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The Health Wrap: sounding the alarm on unsafe drinking water, latest on COVID, community pharmacy trial, health literacy – and a puzzle

Many First Nations communities, particularly in remote areas, are receiving drinking water with levels of uranium, arsenic, fluoride and nitrate and bacterial contamination that are above levels set by the Australian Drinking Water Guidelines, reports Associate Professor Lesley Russell.

In her latest column, Russell also reviews recent publications on COVID, moves to increase pharmacists’ scope of practice, and a stack of recent publications on global and local health. And she brings some good news for crossword puzzlers.


Lesley Russell writes:

Several recent papers assess some of the interventions implemented in Australia and elsewhere during the early stages of the coronavirus pandemic.

Federal Labor politician Andrew Leigh (a former academic who currently serves as Assistant Minister for Competition, Charities and Treasury) is the joint author on a paper published in BMJ Global Health looking at claims made by critics that lockdowns in Australia cost lives.

As an example of these criticisms, the signatories of the Great Barrington Declaration argued that “Current lockdown policies are producing devastating effects on short and long-term public health… [including]… worsening cardiovascular disease outcomes, fewer cancer screenings and deteriorating mental health.”

Leigh and co-author Dr Philip Clarke used data from the Australian Bureau of Statistics to estimate the effects of lockdowns and quarantining restrictions on short-term mortality. They compared deaths in 2020-2021 (when there were strict lockdowns but relatively few deaths from COVID-19) with 2015–2019.

They found that during 2020 and 2021, Australian age-standardised mortality rates fell by six percent. Google mobility data indicates that the drop in deaths tracked reductions in movement outside the home.

This drop was similar for men and women and was driven by a reduction in both communicable and non-communicable causes of death. There were declines in mortality for respiratory diseases, cancer and heart disease.

That there were fewer deaths from causes like influenza is logical. The authors postulate that the decline in cardiovascular deaths could be due to people spending more time indoors over winter months (which are traditionally known to have high excess deaths), faster access to emergency services, lower pollution, and a reduction in cardiovascular events following influenza.

Explanation/s for the reductions in cancer deaths are described as more difficult to identify but could be due to the fact that, as indicated by a recent analysis, the pandemic did not disrupt cancer care in Australia. (Our personal experience bears this out; my partner was diagnosed and treated for lymphoma in this period and received what I considered to be an exemplar of multidisciplinary care through the public system. His early diagnosis, and quick access to effective care meant he is now pronounced “cured”.)

The authors note their paper’s limitations – most notably that it considered only deaths that occurred in the short term. It will be important to continue track mortality to see if there are long-run mortality impacts of lockdowns, for example, from the disruption of breast cancer screening services or declining levels of physical exercise.

(Note: in the 19 October edition of The Health Wrap I wrote about the recent report from the Actuaries Institute that analysed the “excess deaths” in Australia in the first half of 2022.)

There is research to show that lockdowns lead to a loss of life satisfaction and worse mental health and wellbeing outcomes and it is clear that the impacts did not fall equally across society but in the absence of vaccines, they did save lives.

As noted by Professor Patrick McGorry on Twitter, “Impressive to see a sitting front bencher publishing in top medical / science journals!”

The value of economic supports in the United States

The November 2022 edition of Health Affairs has a series of papers that looks at the impacts of economic supports and other pandemic interventions such as a moratorium on evictions. Many of these were funded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed by Congress in March 2020 (one of the first pieces of legislation from President Biden).

Among the findings from these papers:

  • Cities with paid sick leave policies had higher COVID-19 vaccination coverage and reduced disparities between less and more vulnerable neighbourhoods.
  • State eviction moratoriums were associated with an improvement in mental health for people who rent.
  • In response to financial hardship caused by the COVID-19 crisis, many states expanded access to Temporary Assistance for Needy Families (TANF). Providing emergency cash benefits and waiving work requirements was associated with reduced days of poor physical and mental health.

Release of people from US prisons resulted in a miniscule number of offences

To protect those most vulnerable to COVID-19, the Cares Act allowed the Justice Department to order the release of people in federal prisons and place them on home confinement.

More than 11,000 people were eventually released. Of those, the Bureau of Prisons reports that only 17 of them committed new crimes, although 442 people were returned to prison for alleged alcohol or drug use or technical violations (like failing to answer the phone when the probationary officer called).

The 17 new offences represent a 0.15 percent recidivism rate, compared to the normal rate of 30 to 65 percent of ex-prisoners reoffending within three years of release.

The release program was focused on two groups of people who pose little to no risk to public safety: the elderly and the ill (ie those most likely to face serious COVID complications) who had an approved home situation to go to.

