H5N1

COVID-19 deaths among US clinicians

Via JAMA Network: COVID-19 Deaths Among US Clinicians.

More than 100 000 US health care personnel have contracted coronavirus disease 2019 (COVID-19) since February and at least 641 have died, according to a report by health officials from the CDC and several states. 

Based on data reported to the CDC between February 12 and July 16, the report reflects a 10-fold increase in cases among personnel at health care facilities since the last CDC analysis in April. At that time, nearly 10 000 COVID-19 cases and 27 deaths had been reported. The authors note that the current total likely underestimates the true number of cases among health care personnel because occupational status was available for fewer than one-quarter who had COVID-19. 

Among nearly 7000 health care personnel with COVID-19 for whom workplace data were available, two-thirds worked in nursing homes or residential care facilities. About one-third of almost 6000 cases with their occupation reported occurred among health care support workers—nursing assistants, medical assistants, and other providers or aides. Nurses accounted for 29% and physicians for about 3% of cases. Among nonclinical staff, 581 administrative staff and 330 environmental health workers contracted the disease. 

Health worker deaths from COVID-19 were most common among men, those aged 65 years or older, and Asian or Black adults. Ninety-two percent of those who died had an underlying health condition compared with 41% of workers who survived. More than half of those who died had cardiovascular disease or diabetes; one-third had both.  

The authors recommended ensuring universal mask use in health care settings, screening for illness before entering the workplace, granting nonpunitive sick leave policies, and recognizing the social inequities that put some workers at higher risk in the workplace and at home. 

“Ensuring adequate allocation of PPE [personal protective equipment] to all [health care personnel] in the workplace is one important approach to mitigating systemic inequalities in COVID-19 risk,” the authors wrote.

'Diseases of despair' skyrocket in America

Via HealthDay.com: 'Diseases of Despair' Skyrocket in America. Excerpt:

TUESDAY, Nov. 10, 2020 (HealthDay News) -- Even before the coronavirus pandemic began, Americans were already suffering: A new study reports that alcohol and drug misuse were up dramatically, and suicidal thoughts and behaviors were up 170% between 2009 and 2018. 

Researchers call these conditions "diseases of despair."  

"The origin of these conditions isn't strictly medical. Rather, they seem to follow conditions of despair in people's lives and communities," explained study author Emily Brignone. She's a senior research scientist with Highmark Health in Pittsburgh, Penn. 

Economic decline, stagnant wages, fewer community ties and unemployment are some of the factors she said can be linked to diseases of despair.  

"Over the past 10 years, diagnoses related to drug and alcohol misuse and suicidal thoughts and behaviors have increased across the board for men and women in all age groups," Brignone noted. 

The information in this study was collected long before COVID-19 began spreading across the United States. But Brignone said the pandemic may worsen conditions related to diseases of despair, like unemployment, social isolation, barriers to health care and uncertainty.  

"There is some evidence of COVID-19-related changes in diseases of despair, including increases in opioid overdoses and high numbers of people reporting suicidal thoughts. However, we won't know the full extent of the impact of COVID-19 on diseases and deaths of despair for many years to come," Brignone said.  

The new study included 12 million Americans insured by Highmark, a large U.S.-based health insurance company. The people covered by the company are concentrated in Pennsylvania, West Virginia and Delaware. These are states that have been disproportionately affected by deaths of despair, according to the researchers. 

Almost one in 20 people in the study were diagnosed with a disease of despair during the study period. 

The biggest increases were seen in suicidal thoughts and behaviors, particularly in young people. Suicidal thinking and behaviors rose by 287% between 2009 and 2018 in people under 18 years of age. For those between 18 and 34, the rate increased by 210%. For all other age groups, there was a rise of at least 70% in suicidal thoughts and behaviors, the findings showed.  

"We don't fully understand why this is happening. Some researchers have pointed to changing social structures and the rise of smartphones and social media. There are also questions about the role of bullying and less sleep. But it is a complex issue without easy answers," Brignone said.  

