Deep thought?

The last few days I've found myself thinking about stuff that just takes too long to talk about to make a good blog post. The blogging form imposes a discipline, which is all to the good, but it can become procrustean at times. I really need to construct a long essay, and this just ain't the place for that.

So, I hope y'all won't begrudge me the day off -- from blogging anyway. And who knows, I might suddenly get inspired to do something later today anyway. But maybe not.

They're all wasted

Ari Hoffman and Steven Pearson, in Health Affairs, provide highlights of medical waste, by which they don't mean used needles, surgical sponges and ascending colons, but rather squandered resources. Distinguishing among the different kinds of waste is important to the political "discussion" we're having right now. The scare quotes are because it's mostly people in separate booths yelling past each other, with facts and logic often in short supply.

First, there's the kind they mention in passing but do not discuss, "excessive administrative costs, misused and wasted materiel, and inefficiencies such as duplicate testing and unnecessary physician visits generated by uncoordinated care." They say nothing further about this, but I will tell you right now that there is a simple, elegant solution that can eliminate almost all of this and has already done so just a a few feet away from Detroit: universal, comprehensive, single payer, national health care. But I digress.

Hoffman and Pearson are actually concerned about the kinds of waste Barack Obama is talking about when he discusses comparative effectiveness research, and Republicans are defending as essential to our freedom: medical interventions that might not be worth it but happen anyway. The subtlety is that they aren't all created equal. H&P identify 4 kinds of questionable interventions:

1. Inadequate evidence of comparative net benefit for any indication;


2. Use beyond boundaries of established net benefit;


3. Higher cost when established benefit is comparable to other options; and


4. Relatively high cost for incremental benefit compared to other options.

As to the first item on the list, it may surprise you to know that a lot of the drugs and medical devices that are widely sold, and surgical procedures that are commonly used, lack any scientific evidence for effectiveness whatsoever. Surgical procedures do not require FDA approval nor any evidence of benefit for doctors to use them, and medical devices can win approval on very flimsy evidence. But even drugs can be approved based on short-term comparison with placebos. They don't have to show that they are better than existing, cheaper drugs, nor that they provide any long-term benefit. That's just plain dumb, and the only reason we have that policy is so that drug companies can get patents on drugs for which there are cheap generic alternatives, without having to prove that their patented drugs are better, and then spend money on TV advertising and efforts to influence doctors so that the more expensive, and quite possibly worse, but new and exciting, drug gets prescribed.

The second item reflects a quirk in the law. Once a drug or device has FDA approval, doctors can prescribe or use it for any purpose whatsoever, which is called "off-label" prescribing. Companies aren't supposed to market drugs for off-label uses, but they do it anyway. Sometimes, the fines are just a worthwhile cost of doing business; more often the companies just get away with it because of lax enforcement.

While we might imagine that most people would readily agree that these practices ought to be curtailed, physicians as a class are against greater restrictions. They tend to see this as a question of professional autonomy and the right to exercise their clinical judgment, which they believe is more powerful than scientific evidence. Many consumers, I must admit, feel the same way. They flock to the GNC and buy mass quantities of stuff for which there is even less evidence of usefulness than there is for SSRIs -- and that's saying something. They trust decision rules (what we eggheads call heuristics) which are different from the ones used in clinical trials, and they expect their doctors to do the same.

The third and fourth categories are rather different. We know the stuff works, but either it costs more than something else that probably works almost as well, or it costs a huge amount and delivers what most people would consider a very small benefit. An example of the latter is paying tens of thousands of dollars for chemotherapy that can be expected to extend the life of a person with cancer by a few weeks. These are the kinds of issues that come up in the UK from time to time when the National Health Service refuses a treatment to some desperate person, and this is where the "rationing" rubber really hits the road.

If we could cut through the mass media tornado of trash talk and have a reasoned discussion, I expect most people would agree that we ought to try to have the best possible evidence for what works best under what circumstances, and we ought to stop mucking around with our bodies in ways that don't actually make us better, might make us worse, and cost a lot -- our God-given right to make choices that bankrupt and harm us is probably secondary, notwithstanding Betsey McAughey, John Stossel and Sam Brownback.

However, when it comes to the question of how much is worth spending to maybe benefit a sick person a little bit, the conversation does admittedly get more difficult. People have a glib reaction that "you can't put a value on human life" and the idea of accountants deciding that some necessarily largely arbitrary amount -- whether it be $10,000 or $50,000 or $10 million -- is too much to spend to "save a person's life" just doesn't sit right. The response ought to be obvious, but for some reason I can't quite grasp it is not to many people.

Note first of all that it is the very same people who are decrying the prospect of "rationing," in many instances, who are also insisting that we cannot afford the cost of providing universal health care. It is also very likely to be the same people who are opposed to environmental regulation, workplace safe and healthy regulation, and social welfare programs because they are "too expensive." We can't afford the economic cost of clean air, but it would be immoral to "ration" health care. These are positions which conservatives hold simultaneously, unapologetically, and apparently completely unaware of any contradiction.

Guest post from Les Izzmoor

Les may come around again from time to time. Clearly we need to hear from him. -- C

The new BMJ (i.e., British Medical Journal), which unfortunately gives the commoners only limited access to the stuff they are probably least inclined to read, has several items of interest to us colonists as we yell and scream about rationing and bureaucrats. The tea slurping decolonization monkeys think about these things rather differently than we do; their pinko doctors offer an instructive perspective.

1. Katy Bell et al find that routine monitoring of bone density in the first three years after post-menopausal women start on the anti-osteoporosis drug bisphosonate is useless and even misleading. Save money, don't do it.


2. CC Butler and a multitude find that there are big regional variations around Europe in the likelihood that adults with coughs will be prescribed antibiotics, but there is no association with better outcomes. Overprescribing of antitbiotics, as our faithful readers know, wastes money, causes adverse effects (for one thing, it can wipe out the endosymbionts in our throats and intestines, causing opportunistic infections), and of course promotes antibiotic resistance in pathogens. In Europe, of course, there tend to be bureaucrats who could get doctors to stop doing this. They should consider restricting people's personal freedom to waste money, harm themselves, and risk the doom of humanity.


3. According to SG Thompson and colleagues, routinely screening men age 65-74 for abdominal aortic aneurysm reduces the 10 year risk of death from .87% to .46%, so according to my calculations you could save a life by screening 243 men. They figure this will cost about 7 600 pounds sterling per avoided death, which they deem worth it. Of course, these guys are already getting on so they may not have long to go even if they avoid the aneurysm, but still. Of course, this doesn't save money, it costs money, but we still might want to do it. Rescreening the guys who were negative ten years later, however, is probably not worth it.


4. Joanna Moncrief and David Cohen argue -- entirely correctly as far as ol' Les is concerned -- that psychiatric drugs, specifically "antipsychotics" and "antidepressants" -- don't really target specific underlying disease processes. No, depression is not a serotonin deficiency and psychosis is not a disorder of dopamine processing. We don't really know what the heck they are. These drugs produce altered mental states which may just happen to make some people feel better, e.g. by suppressing affect they make people with psychosis calmer. That doesn't mean they are treating the disease, however. If patients understood this -- which would first require the drug companies to stop lying about it, although they don't mention that -- they would probably consume less of these drugs, save money, and avoid side effects.


5. New results in the Archive of Internal Medicine show that people with chronic kidney disease do just fine on lower doses of drugs that increase the red blood cell count. The manufacturers, by the way, have pushed for higher doses. Natch.


6. Iona Heath is a physician who declines her own doctor's recommendation that she have screening mammograms. She writes that "for every 2000 women invited to screening for 10 years one death from breast cancer will be avoided but that 10 healthy women will be "overdiagnosed" with cancer. This overdiagnosis is estimated to result in six extra tumorectomies and four extra mastectomies and in 200 women risking significant psychological harm relating to the anxiety triggered by the further investigation of mammographic abnormalities. The percentage of women surviving 10 years if they are not screened is 90.2%; it is 90.25% if they are screened. Is this enough of a difference to risk the possibility of significant harm? For me, it is not." If more women were given this information -- which is entirely accurate, by the way -- fewer might choose to be screened.

So we Americans need to clearly understand that meaningful choice requires accurate information. The freedom to choose to waste money and harm yourself out of ignorance is the opposite of freedom, as far as I'm concerned. People need to stop degrading and abusing the word freedom: it doesn't pertain exclusively to rapacious capitalists, it needs to be our common possession.

Clear Thinking

My post yesterday about a fairly prominent pontificator who is unencumbered by the thought process was like sweeping the beach. Our public discourse is mostly a farrago of well-crafted BS. Here is a useful guide to critical thinking, the provenance of which is not revealed to us but which, as far as I can tell, is entirely trustworthy.

Stossel's argument is an example of Circular Reasoning. If you think about it, you will realize that its essential form is "nobody spends somebody else’s money as wisely or as frugally as he spends his own, therefore nobody spends somebody else's money as wisely or as frugally as he spends his own specifically on health care." But that isn't an argument at all, it's just an assertion. And once you recognize that, it's obvious that it just isn't true. Stossel combines this fallacy with the equally fallacious Appeal to Authority. By citing the false premise as the pronouncement of a famous person, he seeks to forestall us from evaluating its truth.