Australia’s lost opportunities to address poverty and homelessness

It’s worthwhile noting here that there is already good evidence that social measures adopted by Australia during the early days of the pandemic had some very positive (but sadly, not lasting) impacts on poverty and homelessness.

A report released last March showed how poverty and inequality were dramatically reduced in 2020, during the first wave of the pandemic, by special support payment provided via the Coronavirus Supplement and Jobkeeper.

Despite an effective unemployment rate of 17 percent at the time, many people on the lowest incomes could afford to pay their rent and household bills and feed themselves properly for the first time in years, the report shows.

But the Morrison Government abolished these special payments after lockdowns eased in late 2020 and later excluded people on the lowest income supports from the COVID Disaster Payment. When Delta struck later that year, there were no pandemic income supports for about a million people who were still unemployed.

Despite the remarkably quick progress in reducing poverty, abandoning these efforts (likely cost effective) meant that poverty rates were soon higher than ever.

A report released a year earlier by Good Shepherd Australia New Zealand came to the same conclusions. I wrote about this report in the 21 March 2021 edition of The Health Wrap.

Other reports also show how the efforts to very successfully address homelessness in the first year of the pandemic (ie during lockdowns) were not sustained. See, for example, this story from ABC News about the successful solutions to what has so often been seen as a “wicked” problem.

However, a 2021 report shows that the gains made on reducing homelessness during 2020 were already slipping away. Less than a third of those assisted with temporary hotel accommodation during the crisis were later transitioned into longer-term affordable housing, mainly due to a shortage of social housing.

The Australian Housing and Urban Research Institute estimated that four billion dollars in new or expedited funding for 98 housing program initiatives were announced by Australian governments due to the coronavirus pandemic between March and June 2020.

Sadly few of these programs were sustained and some of them had long-term adverse effects. For example,  tens of thousands of people renting across the country were left with mounting rental debts after having their payments deferred (but not reduced) while eviction moratoriums were in place.

New SARS-CoV-2 strains driving the current fourth COVID-19 wave

Australia is currently in the midst of a fourth COVID wave, and this now seems to be driven by the emergence of a number of new variants and subvariants.

While  BA4 and BA5 Omicron strains are still the most common, their dominance is on the decline. According to the Chief Medical Officer, Dr Paul Kelly, the increase in cases is mainly due to the Omicron variant XBB and possibly a second Omicron variant BQ.1.

You can read more about these new strains and how they are spreading here.

If you have recently seen diagrams like this of the evolution of new strains of SARS-CoV-2, then you are surely demanding some clear explanations.

The World Health Organization tracks the emergence of new variants and the European Centre for Disease Control and Prevention also has a good tracking website for variants of concern. There’s a good report, in non-science language, about new variants in Science, here.

Some viruses change slowly, but SARS-2 mutates extremely fast. Nature is much smarter at genetic experimentation that scientists, and that can lead to some fairly scary scenarios. A recent article in Salon (I know, not known for its science, but some very reputable scientists / epidemiologists are quoted) looks at some of the possibility of two or more slightly different versions of SARS-CoV-2 sharing genetic information and transforming into more troublesome pathogens.

It’s not clear how much actual monitoring for new variants is currently being done in Australia, which is worrying.

While this is definitely a task for the yet-to-be-established Australian Centre for Disease Control, I would argue that such work should be underway as a priority now, especially as our borders are open and people are moving freely internationally.


Expanded scope of practice for community pharmacy

The NSW Government has followed Queensland’s lead with its announcement there will be a 12-month trial allowing pharmacists to prescribe medications for urinary tract infections, ear infection, minor skin ailments and oral contraceptives and expanding the number of vaccines they can administer.

There are no surprises in the responses from the stakeholders – welcomed by pharmacy and panned by the medical organisations. Some pretty strong language was used: the Royal Australian College of General Practitioners said the move was “madness” and “a recipe for disaster” and the Australian Medical Association said it was “writing a prescription for the collapse of general practice”.

It’s a pilot, so we have to see what the evaluation shows, but here is my list of pros and cons:

  • It is increasingly difficult for many patients to get timely and affordable access to increasingly busy GPs, so expanding the scope of practice for pharmacists makes sense.
  • Pharmacists are the experts about the complications and side effects of medications. They generally know what (other) medications the patient is taking and how long they have been taking these.
  • Pharmacists are not trained diagnosticians, but that has long been part of their everyday work. Spend time in any pharmacy to see how much medical advice is delivered.

It would be good to see an increase in situations where local doctors and pharmacists felt they could regularly contact each other over any concerns with patient care, thus broadening the primary care team – but we know this rarely happens.

The Queensland Government announced in July that it would permanently extend the Urinary Tract Infection Pharmacy Pilot program, first introduced in June 2020. It has also announced a more broadly focused pilot program for North Queensland, where there is a critical GP workforce shortage.

