The Health Wrap: pandemic news, Tour de France, care for the elderly, and sad news from England

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The health impacts of the Tour de France, global news on coronavirus, a better future for aged care, the abolition of Public Health England, and an exercise in deliberative democracy are among the topics investigated in this latest edition of The Health Wrap, by Associate Professor Lesley Russell.

Lesley Russell writes:

Progress on coronavirus vaccines was prominent in the news these past two weeks, most notably the halting of the Phase 2/3 trials of the AstraZeneca – Oxford University vaccine because a trial participant developed transverse myelitis and the release of a statement, signed by nine major vaccine companies, committing that vaccines will not be publicly released until they are determined to be safe and effective.

Astra-Zeneca and Oxford University have since resumed vaccine studies in the UK, but are waiting on guidance form other authorities before trials resume elsewhere around the world.

Meanwhile, Pfizer has announced its coronavirus vaccine trial will be expanded from 30,000 to 44,000 people in an effort to recruit a more diverse group of participants and potentially cut down the time needed to get results. It’s surely no coincidence that larger trial numbers also mean a better chance of seeing rare side effects.

The race by governments to get commitments for vaccine supplies continues. Wealthy countries have already pre-ordered more than two billion doses.

The Australian Government has announced a $1.7 billion agreement for 84.8 million COVID-19 vaccine doses — 51 million doses of the University of Queensland’s vaccine candidate and 33.8 million doses of the Astra-Zeneca – University of Oxford’s candidate, of which 3.38 million will be imported.

That’s considerably more than is needed for the Australian population, but the statement by the Prime Minister says Australia “remains committed to ensuring early access to the vaccines for countries in the Pacific as well as regional partners in Southeast Asia. Both agreements allow for additional orders to be negotiated and for doses to be donated or on-sold (with no mark-up) to other countries or international organisations.”

Health Minister Greg Hunt said Australians would be among the first in the world to receive a COVID-19 vaccine, once it is available, which might have been over-promising, given the uncertainties ahead.  . There is no evidence to date that the government has invested any efforts in determinations about which population groups should be prioritised for receiving vaccine shots once they become available.

The predictable international infighting among the richest nations has already started. The British Health Secretary Matt Hancock, when told of the Australian deal with AstraZeneca – Oxford University, said: “We’re ahead of [Australia]”.

The UK has signed up to purchase 340 million doses – that’s five per citizen – and the US has pre-ordered 800 million doses.

Nature has recently published a review of the vaccine development landscape, which is interesting and useful.

An article just out in Science from Zeke Emanuel and colleagues discusses what must be done to ensure the ethical international distribution of a coronavirus vaccine, and another article just published in The Lancet discusses how legal agreements can be both barriers and enablers to global equitable coronavirus vaccine distribution.

In contrast to pandemic influenza, there is not an international legal instrument, agreed to by all WHO member states, for COVID-19.

Nor is there yet a public international agreement on how distribution of vaccines from the COVAX Facility should occur.

The WHO has developed a proposal for a Global Framework to Ensure Equitable and Fair Allocation of COVID-19 Products (discussed here), but how this framework would be adopted and take effect has not (yet) been publicly proposed. It is at times such as these that the lack of US leadership is really noticeable.

Read the article tweeted above here.

Pandemic lessons from Israel

Like Australia, a number of countries that successfully beat back the first wave of the coronavirus pandemic are now experiencing a second wave, in many cases with higher rates of infection than the first wave. These include countries in Europe, the UK and Israel.

A recent article in The New York Times highlights the issues and notes that this time around there are more cases in young people and fewer deaths. In Spain the median age of those infected has dropped from 60 to 37, asymptomatic cases account for more than 50 percent of positive results (partly due to an increase in testing), and the mortality rate is roughly half the rate at the height of crisis (down to 6.6 percent from 12 percent in May).

In Israel, which was one of the early success stories, the pandemic has mushroomed, with Israel’s  new cases near the worst in the world on a per-capita basis. On September 11, Israel reported 4,429 new cases and 23 deaths with nearly 36,000 active cases and 979 people in hospital. Coronavirus wards were beyond 100 percent capacity.

Now there are serious concerns with the approach of the Jewish High Holy Days – what should be a festive and unifying time when Israelis Jews gather in large numbers.  But the country appears to be warring with itself along religious, cultural and political lines in ways that sound very like what is happening in the United States.

In late July, with cases already beginning to rise again, the government appointed a veteran Tel Aviv hospital administrator, Dr Ronni Gamzu, as the national “coronavirus czar”.  The Prime Minister, Benjamin Netanyahu, said he would have “all authority” to cut the virus infection chain. Gamzu enlisted the military to take responsibility for contact tracing, pleaded with Israelis to take the threat seriously, instituted simple directives and vowed to restore the public’s trust.

