H5N1

Deadly Donald Trump and 40 years of health failures

The Tyee has published my article: Deadly Donald Trump and 40 Years of Health Failures. Excerpt:

Four years ago, in the early weeks of Donald Trump’s presidency, I wrote an article describing him as an Ebola-level global health threat.

That was obviously a gross under-estimate. And Ebola was the wrong comparison. The outbreak that began in 2013 in West Africa, the worst in history, took about 11,000 lives. (Another outbreak has just started in Guinea, but now it can be fought with experienced health care workers and vaccine.) 

Compared to the lives Trump is responsible for shortening or ending, Ebola was a rounding error. In a recent article, science writer Laurie Garrett charged him with pandemicide. But COVID-19 is only one factor in the deaths caused by Trump and a 40-year attack on American public health. 

Soon after I wrote my 2017 article, The Lancet, a major British medical journal, established one of its commissions. Unlike its other commissions that look at the impact of this or that disease, this one was to focus on the impact of Trump and his policies. 

That commission has now published “Public policy and health in the Trump era,” an indictment not only of Trump but of the 40 years of neoliberal policies begun by Ronald Reagan. It may take another 40 years to repair the damage.

US could have averted 40% of Covid-19 deaths, says panel examining Trump's policies

The new Lancet commission is already making waves. Via The Guardian: US could have averted 40% of Covid deaths, says panel examining Trump's policies. Excerpt:

The US could have averted 40% of the deaths from Covid-19, had the country’s death rates corresponded with the rates in other high-income G7 countries, according to a Lancet commission tasked with assessing Donald Trump’s health policy record. 

Almost 470,000 Americans have died from the coronavirus so far, with the number widely expected to go above half a million in the next few weeks. At the same time some 27 million people in the US have been infected. Both figures are by far the highest in the world. 

In seeking to respond to the pandemic, Trump has been widely condemned for not taking the pandemic seriously enough soon enough, spreading conspiracy theories, not encouraging mask wearing and undermining scientists and others seeking to combat the virus’ spread.

Dr Mary T Bassett, a commission member and director of Harvard University’s FXB Center for Health and Human Rights, told the Guardian: “The US has fared so badly with this pandemic, but the bungling can’t be attributed only to Mr Trump, it also has to do with these societal failures … That’s not going to be solved by a vaccine.” 

In a wide-ranging assessment published on Thursday, the commission said Trump “brought misfortune to the USA and the planet” during his four years in office. The stinging critique not only blamed Trump, but also tied his actions to the historical conditions which made his presidency possible. 

“He was sort of a crowning achievement of a certain period but he’s not the only architect,” said Bassett, “And so we decided it’s important to put him in context, not to minimize how destructive his policy agenda has been and his personal fanning the flames of white supremacy, but to put it in context.” 

The commission condemned Trump’s response to Covid, but emphasized that the country entered the pandemic with a degraded public health infrastructure. Between 2002 and 2019, US public health spending fell from 3.21% to 2.45% – approximately half the share of spending in Canada and the UK. 

To determine how many deaths from Covid the US could have avoided, the commission weighted the average death rate in the other G7 countries – Canada, France, Germany, Italy, Japan and the UK – and compared it to the US death rate. 

In another comparison, the commission found if US life expectancy was equivalent to the average in the other G7 countries, 461,000 fewer Americans would have died in 2018. 

The Lancet commission on public policy and health in the Trump era, launched in April 2017 to catalogue Trump health policies, examines the driving forces of his 2016 election win and offers policy recommendations. The 33 commissioners are from the US, UK and Canada and work in public health, law schools, medicine, unions, indigenous communities and other groups. 

The commission devotes as much time in the report to its namesake as it does to the conditions that made him possible. 

A line is drawn from neoliberal policies pushed in the past 40 years, such as those that intensified the drug war and resulted in mass incarceration, to health inequities Trump exacerbated while in office. Many of the connections date back even further, to the colonization of the Americas and the persistence of white supremacy in society.

US health and health care are a mess: Now what?

Via The Lancet: US health and health care are a mess: now what? Excerpt:

The report of the Lancet Commission on Public Policy and Health in the Trump Era is a tour de force as a chronicle of the failings of both the health-care system in the USA and the society and public institutions that create and perpetuate those failings. This Commission's report is likely to serve as a reference document on these matters for years to come. In surfacing the ideological and systemic causes of US health-care problems, this Commission confronts the challenge of correcting them. In that respect, its analysis still leaves deep uncertainty about a path forward. 

