H5N1

How the US vaccine effort derailed and why we shouldn’t be surprised

Via The Guardian: How the US vaccine effort derailed and why we shouldn’t be surprise. Excerpt:

There are very specific, well-documented reasons that Americans are hesitant to take vaccines. They vary from the troubling way the medical system treats people of color, to vaccine misinformation campaigns overwhelmingly popular in conservative circles, to logistical challenges.  

But population health researchers, whose work considers how society as a whole is fairing, said low vaccine uptake may be looked at another way: as the predictable outcome of a campaign subject to entrenched social forces that have diminished American health and life expectancy since the 1980s.  

“When I look at this I do see a very familiar pattern,” said Dr Steven Woolf, a prominent population health researcher at Virginia Commonwealth University. “When Operation Warp Speed came out I thought I was just seeing a modern example of this old problem where the scientific community developed the vaccine at ‘warp speed,’ but the implementation system for getting it out into the community was inadequate”.  

Woolf calls this “breakthrough without follow-through”. In that light, the plodding vaccination campaign could be seen as one more aspect of the American “health disadvantage”.  

The phrase describes a paradox: the US houses among the most advanced medical and research centers in the world, but performs poorly in basic health metrics such as maternal mortality and infant mortality; accidental injury, death and disability; and chronic and infectious disease.

"So much of the whole issue of social determinants of health and the US ‘health disadvantage’ is rooted in a lack of trust and a lack of trustworthiness in many parts of our society,” said Laudan Y Aron, a senior fellow at the Urban Institute’s health policy center. 

A key piece of research in this area is a 2013 report by a panel chaired by Woolf, directed by Aron, and funded by the National Institutes of Health. Called US Health in International Perspective: Shorter Lives, Poorer Health, the report describes how Americans spend more than double per person on healthcare compared to 17 peer nations, but rank near the bottom in health outcomes.  

The phenomenon is described as “pervasive”, impacting all age groups up to 75, with life expectancy declining especially for women. In just a few examples, Americans have the highest infant mortality, children are less likely to live to age five, and the US has the worst rates of Aids among peer nations.  

The US also has the highest or among the highest rates of cardiovascular disease, obesity, chronic lung disease and disability. Together, these risk factors culminate in Americans having the worst or second worst probability of living to age 50.  

Americans know intuitively that their healthcare is expensive, frustrating and often unfair. Remarkably, even amid the pandemic, roughly 30 million Americans went without health insurance, exposing them to potentially ruinous medical debt.  

“It’s also really interesting how often the messaging is: talk to your doctor, talk to someone you trust,” said Aron. “Yet, we don’t really acknowledge how many people don’t have a doctor, or a doctor they have a trust-based relationship with them”.

US public health workers leaving ‘in droves’ amid pandemic burnout

Via The Guardian, a predictable but still alarming report: US public health workers leaving ‘in droves’ amid pandemic burnout. Excerpt:

Alexandra was working in the public health emergencies unit in a major north-eastern American city when the first wave of the pandemic hit. Although her job was in public health policy research, and not treating Coovid-19 patients on the frontlines of the healthcare system, she recalls the spring of 2020 as a blur of 24-hour shifts.

Beginning last March, Alexandra estimates that she and her colleagues worked the equivalent of three full-time years in 12 months. (Her name has been changed to protect anonymity.) 

“There was no overtime, there was no hazard pay,” Alexandra recalls. Throughout the public health department where she worked, symptoms of anxiety, depression and stress-related physical maladies were commonplace among staff.  

This summer, despite the protestations of her superiors, Alexandra quit. She says she’s one of roughly 25 staff members who have left the department since the start of the pandemic.  

Alexandra’s story is not unique. Just as the pandemic has fuelled a burnout crisis among frontline medical staff, it has been calamitous for the mental health of workers in public health – the data analysts and policy advisers whose recommendations are supposed to shape the nation’s pandemic response. Many feel stonewalled by elected officials and scapegoated for the death toll of Covid-19.  

Some, like Alexandra, are opting to leave the job for good.  

The results of a nationwide CDC survey of public health workers, released this July, were revealing. Of the more than 26,000 surveyed individuals working in public health departments across the United States, more than half reported recent symptoms of at least one major mental health condition. Their reported prevalence of PTSD was 10 to 20% higher than in frontline medical workers and the general public. Advertisement  

Some public health workers, including Alexandra, cite a lack of cooperation from elected officials as a driving source of widespread overwork and discontent. Others even say they have faced pressure from elected officials to alter their findings to fit a political agenda.  

