August 13, 2005
Wanted: A Health Care System That Actually Provides What the "Old Old" Need
Jerald Winakur, who has practiced internal medicine and geriatrics in San Antonio for almost 30 years and is an associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center, published an interesting piece in last Sunday's Washington Post: "What Are We Going to Do With Dad?" [tm]
I find this hard to believe . . . . CNN.com reports on people who lost weight eating only McDonald's.
One person went so far as to make her own independent film about dieting at McDonald's. "Me and Mickey D" follows Soso Whaley, of Kensington, New Hampshire, as she spends three 30-day periods on the diet. She dropped from 175 to 139 pounds, eating 2,000 calories-a-day at McDonald's.
"I had to think about what I was eating," Whaley said. "I couldn't just walk in there and say 'I'll take a cinnamon bun and a Diet Coke.' ... I know a lot of people are really turned off by the whole thought of monitoring what they are eating, but that's part of the problem."
Somehow I don't see McDonald's becoming the new Subway and I really wonder what some of these people were eating before ther started the McDonald's Diet. [bm]
August 12, 2005
Big Pharma and CAFTA
As you are probably all aware, after a bit of arm-twisting, Congress passed and the President signed the Central American Free Trade Agreement (CAFTA). Salon.com reports on some of the provisions that benefit Big Pharma in the bill that have received much attention. The article states,
Though protections for the environment and workers' rights are often the most contentious issues surrounding trade deals such as CAFTA and NAFTA, pharmaceutical giants, aided by the U.S. government, are increasingly using these pacts to assert their power over markets in developing countries. Activists and public-health groups working on the ground say these companies put profits above public health by keeping generic medicines off the shelves, which keeps prices high and drugs out of reach to all but the most wealthy. These deals apply to all prescription drugs, but generics have been particularly effective at driving down the prices of drugs used to treat AIDS -- in some cases by 98 percent -- even as AIDS rates have skyrocketed. CAFTA is signed and delivered, and the United States is now preparing trade pacts with Thailand, South America and other parts of the developing world. . . . .
Costa Rica's free, universal system depends on cheap drugs to keep costs down. Roman Macaya, executive director of the National Chamber of Generic Products of Costa Rica, says that if CAFTA-like protections had been in place, buying drugs would have put the system in financial jeopardy. Along with the Dominican Republic and Nicaragua, Costa Rica has yet to sign on to CAFTA and drug-pricing promises to be a big issue in the country's upcoming presidential election. "Costa Rica will most likely have to adopt a policy where older drugs are prescribed rather than the latest drugs even if HIV strains have evolved to be resistant to those older drugs," Macaya says. "Most of the drug prices for the new drugs are going to be out of reach under CAFTA."
That, he and others say, is because CAFTA contains several provisions designed to limit generic access. For example, drug companies get 20-year patent protection for their drugs from the moment they begin research and development, but they can apply to extend that time period. (A drug usually takes about 15 years to come to market.) In the United States, that time is limited, but under CAFTA, there's no upper limit on the extension the companies could obtain.
A more dire consequence lies in the short term. Generic companies seeking approval of their drugs usually use safety data from clinical tests that the name-brand companies conducted, obviating the need to repeat expensive and time-consuming work. CAFTA allows the original manufacturers to keep that data secret for five years after a company registers a drug. Generic companies need that data to market their drugs because it's not financially feasible to repeat those studies. And according to Rachel Cohen of Doctors Without Borders' Campaign for Access to Essential Medicines, "The requirement to retest a drug already proven to be safe and effective is medically unethical, because it forces a number of patients to take part in clinical trials which are not necessary and requires some to take placebos in order to compare outcomes with the actual drug and therefore forgo a proven treatment."
You can read the entire article at Salon.com after viewing a brief ad. [bm]
WSJ Disses Canadian Healthcare System (and Dog Bites Man)
Today's Wall Street Journal published a run-down of the troubles experienced by Canada's national single-payer health care system. It's "Canada's 'Free' Health Care System Has a High Price Tag," by John H. Fund. (The joke in the title is from P.J. O'Rourke's line that if you think the price of health care is high now, just wait until it's free.) Among Fund's observations:
- "[L]ast June, a majority of Canada's Supreme Court struck down a Quebec law that banned private health insurance and held that the public system inflicted cruel and unusual punishment on many of its patients. . . . Canada's Supreme Court was scathing in its indictment of the system. 'Access to a waiting list is not access to health care,' the court ruled. 'Delays in the public health care system are widespread . . . in some serious cases, patients die as a result of waiting lists.' The court struck down a Quebec law banning private medical insurance, which should lead to successful challenges to similar laws in other provinces." The opinion is Chaoulli v. Quebec (Attorney General), 2005 SCC 35 (June 9, 2005).
