Prof Raina McIntyre argues that the COVID19 problems in the developed world, particularly the Anglo world are the result of an understanding of and a lack of respect for public health. She charts this as within the medical profession, which has its own hierarchies, but also in the political arena. The overwhelming influence of the corporate sector and the profit motive, and the managerial approach which assumes that if you are not an expert, you can quickly find one, bone up and take over has been found sadly wanting. For a manager or politician, selecting an expert is not as easy as it sounds as there are many people who want to tart up their CVs and market themselves with dubious claims to expertise.
This has resulted in a very suboptimal preparation for and response to the pandemic. The failure in the managerial decision-making process has been laid bare in the COVID situation, but this is not an isolated example. The lack of respect for expertise, the replacement of knowledge with marketing spin, and public good with corporate profits will lead to more bad decisions, which often take a crisis to become evident. It happened in the bushfires, and is happening with climate change. Examples in foreign policy, education, health and defence all come to mind.
I attended a DRS (Doctors Reform Society) zoom webinar on the future of health care with Professor Stephen Duckett and aged care with Professor Joseph Ibrahim of Monash Uni, a geriatrician whose experience is in evidence-based aged care.
It was not encouraging.
Preamble:
My own experience of nursing homes was initially as an after-hours doctor when I used to judge nursing homes by what I turned the Urine Smell Index; the worst ones smelled of urine when you opened the door at night. As a GP years ago I found it increasingly difficult to find someone trained to talk to about the patients’ treatments.
In New South Wales Parliament as an MP I was asked to pass legislation that lessened the number of trained nurses required on staff. ‘Flexibility’ was the key and many homes and facilities ‘had people who were not really sick’ we were told. I was not convinced but the legislation went through anyway.
When my widowed mother was no longer able to cope at home and the family went looking for supported accommodation it soon became clear that the driving force in Aged Care is real estate profits. The family home is sold and the object is to get the family to buy an overpriced retirement Villa with varying levels of support in the villa and then hopefully automatic entry into an attached nursing home, usually with quite a poor urine smell index. When the old person dies the villa profit largely reverts to the corporation.
A dear old widower professor who lived up the road needed support in his 90s. The home support contract offered needed at least 4 hours per week at $65 per hour. The person delivering the care was paid $20 an hour. I am unsure how District Nurses are allocated.
In 2000 Prime Minister Rudd asked for ideas for his ‘2020 Vision’. I wrote and suggested that he register the skills and training of Home Care workers so that they could be hired and evaluated like Uber of any other online service and the ‘quality control and insurance’ would not be why the contracting agency became so ‘vital and expensive’ (that it would end up costing more than the person who actually did the work). I never even had an acknowledgement of my suggestion.
Prof Duckett was of the opinion that things had got a lot worse since the 1997 Aged Care Act, John Howard’s work, which created ‘a business opportunity’ Prior to this there was a system called CAMSAM which was two modules; Care Aggregated Module and Standard Aggregated Module. These were funded separately. If they did not spend their Care money it was forfeited, so they could only profit on Services.
After 1997 there was no distinction so profits could be made from either component, so the quality of care declined, usually with lower staffing levels.
Some private-for-profit nursing homes have good care, but this is not common. Some not-for-profits also had very poor care, but the general rule is that the standard of care relates to the number and training of staff. The low wages (approximately equals $20 per hour) mean that the staff need to work multiple jobs in multiple locations which is what spread the COVID epidemic in Melbourne. Government run homes tended to have better staffing ratios, so were better able to act against the infection.
Professor Joseph Ibrahim commented that the terms of reference of the current Royal Commission on Aged Care were very narrow, only covering 5 years, and could not lead to prosecution. He felt that this was deliberate. The issues of overprescribing and assault have come up often.
He felt that this meant that it’s conclusions might be weaker and then not implemented, with a tendency to kick difficult problems down the road.
