In her latest edition of The Health Wrap, Dr Lesley Russell reports on growing concerns around food insecurity, the wide-ranging health impacts of racism, and calls to address the moral determinants of health.
She also shares a stack of recommended reading and resources, as well as some good news from the United States Supreme Court.
Lesley Russell writes:
The focus of The Health Wrap this week is mostly on the inequalities and divides that the coronavirus pandemic and the Black Live Matter movement have so clearly highlighted.
There is such hope that one of the good things to come out of the pandemic will be new and better ways of delivering better health and addressing health disparities that have been thrown into high relief in even the richest countries like Australia, the United States and the United Kingdom.
Will governments – now seemingly obsessed with their economies and budgets – see that improving health outcomes is an economic issue and a key budgetary investment?
Food insecurity and the pandemic
In the last edition of The Health Wrap I wrote about growing food insecurity in the US.
I also recently wrote an article for Inside Story magazine on how the coronavirus pandemic and its economic consequences in the US have caused severe disruptions in the food supply chain and increased food insecurity to levels not seen since the Great Depression. It’s a pretty scary story that is likely to worsen over the summer as the coronavirus reaches rural America.
My article was published alongside another, on how Pacific Islanders are responding to disruptions to food security with cultural solidarity and new technology, that was more encouraging.
Suddenly I am seeing articles about food insecurity everywhere. I suspect this is not just about coronavirus, but the combined impacts of the pandemic (including loss of jobs and income) with low basic wages, a frayed social security net, climate change and drought.
In Australia there are reports of families with young children, workers who have lost their jobs, migrants and international students queuing for emergency support and food.
A recent study by the Institute for Social Change at the University of Tasmania surveyed 1,170 Tasmanians and found that one in four reported running out of food because they could not afford to buy more during the coronavirus pandemic. Tasmanians whose jobs have been impacted and vulnerable groups such as people with disabilities, youth, single parents and Indigenous were most affected.
One in two of Tasmanian respondents who are currently receiving JobSeeker payments reported running out of food and being unable to buy more, double the level of food insecurity experienced by those receiving JobKeeper Payments (25%).
As government supports provided during the pandemic lock down period are withdrawn, this situation will be exacerbated.
An article in The West Australian (unfortunately behind a pay wall) states that 55 percent of families say childcare fees are so high they limit their weekly grocery budget. For low-income families who earn less than $60,000 a year, 64 percent say childcare costs impact how much food they buy.
Also, don’t miss the #HealthReimagined series of webinars from VicHealth, which this week puts the focus on food security, systems and sustainability as part of a longer-term examination of wide-ranging social determinants of health. Marie McInerney is covering the series for the Croakey Conference News Service; bookmark this link to track her coverage.
In the United Kingdom
In the UK, the food system was already in trouble, facing climate change, biodiversity loss, unsustainable diets and the fall-out from Brexit. Two years ago, the UN Special Rapporteur on Extreme Poverty and Human Rights was highly critical of the UK’s extensive food poverty and continued reliance on charities and food banks to address this.
Last week Prime Minister Boris Johnson bowed to pressure and agreed to provide a summer food fund for struggling families in England after his government had originally said school food vouchers would not be available over the long summer holiday. Scotland and Wales will also continue the voucher program.
Manchester United player Marcus Rashford led the campaign to prevent children from going hungry during the coronavirus pandemic. He used a column in the Times newspaper to argue that while he may not have the education of a lawmaker in Parliament, he did have a social education. He has already helped to raise around 20 million pounds with charity Fareshare UK to supply meals to struggling families.
In England, about 1.3 million children claimed for free school meals in 2019 (about 15 percent of state-educated pupils). In Manchester, where Marcus Rashford grew up, the figure is 28.1 percent.
In the developing world
In April a report from the United Nations World Food Program (WFP) estimated that, without swift action to provide humanitarian aid, the coronavirus crisis will push more than a quarter of a billion people to the brink of starvation. About 265 million people around the world are forecast to be facing acute food insecurity by the end of this year, a doubling of the 130 million estimated to suffer severe food shortages last year.
The Executive Director of WFP told the UN Security Council, “If we don’t prepare and act now – to secure access, avoid funding shortfalls and disruptions to trade – we could be facing multiple famines of biblical proportions within a short few months.”
Food experts are worried that donor nations have barely begun to deliver the funding needed urgently on the ground to set up networks to deliver humanitarian relief to the worst-hit areas.
The World Bank has an internet site that summarises, with regular updates, the evolving agriculture and food situation in a range of countries.
