H5N1

Effect of economic recession and impact of health and social protection expenditures on adult mortality

Via The Lancet Global Health, an important study: Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities. The summary:

Background 

Economic recession might worsen health in low-income and middle-income countries with precarious job markets and weak social protection systems. Between 2014–16, a major economic crisis occurred in Brazil. We aimed to assess the association between economic recession and adult mortality in Brazil and to ascertain whether health and social welfare programmes in the country had a protective effect against the negative impact of this recession. 

Methods 

In this longitudinal analysis, we obtained data from the Brazilian Ministry of Health, the Brazilian Institute for Geography and Statistics, the Ministry of Social Development and Fight Against Hunger, and the Information System for the Public Budget in Health to assess changes in state unemployment level and mortality among adults (aged ≥15 years) in Brazil between 2012 and 2017. Outcomes were municipal all-cause and cause-specific mortality rates for all adults and across population subgroups stratified by age, sex, and race. 

We used fixed-effect panel regression models with quarterly timepoints to assess the association between recession and changes in mortality. Mortality and unemployment rates were detrended using Hodrick–Prescott filters to assess cyclical variation and control for underlying trends. We tested interactions between unemployment and terciles of municipal social protection and health-care expenditure to assess whether the relationship between unemployment and mortality varied. 

Findings 

Between 2012 and 2017, 7 069 242 deaths were recorded among adults (aged ≥15 years) in 5565 municipalities in Brazil. During this time period, the mean crude municipal adult mortality rate increased by 8·0% from 143·1 deaths per 100 000 in 2012 to 154·5 deaths per 100 000 in 2017. An increase in unemployment rate of 1 percentage-point was associated with a 0·50 increase per 100 000 population per rter (95% CI 0·09–0·91) in all-cause mortality, mainly due to cancer and cardiovascular disease. 

Between 2012 and 2017, higher unemployment accounted for 31 415 excess deaths (95% CI 29 698–33 132). All-cause mortality increased among black or mixed race (pardo) Brazilians (a 0·46 increase [95% CI 0·15–0·80]), men (0·67 [0·22–1·13]), and individuals aged 30–59 years (0·43 [0·16–0·69] per 1 percentage-point increase in the unemployment rate. 

No significant association was identified between unemployment and all-cause mortality for white Brazilian, women, adolescents (aged 15–29 years), or older and retired individuals (aged ≥60 years). In municipalities with high expenditure on health and social protection programmes, no significant increases in recession-related mortality were observed. 

Interpretation 

The Brazilian recession contributed to increases in mortality. However, health and social protection expenditure seemed to mitigate detrimental health effects, especially among vulnerable populations. This evidence provides support for stronger health and social protection systems globally.

No cause identified for death of children in Bihar, India

Via The Lancet: No cause identified for death of children in Bihar, India. Excerpt:

Since June 1, Bihar in eastern India, known for its lush lychee orchards, has been in the news because almost 150 children in Muzaffarpur and adjoining districts have died from an illness that many experts call acute encephalitis syndrome, a blanket term for several neurological manifestations. 

There is no definitive epidemiological diagnosis of these deaths as yet, but local reports suggest that several factors could be responsible, including a toxin that can be found in lychees, extreme heat and humidity, child malnutrition, and an ill-equipped public health system that could not offer timely treatment. The children who died were from very poor families, and most deaths have been attributed to hypoglycaemia. 

Bouts of recurring acute encephalopathy have been reported in Bihar since 1995. A Lancet Global Health study found that these outbreaks are “associated with both hypoglycin A and [methylenecyclopropylglycine] toxicity from lychee consumption” and that “this illness is also associated with absence of an evening meal”. 

“Muzaffarpur is a poor district with a cluster of significant risk factors for widespread child undernutrition—the available data from the National Family Health Survey highlights this very clearly”, Purnima Menon, a senior research fellow at the International Food Policy Research Institute's Poverty, Health and Nutrition Division, told The Lancet. “While we await the epidemiological diagnoses, at this point in time, it seems very much like this cluster of child deaths is very similar to what occurred in the same district in previous years.” 

T Jacob John, a retired virology professor from the Christian Medical College, Vellore, Tamil Nadu, who, along with colleagues, had investigated the disease in Muzaffarpur during outbreaks in 2012, 2013, and 2014, says the children would not have died had they not gone to sleep on an empty stomach. 

“The lychee is not the primary cause”, John told The Lancet. “You have to fix the primary health-care system and the gross malnutrition. No child from a well-to-do family has ever suffered because he or she ate lychees.”

US: ‘Urgent needs from head to toe’: This clinic had two days to fix a lifetime of needs

Via The Washington Post: ‘Urgent needs from head to toe’: This clinic had two days to fix a lifetime of needs. Excerpt:

CLEVELAND, TENN. — They were told to arrive early if they wanted to see a doctor, so Lisa and Stevie Crider left their apartment in rural Tennessee almost 24 hours before the temporary medical clinic was scheduled to open. They packed a plastic bag with what had become their daily essentials after 21 years of marriage: An ice pack for his recurring chest pain. Tylenol for her swollen feet. Peroxide for the abscess in his mouth. Gatorade for her low blood sugar and chronic dehydration. 

