Writing from the Colorado Rockies, Adjunct Associate Professor Lesley Russell finds some solace in the local landscape’s beauty amid bleak news of United States politics.
Her latest column investigates the political power of anti-vaxxers in the US, the political power of pharmacy owners in Australia – and how the political and social determinants of health undermine women’s health and wellbeing, in Australia and globally.
The quotable?
Women make up half of our population but women’s health research has been understudied and underfunded.
That’s why I’m signing an Executive Order to ensure women’s health is prioritised across the federal research portfolio and budget.”
Lesley Russell writes:
Greetings from Keystone in the Colorado Rockies where our #skibumsojourn continues. We are out skiing or snowshoeing nearly every day, and in between we are getting some work done.
The political mood here is very sober – often dark – with very few Americans enthusiastic about a Biden-Trump political rematch and many deeply worried about Trump’s worsening demeanour and language and the threats of violence and revenge that now seem part of every rally he gives.
We are so grateful for the inner peace the local landscape brings.
This photo is of the Snake River which runs by the Keystone ski fields (you can just see the lower slopes of several ski runs in the background). It makes a lake in front of our apartment where in winter you can skate and play ice hockey.
The surrounding, environmentally protected wetlands are used by beavers, moose, elk and hares (and this year there are stories about a lurking pair of mountain lions, although we are yet to see them). There’s fly fishing in the summer and some lovely, easy hiking paths.
The area around Keystone was originally used by the Ute and Arapaho Native American tribes during summer but was overtaken by miners in search of precious metals in the 1860s.
Women’s health, wellbeing and equity
There’s lots of news about actions on women’s health and wellbeing and efforts to address equity and discrimination to kick off this edition of The Health Wrap.
Many of the new announcements were timed to coincide with International Women’s Day on March 8.
Australian announcements
First, the Albanese Government’s 2024 National Women’s Health Summit, hosted by Assistant Minister for Health and Aged Care, Ged Kearney. This was held in Parliament House, Canberra on 14 March. The program for the day is here.
This conference was an important follow-on from work in this space recently done in Victoria that I reported on in The Health Wrap, 12 February, 2024.
As part of the Summit, Kearney launched the summary report of the #EndGenderBias survey, which was conducted by the National Women’s Health Advisory Council.
This Australian-first survey had more than 2,800 responses in which women, healthcare professionals and peak stakeholder groups shared their experiences or understanding of gender bias in the health system.
Two-thirds of women reported they experienced healthcare-related gender bias or discrimination themselves and almost 80 percent of caregivers – mostly mothers advocating on behalf of their children – reported similar experiences.
Consistent themes included women feeling dismissed and disbelieved, being stereotyped as ‘hysterical’ and a ‘drama queen’, and women’s symptoms being readily attributed to other causes such as menstruation, lifestyle factors or even ‘faking it’. This was particularly evident when women’s symptoms related to pain.
More than 80 percent of both women with a disability and LGBTIQA+ survey respondents reported discrimination and bias compared to around 67 percent of other women.
You can read more in this article in The Guardian.
The transcript of the media conference that preceded the Summit is here. It talks encouragingly about what is hoped to be achieved, but there is little publicly available about what goals and actions were agreed at the Summit.
Also this month the Albanese Government has released a new strategy, Working for Women: A Strategy for Gender Equality, along with the latest Status of Women Report Card.
While the Report Card highlights some good news – exemplified by the fact that Australia’s international ranking for gender equality has improved from 43rd in 2023 to 26th in 2024 – there is also much room for improvement.
For example: mothers who change from partnered to single mother households experience a 20 percent decline in household income; one in five women have experiences sexual violence since the age of 15; and over half of women experiencing menopause symptoms reported negative impacts on their mental and emotional wellbeing.
The Strategy has these priority areas:
- Gender-based violence
- Unpaid and paid care
- Economic equality and security
- Health
- Leadership, representation and decision-making.
