H5N1

UK: Early death rate in deprived Blackpool 'twice that of the most affluent areas'

Via The Guardian: Early death rate in deprived Blackpool 'twice that of the most affluent areas'. Excerpt:

Blackpool, the most deprived area of England, has twice the rate of early deaths of Wokingham, the most affluent, new research shows. 

The north/south divide in health has long been known, but a major study published by the Lancet medical journal shows that high rates of premature deaths from avoidable illnesses such as heart disease and some cancers are firmly tied to poverty and deprivation. 

Blackpool’s rate of premature mortality – death earlier than it should have been according to life expectancy at birth – was twice that of the most affluent local authorities – Wokingham, Surrey, Windsor and Maidenhead, and West Berkshire – according to the Global Burden of Disease initiative. 

“The scale of it was a surprise to us,” said Prof Nicholas Steel, lead author from the University of East Anglia. “There is more than a twofold variation.” 

The main cause of early deaths was heart disease, with rates for men twice that of women. Half of all of the early deaths in 2016 were linked to preventable lifestyle risks. 

“The big ones – tobacco, diet, alcohol and drugs, obesity and high blood pressure – we see them clustering in the poor areas,” said Steel. “Blackpool has hugely high rates of smoking and poor diet.” 

One of the big questions the study raises, he said, is “to what extent this tailoff in life expectancy would be due to austerity. We think because of these links to specific conditions, it is much less likely to be due to austerity than something linked to these conditions.”  

That suggests that the issue is not about the funding of the health service; however, he said, austerity makes a difference to the environment in which people live, affecting their education and employment, for instance, which in turn affects their health. 

Steel says the study points to the need to tackle the factors that prevent people living healthier lifestyles. “In many cases the causes of ill health and the behaviours that cause it lie outside the control of health services,” he said.

Quebec Inuit leaders plead for mental health support in wake of youth suicides

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Via CBC News: Quebec Inuit leaders plead for mental health support in wake of youth suicides. Excerpt from a very grim story:

In Nunavik, Quebec's expansive northern region dotted by remote fly-in Inuit villages, most residents are connected to at least one, if not several of the young people who have recently ended their own lives. 

Mary Simon, Canada's first ambassador for circumpolar affairs and a longtime Inuit rights advocate, learned her 22-year-old niece took her life last week.  

"Natalie was an exceptional person. She was vivacious and very friendly," Simon said.

Simon has just returned to Ottawa, where she lives, after flying to Kuujjuaq, Nunavik for her niece's funeral. 

"There's a stillness in the community. Nobody's really talking about it. People are on high alert, wondering where it's going to happen next," she said.  

Since the beginning of the year, across all of Nunavik, where roughly 12,000 people live, there have been at least 13 suicides. Eleven of those were in one village, Puvirnituq, a small community of 1,779 people on the Hudson Bay. 

Simon said her niece, who lived in Kuujjuaq​, had struggled with mental health issues in her teens, and had spent a year living in Ottawa with Simon and her family.  

May improved with regular access to counselling and support, but when she returned home, Simon said, there was a lack of followup.

"When you look at the lives that are being lost through suicide, it is a state of emergency. If it was happening anywhere else in Canada, I don't think that we would be standing aside and watching it happen," Simon said.  

May's death also touched 26-year-old Nigel Adams, whose life has been punctuated by the violent deaths of friends and family.   

When he was 20, he tried to take his own life. "My father was in the bathtub, my mother was making bannock. My buddy walked into my closet. He saved my life," he said. 

A few years later, that same friend killed himself. 

Deaths of despair: The opioid epidemic is just part of the problem

Via Columbia University Mailman School of Public Health: Deaths of Despair: The Opioid Epidemic Is Just Part of the Problem.

Although recent declines in life expectancy among white Americans, coined “deaths of despair” grabbed headlines, scientists at Columbia University Mailman School of Public Health have assembled evidence that these declines are neither a recent problem nor confined to whites. 