“When they didn’t like how our [data on] vaccination coverage by race/ethnicity was looking, they actually asked me – the least senior member of the health department – to edit the data to artificially inflate BIPOC categories,” alleges Kristine, an epidemiologist at a Connecticut health department. (Her name has been changed out of fear for her job.)  

Meanwhile, public health workers are at the receiving end of mounting resentment. Since last March, threats against public health officials have increased. In a high-profile incident this past July, an angry crowd targeted Dr Faisal Khan – the acting director of the St Louis department of health – at a meeting on mask mandates. The disgruntled attendees lobbed racial epithets and surrounded Khan after the meeting like a mob.

Over half of states have rolled back public health powers in pandemic

Via Kaiser Health News, a discouraging report by Lauren Weber and Anna Maria Barry-Jester: Over Half of States Have Rolled Back Public Health Powers in Pandemic. Excerpt:

Republican legislators in more than half of U.S. states, spurred on by voters angry about lockdowns and mask mandates, are taking away the powers state and local officials use to protect the public against infectious diseases.

A KHN review of hundreds of pieces of legislation found that, in all 50 states, legislators have proposed bills to curb such public health powers since the covid-19 pandemic began. While some governors vetoed bills that passed, at least 26 states pushed through laws that permanently weaken government authority to protect public health. In three additional states, an executive order, ballot initiative or state Supreme Court ruling limited long-held public health powers. More bills are pending in a handful of states whose legislatures are still in session.

In Arkansas, legislators banned mask mandates except in private businesses or state-run health care settings, calling them “a burden on the public peace, health, and safety of the citizens of this state.” In Idaho, county commissioners, who typically have no public health expertise, can veto countywide public health orders. And in Kansas and Tennessee, school boards, rather than health officials, have the power to close schools.

President Joe Biden last Thursday announced sweeping vaccination mandates and other covid measures, saying he was forced to act partly because of such legislation: “My plan also takes on elected officials in states that are undermining you and these lifesaving actions.”

All told:

• In at least 16 states, legislators have limited the power of public health officials to order mask mandates, or quarantines or isolation. In some cases, they gave themselves or local elected politicians the authority to prevent the spread of infectious disease.

• At least 17 states passed laws banning covid vaccine mandates or passports, or made it easier to get around vaccine requirements.

• At least nine states have new laws banning or limiting mask mandates. Executive orders or a court ruling limit mask requirements in five more.

Much of this legislation takes effect as covid hospitalizations in some areas are climbing to the highest numbers at any point in the pandemic, and children are back in school.

“We really could see more people sick, hurt, hospitalized or even die, depending on the extremity of the legislation and curtailing of the authority,” said Lori Tremmel Freeman, head of the National Association of County and City Health Officials.

Public health academics and officials are frustrated that they, instead of the virus, have become the enemy. They argue this will have consequences that last long beyond this pandemic, diminishing their ability to fight the latest covid surge and future disease outbreaks, such as being able to quarantine people during a measles outbreak.

“It’s kind of like having your hands tied in the middle of a boxing match,” said Kelley Vollmar, executive director of the Jefferson County Health Department in Missouri.

But proponents of the new limits say they are a necessary check on executive powers and give lawmakers a voice in prolonged emergencies. Arkansas state Sen. Trent Garner, a Republican who co-sponsored his state’s successful bill to ban mask mandates, said he was trying to reflect the will of the people.

“What the people of Arkansas want is the decision to be left in their hands, to them and their family,” Garner said. “It’s time to take the power away from the so-called experts, whose ideas have been woefully inadequate.”

Seizing the moment to rethink health systems

Via The Lancet Global Health: Seizing the moment to rethink health systems. The summary:

The COVID-19 pandemic has made vivid the need for resilient, high-quality health systems and presents an opportunity to reconsider how to build such systems. Although even well resourced, well performing health systems have struggled at various points to cope with surges of COVID-19, experience suggests that establishing health system foundations based on clear aims, adequate resources, and effective constraints and incentives is crucial for consistent provision of high-quality care, and that these cannot be replaced by piecemeal quality improvement interventions. 

We identify four mutually reinforcing structural investments that could transform health system performance in resource-constrained countries: revamping health provider education, redesigning platforms for care delivery, instituting strategic purchasing and management strategies, and developing patient-level data systems. 

