H5N1

US: A disaster for American healthcare

Via The New York Times: Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional. Excerpt, and then a response to the decision:

WASHINGTON — A federal judge in Texas struck down the entire Affordable Care Act on Friday on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it. 

The ruling was over a lawsuit filed this year by a group of Republican governors and state attorneys general. A group of intervening states led by Democrats promised to appeal the decision, which will most likely not have any immediate effect. But it will almost certainly make its way to the Supreme Court, threatening the survival of the landmark health law and, with it, health coverage for millions of Americans, protections for people with pre-existing conditions and much more. 

In his ruling, Judge Reed O’Connor of the Federal District Court in Fort Worth said that the individual mandate requiring people to have health insurance “can no longer be sustained as an exercise of Congress’s tax power.”  

Accordingly, Judge O’Connor, a George W. Bush appointee, said that “the individual mandate is unconstitutional” and the remaining provisions of the Affordable Care Act are invalid.  

At issue was whether the health law’s insurance mandate still compelled people to buy coverage after Congress reduced the penalty to zero dollars as part of the tax overhaul that President Trump signed last December.  

When the Supreme Court upheld the mandate as constitutional in 2012, it was based on Congress’s taxing power. Congress, the court said, could legally impose a tax penalty on people who do not have health insurance.  

But in the new case, the plaintiffs, led by Texas, argued that with the penalty zeroed out, the individual mandate had become unconstitutional — and that the rest of the law could not be severed from it. 

The Justice Department’s response to the case was highly unusual: though it disagreed with the plaintiffs that the entire law should be struck down, it declined this year to defend not just the individual mandate, but the law’s provisions that protect people with pre-existing conditions. That prompted a coalition of 16 states and the District of Columbia, led by California, to intervene and defend the law. 

On Friday night, a spokeswoman for Xavier Becerra, the California attorney general, said California and the other defendant states would challenge the ruling with an appeal in the United States Court of Appeals for the Fifth Circuit in New Orleans.

The American Medical Association has published this response:

CHICAGO – The American Medical Association (AMA) released the following statement after the federal district court in the Northern District of Texas sided with the plaintiff, striking down popular key provisions of the Affordable Care Act (ACA).

“Today’s decision is an unfortunate step backward for our health system that is contrary to overwhelming public sentiment to preserve pre-existing condition protections and other policies that have extended health insurance coverage to millions of Americans,” said AMA president Barbara L. McAneny, M.D. “It will destabilize health insurance coverage by rolling back federal policy to 2009. No one wants to go back to the days of 20 percent of the population uninsured and fewer patient protections, but this decision will move us in that direction.”

The AMA will work with patient and other health stakeholder groups in pursuing an appeal and reversal of this unfortunate decision at the district court level.

The AMA led an amicus brief in June that urged the court to reject the challenge. Additional organizations joined the AMA in filing the amicus brief, including the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry. Download or view the amicus brief.

Ebola vaccine is having ‘major impact’ but Congo outbreak may still explode (for lack of funding)

Via Science, Jon Cohen writes a good summary of the situation, but buries the lede: Money for the Ebola response will run out next month. Ebola vaccine is having ‘major impact’ but Congo outbreak may still explode. Excerpt, with my bolding:

As an Ebola outbreak in a conflict-plagued region of the Democratic Republic of the Congo (DRC) continues to spread after 4 months, there’s a glimmer of hope: An experimental Ebola vaccine appears to be helping the communities it reaches. More than 40,000 people have received the vaccine, by far the largest use of it since a trial in 2015 showed it worked well. The vaccine’s effectiveness in this outbreak has not been formally assessed. But Peter Salama, who heads the Ebola response for the World Health Organization (WHO) in Geneva, Switzerland, says, “I think it’s having a major impact.” 

WHO, which works in concert with the DRC’s Ministry of Public Health, can’t distribute the vaccine as widely as it would like, however, because of limited supplies, Salama notes. And the obvious targets for vaccination—people who have had contact with cases—have been difficult to identify and reach because of the ongoing conflict; a small number of front-line health care workers have even been caught in the crossfire.  