The Commission's critique of US health care is broad, deep, and innovative. It provides a thorough review of the presidency and administration of Donald Trump and the many destructive executive orders he signed, which have led to, among other things, loss of health coverage for millions of US residents. The report could serve as a starting point for the corrective actions and policies of the new administration of President Joseph Biden and Vice President Kamala Harris. 

The Commissioners comprehensively document the inadequate support of the US public health apparatus, including the fateful decrease in public health funding between 2002 and 2019 from 3·21% to 2·45% of national health spending and the resulting loss of about 50 000 public health positions nationally, just when they were most needed to confront COVID-19. 

Also compelling is the Commission's framing of reduced life expectancy in the USA compared with other high-income nations. In 2018, the Commission states that 461 000 US residents “went missing” as a result of the nation's reduced longevity. This silent epidemic of shortened lives suggests that hundreds of thousands of avoidable deaths could be added to the close to 500 000 deaths that COVID-19 will have claimed in the USA by the middle of February, 2021. 

The Commission also links shortcomings in US health care to the country's history of racism, economic inequality, and social policy choices that have failed to create a minimally secure safety net for the US population. The Commission correctly points out that changes in public policy related to housing, food and income security, education, and systemic racism will be necessary for the country to overcome its health-care deficits.

Coronavirus today: Surviving post-COVID-19 medical bills

Via the Los Angeles Times, another reason to be glad we live in Canada: Coronavirus Today: Surviving post-COVID medical bills. Excerpt:

Good evening. I’m Amina Khan, and it’s Tuesday, Feb. 9. Here’s what’s happening with the coronavirus in California and beyond. 

We’re learning a lot about the long-term damage the coronavirus can inflict on victims, including breathing problems and chest pain. As the pandemic rages on, another lasting condition has emerged among COVID-19 survivors: overwhelming medical bills that threaten to cripple them financially just as they’re trying to get back on their feet. 

 Take Patricia Mason, who was rushed to the emergency room by her husband and didn’t see him again for nearly a month. The 51-year-old Vacaville woman was transferred to a different hospital in the middle of the night as her condition deteriorated; two days later, her doctor put her chances of survival at less than a 30%. 

Mason did make it through her ordeal last spring, but she did not emerge unscathed, my colleague Maria L. La Ganga reports. She suffers from brain fog, her joints are swollen and painful, and she takes baby aspirin and a handful of supplements every day. 

And then there’s the bill for saving her life: $1,339,181.94. Mason and her husband are on the hook for $42,184.20 of that total. 

The couple, with five jobs and nine mostly-grown kids between them, knows there’s zero chance of paying it off in full. And they’re not alone. 

“The deck is absolutely stacked against the consumer and the patient,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. She added that “getting answers about why certain things are on the bill is almost impossible.” 

During the Obama administration, the federal government put a cap on the amount most insurance plans can require patients to pay. But not all plans have so-called out-of-pocket maximums. Even when they do, the annual limit for a family was $16,300 last year. That ceiling rose to $17,100 this year, though insurance companies can adopt a lower limit. Regardless, that kind of money is still hard for many families to spare during the worst recession in nearly a century. 

Mason is insured through her husband’s union on a plan administered by Blue Shield of California, but it’s what’s called a self-funded plan that happens to be “grandfathered in” and doesn’t have to abide by federal out-of-pocket maximums. The Kaiser Family Foundation estimates that 61% of Americans who get their insurance through their jobs are covered by these kinds of self-funded plans, though it’s unclear how many are also exempt from the federal out-of-pocket limit. 

Many insurance companies said early in the pandemic that they would waive all out-of-pocket costs for policyholders’ COVID-19 treatment. But most waivers do not include self-funded plans. 

A lot of folks could find themselves in the same boat as Mason. 

“I don’t have $42,000 to spare,” Mason said. “I am lucky enough to be alive, so we take that into consideration. But the reality is I don’t have [the money]. It’s not going to happen.”

Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada

Old people use a lot of primary care, and my wife and I have seen what a difference the pandemic has made in the quantity and quality of that care. Via CMAJ: Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada. The abstract:

BACKGROUND: Globally, primary care changed dramatically as a result of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to understand the degree to which office and virtual primary care changed, and for which patients and physicians, during the initial months of the pandemic in Ontario, Canada. 

METHODS: This population-based study compared comprehensive, linked primary care physician billing data from Jan. 1 to July 28, 2020, with the same period in 2019. We identified Ontario residents with at least 1 office or virtual (telephone or video) visit during the study period. We compared trends in total physician visits, office visits and virtual visits before COVID-19 with trends after pandemic-related public health measures changed the delivery of care, according to various patient and physician characteristics. We used interrupted time series analysis to compare trends in the early and later halves of the COVID-19 period. 

RESULTS: Compared with 2019, total primary care visits between March and July 2020 decreased by 28.0%, from 7.66 to 5.51 per 1000 people/day. The smallest declines were among patients with the highest expected health care use (8.3%), those who could not be attributed to a primary care physician (10.2%), and older adults (19.1%). In contrast, total visits in rural areas increased by 6.4%. Office visits declined by 79.1% and virtual care increased 56-fold, comprising 71.1% of primary care physician visits. The lowest uptake of virtual care was among children (57.6%), rural residents (60.6%) and physicians with panels of ≥ 2500 patients (66.0%). 

INTERPRETATION: Primary care in Ontario saw large shifts from office to virtual care over the first 4 months of the COVID-19 pandemic. Total visits declined least among those with higher health care needs. The determinants and consequences of these major shifts in care require further study.

ECDC: Stress test on logistical aspects of COVID-19 vaccination deployment plans

A technical report from ECDC: Stress test on logistical aspects of COVID-19 vaccination deployment plans: final report. The executive summary:

Member States were asked to describe the deployment plans in place for delivering a vaccine with strict cold chain requirements to their target priority groups. All participating Member States were able to describe the process, albeit in varying levels of detail, reflecting that they were at different points in their planning. Most described bespoke cross-government governance arrangements where a task force had been convened to oversee the deployment. Electronic systems for logistics management and vaccination registries were described, some newly developed and others that had been used in previous vaccination programmes. Plans were also in place, or in development, to promote the vaccination campaign including using and monitoring social media to support the roll-out. 

One of the most important aspects of the stress test, however, was to provide an opportunity for those involved in developing their vaccine deployment plan to test it against a realistic scenario, to work through all the elements of deployment and provide reassurance that the plan was robust and that any issues identified could be addressed. Feedback from those who took part in the stress test indicated that this was achieved. The stress test was completed when participants came together in a webinar to hear an overview of the results and share their experiences of vaccine roll-out to date.

The coronavirus Brazil variant shows the world's vulnerability

Via The Atlantic: The Coronavirus Brazil Variant Shows the World's Vulnerability. Excerpt:

Even in a year of horrendous suffering, what is unfolding in Brazil stands out. In the rainforest city of Manaus, home to 2 million people, bodies are reportedly being dropped into mass graves as quickly as they can be dug. Hospitals have run out of oxygen, and people with potentially treatable cases of COVID-19 are dying of asphyxia. This nature and scale of mortality have not been seen since the first months of the pandemic. 

This is happening in a very unlikely place. Manaus saw a devastating outbreak last April that similarly overwhelmed systems, infecting the majority of the city. Because the morbidity was so ubiquitous, many scientists believed the population had since developed a high level of immunity that would preclude another devastating wave of infection. On the whole, Brazil has already reported the second-highest death toll in the world (though half that of the United States). As the country headed into summer, the worst was thought to be behind it. 

Data seemed to support the idea that herd immunity in Manaus was near. In Science this month, researchers mapped the virus’s takeover last year: In April, blood tests found that 4.8 percent of the city’s population had antibodies to SARS-CoV-2. By June, the number was up to 52.5 percent. Since people who get infected do not always test positive for antibodies, the researchers estimated that by June about two-thirds of the city had been infected. By November, the estimate was about 76 percent. In The Lancet this week, a team of Brazilian researchers noted that even if these estimates were off by a large margin, infection on this scale “should confer important population immunity to avoid a larger outbreak.” Indeed, it seemed to. The city was able to largely reopen and remain open throughout its winter with low levels of COVID-19 cases.

