Amid a deluge of worrying news – including infectious diseases alerts, and the Trump Administration’s likely impacts upon health, locally and globally – this column also links to some positives, including the “enduring strength and resilience” of Aboriginal Community Controlled Health Services.
Dr Lesley Russell also investigates the health issues associated with hoarding, and addresses a growing body of research suggesting that 21st-century warfare has become a major driver of antimicrobial resistance.
The quotable?
Elimination of the US National Institutes of Health…would devastate American science + launch a brain drain of scientific talent that would eventually downgrade our national economy and jeopardise our national security.”
Lesley Russell writes:
As 2024 draws to a close, my sense is that the world is a troubled place, and it seems that politics and ideology are increasingly getting in the way of governments acting to address the needs and improve the lives of all the people they were elected to represent.
That is certainly the case in the United States, and I worry that it is increasingly so in Australia, where a federal election and the Western Australian state election loom in the first half of 2025.
As in the recent US election, the issues for Australian voters will be primarily around the cost of living. Underpinning that are growing inequalities, the failures of the social and healthcare safety nets and the growing impacts of climate change.
Croakey Health Media does a marvellous job of highlighting all these issues and more; I am proud to be part of the Croakey team.
My photo this week sends a message that I hope is true for political upheavals – after the storm there are rainbows (sometimes even a double rainbow).
Trump Administration, health and healthcare
I dread the fact that for the next four years every edition of The Health Wrap could have a doom and gloom section with this heading. I’ll try to avoid that!
Nevertheless, given that the policies and actions of the Trump Administration will have far-reaching and international consequences, it seems important to examine this issue as we learn more about those who will be in charge of the various agencies of the Department of Health and Human Services (HHS).
Robert F Kennedy Jr – Trump’s pick to lead the Department of Health and Human Services
Professor Larry Gostin at Georgetown University said about Kennedy’s nomination as Secretary of HHS: “I’ve never seen a darker day for public health… I just call this simply a poke in the eye of science.”
Kennedy’s post requires Senate confirmation. So great is the concern about this nomination that more than 75 Nobel Prize winners have signed a letter urging senators not to confirm Kennedy to lead HHS.
His appointment will likely be opposed by the Democrats and a number of Republicans have expressed concerns about his positions.
With so many of Trump’s nominees for Cabinet positions being so awful, and huge partisan clashes predicted during the confirmation hearings, it’s inevitable that some of the least-worst will simply slide through as the Democrats try to marshal the facts – and the will – to fight multiple battles.
It’s also possible that, to avoid the Senate confirmation process and FBI checks, Trump will either make acting appointments (he did this often in his previous term – and this makes it easier for him to fire people he sees as unsatisfactory) or attempt to make recess appointments (whether that is constitutional or not).
Kennedy’s controversial positions include:
- He is a long-time anti-vaxxer who has advertised misleading information about vaccine ingredients and circulated retracted studies linking vaccines to various medical conditions. He has painted vaccine scientists as villains who should be jailed.
- He has suggested that the coronavirus targeted and spared certain ethnic groups and he called the coronavirus vaccine the “deadliest vaccine ever made”.
- He has likened the Center for Disease Control and Prevention (CDC) and its promotion of childhood vaccination programs to child abusers and fascists.
- He has stated that AIDS is not caused by HIV and blamed the gay lifestyle and drug abuse.
- He claims that man-made chemicals can alter children’s sexuality and that antidepressants are responsible for mass shootings.
- He endorses the idea that Wi-Fi causes cancer and that 5G technology can “harvest our data and control our behaviour”.
- He wants to remove fluoride from water supplies.
However, some of his other views – especially those around his attacks on Big Pharma and what is now being called Big Ag – have some support on Capital Hill, with populists who look to curtail big corporate interests, and from some public health experts.
As part of his Make America Healthy Again movement, Kennedy blames large-scale, industrial agriculture operations and major multinational pharmaceutical companies for making Americans sicker and poorer.