The commissioners themselves were of interest:
Richard Tracey had died before the enquiry started
Another, a Western Australian prosecutor had opted out (an unusual action as being on a Royal Commission is normally a good career move).
The two final commissioners are:
Tony Pagoni, Chairman- a retired judge who had had a specialisation in tax law and
Lynette Briggs- a career health bureaucrat
Commissioner, Briggs has put out a report asking that aged care be returned to the control of the health department. Prof Ibrahim comments that is very unusual for one Commissioner to make a public statement before the final report and this indicates that the commissioners are not in agreement.
Currently there are about 250,000 care workers and about 200,000 Professionals. The care workers need six weeks training at a TAFE level to get a ‘Certificate 3’ About 1/3 are new migrants. They are paid about $20 per hour and casualised to decrease staff costs. The unions are worried that the new RECP (Regional Comprehensive Economic Partnership) trade treaty actually allows trade in people and that more visas for cheap labour in these areas will not help residents or local jobs.
The $20 billion dollar industry is founded approximately $14.5 billion from government, $4 billion from RADS and $2-4 billion for additional services.
There are not-for-profits, but the large for-profit providers have increased since the 1977 act and are largely highly profitable big corporations, some multinational like BUPA.
Professor Ibrahim is concerned that there is a lack of supervision.
There are no forensic accountants looking at what it costs to run an aged care facility and this has allowed supernormal profits by big players. Money has been spent poorly or ‘hived off’. Obviously if the government runs some homes themselves there will be public service experience.
Prof Ibrahim believes that the future directions of aged care will be set by the multinational for-profit providers because these are the people who have direct access to the government. There is no significant advocacy for aged care residents. He contrasts this with breast cancer advocates who pressed for less radical operations, and for Gay men who pressed for more enlightened AIDS/HIV policies.
There have been discussions of ‘quality-of-life’ that have tended to be spoken of as needing less healthcare, but quality of life cannot be good without good health care.
The aged care industry likes home care as it lessens their costs and also pushes the liability back onto GPs. A sense of proportion is necessary:
There are 2.5 million well older people and 200,000 in aged care.
More radical treatments are now done in older age groups such as dialysis or cardiac surgery in the over 90s, very is some debate over this period some would say that it is a just to deny routine treatments but there is some distortion of priorities by having these lucrative procedures as fee-for-service, and there is also some inequity.
Since the development of antibiotics, medicines are seen as curative, but in fact they should be seen as being in three classes:
1. Curative
2. Palliative
3. Preventative
There is quite a lot of cost-ineffective medication use, such as for osteoporosis.
Solutions. (These are not just from the presenters)
A national registration system for all levels of care workers period this should include people who do home help with shopping cleaning and gardening as well as Medical & personal care workers.
Existing TAFE courses should be recognised but more courses will be needed.
There needs to be a feedback database for complaints/praises and ratings as there is for AirBNB, restaurants etc. The feedback database needs to be actively monitored by the regulator to follow up complaints or untoward events.
There needs to be a regulation system with accreditation and regular random inspections of facilities and surveys of residence.
Academic researchers such as AIHW (Aust. Institute of Health and Welfare) should be at arm’s length and should have long-term commissions to do longitudinal studies of aged welfare and satisfaction so that individuals cannot be targeted if they state that they are not happy with the care in their institutions.
This should be combined with health research.
There should be formal structured feedback systems with residents’ groups having paid advocacy groups and formal places and rights on regulatory bodies.
There must be minimum wages and conditions for all workers and minimum staffing standards.
The Regulatory body must have a policing function, supervising staffing and wage levels and food and care standards
Final Comment
Note there are a large number of public submissions on the Royal Commission website, many of which make discouraging reading. The privatisation seems to have led to profit-seeking rather than an improvement in care, and the political forces seem likely to continue this.
