Chapter 3Preventable drivers of excess mortality
3.1This chapter considers preventable drivers of excess mortality during 2020–2023 in terms of:
preventable diseases as contributors to excess mortality, including diabetes, cardiovascular disease, and some cancers;
preventable structural drivers of excess mortality, including geographic health disparities and First Nations’ health disparities; and
Australia’s preparedness for future health crises by considering the lessons learnt from the COVID-19 pandemic in relation to preventive health measures, vaccination and public health information.
Preventable diseases as contributors to excess mortality
3.2In addition to the evidence discussed in Chapter 2 that indicated COVID-19 was the main driver of excess mortality from 2021 to 2023, the committee also received evidence on the potential impact that diabetes, cardiovascular disease, and cancer had on excess mortality during the same period.
3.3These are explored below to illuminate the extent to which these (sometimes) preventable diseases drove excess mortality and gives consideration as to why this occurred.
Diabetes
3.4As discussed in Chapter 2, submitters identified diabetes as a driver of high numbers of deaths and excess mortality throughout the pandemic years. For example, Ms Lauren Moran, Director, Health and Vital Statistics Section at the Australian Bureau of Statistics (ABS) discussed diabetes as a driver of excess mortality, as well as its link to COVID-19, at a public hearing:
There has been some excess mortality in deaths due to diabetes, and some deaths due to diabetes are also considered preventable. Some of these are still likely to be associated with COVID-19 itself—we know that people with diabetes can be highly immunocompromised and more susceptible to infections—but some of that may also be management of health care during the pandemic and not accessing those services.
3.5Relatedly, in its submission, Diabetes Australia raised concern about the high levels of excess deaths that have been attributed to diabetes. Diabetes Australia drew attention to reporting by the ABS that the baseline average in 2023 for diabetes deaths was 4689, but that the number of deaths were 5609 in 2022 and 5403 in 2023. As such, Diabetes Australia noted that diabetes reflected the largest proportion of excess deaths for any cause, apart from COVID-19.
3.6In its submission, Diabetes Australia also explored the likely reasons for excess deaths from diabetes where COVID-19 was not the underlying cause or a contributing factor. It cited the Actuaries Institute’s COVID-19 Mortality Working Group’s findings for 2022, which included:
The impact of [having had] COVID-19 on subsequent mortality risk, including diabetes;
Delays in emergency care, particularly at times of high prevalence of COVID-19 and or/influence; and
Delays in routine care, which refers to missed opportunities to diagnose or treat non-COVID-19 diseases and the likelihood of consequent higher mortality from those conditions in future.
3.7Diabetes Australia also underlined similar findings from the AIHW, which identified an ‘emerging global issue’ where people avoided or delayed medical care for diabetes during the pandemic. Diabetes Australia commented on this occurrence in Australia, and noted associated healthcare resourcing challenges throughout the pandemic:
… reduced access to primary care, diagnostic and hospital services for diabetes, combined with fear of exposure to the virus in these settings, led to a significant drop in access to usual diabetes care. From the diabetes care perspective, there was a significant and concerted diversion of hospital resources and staff to COVID-19 specific activities, and there was a reduction in HbA1c testing (the main biomarker used to assess long-term glycaemic control) amongst people with type 2 diabetes.
Cardiovascular disease
3.8The committee received similar evidence that pointed to cardiac conditions as leading causes of death and preventable drivers of excess mortality during 2021–2023. At a public hearing, Professor Garry Jennings, Chief Medical Adviser at the National Heart Foundation of Australia (the Heart Foundation), discussed the findings of an AIHW report, and told the committee of the preventable nature of cardiovascular disease:
In that 2022 report, the top five things that were listed on the death certificates were coronary heart disease, on 20 per cent; dementia, on 18 per cent; hypertension, on 12 per cent; cerebrovascular disease, including stroke; 11 per cent; and diabetes, also 11 per cent. It's really of interest that all of these are related to cardiovascular disease. They're either heart disease itself, coronary disease, they're risk factors for heart disease, like hypertension or diabetes, or stroke, another kind of vascular disease … they're all preventable; they're all treatable earlier in life …
3.9The Heart Foundation informed the committee that cardiovascular disease was the underlying cause of approximately 25 per cent of COVID-19 related deaths from 2021 to 2023. The ABS also identified chronic cardiac conditions (including coronary heart disease) as one of the most common pre-existing diseases among those who died from COVID-19.
3.10The Heart Foundation noted that during the pandemic, there were ‘significant delays in people seeking treatment for cardiovascular emergencies and general health care reviews’. The Heart Foundation expanded that lockdowns and ‘stay-at-home’ messaging from the government, coupled with a fear of exposure to COVID-19 in a healthcare setting, could have contributed to delays in seeking treatment.
3.11This aligns with the observed reduced rate of screening, which the Stroke Foundation identified in an answer to a question on notice:
The National Heart Foundation of Australia has estimated that 27,000 fewer Heart Health Checks were conducted due to COVID-19. Specifically, between March 2020 to March 2021, 92,380 heart health checks were undertaken.
