insufficient evidence to establish clinical practice guidelines for its use. More robust research is warranted.

Last week there was an interesting article in the New York Times about how doctors in the United States are increasingly promoting this therapy. Access to parks for low-income families has also been found to be beneficial.

Dr Ruth and Dr Lesley certainly recommend it.

“Forest bathing” on the Kumano Kodo trail, September 2017 – admittedly accompanied with a fair amount of exercise.
Family “forest bathing”, Mogo Creek NSW

Writing prescriptions to play outdoors

Richard Louv, co-founder of the Child and Nature Network, writes about what he calls the nature-deficit disorder. Recently I read about Dr. Robert Zarr, a paediatrician in Washington DC, who is the founder and medical director of Park Rx America, a non-profit that encourages doctors to prescribe parks. The two most common patients that receive these prescriptions are overweight children and stressed-out, anxious and depressed teenagers.

In the US, public health has been an aspect of the National Park Service (part of the Department of the Interior) since it first started. This work includes a health promotion initiative called Healthy Parks Healthy People which especially targets both children and the elderly, the most vulnerable communities and also the military.

Under the Trump Administration, America’s iconic parks face continuing, serious threats.

Grand Canyon. Could time in the outdoors be a teenage panacea?

  • Previous editions of The Health Wrap can be read here.
  • Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

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