H5N1

Unravelling the commercial determinants of health

Via The Lancet, an editorial: Unravelling the commercial determinants of health. Excerpt:

In early March, in the wake of the COVID-19 pandemic, nearly 200 people—including former UN Secretary-General Ban Ki-moon—signed a letter strongly criticising pharmaceutical companies for putting a desire to make extraordinary profits before the needs of humanity. Selling publicly funded vaccines, treatments, and tests to the highest bidder resulted in inequities that cost more than a million lives, while private companies made billions of dollars. The signatories called on world leaders to ensure that such an injustice is never repeated.  

The conflict between profits and health equity is not new. The global health community fought for decades to provide access to antiretrovirals for patients with HIV/AIDS in less-resourced settings. Many commercial actors attempt to negatively influence national and international policies, undermine science, or to directly attack individuals calling out their actions. The recent Lancet Series on breastfeeding showed how an extensive network of lobbying by formula milk companies has derailed progress on breastfeeding education. 

This history speaks to the central importance to health equity of the commercial determinants of health, the subject of a Series published in this issue of The Lancet, led by Rob Moodie of the University of Melbourne, along with authors spanning 15 countries and six continents, with the support of the Victorian Health Promotion Foundation of Australia.  

The headline findings are startling: four industries (tobacco, unhealthy food, fossil fuel, and alcohol) are responsible for at least a third of global deaths per year. Yet much of the work to understand the harmful (or beneficial) impact of commercial actors has to date been done in health research silos. Each field faces many of the same tactical battles and strategies without a unified agenda to protect health. There is a lack of consensus across fields of health to define and understand the commercial determinants of health.  

The Lancet Series seeks to remedy this long-standing and complex situation with a consensus definition of the commercial determinants of health (“systems, practices, and pathways through which commercial actors drive health and equity”), a framing to understand commercial entities' impact on health, and a commitment to address its challenges in a holistic way.  

The Series authors set out a bold vision in which governments, commercial actors, and civil society contribute first and foremost to improving health and societal wellbeing. Such a vision is needed urgently. As the second paper in the Series outlines, commercial actors are diverse and many play a vital role in society, but the products and practices of many are having increasingly negative impacts on human and planetary health and equity.  

The Series provides a comprehensive agenda for action, recognising the need for regenerative business models and accountable transparent policies (including an end to commercial actors opposition to health regulation and policies).  

Moodie emphasises that the Series is not anti-business; it is pro-health. There are some notable good models of pro-health-acting businesses. For example, nearly 200 leading financial institutions (which together manage more than US$16 trillion) have signed a pledge to support tobacco-free policies across lending, investment, and insurance. However, although Environmental, Social and Governance frameworks are increasingly used to guide more responsible investment, they still lack specific health indicators.  

Health needs to become a crucial consideration of investor frameworks and global capital markets. Doing so will require the adoption of different economic models, new legislative and regulatory measures, civil society advocacy and accountability, and better corporate social responsibility. Governments must be empowered to encourage businesses to prioritise positive health impacts.  

As Tedros Adhanom Ghebreyesus, WHO Director-General, writes in an accompanying Comment, public health cannot progress without action on the commercial determinants of health. The Lancet welcomes the upcoming WHO Congress and first Annual Report on the commercial determinants of health, especially in helping to address non-communicable diseases. Given their huge unresolved impacts, the commercial determinants of health must be recognised—and funded—as a crucial field of research.

The Lancet Series on racism, xenophobia, discrimination, and health

Via The Lancet: The Lancet Series on racism, xenophobia, discrimination, and health. The executive summary: 

Racism, xenophobia, and discrimination exist in every modern society causing avoidable disease and premature death among groups who are often already disadvantaged.

This Series examines how the historic systems and structures of power and oppression, and discriminatory ideologies have shaped policy and practice today, and are root causes of racial health inequities. 