Yet now, the nightmare scenario is happening a second time. The situation defies expert expectations about how immunity would help protect the hardest-hit populations. By estimates of leading infectious-disease specialists, such as Anthony Fauci, when roughly 70 to 75 percent of the population is immune, there can still be clusters of cases, but sustaining a large-scale outbreak becomes mathematically impossible. Still somehow, according to The Washington Post, hospitals in Manaus that had thought they were well prepared are now overwhelmed.

Preparing for a COVID-19 resurgence in the WHO African region

Via The Lancet: Preparing for a COVID-19 resurgence in the WHO African region.

The emergence of COVID-19 in January, 2020, has led to the largest pandemic in recent history. With fragile health systems, limited testing capacities, and potentially vulnerable populations, Africa was projected to be the worst affected continent. However, as of Dec 31, 2020, the African region, with 14% of the global population and 47 member states, remains among the least affected of the WHO regions, accounting for 2·4% of confirmed cases and 2·4% of deaths globally. In 2020, following substantial increases in June and July, COVID-19 cases declined in August and September, before plateauing in October and steadily increasing again in November and December. 

Although several countries in Europe are experiencing second waves of the pandemic, there is rising fear of a COVID-19 resurgence in the African region. The recent upsurge seen in South Africa, Nigeria, and Senegal indicates possible resurgence, with notable signs of reduced adherence to public health and social measures (PHSM). As a result, transmission in households, schools, prisons, and other close settings has increased. This increase in transmission might force member states to reinstate lockdown measures with the associated negative socio-economic consequences.

Three interventions are crucial to prepare for and respond to a possible COVID-19 resurgence. First, communities should be empowered as first responders. The experiences during recurrent Ebola outbreaks, and the HIV pandemic, suggest that member states should invest more in engaging the community in the COVID-19 response by involving community leaders as partners, so improving buy-ins for PHSM, and mitigating harm from misinformation. Member states are urged to form local committees responsible for community dialogues on preventive measures with tailored messaging based on feedback around COVID-19 risk perceptions. 

Second, the risk of continued spread at subnational levels should be assessed to inform tailored responses. We recommend WHO's new guidance on implementing and adjusting PHSM in the context of COVID-19, which uses a risk–benefit approach at the lowest administrative level, with transmission intensity and health systems' response capacity used to assign a risk level to each area. 

Third, member states should plan for the worst-case scenario by anticipating when health system capacity might be overwhelmed, developing contingency plans aimed at improving and adjusting testing strategy and capacity, scaling up active case finding in areas with widespread community transmission, increasing capacity to isolate all cases, and maximising the current health workforce including redeploying health workers to high-need areas. 

Sustainable and rapidly implemented interventions require strengthened response coordination to reduce transmission to levels that allow economic activity to continue across the region.

Covid-19 response was a global series of failures, WHO-established panel says

Via The New York Times: Covid Response Was a Global Series of Failures, W.H.O.-Established Panel Says. Excerpt:

Laying bare a yearlong cascade of failures, a World Health Organization panel recounts in a damning report how governments and public health organizations worldwide responded slowly and ineffectively to the coronavirus, despite years of warnings. 

The interim report, an early blueprint for reform, describes the faulty assumptions, ineffective planning and sluggish responses — including missteps by the W.H.O., itself — that helped fuel a pandemic that has killed more than two million people.  

“We have failed in our collective capacity to come together in solidarity to create a protective web of human security,” the Independent Panel for Pandemic Preparedness and Response writes. 

Many of the failings, such as the inability of governments to obtain protective equipment or do widespread contact tracing, have long been painfully clear over the course of the pandemic. But the report is stark in its assessment that, time and again, those who were responsible for protecting and leading failed to do either.  

The panel, led by Helen Clark, a former prime minister of New Zealand, and Ellen Johnson Sirleaf, a former president of Liberia, is still conducting its investigation. But in drafting an interim report, and laying out the scope of its inquiry, the panel makes clear that the world needs to rethink its approach to outbreaks.  

The report describes one failure leading to another, from the “slow, cumbersome and indecisive” pandemic alert system, to the years of preparedness plans that failed to deliver, to the disjointed and even obstructive responses of national governments. 

Public health officials stumbled, too. Investigators said they could not understand why a World Health Organization committee waited until Jan. 30 to declare an international health emergency. (The Chinese government had lobbied other governments against declaring such an emergency).  