As early as 1980, researchers began to observe declines in life expectancy relative to other countries and in various measures of psychosocial well-being. According to the new study, increases in despair over time, up to and including a recent spike in deaths related to opioid use, stem from structural problems, including the failure of democratic institutions and the rising costs of medical care. The paper is published in the American Journal of Public Health.  

“The opioid epidemic is sitting on top of a much longer, and more poorly understood, decline in the health and well-being in the United States,” said Peter Muennig, MD, professor of Health Policy and Management at Columbia Public Health. “Virtually any social trend that might correlate over time with changes in health curves is a candidate.”   

There are several plausible contributors to the term coined as “true deaths of despair”—defined broadly as a decline in measures of psychosocial well-being over time. “If there is anything to which one can point that makes the U.S. an outlier in global rankings of health measures, it is rising medical costs which may be compromising Americans ability to satisfy basic needs,” noted Muennig. “These costs are eating into middle-class American’s disposable income.”

Muennig and colleagues describe some of the other more popular and plausible explanations:   

• Failure of democratic institutions and regulations. The United States is falling behind other nations with respect to educational performance, income equality, environmental protection, transportation, waste management, the rule of law, and private gun ownership regulations.   

• Economic stagnation since the 1980s for moderate-income households of all races and ethnicities.   

• A slowdown in immigration. Immigrants are much healthier than native-born people on average.   

• Earlier smoking among white women could be contributing to lagged mortality effects that are surfacing in middle and older ages.   

“The answer rests in a combination of factors,” noted Muennig. “But the attention that has been given to whites as the primary victims of declining health is distracting researchers and policymakers from much more serious, longer-term structural problems that affect all Americans.”

Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: A time-series analysis

Via The Lancet Planetary Health: Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: a time-series analysis. The summary:

Background 

Hurricane Maria struck Puerto Rico on Sept 20, 2017, devastating the island. Controversy surrounded the official death toll, fuelled by estimates of excess mortality from academics and investigative journalists. We analysed all-cause excess mortality following the storm. 

Methods 

We did a time-series analysis in Puerto Rico from September, 2017, to February, 2018. Mortality data were from the Puerto Rico Vital Statistics System. We developed two counterfactual scenarios to establish the population at risk. In the first scenario, the island's population was assumed to track the most recent census estimates. In the second scenario, we accounted for the large-scale population displacement. Expected mortality was projected for each scenario through over-dispersed log-linear regression from July, 2010, to August, 2017, taking into account changing distributions of age, sex, and municipal socioeconomic development, as well as both long-term and seasonal trends in mortality. Excess mortality was calculated as the difference between observed and expected deaths. 

Findings 

Between September, 2017, and February, 2018, we estimated that 1191 excess deaths (95% CI 836–1544) occurred under the census scenario. Under the preferred displacement scenario, we estimated that 2975 excess deaths (95% CI 2658–3290) occurred during the same observation period. The ratio of observed to expected mortality was highest for individuals living in municipalities with the lowest socioeconomic development (1·43, 95% CI 1·39–1·46), and for men aged 65 years or older (1·33, 95% CI 1·30–1·37). Excess risk persisted in these groups throughout the observation period. 

Interpretation 

Analysis of all-cause mortality with vital registration data allows for unbiased estimation of the impact of disasters associated with natural hazards and is useful for public health surveillance. It does not depend on certified cause of death, the basis for the official death toll in Puerto Rico. Although all sectors of Puerto Rican society were affected, recovery varied by municipal socioeconomic development and age groups. This finding calls for equitable disaster preparedness and response to protect vulnerable populations in disasters.

Increasing mortality and declining health status in the USA: Where is public health?

In the Harvard Health Policy Review, Dr. Stephen Bezruchka of the School of Public at the University of Washington writes: Increasing Mortality and Declining Health Status in the USA: Where is Public Health? Excerpt:

Mortality increases at the national level are very rare phenomena this century. In the 1900s, mortality only increased in countries greatly affected by World War I and II, and in the 1990s in Sub-Saharan nations with high AIDS prevalence as well as after the collapse of the Soviet Union in 1991. 

