H5N1

The truth about decolonising global health worth spreading

A letter in The Lancet: The truth about decolonising global health worth spreading.

With any myth about decolonising global health (as Richard Horton describes it), always question intent, dissent, lament, and discontent. Then, remember the wise words of Frederick Douglass, “power concedes nothing without a demand, it never has and it never will”.  

In the words of Chinua Achebe, we are living in a time when the “lions have their own historians”, and they have finally arrived to take the stage to tell the story of the hunt and the stories of their struggle, their own way, as history has glorified the hunter for too long. Those who stand in the way of this moral conscience are part of the problem, not the solution.  

Decolonising global health is an unconventional movement, told from the point of view of everyday people, and soaked in the struggles of their daily living, the bravery even, of the lions. The process is also so much more than a destination—it is a journey. 

I state this knowing that this movement still has struggles ahead. There is a lot of work to do before anyone or any group can claim to decolonise something as rugged and dynamic or complex as global health. This movement might not bear fruit even in one's lifetime, but at least generations will know that with global health, there was a struggle. We might fail, but at least we struggled to tell our stories, our way. This is the truth about decolonising global health worth spreading.

Provisional COVID-19 age-adjusted death rates, by race and ethnicity — United States, 2020–2021

Via MMWR: Provisional COVID-19 Age-Adjusted Death Rates, by Race and Ethnicity — United States, 2020–2021. The summary:

What is already known about this topic?  

In 2020, racial and ethnic disparities in COVID-19 age-adjusted death rates (AADR) were reported among U.S. residents.  

What is added by this report?  

From 2020 to 2021, disparities in AADR ratios from COVID-19 decreased significantly by 14.0%–40.2% for most racial and ethnic groups, including non-Hispanic White persons, who accounted for 59.6%–65.2% of all decedents; and increased nonsignificantly (7.2%) for non-Hispanic Native Hawaiian and other Pacific Islander persons (0.2%–0.3% of all decedents) compared with non-Hispanic multiracial persons.  

What are the implications for public health practice?  

Providing effective preventive interventions, including vaccination and clinical care, to all communities in proportion to their need for these interventions is necessary to reduce racial and ethnic disparities in COVID-19 deaths.

Cracks in the foundation: How COVID-19 showed our failures

Via The Lancet, a review by Mary T. Bassett: Cracks in the foundation: how COVID-19 showed our failures.

In 1963, James Baldwin, one of the USA's greatest essayists, published The Fire Next Time. The book's title comes from a slave song—”God gave Noah the rainbow sign/No more water but the fire next time”. Baldwin's words sounded a warning that the USA needed to confront its racial hierarchy by embracing racial equality or doom its future.  

Sandro Galea's book, The Contagion Next Time, is titled in a homage to Baldwin and it also sounds a warning. Galea's central argument is that vulnerability to COVID-19 lies with a societal failure to recognise that the foundation of health rests on a healthy everyday life and not simply in the provision of health care. He ponders why this key lesson is not at the centre of pandemic discourse, which instead focuses on vaccination and treatment. In often lyrical prose, Galea roams across history, culture, literature, moral values, economics, politics, and personal pandemic experience. Although situated in a global context, the book's focus is the USA. Galea considers especially the enduring impacts of racism on health and the centrality of structural racism to understanding the USA.  

Globally, there were more than 6 million COVID-19 deaths by early April, 2022. Amid this carnage, few have asked why, if this novel virus was the spark, there was so much dry grass. The Contagion Next Time is suffused with Galea's anguish that failure to grapple with this question will cost more lives. Worse, the world may fare even more poorly when the next contagion arrives.

After the omicron (B.1.1.529) surge, which occurred after this book was written, the USA is now approaching a staggering 1 million COVID-19 deaths. An analysis in 2021 by the Lancet Commission on public policy and health in the Trump era, to which both Galea and I contributed, found that about 40% of US COVID-19 deaths “could have been averted had the US death rate mirrored the weighted average of the other G7 nations”. In February, 2022, the per capita cumulative COVID-19 death rate in the USA exceeded that of other wealthy nations and during omicron placed the USA in a league all its own. Just what is going on?  

Galea, who is Dean of the Boston University School of Public Health, USA, seeks the answers with erudition and passion. He begins with reflections of an array of relevant data. But most of the book reads as a journey towards understanding why the USA has fared so poorly. The answers have little to do with the scientific breakthroughs that brought us COVID-19 vaccines in such record time.  

