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The Health Wrap: US election, coronavirus in the US, Africa & Israel, healthy stores, Indigenous evaluation strategy and more

In this latest edition of The Health Wrap, Associate Professor Lesley Russell looks at the ongoing cost of the coronavirus pandemic in the United States, successes and new risks in Africa, and an update on Israel’s response.

She also digs into a host of new research and analysis, including on the implementation of the co-designed Healthy Stores 2020 strategy in community stores in remote Australia, the Indigenous Evaluation Strategy released on Friday by the Productivity Commission, and the latest reports from the Royal Commissions into the bushfires and disability.

Admitting here that she is obsessed with and worried about this week’s US presidential election, Russell, a Croakey contributing editor, and James Blackwell, a Wiradjuri man and Research Fellow (Indigenous Policy) at the Centre for Social Impact UNSW, will moderate a #CroakeyLIVE event from 3pm AEDT on 4 November for real-time discussion of the election as as results begin to roll in. You can register here.


Lesley Russell writes:

We are in countdown mode to election day on Tuesday 3 November in the United States, even as the coronavirus numbers are taking off exponentially, especially in the more rural Mid-West and Mountain West states.

Hospitals in Utah were reported to be preparing to ration care as a record number of coronavirus patients flood their ICUs. In Texas, authorities are scrambling to shore up resources in El Paso, where intensive care units hit full capacity last weekend as COVID-19 hospitalisations have nearly quadrupled to almost 800 in less than three weeks.

Although Trump is doing his best to have it otherwise, this election will be a referendum on his handling of the pandemic. Three recent studies highlight the long-term costs of the Trump Administration’s failures.

  1. A more robust US response could have avoided 130,000 deaths

A study from the National Center for Disaster Preparedness at Columbia University estimated how the US might have fared had it followed the example of a more robust response to the coronavirus pandemic.

The researchers compared the coronavirus response of the US to that of six other countries— South Korea, Japan, Australia, Germany, Canada, and France—and found it  rated unfavourably against them all.

By failing to implement the type of response strategies employed in any of these six comparison countries, the US may have incurred at least 130,000 avoidable deaths.

It’s interesting to look at how well Australia comes out in this analysis.

  1. Coronavirus has claimed 2.5 million years of potential life in the US

An analysis from Harvard shows that that the coronavirus has claimed more than 2.5 million years of potential life in the US since the start of 2020. Nearly half of those years were taken from people under the age of 65.

  1. The estimated cumulative financial costs of the COVID-19 pandemic are estimated at more than US$16 trillion

In a paper published in JAMA, well-known economists David Cutler and Larry Summers calculate the cumulative financial costs of the COVID-19 pandemic related to the lost output and health impacts.

The total cost is estimated at more than US$16 trillion, or approximately 90 percent of the annual gross domestic product of the US. For a family of four, the estimated loss would be nearly US$200,000. Approximately half of this amount is the lost income from the COVID-19–induced recession; the remainder is the economic effects of shorter and less healthy life.

Trump hinders efforts to address the pandemic

By now everyone is well aware of the shocking way the Trump Administration treats science, scientists and data. This past week, two more issues were raised but were largely lost in the noise around the debate.

  1. Where are the data?

The New York Times has revealed that the Trump administration has continually declined to release critical data to outside public health experts – information that would enable them to devise more effective and targeted strategies against the coronavirus pandemic.

Federal agencies such as the Centers for Disease Control and Prevention (CDC) are compiling data for each county and city on testing, COVID-19 cases, hospitalisations, deaths, when social distancing mandates were introduced, and other factors, often broken down by race and ethnicity.

But inexplicably, much of this is not available outside the government. As an example, The New York Times had to sue the CDC under the Freedom of Information Act to obtain basic information on cases tabulated by race and ethnicity.

The CDC does provide data at the national level for cases by age, sex and race/ethnicity, but not at the state or county levels.

In June, in response to criticisms about the incompleteness of racial and ethnic data for coronavirus testing , the Trump Administration released new requirements for reporting to the CDC. However it appears that compliance with these new regulations is inadequate and, in some cases, completely lacking.

The COVID-19 Racial Data Tracker is run under the auspices of The Atlantic, and uses publicly available data from state and local health departments, as well as the CDC.