- "The Fraser Institute has found it takes an average of 17.9 weeks between the time a patient makes an appointment to see a general practitioner and when he can then see a specialist. He will then be treated by a system that ranks 13th out of 22 advanced countries in access to MRI technology; 17th out of 21 in access to CT scanners and seventh out of 22 in access to radiation machines. The safety valve in the system is that nearby U.S. hospitals can provide treatment for emergency cases and patients willing to pay."
As the article also points out, however, Canada's Medicare program enjoys healthy levels of public support -- Fund would say irrational levels of support -- despite its weaknesses. During the first few decades of the system, Canada experienced robust growth in its economy most years, and a steadily increasing pie helped buffer Canadians from the economic pain that would otherwise have resulted from steadily increasing health care costs. When the Canadian economy stopped showing strong growth, the Medicare system came under enormous pressure to cut back. Somehow, through it all, Canadians remain loyal to their system. The question raised by Fund's article is this: Are Canadians poorly informed about the performance of their health care system, or are Fund and other critics of Canadian Medicare looking at the wrong indicators? What matters most: the number of MRI's and mean waiting times, or infant mortality, life expectancy, and other measures of health care outcomes?
Thanks to my former student, Julie Timmer, for sending me this article. [tm]
Concierge Medical Practice: New GAO Report
The Government Accountability Office has published a report (GAO-05-929) on concierge medicine, "an approach to medical practice in which physicians charge their patients membership fees in exchange for enhanced services or amenities. Concierge physicians typically care for fewer patients than do doctors in conventional practice, and they are more readily available to member patients, for example, by cell phone or same-day appointments." Here's the abstract:
Concierge care is practiced by a small number of physicians located mainly on the East and West Coasts. Nearly all of the 112 concierge physicians responding to GAO’s survey reported practicing primary care. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500 to $1,999. The most often reported
features included same- or next-day appointments for nonurgent care, 24-hour telephone access, and periodic preventive care examinations. About three-fourths of respondents reported billing patient health insurance for covered services and, among those, almost all reported billing Medicare for covered services.
Two principal aspects of concierge care are of interest to the Medicare program and its beneficiaries: compliance with Medicare requirements and its effect on beneficiary access to physician services. HHS has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements; for example, the membership fee must not
result in additional charges for items or services that Medicare already reimburses. Some concierge physicians reported to GAO that they would like more HHS guidance. The small number of concierge physicians makes it unlikely that the approach has contributed to widespread access problems. GAO’s review of available information on beneficiaries’ overall access to physician services suggests that concierge care does not present a systemic
access problem among Medicare beneficiaries at this time. In comments on a draft version of this report, HHS agreed with GAO’s finding on concierge care’s impact on beneficiary access to physician services and indicated it will continue to follow developments in this area.
News on the Heart Disease Front
The New York City health department is taking a new stand against heart disease. The New York Times reports that the city health department has encouraged all city restaurants to stop serving food containing trans fats. The story states,
The request, the first of its kind by any large American city, is the latest salvo in the battle against trans fats, components of partially hydrogenated vegetable oils, which three decades ago were promoted as a healthy alternative to saturated fats like butter.
Today, most scientists and nutrition experts agree that trans fat is America's most dangerous fat and recommend the use of alternatives like olive and sunflower oils.
"To help combat heart disease, the No. 1 killer in New York City, we are asking restaurants to voluntarily make an oil change and remove artificial trans fat from their kitchens," said Dr. Thomas R. Frieden, the city's health commissioner, who compared trans fats to asbestos and lead as public health threats. "We are also urging food suppliers to provide products that are trans-fat free."
It is far from clear how many restaurants will heed the call of Dr. Frieden, one of the city's most activist public health commissioners in a generation.
A survey by the department's food inspectors found that from 30 to 60 percent of the city's 20,000 restaurants use partially hydrogenated oil in food preparation, meaning that thousands of cooks and chefs might need to change their cooking and purchasing habits to meet the request. Trans fats are particularly prominent in baked goods, frying oils, and breading, and can be hard to replace without raising costs or changing the taste of familiar foods like cookies and French fries.
