H5N1

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. 

Socioeconomic disparities associated with 29 common infectious diseases in Sweden, 2005–14

Via The Lancet Infectious Diseases: Socioeconomic disparities associated with 29 common infectious diseases in Sweden, 2005–14: an individually matched case-control study. The summary:

Background 

Although the association between low socioeconomic status and non-communicable diseases is well established, the effect of socioeconomic factors on many infectious diseases is less clear, particularly in high-income countries. We examined the associations between socioeconomic characteristics and 29 infections in Sweden. 

Methods 

We did an individually matched case-control study in Sweden. We defined a case as a person aged 18–65 years who was notified with one of 29 infections between 2005 and 2014, in Sweden. Cases were individually matched with respect to sex, age, and county of residence with five randomly selected controls. We extracted the data on the 29 infectious diseases from the electronic national register of notified infections and infectious diseases (SmiNet). We extracted information on country of birth, educational and employment status, and income of cases and controls from Statistics Sweden's population registers. We calculated adjusted matched odds ratios (amOR) using conditional logistic regression to examine the association between infections or groups of infections and place of birth, education, employment, and income. 

Findings 

We included 173 729 cases notified between Jan 1, 2005, and Dec 31, 2014 and 868 645 controls. Patients with invasive bacterial diseases, blood-borne infectious diseases, tuberculosis, and antibiotic-resistant infections were more likely to be unemployed (amOR 1·59, 95% CI 1·49–1·70; amOR 3·62, 3·48–3·76; amOR 1·88, 1·65–2·14; and amOR 1·73, 1·67–1·79, respectively), to have a lower educational attainment (amOR 1·24, 1·15–1·34; amOR 3·63, 3·45–3·81; amOR 2·14, 1·85–2·47; and amOR 1·07, 1·03–1·12, respectively), and to have a lowest income (amOR 1·52, 1·39–1·66; amOR 3·64, 3·41–3·89; amOR 3·17, 2·49–4·04; and amOR 1·2, 1·14–1·25, respectively). By contrast, patients with food-borne and water-borne infections were less likely than controls to be unemployed (amOR 0·74, 95% CI 0·72–0·76), to have lower education (amOR 0·75, 0·73–0·77), and lowest income (amOR 0·59, 0·58–0·61). 

Interpretation 

These findings indicate persistent socioeconomic inequalities in infectious diseases in an egalitarian high-income country with universal health care. We recommend using these findings to identify priority interventions and as a baseline to monitor programmes addressing socioeconomic inequalities in health.

US: A disaster for American healthcare

Via The New York Times: Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional. Excerpt, and then a response to the decision:

WASHINGTON — A federal judge in Texas struck down the entire Affordable Care Act on Friday on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it. 

The ruling was over a lawsuit filed this year by a group of Republican governors and state attorneys general. A group of intervening states led by Democrats promised to appeal the decision, which will most likely not have any immediate effect. But it will almost certainly make its way to the Supreme Court, threatening the survival of the landmark health law and, with it, health coverage for millions of Americans, protections for people with pre-existing conditions and much more. 

In his ruling, Judge Reed O’Connor of the Federal District Court in Fort Worth said that the individual mandate requiring people to have health insurance “can no longer be sustained as an exercise of Congress’s tax power.”  

Accordingly, Judge O’Connor, a George W. Bush appointee, said that “the individual mandate is unconstitutional” and the remaining provisions of the Affordable Care Act are invalid.  

At issue was whether the health law’s insurance mandate still compelled people to buy coverage after Congress reduced the penalty to zero dollars as part of the tax overhaul that President Trump signed last December.  

When the Supreme Court upheld the mandate as constitutional in 2012, it was based on Congress’s taxing power. Congress, the court said, could legally impose a tax penalty on people who do not have health insurance.  

But in the new case, the plaintiffs, led by Texas, argued that with the penalty zeroed out, the individual mandate had become unconstitutional — and that the rest of the law could not be severed from it. 

The Justice Department’s response to the case was highly unusual: though it disagreed with the plaintiffs that the entire law should be struck down, it declined this year to defend not just the individual mandate, but the law’s provisions that protect people with pre-existing conditions. That prompted a coalition of 16 states and the District of Columbia, led by California, to intervene and defend the law. 

On Friday night, a spokeswoman for Xavier Becerra, the California attorney general, said California and the other defendant states would challenge the ruling with an appeal in the United States Court of Appeals for the Fifth Circuit in New Orleans.

The American Medical Association has published this response:

CHICAGO – The American Medical Association (AMA) released the following statement after the federal district court in the Northern District of Texas sided with the plaintiff, striking down popular key provisions of the Affordable Care Act (ACA).

“Today’s decision is an unfortunate step backward for our health system that is contrary to overwhelming public sentiment to preserve pre-existing condition protections and other policies that have extended health insurance coverage to millions of Americans,” said AMA president Barbara L. McAneny, M.D. “It will destabilize health insurance coverage by rolling back federal policy to 2009. No one wants to go back to the days of 20 percent of the population uninsured and fewer patient protections, but this decision will move us in that direction.”