Beginning this century, mortality is now increasing in the United States. The National Center for Health Statistics reports that life expectancy is declining, and infant mortality is increasing. The reported life expectancy decline is for the period 2014 to 2016 and will continue through 2017. This three-year decline is unprecedented in the U.S. All-cause death rates are similarly increasing except for those over age 65. For adults, aged 24 to 65, mortality has increased for all race-ethnicity groups. This includes all-cause mortality, as well as cause-specific mortality that includes hypertensive, alcoholic liver, and respiratory diseases, drug overdoses, as well as suicides and homicides.  

Relative declines in U.S. life expectancy compared to other nations have been observed for half a century. That is, while mortality had been decreasing in the U.S., the improvements were better in many other nations. Life expectancy in the USA lags 4.5 years behind Japan. If we eradicated our leading killer, heart disease, we still wouldn't bridge the gap. If health were an Olympic event, our performance would be falling behind 35 to 60 other nations depending on the mortality indicator chosen. 

This represents a marked change compared to the early 1950s when our mortality rates were among the lowest in international comparisons. The relative decline has been more marked in women. Huge expectations are placed on women in the US without much support from government in comparison to other nations. A 2013 report from the Institute of Medicine documenting this has received little attention or response by our federal institutions responsible for our health status.  

Public health agencies at the federal, state and local level have not drawn attention to this most mortal of all perils. Why? There are almost no public surveys of our health status as a nation. A population-based survey of medical students carried out in 2002 found that a third of medical students thought the United States led the world in the highest life expectancy and lowest infant mortality. No attention is devoted to our health as a nation, in comparison to other nations, in our health care schools. The same is true for schools of public health. 

Medical care is about diagnosing and treating illness and injury, which focuses on individuals and their issues. The United States spends more on health care than the rest of the world combined. Logically, medical care cannot be responsible for our health decline. Even with the advent of the Affordable Care Act, it is difficult to demonstrate related health improvements. The same was true after the adoption of Medicare. 

The public doesn't distinguish health from health care. We access health, we pay for health, we invest in health, we get health and so on, but those statements are all about health care. The question that should be asked is whether we want health or health care. Ideally we should have both. We do not.

Beat Richner, doctor to Cambodia’s needy young, dies at 71

A long, appreciative obituary in The New York Times: Beat Richner, Doctor to Cambodia’s Needy Young, Dies at 71. Excerpt (but read the whole article):

PHNOM PENH, Cambodia — Beat Richner, a Swiss pediatrician who opened a network of children’s hospitals in Cambodia at a time when quality health care was all but nonexistent in that country, died on Sept. 9 in Zurich. He was 71.  

His death was confirmed by Dr. Denis Laurent, his longtime deputy director at the Kantha Bopha Children’s Hospitals in Cambodia. No cause was given. Dr. Richner had been treated for a degenerative brain disease.  

He arrived in Phnom Penh, the capital of Cambodia, in 1992 to take over a 60-bed pediatric hospital in a country ravaged by civil war during the Khmer Rouge era, mired in poverty and rife with corruption. 

His facility became known as the Angel Hospital because it treated anyone, no matter how poor, while providing care at a level many did not believe possible in Cambodia. 

Through fund-raising and fierce advocacy, he gradually turned the building into a network of five medical centers in two cities, Phnom Penh and Siem Reap. They now treat about one million patients a year.  

Dr. Richner, whose motto was “One child, one life,” was beloved by many Cambodians, who saw his devotion to patient care as a corrective to their government’s failures in helping the sick and even disregard for human life.  

But he could be irascible and uncompromising and often clashed with international public health experts, some of whom found his efforts ego-driven and unsustainable.  

In one instance he took out newspaper advertisements accusing the World Health Organization of “passive genocide,” saying it emphasized adhering to rules and protocols over saving lives. He dared the organization to donate its entire annual budget to create 200 of his hospitals around the world. (It did not.)  