Furthermore, by applying a global lens and intersectional framework, overlapping forms of oppression such as age, gender, and socioeconomic status and their impact on discrimination are analysed. Interventions to address the spectrum of drivers of adverse health outcomes with a focus on the structural, societal, legal, human right, institutional and system level are reviewed. 

Research recommendations and key approaches for moving forward are proposed.

Symptoms and risk factors for long COVID in non-hospitalized adults

Via Nature Medicine: Symptoms and risk factors for long COVID in non-hospitalized adults. The abstract:

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. 

We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. 

A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02–8.39), hair loss (3.99, 3.63–4.39), sneezing (2.77, 1.40–5.50), ejaculation difficulty (2.63, 1.61–4.28) and reduced libido (2.36, 1.61–3.47). 

Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. 

SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

This article in The Guardian is likely only the first of many to discuss these findings.

Will COVID force public health to confront America's epic inequality?

Via Nature, an important article by Amy Maxmen: Will COVID force public health to confront America's epic inequality? Excerpt:

On a hazy day in November, Hardeep Singh received a text message from the COVID-19 testing system at Foster Farms poultry company saying that his mother had tested positive for the coronavirus.  

He got the alert because his mother, a 63-year-old line worker at one of the company’s meat-packing plants in California’s San Joaquin Valley, doesn’t speak English and doesn’t own a smartphone.  

Singh couldn’t reach her as she continued to handle chicken parts alongside her co-workers. Her supervisors didn’t tell her, either. In fact, they assigned her more shifts for the week.  

Singh broke the news to her that evening, and convinced her not to return to work, where she might spread the infection to others. But he couldn’t reach anyone at the company for another five days, to ask whether she qualified for paid time off while she isolated.  

Singh’s mother ended up being among the more than 400 employees at the plant who were diagnosed with COVID-19 last year, and one of about 90,000 cases linked to food-production facilities and farm work across the United States. Because the sector feeds Americans and powers part of the US economy, agricultural workers such as Singh’s mother have been considered essential workers during the COVID-19 pandemic.  

That important role comes at a cost. One study1 found that food and agricultural workers in California had an almost 40% increased risk of dying last year, compared with the state’s general population. And within that imbalance lies another contrast. Latinx food and agriculture workers experienced a nearly 60% increase in deaths compared with previous years; the increase for white workers was just 16%.  

The reasons for such disparities, say public-health researchers, include discrimination, low wages, limited labour protections and inadequate access to health care, affordable housing and education. These are some of the ‘social determinants of health’, a concept that has been around for at least 150 years, but which has gained recognition during the pandemic.

Cracks in the foundation: How COVID-19 showed our failures

Via The Lancet, a review by Mary T. Bassett: Cracks in the foundation: how COVID-19 showed our failures.

In 1963, James Baldwin, one of the USA's greatest essayists, published The Fire Next Time. The book's title comes from a slave song—”God gave Noah the rainbow sign/No more water but the fire next time”. Baldwin's words sounded a warning that the USA needed to confront its racial hierarchy by embracing racial equality or doom its future.  

Sandro Galea's book, The Contagion Next Time, is titled in a homage to Baldwin and it also sounds a warning. Galea's central argument is that vulnerability to COVID-19 lies with a societal failure to recognise that the foundation of health rests on a healthy everyday life and not simply in the provision of health care. He ponders why this key lesson is not at the centre of pandemic discourse, which instead focuses on vaccination and treatment. In often lyrical prose, Galea roams across history, culture, literature, moral values, economics, politics, and personal pandemic experience. Although situated in a global context, the book's focus is the USA. Galea considers especially the enduring impacts of racism on health and the centrality of structural racism to understanding the USA.  

Globally, there were more than 6 million COVID-19 deaths by early April, 2022. Amid this carnage, few have asked why, if this novel virus was the spark, there was so much dry grass. The Contagion Next Time is suffused with Galea's anguish that failure to grapple with this question will cost more lives. Worse, the world may fare even more poorly when the next contagion arrives.

