H5N1

Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study

Via The Lancet Regional Health - Americas: Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study. The summary:

Background  

Before widespread vaccination, the United States was disproportionately affected by COVID-19 with a mortality rate several times that of other affluent societies. Comparing regions with different rates of health insurance, we assess how much of this excess mortality may be due to the relatively large population without health insurance.  

Methods  

We use daily surveillance data from the US Centers for Disease Control and Prevention (CDC) stratified by region, age group, gender, and race in regression analysis of daily COVID-19 cases, hospitalization, and mortality. COVID-19 data have been matched with structural characteristics of the region including average proportion with health insurance. As checks, we have estimated regressions for different time periods, different groups of states, and by comparing adjacent counties between states with and without Medicaid expansion.  

Findings  

Groups with lower health insurance coverage had significantly higher mortality as well as greater case counts and hospitalization. Early in the pandemic, they were also less likely to be tested for COVID-19. Applying our regression estimates, we estimate that had there been full health insurance coverage of the population, there would have been 60,000 fewer deaths, 26% of the total death toll in the period of this analysis.  

Interpretation  

Our study demonstrates that a significant share of COVID-19 mortality in the United States, and much of the excess mortality in the United States compared with other countries, is due to our reliance on a system of market-driven healthcare. Providing universal insurance coverage should be part of our campaign to reduce COVID-19 mortality. It also suggests that these concerns should not be restricted to COVID-19 but apply across all diseases, contributing to many unnecessary deaths in the United States each year even apart from the COVID-19 pandemic.

Future pandemics: Failing to prepare means preparing to fail

An editorial in The Lancet Respiratory Medicine: Future pandemics: failing to prepare means preparing to fail.

Governments of high-income countries with high SARS-CoV-2 vaccination rates have been encouraged by evidence of decreasing COVID-19-associated morbidity and mortality, and can begin to think about the change from pandemic to endemic and the prevention of future pandemics. Meanwhile, some low-income and middle-income countries (LMICs) are still grappling with high numbers of COVID-19 cases, hospitalisations, and deaths, and low vaccination rates. 

A similar pattern has been seen with previous pandemics, including HIV/AIDS, tuberculosis, and malaria. Although these diseases kill millions of people globally every year, they are often referred to as endemic. As stated by Prof Ali Zumla in a recent Perspectives article, “The pandemic exposes weaknesses of current leadership of global public health systems, inequities of resource allocation to Africa, and broken promises by wealthier nations for vaccine equity and resource allocation. This status quo is unacceptable.” 

Rather than allowing a splintering of attention and resources across the COVID-19 pandemic, other current pandemics, and future threats, we should move towards an integrated, multipronged approach that targets these threats collectively. We must learn from the way in which different countries responded to the COVID-19 pandemic and build on successful approaches to ensure equitable pandemic preparedness in the future. Tackling a pandemic requires a global response. Individual countries need to prepare, but success will be hindered if some countries are left without the capacity to respond to a new threat. 

An analysis in the BMJ examined 28 national responses in the first year of the COVID-19 pandemic. Countries that were considered to be high performing were able to “partner, coordinate, develop, and strengthen” various public health, health-care system, and socioeconomic measures. Ultimately, these actions led to decreased disease transmission and lower mortality rates. Government cooperation, effective community engagement, and coordination across all levels of response led to successful procurement of resources and transformation from evidence-based policy to practice. 

A recent Global Burden of Disease study also found that measures of trust in government, and less government corruption, were associated with lower infection rates and higher SARS-CoV-2 vaccination coverage in middle-income and high-income countries. Therefore, efforts to improve communication surrounding risk of disease and community engagement strategies could help to boost public confidence in pandemic response strategies. 

Low-performing countries identified in the BMJ analysis had four common themes: devaluation of effective pandemic preparedness plans through inadequate infrastructure and underfunded health systems; denial from heads of state of scientific evidence that COVID-19 was a severe risk to health, and lack of support for those most vulnerable to economic risks of COVID-19; delays in enacting rapid responses to different stages of the pandemic despite supporting evidence; and finally, distrust between the public, government leaders, and the scientific research community. Unfortunately, these factors have been compounded by the politicisation of many actions, including the use of facemasks and vaccines. 

At present, many countries are severely underprepared to enact any plans for future pandemic prevention or response. They face numerous challenges in providing universal health coverage for citizens and are not able to allocate adequate investment or resources towards, for example, an increased workforce equipped to deal with current or future pandemics.

