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The Health Wrap: the pandemic, food insecurity, palliative care, mental health and so much more…

In her latest edition of The Health Wrap, Dr Lesley Russell reports on concerns about food insecurity, mental health and other health impacts of the pandemic response, as well as updating readers on a stack of new resources and reports.


Lesley Russell writes:

The coronavirus pandemic continues to dominate the news, but now, as the pandemic moves into its fifth month, the focus is increasingly on the long-term impacts of the ways our lives have changed and will continue to be different into the future.

In Australia it is now two months since lockdown measures were implemented and even as these start to ease, the economic impacts are beginning to be felt. This is also true of many other countries, regardless of how well the infection rate is controlled.

The economic downturn affects people’s lives through increased unemployment, decreased employment, reductions in income and wealth, and increased uncertainty about future jobs and income. This is aggravated because it is impossible to predict how and when the coronavirus pandemic will end.

A recent briefing note from the UK Institute for Fiscal Studies is an excellent summary of the issues. Read this in conjunction with Janke et al (2020), “The impact of COVID-19 on chronic health in the UK”.

Work based on the 2008 financial crisis indicates that a 1 percent fall in employment leads to a 2 percent increase in the prevalence of chronic illness. The largest increase is seen in mental health conditions and the full impact is not be seen for several years.

These health effects are complex and differ across generations, geographic regions and socio-economic groups, but groups that are already vulnerable to poor health are likely to be hit hardest.

Of particular concern are families with young children or where mothers are pregnant and low-income or low-socio-economic-status individuals of all ages where health vulnerabilities and mental health problems are already prevalent.

There is evidence that the state of the business cycle at birth affects cognitive abilities and mortality: being born in a recession reduces lifespan by about 5 percent and the adverse impact of recessions on mental health and mortality from suicide has been clearly documented. This will be aggravated by the consequences of social distancing.


How to flatten the mental health curve

The mental health findings from the UK outlined above are echoed in recent research done in Australia.

Modelling commissioned from Orygen by the Victoria Government shows that without action, an extra 370,000 people in the state will seek treatment or be hospitalised over the next three years as a result of mental health problems related to coronavirus, with young people disproportionately affected, and there will be hundreds more suicides.

Work by the Brain and Mind Institute (BMI) at the University of Sydney indicates the extent of the suicide surge that could take many more lives than COVID-19. Annual suicide rates are forecast to rise dramatically – from 3000 currently to up to 4500 a year over each of the next five years. Youth suicides will make up almost­ half of the projected increases which are based on unemployment rates rising as high as 15 percent. Hospitalisations and emergency department visits for self-harm could also go up as much as 20 percent.

Unchecked, this would mean a generational mental health crisis with some regions, like those hit hard by the collapse of tourism.

In one such area on the NSW North Coast, it is estimated that over the next five years, without urgent and effective action, there would be up to half a billion dollars in productivity losses directly attributable to coronavirus-generated increases in mental health and suicide.

The BMI experts offered solutions to prevent this disastrous outcome, based on increasing specialised mental health services with IT-enabled coordinated care and assertive post-suicide attempt aftercare. If implemented nationwide, these additional services would translate to 2,650 lives saved, 33,450 fewer suicide attempts and 225,800 fewer presentations to emergency departments over the next five years.

This research work was provided to the National Cabinet, backed by a letter from Professor Pat McGorry at Orygen, Professor Ian Hickie at BMI and Dr Tony Bartone, president of the Australian Medical Association.

The letter concludes:

The duration and depth of the disruption to our lives is not yet known.

However, we do know that people living in outer urban areas, rural and regional Australians, casual workers, those recently unemployed, and older workers will most likely be affected by the social and economic impacts.

We must act quickly to increase key capabilities before the surge in demand for mental health services becomes evident.”

However, perhaps controversially, the new deputy chief medical officer for mental health, Dr Ruth Vine, has sounded a cautionary note over the study predicting massive increases in suicide following the COVID-19 pandemic.

The response from National Cabinet and the Australian Government came promptly with the announcement on 15 May of $48 million for the National Mental Health and Wellbeing Response Plan.