The AMA will work with patient and other health stakeholder groups in pursuing an appeal and reversal of this unfortunate decision at the district court level.

The AMA led an amicus brief in June that urged the court to reject the challenge. Additional organizations joined the AMA in filing the amicus brief, including the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry. Download or view the amicus brief.

Dissecting the life expectancy gap in England provides clues on how to reduce it

Via The Lancet Public Health: Dissecting the life expectancy gap in England provides clues on how to reduce it. Excerpt:

Major health inequalities in countries such as England have been well documented for decades. Arguably, the problem has been sufficiently described for action to be taken. However, James Bennett' and colleagues' study of the life expectancy gap between socioeconomic groups in England, published in The Lancet Public Health, shows that, on the contrary, there is still much to learn about health inequalities from descriptive analysis of routine mortality data. 

Bennett and colleagues' study of vital registration data from the Office of National Statistics provides a detailed understanding of the contribution of different causes of death to the inequality gap and a dynamic view of the gap and its components over a 15-year period. Can it really be that no one has published a study quite like this before? Surprisingly, yes. 

One reason for this gap in the literature is that the objective of the study is methodologically demanding. There are more than half a million deaths per year in England, but when broken down into the various subcategories—not just by sex and 5-year age groups, but also by deprivation decile, multiple individual causes, and single calendar years—the number of events in the many cells quickly becomes very small. To overcome this problem, the authors used a Bayesian hierarchical model to produce stable estimates for the multitude of individual results generated. This is such a powerful technique in their hands that it seems obvious that it should be used more routinely in this type of analysis. 

The other reason must be that, rather like her uniforms, the descriptive statistical approaches that Florence Nightingale pioneered in the 19th century have fallen out of fashion. With the outstanding exception of the Global Burden of Disease study, it is relatively rare these days to find descriptive studies published in high-impact-factor journals. 

The rise of so-called precision public health might change that because funders such as the Bill & Melinda Gates Foundation recognise the value of surveillance and sophisticated analysis of large datasets to inform interventions for population benefit. 

England has excellent vital registration data. We know, therefore, that there are big differences in life expectancy according to where people live—or, more correctly, where they die. It is still a shock to read that in 2016, life expectancy in England varied from 78·8 years (95% credible interval 78·7–78·9) in the most deprived areas to 86·7 years (86·6–86·8) in the most affluent areas for females and from 74·0 years (73·9–74·1) to 83·8 years (83·6–83·9) for males. The differences of 7·9 years (7·7–8·1) for females and 9·7 years (9·6–9·9) for males are roughly equivalent to the differences between life expectancy in the UK and that in Libya or Azerbaijan. 

Although life expectancy at birth improved in all deprivation deciles from 2001 to 2016, the gap between the top and bottom increased by 1·8 years for women and 0·7 years for men over that period. Since 2011, life expectancy has declined in the poorest parts of the country and stagnated in others. 

The most deprived group seems to be doing especially badly. The gap between the most deprived decile and its nearest neighbour is 1·5 years (1·4–1·7) for females and 2·2 years (2·0–2·3) for males, whereas the difference between the other ordered deciles is often just 0·5 years, particularly between the most affluent deciles.

Belluz: What the dip in US life expectancy is really about: Inequality

In Vox.com, Julia Belluz has a must-read report: What the dip in US life expectancy is really about: inequality. Click or tap through for the full article with excellent links, tables, and graphs. Excerpt:

Living in the US increasingly looks like a health risk. Average life expectancy in the country dropped for the third year in a row, according to recent data from the Centers for Disease Control and Prevention. That’s the longest downturn since the Spanish flu wiped out more than 50 million people a century ago. 

The grim trend stems from a toxic mixture of more drug- and alcohol-related deaths and more suicide in many parts of the country. And it puts Americans at a higher risk of early death compared to their counterparts in other wealthy countries. 

But what’s often lost in the conversation about the uptick in mortality in the US is that this trend isn’t affecting all Americans. In fact, there’s one group in the US that’s actually doing better than ever: the rich. While poor and middle-class Americans are dying earlier, the wealthiest among us are enjoying unprecedented longevity. 

So when we talk about life expectancy slipping, what we should also talk about is the growing problem of health inequality in America. And it’s an increasingly urgent discussion, health researchers are warning, because of policy changes on the horizon that are poised to make the mortality gap even wider. 

Some of these policies will hamper access to medical care (such as rescinding funding for CHIP, the health insurance program for low-income children) but others that aren’t even directly related to health care, like tax cuts, may have even more insidious effects on the American mortality gap. 

America’s alarming life expectancy gap 

The rich have long enjoyed more longevity than the poor, but the gap in life expectancy has been widening in the US over the past few decades, along with other types of social and income inequality.  

The CDC’s Division of Vital Statistics, which tracks mortality in the US, uses death certificates as the data source and doesn’t collect family income data. But we do have good data on the mortality gap and income from a study published in JAMA in 2016. 

A group of researchers, led by Stanford University economist Raj Chetty, analyzed income data for the US population from 1.4 billion tax records between 1999 and 2014. They then compared it with mortality data from Social Security Administration death records. They found that, from 2001 to 2014, the richest Americans gained about five years of longevity, while life expectancy for the poor didn’t budge.