So far the outbreak has tallied some 500 cases, about half of whom have died, according to the DRC’s Ministry of Public Health. It spans a region of the DRC’s northeast that abuts four other countries, and Salama and many others worry about the deadly virus jumping a border, which would require separate response teams and boost the potential for wider spread by infecting people with increased transportation options. 

Without more financial and personnel support from wealthy countries, the situation could explode into a long-running calamity similar to the Ebola epidemic that devastated three West African countries from 2014 to 2016, warns an editorial published last month in The New England Journal of Medicine (NEJM). A consensus statement from 25 public health and policy experts published the same week in The Journal of the American Medical Association calls the outbreak “exceptionally” dangerous. 

The editorials urge the U.S. government to change a policy that prevents its Centers for Disease Control and Prevention (CDC) from sending staff to the region because of security concerns. And many are calling for a WHO-established review committee to designate the outbreak a Public Health Emergency of International Concern, which could drive more countries to contribute to the response; in October, the panel said the designation wasn’t yet necessary. 

Although the toll so far is much smaller than the West African epidemic’s 28,000 cases and 11,000 deaths, it’s now the second largest Ebola outbreak ever documented, and one of the longest running. The outbreak has hit mothers and their young children especially hard, because many sought care for malaria at health centers that unknowingly have Ebola cases. Women have made up 62% of all cases, and 24% were children under age 15. Only about 50% of new infections are in people previously identified as having been in contact with a case, which underscores how the violence has interfered with contact tracing. 

Salama says funding for the response in the DRC has been ample so far, but will run out in January 2019. Programs to support readiness and preparedness efforts in nine neighboring countries need another $45 million, he says. He’s particularly worried about Uganda, Burundi, Rwanda, and South Sudan, all bordering the DRC. “If there is a case, as is very likely in surrounding countries, we want to pick up that first one so we can have a very robust response,” Salama says.  

He adds that the front-line responders from the DRC, WHO’s 300 staffers on the ground, and personnel from nongovernmental organizations such as Doctors Without Borders and ALIMA are “frankly exhausted” from working long days in a conflict zone. “Where can we keep finding these brave people who are expert in viral hemorrhagic fever and know how to operate in a conflict-affected area?” he asks.

The impact of air pollution on deaths, disease burden, and life expectancy across the states of India

Via The Lancet Planetary Health: The impact of air pollution on deaths, disease burden, and life expectancy across the states of India: the Global Burden of Disease Study 2017. The summary:

Background 

Air pollution is a major planetary health risk, with India estimated to have some of the worst levels globally. To inform action at subnational levels in India, we estimated the exposure to air pollution and its impact on deaths, disease burden, and life expectancy in every state of India in 2017. 

Methods 

We estimated exposure to air pollution, including ambient particulate matter pollution, defined as the annual average gridded concentration of PM2.5, and household air pollution, defined as percentage of households using solid cooking fuels and the corresponding exposure to PM2.5, across the states of India using accessible data from multiple sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three Socio-demographic Index (SDI) levels as calculated by GBD 2017 on the basis of lag-distributed per-capita income, mean education in people aged 15 years or older, and total fertility rate in people younger than 25 years.

We estimated deaths and disability-adjusted life-years (DALYs) attributable to air pollution exposure, on the basis of exposure–response relationships from the published literature, as assessed in GBD 2017; the proportion of total global air pollution DALYs in India; and what the life expectancy would have been in each state of India if air pollution levels had been less than the minimum level causing health loss. 

Findings 

The annual population-weighted mean exposure to ambient particulate matter PM2·5 in India was 89·9 μg/m3 (95% uncertainty interval [UI] 67·0–112·0) in 2017. Most states, and 76·8% of the population of India, were exposed to annual population-weighted mean PM2·5 greater than 40 μg/m3, which is the limit recommended by the National Ambient Air Quality Standards in India. Delhi had the highest annual population-weighted mean PM2·5 in 2017, followed by Uttar Pradesh, Bihar, and Haryana in north India, all with mean values greater than 125 μg/m3. 