This is a very small level of funding given what is needed, and it’s not clear how well targeted this is.

The new mental health and wellbeing plan has been criticised because “It [the plan] doesn’t yet seem to reach the scale or the immediacy really required now to be ready for the really significant mental health problems that we will face over the next two years.”

It has little to say about the need to integrate mental health and substance abuse services and no funding for the latter, despite polling showing that many Australians are consuming more alcohol. The already over-burdened rehabilitation system is being pushed to breaking point.

“This is a very big wall we’re trying to build and we saw a couple of bricks put in the wall [on Friday], but when is the rest of the wall going to be built?” said Professor McGorry.

See my related analysis for Inside Story.

Also see these comments below from my Croakey colleague and GP, Dr Tim Senior.

As he notes, mental health issues are a major reason for visits to GPs, so consideration needs to be given to extra assistance for them and mental health nurses in primary care.


Mitigating the wider health effects of the pandemic response

A paper recently published in BMJ looks at how health inequalities are likely to widen without action to support those most vulnerable to the economic and other effects of social distancing measures.

The authors argue that policy decisions made now will shape the future economy in ways that could either improve or damage health and health inequalities. These include decisions about which sectors and population groups to prioritise for support, whether to direct financial support to business or workers, and how to fund the costs.

Any subsequent period of austerity instituted by governments looking to address budget deficits through reductions in social security and public service spending will further adversely affect population health.

The paper includes a figure that is worth checking which provides an elegant summary of the pandemic responses and their consequences.

A BMJ preprint just out also has this focus on the future. It looks at lives saved and the impact on life expectancy from full blown efforts to prevent coronavirus infections and compares these with the reduction in life expectancy due to socio-economic inequalities. 

The research (using age-standardised deaths and the Imperial College modelling of the impact of coronavirus on the UK) estimated that the impact of fully mitigating coronavirus infections (ie social isolation and related actions) prevents a loss of 5.63 years of life expectancy.

The loss of life expectancy due to inequalities (defined as all deaths higher than the rate of mortality in the least deprived tenth of the population) is estimated to be 3.51 years.

The authors note that the rapid policy responses to coronavirus demonstrates what governments can and should do in the face of a massive population health challenge.

Yet the mortality risks from socially-generated causes, which have existed for decades, are not given the same efforts. The key question is whether the policy response should consistently match the mortality challenge – and if not, why?

They write, “The post-COVID-19 pandemic period should be used to ‘build back better’ and ensure that society and the economy in the future provides the basis to reduce social inequalities in health and all avoidable causes of death.” 

It’s an instruction all governments should act an.


Food insecurity

The news from the United States in these coronavirus times just seems to get worse every day. Recent analyses show that since the onset of the pandemic, food insecurity has increased, especially in households with young children.

A study from the Brookings Institute looked at the results from two national surveys conducted in late April. In these surveys, households and children were considered food insecure if the respondent indicated the following statements were often or sometimes true:

The food we bought didn’t last and we didn’t have enough money to get more.

The children in my household were not eating enough because we couldn’t afford enough food.

It found that more than one in five US households and two in five mothers with children under 12 years of age were food insecure.

In about half of the latter households, the children were experiencing food insecurity (see figure below).

The rates of food insecurity observed in April are unprecedented in modern times.

The incidence of hardship, as measured by the response to the question about children not eating enough because  there was no ability to buy food, has increased by 460 percent since 2018 and 34.5 percent of households with a child under 18 were food insecure in April, up from 14.7 percent in 2018.

High levels of food insecurity is not just a problem in households with children. Survey data from The Urban Institute found 21.9 percent of households with non-elderly adults were food insecure, up from 11.1 percent in 2018.

The situation is aggravated because the Trump Administration and a number of Republican governed states are looking to limit access to the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamps Program)  and many children are currently not able to get free or inexpensive school meals. Food banks are under extraordinary pressure as cars and people queue for miles to get needed food supplies. 

In New York City, hard hit by the pandemic, it is estimated that one in four people (around 2 million) face food insecurity. City officials are planning to begin delivery of more than a million free meals a day and Mayor de Blasio has appointed a “food czar” to oversee this.

