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The Health Wrap: why public policy making is broken, COVID in China and the House – and some reasons for celebration

The world is watching what is happening with COVID in China because the implications are so far-reaching, reports Adjunct Associate Professor Lesley Russell in her final column for the year.

Russell also digs into the latest Closing the Gap report, a global crisis in oral health, and has some suggestions for the Albanese Government’s to-do list in 2023.


Lesley Russell writes:

This is the last edition of The Health Wrap for 2022. What a year it has been!

When I look back, there has always been something new to report about the COVID-19 pandemic. It would be so nice to think it is over; however, the statistics from Australia and elsewhere (sadly now poorly and irregularly reported) indicate that is not the case, as the Prime Minister has himself discovered.

While we are clearly learning to live with the disease, experts and those who pay attention to the science worry about what continuing infections mean for the Long COVID burden in the years ahead.

I think that it will be important to watch what happens to the infection rate and the advent of problematic new variants during the upcoming northern winter. I do have hope that there are new vaccines on the horizon that will be more effective at preventing infection than those currently available.

The other issue that has been a constant in my reporting for The Health Wrap this year is politics. Things look much brighter now that the adults are in charge in the federal parliament, and the Albanese Government is doing a good job on delivering on their election commitments.

While they deserve credit for this, the Government is yet to tackle the really difficult problems – the cans that have, for too long, been kicked down the road. These include: reforms in healthcare, aged care and disability services; addressing the social determinants of health, health disparities and societal inequalities; implementing a full partnership with First Nations communities to do a better job of Closing the Gap; and delivering social and environmental justice. (I’m sure every reader could add to that list.)

I will be back in 2023, hopefully reporting on lots of good news stories in health and related areas. And I have an impressive hiking schedule lined up, with adventures and exertions to share.

My best wishes for a relaxing, peaceful and happy holiday season and for a great new year ahead.


China looks to abandon its zero COVID-19 strategy

In the past few weeks a lot of media attention has focused on China and the way the Chinese Government is being forced to modify its “zero COVID” approach to managing the pandemic.

In response to large and widespread protests, China’s top leadership has signalled recognition that a blanket approach to controlling the pandemic is inflicting a growing economic and social toll. They are now calling for measures more targeted to local situations rather than the current “one-size-fits-all” approach.

In November the Chinese National Health Commission announced an easing of COVID-19 restrictions. Since then, in the face of increasing protests, a number of districts and cities have acted: for example, Beijing has modified testing requirements and announced that malls and supermarkets will reopen and Guangzhou will allow close contacts of COVID-19 cases to quarantine at home.

Last week Vice Premier Sun Chunlan, who oversees China’s pandemic efforts, indicated that the country is turning from an elimination strategy to a mitigation strategy, thus signifying a willingness to accept an unspecified level of infections and deaths.

She said: “The country is facing a new situation, and new tasks in epidemic prevention and control as the pathogenicity of the Omicron virus weakens, more people are vaccinated, and experience in containing the virus is accumulated.”

Sun said that “preventing the epidemic” would now focus on vaccinations (especially of the elderly), making medical resources available, and developing therapeutics (including the use of traditional Chinese medicine).

Lifting China’s stringent COVID-19 measures will be difficult for both public health and political reasons. China’s population (especially older adults) is not sufficiently vaccinated to withstand a major outbreak, and the country’s health infrastructure is under-developed and poorly prepared, especially in smaller towns and rural areas.

Experts worry that without proper planning and improved vaccination coverage, any sudden shift away from “zero COVID” could create a crisis of mass infections, overwhelming hospitals.

A widespread COVID-19 outbreak in China would have international ramifications. While the endless lockdowns are currently causing shortages for western firms that are supplied from China, increasing freedom of movement that allows the virus to rip through the population would mean even more problems for the “world’s workshop” and cast a shadow over international trade.

Vaccination issues are at the heart of China’s pandemic problems. Nearly 90 percent of the population has received two doses of Sinovac or Sinopharm, the Chinese-made vaccines. However, only two-thirds of people aged 80 and older are vaccinated and only 40 percent of this population cohort has received a booster dose.

This is a critical shortcoming because Chinese-made vaccines offer weaker protection than the Pfizer-BioNTech and Moderna mRNA vaccines. (China is researching mRNA vaccines but an effective candidate is yet to emerge.)