There's another little trick here, which is the word "nobody." That makes this an assertion of non-existence. When we first read the statement, our inclination is to nod our head and think, "That's right, I certainly prefer to decide how to spend my own money," because we don't notice that it purports to be absolute and universal. But then Stossel hopes we won't notice when he universalizes the assertion to a realm in which it clearly does not apply.

In the debate over reforming our medical financing, there is far more fallacy than reason. This is not fundamentally a debate over values, about which we might differ, it is a debate between sense and nonsense. And there is a very good reason for that: most resistance to meaningful reform comes from a small minority of wealthy and powerful people who stand to lose some of their existing, undeserved privileges.

They obviously can't go around proclaiming their real motives, so they have to muddy the waters. They do this using the standard tool in the rhetorical arsenal of the economically advantaged, the Gospel According to Friedman, which purports to be scientific and logical and wise. Actually it's a vast edifice of fallacy which begins with its innumerable glib yet either false or essentially meaningless premises. The particular Friedman aphorism at issue here is entirely typical. Economists just make assertions, treat them as axioms, and off they go. Checking in with reality is for the naive and untutored, who are too limited to comprehend the ineluctable power of their faith.

Of course there are additional fallacious arguments available. Here Media Matters runs down an RNC ad for us:

Republicans want health care reform that reduces costs across the board.

Republicans believe every single American deserves quality health care.

Republicans also believe another government takeover would diminish health care choice and quality.

President Obama talks about a, quote, public option. When he says "public option," that means putting government bureaucrats in charge, instead of patients and their doctors. It's a bad idea.

Republicans want bipartisan health care reform, a responsible plan that we can afford, where people are free to choose the best care for their families - without a government takeover.

Tell President Obama to work with Republicans, and to stop rushing into another government takeover.

Saying that "Republicans believe" something obviously doesn't make it true. Labelling the president's proposal as a "government takeover" is just name calling. Presumably we're supposed to think that's bad, just because. But what has Obama really proposed, and what will it actually do? Does the "public option" put bureaucrats in charge of something that patients and doctors are in charge of today? What specifically is that? (Hint: It's nothing that Aetna and Blue Cross/Blue Shield bureaucrats aren't in charge of right now.) Would the purported "government takeover" mean that people aren't free to choose the "best" care for their families, compared with the freedom they have now? How would it do that?

On the contrary, of course, right now your freedom is limited to physicians and hospitals who accept your insurance. (And by the way, if you had Massachusetts Blue Cross Blue Shield, you would not have been free to come to my hospital or see my doctor a couple of months ago.) With a "government takeover," you would be free to go to any doctor, hospital, or other health care insitution in the country -- which you demonstrably are not free to do today, even if you're lucky enough to have insurance at all. But words like "freedom" and "bureaucrats" and the implied threat of communism have built-in resonance.

Painfully, however, all this bamboozlement is likely to be effective. All the reactionaries have to do is throw labels around and spout theological sophistry from economics textbooks. The reporters are either too ignorant or too cowardly to call them out on it, and the Democrats -- well I don't know what the heck their problem is. They just won't confront the BS head on, all they do is duck and cover. It's pathetic.

It's actually difficult . . .

to shoot fish in a barrel, or at least I would think it is. I haven't actually tried it. Anyway, a reader implores me to once again attack the ridiculous John Stossel for engaging in the Argument from Authority:

Washington promises to control health care spending, it makes me look back at what the late Nobel Prize winner Milton Friedman wrote in 2001:

“Two simple observations are key to explaining both the high level of spending on medical care and the dissatisfaction with that spending. The first is that most payments to physicians or hospitals or other caregivers for medical care are made not by the patient but by a third party—an insurance company or employer or governmental body. The second is that nobody spends somebody else’s money as wisely or as frugally as he spends his own.”

Consumers spending their own money holds costs down in every other sector of the economy: Consumers obsess about prices; providers fight to earn their business. Trying to duplicate this process through a government board of experts is pointless.

Stossel is perpetually unencumbered by the thought process, and by those stupid things, facts. In the United States consumers already face the highest out of pocket costs for health care of any of the wealthy countries, with the exception of Switzerland, and what is more, Americans' out of pocket costs have been sharply increasing recently, even as total spending on medical services continues its relentless rise. And yet, as we have seen, we still get the worst results, even though we spend the most.

Let me give you a tip: if the conclusions of an argument are false, then either its premises are false, or there is something wrong with its logic. But Stossel is an ideologue. He believes things, not because they are true, but because they correspond to his faith, the Church of Friedman. Let's look at the Holy One's second premise, "nobody spends somebody else’s money as wisely or as frugally as he spends his own." Is this actually true?

We all know of people who have spent money unwisely and profligately, who might well have benefited from better informed or more prudent advice. And what do corporate managers do? They spend the owners' money. They are paid to do so wisely and frugally. If they succeed, as they often do, the corporation is profitable. Would you expect the shareholders to make these decisions better?

Hmm. Do you trust yourself to spend your health care dollar wisely and frugally? Suppose you have chest pain, and you go to the hospital, and the doctors want to do an angiogram. It turns out there's a $250 co-pay. You might decide that you can't afford it, and say no thanks. Have you been wise and/or frugal? Who the hell knows? Maybe you have a blocked coronary artery and you're going to go home and die, or survive your heart attack and come back and cost 200 times as much - and since John Stossel wants much of that to come out of your own pocket, it's going to bankrupt you and you'll lose your house and your kids will have to drop out of college. On the other hand, maybe you did just have indigestion and it really would have been a waste of money. But who is the best judge of those odds? You or the doctor? The problem here is not your incentive to save money, it's the nature of the doctor's incentives, since it's actually the doctor who at least putatively has the expertise to act wisely and frugally in this situation, which you entirely lack.

This argument is, in short, ridiculous on every possible ground. Its essential premise is false. It makes no sense when you subject it to a simple thought experiment. Its conclusion is demonstrably false, all you need to do is glance quickly at readily available information about the real world.

So why do we keep hearing it? Is John Stossel really that stupid? Or is he a con man? I vote for option number 2.

Update: And while we're on the subject of lies and the lying wingnuts who tell them, let's get reacquainted with our friend Betsy McCaughey. Again, I vote for option 2.

Satire is obsolete department

Remember the big awards dinner of the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria? They have now sent me their complete list of awardees -- those companies whose bleeding hearts have nourished the orphans of Africa. Drum roll please:

The companies to be honored are Standard Chartered Bank (LSE: STAN.L), Marathon Oil Corporation (NYSE: MRO), Warner Bros. Entertainment (NYSE: TWX), Royal Dutch Shell plc (NYSE: RDS-B), Unilever (NYSE: UN, UL), Anglo American plc (NASDAQ: AAUK), Levi Strauss & Co. and Chevron Corporation (NYSE: CVX). The awards will be formally presented at the GBC Business Excellence Awards Dinner in Washington, D.C on June 24.

I'll get around to writing something of my own later today, on another subject. Meanwhile, here's a little something about Business Excellence Award winner Royal Dutch Shell, from Essential Action. I have nothing particularly to add.

Since the Nigerian government hanged 9 environmental activists in 1995 for speaking out against exploitation by Royal Dutch/Shell and the Nigeria government, outrage has exploded worldwide. The tribunal which convicted the men was part of a joint effort by the government and Shell to suppress a growing movement among the Ogoni people: a movement for environmental justice, for recognition of their human rights and for economic justice. Shell has brought extreme, irreparable environmental devastation to Ogoniland. Please note that although the case of the Ogoni is the best known of communities in Shell's areas of operation, dozens of other groups suffer the same exploitation of resources and injustices.

The Problem

"The most conspicuous aspects of life in contemporary Ogoni are poverty, malnutrition, and disease."
-Ben Naanen, Oil and Socioeconomic Crisis in Nigeria, 1995, pg. 75-6

Although oil from Ogoniland has provided approximately $30 billion to the economy of Nigeria, the people of Ogoni see little to nothing from their contribution to Shell's pocketbook. Emanuel Nnadozie, writing of the contributions of oil to the national economy of Nigeria, observed "Oil is a curse which means only poverty, hunger, disease and exploitation" for those living in oil producing areas. Shell has done next to nothing to help Ogoni: by 1996, Shell employed only 88 Ogoni (0.0002% of the Ogoni population, and only 2% of Shell's employees in Nigeria). Ogoni villages have no clean water, little electricity, few telephones, abysmal health care, and no jobs for displaced farmers and fisher persons, and adding insult to injury, face the effects of unrestrained environmental molestation by Shell everyday.

Let's get rational

Norton Hadler -- one of the good guys in the white coat -- on rationing. Back when I was a student at the Heller School, our dean, elder statesman of health economics, always used to say, "What's wrong with rationing? It means, to apportion reasonably." The word is related to rational; it's a good thing.

