H5N1

Brazil fails to replace Cuban doctors, hurting health care of 28 million

Via The New York Times: Brazil Fails to Replace Cuban Doctors, Hurting Health Care of 28 Million. Excerpt:

EMBU-GUAÇU, Brazil — The shiny plastic chairs all sat empty in a public health clinic, and the patients who staggered in were told to come back Thursday — the only day of the week now when a doctor is there.  

This small Brazilian city, Embu-Guaçu, home to 70,000 people, recently lost eight of its 18 public-sector doctors, a devastating loss for the city’s network of free clinics, forcing hard choices about who gets care and when.  

“It’s heartbreaking,” said Fernanda Kimura, a doctor who coordinates the assignment of physicians to the clinics for the local health department. “Like choosing which child to feed.”  

The sick and the injured turned away that day in a working-class neighborhood of Embu-Guaçu represent only a tiny fraction of the estimated 28 million people across Brazil whose access to health care has been sharply curtailed, according to the National Confederation of Municipalities, following a confrontation between Brazil’s new president, Jair Bolsonaro, and Cuba.   

In November, Cuba announced it was recalling the 8,517 doctors it had deployed to poor and remote regions of Brazil, a response to the tough stance against Cuba that Mr. Bolsonaro had vowed to take when he was elected in October.  

The abrupt departure of thousands of doctors has presented Mr. Bolsonaro with one of his first major policy challenges — and has tested his ability to deliver on a promise to find homegrown substitutions quickly.

“We are graduating, I am certain, around 20,000 doctors a year, and the trend is to increase that number,” Mr. Bolsonaro said in November. “We can solve this problem with these doctors.”  

But six months into his presidential term, which started in January, Brazil is struggling to replace the departed Cuban doctors with Brazilian ones: 3,847 public-sector medical positions in almost 3,000 municipalities remained unfilled as of April, according to the most recent figures available. 

“In several states, health clinics and their patients don’t have doctors,” said Ligia Bahia, a professor at the Federal University of Rio de Janeiro. “It’s a step backward. It impedes early diagnoses, the monitoring of children, pregnancies and the continuation of treatments that were already underway.”

Austerity to blame for 130,000 ‘preventable’ UK deaths – report

Via The Guardian: Austerity to blame for 130,000 ‘preventable’ UK deaths – report. Excerpt and then a comment:

More than 130,000 deaths in the UK since 2012 could have been prevented if improvements in public health policy had not stalled as a direct result of austerity cuts, according to a hard-hitting analysis to be published this week.  

The study by the Institute for Public Policy Research (IPPR) thinktank finds that, after two decades in which preventable diseases were reduced as a result of spending on better education and prevention, there has been a seven-year “perfect storm” in which state provision has been pared back because of budget cuts, while harmful behaviours among people of all ages have increased. 

Had progress been maintained at pre-2013 rates, around 131,000 lives could have been saved, the IPPR concludes. Despite promises made during the NHS’s 100th birthday celebrations last year to prioritise prevention, the UK is now only halfway up a table of OECD countries on its record for tackling preventable diseases.  

The report is concerned with preventable diseases or disorders such as heart disease, lung cancer or liver problems, which can be caused by unhealthy lifestyles and habits, formed often at a young age. It finds evidence of disturbing reductions in physical activity in schools and chronic underfunding of health visitors. 

The lead researcher and author, Dean Hochlaf, said: “We have seen progress in reducing preventable disease flatline since 2012. At the same time, local authorities have seen significant cuts to their public health budgets, which has severely impacted the capacity of preventative services. 

“Social conditions for many have failed to improve since the economic crisis, creating a perfect storm that encourages harmful health behaviours. This health challenge will only continue to worsen.” 

The IPPR calls for a “radical new prevention strategy” involving a renewed and increased commitment to the state’s role in preventing disease. 

“No longer can we place the burden of responsibility exclusively upon the individual, while turning a blind eye to a social environment which makes healthy lifestyles difficult to achieve. This means investing in public health and ensuring the government takes a greater responsibility to create a healthy environment.”

This is not exactly breaking news. I reviewed a book on the subject back in 2013, and Rupert Virchow, the author of this blog's catchphrase, said much the same thing almost 150 years ago.