“For a poverty-stricken child who needs to be healed and saved, the theoretical and ideological question of sustainability that the experts in their offices are concerned about is absolutely meaningless,” Dr. Richner wrote in 1998. 

He had almost no personal life or interests outside of medicine, with one exception: He moonlighted as a cellist, giving performances as an alter ego named Beatocello, whom he described as “a poetic and musical comedian or clown.”  

In this guise, he would play soulful renditions of Bach’s cello suites and his own original compositions for tourists in exchange for donations, which he then poured back into his hospitals.  

“His life was very limited and connected to only two things,” said Dr. Ky Santy, who became the director of Kantha Bopha after Dr. Richner stepped down for health reasons last year. “First, to the daily life of the hospital; and second, to the cello.”

US: A new threat to immigrants’ health — the public-charge rule

Via NEJM: A New Threat to Immigrants’ Health — The Public-Charge Rule. Excerpt:

The United States is making major changes to its immigration policies that are spilling over into health policy. In one such change, the Trump administration is drafting a rule on “public charges” that could have important consequences for access to medical care and the health of millions of immigrants and their families. 

The concept of a public charge dates back to 19th-century immigration law. Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States. They can also be prevented from adjusting their status from a nonimmigrant visa category (e.g., a student or work visa) to legal permanent resident status. 

In addition, if they become public charges within the first 5 years after their admission to the United States, for reasons that existed before they came to the country, in rare cases they can be arrested and deported. Immigrants and their families consequently have strong incentives to avoid being deemed public charges.  

Current guidelines define a public charge as a person who is primarily dependent on the government for more than half of personal income. In evaluating whether a person is likely to become a public charge, immigration officials take account of factors such as age, health, financial status, education, and skills. The use of cash assistance for income maintenance (e.g., Supplemental Security Income or Temporary Assistance for Needy Families) and government-funded long-term care are considered in making these determinations. Other noncash benefits such as health and nutrition programs are specifically excluded from consideration, and use of cash-assistance benefits by the immigrant’s dependents is not currently factored in. 

The Trump administration is proposing sweeping changes to these guidelines. A draft rule from the Department of Homeland Security (DHS) would substantially expand the definition of a public charge to include any immigrant who “uses or receives one or more public benefits.” 

Not just cash assistance but nearly all public benefits from federal, state, or local governments would be considered in public-charge determinations, including nonemergency Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized health insurance through the marketplaces created by the Affordable Care Act (ACA); Medicare would be excluded. The DHS draft notes that in making these determinations, “having subsidized insurance will generally be considered a heavily weighted negative factor.” 

The broadened definition of public charge would also encompass food assistance (the Supplemental Nutrition Assistance Program [SNAP] and the Women, Infants, and Children Program [WIC]), programs designed to assist low-income workers (e.g., the Earned Income Tax Credit [EITC]), housing assistance (Section 8 vouchers), and the Low Income Home Energy Assistance Program. 

Moreover, not only immigrants’ use of public assistance but use of these programs by any dependents, including U.S.-born citizen spouses and children, would also be considered. Already, the State Department has revised instructions to its officials abroad who process applications to enter the United States that incorporate this broader definition. 

The potential impact of these changes is enormous. In 2016, about 43.7 million immigrants lived in the United States. If enacted, the new regulations would affect people seeking to move to the United States to be reunified with family members and to work, as well as lawfully present immigrants who hope to become legal permanent residents (green-card holders). 

One estimate suggests that nearly one third of U.S.-born persons could have their use of public benefits considered in the public-charge determination of a family member. This includes “10.4 million citizen children with at least one noncitizen parent.” 

Notably, unauthorized immigrants are not the primary target of the draft rule, since they are already ineligible for most federally funded public assistance. Instead, lawfully present immigrants would bear the brunt, as well as persons living in “mixed-status” families (those in which some members are citizens and others are not) and persons living abroad who wish to immigrate to the United States.