In early September Gamzu won cabinet approval for a traffic light-themed plan to impose strict lockdowns on “red” cities with the worst outbreaks, while easing restrictions in “green” ones where the virus was finding fewer victims. The goal was to avoid, or at least delay, another economically tough nationwide lockdown.

But the designated red zones were mostly either Arab or ultra-orthodox. The leaders of these population groups felt their communities were being stigmatised and revolted against the traffic light plan. The ultra-orthodox leaders directed their anger at the Prime Minister and he, under fierce public pressure from one of his most vital constituencies, caved in on the targeted lockdown plan.

At that point, his government instead decided to impose a curfew and close schools in about forty cities and towns with high ­infection rates.

But as cases continue to rise precipitously it became clear that would be insufficient. After tough considerations, the Israeli Cabinet has just announced it will impose a second COVID-19 national lockdown. It will begin on Friday, the start of the High Holy Days, and last until October 9.

The three-week lockdown will make Israel the first country to reimpose such stringent restrictions on a national scale. Gatherings will be limited to 10 people indoors and 20 people outdoors. The Prime Minister has said there will be special rules for prayer services during the Jewish holidays, but these are yet to be issued.

And now public health experts say “Public trust is at best cracking, if not completely gone.”

This Twitter thread summarises the Israel timeline and issues well.  The main take-out: science and politics don’t mix well when it comes to coronavirus!

Focus on COVID’s post-acute impacts

Some useful links on “Long Covid” – the lasting effects of infection with coronavirus:

Andy Slavitt on Twitter: a thread on “Long Covid”.

The physiology of riding the Tour de France

I confess I’m addicted to the Tour de France and watch it religiously every year. I’m not much of a cyclist, just looking at those athletes makes me feel exhausted (I’ve seen it described as the most maniacal major sporting event on earth), and I don’t understand the peloton tactics – but I love the scenery and the crowds. You can read the sad history as to why there is no Tour de France Féminin  here.

I once used to teach the Krebs Cycle in terms of what happens as you run a marathon, so I’m interested in what happens to the bodies of the participants in this gruelling race. Here’s what I discovered.

In essence, the Tour de France riders “cannibalise” their own bodies over the three weeks of the race. In physiology terms, they are in a continuous state of catabolism: losing muscle mass, losing fat mass. As early as the first week the riders begin to lose muscle, their immune systems start to fail, they lose their mental acuity, and they practically have to force-feed themselves to maintain enough function to do those gruelling climbs. Humans shouldn’t do their bodies what Tour riders do to theirs – which might explain why there are doping and drug problems.

There are estimates of daily energy expenditure (using a unit called TRIMP) that show the Tour is arguably the hardest endurance race in the world. One study found that the Tour demands an average of 350 to 400 TRIMPs per day over the three -week period, with over 500 TRIMPs for several consecutive stages and up to 600 TRIMPs for the most extreme stages. The authors postulate that this is the limit of daily energy expenditure that can be tolerated by humans, because two consecutive days of 600 TRIMPs have never been recorded. (The demand for a marathon is about 300 TRIMPs).

On top of this there are environmental considerations – heat and dehydration, cold and altitude – and accidents. Lycra is not much of a protection for a skid across the bitumen.

All this means a major focus each day on glucose regeneration, glycogen and energy availability (so how much of the Krebs cycle can you remember?). As the riders get further into the race, they have less energy storage, they have to eat more, but at the same time, under extreme stress, they lose their appetites.

So it’s effectively force feeding both on the bike and off the bike. Indeed  the race is almost defined by a rider’s ability to eat, drink and absorb energy throughout the race.

Riders burn over 5,000 calories a day (21,000 joules/ day). The cyclists’ carbohydrate intake must be sufficient to replenish glycogen stores within 18 hours—the period that elapses from the end of a stage to the time the next day’s stage begins.

The carbohydrate intake during the first six hours after finishing the day’s stage is particularly important. This is complemented with protein to increase muscle glycogen resynthesis.  The daily energy intake averages ~840 g of carbohydrates, ~200 g of protein, and ~158 g of fat. Hydration levels vary from 3.3 – 6.7 litres per day depending on the amount of carbohydrates consumed in liquid form as sports drinks.

During the race you can see the handlers giving little bags (called “musettes” by the French and “bonk bags” by the British) to the riders along the route. These contain food and fluids in the form of energy bars, gel packs and bottles of sports drink.

Home care for the elderly

Over the past few weeks the Royal Commission into Aged Care Quality and Safety has been focused  on home care for the elderly. (You can read the transcripts here).

This is an extremely complex and opaque system, but one that we should all struggle to understand – especially the costs and fees – because one day we will need to make decisions about it for someone, maybe even ourselves!