The proportion of population using solid fuels in India was 55·5% (54·8–56·2) in 2017, which exceeded 75% in the low SDI states of Bihar, Jharkhand, and Odisha. 1·24 million (1·09–1·39) deaths in India in 2017, which were 12·5% of the total deaths, were attributable to air pollution, including 0·67 million (0·55–0·79) from ambient particulate matter pollution and 0·48 million (0·39–0·58) from household air pollution. Of these deaths attributable to air pollution, 51·4% were in people younger than 70 years. 

India contributed 18·1% of the global population but had 26·2% of the global air pollution DALYs in 2017. The ambient particulate matter pollution DALY rate was highest in the north Indian states of Uttar Pradesh, Haryana, Delhi, Punjab, and Rajasthan, spread across the three SDI state groups, and the household air pollution DALY rate was highest in the low SDI states of Chhattisgarh, Rajasthan, Madhya Pradesh, and Assam in north and northeast India. 

We estimated that if the air pollution level in India were less than the minimum causing health loss, the average life expectancy in 2017 would have been higher by 1·7 years (1·6–1·9), with this increase exceeding 2 years in the north Indian states of Rajasthan, Uttar Pradesh, and Haryana. 

Interpretation 

India has disproportionately high mortality and disease burden due to air pollution. This burden is generally highest in the low SDI states of north India. Reducing the substantial avoidable deaths and disease burden from this major environmental risk is dependent on rapid deployment of effective multisectoral policies throughout India that are commensurate with the magnitude of air pollution in each state.

WHO: Health benefits far outweigh the costs of meeting climate change goals

A news release from WHO: Health benefits far outweigh the costs of meeting climate change goals. Excerpt:

Meeting the goals of the Paris Agreement could save about a million lives a year worldwide by 2050 through reductions in air pollution alone. The latest estimates from leading experts also indicate that the value of health gains from climate action would be approximately double the cost of mitigation policies at global level, and the benefit-to-cost ratio is even higher in countries such as China and India.  

A WHO report launched today at the United Nations Climate Change Conference (COP24) in Katowice, Poland highlights why health considerations are critical to the advancement of climate action and outlines key recommendations for policy makers.  

Exposure to air pollution causes 7 million deaths worldwide every year and costs an estimated US$ 5.11 trillion in welfare losses globally. In the 15 countries that emit the most greenhouse gas emissions, the health impacts of air pollution are estimated to cost more than 4% of their GDP. Actions to meet the Paris goals would cost around 1% of global GDP. 

“The Paris Agreement is potentially the strongest health agreement of this century,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “The evidence is clear that climate change is already having a serious impact on human lives and health. It threatens the basic elements we all need for good health - clean air, safe drinking water, nutritious food supply and safe shelter - and will undermine decades of progress in global health. We can’t afford to delay action any further.”  

The same human activities that are destabilizing the Earth’s climate also contribute directly to poor health. The main driver of climate change is fossil fuel combustion which is also a major contributor to air pollution. “The true cost of climate change is felt in our hospitals and in our lungs. The health burden of polluting energy sources is now so high, that moving to cleaner and more sustainable choices for energy supply, transport and food systems effectively pays for itself,” says Dr Maria Neira, WHO Director of Public Health, Environmental and Social Determinants of Health. “When health is taken into account, climate change mitigation is an opportunity, not a cost.” 

Switching to low-carbon energy sources will not only improve air quality but provide additional opportunities for immediate health benefits. For example, introducing active transport options such as cycling will help increase physical activity that can help prevent diseases like diabetes, cancer and heart disease.  

WHO’s COP-24 Special Report: health and climate change provides recommendations for governments on how to maximize the health benefits of tackling climate change and avoid the worst health impacts of this global challenge.  

It describes how countries around the world are now taking action to protect lives from the impacts of climate change – but that the scale of support remains woefully inadequate, particularly for the small island developing states, and least developed countries. Only approximately 0.5% of multilateral climate funds dispersed for climate change adaptation have been allocated to health projects.