This resonates with voters who struggle to access needed healthcare and affordable, healthy foods and feel powerlessness to do anything about it. It also speaks to those who work in public health and see the powerful influence of the food and beverage industries.
It will be interesting to see what, if anything, Kennedy can do to address the prevalence of ultra-processed foods and food additives, especially as the Trump Administration has plans to gut the Food and Drug Administration and the regulations it oversees.
Plans to “blow up” the NIH
With the help of Kennedy and Trump’s nominee to head the National Institutes of Health, Dr Jay Bhattacharya, the Trump Administration has big plans to shake up the NIH.
Kennedy and others have proposed a dramatic restructuring of what has been called “the crown jewel of the federal government”. This would halt infectious disease research, pare down the 27 institutes to 15, and replace current employees with those who pledge allegiance to Trump.
Bhattacharya has characterised the NIH as a bureaucratic, wasteful institution that has stifled creativity in research and blocked contributions like his own controversial epidemiological ideas. He has called for “an absolute revamping of the scientific community”.
Kennedy has proposed reallocating half of the agency’s budget to “preventative, alternative and holistic approaches to health” instead of infectious disease.
It’s hard to argue there shouldn’t be more research on chronic diseases, but at a time when international threats from infectious diseases are growing, abandoning this work would be catastrophic.
Experts are also concerned about politically-appointed institute directors, who could be chosen to approve only research deemed acceptable by the new administration.
Cuts to the NIH research budget will have consequences for Australian researchers who look to access these funds.
I have been unable to find an estimate of how much NIH funding comes to Australian-based researchers, but most Australian university websites have information on how to apply for these grants.
What will happen to Medicare and Medicaid?
Trump has nominated Dr Mehmet Oz, best known as talk show host Dr Oz, to serve as the Centers for Medicare and Medicaid Services (CMS) administrator.
CMS oversees Medicare (the federal health insurance program for people aged 65 or older and disabled people), Medicaid (the state-based health insurance program for lower-income people which is jointly funded by states and the federal government), the Children’s Health Insurance Program and the Health Insurance Marketplace which was created by the Affordable Care Act (ACA; Obamacare). These programs provide health insurance for more than 140 million Americans.
Oz has a long history of dispensing dubious medical advice and promoting miracle cures through the media and has broad investments in healthcare, technologies and food companies that would pose significant conflicts of interest.
His holdings include a stake, worth as much as $600,000, in UnitedHealth Group, one of the largest healthcare companies in the nation and – as the leading provider of commercial health insurance plans available to Medicare beneficiaries – an important business partner of CMS.
Note that these Medicare Advantage plans have been criticised for deceptive marketing, discriminating against sick patients, unethical prior authorisation denials, excessive costs and defrauding the government.
However, we can expect the Trump Administration to push for further privatisation of Medicare and Oz is on record as calling for the full privatisation of Medicare.
The targeted killing last week of the CEO of UnitedHealth has highlighted the simmering public rage against the health insurance industry
Trump’s economic advisers and congressional Republicans are currently discussing possible cuts to Medicaid.
It is estimated that more than three million people could lose their Medicaid coverage if cuts are made to federal funding for Medicaid expansion alone, and it is likely that other restrictions will be imposed on federal funds for this important program.
About 72 million people receive health coverage through Medicaid. It pays for two in five births and is the nation’s largest payer both of mental health and substance use disorder services and long-term care services, either at home or in nursing facilities.
At the same time, failure to extend the enhanced ACA premium assistance beyond 2025 (when it currently expires) could ultimately lead to 3.8 million more people becoming uninsured.
Project 2025 – the conservatives’ playbook – proposes to deregulate Medicare Advantage and make it the default enrolment option for Medicare beneficiaries and would impose block grants and work requirements for Medicaid.
See this opinion piece from Larry Levitt of KFF in JAMA Forum: With or Without ACA Repeal, ACA and Medicaid Cuts Are Looming.