According to The Lancet, the Tracker reported on September 13  that among the 6,448,573 cases recorded (notably larger than the tally reported by the CDC), 37.5 percent were missing data on race; some states did not report any race/ethnicity data at all.

One clear takeout (of many) from all this is the crucial role played by the media in tracking and highlighting and revealing the inadequacies of this information.

  1. What happened to the National Vaccine Advisory Office?

This past week it was also made public that the Trump Administration didn’t shut down just the White House’s National Security Council Directorate for Global Health Security and Biodefense that was set up by the Obama Administration.

Now it emerges that in 2019 Trump Administration closed the National Vaccine Program Office, saying this would “increase operational efficiencies by eliminating program redundancies and decreasing program costs.”

This Office monitored long-term safety issues with vaccines – something that will be critical when coronavirus vaccines become available for public use. Hundreds of millions of Americans may get different coronavirus vaccines from a variety of drug makers – this will be a tracking project like no other.

Who will do this work now? In a statement reported by The New York Times, a spokesperson said that Operation Warp Speed was working closely with the CDC “to synchronize the IT systems” involved in monitoring vaccine safety data. Hmmm!

Photo: Jose M/unsplash

Implications of the election for US health policy

I confess I’m obsessed with the US presidential election polls and worried about the outcome.

This is not an election where policy has played a major role – it’s more about competing ideologies and world views.  But there will be policy ramifications, particularly around health, healthcare and the coronavirus pandemic.

We explored some of these issues, along with the consequences for global health, climate change and the environment in the first CroakeyLIVE Zoom event. You can read the background paper I prepared here, and Jennifer Doggett’s excellent summary of the discussion here.

A paper in the New England Journal of Medicine this past week has an interesting and insightful take on the consequences of the election for health policy.

It finds that policy decisions made by nationally elected officials in recent years more closely reflect the views of their party’s adherents than they do the views of the general voting public as a whole. They also reflect to some degree the views of each party’s largest financial donors.

This means that future major policy directions will be influenced heavily by which party gains control of the presidency, the House, and the Senate in this election.

That’s really no surprise – it’s been increasingly evident in recent years.

The NEJM paper points out that in 2019 average Republicans differed from average Democrats in their views across 30 policy-related issues about what government should do in the future by 39 percentage points — more than double the gap in 1994. The differences between the parties encompass not only critical health policy and social issues like abortion but also issues related to the preferred role for government in addressing critical national problems (including, most obviously, the coronavirus pandemic).

This may change somewhat if Biden wins – he has had considerable experience in congressional negotiations and he may well be able to wrangle the views of left-leaning Democrats (who would push for Medicare for All) and some of the more moderate Republicans (if there are any left) to enact legislation to rebuild Obamacare. But the political divide will only worsen under Trump.

I concur with the paper’s predictions that the Democratic party will look to move in the direction of at least a partial Medicare for All program, whereas if Republicans are in the majority they are likely to move to state-directed health care programs offering more limited benefits and with many private-sector options.

As mentioned, a key policy difference between the two parties centres around how the coronavirus pandemic should be managed.

A recent study from the independent and bipartisan Committee for a Responsible Federal Budget analysed the budgetary effects of the presidential candidates’ plans to address the health and economic impacts of the pandemic.

The modest additional proposals Trump has put forward would cost between $530 billion and $870 billion, with a central estimate at $650 billion.

The much more wide-ranging proposals Biden has put forward would cost $2 trillion to $4.2 trillion, with a central estimate at nearly $3.1 trillion.

If you are interested in the health economic aspects of US policies, then the Committee for a Responsible Federal Budget has some excellent analyses on their website.

Other valuable websites perhaps less well-known in Australia include the Bipartisan Policy Center and the Center on Budget and Policy Priorities.

Coronavirus in Africa: relative success and new risks

We are hearing little about what is happening with the coronavirus in Africa. So I went looking for information.

In almost every respect, Africa is at a disadvantage compared with richer continents, apart from one key issue: there is lots of experience with infectious diseases, both endemic and emerging.

That may explain why, so far, the coronavirus pandemic has been relatively contained in Africa and the reported death rate per capita on the continent has been low compared with other parts of the world, despite the poor health infrastructure.

South Africa has been harder hit than other African countries, perhaps because its population is older or because there are more people with diabetes and heart disease.