About 37 years ago BUGA UP (Billboard Utilising Graffitists Against Unhealthy Promotions) identified the problem of advertisers marketing to children and produced a guide, ‘AdExpo- A Self-Defence Course for Children’. It was in black and white as BUGA UP had no money and the ads are a bit dated now, but the text us still relevant. www.bugaup.org/publications/Ad_Expo.pdf
Advertisers market to children, and are successful with it. Now there is the internet, which has made things a lot worse. Kids can be targeted with the parents only dimly aware of what is going on, and before the kids have actually been formally ‘taught’ anything. The ads are part of the exciting environment that their little heroes show them. At last attention is being drawn to this. This article is from the NY Times, with a cut-down version in the SMH of 7-8/11/20.
Popular YouTube channels often bombard young children with thinly veiled ads for junk food, a new study finds.
One of the most popular YouTube videos from Ryan’s World shows its star, Ryan Kaji, pretending to be a cashier at McDonald’s. “It’s a stealthy and powerful way of getting these unhealthy products in front of kids’ eyeballs,” a public health expert says.Credit…via YouTube
That is the conclusion of a new study published on Monday in the journal Pediatrics. The authors of the study analyzed over 400 YouTube videos featuring so-called kid influencers — children with large social media followings who star in videos that show them excitedly reviewing toys, unwrapping presents and playing games. The study found that videos in this genre, which attract millions of young followers and rack up billions of views, were awash in endorsements and product placements for brands like McDonald’s, Carl’s Jr., Hershey’s, Chuck E. Cheese and Taco Bell.
About 90 percent of the foods featured in the YouTube videos were unhealthy items like milkshakes, French fries, soft drinks and cheeseburgers emblazoned with fast food logos. The researchers said their findings were concerning because YouTube is a popular destination for toddlers and adolescents. Roughly 80 percent of parents with children 11 years old or younger say they let their children watch YouTube, and 35 percent say their children watch it regularly.
A spokeswoman for YouTube, citing the age requirement on its terms of service, said the company has “invested significantly in the creation of the YouTube Kids app, a destination made specifically for kids to explore their imagination and curiosity on a range of topics, such as healthy habits.” She added, “We don’t allow paid promotional content on YouTube Kids and have clear guidelines which restrict categories like food and beverage from advertising on the app.”
Young children are particularly susceptible to marketing. Studies show that children are unable to distinguish between commercials and cartoons until they are 8 or 9 years old, and they are more likely to prefer unhealthy foods and beverages after seeing advertisements for them.
Experts say it is not just an advertising issue but a public health concern. Childhood obesity rates have skyrocketed in recent years: Nearly 20 percent of American children between the ages of 2 and 19 are obese, up from 5.5 percent in the mid 1970s. Studies have found strong links between junk food marketing and childhood obesity, and experts say that children are now at even greater risk during a pandemic that has led to school closures, lockdowns and increased screen time and sedentary behavior. The new findings suggest that parents should be especially wary of how children are being targeted by food companies on social media.
“The way these branded products are integrated in everyday life in these videos is pretty creative and unbelievable,” said Marie Bragg, an author of the study and an assistant professor of public health and nutrition at the New York University School of Global Public Health. “It’s a stealthy and powerful way of getting these unhealthy products in front of kids’ eyeballs.”
Dr. Bragg was prompted to study the phenomenon after one of her co-authors, Amaal Alruwaily, noticed her young nieces and nephews obsessively watching YouTube videos of “kidfluencers” like Ryan Kaji, the 9-year-old star of Ryan’s World, a YouTube channel with 27 million subscribers, formerly named Ryan ToysReview.
The channel, run by Ryan’s parents, features thousands of videos of him excitedly reviewing new toys and games, doing science experiments and going on fun trips to stores and arcades.