After the omicron (B.1.1.529) surge, which occurred after this book was written, the USA is now approaching a staggering 1 million COVID-19 deaths. An analysis in 2021 by the Lancet Commission on public policy and health in the Trump era, to which both Galea and I contributed, found that about 40% of US COVID-19 deaths “could have been averted had the US death rate mirrored the weighted average of the other G7 nations”. In February, 2022, the per capita cumulative COVID-19 death rate in the USA exceeded that of other wealthy nations and during omicron placed the USA in a league all its own. Just what is going on?  

Galea, who is Dean of the Boston University School of Public Health, USA, seeks the answers with erudition and passion. He begins with reflections of an array of relevant data. But most of the book reads as a journey towards understanding why the USA has fared so poorly. The answers have little to do with the scientific breakthroughs that brought us COVID-19 vaccines in such record time.  

Galea points to the US obsession with individualism, making achievement of health a personal project, rather than a collective one, and an attachment to technology that has given priority to medical care over public health. He also posits widespread lack of compassion, which erodes solidarity. Galea does not shrink from naming an aversion to complexity in some quarters that made policy making difficult in the pandemic. COVID-19 demanded high-impact decisions that rested on imperfect, incomplete information. A lack of humility may also have contributed to at times contradictory public pronouncements. And there is a failure to confront racism (embedded in the founding of the USA), marginalisation, and socioeconomic inequality.  Galea ends by observing that choosing health will mean “reorienting our social, economic and political priorities” to support our collective wellbeing.  

But there are questions that go unasked and unanswered. Just why would a belief that medical care creates health persist, faced with decades of public health thinking that has shown the minor share of population health attributable to clinical care? The WHO Commission on Social Determinants of Health began its 2008 final report, “Social justice is a matter of life and death.” It would seem time to ask, who benefits from these unhealthy arrangements?  

And there are answers. At their root lies an unfettered pursuit of profit that is not good for health. The US departure from the health performance of its peer nations began in around 1980 as market-oriented policies triumphed. Nicholas Freudenberg in his book At What Cost: Modern Capitalism and the Future of Health confronts directly how with present predatory capitalism in the USA there is widespread damage to the public's health. Haven’t we seen this also with COVID-19? Millions lost their jobs while the stock market flourished. Income inequality increased as life expectancy plunged precipitously among racially marginalised groups in the USA. Meanwhile, equitable access to COVID-19 treatments and vaccines is not a reality for many people in low-income and middle-income countries. Debates continue over patent protections.  

The impact of anti-communism in the USA has limited interrogation of capitalism. But the USA is a capitalist country. Nearly 60 years ago, Baldwin sounded the alarm for the enduring harm of racism to the future of the USA, a lesson which Galea has amplified. Perhaps a more courageous book that contemplates the next contagion would go a step further in sounding the alarm for the health effects of modern capitalism.

Changes in life expectancy between 2019 and 2021: United States and 19 peer countries

Via medRxiv: CHANGES IN LIFE EXPECTANCY BETWEEN 2019 AND 2021: UNITED STATES AND 19 PEER COUNTRIES. The abstract" 

BACKGROUND Prior studies reported large decreases in US life expectancy during 2020 as a result of the COVID-19 pandemic, disproportionately affecting Hispanic and Black populations and vastly exceeding the average change in life expectancy in other high-income countries. Life expectancy estimates for 2021 have not been reported. This study estimated changes in life expectancy during 2019-2021 in the US population, in three US racial/ethnic groups, and in 19 peer countries.  

METHODS US and peer country death data for 2019-2021 were obtained from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. The 19 peer countries included Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland. Life expectancy was calculated for 2019 and 2020 and estimated for 2021 using a previously validated modeling method.  

RESULTS US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.40 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years. 

The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.  