Belluz: What the dip in US life expectancy is really about: Inequality

In Vox.com, Julia Belluz has a must-read report: What the dip in US life expectancy is really about: inequality. Click or tap through for the full article with excellent links, tables, and graphs. Excerpt:

Living in the US increasingly looks like a health risk. Average life expectancy in the country dropped for the third year in a row, according to recent data from the Centers for Disease Control and Prevention. That’s the longest downturn since the Spanish flu wiped out more than 50 million people a century ago. 

The grim trend stems from a toxic mixture of more drug- and alcohol-related deaths and more suicide in many parts of the country. And it puts Americans at a higher risk of early death compared to their counterparts in other wealthy countries. 

But what’s often lost in the conversation about the uptick in mortality in the US is that this trend isn’t affecting all Americans. In fact, there’s one group in the US that’s actually doing better than ever: the rich. While poor and middle-class Americans are dying earlier, the wealthiest among us are enjoying unprecedented longevity. 

So when we talk about life expectancy slipping, what we should also talk about is the growing problem of health inequality in America. And it’s an increasingly urgent discussion, health researchers are warning, because of policy changes on the horizon that are poised to make the mortality gap even wider. 

Some of these policies will hamper access to medical care (such as rescinding funding for CHIP, the health insurance program for low-income children) but others that aren’t even directly related to health care, like tax cuts, may have even more insidious effects on the American mortality gap. 

America’s alarming life expectancy gap 

The rich have long enjoyed more longevity than the poor, but the gap in life expectancy has been widening in the US over the past few decades, along with other types of social and income inequality.  

The CDC’s Division of Vital Statistics, which tracks mortality in the US, uses death certificates as the data source and doesn’t collect family income data. But we do have good data on the mortality gap and income from a study published in JAMA in 2016. 

A group of researchers, led by Stanford University economist Raj Chetty, analyzed income data for the US population from 1.4 billion tax records between 1999 and 2014. They then compared it with mortality data from Social Security Administration death records. They found that, from 2001 to 2014, the richest Americans gained about five years of longevity, while life expectancy for the poor didn’t budge.

Excess winter deaths in England and Wales highest since 1976

Via The Guardian: Excess winter deaths in England and Wales highest since 1976. Excerpt:

There were 50,100 excess deaths in England and Wales last winter, when there was a prolonged spell of extreme cold, making it the highest number since 1976, figures have shown.  

The Office for National Statistics said flu and the ineffectiveness of the flu vaccine were key reasons for the rise of excess winter deaths in 2017-18.  

The deaths occurred during the NHS’s most serious “winter crisis” for many years. A lack of staff and beds meant all types of health services, particularly hospitals, were unable to cope with both the number of patients needing treatment and the severity of many of their conditions.  

Women and people aged over 85 were among those most likely to die last winter, although the rate of winter deaths among males aged up to 64 doubled in just a year, the ONS found. A third of the deaths were due to serious breathing difficulties, including flu, asthma and bronchitis.  

The 50,100 excess deaths were about 15,000 (45.1%) more than those that occurred in 2016-17 and double the total in 2015-16. 

Nick Stripe, a specialist in health analysis and life events at the ONS, said: “It is likely that last winter’s increase was due to the predominant strain of flu, the effectiveness of the influenza vaccine and below-average winter temperatures.”  

Doctors and groups representing older people said too little was being done to keep older people warm and safe, and to give the NHS the resources it needs. 

Caroline Abrahams, Age UK’s charity director, said: “A toxic cocktail of poor housing, high energy prices and ill-health can make winter a dangerous time for many older people, and tragically it is the oldest and those who are the most vulnerable who particularly suffer the consequences. 

“Last winter, there were nearly 46,000 excess winter deaths among people aged 65 and over – a shocking 92% of all excess deaths – equating to 379 older people a day. These distressing figures are now the highest we’ve seen in over 40 years.”

Health effects of diesel 'cost European taxpayers billions'

Via The Guardian: Health effects of diesel 'cost European taxpayers billions'. Excerpt:

Air pollution from roads causes at least €70bn (£62bn) in health damage every year in the European Union, according to a new report, with diesel fumes responsible for three-quarters of the harm. 