3.12The AIHW concluded that concluded that ongoing monitoring will be important to determine the impact of COVID-19 on cardiovascular diseases and diabetes, as well as the overall health of the population.
Cancer
3.13Some inquiry participants raised concerns that cancer cases and deaths had increased during the pandemic years. The Department of Health and Aged Care (the Department) explained that cancer deaths have indeed been increasing, but that this is due to increases in population size and ‘increasing numbers of people reaching older ages for which cancer incidence rates are higher’.
3.14As such, Ms Moran from the ABS told the committee at a public hearing that ‘[s]ome cancers are considered preventable’ but noted that in terms of excess mortality, ‘we haven't seen an increase in cancer at all’.
3.15The AIHW also noted that the age‑standardised mortality rate for cancer has been declining:
In looking at trends over the past decade, the number of deaths and age‑standardised mortality rates for cancer in 2021 and 2022 are in line with what would be expected based on past trends. While the number of cancer deaths has been steadily increasing, the age-standardised mortality rate (for all cancers combined) has been slowly declining from 169 per 100,000 in 2012 to 159 per 1,000 in 2019, and to around 152 per 100,000 in 2020, 2021 and 2022 (AIHW 2023a; AIHW 2024a).
3.16Similar to the lower screening rates for Australians with diabetes and cardiovascular disease, the Department also reported on delayed or missed cancer screening and procedures. However, it noted that the impact of the pandemic on national screening programs cannot be quantified without further years of data.
3.17Ms Moran commented on the potential impacts of missed cancer screening on the population:
Of course, regarding some screening programs, it may take a long time for somebody to die of cancer, so that's something that we would need to monitor on an ongoing basis, but it certainly hasn't been the case so far.
3.18The committee also received evidence that indicated a possible link between COVID‑19 vaccines and cancer. In response to this suggestion, the Department stressed that ‘neither the [Therapeutic Goods Administration] nor any international regulator has detected any safety signals to indicate that COVID‑19 vaccines are associated with any type of cancer’.
Preventable structural drivers of excess mortality
3.19This section considers preventable structural drivers of excess mortality by exploring the health disparities experienced by Australians living in rural and regional Australia, as well as First Nations peoples.
Geographic health disparities
3.20Despite existing data gaps (as identified in Chapter 2), Ms Susanne Tegen, Chief Executive Officer of the National Rural Health Alliance (NRHA), confirmed that excess mortality was higher in regional areas compared to metropolitan areas during the pandemic years.
3.21In its submission, the NRHA informed the committee that the pandemic exacerbated existing health inequities for rural, remote and regional Australians due to ‘inadequate health resourcing’, where these Australians have a ‘lower life expectancy, higher burden of disease, and an increased rate of potentially avoidable deaths’.
3.22Further, the NRHA raised that on average, rural Australians are more likely to die at a younger age than their metropolitan counterparts, and the rate of potentially avoidable deaths and burden of disease also increase with remoteness.
3.23The NRHA noted that rural healthcare services have ‘less healthcare infrastructure,’ such as hospitals and intensive care units, that can support complex cases of COVID-19. As such, it suggested that this ‘may have contributed to COVID-19-related mortality in rural Australia’. The NRHA also contended that delayed healthcare utilisation may have also contributed to increased rural mortality rates.
3.24The NRHA claimed that ‘findings of missed and delayed care’ are supported by Australian data for rural and remote areas. It pointed to the Royal Flying Doctors Service’s (RFDS) ‘Best for the Bush Report 2022’, which noted a ‘25 per cent increase in priority one aeromedical retrievals post COVID-19’. The NRHA commented that this suggests the RFDS was:
… retrieving patients who were sicker, later in the course of their disease or illness at this time. The RFDS attributes this to additional reductions in access to primary healthcare during the pandemic.
3.25In order to address geographic health disparities, the NRHA recommended that the development and implementation of a National Rural Health Strategy, which would be ‘targeted at achieving outcomes and equity for rural Australians’.
3.26The NRHA expanded that focussing the National Rural Health Strategy on ‘multidisciplinary care that is flexible and responsive to local needs will be a significant measure in driving health outcomes forward’.
First Nations’ heath disparities
3.27The National Aboriginal Community Controlled Health Organisation (NACCHO) noted that avoidable and preventable deaths are already a considerable burden on Aboriginal and Torres Strait Islander communities. It explained that this is owing to a ‘broad range of structural, social, commercial, political, environment and cultural determinants’ that influence the health of Aboriginal and Torres Strait Islander peoples.
3.28NACCHO stated that this results in a significant health disparity, where 34 per cent of the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians is attribute to ‘social determinant factors’.
3.29The health outcomes disparities were mirrored in data highlighted by the NRHA, which illustrates the disproportionate impacts of COVID-19 on First Nations people in all geographic regions throughout Australia:
… deaths from or with COVID-19 to 28 Feb 2023 in non-Indigenous people occurred at the highest rate in major cities and reduced with remoteness; in contrast, deaths from or with COVID-19 in Aboriginal or Torres Strait Islander people occurred at a similar rate in major cities and inner/outer regional areas but were 1.3 times more likely in remote/very remote areas. The death rate was higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people in all geographic regions, increasing with remoteness – 1.5 times higher in major cities and 3.7 times higher in remote/very remote areas.