Our biggest health factor is largely ignored

My Tyee colleague Andrew MacLeod has published Our Biggest Health Factor Is Largely Ignored. It's the first of four parts from his new book All Together Healthy: A Canadian Wellness Revolution. Excerpt:

Magazine racks and newspapers overflow with advice on how to boost your energy, shrink your belly, renew your body and look great naked. You should walk more, practise safer sex and avoid smoking, the articles tell us. Get out of your chair, build a standing desk and walk on a treadmill while working. Eat a rainbow of vegetables. Get enough sleep. 

If you fail to follow the advice, well, you’ve made your choice. 

This perspective ignores decades of evidence that most of what determines a person’s health is beyond the individual’s control. It individualizes the problem, implying that if you are fat, diabetic or sick, it’s your own fault. 

The message that health is solely an individual responsibility is reinforced by disease advocacy groups. The website for Diabetes Canada, for example, promotes diet, nutrition, exercise and managing your weight. It includes lifestyle tips and makes clear who it sees as responsible: “Taking care of your health should be your top priority.” 

There is, however, abundant evidence that type two diabetes, which accounts for 90 per cent of cases, is closely tied to income. As Dennis Raphael, a health policy and management professor at York University in Toronto, put it in a phone interview, “Even if poor people exercised and their weight was in the so-called ‘normal’ range, they’d still be two to three times more likely to get diabetes.”

And yet a search last year of the Diabetes Canada website for the word “poverty” returned just one document, a press release noting that Nova Scotia’s 2017 budget included $2 million to begin addressing poverty. 

There’s little acknowledgement that at each step down the income ladder the chances a person will become diabetic increase. 

The problem is that for most people, for most diseases, knowledge isn’t enough. Staying up to the minute on all the latest health information is daunting and may not provide the hoped-for benefits. 

There are much larger forces underlying the choices individuals make that have a much larger effect on how healthy we are as a people. Often described as the “social determinants of health,” these forces play out across populations, providing an answer to the question of why some people appear to make worse choices than others, and pointing towards why some people are healthier than others.

Chikungunya in Colombia: A description of an epidemic within the framework of a COPCORD study

Via bioRxiv: Chikungunya in Colombia: a description of an epidemic within the framework of a COPCORD study. The abstract:

During 2014 and 2015 the chikungunya virus reached Colombia unleashing an epidemic that spread throughout the whole territory. Concurrently, the Colombian Rheumatology Association was conducting a Community Oriented Program for Control of Rheumatic Diseases (COPCORD) to establish rheumatic disease prevalence in the country. Chikungunya infected patients were identified within the COPCORD population. 

The aim of this study was to describe the demographics, clinical characteristics and disability of patients with clinical suspicion of chikungunya infection. To confirm chikungunya infection, ELISA IgM and IgG serology was performed. From the 6528-surveyed people of the COPCORD study, 548 where included in the study because of clinical suspicion of chikungunya virus infection. Of those, 295 were positive for IgG or IgM chikungunya serology with 151 patients fulfilling WHO clinical criteria for chikungunya infection (true positives). 

Most patients were > 45 years (57.7%), and females (69.7%). Patients with low income and low socio-economic strata had increased risk of chikungunya infection (p = 0.00; OR: 2.36, CI: 1.47-3.77 and p = 0.00; OR: 2.81, CI: 1.90-4.17 respectively). True positive patients were associated with symmetric arthritis (p = 0.00; OR: 22.49, CI: 12.71-39.80) of ankles (p = 0.00; OR: 16.06, CI: 7.57-34.08), hands (p = 0.00; OR: 16.12, CI: 8.25-39.79), feet (p = 0.00; OR: 16.35, CI: 7.41-36.05) and elbows (p = 0.00; OR: 14.00, CI: 3.03-64.70). Most patients developed mild to moderate disability (95.2 to 100%). 

Our study showed that poverty and low socioeconomic status are associated with increased risk of chikungunya infection. Also, we found two distinctive phenotypes of chikungunya infection; those with positive chikungunya serology and typical clinical symptoms (true positives) and those with positive serology without clinical symptoms (false negatives). Finally, a distinctive clinical picture presented by chikungunya infected patients was found which should be considered as the hallmark for diagnostic clinical criteria.