The research, commissioned by the European Public Health Alliance (EPHA), found the vast majority of the costs were borne by taxpayers through government-funded health services. But these costs could be reduced by 80% by 2030 if ambitious action were taken, the report concluded. 

Diesel emissions have been in the spotlight since 2015 when Volkswagen was caught cheating regulatory tests. Virtually all diesel cars were then revealed to be pumping out far more pollution on the road than in official tests. Research in 2017 showed at least 38,000 people a year were dying early as a result of this failure. 

In the UK, most urban areas have illegal levels of air pollution and ministers have lost three times in the high court over the inadequacy of their action. The latest government action plan, called “pitiful” by environmental lawyers, revealed air pollution was actually much worse than previously feared.

Some of the very latest diesel models do comply with official limits in real-world driving, but Zoltán Massay-Kosubek, policy manager at the EPHA, said: “I would not consider diesel as part of the solution, but as part of the problem. You can improve the filters but it still remains a fuel-burning technology.”  

“Low and zero-emission alternatives would be a much more appropriate solution,” he said. “But as a public health advocate, I cannot stress enough the importance of walking and cycling, which give additional health benefits.”

Thousands of Cuban doctors leave Brazil after Bolsonaro's win

Via The Guardian, yet another example of politics as medicine on a large scale: Thousands of Cuban doctors leave Brazil after Bolsonaro's win. Excerpt:

Cuba has begun withdrawing 8,300 doctors working in some of the poorest regions of Brazil, prompting fears that indigenous villages, small towns and isolated rural communities could soon be left without medical care.  

The move came after Brazil’s far-right president-elect Jair Bolsonaro threatened to cut relations with Cuba and modify the conditions of a five-year-old agreement between the two countries and the World Health Organisation. The growing row offers a worrying sign of how the former army captain may handle diplomacy after assuming office on 1 January. 

On Tuesday, Brazil published an emergency tender for doctors trained in the country to replace the Cubans who were working under a programme called Mais Medicos, or More Doctors.  

Chartered flights have begun carrying the Cuban doctors home, some carrying televisions and other goods, causing queues and cancelled appointments where they worked. Medical experts are worried the government will be unable to fill all the vacancies before they have all left by WHO’s expected final date of 12 December. 

“I am extremely concerned about the potential health impact of this and how Brazil will be able to fill those positions,” said Albert Ko, a professor of epidemiology at the Yale School of Public Health who has worked in Brazil.  

The result will be “an abrupt fall in medical attention,” said Henrique Passos, a medical supervisor for Cuban doctors working in far-flung indigenous communities in the Amazon, many of which got their first doctor under More Doctors.  

Cuba announced it was pulling out of the programme on 14 November, blaming Bolsonaro for declaring plans to modify the terms of the programme by insisting that Cuban doctors validate their diplomas and sign individual contracts. It also accused him of making “direct, contemptuous and threatening comments.” 

Earlier in the month, Bolsonaro, had questioned whether Brazil could maintain diplomatic relations with Cuba and said the More Doctors could only continue if Cuban doctors validated their diplomas and received their full pay. 

Currently, Cuba keeps around 75% of the doctors’ £2,400 allowance, though housing and food is paid by local authorities. 

Even so, for Cuban doctors, the experience can be life-changing.  

Yanet Rosales Rojas, 30, spent three years working in the Brazilian town of Poços de Caldas, where on average she earned more than 10 times her monthly salary in Cuba. She returned to the island last year, and was able to buy an apartment in Havana. 

“You earn much more than what you get in Cuba. I always wanted to travel and treat people in other countries. This was my chance,” she said. 

Leasing medical professionals is Cuba’s main export, bringing in more hard currency than tourism: last year professional services by doctors and nurse brought in $11bn , compared to $3bn in tourism.

Deadliest year for dengue fever in Bangladesh as cases explode in Dhaka

Via The Guardian: Deadliest year for dengue fever in Bangladesh as cases explode in Dhaka. Excerpt:

Dengue season usually begins with June’s monsoon rains in Dhaka. An unavoidable fact of life, it proves deadly to a handful of unfortunate victims but by September it has mostly disappeared from the Bangladeshi capital.  