New Zealand 'wellbeing' budget promises billions to care for most vulnerable

When you see what the Kiwis are proposing, you'll be gobsmacked that it makes so much sense—and you'll wonder what the hell is wrong with your own country. Via The Guardian: New Zealand 'wellbeing' budget promises billions to care for most vulnerable. Excerpt:

After more than a year of curiosity and speculation, New Zealand’s Labour coalition government has unveiled its “world-first” wellbeing budget, to widespread praise from social agencies charged with looking after the country’s most vulnerable people. 

The finance minister, Grant Robertson, unveiled billions for mental health services and child poverty as well as record investment in measures to tackle family violence. 

“Success is making New Zealand both a great place to make a living, and a great place to make a life,” Robertson told parliament. 

He said many New Zealanders were not benefitting from a growing economy in their daily lives, and this year’s budget had been designed to address the growing disparity between the haves and have-nots. According to predictions by the International Monetary Fund, the economy is expected to grow at about 2.5 % in 2019 and 2.9% in 2020. 

Although comparable countries such as the UK have begun to measure the national rate of wellbeing, New Zealand is the first western country to design its entire budget based on wellbeing priorities and instruct its ministries to design policies to improve wellbeing.

As expected, mental health received the biggest funding and investment boost on record, receiving NZ$1.9bn (£980m). Half a billion was earmarked for the “missing middle” particularly – New Zealanders suffering from mild to moderate anxiety and depressive disorders that did not require hospitalisation but significantly affected their quality of life. 

Close to half a billion would be spent on new frontline mental health workers stationed in doctor’s surgeries and Indigenous clinics, with the government aiming to help 325,000 people with “mild to moderate” mental health and addiction needs by 2023/24. 

Mental Health experts described the government’s focus on mental health as “ambitious”, and expressed excitement and relief that improving the mental health of New Zealanders across the board was finally becoming a priority, as year on year the New Zealand suicide rate continued to climb. 

“Mental health is no longer on the periphery of our health system. It is front and centre of all of our wellbeing,” said Robertson. 

Prime minister Jacinda Ardern said for her, the issue of mental health was “deeply personal”. “Almost all of us have lost friends or family members. Ensuring that New Zealanders can now just show up to their GP or health centre and get expert mental health support is a critical first step.”  

Measures to combat family violence also received a record investment of $320m, in a bid to tackle the country’s entrenched family and sexual violence statistics, which see the police respond to a domestic violence incident every four minutes.

Firearms as a public health hazard for young brown and black men

Via The Lancet Public Health, a quietly appalling report: Geospatial, racial, and educational variation in firearm mortality in the USA, Mexico, Brazil, and Colombia, 1990–2015: a comparative analysis of vital statistics data. The summary:

Background 

Firearm mortality is a leading, and largely avoidable, cause of death in the USA, Mexico, Brazil, and Colombia. We aimed to assess the changes over time and demographic determinants of firearm deaths in these four countries between 1990 and 2015. 

Methods 

In this comparative analysis of firearm mortality, we examined national vital statistics data from 1990–2015 from four publicly available data repositories in the USA, Mexico, Brazil, and Colombia. We extracted medically-certified deaths and underlying population denominators to calculate the age-specific and sex-specific firearm deaths and the risk of firearm mortality at the national and subnational level, by education for all four countries, and by race or ethnicity for the USA and Brazil. Analyses were stratified by intent (homicide, suicide, unintentional, or undetermined). We quantified avoidable mortality for each country using the lowest number of subnational age-specific and period-specific death rates. 

Findings 

Between 1990 and 2015, 106·3 million medically-certified deaths were recorded, including 2 472 000 firearm deaths, of which 851 000 occurred in the USA, 272 000 in Mexico, 855 000 in Brazil, and 494 000 in Colombia. Homicides accounted for most of the firearm deaths in Mexico (225 000 [82·7%]), Colombia (463 000 [93·8%]), and Brazil (766 000 [89·5%]). Suicide accounted for more than half of all firearm deaths in the USA (479 000 [56·3%]). 