Even so, it has done better than expected and there has been no second wave of infections. The rest of the continent has so far avoided the worst of the coronavirus storm. By October, Africa, which makes up 17 percent of the global population, had recorded just 3.5 percent of COVID-19 deaths.

The low fatalities, even if they underestimate the true numbers, could not be attributed to policy alone. It looks increasingly as if other factors, including pre-exposure to related viruses, might have made people less vulnerable to coronavirus.

Now there are concerns that this might be changing.

The following data are taken from the  University of Washington’s Institute for Health Metrics and Evaluation COVID-19 briefing package  from October 25:

  • Regional cases and deaths from COVID-19 are slowly rising across the WHO African Region, and transmission is increasing in Algeria, Kenya, and Tanzania.
  • Daily cases have increased to over 5,000 a day in the last week.
  • Daily deaths increased to 130 a day in the last week.
  • The effective R, calculated based on cases, hospitalisations, and deaths, is over 1 in Algeria, Angola, Côte d’Ivoire, Ethiopia, Kenya, Sierra Leone, South Sudan, and Tanzania.
  • Diagnostic testing rates in Africa remained low in the last week at around 10 per 100,000 people; only a few countries – Botswana, Cameroon, Gabon, and Namibia – test more than 50 people per 100,000.

The IHME expects the daily death rate to rise steadily in December, reaching 600 a day in the first week of February. Cumulative deaths for the WHO African Region are forecasted to be approximately 56,000 by February 1. By then South Africa, Uganda and Kenya will have more than 12 percent of their population infected.

Increasing mask use to 95 percent (it currently averages 40 percent and is declining), the level observed in Singapore, could prevent 18,000 deaths by February 1.

There’s a very interesting and detailed analysis of the pandemic on the African continent here, plus a a great video on how Rwanda has been able to effectively confront coronavirus here.

What is happening in Israel – a follow-up

A brief follow-up to my September 15 The Health Wrap which was written just ahead of Israel going into a second lockdown, which has shown to have worked surprisingly well, faster and more effectively than the first lockdown, despite being less tight.

See data from this Twitter thread from an epidemiologist at the Weizmann Institute.

The Weizmann Institute has also looked at the impact broken down by population groups – Orthodox, Arab and general population. It took 20 days for the effects of the lockdown to be seen in the Orthodox population, 17 days in the general population and the drop in cases in the Arab population actually started ahead of the lockdown.

Healthy eating – what works at the store?

Supermarkets and food retail stores are the principal source of people’s food and beverage needs and are therefore a prime setting to implement changes designed to increase the purchase of healthy food and decrease the purchase of unhealthy food in order to improve population diet and health.

There is growing awareness that where foods are placed in shelves is an important marketing strategy.

A recent study from New Zealand, involving a retailer/academic collaboration, explored the impact of more prominent shelf placement of healthier products. However, the study found that placing healthier breakfast cereals at adult eye level had no impact on sales.

Failure to show any meaningful outcomes is not uncommon in this research area, so it is great to see some results from a study with Aboriginal and Torres Strait Islander communities in remote Australia.

The Lancet has just published a study led by Professor Anna Peeters at Monash University in conjunction with the Arnhem Land Progress Aboriginal Corporation (ALPA) which owns and manages community stores in remote Australia and has looked at the implementation of the co-designed Healthy Stores 2020 strategy.

The Strategy involves restricting the merchandising of discretionary products and thus their desirability, while allowing for the substitute merchandising of healthy core foods.

The overarching aim is to reduce the volume of targeted discretionary items purchased and hence the amount of free sugar (that is, added sugars to food and drinks and sugars naturally occurring in honey, fruit juice, and fruit juice concentrates) purchased. You can read more here. The Supplementary Appendix to the paper also has some useful information.

Over 12 weeks, the Strategy was successful in achieving a significant overall reduction in free sugar with no adverse impact on gross profit. A large reduction of 13.4 percent in targeted soft drink free sugar was observed (alongside a large increase of 23.5 percent in non-targeted soft drinks) and targeted confectionery free sugar was also significantly reduced (7.5 percent).

The authors conclude: “Restricted merchandising of unhealthy foods and beverages, while allowing for complementary merchandising of healthier foods and beverages in a real-world store setting and co-designed with retailers, can achieve both public health and business relevant gains.”