In March 2020, 136,909 people were using a home care package (HCP) and a further 15,049 people assigned a HCP and considering whether to take up their offer (in general they were considering because the level of package they were offered was not suitable for their needs). Meanwhile, more than 103,000 Australians are waiting for care, with the number rising every month.

Modelling supplied to the Royal Commission shows that just 300 of the new 50,000 HCPs released by the Morrison Government in the past three years were actually “new” compared to forward estimates in the budget. New packages that were announced (for example in February 2019 and in November 2019) had been merely released earlier than forecast with little change to the overall number of places forecast to be in operation by 2024.

But, as recently exposed by the ABC 7:30 program, those lucky enough to receive a HCP still face fees of thousands of dollars charged by their provider – and some are paying more in fees than tis spent on their care. Meanwhile, the agencies supposed to be providing services are sitting on (and earning interest on) an estimated $1 million in unspent funds.

Another shocker this past week was the release of an audit of the aged care sector conducted for the Royal Commission. It found that despite the fact taxpayer funds account for some 80 percent of the $25 billion spent annually on aged care, the Health Department’s financial reporting rules mean it is difficult to ­establish a link between money received, money spent and care provided.

The Dutch Buurtzorg model of home care for the elderly

If you work in and around ageing and aged care then you know the Dutch do it well, largely I think because (1) they see older citizens as an important, valuable population group that should remain integrated within society and (2) they are willing to think outside the box.

This article on the Dutch National Care for the Elderly Program exemplifies this, as does this article about innovative living arrangements.

Professor Kathy Eagar alerted me to the Buurtzorg model of neighbourhood care for the elderly, which was established in The Netherlands some ten years ago. It is now being emulated internationally – but not yet here in Australia. She says that this model is one reason why 85 percent of older Dutch citizens elect to receive their in-home services from block-funded, not-for-profit providers rather than individualised funding via a voucher-type system (they do have a choice).

The model uses self-managed teams of up to twelve nurses to look after groups of around sixty elderly people living in their own homes. Each nurse visits three to four people a day, and each person is seen at least once a week. The nurses must spend 61 percent of their time in direct contact with the people they support.

The nurses liaise with a network of primary carers including GPs, physiotherapists and social workers and are in contact with police and welfare officers. Rather than relying on different types of personnel to provide the range of services that the elderly need – the approach taken by most home health providers – Buurtzorg expects its nurses to deliver the full range of medical and support services to clients.

The Dutch Government was sufficiently impressed by the potential of this model that within two years of its launch, the Government changed the reimbursement rules. Previously service providers had to bill separately for some twenty different categories of care but now they could bill for a single all-encompassing category labelled “community health”.

This model has earned high patient and employee ratings and appears to provide high-quality home care at lower cost than other models. The overhead costs average eight percent of turnover (compared to an average of 25 percent in Australia).

If you would like to read more (and, by the way, the model is not perfect!) here are some references:

  • The US-based Commonwealth Fund did a 2015 review of this model.
  • There is an article in The Guardian, from 2017, here.
  • In 2018 the Centre for Public Impact published a case study of how Buurtzorg has revolutionised the provision of home care.

Meanwhile, many readers may be interested in this 16 September webinar, where Ged Kearney MP, Shadow Assistant Minister for Skills and the Shadow Assistant Minister for Aged Care, Beris Campbell, Board member of Homeshare, and Ruth Kestermann, CEO of Holdsworth Community Sydney will discuss “the critical but badly neglected aged care sector and how we can help older Australians to age well, preferably at home”. It is part of the Australia Institute’s Economics of a Pandemic webinar series.

Abolition of Public Health England

The impact of the coronavirus pandemic in the UK has magnified the nation’s substantial health and racial inequalities.

Now it seems that the Public Health England (PHE), the national public health agency, is being scapegoated by the very politicians who are ultimately responsible for the response to the pandemic. The UK health and healthcare systems have been subject to immense upheaval, reorganisation and financial stress in recent years, and this is yet another unfortunate example.

Many public health experts have been shocked and surprised that, with the pandemic far from under control, the Johnson Government has announced PHE will be abolished and replaced with a new agency – the National Institute for Health Protection.

An editorial in the BMJ described it this way: “Choosing this moment to completely recast England’s public health structures looks foolhardy in the extreme. Not so much a strategic change of direction but more like throwing your cards up in the air in the hope you end up with a better hand.”

The new agency will also incorporate two organisations created in the middle of the pandemic, the Joint Biosecurity Centre and NHS Test and Trace. It will begin operations in early 2021 with a primary focus on public health protection, infectious disease capability and pandemic preparedness.

“One of the lessons from the crisis is that we need an institution whose only job is to prepare for and respond to external threats like pandemics,” said Health Secretary, Matt Hancock in his speech announcing the change.