Alcohol problems increased in all age groups, except for those under 18. The biggest jump (59%) in alcohol misuse was seen in people between the ages of 55 and 74.  

Brignone said a number of things might trigger greater alcohol misuse later in life, including increases in health conditions, pain, mental health concerns, and increased disconnection from family, friends and neighbors. She also noted that alcoholism and the other diseases of despair often occur together.  

Older Americans (aged 55 to 74) also had the largest increase in substance misuse, with an increase of 172% during the study. The overall prevalence of substance-related diagnosis increased by 94%. 

Men had nearly 50% higher odds of being diagnosed with a disease of despair than women were, the researchers reported.

US: The COVID-19 racial data tracker

A screenshot from covidtracking.com: The COVID Racial Data Tracker:

I wish Canada reported similar data.

The COVID-19 syndemic is not global: Context matters

A letter in The Lancet: The COVID-19 syndemic is not global: context matters.

Richard Horton recently called COVID-19 a syndemic. He aptly used this concept to describe how COVID-19 clusters with pre-existing conditions, interacts with them, and is driven by larger political, economic, and social factors. 

Calling COVID-19 a global syndemic is misguided. Syndemics matter because they focus on what drives diseases to cluster and interact. What is driving coronavirus to move through the population in the USA and interact with biological and social factors, however, differs from other contexts. US political failures have driven COVID-19 morbidity and mortality, and this cannot be divorced from our historical legacy of systemic racism4 or our crisis of political leadership.  

This matters because in other contexts COVID-19 is not syndemic. New Zealand's political leadership in response to the crisis has been exemplary. COVID-19 is not syndemic there. 

In this sense, syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases. Recognising contexts are different matters a great deal. For instance, contexts throughout sub-Saharan Africa are doing much better than the most burdened contexts, like the USA, Brazil, and India. Many people have questioned, why? Some have argued that this reflects a racist frame thinking that African contexts should suffer more. Yet, many African governments acted more swiftly and confidently than wealthier countries. The political leadership in these contexts, therefore, prevented the extensive death tolls, compared to contexts like the UK and the USA, where political leadership failed. 

Recognising political determinants of health is central to the syndemic construct. By calling the COVID-19 syndemic global, we miss the point of the concept entirely. 

I do not write this to dampen Horton's use of the term, as I believe COVID-19 is syndemic in my country (the USA). This is precisely because pre-existing conditions such as hypertension, diabetes, respiratory disorders, systemic racism, mistrust in science and leadership, and a fragmented health-care system have driven the spread and interacted with the virus. These synergistic failures have caused more death and devastation than many other contexts. 

Recognising failures of wealthy countries is imperative as we think about where global knowledge and power sit within fields like global health. Syndemic frames provide us with an opportunity to do this.

Richard Horton: Reasons for hope

In The Lancet, its editor Richard Horton writes: Offline: Reasons for hope.

Fatigue. Despair. Misery. Cracks are beginning to appear in our mental resilience. 10 months of this calamity. How much more can we bear? It was always so. When the Bishop of Winchester died of plague in 1626, John Milton issued a searing cry of anguish in his Elegia Tertia. The great poet was just 17 years old, “sad...with no companion, and many sorrows clung to my soul”. He sought to commemorate this “grim killing” of a revered literary figure, a “dreadful death, fearsome with her sepulchral torch”. “Why does it please you”, Milton asked, “to stain your hands with human slaughter, and to have sharpened sure arrows against a noble breast, and to have driven a half-divine soul from its home?” 

It would be easy to sink into despondency. Governments are struggling. The public is restless. We need hope. There was one buoyant piece of news last week. The UK's National Health Service (NHS) committed itself to becoming the world's first carbon net zero health system by 2040. WHO's Director-General, Tedros Adhanom Ghebreyesus, welcomed the news, noting that “Health is leading the way to a greener, safer planet.” The NHS has appointed Nick Watts, who has blazingly led The Lancet's Countdown on Health and Climate Change, as its first Chief Sustainability Officer. This news is certainly one reason for hope.