Now, it obviously has bad connotations because people associate it with scarcity. There isn't enough food to go around so everybody gets 5 pounds of rice and an onion every week, that sort of thing. But too much food is bad for you, and if you have a tendency to overeat, you should ration your portions. Health care is the same way -- more is not better. Too much ice cream will make you fat, but it won't bankrupt you. Too much health care, unfortunately, will not only hurt you and just possibly kill you, it will cost enough to buy 20,000 or half a million banana splits.

What bothers me about the way this whole debate is going is that you have to read fairly obscure columns by people like Dr. Hadler in order to get a decent explanation of the issues. Politicians who favor meaningful reform won't confront the sophistry of conservatives head on, they just try to duck it. "The last thing in the world we want is a government takeover of health care," they'll say. "What we are proposing isn't anything like rationing, we aren't going to take anything away from anybody." Who in the Congress is appearing on Press the Meat to say:

Consumers don't undergo expensive surgery and procedures, or take pills every day for their entire lives, because they aren't paying out of pocket for these things. I'm not going to run over to the hospital and get a triple bypass or a PET scan or have three vertebrae fused just because my insurance will pay for it. The only reason I would ever do any of those things is because my doctor tells me I need to. So, wouldn't you like to be reasonably sure that when your doctor tells you to have surgery, she or he is right?

Wise doctors like Norton Hadler, who truly care about their patients, know that right now, you can't be sure. That's not a rap on the profession -- doctors are human, clinical decisions are very complicated, and there are all sorts of influences on people's decision making of which they are not even conscious. Physicians make their money by doing stuff, and the incontrovertible truth is, they do too much of some stuff. They're going to have to do less of that stuff, and that means the ones who specialize in unnecessary stuff won't make as much money. That's bad news for them, which is why the AMA is trying to prevent it, but it will be good news for the rest of us.

That's the truth. Now will somebody get up on the floor of the Senate and say it?

Pure Drivel

As one strategy in its desperate struggle for survival, the Boston Globe has a 50% interest in a free tabloid that's distributed at mass transit stations, called the Metro. It's an itty-bitty newspaper, with a front page headline, a couple of pages of news stories inside, columnists, sports, comics, astrology, but all completely digestible between Forest Hills and Downtown Crossing. Today's screaming, front page headline, and sole front page story? "Jon and Kate hit the heights of hypocrisy!"

I have no idea who the fuck Jon and Kate are, and I'm pretty sure that if I did know, their hypocrisy, of whatever degree, would be of no interest to me. But evidently I'm a weirdo.

According to today's NYT, former CNN anchor Bobbie Battista is now the main talking head on the Onion News:

Ms. Battista said she initially had qualms about how joining The Onion would be perceived by former colleagues. “It occurred to me that some would say, ‘Oh, how the mighty have fallen,’ ” she said. “I thought about that, but I said, ‘Hey, why not?’ ” She also considered her (low) opinion of the state of cable news today and saw that the space between real and fake news was shrinking.

“You watch the news today, and you don’t know what is real,” she said. “When I was doing newscasts at CNN, people would come up to me and say, ‘That story can’t be real.’ Now the lines are really getting blurred.” She mentioned a recent segment she saw about “lingerie football” on a cable news show. “My mouth was hanging open. How does this belong on the news?”

To be honest, it doesn't bother me so much that they devote a certain amount of space to stupid stuff. I actually enjoyed Tanya and Nancy, Joey Buttafuoco, and Lorena Bobbit.* Of course, I lost my ability to enjoy crap like that during the Cheney administration, but I might be able to get it back now. Unfortunately, it's not the oddball stories and celebrity scandals that are the problem with corporate media today, it's their total incompetence at covering stuff that's actually important. They have no inclination to distinguish between truth and lies. Whether they have the ability or not I do not know but I suspect they don't. Why should they bother to cultivate it? Reporting doesn't mean actually learning about a subject, it just means writing down what somebody says aboutit -- not somebody selected for expertise, but rather someone sought out intentionally for partisanship, even extremism.

Even the BBC has deteriorated to this point. Driving home on Saturday I listened to a BBC special on health care reform in the U.S. Who do they get as the main discussant, and give the last word on everything? A spinal surgeon from Florida who is there to represent the AMA, and who spewed a continual torrent of lies for 20 minutes without the slightest hint of a correction from anyone. A reporter asked him, "But aren't there big differences in health care spending depending on region?" and he just answered no, that's a myth. There are places where there are lots of old people who need knee surgery, for example, and spending may be higher because needs are different, but that doesn't mean costs are higher. And she just sat there and took it -- maybe because she doesn't actually know any better, maybe because she doesn't think it's her job to call the guest a liar. But he is a liar, and that's a fact, and facts ought to be reported.

*This guy goes to a bar and he picks up Tanya Harding, Lorena Bobbit, and Hillary Clinton, and takes them all home for a gang bang. When he wakes up in the morning, his pecker is gone, both his kneecaps are broken, and the worst part is . . . he doesn't have any health insurance.

Update: Should be read aloud from every pulpit in the land this Sunday.

What Robert Reich says

Since he's famous and everything.

The Defeatocrats Writhe Again

So the CBO tells the Senate Finance Committee their health care reform bill will cost $1.6 trillion, so Chairman Max Baucus immediately decides he needs to scale the bill back so it will cost less. "[The bill] included an array of coverage provisions that were drastically scaled back from earlier versions, as lawmakers seek to shrink the bill's overall cost. The proposal, for instance, would reduce the pool of middle-class beneficiaries eligible for a new tax credit meant to make insurance more affordable. The absence of a "public option" marks perhaps the most significant omission. Obama and many Democrats had sought a public option to ensure affordable, universal coverage, but as many as 10 Senate Democrats have protested the idea as unfair to private insurers."

Baucus met with several Republicans in order to craft a bill that would be acceptable to them, and this appears to be his trial balloon.

The Senate Democrats are fools, when it comes to public policy, and when it comes to politics.

Public Policy: The way to save money is not to scale reform back and do less: the way to save money is to do have more radical reform. Dartmouth University -- you know, that commie college in the People's Republic of New Hampshire -- has for two decades kept careful track of patterns of health care spending in the U.S. Not that the Senators who are writing the "reform" legislation would ever bother to inform themselves about anything so effete as actual facts, but it turns out there are huge variations in patterns of medical spending around the U.S., with no perceivable relationship to people's health or medical outcomes. "[Physicians] in higher-spending regions . . . were much more likely than those in lower-spending regions to recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family." But wait, there's more:

[I]n regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital—and Medicare will spend more on hospital care. In regions where there are more intensive care unit beds, more patients will be cared for in the ICU—and Medicare will spend more on ICU care. And the more CT scanners are available, the more CT scans patients will receive. Conversely, in regions where there are relatively fewer medical resources, patients
get less care—and Medicare spends less. So geography becomes destiny for Medicare patients.

Using more resources and spending more money would not be controversial if it produced better health care or better outcomes. So the critical question underlying the variations in practice and spending is: What is the relationship between quantity
and quality? Over the past ten years, a number of studies have explored the relationship between higher spending and the quality and outcomes of care. The findings are remarkably consistent: higher spending does not result in better quality of care, whether one looks at the technical quality and reliability of
hospital or ambulatory care, or survival following such serious conditions as a
heart attack or hip fracture.

So if you want to save money, don't cover fewer people -- STOP WASTING MONEY! Will the AMA like that? No. Will the drug companies like it? No. Will the medical device manufacturers like it? No.

And suprisingly, perhaps, the insurance companies won't even like it. Sure, they spend more for many patients than they have to, but they just charge higher premiums and work harder to keep sicker people off their books in order to keep their profits high. If they tried to compete by constraining physicians from providing wasteful services, the doctors and hospitals would just stop taking their insurance, and they'd be out of business. So they're in this thing together. Actually solving this problem will require taking control of their business -- which also contains another tempting target for cost savings, that 25% or so they spend on marketing, denying benefits not because the proposed services are wasteful but because the people have pre-existing conditions, kicking sick people off their roles, paying huge executive salaries, and delivering profits to their owners.

So that public option would indeed be unfair to the insurance companies. Of course, in order to make it work, you'd have to do what the AMA absolutely loathes, and that is require doctors to accept it. That way, it can require them to follow evidence based guidelines. The publicly sponsored plan will accept everybody and it won't have profits, executive salaries, or underwriting expenses. Over time, it will make the insurance companies go away. Too bad. Bye bye.

Politics: The overwhelming majority of Americans want meaningful reform. They even want universal, comprehensive, single payer national health care. If some people right now are afraid of it or are inclined against it, they'll change their minds and like it after all when it works, just like the people in Europe like what they've got. Ergo, if you were for it, and the Republicans were against it, you will get all the credit and they will get none.

Why, then, is it necessary to have a bill that they will accept so that they can share the credit? And that's assuming there is any credit, because a half-assed bill won't work, and the people won't like it, and then you will get the blame. The Republicans will get much less of the blame because the whole thing was your idea, you just dragged them along and they did their best to water it down, or else just think how much worse off we'd be.

The Democrats do not need one single Republican vote to pass meaningful, progressive health care reform. So why grovel for their approval? It's insane. Screw 'em.