Children’s channels like Ryan’s World — which are frequently paid to promote a wide range of products, including toys, video games and food — are among the highest grossing channels on YouTube, raking in millions of dollars from ads, sponsored content, endorsements and more. According to Forbes, Ryan earned $26 million last year, making him the top YouTube earner of 2019. Among the brands he has been paid to promote are Chuck E. Cheese, Walmart, Hasbro, Lunchables and Hardee’s and Carl’s Jr., the fast food chains. One of his most popular videos shows him pretending to be a cashier at McDonald’s. In it, he wears a hat with the McDonald’s logo, serves plastic Chicken McNuggets, cheeseburgers and French fries to one of his toys, and then eats a McDonald’s Happy Meal. The video has been viewed about 95 million times.
“It looks like a normal child playing with their normal games, but as a researcher who studies childhood obesity, the branded products really stood out to me,” Dr. Bragg said. “When you watch these videos and the kids are pretending to bake things in the kitchen or unwrapping presents, it looks relatable. But really it’s just an incredibly diverse landscape of promotion for these unhealthy products
In a statement, Sunlight Entertainment, the production company for Ryan’s World, said the channel “cares deeply about the well-being of our viewers and their health and safety is a top priority for us. As such, we strictly follow all platforms terms of service, as well as any guidelines set forth by the FTC and laws and regulations at the federal, state, and local levels.”
The statement said that Ryan’s World welcomed the findings of the new study, adding: “As we continue to evolve our content we look forward to ways we might work together in the future to benefit the health and safety of our audience.”
Other popular children’s channels on YouTube show child influencers doing taste tests with Oreo cookies, Pop Tarts and Ben & Jerry’s ice cream or sitting in toy cars and ordering fast food at drive-throughs for Taco Bell, McDonald’s, Burger King, KFC and other chains. “This is basically a dream for advertisers,” said Dr. Bragg. “These kids are celebrities, and we know from other rigorous studies that younger kids prefer products that are endorsed by celebrities.”
To document the extent of the phenomenon, Dr. Bragg and her colleagues identified five of the top kid influencers on YouTube, including Ryan, and analyzed 418 of their most popular videos. They found that food or beverages were featured in those videos 271 times, and 90 percent of them were “unhealthy branded items.” Some of the brands featured most frequently were McDonald’s, Hershey’s, Skittles, Oreo, Coca-Cola, Kinder and Dairy Queen. The videos featuring junk food have collectively been viewed more than a billion times.
The researchers could not always tell which products the influencers were paid to promote, in part because sponsorships are not always clearly disclosed. The Federal Trade Commission has said that influencers should “clearly and conspicuously” disclose their financial relationships with brands whose products they endorse on social media. But critics say the policy is rarely enforced, and that influencers often ignore it.
McDonald’s USA said in a statement that it “does not partner with kid influencers under the age of 12 for paid content across any social media channels, including YouTube, and we did not pay or partner with any of the influencers identified in this study. We are committed to responsibly marketing to children.”
Last year, several senators called on the F.T.C. to investigate Ryan’s World and accused the channel of running commercials for Carl’s Jr. without disclosing that they were ads. The Council of Better Business Bureaus, an industry regulatory group, also found that Ryan’s World featured sponsored content from advertisers without proper disclosures. And a year ago the watchdog group Truth in Advertising filed a complaint with the F.T.C. accusing the channel of deceiving children through “sponsored videos that often have the look and feel of organic content.”
In March, Senators Edward J. Markey of Massachusetts and Richard Blumenthal of Connecticut introduced legislation to protect children from potentially harmful content online. Among other things, the bill would limit what they called “manipulative” advertising, such as influencer marketing aimed at children, and prohibit websites from recommending content that involves nicotine, tobacco or alcohol to children and teenagers.
The F.T.C. has long forbidden certain advertising tactics on children’s television, such as “host selling,” in which characters or hosts sell products in commercials that air during their programs. Critics say the agency could apply the same rules to children’s programs on the internet but so far has chosen not to.
“It’s beyond absurd that you couldn’t do this on Nickelodeon or ABC but you can do this on YouTube just because the laws were written before we had an internet,” said Josh Golin, the executive director of the Campaign for a Commercial-Free Childhood, an advocacy group.