In a study during Hong Kong’s Omicron surge, two doses of China’s main domestic vaccine, Sinovac, were only 58 percent effective against severe COVID-19 or death in people ages 80 and older. Two Pfizer-BioNTech doses, by contrast, were 87 percent effective in the same group.

The situation is worsened because China’s last major vaccination push was early this year, so for many Chinese there is an interval of eight months or more since their last dose and so their immunity is waning.

Additionally, the zero COVID policy means that very few people have gained immunity by infection. China reports fewer than 1.5 million infections in a population of 1.4 billion, and the national death toll is 5,229. In comparison, it is estimated that two-thirds of all Australians have been infected at least once (knowingly or unknowingly).

The National Health Commission has announced that China will renew efforts to vaccinate its oldest citizens, using mobile vaccination stations, bringing vaccination teams into nursing homes and going door-to-door to reach the most vulnerable.

Read the thread about vaccination in China.

Apparently the low rates of vaccination in the elderly are due to persistent vaccine hesitancy – fears about vaccine safety and a sense that it is safer to isolate from the virus – combined with vague guidelines that caution against vaccinating people with chronic health conditions (the very cohort most in need of protection).

Shanghai used cash rewards and house calls to persuade the elderly to get their first shots, but that has been less successful for boosters for the elderly. Beijing tried a vaccine mandate last July but, after a public outcry, was forced to revoke it less than two days later.

It is interesting to note that a January 2022 report from Taiwan indicated that vaccine hesitancy among that country’s elderly was marring its pandemic performance and hindering reopening. There may be lessons here for Australia in ensuring culturally appropriate and well-targeted messages to older citizens of Chinese heritage.

And as a final note – to emphasise the magnitude of this problem – there are some 32 million people in China aged 80 and over.


COVID-19 – now a plague of the elderly

As China worries about their unvaccinated elderly, recent data from the United States shows that COVID-19 is now a plague of the elderly.

Nearly 9 out of 10 deaths from COVID-19 in the United States are now in people 65 or older, the highest rate since the pandemic began.

The proportion of deaths among those 65 or older has fluctuated from 8 out of 10 in the first few months of the pandemic, to a low of 6 out of 10 when the Delta wave struck in the summer of 2021, to a high of 9 out of 10 today.

I looked for Australian statistics: according to data current as of 5 September 2022 on the Statistica website, 8,711 of a total of 13,331 deaths (65 percent) since the pandemic began were people aged 80 and over.

The best indication I can get that COVID-19 deaths are increasingly among the elderly is an analysis that found more than 3,000 Australians have died with COVID-19 in aged care facilities this year – triple the number of deaths in nursing homes during the first two years of the pandemic.

What this also means is that this is no longer a pandemic of the unvaccinated. In the United States people who had been vaccinated or boosted made up 58 percent of COVID-19 deaths in August (up from 42 percent in January and 23 percent in September 2021).

Again, comparable Australian data are hard to find. The 16 September update from the Victorian Chief Medical Officer reports 1,619 COVID-19 related deaths in Victoria in the previous three months. Of those deaths, 735 (45.4 percent) were unvaccinated, 12 had received one dose, 131 had two doses, 341 had received three doses and 400 had received four doses. The important number is that 54.2 percent had not received their third COVID-19 vaccine dose.

Some epidemiologists and demographers predict the trend of older, sicker and poorer people dying at disproportionate rates will continue, raising hard questions about the trade-offs countries like Australia, the United States and, yes, China too, are willing to make in pursuit of normalcy — and at whose expense.

In this light it is interesting to read an opinion piece from Chinese scientists published in The Lancet in September: Protecting older people: a high priority during the COVID-19 pandemic.

The authors note that multiple reasons have contributed to low vaccination rates in the elderly, including:

In a society that has embraced Confucianism for over 2000 years, Chinese people cherish filial piety as one of their fundamental values. Older people are usually regarded as the most prestigious members of a community.

Therefore, Chinese people tend to accept older people’s choice of being unwilling to take vaccines, which include the COVID-19 vaccine. Additionally, many older people and their family members were not motivated to take vaccines because of the well controlled COVID-19 situation in China.”