Greece—the cost of recovery

Via The Lancet Public Health, an editorial: Greece—the cost of recovery.

The worst wildfires in a decade have engulfed parts of Greece, leaving scores of people dead and injured. “We will do whatever is humanly possible”, said Greek Prime Minister Alexis Tsipras. Emergency services across the country have been mobilised. A national state of emergency has been declared. 

European nations are urgently coming to Greece's assistance. These immediate actions are welcome, appropriate, and proportionate. But they are in stark contrast to the international response to Greece's long-term health crisis. 

On August 20, Greece will exit its third and final international bailout programme; a long and painful odyssey during which the country was plunged into an unprecedented recession. Since 2010, wages have fallen by nearly 20%, and unemployment remains high, with an alarming 43% youth unemployment. In its latest Economic Survey of Greece, published in April, 2018, the OECD notes the reform efforts with GDP growth projected to strengthen to above 2% in 2018 and 2019. 

But, importantly, the report also warns that poverty in Greece has risen dramatically, especially among children: “The long crisis combined with an ineffective social protection system caused a surge in poverty, especially among families with children, the young and unemployed. In-work poverty is also high.” 

According to Eurostats, the severe material deprivation rate is now at 22·4% (compared with 7·5% across the EU). Worryingly, 14·5% of the population reports unmet medical need, more than three times the EU average (4·5%). While the (fragile) economic recovery in Greece is certainly good news, the health and wellbeing of its population cannot be complacently disregarded.  

To understand the potential health consequences of Greece's austerity programme, in this issue of The Lancet Public Health, Georgios Kotsakis and the Global Burden of Disease 2016 Greece Collaborators report an evaluation of mortality, risks factors, and health financing in Greece from 2000 to 2016. The authors compare trends in health outcomes and health expenditures from 2000–10 (pre-austerity) and 2010–16 (post-austerity). 

Mortality in Greece increased from 944·5 deaths per 100 000 in 2000 to 997·8 in 2010 and 1174·9 in 2016. Age-standardised mortality showed reduced improvement after 2010 and the onset of the financial crisis, in line with the findings from Ioannis Laliotis and colleagues' 2016 study that also reported slowing of mortality reduction in Greece after the crisis. The proportion of older people has increased, probably reflecting the fact that half a million Greeks left the country during the crisis. 

Importantly, the Global Burden of Disease 2016 Greece Collaborators go beyond mortality, and also look at years lived with disability and risk factors. They also investigate the relation between health outcomes and government expenditure on health. For the authors, “there is evidence of a disproportionate decrement in the health of Greeks compared with regional populations, which parallels the course of the economic crisis… and suggest that an effect of the abruptly reduced government health expenditure on population health is likely.” 

Greece's health system had been in need of reform well before its economic crisis. Founded in 1983, the Greek national health system (NHS) had been unable to allocate and control spending efficiently. In particular, there had been over-prescription of drugs and services, absence of health technology assessment, and chronic weaknesses in the primary care system. The pressure from the Troika to reduce Greek public health expenditure to 6% of GDP forced the government to put in place effective cost-containment measures, such as a new unified public health organisation merging the NHS and the four main social health insurance funds. 

For Martin McKee and David Stuckler, writing in The Lancet Public Health, “Major cuts to health care cost lives.” Indeed, the implementation of large and indiscriminate cuts, short-term responses to a crisis in the country's finances with little consideration for long-term effects on quality of care and health equity, might well have harmed the population to an extent we still have yet to understand.

The Greek government will need to find a fine balance. Greece's people have endured and suffered enormous sacrifices during the past decade. They have shown courageous resilience. Greek democracy has been challenged. It has survived. As the country faces yet another national crisis, with fires threatening already vulnerable communities, the government, together with its European neighbours, now owes the Greek people not only a commitment to immediate protection, but also a promise to invest in the health of the nation for a sustainable long-term recovery. If Europe stands for anything, it must stand for solidarity.