The devastating impacts of global heating, the United Kingdom’s infected blood scandal, planning for the next pandemic, and the impact of Trumpian politics upon public health are among the topics covered in The Health Wrap this week.
Dr Lesley Russell also investigates the systems that are meant to prevent misuse of prescription drugs, and some of the delays and complexities involved, raising important questions and concerns for policymakers and clinicians.
The quotable?
The heat is particularly difficult for people living in refugee camps and informal housing, and in poor quality housing, as well as for outdoor workers.”
Lesley Russell writes:
This edition of The Health Wrap sees a return to several topics that have been addressed previously – the growing impact of climate change, the failure to adequately prepare for the next pandemic, the importance of vaccines, and the impact of Trump and Trumpism on health policy and healthcare.
These all serve to highlight the political, economic and social determinants of health.
As a relief from the not-so-good health news: Sydney is currently in the middle of the Vivid light festival and the city landmarks are all magnificently lit up.
The highlights for me are Reg Mombasa’s Aussie Gumscape with Road and Creatures on the Customs House and Julia Gutman’s story of Narcissus on the sails of the Opera House.
The world is getting unbearably hot – and people are dying
My inbox and Twitter/X feed are full of stories about the impact of climate change and global warming.
It seems that once again the Northern Hemisphere will be hit with summer temperatures that, for many – in both developed and developing nations – will make life unbearable. One tweet from a climate change scientist in The Netherlands called this “the summer of death”.
He was provoked to say this by reports from Mexico of an early summer, extreme heat wave that has already caused dozens of deaths.
In the United States, southern states are also experiencing extreme temperatures.
Europe, which has had eleven record-breaking months of warm temperatures in a row, is bracing for what could be the hottest summer ever. The ski season was ruined and the organisers of the Paris Olympic Games are worried about the safety of the athletes.
Sea surface temperatures in the North Atlantic have soared to their highest in at least 40 years.
Throughout April and May, extreme record-breaking heat led to severe impacts in the Middle East and across the Asian continent. The north of India is experiencing temperatures as high as 50 degrees Celsius.
The heat is particularly difficult for people living in refugee camps and informal housing, and in poor quality housing, as well as for outdoor workers.
There are predictions that increasing numbers of increasingly extreme heatwaves will make parts of some countries in the Middle East and the sub-continent “intolerable to humans” (and likely many animals too). An article in The Washington Post this week was headed “‘Unbearable’ heat in Delhi is testing limits of human survival”.
The impacts are being felt everywhere.
The city of Phoenix in Arizona is one of America’s hottest cities and has seen a huge surge in deaths due to the high temperatures. Last year there were 645 deaths in Maricopa County, a large metropolitan area that includes Phoenix.
The county is also facing a homelessness crisis and consequently almost half of the victims (290 people) were homeless. Many others, who tended to be older and unwell, died in uncooled homes.
The Biden Administration is planning new regulations that would require employers to protect an estimated 50 million people exposed to high temperatures while they work. They include farm laborers, construction workers, people who work in warehouses, and cook in commercial kitchens.
This is expected to meet stiff resistance from business and industry groups opposed to requirements for more breaks and access to water, shade and air-conditioning. Of course, should Trump win in November, such rule-making will go nowhere.
Australia is far from immune from these issues. See, for example, this article in The Sydney Morning Herald, titled ‘Here comes winter … and more rain’.
A summary on the NSW Government website AdaptNSW discusses how climate change will have a huge effect on the economy through reductions in productivity and increases to infrastructure and service costs.
A 2021 analysis by NSW Treasury predicts that by 2061, between 700,000 and 2.7 million days of work will be lost every year because of more frequent and intense heatwaves.
A paper published last year by researchers at Charles Sturt University looked at the impacts of climate change on work health and safety in Australia. It predicts an increasingly high risk of heat-related illnesses and injuries for many employees, both outdoors and indoors.