But this year the disease has seen more than a tripling of numbers of recorded cases in the city – alongside a lengthening of its season. 

And the explosion is being reported in other countries too. Dengue, a mosquito-borne viral disease, has been spreading rapidly in the past few years.  

By mid-October, almost 7,450 cases of dengue had been reported in Bangladesh and 17 deaths, making it the deadliest year since the first recorded epidemic in 2000.  

Last year, 68 dengue cases were recorded in Dhaka in the first four months, compared with 254 this year. Researchers believe the true numbers are much higher. 

There are four strains of dengue, including the most life-threatening, hemorrhagic dengue. But only patients with severe cases end up in hospitals, from where the government collects data.

Dengue comes from the same female mosquitoes which transmit chikungunya, yellow fever and Zika infection, and is widespread throughout the tropics, influenced by rainfall, temperature and unplanned rapid urbanisation. All three risk factors are what is leading to an expansion of the dengue season in overcrowded cities such as Dhaka – with 20 million people, poor sanitation and pollution making it among the worst cities to live in.  

The dengue season is getting longer, thanks to poor urban planning and healthcare in a rapidly growing city.  

“The majority of cases used to be seen between June and September,” says Dr Rashidul Haque, an expert in infectious diseases from the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). 

“But more and more we are seeing cases earlier in the year, and later through to November and December.”  

Economic growth, as much as population growth, may also be creating problems. Bangladesh is a fast growing economy, and Dhaka the hub. Hasty building of high-rise business centres, hotels and apartment blocks has seen the destruction of some of the few municipal housing projects, pushing occupants out into the already overcrowded slums. 

It has also turned much of the city into a vast building site, with barrels of stagnant water or reservoirs. When it rains in Dhaka, the water stays pooled on the concrete surfaces.

Rates of premature mortality are two times higher in the most deprived areas of England, compared to most affluent

Via the Institute for Health Metric and Evaluation at the University of Washington: Rates of premature mortality are two times higher in the most deprived areas of England, compared to most affluent. Excerpt:

Rates of premature mortality are two times higher in the most deprived areas of England (Blackpool), compared to the most affluent (Wokingham), according to a new comprehensive analysis of health at a local, national, and regional level across the UK. 

In addition, the study reveals the huge burden of disability linked to long-term conditions such as low back and neck pain, anxiety, and depression, highlighting the need for health services to adapt to managing these conditions.  

While overall rates of premature death have improved since 1990, half of all premature deaths in 2016 were linked to risk factors including tobacco use, unhealthy diet, alcohol and drug use, obesity, and high blood pressure, pointing to the urgent need for policies and programs targeting prevention, especially in areas outside the control of the health service.  

The study, from the Global Burden of Disease initiative, provides data on premature mortality, disability, and risk factors from 1990 to 2016 for 150 Upper-Tier Local Authority (UTLAs) in England, as well as Scotland, Northern Ireland, and Wales, with the aim of informing resource allocation and priorities at a local, regional, and national level. 

Years lived with disability exceed years of life lost 

Ischemic heart disease was the leading cause of premature death in the UK in 2016, and rates were two times higher in men than in women. Self-harm was the third leading cause of premature death for men.  

In England, Wales, and Northern Ireland (but not Scotland), the years lived with disability exceeded the years of life lost. Low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, sense organ disorders, and anxiety disorders were the leading causes of disability.

 “As death rates decrease, people continue to live with long-term, often multiple, conditions,” says Professor Nicholas Steel, lead author, University of East Anglia, UK. “Our findings show a significant shift from mortality to morbidity, yet our health services are still designed to deal with the big killers. Today, conditions such as back and neck pain and anxiety and depression are huge causes of disability in the UK.” 

Health and deprivation  

Rates of premature mortality from all causes were more than two times higher in the most deprived UTLAs in England (Blackpool), compared to the most affluent (Wokingham, Surrey, Windsor and Maidenhead, and West Berkshire). 

Rates of premature mortality were consistently higher for the 15 most deprived areas of England, compared to the 15 least deprived, and the association with deprivation was particularly strong for lung cancer and chronic obstructive pulmonary disease.