They took a bus into the center of Cleveland, Tenn., a manufacturing town of 42,000, and slept for a few hours at a budget motel. Then they awoke in the middle of the night and walked toward the first-come, first-served clinic, bringing along a referral from a social worker for what they hoped would be their first doctor’s checkup in more than four years. 

“Urgent needs from head to toe,” the social worker had written. “Lacking primary care and basic medication. They have fallen into the gap.” 

 Only when Stevie and Lisa arrived at the clinic a little after 2 a.m. did it occur to them how large that medical gap has become in parts of rural America. Dozens of people were sprawled out in sleeping bags on the asphalt parking lot. Others had pitched tents on an adjacent lawn. The lot was already filled with more than 300 cars from all over the rural South, where a growing number of people in medical distress wait for hours at emergency clinics in order to receive basic primary care. 

Tennessee has lost 14 percent of its rural physicians and 18 percent of its rural hospitals in the past decade, leaving an estimated 2.5 million residents with insufficient access to medical care. The federal government now estimates that a record 50 million rural Americans live in what it calls "health care shortage areas," where the number of hospitals, family doctors, surgeons and paramedics has declined to 20-year lows.

What’s arrived in their place are sporadic free clinics such as the one in Cleveland, where a nonprofit agency called Remote Area Medical brought in a group of doctors, nurses and other volunteers for the weekend to transform the local high school into a makeshift hospital. There would be a triage station in the entryway, bloodwork in the science lab, kidney scans in the gym, dental extractions in the cafeteria, and chest X-rays in the parking lot — a range of medical care that would be available for only two days, until the clinic packed up and moved on to Hazard, Ky., and then Weatherford, Okla. 

“We’ll do as much as we can for as many as we can,” a clinic volunteer promised as she patrolled the parking lot late at night and handed out numbers to signify each patient’s place in the line. No. 48 went to a woman having panic attacks from adjacent Meigs County, where the last remaining mental-health provider had just moved away to Nashville. No. 207 went to a man with unmanaged heart disease from Polk County, where the only hospital had gone bankrupt and closed in 2017.

A growing lack of trust in authority poses a serious danger to our health

Via The Guardian, a thoughtful and insightful article: A growing lack of trust in authority poses a serious danger to our health. Excerpt:

Virtually every Bangladeshi and Rwandan believes that vaccines are safe. Fewer than half of Japanese or French do so. In western Europe, almost one in six of those with college education reject vaccines. In southern Africa, you’re twice as likely to do so if you attended university. 

These are among the often disturbing facts that tumble out of a new study, the Wellcome Global Monitor, published last week. A survey of 140,000 people from 140 countries, it is at heart an exploration of the relationship between science, trust and attitudes to vaccination.  

Trust has become a vital political issue. Many worry about the erosion of confidence both in expertise and in public institutions and about the social consequences of that erosion. One is the growing refusal to believe medical authority, especially about vaccination. From measles outbreaks in America and Europe to the spread of Ebola in central Africa, scepticism about vaccines has had a devastating impact.

The Wellcome survey suggests that the relationship between scientific and social trust and attitudes to vaccination is more complex than many imagine. One might think, for instance, that better scientific education and greater confidence in healthcare professionals would be linked to greater trust of vaccines. It isn’t. There tends to be greater scepticism about vaccines in richer, better-educated countries than in poorer states in which people have less education and are more sceptical about the benefits of science.  

Western Europe shows some of the highest levels of trust in both scientists and healthcare professions: 88% have “high” or “medium” trust in scientists, 68% have “a lot” of trust in medical professionals and 78% believe that science benefits people like them. But, with the sole exception of eastern Europe, western Europe also has the lowest level of trust in the world in vaccines.  

Compare this with north Africa. Here, just 61% have trust in scientists, medical professionals are trusted “a lot” by less than a third of the population and fewer than half think that science benefits people like them. Yet whereas only 59% of western Europeans believe that vaccines are safe, 85% of north Africans do so. 

In low-income countries, 81% of even those with low trust in scientists have confidence in vaccines. In rich countries, that figure drops to less than half. 

Poor countries remain ravaged by diseases long eliminated from western nations. Globally, some 2.5 million children under five die every year from vaccine-preventable diseases. In countries such as Bangladesh and Rwanda, vaccination programmes have helped transform the lives of millions. In richer countries, medical advances, including vaccines, have been so effective that many no longer recognise their importance or the consequences of rejection.  

There are, however, deeper problems than just a lack of historical memory. Trust is shaped by myriad social forces. Inequality is one. According to the Wellcome report, the more unequal a nation, the greater the distrust of science. In both rich and poor countries, those whose lives are more precarious are more sceptical of science than those who say they are “living comfortably”, a trend particularly pronounced in rich nations.  

There is also the question of the relationship between scientific and political trust. According to Wellcome: “The level of confidence people have in their national institutions – their government, judicial system and military – was a good predictor of their level of trust in science.”

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.”