DISCUSSION The US mortality experience during 2020 and 2021 was more severe than in peer countries, deepening a US disadvantage in health and survival that has been building for decades. Over the two-year period between 2019 and 2021, US Hispanic and non-Hispanic Black populations experienced the largest losses in life expectancy, reflecting the legacy of systemic racism and inadequacies in the US handling of the pandemic. 

Reasons for the crossover in racialized outcomes between 2020 and 2021, in which life expectancy decreased only in the non-Hispanic White population, could have multiple explanations.

Marmot: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented

Via The Guardian, Sir Michael Marmot writes: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented. Excerpt:

Dignity. It is fundamental to who we are and our place in society. One way to deprive people of the opportunity to lead dignified lives is to take away the means to meet their material needs. It is undignified to have to resort to food banks to feed your children; to wear two coats indoors against the cold; to plead against eviction because of an inability to pay the rent; to deny children a birthday party because of cost.  

The poorest people in the UK are about to experience a fresh wave of such indignities. These psycho-social assaults will be joined by the physical ill-effects of poverty.  

My life’s work has been studying the relationship between social conditions and inequalities in health. In the UK, a decade of austerity damaged public health and made health equity worse. But the cost of living crisis – and the chancellor’s failure to deal with it – is unprecedented, with its threats to the health and wellbeing of the nation. A 54% rise in the energy price cap will now mean an average household will pay £1,971 a year for gas and electricity, at the same time that council tax, water bills and car tax are all increasing. In October, a further rise pushing the annual energy bill up to £2,300 is expected.  

The typical working-age household will, according to the Resolution Foundation, experience a 4% fall in income, £1,100, in 2022-23. Surely, one might think, 4% is scarcely noticeable, hardly a matter of life and death? It is if you are on the margins.  

The Resolution Foundation gives the example of a single parent, with one child, working 20 hours a week at a low-to-medium wage. In September 2021, this person might have had an income of £18,265. The precipitate removal of the universal credit boost will have reduced income by £1,040. The cost of living rise to September 2022 will take another £1,198 off income. With the chancellor’s changes to taxes and allowances, and salary increases, this person’s income in September 2022 will be £17,681 – £584 less than it was a year earlier. (By contrast, a couple working full-time, both at the median wage, will see their net income fall by 1%, £392.)  

Inflation of more than 8%, and the government’s failure to deal with the cost of living crisis for the poorest people – an unemployed single person will see a 15% drop in income – will put an extra 1.3 million people, including 500,000 children, below the poverty line.

Mortality rates by college degree before and during COVID-19

Via the National Bureau of Economic Research, a paper by Anne Case and Angus Deaton: Mortality Rates by College Degree Before and During COVID-19. Click through to download the paper. The abstract:

It is now established that mortality and excess mortality from COVID-19 differed across racial and ethnic groups in 2020. Less is known about educational differences in mortality during the pandemic. We examine mortality rates by BA status within sex, age, and race/ethnic groups comparing 2020 with 2019. 

Mortality rates have increasingly differed by BA status in the US in recent years and there are good reasons to expect the gap to have widened further during the pandemic. Using publicly available provisional data from the National Center for Health Statistics we find that mortality rates increased in 2020 over 2019 for those with and without a BA, irrespective of age, sex, or race/ethnicity. Although mortality rates increased by more for those without a BA, the ratio of mortality rates for those with and without a BA changed surprisingly little from 2019 to 2020. The BA was protective against mortality prior to the pandemic, and it was equally protective during the pandemic. 

Among 60 groups (sex by race/ethnicity by age) that are available in the data, the ratio of mortality rates of those without a BA to those with a BA fell for more than half of the groups. Our results suggest that differences in the risk of infection were less important in structuring mortality by education than differences in the risk of death conditional on infection.

Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study

Via The Lancet Regional Health: Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study. The summary:

Background  

Ethnically diverse and socio-economically deprived communities have been differentially affected by the COVID-19 pandemic in the UK.  