Galea points to the US obsession with individualism, making achievement of health a personal project, rather than a collective one, and an attachment to technology that has given priority to medical care over public health. He also posits widespread lack of compassion, which erodes solidarity. Galea does not shrink from naming an aversion to complexity in some quarters that made policy making difficult in the pandemic. COVID-19 demanded high-impact decisions that rested on imperfect, incomplete information. A lack of humility may also have contributed to at times contradictory public pronouncements. And there is a failure to confront racism (embedded in the founding of the USA), marginalisation, and socioeconomic inequality.  Galea ends by observing that choosing health will mean “reorienting our social, economic and political priorities” to support our collective wellbeing.  

But there are questions that go unasked and unanswered. Just why would a belief that medical care creates health persist, faced with decades of public health thinking that has shown the minor share of population health attributable to clinical care? The WHO Commission on Social Determinants of Health began its 2008 final report, “Social justice is a matter of life and death.” It would seem time to ask, who benefits from these unhealthy arrangements?  

And there are answers. At their root lies an unfettered pursuit of profit that is not good for health. The US departure from the health performance of its peer nations began in around 1980 as market-oriented policies triumphed. Nicholas Freudenberg in his book At What Cost: Modern Capitalism and the Future of Health confronts directly how with present predatory capitalism in the USA there is widespread damage to the public's health. Haven’t we seen this also with COVID-19? Millions lost their jobs while the stock market flourished. Income inequality increased as life expectancy plunged precipitously among racially marginalised groups in the USA. Meanwhile, equitable access to COVID-19 treatments and vaccines is not a reality for many people in low-income and middle-income countries. Debates continue over patent protections.  

The impact of anti-communism in the USA has limited interrogation of capitalism. But the USA is a capitalist country. Nearly 60 years ago, Baldwin sounded the alarm for the enduring harm of racism to the future of the USA, a lesson which Galea has amplified. Perhaps a more courageous book that contemplates the next contagion would go a step further in sounding the alarm for the health effects of modern capitalism.

Changes in life expectancy between 2019 and 2021: United States and 19 peer countries

Via medRxiv: CHANGES IN LIFE EXPECTANCY BETWEEN 2019 AND 2021: UNITED STATES AND 19 PEER COUNTRIES. The abstract" 

BACKGROUND Prior studies reported large decreases in US life expectancy during 2020 as a result of the COVID-19 pandemic, disproportionately affecting Hispanic and Black populations and vastly exceeding the average change in life expectancy in other high-income countries. Life expectancy estimates for 2021 have not been reported. This study estimated changes in life expectancy during 2019-2021 in the US population, in three US racial/ethnic groups, and in 19 peer countries.  

METHODS US and peer country death data for 2019-2021 were obtained from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. The 19 peer countries included Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland. Life expectancy was calculated for 2019 and 2020 and estimated for 2021 using a previously validated modeling method.  

RESULTS US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.40 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years. 

The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.  

DISCUSSION The US mortality experience during 2020 and 2021 was more severe than in peer countries, deepening a US disadvantage in health and survival that has been building for decades. Over the two-year period between 2019 and 2021, US Hispanic and non-Hispanic Black populations experienced the largest losses in life expectancy, reflecting the legacy of systemic racism and inadequacies in the US handling of the pandemic. 

Reasons for the crossover in racialized outcomes between 2020 and 2021, in which life expectancy decreased only in the non-Hispanic White population, could have multiple explanations.

Marmot: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented

Via The Guardian, Sir Michael Marmot writes: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented. Excerpt:

Dignity. It is fundamental to who we are and our place in society. One way to deprive people of the opportunity to lead dignified lives is to take away the means to meet their material needs. It is undignified to have to resort to food banks to feed your children; to wear two coats indoors against the cold; to plead against eviction because of an inability to pay the rent; to deny children a birthday party because of cost.  

The poorest people in the UK are about to experience a fresh wave of such indignities. These psycho-social assaults will be joined by the physical ill-effects of poverty.  

