H5N1

In China’s Xian lockdown, tales of anguish as hospitals demand patients be covid-free

Via The Washington Post: In China’s Xian lockdown, tales of anguish as hospitals demand patients be covid-free. Excerpt:

On the first day of 2022, outside Xian Gaoxin Hospital, in the middle of China’s worst coronavirus outbreak since Wuhan, a woman eight months pregnant miscarried after being refused care until she had tested negative for the virus.  

After feeling pain in her belly, the woman called an ambulance, according to an account from her niece posted Tuesday evening on the microblog Weibo. Without a negative coronavirus test, she had to wait outside emergency care for two hours until staffers relented when they saw that she was bleeding heavily.  

But by then, the woman had miscarried, said the post from her niece, which was deleted after gaining nearly 6 million views. Neither woman was identified, and The Washington Post was unable to independently confirm details of the account. An employee of the hospital’s quality-of-care department who answered the phone Wednesday said the matter has been investigated and that an official statement would be released soon.  

The reported tragedy has tapped into mounting anguish and disbelief about dysfunction in Xian, the central Chinese city of 13 million that has imposed China’s strictest all-resident lockdown since Wuhan two years ago. Nearly 1,800 symptomatic infections have been confirmed in the city after the local government ordered mass testing and centralized quarantine to halt spread of the virus.

As the rest of the world has become resigned to strategies of mitigating the virus, China has stuck fast to a policy of attempting to completely cut off transmission as soon as new outbreaks emerge, an approach it calls “dynamic zero covid.”  

That whack-a-mole strategy has been largely effective. The Chinese Communist Party’s decision to make covid-19 prevention a top priority spurred local officials to impose rapid and severe — but relatively targeted — lockdowns whenever infections appeared. In the past year, even larger outbreaks were limited to a few hundred cases.  

But the problems in Xian caused by the city’s poorly managed, containment-at-all-costs approach are raising alarm about unacceptable human distress when the unyielding policy goes wrong.   

Residents, who are confined to their homes, already feared delayed or insufficient food deliveries in some areas of the city. They are now worried that hospitals, overwhelmed with coronavirus cases, are struggling to provided adequate care to non-coronavirus patients, a repeat of similar chaotic scenes in Wuhan nearly two years ago.  

By Wednesday morning, the reported miscarriage had become one of the top trending topics on Weibo, as outraged users called for the hospital to take responsibility should it become clear that the delay caused the loss.

Helen Branswell talks with Mike Ryan

Via STAT, Helen Branswell interviews Mike Ryan, head of WHO's health emergencies program: WHO official weighs in on Covid, vaccines, and mistakes that were made. This excerpt is a key part of an interview you should read in its entirety:

Are there things you wish the world had done differently from the jump? Where did we make our biggest mistakes? 

This interview could go on for a while.        

The biggest collective failing has been that we’ve underestimated this microbe. We’ve always made judgments assuming the best-case scenario. And I’m not one for assuming the worst-case scenarios as a modus operandi, because otherwise, you can strangle society. But I think at every opportunity we’ve seem to have taken the best-case scenario as the basis for our policy. And this virus, I think, has sequentially exploited that.  

In the end, the virus doesn’t have a brain. It’s just, from an evolutionary point of view, exploiting opportunities. And we seem to have consistently and persistently given it the opportunity.  

There’s been tremendous social, economic, and political pressure to go back to normal.   

Time and time again governments have tried to get back to normal and have overshot that runway by opening up too early. Releasing restrictions too early. They haven’t really convinced people or empowered people to continue with these basic measures to reduce the risk of infection. I think that’s been a problem, the whole way through the pandemic.  

I don’t mean getting rid of lockdowns. To me lockdowns have been last resort measures in most cases. Many countries in the East have managed to forgo lockdowns. But they’ve maintained quite strict measures in terms of mask wearing, in terms of crowds, in terms of testing and other stuff. So they’ve taken a much more comprehensive, layered strategy. They’ve maintained an intensity of control measures without ever going for full lockdown, without ever going for full open. They’ve taken the corner without under- or over-steering.  They’ve gotten people to buy into the idea that it’s going to take a long time and it’s going to have to be a sustained effort. I think if everyone had done that maybe we’d be in a better place.   

But I think for me just personally as a public health physician, the biggest tragedy has been the vaccine equity issue. It really has been horrific. Horrific. The world just has not ever come to terms with the fact that vaccinating the most vulnerable people first would have been a better bet, not only epidemiologically but just from an equity perspective.   

The idea of coherence and coordination and solidarity — these are all lovely words. But it’s very hard to deliver that in societies that don’t trust governments, [don’t buy into] that social contract, that inherent trust that a community should have in its government to say, “Yes, you are there to protect me.”  

What’s shocked me most in this pandemic has been that absence or loss of trust.  

It’s staggering to read about public health personnel quitting their jobs, being subjected to death threats during a pandemic. They’re facing hatred and vitriol from the people they’re trying to protect.   

It’s tragic. And it’s tragic to think that there are millions of people right now in the Northern Hemisphere who are not vaccinated because they don’t believe their government. Whatever the reasons for that are, whether it’s because governments perform poorly in building that trust, or whether they’ve been actively undermined by misinformation and by other things, historians and social historians will be talking about that one for decades.   