In each country, firearm mortality was highest among men aged 15–34 years, accounting for up to half of the total risk of death in that age group. During the study period, firearm mortality risks increased in Mexico and Brazil but decreased in the USA and Colombia, with marked national and subnational geographical variation. Young men with low educational attainment were at increased risk of firearm homicide in all four countries, and in the USA and Brazil, black and brown men, respectively, were at the highest risk. 

The risk of firearm homicide was 14 times higher in black men in the USA aged 25–34 years with low educational attainment than comparably-educated white men (1·52% [99% CI 1·50–1·54] vs 0·11% [0·10–0·12]), and up to four times higher than in comparably-educated men in Brazil, Colombia, and Mexico.

In the USA, the risk of firearm homicide was more than 30 times higher in black men with post-secondary education than comparably educated white men. 

If countries could achieve the same firearm mortality rates nationally as in their lowest-burden states, 1 777 800 firearm deaths at all ages and in both sexes could be avoided, including 1 028 000 deaths in men aged 15–34 years. 

Interpretation 

Firearm mortality in the USA, Mexico, Brazil, and Colombia is highest among young adult men, and is strongly associated with race and ethnicity, and low education levels. Reductions in firearm deaths would improve life expectancy, particularly for black men in the USA, and would reduce racial and educational disparities in mortality.

Liberia post Ebola: Ready for another outbreak?

Via The Lancet, an excellent report: Liberia post Ebola: ready for another outbreak? Excerpt:

Comfort Gbainsay is huddled on a bed under a mosquito net at the CB Dunbar Maternity Hospital in Gbarnga, a small city about a 3 hours' drive from Liberia's capital Monrovia. A few days ago, she started feeling weak. She had stomach cramps and was breathing fast. At the hospital, she was diagnosed with stomach ulcers and typhoid fever. The 37-year old is 3 months' pregnant. 

The ward is veiled in darkness. With a torch in one hand and a spoon in the other, Gbainsay is eating her dinner from a plastic container. There are not enough funds to run the hospital generators 24 h a day, so electricity is scheduled. This will be her third child, says Gbainsay. Her large eyes look exhausted, her voice is muted. She gave birth to her other two children at CB Dunbar, but back then, she says, she did not have to pay for any of her medication. 

CB Dunbar is a government hospital and therefore drugs and services should be free. The National Health and Social Welfare Policy 2011–2021 focuses on an essential package of health services, and the country has set itself the goal of reaching universal health coverage. However, the coverage index for essential health services lies at 34, the target value being 100. Gbainsay has already spent more than LRD3000, or around US$18, on medication during her stay, a third of her monthly income as a teacher. 

“The drugs that were here, they gave me; the ones that were not here, they told me to go out and buy”, she says. One of the prescribed medicines is out of stock at all pharmacies in Gbarnga and she had to send her husband to Monrovia to buy it. 

“Everything is becoming very difficult because of, I don't know, the economic condition or because of the new president”, she says. “Over the past year, things that we easily used to do just can't be done easily nowadays. If you don't have money, things don't work for you.” 

The new president Gbainsay is referring to is ex-footballer George Weah, who was sworn in as head of state in January, 2018. Voters had high expectations and hoped he would rein in corruption, kick-start the economy, alleviate poverty, and rebuild the health system after the Ebola outbreak of 2014–15, which killed 4810 people in Liberia, including almost 180 health workers. When the haemorrhagic fever struck, the health sector was on a slow path to recovery after years of brutal civil war that had ended in 2003. 

However the new president has other priorities, as he highlighted in his second annual message in January, of this year. “…I have set my eyes on roads as my administration's path to delivering a better living condition for the Liberian people”, he said and added that good road connectivity will, among other things, “reduce travel times to schools and hospitals”. Health care was otherwise barely touched upon.

Uneven access to health services drives life expectancy gaps: WHO

A WHO news release: Uneven access to health services drives life expectancy gaps. Excerpt:

• Where women can access health services, maternal deaths decrease, lengthening women’s life expectancy.  

• In many circumstances, men access health care less than women. 

• Men are much more likely to die from preventable and treatable noncommunicable diseases and road traffic accidents. 

• 18.1-year gap in life expectancy between poorest and richest countries. 

Women outlive men everywhere in the world – particularly in wealthy countries. The World Health Statistics 2019 – disaggregated by sex for the first time – explains why.  