The Global Fund is actively involved in pandemic preparedness and response with their COVID-19 Response Mechanism (C19RM), which provides grant support to LMICs for COVID-19 tests, treatments, personal protective equipment, and critical elements of health system strengthening. C19RM aims to mitigate the impact of COVID-19 on programmes to fight HIV, tuberculosis, and malaria, and initiates urgent improvements in health and community systems; as of Jan 25, 2022, total funds approved to support C19RM reached US$4·1 billion, made available through support from donors in the USA, Germany, the Netherlands, and Switzerland. The hope is that funding will not be diverted from current pandemic action and that separate income will be generated for future threats.

Increased investment in COVID-19 tests, treatments, and vaccines has been extraordinary. To fully prepare for future pandemics, investment in mechanisms to prevent, detect, and respond to emerging pathogens is crucial.

Global Health Security Index: We haven't learned a damn thing

The Global Health Security Index came in for some deserved ridicule in 2020 when it declared the US health system as the best-prepared for a pandemic. But its latest report heaps scorn back on almost everyone, especially wealthy nations. As we stumble into the third year of this pandemic, such failure to prepare is inexcusable. An excerpt from its latest Report & Data:

Overall Finding

Although many countries were able to quickly develop capacities to address COVID-19, all countries remain dangerously unprepared for meeting future epidemic and pandemic threats. A great opportunity exists, however, to make new capacities more durable to further long-term gains in preparedness.

Additional Findings

Most countries, including high-income nations, have not made dedicated financial investments in strengthening epidemic or pandemic preparedness. 

• The overall average score for national-level financing is 35.2 out of 100.  

• 90 countries have not fulfilled their full commitment to contribute to the WHO; of those, 14 are high-income countries.  

• 66 countries have not identified special emergency public financing mechanisms and funds that the country can access in the face of a public health emergency; of those, 32 are high-income countries.  

• 155 countries have not allocated nonemergency national funds within the past three years to improve their capacity to address epidemic threats; among those, only two low-income countries have evidence of allocated funds.  

• The average score for national financing for epidemic preparedness is 21 out of 100; low-income countries have an average score of 7 out of 100.  

• Financing for emergency response has a global average score of 66.  

• High-income countries have the lowest average score of 46; low-income countries have the highest average, with 93.  

• Only four countries (Eritrea, Indonesia, Liberia, and Timor-Leste) have a JEE or NAPHS that describes specific funding from the national budget to address previously identified gaps.  

• High-income and upper-middle-income countries receive the lowest scores for financing when reviewed under the JEE and OIE Performance of Veterinary Services (PVS) Pathway assessments and related to financing for emergency response.  

• The average score for financing under the JEE and PVS report is 1 out of 100; this score reflects the provisions for funding IHR implementation through the national budget or other mechanisms.

Our long night of the virus

The Tyee has published my long review of four important new books about the pandemic: Our Long Night of the Virus. Excerpt:

The pandemic and climate change, combined, have triggered what [Adam] Tooze calls a “great acceleration,” when events outrun earlier predictions and solutions. We will therefore have to improvise new solutions — or, like the populists, stick to a very old non-solution of anti-science white supremacy in the hope of returning to the “before times.” 

The imperial infection  

Rupa Marya, an American physician of Indian descent, and Raj Patel, a British academic, journalist and author, offer a solution from the before times in their book Inflamed: Deep Medicine and the Anatomy of Injustice. They argue that this pandemic, like countless disease outbreaks before it, is a consequence not just of a virus but of an imperialist world order that triggered disease and then built a medical system to serve the rulers, not the victims.  

This is not some radical Marxist spin, but established medical history. In the early 19th century, British development turned wetlands into farmlands in what is now Bangladesh, and brought a marine bacterium called Vibrio cholera into human guts. Cholera rapidly migrated on trade routes to London and beyond.  

In London, Dr. John Snow founded modern epidemiology by spotting the precise well that was infecting the neighbourhood. His medical colleagues dismissed his idea, but eventually Britain rebuilt its water supply system and greatly improved its workers’ health. Travellers from India were screened at Suez to try to stop further outbreaks from reaching Europe. But like Omicron, cholera was all over the planet by the time it was recognized.  

