H5N1

Fixing the crisis in public health

The Tyee has published my article Fixing the Crisis in Public Health. Excerpt:

After three years of pandemic and the turmoil it’s generated, Canada is looking a little the worse for wear. We may want to think it’s over, but 50,344 Canadians have died of COVID — 18,920 of them in 2022. As well, the winter of 2022-23 has put a brutal strain on health-care workers and their patients.

Meanwhile, Ottawa and the provinces have been growling at one another about health-care funding. Given the mess in the health-care system, they seem likely to come up with some kind of cost-sharing formula on Feb. 7, which may improve the situation.  

Dr. Theresa Tam, Canada’s chief public health officer, has made some excellent suggestions for improving the health-care system in her annual reports for 2021 and 2022. But I expect the politicians will ignore her.  

Health spending has been enormous since the pandemic began in 2020. According to the Canadian Institute for Health Information, total health spending in 2022 was expected to reach $331 billion, or $8,563 per capita. Hospitals got 24.6 per cent, physicians received 13.6 per cent, and 13.6 per cent of all health spending was for drugs.  

Strikingly, only 5.3 per cent of that was for public health.

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.

COVID-19: It ain’t over ’til it’s over

Via Science, an editorial by Editor in Chief H. Holden Thorp: It ain’t over ’til it’s over. Excerpt:

The Biden administration is sheepishly waving a checkered flag on the pandemic. If you look closely, you can see its members cringing as they do so. 

Chief Medical Advisor Anthony Fauci told the PBS Newshour that the United States was “out of the pandemic phase” and then walked it back, saying he meant that the “acute compo­nent” of the pandemic phase was over. President Biden attended the likely superspreading White House Corre­spondents’ Dinner last weekend but skipped cocktails and the meal, opting to just give his talk. Fauci avoid­ed the whole affair. 

Meanwhile, Vice President Harris continued to isolate after her positive COVID-19 test, and many members of Congress and the administra­tion announced positive test results as well. All of this happened while the White House allowed a renegade federal judge in Florida (where else?) to end the nationwide mask mandate without much of a fight. 

These mixed messages have been emanating from the administration for months now, and although those with resources have tools to manage COVID-19, care needs to be taken that those without such means are not forgotten. 

When Biden pledged to “follow the science,” it was hard to imagine that the country could have ended up here. But the administration made a big bet that vaccines would provide sterilizing immunity and end the pandemic, allowing it to move on to other priorities. 

Leaving behind the insanity of ivermectin, hydroxy­chloroquine, and bleach was certainly a great step forward. However, evolution has had other plans, and variants of severe acute respiratory syndrome corona­virus 2 (SARS-CoV-2, the virus that causes COVID-19) have kept the pandemic going. This left the White House in a very tight spot: There was little political will to keep pushing nonpharmaceutical interven­tions, yet the pandemic was far from over. Add to this mounting inflation worries and concerns about the war in Ukraine, and the response has been a clumsy pivot to a message that politicians always turn to: personal responsibility. 

Get vaccinated, get boosted, wear a mask, get a prescription for the antiviral Pax­lovid—if you want to. This may be fine if you have a healthy immune system, great health insurance, and the ability to navigate the US health care system. But what about everyone else? 

COVID-19 is at a similar place to where the HIV/AIDS global pandemic was when the antiretroviral drugs came along. Yale epidemiologist Gregg Gonsalves told me about important parallels between both pandem­ics. “The HIV epidemic didn’t go away,” he said. “It just went to where people could ignore it. It went into the rural South, it went to communities that were already facing disparities in health.” 

At that time, confusion between medicine and public health was also an im­portant factor. “The discourse shifting to private choice and private adjudication of risk is really not what public health science is,” he said. “We work in populations. And if we’re talking about medicine, it’s about private risk and private choices.”

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.

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.

A new study ties lifespans to wealth gaps in Greater Vancouver

The Tyee has published my latest article: A New Study Ties Lifespans to Wealth Gaps in Greater Vancouver. Excerpt:

We like to think of Greater Vancouver as one of the best places to live in Canada, if not in the world. Yes, it is — especially for those of us living in the most affluent neighbourhoods. Those in the poorest neighbourhoods, however, are dying younger than their rich neighbours, sometimes by many years. And the gap between them was getting wider even before the opioid-overdose crisis and the COVID-19 pandemic became twin health emergencies. 

That’s an easy conclusion to draw from a recent study published in the journal Health & Place. Of course it’s more complicated than that, but it still seems paradoxical that a region as prosperous as Greater Vancouver should see some people die years younger than others living just a few kilometres away.  

The study involved UBC researchers working with the Institute for Health Metrics and Evaluation at the University of Washington and with Imperial College, London. Its ambitious goal was to track life expectancy and major causes of deaths in Greater Vancouver over a quarter-century, from 1990 to 2016. Moreover, they broke the numbers down to the census-tract-level — in effect, neighbourhood by neighbourhood. Overall, the study offers an invaluable portrait of our collective health before the pandemic.  

In some ways, it’s a very flattering portrait. Even the poorest males, in the tenth percentile, had a median life expectancy in 2016 of 77.6; that is, half died before that age and half later. For tenth-percentile females, median life expectancy was 82.5.  