“Breaking down data by age, sex and income group is vital for understanding who is being left behind and why,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“Behind every number in the World Health Statistics is a person, a family, a community or a nation. Our task is to use these data to make evidence-based policy decisions that move us closer to a healthier, safer, fairer world for everyone.”  

The gap between men’s and women’s life expectancy is narrowest where women lack access to health services. In low-income countries, where services are scarcer, 1 in 41 women dies from a maternal cause, compared with 1 in 3300 in high-income countries. In more than 90 per cent of low-income countries, there are fewer than 4 nursing and midwifery personnel per 1000 people.  

Attitudes to healthcare differ. Where men and women face the same disease, men often seek health care less than women.  In countries with generalized HIV epidemics, for example, men are less likely than women to take an HIV test, less likely to access antiretroviral therapy and more likely to die of AIDS-related illnesses than women. Similarly, male TB patients appear to be less likely to seek care than female TB patients.  

The report also highlights the difference in causes of death between men and women – some biological, some influenced by environmental and societal factors, and some impacted by availability of and uptake of health services.  

Of the 40 leading causes of death, 33 causes contribute more to reduced life expectancy in men than in women. In 2016, the probability of a 30-year-old dying from a noncommunicable disease before 70 years of age was 44% higher in men than women. 

Global suicide mortality rates were 75% higher in men than in women in 2016. Death rates from road injury are more than twice as high in men than in women from age 15, and mortality rates due to homicide are 4 times higher in men than in women. 

Published to coincide with World Health Day on 7 April, which this year focuses on primary health care as the foundation of universal health coverage, the new WHO statistics highlight the need to improve access to primary health care worldwide and to increase uptake. 

“One of WHO’s triple billion goals is for 1 billion more people to have universal health coverage by 2023,” said Dr. Tedros. “This means improving access to services, especially at community level, and making sure those services are accessible, affordable, and effective for everyone – regardless of their gender.”

UK: Life expectancy gap widens between rich and poor women

Via The Guardian: Life expectancy gap widens between rich and poor women. Excerpt:

The life expectancy of women in the poorest parts of England has fallen by three months, while that of women in the wealthiest areas rose by almost as much, new figures show. 

There was a drop of 98 days in life expectancy at birth among women in the most deprived areas between 2012-14 and 2015-17, according to the Office for National Statistics (ONS). Life expectancy for women in the least deprived areas rose by almost 84 days, representing a divergence of around half a year in the length of the lives of the poorest and wealthiest women.  

Overall, life expectancy at birth between 2015 and 2017 for women living in the most deprived areas of England was 78.7 years, compared with 86.2 years for those in the least deprived areas – a gap of around seven and a half years.  

Among men, life expectancy for those in the most deprived parts of England was 74 years, compared with 83.3 years in the least deprived areas – a gap of nearly 10 years. The discrepancy between men in the richest and poorest areas had widened by about three months, but this was driven by a faster rise in life expectancy for the wealthy, while figures remained flat or fell slightly for the most impoverished. 

Widening inequality, austerity-fuelled cuts to health and social care, increasing job insecurity, access to good food and hunger could all be playing a role in the increasing differences in life expectancy, suggested Faiza Shaheen, the director of the Class thinktank.

“For a long time, of course, growing life expectancy has been a sign of society progressing, so if that’s reversing, and we have seen this for the last few years now, then we have got some serious questions to ask ourselves about what progress looks like,” Shaheen said. “One hundred days is a lot. A lot of people would love to have just one more day with their loved ones.”

Socioeconomic inequality in recent adverse mortality trends in Scotland

Via bioRxiv, more evidence that inequality is harmful to your health, especially if you're at the bottom of the ladder: Socioeconomic inequality in recent adverse mortality trends in Scotland. The abstract:

Background: 

Gains in life expectancies have stalled in Scotland, as in several other countries, since around 2012. The relationship between stalling mortality improvements and socioeconomic inequalities in health is unclear. 

Methods: 

We calculate the percentage improvement in age-standardised mortality rates (ASMR) in Scotland overall, by sex, and by Scottish Index of Multiple Deprivation (SIMD) quintile and gender, for two periods: 2006-2011 and 2012-2017. We then calculate the socioeconomic gradient in improvements for both periods. 