It notes the impact of increasing air pollution, which together with saline freshwater, wildfires, ozone depletion, water scarcity, and, , reduced crop yields, negatively affects health and the economy.
Climate change increases housing insecurity and the Climate Council estimates that one in 25 Australian homes will be uninsurable by 2030.
As climate change brings worsening disasters, Australia must act to protect the loss by fire, water and extreme weather of thousands of houses. Houses need to be built to better withstand the impacts of climate change.
Particular attention needs to be paid to Indigenous housing in remote areas – already a problematic issue. (The 2021 AHURI report on sustainable Indigenous housing in regional and remote areas is here.)
A 2022 paper in The Medical Journal of Australia shows how climate change will drive inequities in housing, energy and health in remote Indigenous communities even further.
Some of the authors of that paper wrote a follow-up article in The Conversation that outlined how climate change is turning remote Indigenous houses into dangerous hot boxes.
They issued a call for action that has yet to be systematically addressed, although it’s an essential aspect of Closing the Gap and social justice.
As Croakey has recently reported, climate and health concerns featured prominently at the World Health Assembly in Geneva recently. Yet many are concerned by the Albanese Government’s failure to invest in implementation of the National Health and Climate Strategy.
UK inquiry into infected blood and blood products
The seven-volume report from the Infected Blood Inquiry – set up by then Prime Minister Theresa May in July 2017 – has finally been released. (No, I have not read all seven volumes!)
The report details how tens of thousands of people across the United Kingdom were infected with HIV, hepatitis, and other bloodborne infections by transfusions of blood and blood products, from the 1970s to the 1990s.
It looks at the many failures of the National Health Service to prevent this, the deaths that resulted, and the ongoing costs to the economy and to individuals.
A compensation scheme will be set up (preliminary details are here) and – most importantly – the report calls for changes in health and government culture, including around attitudes to public health risks.
This includes requiring medical education bodies to update doctors’ training; strengthening the attention paid to safety; addressing a culture of dismissing patient concerns and failing to be fully transparent; a UK-wide review of healthcare safety regulation; a healthcare records audit; and an end to the “defensive culture” in the civil service and government.
The Guardian UK has a really good summary of the key issues in the report here.
There is an Australian link to this inquiry which investigated whether contaminated blood products exported from Australia were used in the United Kingdom. (I have been unable to determine if this was found to be the case.)
In the wake of the release of the UK report, Australians infected with Hepatitis C and HIV from blood and blood products have called for a royal commission.
Thousands of Australians (there is considerable disagreement about the number, with estimates ranging from 8,000 to 20,000) were infected with blood containing hepatitis C or HIV between the 1970s and early 1990s, before crucial advances in screening procedures.
Australia was somewhat protected because it had a policy of self-sufficiency in the blood supply, with blood donations sourced only from Australia, and it was one of the first countries to introduce testing of the blood supply.
In the early 1990s a trust was established to provide financial assistance (not compensation) to people with medically acquired HIV/AIDS; this trust was wound up in 2001, by which time 423 people had received payments totalling $20.16 million.
A Senate Inquiry into Hepatitis C and the Blood Supply was held in 2004 but the Government never implemented the recommendation that victims’ medical costs be covered. The report ruled out a compensation scheme.
Australian governments have contributed to Hepatitis C litigation settlement schemes for eligible people (those who contracted the virus via the blood supply between 1985 and 1991, prior to the introduction of screening tests).
The 2024-2025 Federal Budget provides $100,000 annually in the Contingency Fund for the Hepatitis C Settlement Fund which contributes to out-of-court settlement costs for eligible people (Budget Paper #3, page 109).
Perhaps to preclude calls for an Australian compensation scheme in the wake of the UK inquiry – or perhaps just because it makes good public health policy – the Albanese Government Budget this year includes $126.5 million over two years from 2024–25 to extend and expand activities to support the prevention, testing and treatment of bloodborne viruses and sexually transmissible infections (see Budget Paper #2).
This is a considerable boost in funds for this area, but why only for two years?