This pilot was initially planned to be rolled out from June 2022 but, in the face of strong opposition from doctors’ groups, the government has modified the plan, which will now start in 2023. It should be noted that pharmacists who participate in this program must undertake a series of additional training requirements.

As part of their campaign against these moves, the Queensland AMA has released a study that highlights patient complications resulting from the UTI Pharmacy Pilot. This was based on an AMA survey of doctors which reported that one in five GPs, and one in eight of all doctors who responded to the survey reported seeing at least one complication.

The implementation and evaluation of the UTI Pharmacy Pilot was managed by the Queensland University of Technology which has provided a research study to Queensland Health. However, this information has not been made publicly available.


Unsafe drinking water in remote Australia

Most of us take safe drinking water for granted, but for many Australians that is not the case. Despite access to safe, acceptable and affordable water being a basic human right, according to the United Nations Sustainable Development Goals, many Australians are compromising their health when they drink water from the tap.

Almost 200,000 people in remote Australia don’t have access to drinking water that consistently meets health guidelines and 40 percent of the affected locations are remote Indigenous communities.

A further 400,000 people across Australia regularly drink water that fails aesthetic standards.

In research included in a new report by the Water Services Association of Australia, researchers from the Australian National University discovered unsafe drinking water in 115 locations, in the Northern Territory, South Australia, Queensland and Western Australia.

The report, “Closing the Water for People and Communities Gap: A review on the management of drinking water supplies in Indigenous remote communities around Australia”, presents some pretty shocking information and highlights how much must be done to address the basic requirements of health if efforts to Close the Gap on Indigenous health disparities are to be successful.

The Water Services Association estimates that it will require a minimum investment of $ 2.2 billion to bring drinking water in line with the Australian Drinking Water Guidelines, more if it includes replacing old pipes and plumbing.

Over 500 First Nations communities do not have regular water quality testing. First Nations communities, particularly in remote areas, are receiving drinking water with levels of uranium, arsenic, fluoride and nitrate and bacterial contamination that are above levels set by the Australian Drinking Water Guidelines.

Research has identified that unsafe nitrate levels in drinking water are associated with low birth weights, diabetes, dementia, and heart and kidney disease, among a range of other health complications.

The report calls for all States and Territories to formalise the Australian Drinking Water Guidelines to ensure that minimum quality standards are met across the nation. So far, at least the Northern Territory has responded.

The Australian Drinking Water Guidelines (last updated in 2018) are non-mandatory standards, intended for use by all agencies involved in the supply of drinking water including catchment and water resource managers, drinking water suppliers, water regulators, and health authorities.

The guidelines, which are managed by the National Health and Medical Research Council, are part of the National Water Quality Management Strategy.

It is encouraging to see that last month the Albanese Government announced changes to the Investment Framework for National Water Grid funding to allow for a broader range of projects to be considered. This includes essential town water supplies in regional and remote communities, as well as increased engagement with First Nations peoples as projects are developed.

However, the announcement was short on details about how First Nations communities will benefit. First Nations communities need a stronger voice in the services they receive, which must be better managed with clear accountabilities – currently water responsibilities lie across a myriad of agencies.

Making improvements to water supplies will also require investment in innovative new technologies that are resilient to climate change impacts, and ideally integrated with renewable energy and digital communications.

There is also an opportunity to invest in skills development for Indigenous workers in water services and cultural safety training, and for First Nations businesses to grow and expand expertise in water services.

ABC News covered this story in August here.

However, this is not a new issue: last year a report from the Western Australian auditor general highlighted these very issues.

You can read about the work that Murdoch University is doing with communities in the Kimberly here.


Deaths of despair

Back in early 2021, I wrote about the epidemic of “deaths of despair” in the United States. The term deaths of despair comes from Princeton economists Professor Anne Case and Professor Angus Deaton, who set out to understand what accounted for falling US life expectancies.

They found that the fastest rising death rates among Americans were from drug overdoses, suicide and alcoholic liver disease. These deaths disproportionately occurred in white men who had not earned college degrees (co-incidentally the very group most likely to vote for Donald Trump). Case and Deaton argue that a key driver of these deaths is economic misery.

As outlined in a 2021 article in StatNews, the COVID-19 pandemic has served only to aggravate this situation.

In a recent interview, Anne Case says that the people at risk of deaths of despair (essentially death by their own hand) feel that their pillars of life – family, work, religion – have been eroded, and lack of education means their ability to contribute to society has been thwarted.

The United States is experiencing a decline in life expectancy and the US National Academy of Sciences attributes this to a steep rise in mortality for white adults with a secondary education or less. The Academy adds the cardiovascular effects of rising obesity to the toll caused by suicide and poisoning by alcohol and drugs.