“These videos are incredibly powerful,” he said. “Very busy parents may take a look at them and think that it’s just a cute kid talking enthusiastically about some product and not realize that it’s often part of a deliberate strategy to get their children excited about toys, or in the case of this study, unhealthy food.”
Anahad O’Connor is a staff reporter covering health, science, nutrition and other topics. He is also a bestselling author of consumer health books such as “Never Shower in a Thunderstorm” and “The 10 Things You Need to Eat.”
It seems that COVID-19 affects not only the lungs, but the heart, kidney, brain, gut, clotting and blood vessels, and that a lot of facts are still not clear.Here is an article from ScienceMag from the Australian Association for the Advancement of Science.www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes
Sweden likes to present itself as a highly sophisticated welfare society where a caring State looks after all its citizens. But conservative governments have been quietly undermining its welfare system for some time, and this opening up of the country and talk of ‘herd immunity’ may be both hypocritical and very poor public policy.
The assumption that healthy people will not die, and the rest do not matter is a very callous moral judgement. The assumption that without normal commerce the economy will not function and thus it is the economy versus a few oldies welfare is a morally appalling position, which is creeping in by default.
When I was a NZ sheep and beef farmer standard practice was that the breeding females had a performance criterion. If they did not get pregnant before winter, they went to the abattoirs as they were too expensive to feed over winter.
Managers love performance criteria, and as Management now dictates political actions people now have to perform also. Not strong enough to survive a COVID19 infection? Funeral for you! It is assumed that the rest will be infected once and then be immune. And when most people have been infected so that the virus cannot propagate in the society, we (hopefully) have ‘herd immunity’.
Politics being what it is, things have to dressed up a bit. Less tests, fewer masks, omit certain types of hospitals, change the death certification. Do not state the policy bluntly, and give no mandatory orders from the top, but make it vague enough with scope for non-implementation of best practice and plausible deniability. Make concerned statements of good intent, select some good figures to quote, and praise the people for their fortitude. If the odd whistleblower says something and manages to get publicity, be surprised, deny, promise to investigate and call it a ‘one off’ case or situation.
Brave New World is here. The only surprise is that it has started in Sweden.
3 May 2020 In a move that will surely damage it credibility the Australian Electoral Commission has approved a name change for the ‘Involuntary Medication Objectors (Vaccination/Fluoride) Party’ to be called the ‘Informed Medical Options Party’. Amazingly this was under the Australian Electoral Act, as it did not allow confusion with another party, was not […]
30 April 2020The US health system which is largely private is poorly set up to handle a pandemic. It is set up to make money, so is not flexible when different equipment and procedures are needed. Added to this 12% of people have no health care insurance, so cannot get healthcare and of those insured, […]
30 April 2020 People are asking why people getting sick with COVID-19 in aged care homes are not on ventilators. The reason is probably that the ventilators are unlikely to save them. One also needs to ask what is the Key Performance Indicator of an ICU. When I worked in them, it was leaving the […]
People are asking why people getting sick with COVID-19 in aged care homes are not on ventilators. The reason is probably that the ventilators are unlikely to save them. One also needs to ask what is the Key Performance Indicator of an ICU. When I worked in them, it was leaving the unit alive. The statistics of this have always been improving, because as the units get bigger they take less sick patients. It the unit has 4 beds as they used to, and have the 4 sickest patients in the hospital, they will have much worse survival statistics than if they take 40 patients including a lot who are scheduled to go there for a few days after elective heart or other surgery. But the question still remains for the ones that did not get there in a planned way, what level of life-functioning will they have after discharge? Is no one allowed to die without some time on a ventilator, however hopeless the quest and whatever their quality of life after discharge?