Update: From CQ, via Kos:

Senate Finance Chairman Max Baucus of Montana plans to take a break from the grind of crafting a health care overhaul to serve as a Democratic rainmaker with a few of his friends along the Madison, Gallatin and Yellowstone rivers in the Treasure State this weekend.

Lobbyists and political supporters will get their chance to cast fishing lines and drive golf balls with the Senate's top tax writer at his Fly-Fishing & Golfing in Big Sky event. The cost is $2,500 per person, $5,000 for a political action committee. And for the same price, more fun lies ahead at Camp Baucus, the summer camp he holds for friends and their families in his home state between July 31 and Aug. 2. . . . Baucus brushed aside . . .criticism. "There's no problem. I've been doing these events for more than 10 years," he said. Baucus said he did not know how many contributors would be attending.

Res ipsa loquitur.

Who da bomb?

So Whisker wants to know, if the U.S. health care system is, contrary to our usual narcissistic self-perception, a major fail, what country has the best?

There isn't really any single answer to that, because you can compare countries' sysems on various measures and people will value them differently. And, the research just hasn't been done that compares every candidate country on every measure that you might put forward.

Nevertheless, people have tried. One way that seems fairly straightforward is to look at results. I said seems straightforward because it isn't. Medical intervention accounts for only a fraction of population longevity and health status -- and what fraction presumably varies from country to country, making it even tougher. Nolte and McKee have tried to cut this knot by isolating deaths considered amenable to health care, that occur in people younger than age 75. They include bacterial infections, treatable cancers, diabetes, and complications of surgery. They only count half of ischemic heart disease deaths because those seem only partially "amenable" to health care. They also set younger age limits for diabetes (50) and common infections (15). Read the article if you want to see all their arguments. Anyhow . . . .

From 1997-98 through 2002-2002, "amenable" mortality fell in all 19 countries for which they did the comparison, but it fell more slowly in the U.S. than anywhere else. We started off not looking good, and ended up looking even worse. The rankings are slightly different for males and females, but we're number last for both sexes. The winners? France for males, Japan for females. France comes in #2 for females, making it best overall. Japan is 8th best for males. The final ranking for both sexes combined is (may I have the drumroll please): France, Japan, Australia, Spain, Italy, Canada, Norway, Netherlands, Sweden, Greece, Austria, Germany, Finalnad, New Zealand, Denmark, United Kingdom, Ireland, Portugal, United States.

Yup, the cheese eating surrender monkeys win. However, not all countries are included in the research, obviously. I got an e-mail yesterday from something called The Israel Project, claiming that Israel has the world's best health care. I won't take their word for it -- among other reasons because they appear to be big boosters of Netanyahu, of whom I am not, as you might imagine, a big admirer -- but you never know, there are reasons why that might be true.

Another way to look at international comparisons is by what we call "process" indicators - do the right things happen under given circumstances. These aren't collected consistently and universally across systems, or even necessarily within systems, particularly in the U.S. given our extreme fragmentation. So, the Commonwealth Fund depends on surveys of patients and doctors. In 2007 report, they compared Australia, Canada, Germany, New Zealand, the UK and the US. Overall, the UK won this one hands down, with big wins on quality, right care, patient-centered care, efficiency, and "healthy lives." So, on this comparison, it's the hard core, flat out socialized medicine that triumphs. Not only that, but they're very close to the cheapest, which means the Brits have more money left over for tea and crumpets. (What he hell is a crumpet, anyway?) Oh yeah -- we're number last on this one too. We always are, no matter how you do it. And we spend the most.

That basically seals the deal, as far as I'm concerned. All this wailing about how we can't allow ourselves to become like the Europeans, with their "socialism" and "rationing" and "restrictions on individual rights" is manifestly nonsensical because all you have to do is look at the bottom line: they pay less, a lot less; and they get more, a lot more. So yes, we should be like them.

QED

We continue to fail

Part of the background noise to the health care reform debate, issuing principally from the drug and medical device companies and hospital industry and health insurance industry and AMA -- that is to say the Medical-Industrial Complex -- and its allies in the Republican Party and a good chunk of the Democratic Party -- is the claim that the United States has the world's highest quality, most technologically advanced health care; that most people are well-served by the current system; and that proposed reforms such as Comparative Effectiveness Research, a public insurance option, and cost containment, will take something away from people. (Sorry for that Faulknerian sentence.)

Sorry, but the truth is otherwise. We, in fact, suck. Politicians and pundits could easily inform themselves by reading AHRQ's latest reports on health care quality and disparities. Now, there are weaknesses in the data available to measure quality, but based on what we've got:

Overall, despite promising improvement in select areas, the health care system is not achieving the more substantial strides needed to close the gap or "quality chasm" that persists. Despite efforts to transform the U.S. health care system to focus on effective preventive and chronic illness care, it continues to perform better when delivering diagnostic, therapeutic, or rehabilitative care in response to acute medical problems. This system achieves higher performance on measures related to acute treatment, such as that for heart attacks, as opposed to prevention and anticipatory management of chronic illnesses, such as cancer screening and diabetes management.

Overall, progress on quality measures has been exceedingly slow -- a median of 1.8% per year for "core measures," and 1.4% per year for all measures. 31% of measures showed no improvement at all. Examples of what this means specifically include an increase in recent years in the percentage of patients with central lines who got blooodstream infections, from 1.7% to 2.8%. That's a really bad thing to have happen to you. On the whole, hospital acquired infections continue to be a growing problem.

And, as for disparities:

Both categories of measures, quality of care and access to care, show that disparities persist for all populations. Measures of quality include effectiveness (the percentage of patients with a disease or condition who get recommended care), patient safety, and timeliness. The NHDR includes the added dimension of access to care to measure differences in health insurance coverage, utilization of general health services, and other barriers to care. Below are figures that illustrate for each population how disparities in quality and access have changed in the past 5 years.

[F]or Blacks, Asians, American Indians/Alaska Natives (AI/ANs), Hispanics, and poor people, at least 60% of measures of quality of care are not improving (either stayed the same or worsened).

So no, we don't have high quality care and we don't have equity and justice either. This is really basic, and its incontrovertible. In the next post, I will discuss why less is more -- why an essential step toward improving quality and equity is to produce less medical intervention. Ridiculous frames like "the European medical scarcity model" need to be purged from our discourse. We're drowining in not just unnecessary, but downright harmful, medical intervention.

It's a capitalist world

A regular correspondent is irate that vaccines are made by for-profit companies, which causes no end of problems. There isn't a lot of profit in vaccines to begin with. You get them once or twice, unlike chemicals such as statins and anti-depressants that people take more or less forever. For diseases that mostly afflict poor countries, there's even less incentive to develop vaccines, obviously, because you can't charge a high price.

Now, you might think that setting up a not-for-profit corporation and investing some of the government and foundation funds that currently go to international health promotion in vaccine development and production would make sense. But the Bill and Melinda Gates Foundation writes to tell us that they're participating in another strategy, called Advance Market Commitments, AMCs, to extract vaccines from corporate manufacturers. This basically means that donors get together to promise manufacturers that they'll purchase at least a minimum amount of some vaccine. The theory is that the manufacturers know they'll make sales, so they agree to produce the product. The group has decided to start with an offer to buy vaccine against pneumococcal pneumonia. Sounds good, although as far as I can tell so far they don't have any manufacturers on board. We'll see.

By the way Americans don't hear much about the international health funding structures, in part perhaps because it's all rather byzantine but also because our corporate media and even our health bloggers as a class don't seem to care very much. So, just to start getting some of this story out there I'll mention that one of the partners in the AMC strategy is called the GAVI Alliance, a redundant and repetitive name derived from Global Alliance for Vaccines and Immunization. Apparently people couldn't agree on how to spell "immunization" so they just said to heck with it. GAVI includes UNICEF, the WHO, governments, foundations such as B&MG, and yup, the vaccine industry. As they say on their web site, "GAVI uses two mechanisms that draw heavily on private-sector thinking to help overcome historic limitations to development funding for immunisation. These mechanisms are the AMC and the IFFIm. The former reflects the need to meet disproportionately high costs in the early stages of implementing aid programmes; the latter developing countries' need for sustainable predictable funding." IFFIm stands for International Finance Facility for Immunization, which is basically a pool of long-term pledges from donors against which GAVI can borrow.

Which brings us to our next press release. It seems "The Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria will host its Annual Conference June 23-24 where policymakers, business leaders and global health advocates will unite to take action on HIV/AIDS, tuberculosis and malaria around the world." Sponsors include Pfizer, Chevron oil, Johnson & Johnson, and Marathon Oil, which is taking the opportunity to give itself an award. Fareed Zakaria will be your genial host. Now, exactly what amount of credit or blame these oil and drug companies should get for the health of people in poor countries is matter we could discuss at some length. But the WHO, Obama administration, UN, and the whole gang have decided that constructive engagement is the way to go. This conference will let the corporations walk away with plaques and testimonials that say they're good guys after all. What we're really getting in return is another question.