Method  

Using a multilevel regression model we assessed the time-varying association between SARS-CoV-2 infections and areal level deprivation and ethnicity from 1st of June 2020 to the 19th of September 2021. We separately considered weekly test positivity rate and estimated debiased prevalence at the Lower Tier Local Authority (LTLA) level, adjusting for confounders and spatio-temporal correlation structure.  

Findings  

Comparing the least deprived and predominantly White areas with most deprived and predominantly non-White areas over the whole study period, the weekly positivity rate increases from 2·977% (95% CrI 2.913%-3.029%) to 3·347% (95% CrI 3.300%-3.402%). Similarly, prevalence increases from 0·369% (95% CrI 0.361%-0.375%) to 0·405% (95% CrI 0.399%-0.412%). Deprivation has a stronger effect until October 2020, while the effect of ethnicity becomes more pronounced at the peak of the second wave and then again in May-June 2021. In the second wave of the pandemic, LTLAs with large South Asian populations were the most affected, whereas areas with large Black populations did not show increased values for either outcome during the entire period under analysis.  

Interpretation  

Deprivation and proportion of non-White populations are both associated with an increased COVID-19 burden in terms of disease spread and monitoring, but the strength of association varies over the course of the pandemic and for different ethnic subgroups. The consistency of results across the two outcomes suggests that deprivation and ethnicity have a differential impact on disease exposure or susceptibility rather than testing access and habits.

Vastly unequal US has world’s highest Covid death toll – it’s no coincidence

Via The Guardian: Vastly unequal US has world’s highest Covid death toll – it’s no coincidence. Excerpt:

The US has suffered 900,000 deaths from Covid-19, the highest figure of any nation. The death toll would be equivalent to the 15th most populous city in the country, more than San Francisco, Washington DC or Boston – a city of ghosts with its population swelling each day.  

It’s not just the total numbers. America also has the highest death rate of any wealthy country, with half of the deaths occurring after vaccines became available.  

The US has never responded to the Covid pandemic in a sustained, proactive way as a unified nation. Instead, much of the responsibility – and blame – has fallen on individuals. In a country with vast income inequality, poor health and sharp political divides, the results have been grim.  

“All of those factors put people at higher risk of Covid death,” said Megan Ranney, emergency physician and academic dean of public health at Brown University.  

Vaccinations, in particular, have lagged, especially compared with other wealthy countries. The health system was already precarious when it began to be battered by wave after wave of Covid.  

Other countries with similarly high death tolls earlier in the pandemic have seen fewer fatalities from the Omicron variant – yet in the US, the Omicron death toll is surpassing the Delta wave of autumn 2021. Last month was one of the deadliest of the entire pandemic.  

Meanwhile, American leaders are attempting to mimic other countries’ return to normal, despite a markedly different situation with hospitalizations and deaths – which, every day, nearly reach the losses from the September 11 terrorist attacks.  

“The first and most obvious [issue] is our vaccination and booster rate,” said Ranney. “Our rate of vaccination, period, is lower than in most other high-income countries, and our booster rate is lower as well. And as ample CDC data proves, vaccines and boosters are tremendously effective at protecting against death, even with Omicron.”  

Less than two-thirds – about 64% – of Americans are vaccinated, and only 48% of those are boosted, despite ample vaccine supply. 

“For a country which has a vaccines-only strategy, we’re not very good at vaccination,” said William Hanage, associate professor of epidemiology at the Harvard TH Chan School of Public Health and co-director of the Center on Communicable Disease Dynamics. “There are large parts of the country which are not vaccinated to higher levels … and that’s made worse by the fact that with Omicron, to get really good protection, you also need to be boosted.”  

Problems with access to vaccines linger, too. Better-off people have had plenty of opportunities to be vaccinated, but those in poorer households still struggle to get vaccines – and time off to recover from any side effects. Some 15% to 20% of unvaccinated Americans say they are still interested in getting their shots, Hanage said – they simply haven’t been able to yet.  

Meanwhile, poorer unvaccinated people also face a “double whammy” because they are also more likely to contract Covid, he said.