Latest Closing the Gap report

Last week saw the release of the Closing the Gap Annual Report 2022 from the Australian Government, prepared by the National Indigenous Australians Agency (NIAA).  This is the first such report since the launch of the revamped National Agreement on Closing the Gap in July 2020 and the development of the Closing the Gap Implementation Plan in August 2021.

This is a much more substantive document than we have seen from the NIAA in recent years; under the Coalition Government these reports tended to be glossy affairs with more photos than substance. This edition incorporates data and assessments from the Productivity Commission’s 2022 Closing the Gap Annual Data Compilation Report.

The news from this report is sobering. Fourteen years on from the release of the first Closing the Gap Framework in 2008, there’s mixed progress with only two targets (babies born with a healthy birthweight and children enrolled in preschool) on track. Four targets (children being school-ready; adults in prison; children in out-of-home care; deaths by suicide) are worsening. Other targets like closing the gap on life expectancy are moving in the right direction, but not fast enough. Only four of the 18 socio-economic targets are on track.

It is good to see this report outlining in some detail what is being done to address both the Priority Reforms (these are at the heart of transforming how Australian governments will work with First Nations organisations and people) and to achieve the health, social justice and socio-economic targets.

The four Priority Reforms are:

  • Partnership and shared decision-making
  • Building the community-controlled sector
  • Transforming government organisations (making them and the services they fund culturally safe and responsive to the needs of First Nations people)
  • Sharing access to data and information at a regional level (to enable communities to make decisions about Closing the Gap and their development).

The report states: “Whether this approach will sufficiently shift the dial on progress will become clearer over the next few years” and there’s a commitment for a “whole-of-Commonwealth project to identify any existing limitations and consider new actions.”

New actions under the Priority Reforms will be included in an update to the Implementation Plan. One deficiency is that there is currently no agreed way to measure progress in implementing the Priority Reforms.

Likewise it is frustrating to see that for some of the targets (for example, the proportion of Aboriginal and Torres Strait Islander people attaining year 12 or equivalent qualifications, the proportion who have completed a tertiary qualification, and the proportion of those aged 15-24 years who are in employment, education or training), there is no new data to assess progress.

It is really infuriating and incomprehensible that there is no data to assess progress in the reduction of family violence and abuse – something that the report admits is an urgent national priority. The report states that there is no single data source for this information, but at least the 2021-22 budget provides $31.6 million over five years to establish a new primary national collection of family, domestic and sexual violence statistics for First Nations people (this collection will include and identify those living with a disability).

A section in the report outlines what is being done to address the needs of Aboriginal and Torres Strait Islander people living with disability. This includes the Disability Sector Strengthening Plan which is being developed in partnership between First Peoples Disability Network, the community-controlled sector and Australian governments. This will serve as the key link between Australia’s Disability Strategy 2021-2031 and Closing the Gap.

There are also sections on addressing First Nations needs and issues in gender equality and aged care.

Appendix 1 – a stocktake of partnership arrangements – makes useful and interesting reading. There are 31 partnerships in all.

I was encouraged to read in Appendix 2 that progress is being made both on providing stability and growth in funding to Aboriginal community-controlled health services and in ensuring that funding provided under the Indigenous Australian Health Program is being re-prioritised from mainstream providers to the community-controlled sector.

There is no escaping the magnitude of the task ahead and it is shocking how little progress has been made in the past decade. However, I am encouraged by the tone and focus of this report, and I’m optimistic that with a new federal government and new approaches to working in partnership, next year’s report will be able to highlight real progress towards the targets.

It’s important to realise that national reports such as this mask the local success stories, of which there are many. More must be done to highlight these positives, so I encourage you to also read the Close the Gap Campaign Reports. This year’s is entitled Transforming Power: Voices for Generational Change.

Read the statement here.


Scrutiny of public policy making

For the last five years, the Evidence-Based Policy Research Project has assessed a range of federal and state policies in a unique way, using input from both a conservative (right wing) think tank (the Institute of Public Affairs in the first four years and the Blueprint Institute in the last year), and a  progressive (left wing) think tank (Per Capita Australia).

The think tanks each asked 10 questions around issues that go to the heart of good policy-making of 20 federal and state laws enacted each year.