Oh, freedom

A couple of days back I noted in passing that there is a "libertarian" backlash to BHO's plans to encourage health eating and physical fitness. To save y'all a click, Politico's Carrie Budoff Brown reports that:

The whole situation has libertarians craving a basket of onion rings and a beer. "If you care about the sorts of things I do, then you are going to be losing big-time for the next four to eight years," said David Harsanyi, a Denver Post columnist and author of the book "Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists and Other Boneheaded Bureaucrats Are Turning America Into a Nation of Children."

and:

"[CDC nominee]Frieden's stick-over-carrot, for-your-own-good approach to public health is no longer confined to the Big Apple," the industry-backed Center for Consumer Freedom wrote on its blog. "Get ready, because the 'nanny state on steroids' is going national."

Budoff Brown errs rather severely later in the story when she writes:

But other skeptics have critiqued the healthier-is-happier approach with the numbers. An article this year in the journal Health Affairs concluded that prevention measures usually add more to medical costs than they save.

That isn't talking about getting people to eat a balanced diet and maintain a proper body weight: it's talking about medical interventions such as screening tests and prophylatic drug regimens. That is an entirely separate, essentially unrelated subject (which I have addressed previously, if you're interested.) So consider that one deconstructed at the preceding link, and let us turn to this question of freedom.

In the U.S., "freedom" and "liberty" have enormous resonance. Everybody wants to fly the banner of liberty, no matter what their cause: we have to torture people to preserve our liberty, we have to abolish taxes, we have to stop telling people it's bad for their health to eat a lot of animal fat. Sadly, I have concluded that the conservative definition of "liberty" is "I get to do whatever I feel like and to hell with you." That may be good for your liberty, but it obviously isn't good for mine. And it leads on a very straight path to an obvious paradox. If every one is granted this unrestrained liberty, then the most ruthless sociopath in the group will seize absolute power by means of terror and violence. If you believe that some magic dust will prevent that from happening, and that we can instead have an anarchists' paradise, then we won't have roads, bridges, airports, educated children, enforcement of contracts, money, fire protection. We won't know what's in the food that's offered for sale and we won't know whether our employer will ultimately bother to pay us for our work. Addicts will be sitting on our front porches with the crack pipe, and a drum circle will be playing outside your window at 2:00 am. I mean, duhh.

Many Americans don't seem to understand that Homo sapiens is a social animal. We survive by cooperation, division of labor, and mutual regard. Ron Paul fans who exercise their liberty by driving their Hummer at 90 miles an hour to the Ayn Rand festival would not have the "liberty" to do so if not for the elaborate system of economic regulation which makes the automobile industry possible in the first place, and the public works apparatus which gives them a road to drive on. And if everybody made their choice to drive too fast, they would probably be dead by now.

"No man is an island," sayeth the preacher (John Donne, specifically). Mr. Harsanyi, if you pig out on deep fried lard dumplings for 15 years and end up with heart disease and diabetes, the following will occur: you won't be able to work, and you will become a public charge; you will not be able to provide support to your dependents, who will likely have their education aborted; the value of your personal productivity (such as it is) will be lost to society; and you will stop being a libertarian and start complaining that your disability check is too small and your co-pay for the 12 prescriptions is too high. That will be bad for your liberty and mine as well.

The government has a legitimate interest in discouraging you from doing that, most strongly in assuring us that we won't have to listen to you kvetching about how it's everybody else's fault when you get sick. Now, exactly how government ought to go about promoting public health, and where to strike the balance between achieving a healthier population and annoying David Harsanyi, is a question worthy of debate. But let us recognize that libertarianism is nonsense. It's just a conspiracy by the powerful, wealthy and rapacious to throw sand in people's eyes and fool them into voting against their own interests.

Inbox

One of the joys and horrors of blogging is all the stuff I get from publicists. Free books to review, for better or for worse; offers to do interviews with various people from heroes of mine to obnoxious cranks; commercial spam; promotions of causes good or evil; you name it. Here's a sampling of today's yield, just to give you an idea.

A+: The American Cancer Society is bragging about the legislation giving the FDA authority to regulate tobacco. Congratulations to them! Here's an excerpt, and I got nothin' to add:

Statement of John R. Seffrin, PhD, CEO
American Cancer Society Cancer Action Network

WASHINGTON, D.C. – June 11, 2009 – “Today is an historic day for public health, as the U.S. Senate passed legislation by a bipartisan 72-17 vote that will finally put an end to Big Tobacco’s despicable marketing practices that are designed to addict children to its deadly products. Senate passage of the ‘Family Smoking Prevention and Tobacco Control Act’ (S. 982) has the potential to reduce the scourge of tobacco products, which kill more than 400,000 Americans every year.

“This critical bill, which has been in the works for more than a decade, would finally grant the U.S. Food and Drug Administration (FDA) authority to regulate the manufacturing, marketing, and sale of tobacco products.

“Tobacco is virtually the only consumable product not regulated in the U.S. and the tobacco industry exploits this undeserved free pass by spending nearly $40 million every day aggressively marketing its products, especially to children, with enticing candy- and fruit-flavored cigarettes. The legislation would stop the marketing of tobacco products to children, require tobacco companies to list the poisons in their products and mandate larger and more effective warning labels on tobacco product packaging. . . .

“ACS CAN commends Senators Harry Reid (D-NV), Christopher Dodd (D-CT) and Richard Durbin (D-IL) for their determination to get this legislation to the President to be signed into law this year, and Senator Edward Kennedy (D-MA) for his leadership on this legislation and his long-time record of championing public health issues.

“Every day, 3,500 children pick up their first cigarette and 1,000 become addicted smokers. We call on Congress to finish their work on this legislation as quickly as possible so the President can sign it into law.”

C-I am a resolute opponent of factory farms, and it is largely because of the industrial meat production system that I do not personally consume the flesh of tetrapods. I am also well known as a crusader against feeding antibiotics to livestock. However, I have a problem with this:

Farm Sanctuary Issues Statement on the Swine Flu Outbreak

Renowned Public Health Expert and Farm Sanctuary Board Member, Dr. Allan Kornberg, Submits Statement on Public Health and Animal Welfare Implications of the H1N1 (Swine Flu) Outbreak

“The pigs are not to blame for this. In fact, it is the industry that pushes for the ever more expansion of factory farms at all costs that needs to be held accountable for the breeding ground of human as well as animal disease.”


WATKINS GLEN, N.Y. – May 11, 2009 – Farm Sanctuary, the nation’s leading farm animal protection organization, today released a statement from Dr. Allan Kornberg, a member of the organization’s board of directors. As one of the few public health experts who also retains a deep knowledge of farm animal welfare issues, Dr. Kornberg offers his perspective on the H1N1 (swine flu) outbreak and the health and welfare implications for both humans and farm animals:

“Even though swine flu now is not as deadly as many other illnesses, it is still a public health threat that must be taken seriously, and as such merits a concentrated investigation into its origins. Only by tracing the source of the infection can we hope to prevent future outbreaks (especially those that could prove far more lethal). The most current evidence seems to indicate that the recombinant pig-bird-human strain plaguing the world today germinated on a factory farm — an industrial pig farm in North Carolina (the nation’s top pork-producing state), to be exact. …

“The sheer number of animals being raised indoors in close quarters is serious cause for concern from both an animal welfare and public health standpoint. Add to that the immunosuppression that results from stressful overcrowding, unnatural confinement in gestation crates (2-foot-wide metal enclosures that prevent breeding sows from turning around or lying down comfortably) for months at a time, and the filth and feces that accumulates under the animals’ feet, and you have a virtually perfect laboratory for the development of new disease strains.

“Zoonotic diseases including campylobacter poisoning, acute salmonellosis, E. coli, variant Creutzfeldt- Jakob Disease (the human form of mad cow disease), MRSA and H5N1 (avian influenza) have all been linked directly, or indirectly, to intensive animal agriculture. Swine flu now joins these ranks, and as long as factory farms continue to propagate, this won’t be the last infectious disease to emerge. …

My problem is that they are trying to capitalize on an event in the news -- the emergence of the novel H1N1 virus -- which is probably not related to their cause. While it is possible that this strain of flu originated in a factory farm -- and no, we do not yet know -- in fact the risk of swine and bird flu strains jumping to humans is greatest in the small-scale, subsistence husbandry practices of Asia, where people keep chickens and pigs in their households, in continuous close proximity to people. Industrial meat growers do their best to keep influenza out. Their animals have limited contact with humans, workers with flu like illnesses are obviously told to stay home, and sick animals are culled. So this isn't really honest. Sorry.


F-Whoa, did these clowns come to the wrong circus:

Dear Editor/Producer,

Betsy McCaughey (former Lt Governor of New York State) presents a powerful argument against the proposed White House healthcare plan coming up for vote in July because she says it's based on the European "medical scarcity"
model.

See her June 5 OpEd in The Wall Street Journal:
http://online.wsj.com/article/SB124416366699887489.html,
and her June 9 article in The American Spectator:
http://spectator.org/archives/2009/06/08/downgrading-american-medical-c.

As the major opponent to Hillary Clinton's health plan in the 90s, she packs a formidable punch. Betsy is seen as the one most responsible for exposing and then defeating that plan. Today she has the White House health plan in her cross hairs.