Will overseeing this spending be the responsibility of the Australian Centre for Disease Control?
Planning for the next pandemic
I have written previously about the stalled and fractious negotiations over the international Pandemic Agreement, which was due for completion in May.
There’s a good summary of why a pandemic agreement is needed and the obstacles in getting an international agreement here.
The World Health Assembly was meeting as I wrote this column. It finally passed amendments to the International Health Regulations (IHR) and committed to completing pandemic agreement talks within a year. I think this is a better-then-expected outcome. Let’s hope it can deliver!
A Twitter / X thread that takes a “glass half full” approach to the progress already achieved before WHA points out that, given the unavoidable blind spots of international law, an adopted treaty (while important) may matter less than the norms and principles it reinscribes along the way.
Equity is now seen as a core principle for pandemic prevention, preparedness and responsiveness and major issues like One Health (an approach that recognises the intersections between animal health, human health, and the environment), research and development and the WHO Pathogen Access and Benefit Sharing System (PABS) were discussed for the first time in the context of a legally binding instrument on health.
The Independent Panel for Pandemic Preparedness and Response, previously co-chaired by Helen Clark, the former New Zealand Prime Minister, called for more time for WHO member states to negotiate the Pandemic Agreement, but with a reset process which could lead to a stronger text within several months. The statement of the Australian Global Health Alliance is here.
As Professor Larry Gostin points out, it is imperative to get an agreement ahead of the US presidential election in November. If Trump wins, he will certainly withdraw the United States from any such negotiations and agreements.
Already Republican Members of Congress are spreading misinformation about what the proposed agreement would mean for the United States, as outlined in an article by Gostin and Dr Alexandra Phelan here.
As an aside, but in support of the point about what a Trump re-election would mean for public health and pandemic preparedness, a new paper in Health Affairs looks at how US courts (including emergency interventions by the US Supreme Court) constrained public health powers during the COVID-19 pandemic.
Individuals and organisations have successfully challenged many community mitigation orders (for example, mask mandates, vaccination mandates, and restrictions on gatherings), demonstrating the legal vulnerability of disease control measures in the United States.
The authors conclude that public health officials contemplating issuing health orders “must anticipate and prepare for litigation as part of policy implementation”.
Vaccines – a valuable contribution to survival and health
One of the key issues tying up talks on the Pandemic Agreement is vaccines – specifically, the ability of poorer nations to get the vaccines they need. Better vaccines and therapeutics, developed and scaled up faster and with more equitable access are needed to optimise the response to future pandemics.
An effort by Moderna to locate vaccine manufacturing in South Africa is currently stalled.
A paper just out in The Lancet looks at the contribution to improved survival and health that vaccines have made over the past 50 years of the WHO Expanded Program on Immunisations.
Modelling shows that since 1974, vaccination has averted 154 million deaths, including 146 million among children younger than five. For every death averted, 66 years of full health were gained on average.
The authors estimate that vaccination has accounted for 40 percent of the observed decline in global infant mortality.
One of the things that is urgently needed is combination vaccines. This is discussed in a paper in The Lancet Global Health.
The need for more combination vaccines arises because the current abundance of recommended and pipeline vaccines is now at odds with the number of acceptable vaccine administrations and feasible health-care visits for vaccine recipients and health-care providers.
But few combinations (like Diphtheria/Pertussis/Tetanus and Measles/Mumps/Rubella) are in development because, in addition to the scientific and manufacturing hurdles intrinsic to co-formulation, developers face a gauntlet of regulatory obstacles.
At the height of the COVID-19 pandemic there were efforts to improve the capacity to manufacture vaccines, therapeutics and diagnostic in sub-Saharan Africa.
Moderna looked to set up a mRNA vaccine manufacturing plant in Keny. But now those plans are stalled; Moderna said this is due to declining demand for COVID-19 vaccines in Africa, making the project financially unviable.
“Moderna has not received any vaccine orders for Africa since 2022 and has faced the cancellation of previous orders, resulting in more than $1 billion in losses and write-downs”, the company said in a statement.