Results: 

Between 2006 and 2011, ASMRs fell by 10.6% (10.1% in females; 11.8% in males), but between 2012 and 2017 ASMRs only fell by 2.6% (3.5% in females; 2.0% in males). The socioeconomic gradient in ASMR improvement more than quadrupled, from 0.4% per quintile in 2006-2011 (0.7% in females; 0.6% in males) to 1.7% (2.0% in females; 1.4% in males). Within the most deprived quintile, ASMRs fell in the 2006-2011 period (8.6% overall; 7.2% in females; 9.8% in males), but rose in the 2012-2017 period (by 1.5% overall; 0.7% in females; 2.1% in males). 

Conclusion: 

As mortality improvements in Scotland stalled in 2012-2017, socioeconomic gradients in mortality became steeper, with increased mortality rates over this period in the most socioeconomically deprived fifth of the population.

When the gig economy become a public health issue

An opinion piece in The Globe and Mail: When the gig economy become a public health issue. This is not news to anyone who follows the social determinants of health, but it may be a shock to some the Globe's more affluent readers. Excerpt and then a comment:

Another day, another dollar, right? Not exciting maybe, maybe not that fun either, but at least predictable. 

Having a job that provides a paycheque at regular intervals is a source of comfort, while not having one is a source of stress. Today, an increasing number of workers get that dollar some days but for one reason or another, some days they do not. As a result, they may be more or less employed, but stressed all at the same time. Income instability is becoming the reality for many, and with that instability comes worry and strain – and maybe health consequences as well. 

There is indeed evidence to suggest that income volatility is hazardous to your health. A new study published in the journal Circulation had researchers tracking data for nearly 4,000 individuals in the United States starting from the age of 23 through to 35. Looking at income levels five times over that span, they also monitored individuals’ medical records during the same period. 

Their findings showed that individuals with the biggest fluctuations in personal income had nearly twice the risk of death and more than twice the risk of heart problems such as strokes and cardiac arrest as compared with those with more stable incomes. Their conclusion: The trend toward fluctuating incomes poses a threat to public health.

See also my review of Dying for a Paycheck, an excellent book on the stress involved even in regular employment.

India: The persistent influence of caste on under-five mortality

Via bioRxiv: The persistent influence of caste on under-five mortality: Factors that explain the caste-based gap in high focus Indian states. The abstract:

Objective: Although under-five mortality (U5M) is declining in India, it is still high in a few selected states and among the scheduled caste (SC) and scheduled tribe (ST) population of the country. This study re-examines the association between castes and U5M in high focus Indian states following the implementation of the country's National Rural Health Mission (NRHM) program. In addition, we aim to quantify the contribution of socioeconomic determinants in explaining the gap in U5M between the SC/ST population and non-SC/ST population in high focus states in India. 

Data and method: Using data from the National Family Health Survey (NFHS), we calculated the under-five mortality rate (U5MR) by applying a synthetic cohort probability approach. We applied a binary logistic regression model to examine the association of U5M with the selected covariates. Further, we used Fairlie's decomposition technique to understand the relative contribution of socioeconomic variables on U5M risk between the caste groups. 

Findings: In high focus Indian states, the parallel gap in U5M between well-off and deprived caste children has disappeared in the post-NRHM period, indicating a positive impact in terms of reducing caste-based inequalities in the high focus states. Despite the reduction in U5M, particularly among children belonging to STs, children belonging to the SC and ST population still experience higher mortality rates than children belonging to the non-SC/ST population from 1992 to 2016. Both macro level (district level mortality rates) and individual (regression analysis) analyses showed that children belonging to SCs experience the highest likelihood of dying before their fifth birthday. 

A decomposition analysis revealed that 78% of the caste-based gap in U5M is due to the effect of women's level of educational attainment and household wealth between the SC/ST and non-SC/ST population. Program indicators such as place of delivery and number of antenatal care (ANC) visits also contributed significantly to widening caste-based gaps in U5M. 

Conclusion: The study indicates that there is still scope to improve access to health facilities for mothers and children belonging to deprived caste groups in India. Continuous efforts to raise the level of maternal education and the economic status of people belonging to deprived caste groups should be pursued simultaneously.