The fairly impressive list of what’s underway to address these priorities is here.
See commentary from Professor Susan Harris Rimmer – Australia finally has a strategy for gender equality. Is it any good? – in The Mandarin.
Minister for Women Katy Gallagher has highlighted that the public service will have to step up efforts for gender equality. The Strategy asks for department-level reporting on actions being taken to reduce inequality in the federal workplace. But clear guidelines and processes about how this will happen have yet to be developed.
One of the biggest economic equity barriers facing Australian women, resulting in many who were once middle-class spending their old age living in poverty, is the fact that they have less superannuation. Generally this is because they have taken time out from paid work to care for family and because many feminised jobs are paid less.
The Albanese Government has announced that, from July 2025, all workers who receive paid parental leave from the government will get 12 percent superannuation paid for that period.
This initiative is in response to a 2023 report from the Women’s Economic Equality Taskforce. It found that Australian women who have at least one child earn $2 million less over their lifetime than their male counterparts. The economic inequality between men and women was estimated to cost the economy about $128 billion annually.
On the one hand, these efforts make me feel buoyed that finally something is being done to address these issues.
And then there’s this to remind us how much hard work there is ahead. In South Australia conservative Senator Alex Antic has succeeded in having South Australia’s most senior female Liberal, Shadow Minister for Health and Aged Care Anne Ruston, ousted from the number one spot on the state Senate ticket in a preselection brawl that has split the party (the vote to give Antic the top spot was 108 to 98).
In comments addressing this, Antic said that gender was ‘a grievance narrative’ and that the party needed to get back to its conservative roots. “The ‘gender card’ is nothing but a grievance narrative, constructed by the activist media and a disgruntled political class,” he said.
The rest of us are shaking our heads!
Global focus
Economist Impact has released a groundbreaking report – The Road to Health Inclusivity: from policy to practice – and have pulled out from this assessment of the Phase 2 Health Inclusivity Index a special report on Understanding health inclusivity for women.
This latter report echoes many of the issues that must be confronted in Australia and sees many similarities in the barriers that perpetuate health disparities between men and women across many countries.
These include: the social and cultural norms that define women as primary caregivers; the lack of access to essential health services (including preventive health services); rising levels of gender-based violence; and the burden of widening gender pay gaps.
This month, from the World Health Organization, there’s a global report on how gender-equitable investments in health and care work can help fully recognise the value of this work and drive fairer and more inclusive economies and better health outcomes. The focus is on the well-recognised fact that much of this (often unpaid) work is done by girls and women.
The report, Fair share for health and care: gender and the undervaluation of health and care work, presents six policy levers:
- Improve working conditions for all forms of health and care work, especially for highly feminised occupations
- Include women more equitably in the paid labour workforce
- Enhance conditions of work and wages in the health and care workforce and ensure equal pay for work of equal value
- Address the gender gap in care, support quality care work and uphold the rights and wellbeing of caregivers
- Ensure that national statistics account for, measure and value all health and care work
- Invest in robust public health systems.
Action in the United States
In the United States, the Biden Administration (with great leadership from Vice President Kamala Harris) has introduced and started to implement a suite of new policies and strategies to advance national and global gender equality.
The White House unveiled a National Strategy on Gender Equity and Equality in 2021. The Strategy, which is under the auspices of the White House Gender Policy Council, aims to support women and families through both domestic and foreign policy.
It identifies ten priorities to address gender discrimination and systemic barriers that women and girls experience, ranging from economic security and education to climate change and immigration.
There are good summaries of this work and the progress reports from various US federal agencies on the implementation of the Strategy from the Brookings Institution here and the Center for Strategic and International Studies here.
The President’s FY 2024 Budget, just released, includes billions of dollars to advance this work, along with US$12 billion for women’s health research (this effort will be led by the First Lady, Dr Jill Biden), but it remains to be seen how much of these requests the Congress will approve. (The Republicans have called these funding requests “woke”).