As Laura Spinney pointed out in her history of the 1918 influenza pandemic, Pale Rider (2017), humanity was left transformed once the infection ebbed. Out of tragedy came regeneration. “The 1918 pandemic accelerated the pace of change in the first half of the twentieth century, and helped shape our modern world.” Societies bounced back. The 1920s ushered in a new era of intellectual and artistic creativity. Governments embraced health and made it an explicit political priority—“The state of a nation's health came to be seen as an index of its modernity or civilisation.” The conditions for universal health care were created. There was a “psychological shift” across the world. Although we are still in the midst of a dreadful coronavirus syndemic, if we lift our gaze we can see a better future ahead, a future that is up to us to define. Our societies can revive, stronger, smarter, and kinder. The first step is to reinvigorate our conversation about what tomorrow should look like. That conversation has started.  

Fran Baum and Sharon Friel recently proposed the need for a social as well as a biological vaccine to solve the challenge of COVID-19. They argued in the Medical Journal of Australia that we need to go beyond a biomedical vision for solving this syndemic. By a social vaccine, they mean “a metaphor designed to shift the dominant biomedical orientation of the health sector towards the underlying distal factors that cause disease and suffering”. 

They set our four foundational requirements for health—a life with security, opportunities that are fair, a planet that is habitable and supports biodiversity, and governance that is just. Each of these requirements determines the components of a social vaccine. A life with security demands a universal system to guarantee social protection, employment, and shelter; progressive taxation; and international treaties to ensure peace and security. 

Opportunities that are fair include (at a minimum) universal and free education; racial, sex, and disability discrimination laws; decent jobs; and environments that enable healthy choices. A planet that is habitable requires a zero carbon future; protection of biodiversity; and elimination of fossil fuel subsidies. Finally, governance that is just means a universal franchise; robust systems of political accountability; and strong civil society organisations, protected by legislation. 

They write, inspiringly, that, “A global social vaccine will enable a new way of living that is healthy, just, convivial, and sustainable, and will inoculate future society against a return to a world growing increasingly less healthy, sustainable, and equal.” 

Or turn to Rene Loewenson and colleagues who wrote a powerful call to reclaim a comprehensive public health in BMJ Global Health last month—“Biosecurity is not equal to public health”, they insisted. 

Something is stirring in the heart of our society. In health, the debate about our future is intensifying. Old assumptions are being questioned. New directions are being proposed. Amid the carnage of COVID-19, a renaissance of hope is emerging. It's time to join the conversation about the world to come.

My own thoughts on the world to come are here.

Women are excluded from global COVID-19 coverage, experts say

This baffles me, because I rely so heavily on women who are health experts. Via The Washington Post: Women are excluded from global coronavirus coverage, experts say. Excerpt:

On a Canadian Broadcasting Corporation program earlier this month, a debate between two physicians over coronavirus-related restrictions turned into a brief clash over the role of gender in mainstream discourse. “

You’re just shouting; you’re not actually speaking,” infectious-disease expert Neil Rau told his female colleague, interrupting.  

“Do not be sexist,” family doctor and medical anthropologist Nili Kaplan-Myrth responded, not missing a beat. “I’m speaking in an assertive voice.”  

“NEVER tell a woman (professional or otherwise) that she cannot speak with authority,” she wrote later on Twitter. “NEVER tell us we aren’t educated enough, experts enough, or good enough. We have every bit as much authority to speak.”  

The exchange underscored a broader concern over the lack of female voices in media coverage of and policy debates on the coronavirus pandemic. 