3.30As such, NRHA remarked that COVID-19 deaths data indicated a ‘disproportionate burden of death in First Nations people, with increased burden in remote and very remote’ areas of Australia.
Australia’s preparedness for future health crises
3.31Noting the above discussion of preventable diseases and preventable structures as drivers of excess mortality, the committee received evidence on potential recommendations to address preventable drivers of excess mortality going forward. These are explored further below.
Preventive health measures and a resilient healthcare system
3.32Some submitters raised the importance of preventive health measures when discussing potential ways to drive down future excess mortality. For example, the Royal Australian College of General Practitioners stated that the leading causes of death and disability in Australia are either preventable, or able to be delayed by early treatment and intervention.
3.33Noting the importance of preventive healthcare, the Department outlined existing measures that it suggested ‘will likely assist in maintaining downward pressure on excess mortality’. This included:
ongoing promotion and provision of COVID-19 and influenza vaccination for the population, particularly for high-risk cohorts;
ongoing infection prevention and control measures to reduce the impact and spread of communicable diseases like COVID-19 and influenza in high‑risk settings, like hospitals or aged care homes; and
opening of Medicare Urgent Care Clinics to reduce the pressure on emergency departments and general practice.
3.34However, as earlier discussed, access to healthcare services were disrupted during the pandemic. This finding was echoed by the Stroke Foundation, who observed that a variety of factors during the pandemic, such as lockdowns, a diversion of staff and resources to provide COVID‑19 specific care, the suspension or cancellation of screening services and health check-ups ‘have compromised key aspects of chronic disease management and preventive care’.
3.35Noting the disruptions to healthcare during the pandemic, some submitters recommended that going forward, the Australian Government should strengthen the resilience of the healthcare system.
3.36For instance, the Heart Foundation recommended that the government ‘should build a framework capable of managing surges in demand caused by pandemic and other emergencies’ which should also be able to provide everyday healthcare services. It contended that this would include ‘maintaining access to critical services’, which would safeguard long-term health ‘even during public health crises.’
3.37The NRHA was of a similar view, specifically in relation to rural healthcare. It recommended planning for periods of increased rural hospital admissions (for example, due to seasonal respiratory viruses) and designing interventions to bolster the healthcare workforce.
3.38This was echoed by NACCHO, who emphasised the particular need for Aboriginal and Torres Strait Islander communities to be able to access comprehensive primary health care in a culturally safe setting. It noted that Aboriginal Controlled Community Health Organisations are a key part of the preventive healthcare system for Aboriginal and Torres Strait Islander people, as they are ‘uniquely placed to address the social determinants of health’.
3.39The Stroke Foundation acknowledged that the Australian Centre for Disease Control is in the process of being established, which will focus on ‘improving our response and preparedness for public health emergencies’. However, it also recommended that the Australian Government should:
… work closely with the primary care sector to identify and implement specific solutions aimed at avoiding the suspension or cancellation of screening services, routine health check-ups, and diagnostic tests during times of national emergency, ensuring chronic disease management and preventive care are not compromised.
Vaccination
3.40Whilst some submitters raised concerns that COVID-19 vaccines caused excess deaths, the Department advised that there is a growing body of research that confirms COVID-19 vaccines ‘are very effective at reducing risk of severe disease and death associated with SARVS-CoV-2 infection’. The Department also highlighted that in countries where community-wide infection was occurring, a more rapid roll-out of vaccination was associated with lower excess mortality than those with a slower vaccination roll-out.
3.41Asthma Australia expressed its support for all immunisation products that may help reduce asthma exacerbations and deaths, and particularly noting COVID‑19, influenza and RSV immunisation products as being important to helping people with asthma ‘maintain their condition’ and ‘staying out of hospital’.
3.42Similarly, the Actuaries Institute asserted that COVID-19 vaccines ‘significantly reduced excess mortality’ and was of the view that excess mortality would be reduced if there was a greater uptake of vaccination against infectious diseases, such as COVID-19.
Public health information
3.43Going forward, the Heart Foundation highlighted the need for targeted public health communications during pandemics. It raised the need for all governments to provide ‘clear, consistent, and frequent public health communications about the safety and availability of medical services’ at such times.
3.44The Heart Foundation also endorsed working with community organisations to assist with disseminating health information to ‘build trust and encourage adherence to appropriate healthcare’ and noted that ‘there needs to be learnings from the COVID-19 pandemic that mainstream health messaging did not reach certain parts of the community’.
3.45Relatedly, the NRHA recognised the importance of ensuring accurate information is provided by governments equitably across the country, and in formats that are relevant ‘to particular populations’. It noted studies that have identified risk factors of lower health literacy being linked to misperceptions about COVID-19 vaccination.
3.44The NRHA also stressed that it is crucial that the media provide evidence-based information, ‘rather than advertorial or promoting misinformation to sensationalise, to the public’.