If we’re looking at pandemic preparedness for the future it’s not all going to be about technology and the machines that go ping and surveillance systems and AI and all of this stuff. We need a social solution for future pandemics, much more than we need a technological solution. Because we’re dealing with a fractured world, fractured communities. We’re dealing with a breach and prolonged breakdown in trust.

I shudder to think of going into a more severe pandemic with that level of community distrust. It has had a real negative impact on people’s awareness and willingness to sustain measures. Because they can constantly find lots of material and reasons not to do what they’re being asked to do, because there’s so much out there telling them that what’s going on there is a government conspiracy, what’s happening is hurting them.

With too few nurses, it won't take much to overwhelm hospitals this winter

Via The Pew Charitable Trusts: With Too Few Nurses, It Won't Take Much to Overwhelm Hospitals This Winter. Excerpt:

Nurse Hannah Drummond routinely must watch patients for hours as they lie in the emergency department, waiting for a hospital bed upstairs. That includes patients so ill they use breathing machines or need hospice or intensive care, she said.    

There often aren’t enough nurses to staff every bed at the Asheville, North Carolina, hospital where she works, Drummond said.  

“We are barely holding it together now,” she said. “If we have an uptick in [COVID-19] cases—yeah. I have to honestly not think about it, or I cannot sleep at night.”  

Even as a new COVID-19 variant starts to spread in the United States, staff shortages have made it impossible for many hospitals to operate at full capacity. That means they’re less prepared to manage an influx of patients this winter, whether those patients have complications from COVID-19 or other significant health problems.  

Hospitals nationwide are canceling nonemergency surgeries, struggling to quickly find beds for patients and failing to meet the minimum nurse-patient ratios experts recommend. Some even have had to turn away critical patients. While hospitals are under the most strain in Midwestern and Northeastern states where COVID-19 cases are surging, workforce shortages also are creating problems in Southern states where cases are relatively low—for now.  

Hospitals employ about 2% fewer people today than they did in March 2020, according to the federal Bureau of Labor Statistics. That may not seem like much, but for many facilities, it makes a big difference. Crucially, experienced nurses have been quitting in search of better pay, less stressful jobs and more time with their families. In some cases, they've also sought to avoid required COVID-19 vaccinations.  

Last month, about 4% fewer hospital beds were staffed in Michigan than in November 2020, when 21,071 were staffed, according to the Michigan Health and Hospital Association, which advocates for hospitals in the state.   

In upstate New York, hospital capacity has shrunk by 10%, The New York Times recently reported. And about 9% fewer intensive care beds were staffed in Colorado last month than the same time last year, according to state data.  

A travel nurse at a Midwestern hospital, who asked to remain anonymous for fear of retaliation from her employer, said that as she moves around the facility, she passes scores of beds that have been blocked off.  

“Every single floor, at least, has like five beds that are blocked,” she said. Rooms will be closed even when many people are waiting in the emergency room for admission to that unit, she said, because the hospital doesn’t have enough nurses to staff every bed.   

Short-staffed hospitals will be less able to add beds during a surge of COVID-19 or other respiratory viruses this winter.

Our long night of the virus

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

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

The imperial infection  

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

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

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

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

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

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

Tracking universal health coverage: 2021 global monitoring report

Via ReliefWeb: Tracking Universal Health Coverage: 2021 Global Monitoring Report. Excerpt:

DUBAI/GENEVA/WASHINGTON DC — 12 December 2021 — New evidence compiled by the World Health Organization and the World Bank shows that the COVID-19 pandemic is likely to halt two decades of global progress towards Universal Health Coverage. The organizations also reveal that more than half a billion people are being pushed into extreme poverty because they have to pay for health services out of their own pockets.  

The findings are contained in two complementary reports, launched on Universal Health Coverage Day, highlighting the devastating impact of COVID-19 on people’s ability to obtain health care and pay for it.  

In 2020, the pandemic disrupted health services and stretched countries’ health systems beyond their limits as they struggled to deal with the impact of COVID-19. As a result, for example, immunization coverage dropped for the first time in ten years, and deaths from TB and malaria increased.  

The pandemic also triggered the worst economic crisis since the 1930s, making it increasingly difficult for people to pay for care. Even before the pandemic, half a billion people were being pushed (or pushed still further) into extreme poverty because of payments they made for health care. The organizations expect that that number is now considerably higher.  

“There is no time to spare,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “All governments must immediately resume and accelerate efforts to ensure every one of their citizens can access health services without fear of the financial consequences. This means strengthening public spending on health and social support, and increasing their focus on primary health care systems that can provide essential care close to home.”  

He added: “Prior to the pandemic, many countries had made progress. But it was not robust enough. This time we must build health systems that are strong enough to withstand shocks, such as the next pandemic and stay on course towards universal health coverage.”  

The new WHO/World Bank reports also warn that financial hardship is likely to become more intense as poverty grows, incomes fall, and governments face tighter fiscal constraints.

Canada: National health expenditure trends

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

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

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

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

Key findings  

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

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

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

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.