Healthcare worker diversity at risk
The Trump Administration has promised a crackdown on diversity, equity and inclusion (DEI) initiatives at public and private institutions, including universities and research facilities.
Already his advisors have threatened the funds and accreditation of universities they have labelled the “enemy”, and pledged to dismantle diversity offices across federal agencies, scrap diversity reporting requirements and use civil rights enforcement mechanisms to combat diversity initiatives they see as “discrimination” and “woke”.
So far, four states – Florida, Texas, Iowa and Utah – have banned DEI initiatives or offices in universities (a primary target in the battle against DEI) and a fifth state, Alabama, has severely restricted them.
DEI bans will make it more difficult to recruit and retain students from racially and ethnically under-represented backgrounds and people from the LGBTQI communities.
There are fears for what this means for public and clinical health where racial and ethnic and sexual diversity in the workforce is essential for cultural safety, effective communication, improved health outcomes and tackling disparities.
The fate of the HHS Office of Minority Health under the new Trump Administration remains unclear.
On a similar topic, there are reports that America’s universities and colleges are scrambling to shield programs such as DEI initiatives, research funding and endowments that face growing hostility from Republicans and are expected to be among many possible targets of the incoming Trump administration.
Future of American health and healthcare
As the most recent analysis of international healthcare systems by the Commonwealth Fund shows, the United States continues to be in a class by itself in the underperformance of its healthcare sector.
A recent published this month in The Lancet highlights what’s at stake for Americans if their health and healthcare needs are neglected. The paper, provocatively titled Ten Americas: a systematic analysis of life expectancy disparities in the USA, offers a novel lens for examining health inequities in the United States.
The research defines ten Americas by dividing the population by race and ethnicity and a variable combination of geographical location, metropolitan status, income, and Black–White residential segregation.
Large disparities in life expectancy between the Americas were apparent throughout the study period but grew more substantial over time, particularly during the first two years of the COVID-19 pandemic.
The gap between Americas with the lowest and highest life expectancies increased from 13.9 years in 2010 to 20.4 years in 2021.
The authors write: “Our analysis confirms the continued existence of different Americas within the USA. One’s life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one’s racial and ethnic identity. This gulf was large at the beginning of the century, only grew larger over the first two decades, and was dramatically exacerbated by the COVID-19 pandemic.”
To quote an editorial in the same edition of the The Lancet headed A roadmap to better health in the USA: “Trump can admire the USA’s rise in life expectancy for all Americans four years from now, or he can watch the USA sink further behind in untimely deaths and unwieldy health costs.”
H5N1 bird flu fears grow
Meanwhile, as I have regularly reported in recent editions of The Health Wrap (see, for example, the 27 August edition), H5N1 bird flu poses a growing threat to humans.
Scientists report that it would take just a single mutation in the H5N1 version of bird flu that is sweeping through dairy herds in North America to produce a virus adept at latching on to human cells.
https://www.science.org/doi/10.1126/science.adt0180
Concerns about a possible outbreak of this disease have grown amid reports that the virus has been found in raw milk. As a consequence, California has announced a broad recall of raw milk and cream.
This situation is not helped by the fact that RFK Jr has been promoting the consumption of raw milk.
The owner of Raw Farm, which was shut down by California health officials because bird-flu virus was found in its products, told a reporter from The Atlantic that “our consumers are freaking out” – not because they fear being exposed to a potentially deadly virus, but because their raw milk supply is at stake.
Only now is the US Department of Agriculture beginning a national milk testing strategy.
Will this testing and public health guidance about infection control continue under the Trump Administration?
And, if necessary, would a Trump Administration act to use the H5N1 vaccine stockpile that the Biden Administration has recently boosted?
It’s hard to see Kennedy supporting these efforts. After all, he has claimed that that pharmaceutical companies and mainstream media discredited ivermectin and hydroxychloroquine as treatments for COVID-19 because they threatened a billion-dollar “vaccine enterprise”.