Countries should seize the political and moral energy provided by the COVID-19 pandemic to build health systems fit for the future.

New findings on pandemic kids. And what they really tell us

The Tyee has published my article: New Findings on Pandemic Kids. And What They Really Tell Us. Excerpt:

A new report by Children First Canada takes a long and detailed look at the state of our kids in this second year of pandemic. Even if you don’t have children, but hope for a decent and dignified old age, you’d better take note the findings of Raising Canada 2021 — and take appropriate action in this and future elections. 

The report finds that COVID-19 has aggravated ten major threats to our children. Those threats have been still more aggravated by “cross-cutting themes”: access to education and child care, access to health care and social services, inequity and inequality, and climate change. 

The report points to a host of threats to children that are also threats to us all. And those threats are unlikely to be blunted short of the kind of social transformation we usually call a revolution. 

Let’s look at the threats first. Some are simply intensified forms of the pre-pandemic status quo. Kids are coming into emergency departments with opioid and other poisonings, and cannabis ingestions. Their parents’ attempts to cope with stress don’t work with the kids either. 

Pre-pandemic Canada was stressful enough, but the report finds that “the effects of school closures have accelerated this threat,” leading to more eating disorders, substance misuse and suicide attempts among adolescents.

Systemic racism and discrimination stress racialized families, and the pandemic has only stressed them more. So it should be no surprise that “status First Nations, Métis, Inuit and Black children are disproportionately overrepresented in the child welfare system.” 

So stressed parents with no support are taking it out on their kids: “In some jurisdictions, clinicians have seen twice as many infants for maltreatment-related concerns, specifically fractures and head trauma.” 

More work for the health-care system 

Meanwhile, even less-stressed parents have skipped routine childhood vaccinations, ensuring more work for our health-care system when kids start coming down with measles and other preventable diseases. While many Canadian and U.S. states try to vaccinate their kids from age 12 and up, the report says, for those under 12 “vaccines may not be available until 2022.” Cuba is already testing its homegrown vaccines on kids as young as three. 

The pandemic has worsened childhood poverty, notably in a third of female lone-parent families, and “households with children are more likely to face food insecurity compared to households without children.” In other words, kids aren’t getting enough to eat. We are “ranked 37th out of 41 countries when it comes to providing healthy food for children.” Failing to nourish our children today will have consequences for the rest of the century. 

Well, not for those who die in infancy. The report says, “Canada’s infant mortality rate has increased. It is now the second highest among 17 OECD countries, at approximately 4.4 infant deaths per 1,000 live births. This is a marked change from 1960, when Canada ranked fifth lowest.”

Ontario health-care workers warn of 'brutal' nurse shortage as hospitals brace for 4th wave

Via CBC News: Ontario health-care workers warn of 'brutal' nurse shortage as hospitals brace for 4th wave. Excerpt:

Critical care nurses in southern Ontario have reached a breaking point after they say more than a year and a half of brutal pandemic work and stagnant pay has led to a staffing shortage so severe they believe it's putting patients in danger.  

And as the fourth wave begins, with the number of COVID-19 cases in Ontario hitting 639 on Monday, they say they don't know how they or their hospitals will cope. 

CBC News agreed to give four nurses anonymity so they could talk freely about the conditions at their hospitals. All of them said they'd face severe retribution from management for speaking out without permission.  

"I have no doubt I'd be fired," said a Toronto nurse who's worked in the emergency department for more than 20 years. 

But she said she can't stay silent any longer.  

"The anxiety that I feel before having to go back to work because I don't know what I'm going to see or how many people I'm going to have to take care of because we're short staffed ... I am sometimes terrified," she said.  

She is behind the Instagram account @nursewithsign416, which shares images of nurses, their families and other health professionals holding signs describing the importance of experienced nurses and how burned out they are, along with the hashtag #RNsilentnomore.   

Many of the posts are demanding Premier Doug Ford's government repeal Bill 124, 2019 legislation that capped annual salary increases for many public sector employees, including nurses, at an average of one per cent annually for three years. 

The Ministry of Health said it has recently announced $61 million in funding to train, recruit and hire thousands of registered and practical nurses. The province also provided nurses with a four-month pandemic pay salary top-up in 2020 and is working to provide mental health support for front-line health-care workers. 