Betsy McCaughey is a super-smart patient advocate with information the public and legislators need to hear before it's too late. Please call me to set up an interview.

Best,

/Dean 641-472-2257
dean@drazninpr.com

Dean Draznin Communications, Inc.
GLOBAL PR & MARKETING SERVICES

Betsy McCaughey is no patient advocate, she's an insurance company advocate. Her schtick is that health care reform is going to cause reduced spending on medical services, which will deprive us of our God given right to have our pockets picked and our bodies damaged by overtreatment. Sorry Betsy, I'm not buying it. European "medical scarcity" produces healthier, wealthier people. Can't argue with results, now can you?

There's more, but that's enough for today. Keep those cards and letters coming, folks.

Too much to write about

First and most disgusting, the American Medical Association comes out against the so-called "public option" in health care reform. As they should have taught you in history class, but probably did not, the AMA was once the most powerful lobby in Washington, and they are principally responsible for blocking meaningful health care reform from the time of Harry Truman on. They hired Ronald Reagan to to make a recording for the Ladies Auxiliary [sic] of the AMA in which he notoriously said that if they did not stop Medicare, "of these days you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free."

Of course, what the AMA is concerned about, then as now, is not "freedom" or even medical care: it's protecting the incomes of its members, so they can keep their yachts and their horse farms. The American Medical Association is and always has been the enemy of public health.

In other News of the Weak, the WHO is finally raising the flu pandemic alert level to 6, which means that uh, er, well, it doesn't actually mean much of anything. Technically, it means that the mild, largely innocuous strain of flu that's gotten everybody so excited is now widespread around the globe. Excuse me, but one or more strains of flu is widespread around the globe every year, all the time. So what the heck is the point of this? As the MSNBC article notes:

Panic has already gripped Argentina, where so many people worried about swine flu flooded into hospitals this week that emergency health services have collapsed. Last month, a bus arriving in Argentina from Chile was stoned by people who thought a passenger on it had swine flu. Chile has the most swine flu cases in South America.

In Hong Kong, the government on Thursday ordered all kindergartens and primary schools closed for two weeks after a dozen students tested positive for swine flu.

In other words, if everybody would just shut up and ignore this, nothing bad would happen. The damage results exclusively from the overreaction. Pathetic.

Finally, clearly president Obama is failing to keep us safe and he is losing the War on Terrorism. We have now had five terrorist attacks on the homeland since he took office, including two attacks inside Christian churches (for some reason people seem to forget the guy who shot up a Unitarian church while a children's performance was going on), two police officers murdered in Pittsburgh, and yesterday's terrorist attack on the Holocaust Museum. These terrorists had all made violent threats before they acted, and two of them were openly associated with networks of violent extremists and had previously been convicted of terrorism. Yet they were let loose to roam our streets and commit even worse acts of terrorism. Such terrorism is incited by television and radio personalities with audiences in the millions, who operate openly every day, urging violence against American interests.

President Obama is surrendering America to its enemies. He needs to keep us safe by doing what George W. Bush did: task Joe Biden with sending the armed forces to grab these guys -- Randall Terry, William Luther Pierce, Hal Turner, Rush Limbaugh, Bill O'Reilly, Sean Hannity, the lot of 'em -- put adult diapers on them, dress them in orange jump suits, hood and shackle them, and fly them to Diego Garcia non-stop without legal recourse. Tell them they are in Syria and have guys who speak only Arabic torture them for a few days. Then send in a man who speaks English with an impeccable Oxford accent, dressed in the uniform of a colonel in the Bulgarian air force, and carrying a riding crop. Have him demand that they reveal the plans of their associates, and torture them some more until they give it up. I think Rush will enjoy this little fraternity prank.

Update on the lard slurping couch potato issue

In response to my Monday post, a reader expressed disappointment about the prez's highly publicized burger runs. Politico's Carrie Budoff Brown says not to worry. (I'm not sure links to Politico stories are stable, but I can't find an obvious permalink to this one so we'll have to take our chances.) She writes:

President Barack Obama eats his vegetables and exercises every day - and he really wants you to do the same.

From the White House garden to his picks for top health jobs, Obama is telling America's McDonald's-loving, couch-dwelling, doctor-phobic populace that things are about to change.

The article makes a great deal of libertarian objections to the government promoting healthy habits. I think these are completely ridiculous. A good subject for an upcoming post . . .

The Real Harm from H1N1 Influenza

Lawrence Gostin in the new JAMA -- subscription only I am pained to say -- takes the occasion of the recent H1N1 flu brouhaha to discuss pandemic preparedness. You are permitted to read the first few words here, Influenza A(H1N1) and Pandemic Preparedness Under the Rule of International Law, for what it's worth.

Let me say right up front that although Gostin acknowledges the possibility that this strain of virus could somehow mutate to become more dangerous, there was never any particular reason to expect that, and since he wrote experts have developed further understanding of this particular strain which makes it appear even less likely. The fact is that were it not for the enhanced surveillance systems and viral genome testing capacity put in place recently, largely in response to the H5N1 bird flu scare, we would never have known that anything was happening at all regarding H1N1 influenza. We would have observed nothing out of the ordinary, and there would have been no story. As of now, we would simply have an essentially normal end to the flu season in the northern hemisphere, and a normal beginning to the season in the south. For all practical purposes, that is the situation in fact, but we are burdened with widespread and damaging overreaction to this non-event.

Gostin calls for an international regime with greater enforcement powers in anticipation that something more significant might occur some day, and he also calls for more coercive authority on the part of our domestic CDC. I will return to these issues later, but first I must say that the real events he describes constitute a narrative, not of ineffectiveness or excessively cautious response, but rather of overreaction and a response which exclusively did harm, and no good whatsoever. He writes:

On April 29, WHO raised the pandemic alert level to 5, the second highest level . . . . The alert system is based on geographic distribution of sustained spread among humans without due regard to the actual health threat because it could entail relatively mild disease. The threat level, moreover, could heighten fears and cause the public to overreact.*

Indeed. And while the director-general can issue recommendations, she "did not recommend travel or trade restrictions, screenings, or examinations." Well, there is no reason why she should have; there was no scientific evidence that any such measures would have done more good than harm. Gostin notes that nonetheless:

1. China and Hong Kong quarantined travelers from North America, including 22 Canadian students with no symptoms, 300 guests and employees who happened to be in a hotel where a Mexican man was isolated, and everybody in Singapore who happend to have visited Mexico was quarantined.


2. "Social distancing" measures included closure of 700 schools in the U.S., disrupting the education of 245,000 children, although the CDC reversed its recommendation regarding school closure after 4 days. (Of course, it never should have made it in the first place.)


3. Numerous countries restricted travel to and from Mexico and banned meat from North America, causing economic damage. In fact Mexico's GNP declined by up to .5% in a few weeks.


4. Egypt culled 400,000 pigs, an act of irrational discrimination against the country's Christian minority

As Gostin writes, "epidemics often bring out irrational fears and discriminatory behaviors among individuals and governments." It is obvious that these irrational and harmful responses were driven largely by the grotesque overreaction to this event on the part of the corporate media, an overreaction echoed and reinforced on putatively liberal blogs and web sites such as the Huffington Post and Daily Kos. For weeks, the exclusive public health-related focus of these sites was this perfectly ordinary, non-threatening non-event. Regardless of the exact content, excessive coverage inevitably creates the impression that the issue is extremely important, urgent, and ought to preoccupy us. That impression was false, misleading, and damaging.

Let me just conclude by noting that Gostin says that the CDC's legal authority "to prevent the introduction, transmission, or spread of communicable diseases into or within the United States" has "limited applicability" and would be challenged should it try to exercise it. I'm not entirely sure what he means -- the pandemic flu plan is available here and as you can see it presumes very broad powers that would no doubt surprise most people and perhaps strike some as undemocratic. CDC has submitted revised regulations which Gostin considers more effective, but which are as yet in limbo.

I do not personally object to the government having emergency authority in case of dangerous infectious disease outbreaks or epidemics, but I do feel that this ought to be subject to a full democratic airing which it has not had. I have gotten a couple of e-mails from readers who have stumbled across the facts about this authority and become all worked up about totalitarianism and concentration camps. I've tried to talk them down but obviously we have a failure here of democratic process and perhaps of adequate legal checks and balances.

Finally, Gostin makes one observation which I heartily endorse:

Federal and state legislatures have also allocated inadequate resources to the CDC and state and local health departments. As the cost of health care has soared, only about 2.5% of health spending has been allocated to prevention and public health.

We can certainly do better than that, without running off yelling that the sky is falling.

*In the elided section he notes that the alert does not trigger any actual powers or require any action, which of course makes it utterly pointless.

Get off your lardbutts

Periodically, your government surveys a sample of Americans about their health-related habits, and also gives them a physical. Here's the latest from Dana E. King, MD, MS, Arch G. Mainous III, PhD, Mark Carnemolla, BS, Charles J. Everett, PhD, in the American Journal of Medicine. (Get on the faculty and you can read the whole thing.)