This week President Biden signed an executive order aimed at bolstering the Federal Government’s study of women’s health.
The order directs federal agencies to develop and strengthen research and data standards in an effort to address long-standing gender disparities. It also calls for a comprehensive research agenda into health conditions and diseases that disproportionately affect women.
Biden also announced more than 20 new actions and commitments by federal agencies, including:
- The launch of a US$200 million effort at the National Institutes of Health in fiscal year 2025 to fund new, interdisciplinary women’s health research
- A US$10 million investment by the Defense Department into learning more about health issues affecting women in the military, including cancer and mental health
- An initiative at the Centers for Disease Control and Prevention to expand training in women’s health research and public health surveillance.
The Center for American Progress, which works closely with Democrats (and where I worked in the early days of the Obama Administration) has just released a Playbook for the Advancement of Women in the Economy.
Naturally its focus is American but there is much in the Playbook for Australia to consider.
If you are interested in more information in this space, it’s worthwhile looking at the United Nations Development Programme’s (UNDP) Gender Equality Strategy 2022-2025.
The forward to this Strategy references an alarming backlash against women’s rights and gender equality around the world. But it also acknowledges that gender inequality takes a toll on men and other affected groups.
Just as I was finishing writing this edition of The Health Wrap, the World Bank released the 10th edition of Women, Business and the Law. This sobering report finds that no country in the world affords women the same opportunities as men in the workforce and the global gender gap is far wider than previously thought.
For the first time, the Bank’s report investigated the impact of childcare and safety policies on women’s participation in the labour market in 190 countries.
It found that when these two factors were taken into account, women on average enjoyed just 64 percent of the legal protections men have, down from the previous estimate of 77 percent.
The 8th Community Pharmacy Agreement
Last year, the Albanese Government’s announcement of the 60-day dispensing policy (which allows patients to collect double the amount of some medicines with each script) sent the Pharmacy Guild of Australia (PGA) into a very undignified apoplexy.
There were claims that pharmacy owners would suffer losses of $170,000 each year and would be forced to cut staff, reduce hours, and slash services.
The Albanese Government offered an early renegotiation of the Community Pharmacy Agreement (CPA), which was not due to expire until 2025, as a peace offering. Both the PGA and the Pharmaceutical Society of Australia (PSA) accepted this with alacrity.
On 14 March the Minister for Health Mark Butler announced that the Government has reached a Heads of Agreement with the PGA for the 8th Community Pharmacy Agreement (8th CPA).
His media release states: “Full details of the measures contained in the Heads of Agreement will be finalised and announced once the clauses of the 8th CPA have been settled. The Australian Government and the Pharmacy Guild of Australia will now work in good faith to finalise the 8th CPA to commence from 1 July 2024.”
It’s not clear what role, if any, consumer groups such as Consumers Health Forum have been playing and will play in the final negotiations.
The PGA are delighted, because this Heads of Agreement includes an additional $3 billion over the next five years for the delivery of pharmacy PBS services.
That goes a very considerable way to offset the income the PGA said would be lost from the 60-day prescribing policy, which the Guild modelled at $3.5 billion over four years (the Government estimated $1.6 billion in savings over the same time frame).
And is this offset even needed?
It appears that the tales of financial woes were exaggerated: the 60 day change was introduced in September 2023; since then applications to open new pharmacies are 50 percent higher than in the same period last year.
For many years now I have been critiquing the various CPAs as lacking the evaluations and transparency needed for something that accounts for more than 25 percent of the budget of the Pharmaceutical Benefits Scheme (PBS).
I am a strong supporter for an extended role for pharmacists as part of the primary care and aged care teams and I readily acknowledge how important their role is in ensuring the effective and safe prescribing of PBS medicines.