My life’s work has been studying the relationship between social conditions and inequalities in health. In the UK, a decade of austerity damaged public health and made health equity worse. But the cost of living crisis – and the chancellor’s failure to deal with it – is unprecedented, with its threats to the health and wellbeing of the nation. A 54% rise in the energy price cap will now mean an average household will pay £1,971 a year for gas and electricity, at the same time that council tax, water bills and car tax are all increasing. In October, a further rise pushing the annual energy bill up to £2,300 is expected.  

The typical working-age household will, according to the Resolution Foundation, experience a 4% fall in income, £1,100, in 2022-23. Surely, one might think, 4% is scarcely noticeable, hardly a matter of life and death? It is if you are on the margins.  

The Resolution Foundation gives the example of a single parent, with one child, working 20 hours a week at a low-to-medium wage. In September 2021, this person might have had an income of £18,265. The precipitate removal of the universal credit boost will have reduced income by £1,040. The cost of living rise to September 2022 will take another £1,198 off income. With the chancellor’s changes to taxes and allowances, and salary increases, this person’s income in September 2022 will be £17,681 – £584 less than it was a year earlier. (By contrast, a couple working full-time, both at the median wage, will see their net income fall by 1%, £392.)  

Inflation of more than 8%, and the government’s failure to deal with the cost of living crisis for the poorest people – an unemployed single person will see a 15% drop in income – will put an extra 1.3 million people, including 500,000 children, below the poverty line.

Mortality rates by college degree before and during COVID-19

Via the National Bureau of Economic Research, a paper by Anne Case and Angus Deaton: Mortality Rates by College Degree Before and During COVID-19. Click through to download the paper. The abstract:

It is now established that mortality and excess mortality from COVID-19 differed across racial and ethnic groups in 2020. Less is known about educational differences in mortality during the pandemic. We examine mortality rates by BA status within sex, age, and race/ethnic groups comparing 2020 with 2019. 

Mortality rates have increasingly differed by BA status in the US in recent years and there are good reasons to expect the gap to have widened further during the pandemic. Using publicly available provisional data from the National Center for Health Statistics we find that mortality rates increased in 2020 over 2019 for those with and without a BA, irrespective of age, sex, or race/ethnicity. Although mortality rates increased by more for those without a BA, the ratio of mortality rates for those with and without a BA changed surprisingly little from 2019 to 2020. The BA was protective against mortality prior to the pandemic, and it was equally protective during the pandemic. 

Among 60 groups (sex by race/ethnicity by age) that are available in the data, the ratio of mortality rates of those without a BA to those with a BA fell for more than half of the groups. Our results suggest that differences in the risk of infection were less important in structuring mortality by education than differences in the risk of death conditional on infection.

Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study

Via The Lancet Regional Health: Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study. The summary:

Background  

Ethnically diverse and socio-economically deprived communities have been differentially affected by the COVID-19 pandemic in the UK.  

Method  

Using a multilevel regression model we assessed the time-varying association between SARS-CoV-2 infections and areal level deprivation and ethnicity from 1st of June 2020 to the 19th of September 2021. We separately considered weekly test positivity rate and estimated debiased prevalence at the Lower Tier Local Authority (LTLA) level, adjusting for confounders and spatio-temporal correlation structure.  

Findings  

Comparing the least deprived and predominantly White areas with most deprived and predominantly non-White areas over the whole study period, the weekly positivity rate increases from 2·977% (95% CrI 2.913%-3.029%) to 3·347% (95% CrI 3.300%-3.402%). Similarly, prevalence increases from 0·369% (95% CrI 0.361%-0.375%) to 0·405% (95% CrI 0.399%-0.412%). Deprivation has a stronger effect until October 2020, while the effect of ethnicity becomes more pronounced at the peak of the second wave and then again in May-June 2021. In the second wave of the pandemic, LTLAs with large South Asian populations were the most affected, whereas areas with large Black populations did not show increased values for either outcome during the entire period under analysis.  

Interpretation  

Deprivation and proportion of non-White populations are both associated with an increased COVID-19 burden in terms of disease spread and monitoring, but the strength of association varies over the course of the pandemic and for different ethnic subgroups. The consistency of results across the two outcomes suggests that deprivation and ethnicity have a differential impact on disease exposure or susceptibility rather than testing access and habits.

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.

True number of Covid deaths in the US likely undercounted, experts say

Via The Guardian: True number of Covid deaths in the US likely undercounted, experts say. Excerpt:

The true number of deaths from the Covid pandemic in the US is likely being undercounted, due to the long-lasting and little-understood effects of Covid infection and other deadly complications that surged during the past two years.  