In contrast, other wealthy nations, including Australia, are seeing an increase in life expectancy.

The Australian Institute of Health and Welfare has done an analysis of Australian mortality data using methods similar to those used by Case and Deaton to show that Australians are not increasingly dying due to deaths of despair.

The rates of combined deaths by suicide, alcoholic liver disease and cirrhosis, and accidental poisoning over the period 1997 to 2020 show no clear trend. Over the past five years the rate has remained around 23 to 25 deaths per 100,000 population, similar to the rates in 1997 to 1999.

Males are more likely than females to die by these selected causes of death which are about 2.7 times more common in males than females, with suicide accounting for the majority (53–67 percent) of these male deaths.

Australia has not reported increases in suicide rates during the COVID-19 pandemic, due in large part to the boosts to healthcare, financial aid and suicide prevention supports.


In case you missed it

New research shows Australia’s offshore detention policies increase modern slavery risks

A new report by the Melbourne Social Equity Institute and Human Rights Law Centre, Labour in Limbo: Bridging Visa E holders and modern slavery risk in Australia, finds that people on the six-month Bridging Visa E are at increased risk of labour exploitation and modern slavery, such as wage theft, unpaid overtime, excessive hours, and abusive working conditions.

While the visas are typically renewed upon expiry, this persistent insecurity creates vulnerability that enables labour exploitation to thrive.

With Australia’s Modern Slavery Act is currently under review, the report calls for stronger laws that require companies to take action to prevent modern slavery, and for an end to offshore detention together with pathways to permanency for people on perpetual bridging visas.

Is simply increasing access to current treatments an effective means of improving population mental health?

A study from Professor Ian Hickie and colleagues at the Brain and Mind Institute at Sydney University looked at the question that is often asked in the face of the growing prevalence of mental health disorders – is continually expanding access to current treatments improving population mental health?

They found that a modest but significant effect of increasing access to mental healthcare in Australia between 2008 and 2019 was obscured by a concurrent increase in the incidence of high to very high psychological distress.

Their conclusion? While efforts must be made to improving the effectiveness of mental healthcare (the quality gap) and increase investment in prevention programs (the prevention gap), addressing the substantial and persistent treatment gap for mental disorders should be the key priority.

Is obesity policy in England fit for purpose?

An article in the Milbank Quarterly analyses government obesity policies in England from 1992 to 2020, a time frame that has seen increasing growth in obesity prevalence and health inequalities.

It finds that:

  • These policies have largely been proposed in a way that does not readily lead to implementation
  • Governments have rarely commissioned evaluations of previous government strategies or learnt from policy failures
  • Governments have tended to adopt less interventionist policy approaches
  • Policies adopted largely make high demands on individual agency, meaning they rely on individuals to make behaviour changes rather than shaping external influences and are thus less likely to be effective or equitable.

Many of these conclusions apply equally to preventive health initiatives in Australia.

The importance of health literacy for tackling non-communicable diseases

The World Health Organization has just published a report of several volumes on health literacy development for the prevention and control of non-communicable diseases.  This report was prepared with major input from the Swinburne University Global Health and Equity Team.

The report examines the concept that society – and not just the individual – is responsible for the health literacy that is needed to know how to prevent disease and to navigate the healthcare system.

Professor Richard Osborne from the Swinburne team was interviewed on this topic by ABC Radio National. You can listen to his interview here.

The Lancet ran an editorial on the WHO report, asking why health literacy is failing so many. It also sees improved health literacy as a way of addressing misinformation.

Work on developing an Australian Centre for Disease Control is underway

The discussion paper on the role and function of an Australian CDC (will they add Prevention here?) is now out. It includes an outline of its potential scope of functions, examples of how it could improve public health in Australia, and principles guiding its design.

Make sure you also read On the new Centre for Disease Control: here are 28 questions requiring your attention, from Terry Slevin at Croakey Health Media.


The best of Croakey

See these articles published by Croakey as part of the #HealthyCOP27 series, which is funded by the Lord Mayor’s Charitable Foundation and done in partnership with the Lowitja Institute.

Read: As our planet “hurtles towards the point of no return”, who is standing up for climate justice?

Read: Locally and globally, what will it take to reorient towards climate justice?


The good news story

For years, scientists have been trying to figure out whether “brain workouts” such as puzzles and online cognitive games could strengthen our minds and slow the process of aging.

Now, a study published in NEJM Evidence has found that regularly attempting a crossword may help slow decline in some people with mild cognitive impairment, an early stage of faltering memory that can sometimes progress to dementia.

The study has its limitations and some researchers are sceptical, but it offers some good news to those of us who daily attempt a crossword puzzle or two.

No indication as to whether winning at Wordle helps!


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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