US life expectancy declines again, a dismal trend not seen since World War I

Via The Washington Post: U.S. life expectancy declines again, a dismal trend not seen since World War I. Excerpt and then a comment:

Life expectancy in the United States declined again in 2017, the government said Thursday in a bleak series of reports that showed a nation still in the grip of escalating drug and suicide crises.  

The data continued the longest sustained decline in expected life span at birth in a century, an appalling performance not seen in the United States since 1915 through 1918. That four-year period included World War I and a flu pandemic that killed 675,000 people in the United States and perhaps 50 million worldwide.  

Public health and demographic experts reacted with alarm to the release of the Centers for Disease Control and Prevention’s annual statistics, which are considered a reliable barometer of a society’s health. In most developed nations, life expectancy has marched steadily upward for decades. 

“I think this is a very dismal picture of health in the United States,” said Joshua M. Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. “Life expectancy is improving in many places in the world. It shouldn’t be declining in the United States.”  

“After three years of stagnation and decline, what do we do now?” asked S.V. Subramanian, a professor of population health and geography at Harvard’s T.H. Chan School of Public Health. “Do we say this is the new normal? Or can we say this is a tractable problem?” 

Overall, Americans could expect to live 78.6 years at birth in 2017, down a tenth of a year from the 2016 estimate, according to the CDC’s National Center for Health Statistics. Men could anticipate a life span of 76.1 years, down a tenth of a year from 2016. Life expectancy for women in 2017 was 81.1 years, unchanged from the previous year.

Drug overdoses set another annual record in 2017, cresting at 70,237 — up from 63,632 the year before, the government said in a companion report. The opioid epidemic continued to take a relentless toll, with 47,600 deaths in 2017 from drugs sold on the street such as fentanyl and heroin, as well as prescription narcotics. That was also a record number, driven largely by an increase in fentanyl deaths. 

Since 1999, the number of drug overdose deaths has more than quadrupled. Deaths attributed to opioids were nearly six times greater in 2017 than they were in 1999.  

Deaths from legal painkillers did not increase in 2017. There were 14,495 overdose deaths attributed to narcotics such as oxycodone and hydrocodone and 3,194 from methadone, which is used as a painkiller. Those totals were virtually identical to the numbers in 2016. The number of heroin deaths, 15,482, also did not rise from the previous year.

God knows we in Canada (and especially Vancouver) have serious opioid death rates, but according to the Institute for Health Metrics and Evaluation, Canada's 2017 life expectancy for females is 84.0 years; for men, it's 79.9. Women's life expectancy has risen from 80.6 in 1990, and men's from 74.1 in 1990.

Rates of premature mortality are two times higher in the most deprived areas of England, compared to most affluent

Via the Institute for Health Metric and Evaluation at the University of Washington: Rates of premature mortality are two times higher in the most deprived areas of England, compared to most affluent. Excerpt:

Rates of premature mortality are two times higher in the most deprived areas of England (Blackpool), compared to the most affluent (Wokingham), according to a new comprehensive analysis of health at a local, national, and regional level across the UK. 

In addition, the study reveals the huge burden of disability linked to long-term conditions such as low back and neck pain, anxiety, and depression, highlighting the need for health services to adapt to managing these conditions.  

While overall rates of premature death have improved since 1990, half of all premature deaths in 2016 were linked to risk factors including tobacco use, unhealthy diet, alcohol and drug use, obesity, and high blood pressure, pointing to the urgent need for policies and programs targeting prevention, especially in areas outside the control of the health service.  

The study, from the Global Burden of Disease initiative, provides data on premature mortality, disability, and risk factors from 1990 to 2016 for 150 Upper-Tier Local Authority (UTLAs) in England, as well as Scotland, Northern Ireland, and Wales, with the aim of informing resource allocation and priorities at a local, regional, and national level. 

Years lived with disability exceed years of life lost 

Ischemic heart disease was the leading cause of premature death in the UK in 2016, and rates were two times higher in men than in women. Self-harm was the third leading cause of premature death for men.  

In England, Wales, and Northern Ireland (but not Scotland), the years lived with disability exceeded the years of life lost. Low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, sense organ disorders, and anxiety disorders were the leading causes of disability.

 “As death rates decrease, people continue to live with long-term, often multiple, conditions,” says Professor Nicholas Steel, lead author, University of East Anglia, UK. “Our findings show a significant shift from mortality to morbidity, yet our health services are still designed to deal with the big killers. Today, conditions such as back and neck pain and anxiety and depression are huge causes of disability in the UK.” 

Health and deprivation  

Rates of premature mortality from all causes were more than two times higher in the most deprived UTLAs in England (Blackpool), compared to the most affluent (Wokingham, Surrey, Windsor and Maidenhead, and West Berkshire). 

Rates of premature mortality were consistently higher for the 15 most deprived areas of England, compared to the 15 least deprived, and the association with deprivation was particularly strong for lung cancer and chronic obstructive pulmonary disease.

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.