  1. Need: Is there a statement of why the policy was needed based on factual evidence and stakeholder input?
  2. Objectives: Is there a statement of the policy’s objectives couched in terms of the public interest?
  3. Options: Is there a description of the alternative policy options considered before the preferred one was adopted?
  4. Mechanisms: Is there a disclosure of the alternative ways considered for implementing the chosen policy?
  5. Brainstorm: Is there a published analysis of the pros/cons, data/assumptions and benefits/costs of the alternative options/mechanisms considered in 3 and 4?
  6. Pathway: Is there evidence that a comprehensive project management plan was designed for the policy’s rollout?
  7. Consultation: Was there further consultation with affected stakeholders after the preferred policy was announced?
  8. Papers: Was there (a) a green paper seeking public input on possible policy options and (b) a white paper explaining the final policy decision?
  9. Legislation: Was the policy initiative based on new or existing legislation that enabled comprehensive Parliamentary debate and public discussion?
  10. Communication: Is there an official online media release or website that explains the final policy in simple, clear, and factual term

This is done in a “double blind” exercise. Although these think tanks often have opposing policy outlooks, their benchmarking results against these criteria have been similar over the years.

The 2022 assessment has just been released and it’s not an encouraging story. Indeed, for five years running the think tanks have found that basic standards of evidence and consultation-based policy making are inadequately met by Australian federal and state governments.

Over the years 2018-2022, 32 percent of policies were rated as “solid”, 43 percent were rated as “mediocre” and 25 percent were rated as “unacceptable”; the average score (out of 10) over this time frame for the federal, NSW, Victorian and Queensland jurisdictions was 5.8 (mediocre). In 2021-2022 the Federal Government was the lowest performing jurisdiction. A consistent failure was the lack of published proposals inviting public input.

The conclusion is that public policy-making is broken.

But recently, the NSW Legislative Council has introduced a standing order requiring all government bills to include a Statement of Public Interest. This is the first time in Australia that a public policy framework for interrogating bills has been given legal force.


End the global crisis of oral health

The World Health Organization has recently published the Global Oral Health Report – Towards Universal Health Coverage for Oral Health by 2020.

The report provides information about the burden of disease, using the latest data from the Global Burden of Disease Study and new evidence to highlight key risk factors for and determinants of oral diseases, the economic impact of oral diseases, the unequally distributed oral health workforce, and health system challenges.

Common oral diseases, such as dental caries, periodontal (gum) disease, oral cancer, and tooth loss, have reached an all-time high globally: almost half of the world’s population (45 percent ) is affected by these diseases, with about 3·5 billion people living with untreated oral diseases, surpassing numbers for any other non-communicable disease.

Poor, vulnerable, and marginalised populations are disproportionally affected; and three out of four people affected by oral diseases now live in low-income and middle-income countries.

Australia might be a rich country, but – no surprises – does not rank well, based on 2019 data (this despite ranking well in terms of the number of dentists serving the population):

  • Prevalence of dental caries in deciduous teeth is 33.4 – 41.4 percent
  • Prevalence of dental caries in permanent teeth is 30.6 – 35.6 percent
  • Prevalence of severe periodontal disease in people aged 15+ is 10-6 – 19.6 percent
  • Prevalence of edentulism in people aged 60+ is 34.1 – 50.9 percent.

An editorial in The Lancet describes the situation internationally as a “silent crisis” that has existed for too long. It says that the active voices of people affected by oral diseases are not prioritised and oral health has been absent from global health policy agendas for more than 15 years.

The most recent report on Australia’s Oral Health and Dental Care produced by the Australian Institute of Health and Welfare is here (note that in some instances this report uses data from 2012-2014!)

Australia’s Oral Health Tracker, produced annually by the Australian Dental Association, is here.


A special celebration

Last week marked the fiftieth anniversary of the election of the Whitlam Government, which at the time was the first ALP government in 23 years, and that brought such sweeping changes to Australia.

I vividly remember the joy (and the relief) on hearing the news. At the time I was living in London, working as a research fellow in the Physics Department at Guy’s Hospital (part of the University of London) and I had voted at Australia House.

The new government, despite being so short-lived, proved to be resolutely reformist and enacted an unprecedented amount of legislation that would do much to create a new Australian identity for the next decades. The key achievement was undoubtedly the introduction of Medibank.