Meanwhile, cholera was left to ravage India itself, and we are now in the seventh cholera pandemic, which began in Indonesia in 1961 and most recently exploded in Haiti in 2010.  

Marya and Patel are by far the most radical analysts of this pandemic. They have no interest in blaming Donald Trump or the CDC; they are just the agents of a system created to serve the interests of 19th century empires, and which now protects the white heirs of those empires while ignoring the “essential” workers who serve those heirs.  

The authors have strong confirmation from others like Alex de Waal, whose recent book shows how Louis Pasteur’s germ theory defeated the German scientist-politician Rudolf Virchow, who had long argued for social and economic inequality as the root of disease outbreaks. Pasteur had blamed individual microbes, which could be isolated, fought and defeated like rebellious tribesmen in some remote colony. We still fall back on war metaphors to describe our response to the pandemic.

Canada: National health expenditure trends

Via the Canadian Institute for Health Information: National Health Expenditure Trends. Excerpt

November 4, 2021 — National Health Expenditure Trends, 2021 — the 25th edition of the annual publication on health expenditure trends — provides detailed information on health spending in Canada using the National Health Expenditure Database (NHEX).  

This year’s release presents finalized 2019 actual health expenditures and preliminary estimates for 2020 and 2021. The 2020 and 2021 projections include government-budgeted funding for health-related activities as a time-limited emergency response to the COVID-19 pandemic. National Health Expenditure Trends forecasts are based on main estimates and budgets for the public sector.  

Note: Preliminary estimates are subject to revision when actual data becomes available in subsequent years. This year’s spending estimates may experience larger revisions than usual due to uncertainty around COVID-19 pandemic spending.

Key findings  

• Total health spending in Canada is expected to reach a new level in 2021, at more than $308 billion, or $8,019 per Canadian. It is anticipated that health expenditure will represent 12.7% of Canada’s gross domestic product (GDP) in 2021, following a high of 13.7% in 2020.  

• Total health expenditure in Canada rose by 12.8% in 2020 due to pandemic response funding. Prior to the pandemic, from 2015 to 2019, growth in health spending averaged 4% per year.  

• Hospitals (25%), Drugs (14%) and Physicians (13%) are expected to continue to account for the largest shares of health dollars (more than 50% of total health spending) in 2021. A new spending category — COVID-19 Response Funding — makes up 7% of total health spending, which includes federal direct and provincial/territorial government–sector spending.

Consumption in the G20 nations causes particulate air pollution resulting in two million premature deaths annually

Via Nature Communications: Consumption in the G20 nations causes particulate air pollution resulting in two million premature deaths annually. The abstract:

Worldwide exposure to ambient PM2.5 causes over 4 million premature deaths annually. As most of these deaths are in developing countries, without internationally coordinated efforts this polarized situation will continue. As yet, however, no studies have quantified nation-to-nation consumer responsibility for global mortality due to both primary and secondary PM2.5 particles. 

Here we quantify the global footprint of PM2.5-driven premature deaths for the 19 G20 nations in a position to lead such efforts. G20 consumption in 2010 was responsible for 1.983 [95% Confidence Interval: 1.685–2.285] million premature deaths, at an average age of 67, including 78.6 [71.5–84.8] thousand infant deaths, implying that the G20 lifetime consumption of about 28 [24–33] people claims one life. 

Our results indicate that G20 nations should take responsibility for their footprint rather than focusing solely on transboundary air pollution, as this would expand opportunities for reducing PM2.5-driven premature mortality. Given the infant mortality footprint identified, it would moreover contribute to ensuring infant lives are not unfairly left behind in countries like South Africa, which have a weak relationship with G20 nations.

Reading about COVID-19

Early next year, I'll be teaching "Perspectives on Pandemics," a course for Eldercollege here on the North Shore—going back to the Athenian and Justinianic plagues and the Black Death, but focusing on COVID-19. I'm pulling together a suggested reading list for my students, and it occurred to me that others might want to explore some of these titles as well. So here they are. Some include links to my Tyee reviews; others will be mentioned in a long article I'm working on. I'll update this list from time to time.

Peter Baldwin, Fighting the First Wave: Why the Coronavirus Was Tackled So Differently Across the Globe. Cambridge University Press, 2021. My review: https://thetyee.ca/Analysis/2021/03/30/Best-Book-Written-About-COVID-Pandemic/

Alex De Waal, New Pandemics, Old Politics: Two Hundred Years of War on Disease and Its Alternatives. Polity Press, 2021. My review: https://thetyee.ca/Culture/2021/07/09/All-Plagues-Are-Political/

Elaine Dewar, On the Origin of the Deadliest Pandemic in 100 Years: An Investigation. Biblioasis, 2021.