Cost is often cited as the biggest barrier for shifting to a healthier or more environmentally friendly diet.

But a research study from Deakin University which compared the cost of a basket of weekly groceries based on the planetary health diet (eating more plant-based foods) with the cost of a basket based on the typical Australian diet (more red meat and processed food) has found the average Australian family could save more than $1,800 a year by making the switch.

New Indigenous Evaluation Strategy with damning indictment of past failures

Over the years numerous reports have highlighted the need for more evaluation of policies and programs that have an impact on Aboriginal and Torres Strait Islander people.

Only a relatively small number of these policies and programs have been rigorously evaluated (and there is no indication that the finding have been acted upon – as evidenced by the cashless welfare card failures).

On October 30 the Productivity Commission released the Indigenous Evaluation Strategy. This is designed to provide a whole-of-government framework for Australian Government agencies to use when selecting, planning, conducting and using evaluations of policies and programs affecting Aboriginal and Torres Strait Islander people.

There is also a Background Paper and Guide to Evaluation. Submissions to the Productivity Commission on the Strategy are available here.

Releasing the report, Commissioner Romlie Mokak, a Djugun man and a member of the Yawuru people, said:

Policies and programs affecting Aboriginal and Torres Strait Islander people are not working as well as they need to. Evaluation can play an important role filling this gap, but regrettably it is often an afterthought and of poor quality.”

“Importantly, Aboriginal and Torres Strait Islander people are rarely asked about what, or how to evaluate, or what evaluation results mean.”

The key points in the Background Paper are a damning indictment of Government failures, including lack of attention to evidence and to where and how funding is spent, the evaluation against meaningful outcomes, and consultation with Indigenous experts and communities.

Here are just a few:

  • After decades of developing policies and programs designed to improve the lives of Aboriginal and Torres Strait Islander people, we still know little about their impacts, or how outcomes can be improved.
  • Evaluation is often an afterthought rather than built into policy design (and this can affect data collection, evaluation design and result in evaluations that tell you very little).
  • Many evaluations focus on the wrong things (compliance rather than measuring impact, which means findings are often not useful).
  • Aboriginal and Torres Strait Islander people have minimal input into evaluations.
  • There is no whole-of-government approach to evaluation priority setting.
  • While policy makers agree that evidence is critical for good policies, in practice there is little reliance on evaluation evidence when designing or modifying policies.

Hopefully, the Evaluation Strategy will mark a new approach, not least by Aboriginal and Torres Strait Islander people at its centre.

Mokak, the first Indigenous commissioner at the Productivity Commission and former CEO at the Lowitja Institute and the Australian Indigenous Doctors’ Association, said:

Working in partnership with Aboriginal and Torres Strait Islander people is fundamental to lifting the quality of evaluations, as is planning early so that the right questions are asked and the right data collected.”

The Strategy’s proposed governance arrangements (seen as “essential architecture for an effective Strategy”) include an Office of Indigenous Policy Evaluation (OIPE) and an Indigenous Evaluation Council (with all Aboriginal and Torres Strait Islander members).

The OIPE and the Council would work in partnership to monitor and report on agencies’ progress implementing the Strategy, identify evaluation priorities and potential cross-agency/topic evaluations, and provide evaluation leadership and guidance.

The Strategy calls for a central clearinghouse for evidence on the effectiveness of policies and programs affecting Indigenous Australians to both strengthen accountability for undertaking good evaluations and improve the transfer of knowledge.

Longer term, there should be a new independent agency — a Centre for Evaluation Excellence — established to provide evaluation leadership and external oversight for all social and health policy evaluations of Indigenous programs across all Australian Government agencies.

If such a Centre was established, the OIPE could move to the Centre as a standalone branch (with the Indigenous Evaluation Council continuing its role).

It will be very interesting to see the Government’s response to this Strategy and then to follow the effectiveness of its implementation.

Note that the next edition of the Overcoming Indigenous Disadvantage report from the Productivity Commission is due for release on Thursday 3 December 2020.

New reports and associated news

  1. Causes of death, Australia 2019 –  ABS report

This ABS report was released on 23 October. It is useful because it compares the leading causes of death over the years 2010, 2014 and 2019.