This statement has generated fears that needed prevention activities and health improvements will be neglected or even lost as the government loses focus on work done to date and worries solely about coronavirus. Public health threats are not limited to infectious diseases.

PHE, which has 5,500 full-time employees across its wide remit of health protection and health prevention, is organisationally an integral part of the Department of Health and its staff are employed as civil servants. It was established under the Cameron-Clegg Coalition Government after the 2012 Health and Social Care Act abolished the Health Protection Agency, the National Treatment Agency for Substance Misuse and primary care trusts.

It has faced criticism over aspects of its work and in particular, its response to the pandemic, including its handling of testing and tracing of contacts. But much of this criticism is unfounded as PHE was never set up to do this type of work. A predecessor organisation, the Public Health Laboratory Service, once had an extensive network of laboratories, but these were transferred to the NHS some years ago.

It is obvious that over the past decade progress in public health has stalled and this is reflected in the health of England’s population and falling life expectancy for some population groups. Much of this is attributed to years of under-investment in PHE and its work.

This re-structuring will not help; past experience shows that every time UK public health goes through a major reorganisation it loses at least 20-30 percent of its skilled and experienced staff.

In a joint statement sent to the Prime Minister, the Health Secretary, and the interim leadership of PHE, more than 70 health organisations protested the changes and expressed a series of concerns.

A letter from some of the signatories to this statement, published by the BMJ, said this:

“Chronic non-communicable diseases are still, and will remain, responsible for the overwhelming burden of preventable death and disease in this country… It is a false choice to neglect vital health improvement measures, such as those that target smoking, obesity, alcohol and mental health, in order to fight COVID-19.

“Reorganisation is difficult at the best of times and these are not the best of times. Avoiding fragmentation and ensuring seamless transition from the current to any new system is essential. At this time of global pandemic and recession, health improvement is not a ‘nice to have’ but an essential component of a successful response to the challenges we face.”

The Government said that it would consult on the future of PHE’s health prevention functions over the next six months to decide where they should move to in the system (so obviously these are not seen as important).

This Twitter thread on the issues from a UK journalist who covers global health issues is worth reading.

This is a sad public health story – one that is increasingly common even as the pandemic highlights the need for sustained investments in public health and prevention – and there are lessons here for Australia, which is still working on a National Preventive Health Strategy.

A report titled You Had One Job: the shortcomings of PHE and WHO during the Covid-19 pandemic from the London-based Institute of Economic Affairs – a think tank that says it promotes “the dissemination of free-market thinking” and “the role of markets in solving economic and social problems” – serves only to highlight where the UK is headed and as a further warning to Australia.

In case you missed it – some recent publications

The Lancet:  It’s Time to get serious about vaccine confidence

JAMA editorial:  Reassuring the Public and Clinical Community About the Scientific Review and Approval of a COVID-19 Vaccine

International Journal of Medical Informatics: The General Practice and Residential Aged Care Facility Concordance of Medication (GRACEMED) study. (Australian study – some pretty shocking results)

The Marshall Project: COVID-19’s Toll on People of Color is Worse Than We Knew

HealthPopuli:  Behavioural Health Side-Effects in the COVID Era

Medical Journal of Australia: Sexual misconduct by health professionals in Australia, 2011–2016: a retrospective analysis of notifications to health regulators

University of Calgary School of Public Policy: Comprehensive Dental Care in Canada: The Choice Between Denticaid and Denticare.

The best of Croakey

Thanks to Croakey’s Marie McInerney for: Unmasking privilege, stress, anxiety and cruelty in the pandemic.

Good news story

This is a “brave new world” story from several aspects.

There is an expectation that sometime soon the Australian Parliament will vote on whether mitochondrial donation should be a legal part of IVF in Australia. This is a so-called “three-person IVF” technique that allows women with mitochondrial disease and their partners to have genetically related children without the risk of passing on the condition.

It is currently banned in Australia under the Research Involving Human Embryos Act and the Prohibition of Human Cloning for Reproduction Act (it is legal in a number of other countries, including the UK). However, a 2018 report Science of Mitochondrial Donation and Related Matters from the Senate Standing Committee on Community Affairs endorsed this technique and found that “mitochondrial donation is a form of genetic modification that was not envisioned at the time that anti-cloning laws were enacted in Australia”.

The NHMRC then established a Mitochondrial Donation Expert Working Committee to look at this issue. This committee concluded its work in March. Its report is now with Health Minister Greg Hunt.

In anticipation of a vote on this issue, Federal Member of Parliament from the ACT Andrew Leigh (a long-time friend) is working with the Centre for Deliberative Democracy and Global Governance at the University of Canberra so that his vote will be guided by a deliberative democracy process and reflect the thinking of his constituents (see this letter).

Thank you to Dr Liz Allen for alerting me to this. We look forward to hearing how it progresses.

Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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