ABSTRACT
BACKGROUND: Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.
METHODS: Analysis of adherence to 5 healthy lifestyle trends (5 fruits and vegetables/day, regular exercise 12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health
and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.
RESULTS: Over the last 18 years, the percent of adults aged 40-74 years with a body mass index -- 30 kg/m2 -- has increased from 28% to 36% (P <.05); physical activity 12 times a month or more has decreased from 53% to 43% (P <.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P <.05), and moderate alcohol use has increased from
40% to 51% (P <.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P <.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non- Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.
CONCLUSIONS: Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.
© 2009 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2009) 122, 528-534

Bottom line? We've gotten fatter and lazier and we eat more junk, and we're still sucking up the cancer sticks. Even if we've already gotten the bad news from our doctor that we're on the road to a heart attack.

Listen up you knuckleheads! We could pass universal, comprehensive, single payer national health care tomorrow; establish our very own National Institute for Clinical and Health Excellence; and give every single one of you your own personal full time primary care doc who makes house calls, and you'll still be rolling around in a wheelchair with an oxygen bottle and no lower extremities until you croak before you've had time to get half of your social security payments back.

This is not happening because Dr. Spock (not the Vulcan) messed up our childhoods so that we refuse to take individual responsibility.

It's happening because of our toxic behavioral environment. Too much of the wrong kind of food is cheap and easy, and giant corporations spend billions brainwashing us into eating it; we make our living sitting in a chair staring at a glowing screen because we have to, and then spend most of our leisure time doing the same thing because it's cheap, easy and addictive and giant corporations spend billions brainwashing us into doing it; we live in suburbs consisting of endless tract housing built around roads feeding into highways where nothing is within walking distance; and we smoke cigarettes because they're addictive and giant corporations spend billions brainwashing us into doing it.

Fight the power! Eat vegetables, walk places, do stuff.

NYT article here in case I'm not sufficiently authoritative for you.

Puzzle pieces

To get meaningful, postitive health care reform we're going to have to clear away a lot of brambles. Oh sorry, I guess I've already mixed my metaphors. I was also going to say something about lots of moving parts.

Anyway, our great difficulty is that we've waited so long to fix this mess that it's grown into a tangle that's as difficult to describe as it is to dig up and replant. There's no way to get the necessary concepts onto a bumper sticker and it's very easy to confuse the public. I wish I had the magic simple explanation but I don't. Let me at least see how succinctly I can lay out the pieces, and maybe connect them later.

• Medical services satisfy none of the criteria required for the idealized free markets of faith-based economics to work. Consumer sovereignty is utterly meaningless in health care and can never be achieved. Efficient allocation of resources has little relation to consumer preferences; demand is generated principally by providers, in response to some combination of their financial and other external incentives; the merciless generation of disease and risk by genetics, environment, behavior, and chance; the state of medical knowledge and standards of practice; and the individual provider's grasp of said knowledge and standards.


• People's need for medical services, and just claim upon them, is if anything inversely related to their income and wealth. Elementary considerations of equity require that people have some form of guaranteed health care as needed, to which they contribute financially as they are able. Anyone who disagrees with that should try getting oh, kidney failure or lymphoma. Then come back and argue your case.


• Private markets for insurance actively misallocate resources and work against justice because insurers have strong incentives to charge more to people with greater needs, or to exclude them entirely. Insurers individual incentives are further misaligned with social benefit because they do not expect the people they insure to be their responsibility in the future, therefore they underinvest in preventive measures. Finally, they spend a substantial portion of their income on excluding people, denying benefits, marketing, and executive salaries and profits, none of which have any social benefit whatever.


• In medical care, more is not better. The U.S. spends twice as much on medical care as other wealthy countries, and has the worst health status. It is nonsensical to decry the "rationing" and other putative crimes of the United Kingdom and Canada when their people are healthier than ours and spend something like $4,000 a year per capita less on health care.


• The dysfunctionality of our current system is evident in numerous ways. These include:
  

  * Insufficient numbers of primary care practitioners, insufficient access to primary care, and insufficient time and other resources available to primary care providers for individual patients. About 30% of U.S. physicians practice primary care, compared with 50% in most industrialized nations.
  * Overutilization of expensive and useless or dangerous procedures. We do too much back surgery, too many imaging procedures, and too much on worthless drugs that are heavily marketed, for example.
  * As a tragic subset of the above, too many people die in hospitals attached to machines and attended by stranger technicians, kept alive well past the point of hope or purpose.
  * 45 million Americans have no health care insurance at all; medical costs are the leading cause of bankruptcy in the United States; people end up stuck in jobs they would prefer to leave because they can't afford to lose their health care; people on Medicaid who have the opportunity to work often have to turn it down; and so on.
  

In order to solve these problems, several things have to happen all at once. More on that anon.

On another subject . . .

you can check out my review of Juan Cole's book Engaging the Muslim World, along with my regular Sunday post, on Iraq Today. And that's enough blogging for this Sunday.

The silent world of doctors and patients

That's the title of a book by Jay Katz, written maybe 20 years ago. It's less true than it used to be, I suppose, but there's still a significant gulf much of the time. Without going into more detail than I'm allowed to until we get the work published, I will say that in our work here I'm finding more and more that important issues are unlikely to be discussed in routine office visits unless they are forced onto the agenda by some form of intervention. It turns out that this includes not only people's non-adherence to prescribed medications, but also emotional distress and the causes of such distress in patients' lives.

The latter aren't necessarily the province of the physician to solve, and it's quite possible that a patient might not particularly want to share them with the doctor, but there are also many reasons why leaving them out of the medical space can be problematic. For one thing, people who are interested in measuring the outcomes of medical care, and who want to do it in a "patient-centered" way, such as my colleague John Ware, will ordinarily ask people about their well-being and functional status. The answers don't just depend on the physician's measures of health and illness such as laboratory tests and x-ray images: they are all about how the person is getting along in the world. After all, that's what a patient-centered doctor wants to support.

For another thing, people who are stressed out, depressed, or anxious are a) likely to be in poorer health because the emotional stress wears down the body, and b) likely not to engage as effectively in self care -- such as following medication regimens -- as people who are feeling good about themselves. And of course, people who are in distress may be in some sort of physical danger or material want, or they may have treatable mental disorders, all of which are relevant for physicians.

So, while respecting boundaries and the finite scope of the professional relationship between doctor and patient, there is a case to be made for a relationship in which patients can disclose and share personal information and feelings which are not strictly in the biomedical realm. This is called a bio-psycho-social model of medicine.

If it really is what we ought to be doing, we still aren't very good at it. On the other hand, there are people who object to the "medicalization" of more and more realms of life and see physician intrusion into these realms as potentially diminishing our autonomy and redefining human experience in damaging ways. These are actually difficult questions. What do you think?

Pay now . . .

or pay later. JAMA doesn't think you ought to be able to read the article, but here's the abstract of a review by Jack Shonkoff and colleagues of the ways in which injuries and indignities suffered by children are reflected in their health as adults. This is an extremely important, emerging area of knowledge, which goes a long way toward explaining the disparities in health we see according to race, ethnicity, and social status in societies throughout the world. It has profound implications for public policy, including the potential of enormous long-term benefits from making investments in children right now.

Among many key points:

• Cardiovascular disease in adults is associated with malnutrition in childhood


• Childhood psychological trauma is associated with adult coronary artery disease, pulmonary disease, alcoholims, depression, drug abuse, cancer, smoking, obesity . . .


• Psychological stress produces biological stress through neural and hormonal mechanisms, and chronic stress produces cumulative biological damage


• Poor living conditions in early childhood are associated with multiple diseases in adulthood


• Low birthweight is associated with metabolic syndrome and Type 2 diabetes


• The idea that acquired characteristics can be handed down to offspring is not entirely false after all: animal experiments show that the biological effects of early stress on an organism can affect how the next generation's genes are expressed. Of course, in the case of humans, we don't need genetic mechanisms to account for the transmittal of disadvantage across generations. Adults who are less healthy and have less adaptive coping responses are likely to find themselves in environments which are more stressful for their own children.

Many experimental interventions to improve the physical and social environment of young children have been shown to have lifelong benefits -- programs like head start, healthy start programs where nurses or trained community health workers visit young mothers at home, early intervention programs for kids with identified problems. But beyond offering special programs to kids in disadvantaged environments, we can and must provide everyone with safe neighborhoods, good education, employment, adequate income, and dignity and respect. Those are the resources they need to raise healthy children.

Two brief items: I have jury duty tomorrow, so depending on what happens, maybe no post.

Meanwhile, according to a publicist, for some reason Fran Drescher is involved in encouraging people to ask questions of their doctors. They sent me a widget and a link to a Facebook fan page which I can't really figure out the point of, but anyhow it all points to a web site maintained by the Agency for Healthcare Research and Quality, called "questions are the answer," and it's got the kinds of questions I wrote about yesterday plus a whole lot more. It looks pretty good to me so check it out.

Funny Story

Ha ha. According to Richard Wolffe, president Charley McCarthy had to ask Condi Rice to explain what the big deal was over Joe "Robomouth" Biden calling Barack Obama "bright, clean, articulate." That reminds me . . .