The African Centres for Disease Control and Prevention decried the decision and said the continent’s local vaccine manufacturing plan, to produce 60 percent of vaccines administered in Africa by 2040, is still on track.
To highlight the importance of emergency stockpiles and multiple manufacturing sources are in infectious disease outbreaks, there are reports that global stockpile of cholera vaccine has run completely dry, as deadly outbreaks of the disease continue to spread.
In recent months, there have been outbreaks in 17 countries, including Afghanistan, Zambia and Syria. The supply shortage means there are no vaccines available for preventive campaigns in places such as Gaza, where all of the conditions for large outbreaks exist, or in places where cholera is endemic.
Currently there is only one manufacturer of this vaccine, which is given orally, a South Korean company called EuBiologics. This company is working to expand production.
But there is good news: three new vaccine makers are setting up production lines and will join the effort to replenish the stockpile.
You can read more about the cholera vaccine shortage and efforts to address it here and here.
Misuse of prescription drugs in Australia
I was brought up short with a shocking headline in The Sydney Morning Herald: ‘Teen died after getting 64 prescriptions from 31 doctors’!!
The article is about a coroner’s report of a young Victorian man who died from a complex drug addiction. It outlines how, in the 12 months before his death, he was dispensed 64 PBS prescriptions from scripts provided by 31 different doctors arising from more than 100 consultations.
I knew that there were systems in place that are supposed to prevent such doctor shopping and drug misuse, so I did some research to refresh my memory (and maybe yours).
Each state and territory decides what medicines are listed as Schedule 8 (S8) drugs (drugs of addiction) and the prescribing and monitoring requirements for these medicines withing their jurisdiction.
One might well ask why there are not national agreements here – the various governments must all be looking at the same evidence base.
Beginning around 2015 there was a call for the states and territories to implement real time prescription monitoring (although Tasmania has had such a system in place since 2008).
Real Time Prescription Monitoring aims to help tackle the issues around “doctor shopping” for access to prescription drugs of addiction by alerting GPs and pharmacists to patients on high daily doses of high-risk medications; risky medication combinations; and high-risk medications prescribed by multiple providers.
There are two components to Real Time Prescription Monitoring:
- A National Data Exchange (NDE), which captures information from State and Territory regulatory systems, prescribing and dispensing software, and a range of external data sources.
- Regulatory systems within each State and Territory, which manage the authorities or permits for controlled medicines in each state and territory.
The National Data Exchange was developed by the Commonwealth and released in December 2018.
But implementation of the various State and Territory regulatory systems has been painfully slow.
- Tasmania – DORA launched in 2009
- Victoria – SafeScript launched in April 2019
- South Australia – ScriptCheckSA launched in March 2021
- Queensland – QScript launched in September 2021
- Australian Capital Territory – CanberraScript launched in March 2022
- Northern Territory – NTScript launched in March 2022
- New South Wales – SafeScript NSW launched in May 2022
- Western Australia – ScriptCheckWA system launched in March 2023
It’s immediately obvious why the young man in the story that alerted me to this issue was not protected by a Real Time Prescription Monitoring system: he died in January 2019 and Victoria’s system was not in place until April 2019.
Why were there such dreadful delays in getting these Real Time Prescription Monitoring systems set up?
There had been a national Electronic Recording and Reporting of Controlled Drugs Program available to the states since 2013 (now it seems to have disappeared) but none of the States or Territories chose to take this up and they all went ahead with developing their own electronic systems.
They also rejected the idea of expanding the Tasmanian system, which had been well evaluated.
An agreement was reached in 2017, under then Health Minister Greg Hunt, that allowed states to use different systems as long as they were interoperable with a national system.
I have no idea if the current network of systems has achieved this interoperability. The Department of Health and Aged Care has information about Real Time Prescription Monitoring on its website which refers to it as a “national system” – but I suspect this is barely true.