"Our government is incredibly grateful for the contributions of Ontario's health care workers and the critical role they have played throughout the COVID-19 pandemic, providing patients with timely, safe and equitable access to high quality care," said ministry spokesperson David Jensen.  

Jensen said it's "inaccurate" to suggest Bill 124, which applies to nurses, teachers and many other public sector employees, caps wage increases at one per cent a year as they can still get raises for seniority and performance.

The Toronto nurse said that while she's at the top of the pay scale, her one per cent raise has translated to 47 cents an hour, even though she's doing the most dangerous and stressful work of her career.

The fourth wave is crushing nurses and other health-care workers

Via The Tyee: The Fourth Wave Is Crushing Nurses and Other Health-Care Workers. Excerpt:

Two indicators have profoundly shaped the COVID-19 response in B.C. — the estimated potential burden on the health-care system and hospitalization data.

In fact, these two indicators were paramount in justifying the implementation of the most restrictive public health measures before the availability of vaccines. 

But coming out of the third wave, we learned these measures were largely insufficient in preserving the capacity of our health-care workers and our health-care system. 

Furthermore, we learned that the pressure, demands and moral distress generated by the management of COVID-19 in the health-care system exacerbated an already dire shortage of health-care workers. 

In the first quarter of 2021, the health-care sector experienced the most significant increase (39 per cent) in job vacancies in Canada. In June, those vacancies represented about 20 per cent of the job vacancies in the country. That’s 98,700 vacant jobs, half of which are nursing positions.

Nurses have been particularly impacted by COVID-19 and the way it was managed. This has resulted in an unprecedented mass exodus of nurses, which continues today and will continue for the rest of 2021 — and beyond. 

Throughout the summer, there have been numerous reports of closures of acute care beds and emergency departments due to the nursing shortage. Alarms have also been raised about the unsafe working conditions resulting from severe understaffing of nurses in acute care settings. 

These reports only scratch the surface of what is happening in our health-care system. The full extent of the nursing shortage and its impact on the health-care system has remained largely hidden from the public despite rising COVID-19 cases. 

Understandably, the COVID-19 response has shifted to vaccination over the past few months. Yet we remain in a global pandemic with a more infectious variant and a fourth wave that continues to put pressure on our health-care system. 

We are fortunate to work with nurses, teach nurses and study nurses. They are all currently reporting alarmingly high numbers of job vacancies in their fields of practice and severe understaffing that contribute to unsafe care and working conditions.

Cuba’s health system buckles under strain of overwhelming Covid surge

Via The Guardian: Cuba’s health system buckles under strain of overwhelming Covid surge. Excerpt:

Julia, a community doctor in Havana, was drafted to the intensive care unit soon after Covid-19 first reached Cuba. 

Last week, her cousin died from the virus. This week, she also tested positive amid a surge in cases which has pushed the island’s vaunted health service to its limits and prompted rare public criticism from Cuban doctors. 

“It hurts to see people die from this terrible virus,” she said, recovering at home from nausea after being injected with an immune booster. “The mood among doctors gets worse by the day.” 

After recording one of the world’s lowest Covid rates last year, Cuba now has one of the western hemisphere’s highest. The island, which reported 12,225 confirmed cases in all of 2020, has reported almost 50 times that so far this year. And with the Delta variant having taken root, a lack of medical supplies is crippling the medical response. 

“There are no antibiotics, no painkillers, the basic list of medicines is almost all out of stock,” said Daniela, a family doctor in Havana who has hardly had a day off since the pandemic began. 

In the face of extreme scarcity, doctors are increasingly prescribing herbal remedies. Mortuaries are overwhelmed. The country’s main oxygen factory recently broke down, compounding the intensive care crisis. 

Cuba last year hospitalised everybody who tested positive for Covid, including asymptomatic cases. But even for a country with the world’s highest doctor-to-patient ratio, average daily case loads of 9,000 have made that protocol unworkable. Now children, the elderly, pregnant women and severe cases are hospitalised, while others must isolate at home. 

Hundreds of doctors have been brought back from international “missions” abroad – a major hard currency generator for the state – to support exhausted colleagues. But the move has not been enough to stop the system, which last year was a model of test, track and isolate, from fraying.

West Africa COVID-19 deaths surge amid Ebola and other outbreaks

A news release from WHO AFRO: West Africa COVID-19 deaths surge amid Ebola and other outbreaks. Excerpt:

Brazzaville, 20 August 2021 – West Africa has recorded its highest number of COVID-19 deaths since the pandemic began as several countries grapple with outbreaks of cholera, Ebola Virus Disease and Marburg Virus Disease that threaten to further strain the already stretched emergency response capacity in the region. 