In coverage of the coronavirus, female scientists and doctors are cited far less frequently than their male counterparts, according to multiple multicountry studies. And when women are vocal, as with other policy debates and key areas of coverage, they often face online harassment and second-guessing of their expertise, several female scientists told The Washington Post. 

The consequences are far-reaching. The marginalization of female experience and expertise colors the information available to policymakers forming coronavirus responses — which means interests and issues important to women may get underprioritized. This dynamic has, according to a recent study commissioned by the Bill and Melinda Gates Foundation, perpetuated a “war framing” around the virus, reinforcing the gendered stereotype that men are more reliable in emergencies and as decision-makers.  

Marginalized voices 

Since reports of the novel coronavirus began circulating in January, the world has been inundated with news and perspectives. Male scientists and physicians have played an outsize role in global efforts to make sense of the virus. 

“The pandemic exacerbated the lack of women’s voices,” said Muge Cevik, who works on infectious diseases and medical virology at the University of St. Andrews in Scotland. “It just reinforced the prevailing gender norm in which men continue to be allocated to leadership roles, speaking to media.” 

Last month’s Gates Foundation report, written by audience researcher Luba Kassova, analyzed coronavirus coverage published in mainstream publications online in the United Kingdom, the United States, Kenya, South Africa, Nigeria and India. The study focused on articles identified by Google’s news search engine as highly ranked between March 1 and April 15. It found that women are “worryingly marginalized.” On average, every female voice in a coronavirus story was “drowned out” by at least three male interviewees, the study concluded. 

“Women were four times less likely to feature as experts and commentators” in stories on the coronavirus, the study found. When cited, “women are more likely to be used as sources sharing subjective views than experts sharing authoritative expertise,” according to the report. Women constituted 19 percent of experts quoted overall and were less likely to feature as protagonists in coronavirus stories.  

The trend has been documented elsewhere. A report published last month by the French Ministry of Culture and the ministry responsible for gender equality found that during the country’s coronavirus lockdown this spring, “newspapers devote[d] a predominant place to male personalities in their content.” More than 83 percent of the people pictured on the front page of major newspapers during this period were men, who also wrote a majority of opinion pieces. 

A recent University of Zurich study calculated that women made up two of the 30 scientists most frequently cited by the Swiss media in coronavirus coverage during the first half of the year. 

The experiences of female scientists and medical experts echo across sectors. Statistically, few women are part of national-level decision-making processes on the coronavirus, although 69 percent of health professionals around the globe are women. For working mothers and women from minority and marginalized communities, many disparities are growing even deeper amid school and economic disruptions.  

“There are lots of women who are working really hard [on coronaviruses-related research] and they don’t make it into the media or policy advisories,” said Emma Hodcroft, one of the two female scientists among the group most widely cited in Switzerland, who studies and tracks viruses at the University of Basel.

Covid-19 ravages Navajo Nation as Trump makes election play for area

Via The Guardian: Covid ravages Navajo Nation as Trump makes election play for area. Excerpt:

Last spring, the Covid-19 pandemic struck the Navajo Nation worse than just about anywhere else in the United States or the rest of the world. Infections on the country’s largest American Indian reservation soared, reaching the highest per capita rate in the US in May. 

“Our people out here were hit very hard, and it spread like wildfire in our community,” said Jeff Begay, a business consultant living in the tiny community of Navajo Mountain, Utah. 

Begay, who is Navajo, said federal aid on the reservation has been slow and ineffective. More than 550 people on the reservation have died from Covid-19. Even in remote Navajo Mountain, Begay said there was an outbreak of four cases at a nearby church earlier in the pandemic.  

In mid-May, the Nation’s infection rate was 2,304 cases per 100,000 people – one in every 43 Navajos on the reservation had contracted Covid-19. As help from the federal government lagged, nonprofits like Doctors Without Borders stepped in to fill the void. 

Normally known for providing medical aid in war zones, the organization launched a rare US operation on the Navajo Nation, sending a team of medical professionals to help with infection prevention and offer technical support in health facilities. 