What makes this situation even more tragic is that as America’s food banks face huge demands and grocery stores struggle to keep shelves stocked, farmers are dumping fresh milk and ploughing vegetables back into the fields because the food industry supply chains have been disrupted.

Australia cannot afford to be too smug about America’s woes – there is growing evidence that some segments of the Australian population (people who are homeless, international students, even families with children) are doing it tough.


Health hazards inside Australian supermarkets 

In Australia we have been fortunate that the food supply system has continued to function almost normally after some initial panic buying (unless you are a baker wondering why the flour shelves are too often empty).

But new research, from the Global Obesity Centre at Deakin University, shows how displays and discounts entice us to make unhealthy purchases. No wonder 35 percent of what Australians eat is considered unhealthy!

This research, funded by the Australian Prevention Partnership Centre, used an audit of Victorian supermarkets (both the major chains and independents) to look at the healthiness of the foods on offer.

It found that supermarkets promote unhealthy products like soft drinks, chips, chocolate and sweets by giving them more shelf space and prominent placements and discounting them more frequently than healthier options (fresh and frozen fruits and vegetables). 

There was unhealthy food at 90 percent of all staff-assisted checkouts and food specials were 7.5 times more likely to be unhealthy than healthy.

Aldi stores were less likely to promote unhealthy food; there was little difference between Coles and Woolworths; and the two healthiest stores (as measured by the proportion of shelf space allocated to unhealthy food) were both independents.

On some measures, supermarkets in more socio-economically disadvantaged areas were less healthy. This is disturbing because people who live in these areas have higher rates of diet-related diseases, are less likely to eat nutritious food and more likely to over-consumer unhealthy food.

Are supermarkets here merely responding to the needs of their customers or are they directly affecting people’s health status by the foods they offer?

This work follows on from previous studies by the Global Obesity Centre. This includes the 2018 “Inside our Supermarkets” report which assessed the four largest Australian supermarkets (Woolworths, Coles, ALDI, IGA) on their policies and commitments related to obesity prevention and nutrition.


A new science strike force

There are already many examples of how Australian research, ingenuity and innovation have come to the fore during the coronavirus pandemic.

Sadly, these are not matched by the Morrison Government’s willingness to invest in this research and our universities.

A recent article in the Sydney Morning Herald warning that coronavirus is likely to spread faster in cold weather and that we could face annual winter coronavirus seasons alerted me to the existence of the Rapid Research Information Forum.

It is convened by Australia’s Chief Scientist, Dr Alan Finkel and is part of the Australian Academy of Science. The Forum provides a mechanism to bring together quickly relevant multidisciplinary research expertise to address pressing questions about Australia’s response to COVID-19. To date there are nine reports on the website.

The valuable expertise in our universities is also highlighted by the recently released “COVID-19 Roadmap to Recovery: A Report for the Nation” from the Group of Eight University Taskforce. There is a good summary of the roadmap and its recommendations on the Power to Persuade blog.

In the wake of the release of the Group of Eight report, articles in Croakey explored further what role health economists should be playing in the health response to the coronavirus pandemic,  and looked in detail at the chapter in the report that addressed the special considerations needed for Aboriginal and Torres Strait Islanders and their communities through the recovery process.


Health policy alerts

The postponement of the development and release of the 2021-22 Federal Budget means some important policy decisions have (apparently) also been delayed.

What is happening on the following fronts? Can the Morrison Government manage the coronavirus pandemic and, simultaneously, the normal workings of government?

The current National Partnership Agreements on Public Dental Services for Adults between the federal and state and territory governments expires at the end of June. The last agreement, which commenced 1 January 2017 provided $350.3 million, estimated to provide dental services to 580,000 adults. Since then the need has only grown.

The sixth Community Pharmacy Agreement between the government and the powerful Pharmacy Guild of Australia also expires on June 30. 

The current agreement was worth $18.9 billion over five years; the next is likely to be around $20 billion – that’s about 30 percent of the Pharmaceutical Benefits Schedule expenditure.