But in the 95th percentile, the richest five per cent of our population, median male life expectancy was 87.1. For females in the 90th percentile, it was 90.8. The poor were paying with almost a decade of their lives for the privilege of living here. 

 The study makes a striking observation: “Between 1991 and 2016, there was a downward trend in the LE [life expectancy] gap, whereby the lowest gap was observed in 2001 (6.9 years for females and 7.9 for males), but this reversed and increased by 1.4-1.6 years between 2001 and 2016.” By a wild coincidence, 2001 was the year the BC Liberals won a huge majority over the NDP and ran the province under Gordon Campbell and then Christy Clark until 2017.  

British researchers noticed a very similar effect during Margaret Thatcher’s years in power: Around 1980, British and Japanese life expectancy were about the same, but then, as the U.K. income gap widened, British lives grew shorter. In Japan, with a much narrower income gap, life expectancy rose to among the highest on the planet.  

What we’re dying of  

And what have Greater Vancouver residents been dying of? Between 1990 and 2016, deaths from cardiovascular diseases, neoplasms (cancers) and unintentional injuries dropped sharply. Clearly, we’ve been exercising more, smoking less, and taking care of ourselves, at least up to a point.  

But we’ve also seen a 10 per cent increase in neurological disorders, a catch-all term that can include everything from Alzheimer’s to eating disorders to meningitis. Other noncommunicable diseases like diabetes mellitus and kidney disease rose by almost four per cent.  

And while the richest of us had little to fear from infectious diseases in 1991, the poorest were already contending with (and dying from) HIV-AIDS and sexually transmitted infections at 12 times the rate as the richest. The poorest faced seven times the rate of maternal and neonatal disorders. They died of neoplasms at over four times the rate of the richest.

The police as public health crisis

Via The Lancet: Fatal police violence by race and state in the USA, 1980–2019: a network meta-regression. The summary and then a comment:

Background  

The burden of fatal police violence is an urgent public health crisis in the USA. Mounting evidence shows that deaths at the hands of the police disproportionately impact people of certain races and ethnicities, pointing to systemic racism in policing. Recent high-profile killings by police in the USA have prompted calls for more extensive and public data reporting on police violence. 

This study examines the presence and extent of under-reporting of police violence in US Government-run vital registration data, offers a method for correcting under-reporting in these datasets, and presents revised estimates of deaths due to police violence in the USA.  

Methods  

We compared data from the USA National Vital Statistics System (NVSS) to three non-governmental, open-source databases on police violence: Fatal Encounters, Mapping Police Violence, and The Counted. We extracted and standardised the age, sex, US state of death registration, year of death, and race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic of other races, and Hispanic of any race) of each decedent for all data sources and used a network meta-regression to quantify the rate of under-reporting within the NVSS. Using these rates to inform correction factors, we provide adjusted estimates of deaths due to police violence for all states, ages, sexes, and racial and ethnic groups from 1980 to 2019 across the USA.  

Findings  

Across all races and states in the USA, we estimate 30 800 deaths (95% uncertainty interval [UI] 30 300–31 300) from police violence between 1980 and 2018; this represents 17 100 more deaths (16 600–17 600) than reported by the NVSS. Over this time period, the age-standardised mortality rate due to police violence was highest in non-Hispanic Black people (0·69 [95% UI 0·67–0·71] per 100 000), followed by Hispanic people of any race (0·35 [0·34–0·36]), non-Hispanic White people (0·20 [0·19–0·20]), and non-Hispanic people of other races (0·15 [0·14– 0·16]). This variation is further affected by the decedent's sex and shows large discrepancies between states. Between 1980 and 2018, the NVSS did not report 55·5% (54·8–56·2) of all deaths attributable to police violence. When aggregating all races, the age-standardised mortality rate due to police violence was 0·25 (0·24–0·26) per 100 000 in the 1980s and 0·34 (0·34–0·35) per 100 000 in the 2010s, an increase of 38·4% (32·4–45·1) over the period of study.  

Interpretation  

We found that more than half of all deaths due to police violence that we estimated in the USA from 1980 to 2018 were unreported in the NVSS. Compounding this, we found substantial differences in the age-standardised mortality rate due to police violence over time and by racial and ethnic groups within the USA. Proven public health intervention strategies are needed to address these systematic biases. State-level estimates allow for appropriate targeting of these strategies to address police violence and improve its reporting.

Canada is not much different. We have used our police, including the well-marketed Royal Canadian Mounted Police, to suppress Indigenous and other minority peoples, with increasingly poor results. I suggested a solution back in 2007: Disband the RCMP. 

Covid is killing rural Americans at twice the rate of people in urban areas

Via NBC News, a report by Lauren Weber of Kaiser Health News: Covid Is killing rural Americans at twice the rate of people in urban areas. Excerpt:

Rural Americans are dying of Covid at more than twice the rate of their urban counterparts — a divide that health experts say is likely to widen as access to medical care shrinks for a population that tends to be older, sicker, heavier, poorer and less vaccinated.  