Here in Australia, Federal Health Minister Mark Butler has recently announced $95 million to further prepare and protect the nation against H5N. This funding includes $22.1 million to increase the flu vaccines in the National Medical Stockpile.
His media released states that “the interim Australian Centre for Disease Control is focused on ensuring Australia is as prepared as possible for any potential case of human infection”.
It’s encouraging to see that Tasmania has implemented some proactive measures.
New infectious disease emerging in Africa
To compound the fears of public health and infectious disease experts and epidemiologists about what the Trump Administration will mean for international health efforts and infectious disease control, an unknown disease characterised by high fever, severe headaches and respiratory symptoms is spreading in the southwest of the Democratic Republic of the Congo.
To date more there have been more than 70 deaths.
The majority of cases reported are among children, particularly those under five years of age, and all the severe cases have been in patients who are severely malnourished.
The most recent update from the World Health Organization is here. There is an update from the GAVI Vaccine Alliance here.
American infectious disease expert Dr Peter Hotez has warned that the Trump Administration will face a “torrent” of infectious disease outbreaks at home and overseas.
Medical misogyny
This month the Nine newspapers have been running a series of stories on medical misogyny (the articles can be accessed here). Some women have experienced some dreadful discrimination; in some cases, this has been life-threatening.
In early 2023 the Albanese Government announced the formation of a National Women’s Health Advisory Council (the website is here). This Advisory Council meets regularly (communiques are here).
The only work product I can find to date is the #EndGenderBias survey, conducted in 2023 and released at the 2024 National Women’s Health Summit last March.
Held at Parliament House on 14 March, Assistant Minister for Health and Aged Care Ged Kearney will reveal the findings of the Australian-first #EndGenderBias survey.
This survey found that two out of three women reported health care-related bias and discrimination, most commonly in relation to diagnosis and treatment.
Consistent themes included feeling dismissed and disbelieved; being stereotyped as ‘hysterical’ and a ‘drama queen’. Women reported that their symptoms and pain were often attributed to other causes such as menstruation, lifestyle factors or even “faking it”.
Back in December 2022, The Guardian ran an article in which experts outlined areas for action on medical misogyny.
The four priorities were:
- End obstetric violence
- Address tragic outcomes for Indigenous women
- Give women the right medications and doses
- Include trans and gender diverse experiences.
Time for some concrete action!
In the United States the National Academies of Sciences, Engineering, and Medicine has just released a report that outlines what needs to be done to boost research into women’s health issues.
An analysis by the committee that wrote the report finds that just 8.8 percent of NIH grant spending from 2013 to 2023 focused on women’s health research.
There is an NIH Office of Research on Women’s Health, but it is poorly funded.
The report calls for increased funding and the formation of a new institute for women’s health. We can just imagine how the Trump Administration will respond to this.
While I’m on this topic, I came across the review of a book “The Cure for Women” about Dr Mary Putnam Jacobi, an American who was the first woman permitted to enter the Sorbonne’s medical school.
In 1876, she was the first woman to win Harvard’s prestigious Boylston Medical Prize with a provocative essay topic – ‘Do women require mental and bodily rest during menstruation?’
Putnam Jacobi’s meticulously argued that menstruation is an aspect of health, not illness, thus turning the prevailing wisdom upside down.
This argument was central to the larger women’s rights movement at the time.
Hoarding and health
It’s arguably a struggle to get healthcare professionals to see hoarding as a health issue – and indeed they may not have the necessary information and insights into a patient’s life to know that they have a hoarding problem.
I think about it because one of my favourite walks in Sydney takes me past a house (one of a row of what was once small workers’ cottages) where it is increasingly obvious that whoever lives there is a hoarder.
I worry about this person’s ability to enter the house via the front door, about the public health hazards for everyone, and about how the neighbours (in homes that have been smartly renovated) feel about this and/or act on this.