Negotiations have been underway for months, and the Guild will want surety about their funding for the next five years, but so far we have heard nothing. My colleague Jennifer Doggett wrote about this for Inside Story, and her article is also available at Croakey.

The Productivity Commission was due to deliver the final report from their mental health inquiry to the government last week, but suddenly their website announces that this will now happen in  June.

Perhaps the extra time is required to assess the additional implications for the reform of the mental health care system indicated by major crises such as the summer bushfires and the coronavirus epidemic?


New reports you might have missed

AIHW: A profile of primary care nurses

Primary health care nurses are the largest group of healthcare professionals working in primary care.

In Australia, at least 82,000 nurses work outside of the hospital setting including nurse practitioners, registered nurses, enrolled nurses and registered midwives. These nurses are mostly registered nurses (82 percent), mostly women (96 percent), mostly aged between 45 and 60 (60 percent), and are highly qualified and experienced. The majority (86 percent) received their initial nursing or midwife qualification in Australia. For those whose initial qualification was obtained outside Australia, the highest proportion occurred in the United Kingdom and New Zealand.

For me, several points emerge from this profile:

Given that nurses are often the first point of contact for patients in primary care, it would be worthwhile ensuring that these nurses reflected the cultures of the communities in which they worked (there is no information provided about this in the profile) and that there were more male nurses.

Without efforts made now to attract more younger nurses  into primary care, there will soon be a workforce shortage as older nurses retire.

Only about five percent of primary care nurses have midwifery training and only about two percent are nurse practitioners.

See also: https://insightplus.mja.com.au/2020/20/time-to-unleash-the-potential-of-primary-health-care-nurses/

AHSI: The Palliative Care Outcomes Collaboration reports and dashboards

The Palliative Care Outcomes Collaboration (PCOC) is a national program that operates under the auspices of the Australian Health Services Institute and the guidance of the dynamic Professor Kathy Eager at the University of Wollongong.

It uses standardised clinical assessment tools to measure and benchmark patient outcomes in palliative care and the routine collection and public availability of national data is used to drive improvements through reporting and benchmarking. Participation in PCOC is voluntary (one might ask why it isn’t mandated?) but, as @k_eager recently tweeted – why can’t acute care (and aged care) do this?

In response to the coronavirus pandemic, PCOC has begun the immediate collection of data on palliative care patients with COVID-19.

Also, a range of activities are underway as part of National Palliative Care Week.

NDRI: Quantifying the Social Costs of Pharmaceutical Opioid Misuse & Illicit Opioid Use to Australia in 2015/16.

This report from the National Drug Research Institute at Curtin University estimated the social costs arising from extra-medical opioid use (defined as the use of any illegal opioids and the use of pharmaceutical opioids not as prescribed) in Australia for the financial year 2015/16.

Australia has so far avoided the pharmaceutical opioid crisis seen in the United States, but the number of Australian deaths due to pharmaceutical opioids outstrip those from heroin.

In 2017, only 28 percent of opioid deaths involved illicit opioids alone and 63 percent were attributable to pharmaceutical products. However, these figures are rising and so will the estimated costs to individuals, the healthcare system and society

The total cost of opioid misuse was estimated at $15.7 billion, with 32,000 hospital admissions and 2,200 deaths. The tangible costs totalled $5.63 billion including hospital care ($249.3 million), community care ($829.5 million), crime and courts ($936.1 million) and workplace costs ($458.7 million). There was a further $10.13 billion from intangible costs, due to lives lost. Also calculated, but not included, was the cost for lost quality of life, estimated at $14.93 billion.

There is a good summary of this report from The Conversation.


If you or someone you know needs help or support, contact:

Your local Aboriginal Community-Controlled Organisation
Lifeline 13 11 14
Beyondblue 1300 22 46 36
Kids Helpline 1800 551 800
Mensline 1300 78 99 78
Q Life 1800 18 45 27
Open Arms Veterans & Families Counselling 1800 01 10 46
The National Indigenous Critical Response Service 1800 80 58 01.


The good news story

OK, so this has nothing to do with public health, everything to do with a good laugh, courtesy of two great actors.  Enjoy!


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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