COVID-19 fatalities in West Africa over the past four weeks increased by 193% from 348 in the previous four weeks to 1018 in the week ending on 15 August. Although the case fatality ratio, or the proportion of people diagnosed with the disease who have died, stands at 1.4%—below the continental average of 2.5%—it is higher than the previous two waves in the sub-region, a sign that health systems are feeling the strain of a heavy caseload. While new cases in West Africa have dropped this week, they were surging for eight consecutive weeks. 

Overall Africa recorded over 244 000 new cases in the week ending on 15 August, an 11% drop from the week before and a second straight week of declining cases. However, nine out of 23 countries experiencing a resurgence are in West Africa. Cote d’Ivoire, Guinea and Nigeria are experiencing a surge in cases and all three countries are tackling other outbreaks. 

West Africa health systems are even more fragile than those in other sub-regions. A World Health Organization (WHO) assessment of the functionality of health systems in West Africa found that they were 21% lower than in Southern Africa, 

“We are particularly concerned about West Africa and we can expect the pressure of COVID-19 to hit health services harder and faster,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “In addition to the strain of COVID-19, comes Ebola and other outbreaks. Fighting multiple outbreaks is a complex challenge.” 

COVID-19 vaccines deliveries 

West Africa has to date received around 29 million vaccine doses—almost the same amount as East and Southern Africa. However, the rollout has been slow, with 38% of the doses administered compared with 76% in East and Southern Africa and 95% in North Africa. West Africa has delivered 2.4 doses per 100 people. In East and Southern Africa, the figure stands at 4.8 doses per 100 people. 

Vaccine shipments to Africa have picked up with the COVAX Facility delivering almost 10 million doses to Africa so far in August, that is nine times what was delivered in the same period in July. The African Union has so far delivered 1.5 million doses to nine countries. Since June, the number of doses administered per 100 people in sub-Saharan Africa has almost tripled from 1.2 per 100 people to 3.4 per 100 people. 

“While COVID-19 vaccine shipments seem to be taking off, Africa is encountering headwinds. Moves by some countries globally to introduce booster shots threaten the promise of a brighter tomorrow for Africa. As some richer countries hoard vaccines, they make a mockery of vaccine equity,” said Dr Moeti.

Austin warns of ‘catastrophe’ as Texas again becomes center of pandemic

Via The Guardian: Austin warns of ‘catastrophe’ as Texas again becomes center of pandemic. Excerpt:

With Covid-19 cases skyrocketing exponentially and intensive care unit capacity in hospitals dwindling to single digits, officials in the Austin area are warning of “catastrophe” as Texas again becomes an center of the pandemic. 

Austin’s local governments issued an urgent message through their emergency notification system Saturday, imploring residents to stay home, mask up and get vaccinated. 

The entreaty comes mere days after Austin Public Health elevated its risk-based guidance to stage 5, the highest possible tier. 

“The situation is critical,” Desmar Walkes, Austin-Travis county’s health authority, said in a statement. “Our hospitals are severely stressed and there is little we can do to alleviate their burden with the surging cases.” 

The Texas trauma service area that includes Austin only has six available ICU beds, 499 available hospital beds and 313 available ventilators – a stunning dearth of resources for a population nearly 2.4 million strong. 

In Austin’s metropolitan statistical area, 510 Covid patients are currently hospitalized, 184 are in the ICU, and 102 are on ventilators. About a third of recent hospitalizations have been among patients younger than 50, underscoring the Delta variant’s serious threat to younger Texans who have opted against vaccination. 

“Hospital bed availability and critical care are extremely limited in our hospital systems, not just for Covid-19 patients, but for anyone who may need treatment,” Walkes said. “The community has to come together again and stave off disaster.” 

As a whole, Texas currently ranks second behind Florida for the highest daily average Covid-19 cases, with infections up 134% over the last 14 days. And between early February and mid-July, roughly 99.5% of Texans who died from the virus were unvaccinated, the Texas Tribune reported. 

In Austin’s Travis county, almost 64% of kids and adults 12 and older are fully vaccinated, compared to about 53% statewide. But in some neighboring counties and suburbs, vaccination rates are even lower than the state average.