And despite the decades of predictions that a viral pandemic was inevitable, and years of committees, task forces and high-level panels aimed at preparing the W.H.O. for that emergency, reforms were slow to come. “The failure to enact fundamental change despite the warnings issued has left the world dangerously exposed, as the Covid-19 pandemic proves,” the report says. 

But the W.H.O.'s stumbles did not excuse the repeated failing of world leaders. For even after health officials gave a clear warning signal, the report notes, “In far too many countries, this signal was ignored.”

The report also faults public health leaders for responding slowly to early evidence that people without symptoms could spread the new coronavirus. Early reports out of China, and one in Germany, documented this phenomenon. But leading health agencies, including the World Health Organization, provided contradictory and sometimes misleading advice, a New York Times investigation previously found.

W.H.O.’s director general, Tedros Adhanom Ghebreyesus, appointed the panel to review the world’s Covid-19 response. Although the panel said the report was based on hundreds of documents, expert consultations and more than 100 interviews with frontline responders, it is not clear if the investigators have spoken to key health officials or reviewed internal documents.  

Many of the initial findings have been previously identified or been obvious for many months. But the collection of mistakes remains shocking even when it is not surprising, and by spelling them out, the panel hopes to chart a course for change.

Characterisation of the first 250 000 hospital admissions for COVID-19 in Brazil

Via The Lancet Respiratory Medicine: Characterisation of the first 250 000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data. The summary:

Background 

Most low-income and middle-income countries (LMICs) have little or no data integrated into a national surveillance system to identify characteristics or outcomes of COVID-19 hospital admissions and the impact of the COVID-19 pandemic on their national health systems. We aimed to analyse characteristics of patients admitted to hospital with COVID-19 in Brazil, and to examine the impact of COVID-19 on health-care resources and in-hospital mortality. 

Methods 

We did a retrospective analysis of all patients aged 20 years or older with quantitative RT-PCR (RT-qPCR)-confirmed COVID-19 who were admitted to hospital and registered in SIVEP-Gripe, a nationwide surveillance database in Brazil, between Feb 16 and Aug 15, 2020 (epidemiological weeks 8–33). We also examined the progression of the COVID-19 pandemic across three 4-week periods within this timeframe (epidemiological weeks 8–12, 19–22, and 27–30). The primary outcome was in-hospital mortality. We compared the regional burden of hospital admissions stratified by age, intensive care unit (ICU) admission, and respiratory support. We analysed data from the whole country and its five regions: North, Northeast, Central-West, Southeast, and South. 

Findings 

Between Feb 16 and Aug 15, 2020, 254 288 patients with RT-qPCR-confirmed COVID-19 were admitted to hospital and registered in SIVEP-Gripe. The mean age of patients was 60 (SD 17) years, 119 657 (47%) of 254 288 were aged younger than 60 years, 143 521 (56%) of 254 243 were male, and 14 979 (16%) of 90 829 had no comorbidities. 

Case numbers increased across the three 4-week periods studied: by epidemiological weeks 19–22, cases were concentrated in the North, Northeast, and Southeast; by weeks 27–30, cases had spread to the Central-West and South regions. 232 036 (91%) of 254 288 patients had a defined hospital outcome when the data were exported; in-hospital mortality was 38% (87 515 of 232 036 patients) overall, 59% (47 002 of 79 687) among patients admitted to the ICU, and 80% (36 046 of 45 205) among those who were mechanically ventilated. 

The overall burden of ICU admissions per ICU beds was more pronounced in the North, Southeast, and Northeast, than in the Central-West and South. In the Northeast, 1545 (16%) of 9960 patients received invasive mechanical ventilation outside the ICU compared with 431 (8%) of 5388 in the South. In-hospital mortality among patients younger than 60 years was 31% (4204 of 13 468) in the Northeast versus 15% (1694 of 11 196) in the South. 

Interpretation 

We observed a widespread distribution of COVID-19 across all regions in Brazil, resulting in a high overall disease burden. In-hospital mortality was high, even in patients younger than 60 years, and worsened by existing regional disparities within the health system. 

The COVID-19 pandemic highlights the need to improve access to high-quality care for critically ill patients admitted to hospital with COVID-19, particularly in LMICs.