While the initial surge of Covid-19 deaths skipped over much of rural America, where roughly 15 percent of Americans live, nonmetropolitan mortality rates quickly started to outpace those of metropolitan areas as the virus spread nationwide before vaccinations became available, according to data from the Rural Policy Research Institute.  

Since the pandemic began, about 1 in 434 rural Americans have died from Covid, compared with roughly 1 in 513 urban Americans, the institute’s data shows. And though vaccines have reduced overall Covid death rates since the winter peak, rural mortality rates are now more than double that of urban ones — and accelerating quickly.  

In rural northeastern Texas, Titus Regional Medical Center CEO Terry Scoggin is grappling with a 39 percent vaccination rate in his community. Eleven patients died of Covid in the first half of September at his hospital in Mount Pleasant, population 16,000. Typically, three or four nonhospice patients die there in a whole month.  

“We don’t see death like that,” Scoggin said. “You usually don’t see your friends and neighbors die.”

Part of the problem is that Covid incidence rates in September were roughly 54 percent higher in rural areas than elsewhere, said Fred Ullrich, a University of Iowa College of Public Health research analyst who co-wrote the institute’s report. He said the analysis compared the rates between nonmetropolitan, or rural, areas and metropolitan, or urban, areas. In 39 states, he added, rural counties had higher rates of Covid than their urban counterparts.  

“There is a national disconnect between perception and reality when it comes to Covid in rural America,” said Alan Morgan, head of the National Rural Health Association. “We’ve turned many rural communities into kill boxes. And there's no movement towards addressing what we're seeing in many of these communities, either among the public, or among governing officials.”  

Still, the high incidence of cases and low vaccination rates don’t fully capture why mortality rates are so much higher in rural areas than elsewhere. Academics and officials alike describe rural Americans’ greater rates of poor health and their limited options for medical care as a deadly combination. The pressures of the pandemic have compounded the problem by deepening staffing shortages at hospitals, creating a cycle of worsening access to care.  

It's the latest example of the deadly coronavirus wreaking more havoc in some communities than others. Covid has also killed Native American, Black or Hispanic people at disproportionately high rates.  

Vaccinations are the most effective way to prevent Covid infections from turning deadly. Roughly 41 percent of rural America was vaccinated as of Sept. 23, compared with about 53 percent of urban America, according to an analysis by The Daily Yonder, a newsroom covering rural America. Limited supplies and low access made shots hard to get in the far-flung regions at first, but officials and academics now blame vaccine hesitancy, misinformation and politics for the low vaccination rates.

How the US vaccine effort derailed and why we shouldn’t be surprised

Via The Guardian: How the US vaccine effort derailed and why we shouldn’t be surprise. Excerpt:

There are very specific, well-documented reasons that Americans are hesitant to take vaccines. They vary from the troubling way the medical system treats people of color, to vaccine misinformation campaigns overwhelmingly popular in conservative circles, to logistical challenges.  

But population health researchers, whose work considers how society as a whole is fairing, said low vaccine uptake may be looked at another way: as the predictable outcome of a campaign subject to entrenched social forces that have diminished American health and life expectancy since the 1980s.  

“When I look at this I do see a very familiar pattern,” said Dr Steven Woolf, a prominent population health researcher at Virginia Commonwealth University. “When Operation Warp Speed came out I thought I was just seeing a modern example of this old problem where the scientific community developed the vaccine at ‘warp speed,’ but the implementation system for getting it out into the community was inadequate”.  

Woolf calls this “breakthrough without follow-through”. In that light, the plodding vaccination campaign could be seen as one more aspect of the American “health disadvantage”.  

The phrase describes a paradox: the US houses among the most advanced medical and research centers in the world, but performs poorly in basic health metrics such as maternal mortality and infant mortality; accidental injury, death and disability; and chronic and infectious disease.

"So much of the whole issue of social determinants of health and the US ‘health disadvantage’ is rooted in a lack of trust and a lack of trustworthiness in many parts of our society,” said Laudan Y Aron, a senior fellow at the Urban Institute’s health policy center. 

A key piece of research in this area is a 2013 report by a panel chaired by Woolf, directed by Aron, and funded by the National Institutes of Health. Called US Health in International Perspective: Shorter Lives, Poorer Health, the report describes how Americans spend more than double per person on healthcare compared to 17 peer nations, but rank near the bottom in health outcomes.  

The phenomenon is described as “pervasive”, impacting all age groups up to 75, with life expectancy declining especially for women. In just a few examples, Americans have the highest infant mortality, children are less likely to live to age five, and the US has the worst rates of Aids among peer nations.  

The US also has the highest or among the highest rates of cardiovascular disease, obesity, chronic lung disease and disability. Together, these risk factors culminate in Americans having the worst or second worst probability of living to age 50.  

Americans know intuitively that their healthcare is expensive, frustrating and often unfair. Remarkably, even amid the pandemic, roughly 30 million Americans went without health insurance, exposing them to potentially ruinous medical debt.  

“It’s also really interesting how often the messaging is: talk to your doctor, talk to someone you trust,” said Aron. “Yet, we don’t really acknowledge how many people don’t have a doctor, or a doctor they have a trust-based relationship with them”.