The conditions that are allowing the coronavirus to ravage the Navajo Nation – from poverty to poor healthcare to inadequate water infrastructure – are the result of decades of federal policies that have left the reservation’s living standards behind those of every US state. And under the Trump administration, they have remained the same or gotten worse.  

Unemployment and poverty are rampant. A third of families on the Nation don’t have running water, making hand-washing difficult. Many Navajo households are multigenerational and in hard-to-reach areas, giving the virus an easier path to vulnerable elders living far from health services.

Measuring equity from the start: Disparities in the health development of US kindergartners

Via Health Affairs: Measuring Equity From The Start: Disparities In The Health Development Of US Kindergartners. The abstract:

Racialized disparities in health and well-being begin early in life and influence lifelong health outcomes. Using the Early Development Instrument—a population-level early childhood health measure—this article examines potential health inequities with regard to neighborhood income and race/ethnicity in a convenience sample of 183,717 kindergartners in ninety-eight US school districts from 2010 to 2017. 

Our findings demonstrate a distinct income-related outcome gradient. Thirty percent of children in the lowest-income neighborhoods were vulnerable in one or more domains of health development, compared with 17 percent of children in higher-income settings. Significantly higher rates of income-related Early Development Instrument vulnerability—defined as children falling below the tenth-percentile cutoff on any Early Development Instrument domain—were demonstrated for Black/African American and Hispanic/Latinx children. 

These findings underscore the utility of the Early Development Instrument as a way for communities to measure child health equity gaps and inform the design, implementation, and performance of multisector place-based child health initiatives. 

More broadly, results indicate that for the US to make significant headway in decreasing lifelong health inequities, it is important to achieve health equity by early childhood.

Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging

Via The Gerontologist: Intersectionality and inequalities in medical risk for severe COVID-19 in the Canadian Longitudinal Study on Aging. Excerpt:

Background and Objectives 

Older populations with underlying medical conditions are at higher risk of COVID-19 severity and mortality once infected. Intersectional gerontology considers the compounding effects of multiple forms of social inequity. This study explores how racial-nativity status, family income, education level and the intersecting profile of these three social standings stratify differential patterns of chronic conditions among Canadians aged 45 years and older.  

Research Design and Methods 

Using the baseline Canadian Longitudinal Study on Aging (n = 29,748), multinomial logistic regression analyses were conducted to estimate multivariable-adjusted odds of having one and/or two (≤ 2) or multiple (≥3) medical conditions (i.e., diabetes, asthma, cancer, previous heart attack, cardiovascular disease, kidney disease, hypertension, chronic obstructive pulmonary disease, and obesity) based on socio-demographic characteristics.  

Results 

There were significant racial-nativity disparities and social-class gradients in multimorbidity. The odds of having ≥3 medical conditions were greater for Black immigrants (OR=1.79, 95% CI=1.13, 2.82), South Asian immigrants (OR=1.49, 95% CI=1.02, 2.19) and close to double for Aboriginal Canadians (OR=1.96, 95% CI=1.37, 2.80) relative to Canadian-born Whites. Black, South Asian and Aboriginal populations from disadvantaged socioeconomic backgrounds had the highest odds of having ≥3 medical conditions (OR=3.50, 95% CI=1.41, 8.70).  

Discussion and Implications 

Despite a universal health system, marginalized older Canadians who are racialized foreign-born, less educated, and/or low-income have a higher prevalence of multimorbidity that are associated with COVID-19 severe illness and mortality. Upstream health policy and social care tackling intersecting structural inequities should be undertaken to prevent increasing multimorbidity among underserved aging populations.

Horton: COVID-19 is not a pandemic

In The Lancet, editor Richard Horton makes an important point: Offline: COVID-19 is not a pandemic.

As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. 

But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. 

COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. 

The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. 

A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. 

Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. 

Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” 

I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. 

Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.