What I find disconcerting (this may be too mild a term) are the ever-burgeoning costs of the CPAs and the lack of scrutiny about the value that is delivered, especially with the respect to the funding that is provided for a growing number of initiatives that pay pharmacists for activities beyond the dispensing of PBS medicines. In the 7th CPA this amounted to $1.20 billion.
There is a good summary of the provisions of the 7th CPA on the Pharmacy Programs Administrator website (I think this is new/ish).
See also:
- The next Community Pharmacy Agreement. Pearls and Irritations. 27 May, 2020.
- Bad medicine: why we don’t need a 7th Community Pharmacy Agreement. Croakey Health Media. 19 May, 2020.
Butler’s August 2023 media release stated that, “A new agreement will include an assessment of the effectiveness of the current programs under the existing 7th CPA, including how well it delivers for patients and consumers. It will also take note of the past findings and recommendations of reviews into the sector.”
That has certainly not been the case with previous CPAs. Will the 8th CPA be different?
There are a large number of performance measures required under the 7th CPA (note that these were not agreed until February 2022, some 20 months after the Agreement went into effect). There were reports against these performance measures in August 2022, December 2022 and June 2023, but not since.
A Post-Implementation Review of the 7th CPA was published in November 2022. It says, with reference to the $1.2 billion spent on professional pharmacy programs: “Key issues for the 7th CPA, in common with previous CPAs, appear to be a lack of successful evaluation and assessment mechanisms in relation to the operation of programs and related activities funded through the agreement. In particular, the scarcity and quality of available data for robust and meaningful analysis of health outcomes is a continuing concern.”
A paper published in 2023 in Pharmacy – A Qualitative Evaluation of the Australian Community Pharmacy Agreement – involved interviews with a range of stakeholders in community pharmacy. Their opinions of the CPAs make insightful reading.
This statement seems particularly apt: “The consensus of the interviewees was that the Agreements lacked a vision for [community pharmacy’s] role in healthcare and were focused on funding rather than health objectives.”
If you follow the business news, then you will be aware that there is a proposed merger between pharmacy wholesaler Sigma and the pharmacy chain, Chemist Warehouse.
One rationale given for this is that Sigma is facing ‘significant competition’ from pharmacy wholesaler API, which operates pharmacy brands including Priceline and Soul Pattinson chemists. (Note that pharmacy wholesalers also receive PBS funds for the delivery of prescription medicines to pharmacies; in the 7th CPA this amounted to $1.15 billion.)
The ACCC need to make a decision on this, but current business reports are of boosted share prices and profits and billions of dollars.
I’m no economist, but this business deal does not seem to present any indication of a pharmacy industry in financial trouble.
Also see: Australia’s biggest chemist is merging with a giant wholesaler. Could we soon be paying more?
Anti-vaxxers and US politics
In the wake of the COVID-19 pandemic, the anti-vaccination movement has grown dramatically in the United States, and evolved from a fringe culture into a well-organised and networked movement, increasingly associated with the conservative right wing of politics.
This recent history is outlined in a paper, Confronting the evolution and expansion of anti-vaccine activism in the USA in the COVID-19 era, authored by members of the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA, and published in 2023.
The deep partisan divide over COVID-19 vaccination that emerged in America early in the pandemic is still felt today. A study from KFF shows that Make America Great Again (MAGA) supporters are among the groups least likely to get vaccinated against COVID-19.
A survey from the Pew Research Center shows that Democrats are almost three times as likely as Republicans to report being up to date with booster shots. Among those 65 and older, a high-risk age group, the partisan gap in vaccinations has grown from 15 points in summer 2021 to 42 points today.
The conspiracy theories that abound on social media about the COVID-29 vaccine are both shocking and stupid; it’s hard to believe that they can be taken seriously by so many people. Some of them are listed here.
The polarised response to the handling of the coronavirus outbreak in the United States, including the role of COVID-19 vaccines, has been a source of deep concern for medical and public health communities.