A few years back I did a minority needs assessment study for a small city out on the verge of civilization in central Massachusetts. It seems a local night club was turning away Black and Latino patrons, so I went with the head of a local community organization, an African American guy I will call Horace, to discuss this with the owner. He sat us down in a booth and announced, "I'm not a racist. I mean Horace, I don't even think of you as black. You look just like a normal person. You've got a tie and everything."

Horace asked me to explain to the guy what was wrong with that picture. It was surprisingly difficult to get across to him.

Oh yeah -- I also interviewed the Mayor for this study. I sat down in his office and the first thing he said to me was, "What do you call a black kid with a bicycle? A thief!" Ha ha ha.

It's not exactly a miracle that Barack Obama is president -- he looks just like a normal person. But it's close.

Advice column

So Bix (who no doubt plays a sweet, hot trumpet) asks, given that doctors are overeager to do stuff to you -- whether because that's how they make their money, or it's just human nature -- and they aren't necessarily evidence based about the whole thing in the first place, what's a patient to do?

I usually try hard here not to be the Aunt Eppie of health care and public health: this blog is about policy and other big picture stuff. Nevertheless, since I brought it up, I probably do owe y'all my thoughts on this. As I keep repeating to the point of severe urtication, I'm not a real doctor, I'm a doctor of philosophy. So I'm not giving medical advice. Furthermore, whatever I suggest people do is not going to solve the problem because the vast majority of patients cannot or will not do it. The culture and the structure of medicine resist it, and anyway the average person probably shares the physician's proclivity for doing too much. So what, here goes.

First, I recommend that people get a hold of some important basic concepts. One is that the way risks are presented greatly affects how we interpret them. If I tell you that getting a mammogram will cut your risk of dying of breast cancer in half, you'll probably want to do it. But what if I told you that if 2,000 women are regularly screened for breast cancer for 10 years, precisely 1 will benefit by avoiding dying of breast cancer? On the other hand, 10 women who would not have died from breast cancer will undergo breast cancer surgery, and possibly radiotherapy or chemotherapy. What would your decision be? (NB: It's a different story if you have a family history or have never had children. Consult your physician.)

So one question to ask your doctor is, aside from relative risk or by what percentage doing something will reduce my risk, what is my absolute risk? If I don't do this thing, what are the chances that the bad thing will happen to me that it's supposed to prevent? And what are the chances of the bad thing happening anyway if I go ahead and do it? And what bad things might happen because of the intervention, and what are the chances?

Another way of looking at the kind of comparison is the Number Needed to Treat. How many people have to get this intervention to prevent a single instance of the bad thing happening -- be it sickness, disability, or death from the particular cause? And remember -- you will die anyway. It's a question of when and how. Nothing you can possibly do will "save your life." So what are you really trying to avoid? A lot depends on the age at which something is likely to happen, whatever other problems you may have at that time, and your personal preferences about what it's important to be able to do and how well you tolerate pain, and so on.

So when you are confronted with a choice, ask:

What are the risks of doing nothing? What is likely to happen if I just keep eating a balanced diet, exercising regularly, not smoking, avoiding excessive alcohol intake, wearing my seat belt, using condoms, and not keeping a loaded gun in the house?

What are the alternatives to the intervention the doctor proposes? And that includes interventions provided by people in other specialties -- if you're talking to a surgeon, he probably wants to do surgery, but there may be alternatives in physical therapy, pharmaceuticals, or who knows, meditation or cognitive behavioral therapy. Check them all out, Check with those other specialists; get a second or third opinion. It's usually sensible to start with the least intrusive, least expensive, and least risky option. Only when that doesn't work should you think about moving up the ladder.

Now, the cold hard fact is that there are some doctors out there who will not like it if you start asking them these questions. They will be offended, they will disdain you, they will treat you like a defiant child. In that case, just say thank you very much and walk out. Find another doctor, and another, until you find one who is happy to answer these questions; so happy, in fact, that even if she doesn't already know the answers, she will find them out for you. Which is obviously what she should have done before she made any recommendation in the first place. And then, if you finally decide no, I don't want that, accept no bullying, accept no scolding, accept no contempt.

On the other hand, if you do decide to undertake a treatment, you have to hold up your end. Take the pills, on schedule, every time. Do the exercises. Follow the diet. Keep your appointments. If you can't commit to it, it's the wrong choice for you, number one. And number two, I think you do have an obligation to your doctor if she or he is trying to do right by you. Doctors want to succeed, and when their patients don't cooperate by sticking with the plan, it makes them feel bad. At least the good ones. So it's a two way street. If they are listening, if they are giving you balanced and well informed advice, and they are letting you decide what's best for you based on that good advice, let them know you appreciate it. And do your best.

That's all I've got to say. Of course it's hardly ever going to happen.

Primum no Nocere?

We've all learned that "First do no harm" is supposed to be a motto of the medical profession -- I believe the saying is attributed to Hippocrates. But the truth is, any physician who tried to live by that model would be paralyzed, unable to practice. I would put the harms done by medicine in various categories, some unavoidable, some ameliorable or reducible, but harm there will always be. This is why doing too much, medically, is more than just a waste of money. Here is one schema for thinking about iatrogenic -- medically induced -- disease and injury. There are not generally bright lines between these categories.

1) Medical intervention is inherently risky: With exceptions -- basically in cases where a person's death is imminent without intervention -- just about everything doctors do represents a tradeoff between potential benefits and potential harms. In many cases, it's not even a mere chance of harm that's in question: surgery is painful 100% of the time, temporarily incapacitating, and in the case of relatively major surgery may require more than a year for real recovery and leave predictable permanent deficits. Some drugs don't just have a risk of side effects, there are adverse effects that they cause predictably.

People can make the choices that seem best to them in those circumstance, but even more pervasively, medical treatment is a roll of the dice. You can decide that the really bad outcome is snake eyes and hence unlikely, but it is possible. Doctors are always thinking probabilistically: (potential benefit of intervention * probability of benefit)-(potential harm of intervention * probability of harm) > 0? Let's do it. Of course you have to put a value on the potential harm and benefit and there are likely several of them with differing probabilities and importance. That goes for diagnostic procedures as well, by the way. "Let's do it just to make sure" seems hard to argue with, except that it could hurt you in the process.

Unfortunately, doctors have a bias toward action. As Atul Gawande shows in the essay, this may be due to financial incentive, but even without the call of the greenback, doctors like to do stuff. Alas, more is not better. It's always tempting when confronted with an individual decision to think, "Let's do all we can for this person," it's just human nature. Sometimes doing less, or even nothing, is the best choice, but it's the hardest one to make.

2) The nosocomial problem: This could be viewed as a sub-category of (1), but it's sufficiently pervasive and distinctive to merit a paragraph. Hospitals are very dangerous places. They are filled with sick, debilitated people whose immune systems are not up to par, who have extra holes in them with tubes going in and out of said holes as well as some of their natural orifices, which means they are pathogen heaven, no matter how hard they work at keeping everything clean. (Which, by the way, is not hard enough. The cleaners make close to minimum wage, they don't even get health insurance, they get no respect, and they consequently are not particularly interested in sterilizing every square milimeter of urine stained tile. But I digress.)

In an effort to control what would otherwise be plague central, the doctors act like feedlot operators and saturate the place with antibiotics. Alas, bacteria have awesome powers of evolution. Not only can mutations move through populations of the same species, but they can swap genes between species. They can even pick up DNA from dead cells. Hospitals have given us methycyllin resistant Staphylococcus aurea (MSRA), and multi-drug resistance Clostridium difficile, among other gifts. Go into the hospital, and in addition to the distinct risk of having MSRA eat your face and C. difficile destroy your intestines, you are at risk to wind up with a bladder infection, wound infection, pneumonia, and God knows what else. In other words, you don't want to go there.

3) Screwups: Yup, health care providers make flat out mistakes: mixing up patients, amputating the wrong leg, putting the wrong pills in the bottle, using treatments that have been scientifically discredited, you name it.

4) Psychological and cultural iatrogenesis: There is something to be said for just accepting things. While the influenza hysteria mongers were provoking people to ask, "Are we all going to die?" I was waiting here quietly with the comforting answer: Yes. We cannot, for example, conquer cancer, because it is an inevitable feature of senescence: the mechanisms that regulate cell division and specialization wear out over time. If we control one cancer, another will come along. Nor can we expect to live our lives free of pain, or sadness, or some degree of functional limitation. There is a great deal to be said for learning how to live with the ills of the flesh and mind, coping with them, working around them, and keeping on going. This gets into a philosphical and moral thicket of some density, which I will avoid for today, but just remember that it's out there.

So, the point of all this is that the benefits of medical intervention stop outweighing the harms at a point well short of how far we tend to go here in the U.S. Rather than being terrified of "rationing" and having somebody tell us that we can't have all the PET scans and joint scrapings we think we want, we really ought to demand -- affirmatively demand -- to receive less. We'll be a lot better off, and not only because we'll have more money left in our pockets.