Some of the key data point from 2019:

  • Ischaemic heart disease was the leading cause of death in Australia, accounting for 10.8 percent of all deaths.
  • Dementia overtook lung cancer as the second leading cause of death for males.
  • While suicide was the 13th highest cause of death, it accounted for the most years of potential life lost due to a low median age at death of 43.9 years. Three-quarters of those who suicided were men.
  • Chronic lower respiratory disease is now the second leading cause of death of Aboriginal and Torres Strait Islander people, overtaking diabetes.
  • Death rates for lung cancer, emphysema, stroke and ischaemic heart disease showed smoking remained the number one cause of premature death and disability in Australia.
  1. Interim Report and Research Reports from Royal Commission on Disability
Wiradjuri artist and disability advocate Uncle Paul Constable Calcott has depicted the Disability Royal Commission story in a specially designed work of art titled ‘Respectful Listening.

The Disability Royal Commission has just released a 561-page interim report (I confess I am yet to read it in any detail). Despite its size, the report has no recommendations; Chair Ronald Sackville QC, said the enormity of the inquiry meant no firm recommendations could be made at this stage.

The Royal Commission is requesting an extension to September 29, 2023 for the final report (originally due April 2022). However, a report containing findings and recommendations arising out of the Commonwealth’s response to the COVID-19 pandemic will be published next month.

“The task confronting us is formidable, but we are committed to completing the work in a way that will help bring about transformational changes in the laws, policies and practices affecting people with disability,” Sackville said.

The Royal Commission has also released several new research reports, among them “Something Stronger: Truth telling on hurt and loss, strength and healing, from First Nations people with disability”.

This research paper builds upon a comprehensive program of research that was led from within the First Peoples Disability Network, a non-government community organisation established by and for Aboriginal and Torres Strait Islander people with disability.

The testimonies of 47 Aboriginal and Torres Strait Islander people with disability have informed this research paper.

You can access these reports here.

  1. Final report from Royal Commission into National Natural Disaster Arrangements

The so-called Bushfire Royal Commission has handed down its final report.

Croakey colleague Dr Amy Coopes (@coopesdetat) did an excellent Twitter thread on the report here. And there was more from Dr Arnagretta Hunter (@cbr_heartdoc) here.

Last week marked a grim milestone – a year since last summer’s bushfires burst into flames. In a joint statement marking the anniversary, the Australian Medical Association and Doctors for the Environment Australia highlighted the fires’ severe and ongoing health impacts, and noted that “the ongoing failure to address climate change helped fuel” the disaster.

Read more in Coopes’ article for Croakey here.

  1. Insufficient physical activity – AIHW web report

The Australian Institute of Health and Welfare has updated its web report on physical activity. Sadly, its value is undermined by the fact that some data are really old (from 2011-12) (Have you heard me on this topic before? Perhaps I should write “updated”?)

Only 12 percent of children and 2 percent of adolescents met the physical activity and screen-based behaviour guidelines in 2011-12 – and I think there is little reason to hope that these worrying  numbers have improved over the past eight years.

The Department of Health website has quite a section on “Physical Activity and Sedentary Behaviour Guidelines” – but the pages has not been updated since April 2019. The Research and Statistics section has not been updated since 2017. Says it all really!

The best of Croakey

Croakey journalist Amy Coopes provided outstanding coverage of the recent Public Health Association of Australia’s national online conference.

It highlighted the critical issues and discussions that too often stay behind the ‘walls’ of conferences, given the diminishing focus on public health in the mainstream media, even in the face of the 2019-20 bushfires and the coronavirus pandemic .

“The genie is out of the bottle, we have to turn down the heat” – A grim milestone heralds a grim future

“When you ask the community, magic happens”: a stocktake of public health in the pandemic

“This is just taking off”: UK, Victorian experts on outlook, lessons for COVID-19


The good news story

There’s a theory, called the socioemotional selectivity theory, that as we get older we are less likely to waste time with negativity and as a result, social circles narrow and people tend to keep a few good friends around and enjoy them more.

(There are lots of ways we could incorporate this theory into our coronavirus-restricted lives.)

In what is described as a “really elegant” study reported in Science, researchers have found that ageing male chimps also display this inclination. As they got older, the chimps developed more mutual friendships and fewer one-sided friendships. They also exhibited a more positive approach to everyone in their community, with a drop in aggression. This pattern has not been seen in other primates.


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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