The global food systems were already vulnerable; the coronavirus pandemic has exposed the weaknesses. The Global Nutrition Report 2020, written before the pandemic, found that an increasing number of countries experience the double burden of malnutrition, with under-nutrition coexisting alongside obesity and other diet related diseases such as diabetes and cardiovascular disease.
The latest data show that no country is on course to meet all ten of the 2025 Global Nutrition Targets and just eight out of 194 countries are on course to meet four targets. Almost a quarter of all children under five years of age are stunted while rates of overweight and obesity are increasing rapidly in nearly every country in the world.
The report calls on governments, businesses, and civil society to step up efforts to tackle malnutrition in all its forms, as well as injustices in food and health systems.
This report is well summarised in the BMJ here.
Health inequalities in England
While much of the attention about mismanagement of the coronavirus pandemic has focussed on the US, the countries of the UK are also faring badly. In large part the blame can be sheeted home to Prime Minister Boris Johnson and his government, although the roots of many of the problems so obvious today lie in a decade of austerity and failures to invest in the social determinants of health.
The saga of a recent report highlights these issues.
In early May the Johnson Government commissioned Public Health England (PHE) to undertake a rapid review to better understand how different factors such as ethnicity, deprivation, age, gender and obesity could impact on how people are affected by COVID-19.
Early data had already shown that Black, Asian and Minority Ethnic (BAME) communities were being hard hit. This trend first came to public attention when media reports that showed the first eleven doctors who lost their lives to COVID-19, were all from BAME communities.
The Institute for Fiscal Studies (IFS) report found that, after adjusting for age, sex, and geography, the death rate for people of black African descent was 3·5 times higher than for white British people, while for those of black Caribbean and Pakistani descent, death rates were 1·7 times and 2·7 times higher, respectively.
Professor Ken Fenton, a recognised scholar of ethnic variations in health, was charged with addressing these issues in the report and he undertook a wide range of consultations with stakeholders.
When PHE delivered the report in early June, there was dismay, disappointment and anger that it had just a small chapter on ethnicity and health, no new data or insights, and no formal recommendations. It soon emerged that 69 pages covering seven recommendations were removed from the PHE report.
Initially questions about the missing recommendations were deflected by the Secretary of State for Health Matt Hancock – he said there was no missing material and no second report – and Kemi Badenoch, the Minister for Equalities (yes, there is one!), told parliament that PHE did not make recommendations because some of the data needed was not available.
However, an opinion piece in the BMJ from Professor Raj Bhopal, who was asked to review a draft report which included the recommendations, gave the lie to these statements, and the government was then forced to backtrack and say that the recommendations would be published.
Fenton’s report “Beyond the data: Understanding the impact of COVID-19 on BAME communities” was released on June 16. It is described as “a summary of stakeholder insights” into factors affecting the impact of coronavirus on BAME communities.
It summarises the requests for action which came forward and which have been used to inform the recommendations made.
The seven recommendations, briefly summarised, are:
- Comprehensive and quality data collection
- Community participatory research
- Improve access, experiences and outcomes of NHS, local government and integrated care systems
- Culturally competent occupational risk assessment tool
- Culturally competent COVID-19 education and prevention campaign
- Culturally competent health promotion and disease prevention programs for NCDs
- Ensure COVID-19 recovery strategies actively reduce inequalities caused by the wider determinants of health.
There’s nothing controversial here – although addressing these issues in a meaningful way will be difficult and costly. Most likely the Government was shying away from this damning statement:
Racism and discrimination experienced by BAME key workers [is] a root cause affecting health and exposure risk.
For BAME communities, lack of trust of NHS services resulted in reluctance to seek care.”
The reporting in both the mainstream and the medical media following the release of the Fenton report is firmly focussed on “historic racism” as the primary cause of the higher deaths in BAME people from COVID-19.
The real issue is – what happens now?
The Kings Fund issues a statement saying, “too many recommendations from previous inequality reviews now sit gathering dust … we hope this report finally prompts serious, tangible actions that are implemented rapidly.”
Understandably, the Johnson Government is now under pressure to hold a public inquiry about how and why this debacle occurred – and hopefully how it will address the health inequalities now exposed.
Ten years after the Marmot Report
As if to remind us of how many major recommendations now sit gathering dust, the Institute for Health Equity has just published “Health Equity in England. The Marmot Review Ten Years On”.
It’s a sobering view of how quickly governments’ failures to address the social determinants of health are translated into widening health inequalities.