Fang Fang, Wuhan Diary: Dispatches from a Quarantined City, translated by Michael Berry. HarperCollins, 2020. My review: https://thetyee.ca/Culture/2020/05/27/Wuhan-Diary-Book/

Richard Horton, The Covid-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again. Polity Press, 2020. My review: https://thetyee.ca/Culture/2020/06/22/Only-Newly-Vigilant-Society-Can-Stop-Next-Pandemic/

Colin Kahl & Thomas Wright, Aftershocks: Pandemic Politics and the End of the Old International Order. St. Martin’s Press, 2021.

Michael Lewis, The Premonition. W.W. Norton, 2021. My review: https://thetyee.ca/Culture/2021/05/18/Hot-Pandemic-Book-Poses-Danger/

Rupa Marya & Raj Patel, Inflamed: Deep Medicine and the Anatomy of Injustice. Farrar, Straus & Giroux, 2021.

Jon Sternfeld, Unprepared: America in the Time of Coronavirus. Bloomsbury, 2021. My review: https://thetyee.ca/Culture/2020/12/22/Unprepared-America-Time-Coronavirus-Book/

Steven Taylor: The Psychology of Pandemics: Preparing for the Next Global Outbreak of Infectious Disease. Cambridge Scholars Publishing, 2019. My review: https://thetyee.ca/Culture/2020/07/10/Mental-Toll-Covid-Doctors-Saw-Coming/

Adam Tooze, Shutdown: How Covid Shook the World’s Economy. Viking 2021.

Lawrence Wright, The Plague Year: America in the Time of COVID. Alfred A. Knopf, 2021.

Covid recovery poses dire climate, health risks: Lancet

Via The Times of India, an AFP report: Covid recovery poses dire climate, health risks: Lancet. Excerpt:

PARIS: Countries' fossil-fuel powered Covid-19 recoveries will have long-lasting consequences on human health and risk worsening the food and water insecurity, heatwaves and infectious diseases already threatening billions globally, a major assessment warned Thursday.  

The Lancet Countdown is the largest annual study of the impacts of climate change on human health.  

It found that up to 19 percent of Earth's land mass was affected by extreme drought in 2020 and warned that climate change posed a major threat to food security, which already affects more than two billion people.  

Compared with the historic average, the global population of over-65s lived through 3.1 billion additional extreme heat days last year, it found.  

Populations of 134 countries are now at greater threat from wildfires than at any time previously, and millions of farmers and construction workers are losing income because of the rising number of extremely hot days.  

And climate change is creating ideal conditions for infectious diseases such as dengue fever, Zika virus, cholera and malaria across a far larger span of the globe than just a few decades ago and including Europe, it said.  

"Climate change is here and we're already seeing it damaging human health across the world," said Anthony Costello, executive director of the Lancet Countdown.  

"As the Covid-19 crisis continues, every country is facing some aspect of the climate crisis too."  

The assessment found that the five years with the most areas affected by extreme drought have all occurred since 2015.  

Disruption to the water cycle due to global heating shortens the time in which plants reach maturity, resulting in small yields putting ever-greater stress on food production.  

The Lancet said that yield potential for maize -- a global staple -- had already declined 6 percent compared with 1981-2010 levels.  

Wheat has seen a 3-percent yield potential fall, and rice a 1.8-percent fall, it found.  

And the marine food upon which 3.3. billion people depend on for either sustinence or income is under "increasing threat", with average sea temperature rising in nearly 70 percent of territorial waters compared with just 15 years ago.  

The report also warned that nearly three quarters of countries surveyed said they believed they could not afford an integrated national health and climate strategy.  

"This year we saw people suffering intense heatwaves, deadly floods and wildfires," said lead author Maria Romanello.  

"These are grim warnings that, for every day that we delay our response to climate change, the situation gets more critical.  

"It's time to realise that no one is safe from the effects of climate change."  

In an editorial, the Lancet called on world leaders at the forthcoming COP26 summit to divert some of the trillions they are spending on Covid-19 recovery to reduce inequality and safeguard health.  