A new survival study of COVID-19 has been published in JAMA (Journal of the American Medical Association) from a number of hospital in New York. It is an incomplete study in that its final results are not available, published presumably in haste to get some results out. It looked at 5,700 patients, but only had results for 2634 who had reached an end-point, they had either been discharged or died. (The other 3066 are still in hospital). 14% of the 2634 needed to go to ICU and 12% needed to be intubated (i.e. on a ventilator with a tube down to the lungs). Of those who needed intubation in the 18-65 year age group 76% died and in the over 65s 97% died. 3% needed kidney replacement therapy (dialysis). Overall 21% (553/2634) died.
It might be noted, however that no one under the age of 20 died, and the 5700 were not entirely typical citizens in that their median age was 63, and they had co-morbidities; 57% were hypertensive, 41% were obese and 34% had diabetes.
At the time of triage (assessment for admission) 31% had fever, 17% had a respiratory rate greater than 24/min and 28% needed extra oxygen. This is relevant as there is a lot of discussion as to what are the most important signs and symptoms. (Cough was not mentioned in the article).
The New York JAMA results are not dissimilar to an earlier Wuhan Study from The Lancet (24/2/20 Xiaobo Yang et al) studying the outcome of 710 hospital patients. Of these 52/710 were classified as critical (7%). Of the 52, 29 needed ICU for ventilator support (= 56% of the hospital admission and 4% of the total). Of the 29 who needed ventilatory support, 22 needed intubation and of these 19 died and 3 survived. (i.e. 86% of those who needed to go on ventilators died). Of the 29 who needed ventilatory support, 23 died (76%).
To compare the survival; in the US study, 14% of hospital admissions went to ICU and 21% of these died, which is roughly 3% of the number admitted. In the Wuhan study 4% of the total patients needed ICU and 76% of these died, giving a mortality of about 3% also.
There is a lot of difference between countries in terms of the number of cases and the fatality rate. Looking at the numbers on worldometerinfo/covid today the UK leads the fatality rate with 15.8%, followed by Belgium 15.7%, France 14.5%, Italy 13.6%, Sweden 12.3%, Netherlands 12.1%, and Spain on 10.3%. Next there is quite a drop to the next group with Switzerland on 5.8%, the USA on 5.8%, Denmark on 4.4%, Germany and Portugal on 4.0%, Austria on 3.2% and Norway on 2.6%. The USA is earlier in the epidemic, which may make its numbers lower, but the question is why Germany and Denmark can do so much better than adjacent France and the Netherlands. Perhaps it is because they have managed to stop it getting into their old people’s facilities where the fatality rate is much higher. Australia and New Zealand are looking very good at 1.3%, which may be for the same reason- many of our cases were contacts from cruise ships, and two nursing homes here have had conspicuously high death rates, but one might reflect that there are only two of them. The lesson from this is that it is very important to isolate certain areas, and of course if its gets into vulnerable populations where isolation is difficult, such as Aboriginal communities with many transient members, it will not be able to be traced and controlled and there will be ongoing infections forever.
The nursing home managers resisting the government’s more open policy have very sound reasons, and the danger of opening up society when ‘community acquired’ infections are still occurring is high. Undiagnosed cases have a high chance of infecting vulnerable populations which will either result in a lot of deaths or an ongoing source of infections or both.
Australia’s figures today from the health.gov.au COVID website are that there have been 6753 cases in Australia, of which 5714 have recovered and 91 have died. This leaves 948 cases of which 34 are in ICU and 89 are in hospital. (It is not clear whether the 34 are included in the 89). This means that there are either 859 or 825 still active cases that are not in hospitals. There were 8 new cases yesterday, so the other question is whether they came from quarantined people, who hopefully will not spread the infection, or ‘community acquired’ cases, still popping up at random and in danger of infecting a new group.
20 September 2019 VALI is the name the Centre for Disease Control has given to the new epidemic of lung disease that is putting young people in hospital on ventilators and has killed a few people. It is not clear what the problem is as there does not seem to be a common feature in […]