Again, the obvious question is why – given that people who are doctor shopping for drugs of addiction can easily cross borders – there is not a national system in place?
Also, while in Queensland, South Australia and Victoria it is mandatory for prescribers and pharmacists to participate in prescription monitoring, it is voluntary in the other States and Territories.
Then, after some judicious googling, I found the Federal Government’s Prescription Shopping Program on the website of Services Australia.
This program identifies patients who, over a three-month period, have received:
- Any PBS scripts prescribed by six or more different doctors
- 25 or more PBS target drugs (ie high-risk drugs)
- 50 or more target or non-target PBS drugs.
This service for healthcare professionals operates Monday to Friday from 9 am to 5 pm AEST.
Do doctors, pharmacists, dentists and other healthcare professionals with prescribing rights know about these systems and do they use them?
The Royal Australian College of General Practictioners has a set of guidelines for prescribing drugs of dependence in general practice (these were developed in 2015). Part A – Clinical Governance Framework states:
“General practices should consider secondary prevention strategies that attempt to manage problematic drug use in its early stages of development before it results in significant morbidity. Practices should: …. facilitate GP access to information management data designed to monitor potential prescription drug abuse (eg state and territory health ministries’ drug units and Prescription Shopping Information Service [PSIS])…”
As far as I can determine the National Drug Strategy 2017-2026 does not mention the misuse of prescription drugs (there is a brief mention to the “diversion” of prescription drugs).
*** I have not found it easy to find information around this issue and I may well have missed something important. If so, please let me know.
Measuring the economic benefits of preventive health
The news from the United States these days is usually political and nearly always depressing. But here’s something to consider, even to translate to Australia.
I missed that back in March, the House of Representatives, which these days rarely does anything that is not on the MAGA agenda, passed the Preventive Health Savings Act.
This bill was introduced by Representative Michael Burgess, a doctor and a Republican from Texas. Senators Ben Cardin (Democrat from Maryland) and Mike Crapo (Republican from Idaho) have introduced an identical companion measure in the Senate.
The bill would empower the director of the Congressional Budget Office to determine whether a proposed measure of “preventive health and preventive health services” would reap budget savings more than ten years into the future – and, if so, then require that CBO include that analysis of budget savings in its overall projection of the cost of the measure.
It would be great to see this proposal, with bipartisan support, enacted into law.
Good news in Indigenous health
It was wonderful to see news about the opening of a new birthing service at Weipa, enabling Indigenous others to give birth on country.
The Weipa Integrated Health Service officially began operating on 22 May and is expected to initially support around 50 births a year from the communities of Weipa, Mapoon, Napranum and Aurukun.
Australian College of Rural and Remote Medicine President Dr Dan Halliday said: “This service will provide access to continuous culturally safe holistic care that is close to home for people living in rural, remote and First Nations communities.”
Best of Croakey
On 28 May, Croakey held a terrific and informative CroakeyLIVE event on improving healthcare for First Nations people in prisons. This was sponsored by Girra Maa, the UTS Faculty of Health’s Indigenous Health Discipline.
It comes ahead of a review of healthcare for First Nations people in prisons. A discussion paper prepared for the review is here.
You can read Alison Barrett’s outline of the issues, written ahead of the event, here.
You can read Marie McInerney’s report of the discussion and also watch the webinar on replay.
Here are some earlier Croakey articles:
- Investigation of inadequate healthcare in prisons highlights importance of cultural safety and Aboriginal-led solutions
- Some clear recommendations to improve healthcare for First Nations people in prison
- Governments urged to address determinants of incarceration and provide safe healthcare in prison.
Good news story, sort of
Given the warning that University of Queensland scientists have issued about Australia’s loss of bird species and habitat, I think this is more accurately described as “the mostly good news story”…
A recent article in The Conversation UK outlines how bird watching can contribute to improved mental health and foster a sense of wellbeing.
A German analysis published in The Lancet Planetary Health confirms a positive relationship between bird diversity and mental health, especially for people with lower socioeconomic status.
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.