Here is my summary of the report’s findings:
- Since 2010, life expectancy in England has stalled for the first time since 1900 and the social gradients and inequalities have increased. There are marked regional differences
- In particular, mortality rates for people aged 45-49 have increased
- People in deprived areas spend more of their shorter lives in ill-health. The period of time people spend in ill-health has increased since 2010
- The Government has not prioritised health inequalities; there has been no national strategy since 2010.
The paper reviews progress on the six policy priorities Marmot delivered in 2010:
- Give every child the best start in life
- Enable everyone to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill-health prevention.
I’m struck by how succinct, smart, insightful and encompassing these priorities are.
The original Marmot Review – Fair Society, Healthy Lives – is here.
The moral determinants of health
I urge you to read this Viewpoint piece “The Moral Determinants of Health” by Donald Berwick, just published by JAMA Network. It points to what the healthcare system and the people who work in it can do to address inequalities.
Berwick writes that “Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted ‘social determinants of health’.”
He makes the case that the power of these societal factors is enormous compared with the power of healthcare, that there is under-investment in these factors and in actual human well-being, and that this will not happen without an attack on racism and an embrace of what he calls the ‘moral determinants of health’ and a sense of social solidarity.
He then asks: “What would the physicians, nurses, and institutions of US health care insist on and help lead, as an agenda for action?” and offers a list of the first-order elements of a morally guided campaign for better health.
I won’t list these (they are US orientated but have considerable applicability in Australia), but encourage readers to think of what would be on their list for a morally guided campaign for health and healthcare reforms.
In case you missed it
Dr Alexander C. L. Holden, Professor Ramon Z. Shaban and Professor Heiko Spallek. COVID-19 and the Dental Profession: Professional Tensions and Ethical Quandaries. A COVID-19 Sydney Policy Paper In Depth.
Deeble Institute. Data collection for community-based allied health chronic disease management. Health Policy Issues Brief No. 36.
Allied health services are integral to the management of chronic conditions in the community setting, yet little data about them are collected, hampering health service planning, design, and policy decisions. It is unclear what, when, and where allied health services are required and how they would be best provided. This issue brief also discusses workforce supply and redesign of the Chronic Disease Management program.
Poverty in Australia
ACOSS and UNSW Social Policy Research Centre. Poverty in Australia 2020: Part 2 – Who is affected?
This analysis shows the disproportionate impact of poverty on women, especially those who are head of the family. More than a third of single mothers and their children live in poverty – and these are results before the coronavirus pandemic.
There’s an excellent summary on the Women’s Agenda blog here.
Primary care after coronavirus
Professor Stephen Duckett. What should primary care look like after the COVID-19 pandemic? Australian Journal of Primary Health, May 2020.
Jennifer Doggett. COVID-19’s six lessons for Australian healthcare. Croakey, 20 March 2020.
Melissa Sweet. “The genie is out of the bottle”: telehealth points the way for Australia post pandemic. The Guardian, 13 May 2020.
Jayne Nelson and Janelle Devereux. How social prescribing can improve health and wellbeing. Croakey, 19 June 2020.
The Consumers Health Forum of Australia has launched a Consumer Commission to take a consumer-focused look at what is needed in health and social welfare policies post the pandemic. More information is available here.
The best of Croakey
The good news story
Two recent decisions from the US Supreme Court were, perhaps surprisingly with a Trump-stacked bench, favourable to minorities and are well worth celebrating.
- In a 6-3 ruling written by (surprise) Trump nominee Judge Neil Gorsuch, the Supreme Court ruled that the language of the Civil Rights Act of 1964, which prohibits sex discrimination, applies to discrimination based on sexual orientation and gender identity. Until this decision it was legal in more than half the states to fire workers for being gay, bisexual or transgender. The vastly consequential decision thus extended workplace protections to millions of people across the nation. You can read more here. This decision came only a few days after the Trump Administration had rolled back the provisions of Obamacare that banned discrimination against patients based on their sexual orientation and chosen gender.
- In a 5-4 decision written by Chief Justice Roberts (seen as a conservative), the Supreme Court blocked the Trump Administration’s attempt to dismantle the Deferred Action for Childhood Arrivals (DACA) program implemented by President Barack Obama eight years ago. This program protects undocumented immigrants brought to the United States as children, a reprieve for nearly 650,000 recipients known as “Dreamers.” This was a technical ruling – the decision said that the Trump Administration had not provided proper legal justification for ending DACA. You can read more here.
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.