“We are seeing right now the highest death rates we have ever seen in the history of this business,” J Scott Davison, CEO of insurance company OneAmerica, told journalists on 30 December.

“Death rates are up 40% over what they were pre-pandemic,” he said, among working-age people between 18 and 64. Deaths among older Americans have also increased, with one in 100 Americans over the age of 65 dying.  

There have been an estimated 942,431 excess deaths in the US since February 2020, according to the US Centers for Disease Control and Prevention. Hispanic, Black and Native American and Alaska Native populations have been disproportionately affected with high death rates, research shows.  

Previous crises pale in comparison to the pandemic, Davison said. “A one-in-200-year catastrophe would be a 10% increase over pre-pandemic [levels]. So 40% is just unheard of.”  

Many of the deaths aren’t counted in the official Covid tally, he said, because they happen months after Covid infections. “The deaths that are being reported as Covid deaths greatly understate the actual death losses among working-age people from the pandemic. It may not all be Covid on their death certificates, but deaths are up in just huge, huge numbers.”  

In addition to deaths from Covid-19, drug overdoses – already one of the leading causes of death for working-age adults – and homicides have also risen during the pandemic.  

Insurers are also seeing a rise in disability claims – at first for short-term disability and now for long-term disability, because of both long Covid and delayed care for other illnesses, “because people haven’t been able to get the health care that they need because the hospitals are overrun”, Davison said. It’s a trend ”consistent across every player in the business” of insurance.  

Deaths from long Covid have been particularly difficult to track, because the virus may no longer be present at the time of death, but it weakened organs or created fatal new ailments.  

“We’re seeing the statistics get written as we go, almost,” Micah Pollak, associate professor of economics at Indiana University Northwest, said. And high rates of mortality and disability will only continue as more people get infected, he said.

Static socio-ecological COVID-19 vulnerability index and vaccine hesitancy index for England

Via The Lancet Regional Health: Static Socio-Ecological COVID-19 Vulnerability Index and Vaccine Hesitancy Index for England. The summary:

Background  

Population characteristics can be used to infer vulnerability of communities to COVID-19, or to the likelihood of high levels of vaccine hesitancy. Communities harder hit by the virus, or at risk of being so, stand to benefit from greater resource allocation than their population size alone would suggest. This study reports a simple but efficacious method of ranking small areas of England by relative characteristics that are linked with COVID-19 vulnerability and vaccine hesitancy.  

Methods  

Publicly available data on a range of characteristics previously linked with either poor COVID-19 outcomes or vaccine hesitancy were collated for all Middle Super Output Areas of England (MSOA, n=6790, excluding Isles of Scilly), scaled and combined into two numeric indices. Multivariable linear regression was used to build a parsimonious model of vulnerability (static socio-ecological vulnerability index, SEVI) in 60% of MSOAs, and retained variables were used to construct two simple indices. Assuming a monotonic relationship between indices and outcomes, Spearman correlation coefficients were calculated between the SEVI and cumulative COVID-19 case rates at MSOA level in the remaining 40% of MSOAs over periods both during and out with national lockdowns. Similarly, a novel vaccine hesitancy index (VHI) was constructed using population characteristics aligned with factors identified by an Office for National Statistics (ONS) survey analysis. The relationship between the VHI and vaccine coverage in people aged 12+years (as of 2021-06-24) was determined using Spearman correlation. The indices were split into quintiles, and MSOAs within the highest vulnerability and vaccine hesitancy quintiles were mapped.  

Findings  

The SEVI showed a moderate to strong relationship with case rates in the validation dataset across the whole study period, and for every intervening period studied except early in the pandemic when testing was highly selective. The SEVI was more strongly correlated with case rates than any of its domains (rs 0·59 95% CI 0.57-0.62) and outperformed an existing MSOA-level vulnerability index. The VHI was significantly negatively correlated with COVID-19 vaccine coverage in the validation data at the time of writing (rs -0·43 95% CI -0·46 to -0·41). London had the largest number and proportion of MSOAs in quintile 5 (most vulnerable/hesitant) of SEVI and VHI concurrently.  

Interpretation  

The indices presented offer an efficacious way of identifying geographical disparities in COVID-19 risk, thus helping focus resources according to need.