"This year's indicators give a bleak outlook: global inequities are increasing, and the direction of travel is worsening in all health outcomes."

COVID-19 hospital stays cost 3 times more than a stay for heart attack

A news release from the Canadian Institute for Health Information: COVID-19 hospital stays cost 3 times more than a stay for heart attack.

The estimated average cost of a hospital stay for COVID-19 is more than $23,000 [US$18,145]. This includes both intensive care unit (ICU) and non-ICU admissions. New data from the Canadian Institute for Health Information (CIHI) shows that a COVID-19 hospital stay costs about 3 times more than for heart attack ($7,000) or pneumonia ($8,000), 4 times more than the cost of a stay for influenza (approximately $5,000) and almost as much as a kidney transplant ($27,000).   

People who have COVID-19 remain in the hospital about twice as long as the average pneumonia patient (15 days and 7 days, respectively), and a larger proportion of them are admitted to the ICU and ventilated.  

Estimated costs for COVID-19 hospital stays  

The estimated total cost of COVID-19 hospital stays in Canada (excluding Quebec) was almost $1 billion in 2020–2021, tripling between November 2020 and March 2021.  

A COVID-19–related hospitalization with ICU admission is estimated to cost over $50,000 — more than 3 times the cost of a stay without ICU admission ($15,000). By comparison, the average cost of an ICU admission for pneumonia is $22,000 and for heart attack is $8,400.  

More detailed information about COVID-19 hospitalizations and emergency department visits is also available.   

Hospital spending last year  

Before the pandemic began, Canadian hospitals (excluding Quebec and Nunavut) spent more than $55 billion in 2019–2020. Compensation was the largest spending area at 64%, followed by supplies (11%). You can find more information on hospital spending in 2019–2020, including per capita data and provincial/territorial breakdowns, on our website.  

These figures reflect the most recent information available from April 1, 2019, to March 31, 2020. Cost estimates for COVID-19 and other common hospitalizations are forecasted values.

Taiwan reports widening income gap amid COVID-19 pandemic

Via FocusTaiwan.tw: Taiwan reports widening income gap amid COVID-19 pandemic.

Taipei, Aug. 22 (CNA) The COVID-19 pandemic had changed the lifestyles of people in Taiwan dramatically and has led to a sharp rise of income inequality, the Directorate-General of Budget, Accounting and Statistics (DGBAS) said Sunday, citing 2020 data. 

Since COVID-19 was first confirmed to have spread to Taiwan in January last year, it has disrupted the country's manufacturing operations, hurt consumer confidence and dealt a blow to the service industry, the DGBAS said. 

While average household savings grew by a record annual 14.8 percent last year to NT$265,000 (US$9,461) since 1994, the income gap between rich and poor households widened, the DGBAS said, citing its 2020 Survey of Family Income and Expenditure. 

In 2020, income inequality in Taiwan was the highest in eight years, with the top 20 percent of households earning 6.13 times the bottom 20 percent, according to the DGBAS. 

Chu Tzer-ming (朱澤民), head of the DGBAS, attributed the sharp rise income inequality to the fact that disadvantaged employees have been hit harder by the economic fallout from the COVID-19 pandemic, as many of them have been asked to take unpaid leave, for example. 

Meanwhile, the DGBAS survey showed that average household spending in Taiwan fell by an annual 1.7 percent in 2020 to NT$815,000 (US$29,107), registering the biggest drop on record. 

Dachrahn Wu (吳大任), director of the Research Center for Taiwan's Economic Development at National Chengchi University, said the threat of new COVID-19 variants might take a toll on Taiwan's job market this year, dimming the prospects of a reduction of income inequality. 

The COVID-19 outbreak has ravaged Taiwan's economy more heavily this year than in 2020, when compensatory consumption surged in the second half of the year after the government eased some its disease prevention restrictions, he said. 

Taiwan's manufacturing capacity and exports, however, have grown sharply this year, bringing benefits to shareholders and employees of companies in the manufacturing and high tech sectors, he said. 

In comparison, employees in the service industry saw their earnings drop due to job loss or furloughs, as economic activity declined due to the COVID-19 outbreak, Wu said. 

The government should do more to provide relief to economically and socially disadvantaged people affected by the COVID-19 outbreak, Wu said, noting that property sales were brisk in the first half of 2021 and the domestic economy will grow robustly for the whole of the year.