A recent publication from the United States has an interesting and thought provoking discussion of hoarding disorder in older adults.
It notes the serious health consequences such as increased fall risk, fire hazard, poor hygiene, poor nutrition and food contamination, exacerbation of medical problems and, of course, social isolation.
Many of these older adults do not receive regular medical care, despite having substantially higher rates of self-reported medical conditions.
The paper finds caseworkers reporting that older adults with hoarding symptoms were unable to use basic appliances and essential rooms in the house (including bathrooms and kitchens, and had significant plumbing problems.
And, of course, older adults with a hoarding disorder may struggle with eviction and homelessness.
While hoarding behaviours have been described as part of various mental health disorders such as obsessive–compulsive disorder, schizophrenia, and depression, they have also been observed in the absence of other psychiatric or physical causes.
The UK National Health Service recognised hoarding as a medical condition in 2013. In 2018 the World Health Organization recognised hoarding as a medical condition, distinct from other disorders with which it is often associated.
I did find an article from 2020 on the University of NSW Newsroom website that presents an Australian perspective on hoarding and makes the case that it should be recognised mental health condition and treated as such – without the stigma associated with high-profile cases seen in the media.
Modern warfare is breeding deadly superbugs
Antimicrobial resistance is one of the most serious and worrisome international health threats. An analysis published in October by The Lancet predicts that by 2050 antimicrobial resistance (AMR) will kill 8.22 million people every year, more than the number currently killed by cancer.
A growing body of research suggests that 21st-century warfare has become a major driver of the spread of AMR (see this report from GAVI).
Countries such as Iraq, Syria, Yemen, and Afghanistan have from particularly high rates of multidrug-resistant pathogens – superbugs like Klebsiella pneumoniae, Pseudomonas aeruginosa, E. coli, and MRSA.
One such bug, Acinetobacter baumannii, travelled back to the United States with American soldiers and is now known informally as “Iraqibacter.”
Now Ukraine and Gaza seem to have joined that problematic list of AMR countries.
The causes are rooted in the chaos that conflict brings and disruption to services such as water, sanitation, healthcare and public health programs like vaccinations.
The high incidence of traumatic bone and soft-tissue injuries in people exposed to the conflict necessitates emergency surgery, which is often delivered in informal facilities that lack the usual infection controls.
To address these issues, healthcare providers use broad-spectrum antibiotics, which can also increase development of AMR.
More recently, conflict-related heavy metal contamination of the environment has been raised as a possible driver for the emergence of novel mechanisms of resistance.
The Global Health Network has a website here that provides resources and information on the impact of conflict and population displacement on AMR.
You can read more in this article published in The New York Times.
Good news in Indigenous health
The National Aboriginal Community Controlled Health Organisation Members Conference recently proudly celebrated the remarkable achievements of 27 Aboriginal Community Controlled Health Services (ACCHSs), which reached significant milestones (anniversaries ranging from 25 to 50 years) in their histories.
This is a testament to the enduring strength and resilience and community value of these services.
We should note that there are in total 145 ACCHOs with some 300 clinics and together these provide over three million episodes of care to about 410,000 people (not all of whom are Indigenous) each year.
Best of Croakey
If you couldn’t attend in real-time, the recording from this week’s #CroakeyLIVE webinar on leadership for health equity is now online. Watch it below:
Good news story
I’m afraid the news in this edition of The Health Wrap is all rather gloomy, so a good news story is definitely in order.
Here’s one to lift your spirits: Walmatjarri elder, teacher, and singer-songwriter Kankawa Nagarra has won the coveted Australian Music Prize for her album Wirlmarni.
It’s the 80-year-old’s debut album and she beat out a shortlist featuring Nick Cave & The Bad Seeds, Amyl and the Sniffers, and ARIA winner DOBBY.
Nagarra is a Stolen Generations survivor born on Gooniyandi and Walmatjarri country in North Western Australia.
You can read more and listen to her singing here.
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.