There have been real consequences that no-one seems to notice. For example, a Yale study showed excess mortality was significantly higher for Republican voters than Democratic voters after COVID-19 vaccines were available to all adults, but not before.
Last month the Morbidity and Mortality Report from the Centers for Disease Control and Prevention highlighted that the highest rates of long COVID are found in red (Republican) states like West Virginia, Alabama, Montana and North Dakota. While vaccination rates are clearly important, other factors such as obesity and access to affordable healthcare are likely also at play here.
The value and importance of COVID-19 vaccines has been a difficult issue for former President Trump to manage. On the one hand, he wants to take credit for Operation Warp Speed, which helped to get vaccines developed in record time; on the other hand, any mention of this upsets his MAGA supporters.
Back in December 2021, Trump was booed when he said he received a COVID booster. More recently, Trump has angered large parts of his base by taking credit for the COVID-19 vaccine roll out and dismissing their concerns about the vaccine’s safety. He set them off again with a post on Truth Social reacting to Biden’s State of the Union speech when he again claimed credit for the COVID-19 vaccines.
Now Trump is trying to play it both ways (as he is also attempting to do with abortion). In new efforts to embrace the anti-vaccine movement, he is stating that “I will not give one penny to any school that has a vaccine mandate or a mask mandate.”
This is not only worrying to public health officials, it is also upsetting many parents.
Firstly, Trump did not acknowledge, or does not know, that all 50 states, including the most Republican states like Texas and Florida, require public school students to be vaccinated for a number of diseases. These usually include hepatitis A and B, diphtheria, tetanus, polio, chickenpox, varicella, measles, mumps and rubella (with exemptions often allowed for medical reasons and reasons of conscience).
And secondly, Americans have largely positive views about childhood vaccinations. It appears that the vaccine hesitancy connected with COVID-19 vaccines has by-and-large not spilled over into Americans’ views of childhood vaccines.
However, there is one exception to this – Republicans’ support for vaccine mandates. There has been a decline of more than 20 points in Republicans who support vaccine requirements for children to attend public schools; there has been no change in Democrats’ support.
Into this fraught public health situation steps Robert F Kennedy Jr – a notorious anti-vaxxer and purveyor of conspiracy theories – who is running for president, as an Independent candidate.
He gets more attention that his political stature and policies would warrant because of his family heritage – although it’s important to note that almost all of the Kennedy family have gone out of their way to pointedly and publicly note their support for Biden and to castigate RFK Jr for many of his statements on issues like vaccines.
Polls show far more Republicans than Democrats have a favourable opinion of Kennedy. He also has gained support from some far-right conservatives for his fringe views.
There has been some talk that anti-vaccine Republicans might ditch Trump for Kennedy.
Now that would be interesting – but unlikely, I think. Still, in a close election – which this year’s presidential campaign will certainly be – third party candidates can have a significant impact.
The best of Croakey
The World Indigenous Cancer Conference was held in Naarm /Melbourne on 18-20 March 18, and a Croakey Conference News Service team was there reporting:
- World Indigenous Cancer Conference 2024: sharing our way to support knowledge and action.
- What is at the heart of our work to improve cancer outcomes? First Nations Peoples share stories and motivations.
Bookmark this link for ongoing coverage.
Good news stories
The Wiyi Yani U Thangani Institute launched this month with a commitment to elevate the voices of First Nations women and girls in the halls of power.
Read the Croakey Health Media article about the launch, written by Alison Barrett.
In other good news, a tiny nation with only one obstetrician is now a cervical cancer screening leader.
Tuvalu, a collection of nine small coral atolls in the South Pacific that are at risk of being swallowed as ocean levels rise, and with a population of just over 11,000 people, has recently become the first nation in the Pacific to reach the World Health Organization’s global screening goal for cervical cancer screening of 70 percent.
You can read more here and here. And you can read about the role Australia played in helping Tuvalu 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.