John Menadue, who was part of it all, has written a fascinating account of how and when Medibank/Medicare was conceived, some five years earlier at the home of Dr Moss Cass. Of course, it was not implemented until 1975.

It’s a reminder for those who work at the intersections of policy and politics that it takes time (and much effort) to bring good ideas to fruition (sadly, it may be easier to enact bad ideas!). And even then, as history has shown since, you have to work diligently to protect essential programs like Medicare, and even harder to update them and keep them fit for purpose.

John Menadue has also written about how he sees the stars aligning for efforts to update the Whitlam Government’s healthcare legacy.

There are many hopes and ambitions riding on the work of the Strengthening Medicare Taskforce. Submissions to the Taskforce do not appear to be publicly available.

The Grattan Institute has just released its report/submission on strengthening general practice. The report bluntly states “Medicare no longer works, for patients or GPs.” It calls for the way GPs work and are paid to be overhauled.  Already there have been cries of protest from organised medicine (although I suspect many, even most, GPs at the coalface will agree).

There is a good summary of the report’s early reception here, prepared by ABCNews and also at The Conversation. My colleague Jennifer Doggett will be writing more on this report for Croakey.

See the Grattan Institute’s Twitter thread.


In case you missed it

Report from Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability

A research report commissioned by the Disability Royal Commission titled Violence, abuse, neglect and exploitation of LGBTQA+ people with disability, has found that experiences of abuse for LGBTQA+ young people and adults with disability were higher compared to LGBTQA+ people without disability.

The rates of violence and abuse are shockingly high; in particular, 73 percent of people with severe disability reported experiencing violence from an intimate partner in their lifetime.

The report recommends a series of interventions across policy, services and the community, including:

  • Better training for disability support organisations so they can greater understand and respond to experiences of people with disability who are LGBTQA+
  • LGBTQA+ people with disability included in all government health and wellbeing policies and plans
  • Guidance and funded strategies to improve inclusion for LGBTQA+ people with disability and to keep them safe in all services and community settings.

How the Great Depression shaped people’s DNA

An epigenetics study published in Proceedings of the National Academy of Science finds that children born during the historic recession have markers of accelerated ageing later in life.

Although the study is far from the first to link big historical events to changes in the epigenome, the fact that the signal appears in data collected from people in their seventies and eighties is described as “mind-blowing”.

This paper adds to a growing cache of studies indicating that exposure to hardship such as stress and starvation during the earliest stages of development can shape human health for decades.

A commentary in Nature addresses the policy implications for these findings. “What we see from this study is that socio-economic structural inequalities that make it difficult for women to access the care they need [the reference here is to the US Supreme Court decision to strike the federal right to abortion] might have long-term consequences. With social inequality on the rise around the world, the findings also highlight how paid parental leave, welfare payments and other policies and programmes can help to blunt health disparities in the future.”

The global primary care crisis

The US-based Commonwealth Fund has just released the 2022 International Policy Survey of Primary Care Physicians. It shows that the world is facing a crisis of physically and mentally overburdened primary care doctors.

The survey looks at the situation in ten countries including Australia.

Action needed on falls – the $2.3 billion health problem no one talks about

A new report from the Australian and New Zealand Falls Prevention Society (ANZFPS) proposes a plan for urgent and coordinated action that could reduce falls – currently a annual healthcare burden of $2.3 billion – by 30 percent.

Falls and fall injuries among older people are a large and growing problem in Australia. Every day 14 Australians aged 65 and over will die from a fall and 364 will have a fall that puts them in hospital. There is one fall-related visit to an emergency department by an older Australian every two and a half minutes.

You can read more here.  See also this related article in Croakey Health Media on injury prevention.


Best of Croakey

Read: Taking climate action can produce huge health gains: are we ready, willing, able?

Read: On the National Health and Climate Strategy, how’s it shaping up?


The good news story

How wonderful to hear that a group of Indigenous women leading a program to protect the Great Barrier Reef have won an environmental prize worth £1 million ($1.8 million) from the Prince of Wales’ Earthshot fund.

This news comes just days after a United Nations report warned the reef could lose its world heritage status.

The Queensland Indigenous Women Rangers Network has trained more than 60 women to work as reef rangers or in conservation elsewhere. The women are using their cultural knowledge along with modern conservation tools and technology.

You can read more here.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

 

 

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