While the health department will not seek to ban the ingredient outright, it has begun an educational campaign among restaurateurs, their suppliers and the public denouncing trans fats. In a letter sent to all food suppliers in the city last week, Dr. Frieden wrote: "Consumers want healthier choices when eating out. Our campaign will increase consumer demand for meals without trans fat."
Should be interesting to see how this works out - trans fat will be very hard to eliminate - it seems to be in everything that I buy at the grocery store. However, I think this is a good first step to cause people to think about their cooking and eating habits. Who knows - some of these famouse chefs might come up with foods that taste good without trans fats. [bm]
August 11, 2005
Update on Baron-Cohen Autism Study
If you are interested in a more thorough discussion of the recent Baron-Cohen autism article, you can find more about it here and here. These links are to a blog by Kristina Chews entitled, "My Son has Autism." It is a moving and beautiful discussion of her relationship with her son, Charlie. It also details some of her struggles and concerns about identifying the cause of Charlie's autism.
On a personal note, my nephew, age 2, was recently diagnosed with autism so it is a topic in which I have developed a great and increasing interest as we work to find the best way to help support him and his parents. [bm]
The TImes U.K. reports on a rather startling new statistic found in paternity testing results. According to the Times,
Research suggests that, as cases of teenage pregnancies, sexual infidelity and multiple partners increase, 1 in 25 fathers could unknowingly be raising another man’s child.
With improvements in genetic testing, thousands of fathers every year are discovering that “their” child is someone else’s. A study by scientists from Liverpool John Moores University concludes that 4 per cent of all men are unwittingly bringing up a child they have not fathered.
* * * *
The researchers, led by Mark Bellis, of the Centre for Public Health at Liverpool, analysed a wide range of international studies, looking at estimates of paternal discrepancy between 1950 and 2004.
Their findings, published in the Journal of Epidemiology and Community Health, show that rates of cases where a father was not the biological father of his child ranged from 1 per cent in some studies to as many as 30 per cent. Experts generally agree that the rate is below 10 per cent. The Liverpool team said that their meta-analysis suggests a 4 per cent rate, meaning that about one in 25 families could be affected.
“For any father, identifying that the child they are raising as their biological progeny is actually sired by another man can have substantial health consequences,” the researchers said.
“Such knowledge can also destroy families, affecting the health of the child and mother as well as that of any man who is ultimately identified as the biological parent.” Suspected infidelity, as a result of a man finding out that a child is not his own, can lead to domestic violence against women.
August 10, 2005
Leaking Drug Secrets
And you thought only friends of Martha Stewart leaked information about drug trial results. Not so according to a recent article in the Seattle Times. The article by Luke Timmerman and David Heath entitled, "Drug Researchers Leak Secrets to Wall Street," details their recent investigation into the information sharing that allegedly goes on between researchers and investers.
A Seattle Times investigation found at least 26 cases in which doctors have leaked confidential and critical details of their ongoing drug research to Wall Street firms.
The practice involves doctors at top research universities from UCLA to the University of Pennsylvania, and powerful financial firms including Citigroup Smith Barney, UBS and Wachovia Securities.
In 24 of the 26 cases, the firms issued reports to select clients with detailed information obtained from doctors involved in confidential studies. The reports advised clients whether to buy or sell a drug stock.
Trading stock based on secret information bought from medical researchers is illegal, say legal experts who were told of The Times' findings.
"That's a good way to go to jail," said lawyer Thomas Newkirk, former associate director of enforcement at the Securities and Exchange Commission (SEC).
Whether they are paid or not, medical researchers who talk with Wall Street about their ongoing research violate confidentiality agreements they sign before drug companies allow the drug testing to begin.
Until now, the selling of drug secrets has been hidden from securities regulators and the public, but biotech and Wall Street insiders said the practice is widespread.
Health Care Renewal Blog has more information about this article and its contents here and here. The blog editor thinks that the researchers may not be the super bad guys the article potrays, but instead poster children for much needed revision in how we currently fund research in this country. [bm]
Update: A Good Death
The Diane Rehm show yesterday discussed some of the same end-of-life issues and provided gripping personal stories concerning how individuals are making decisions for loved ones at the end of life. [bm]
The "Good Death"
The New York Times ran a remarkable article in its Sunday magazine this week: "Will We Ever Arrive at the Good Death?" It's a close up and personal view hospice, palliative care, and other aspects of dying in America. Here's a brief excerpt:
[T]he new trend in hospice [is] toward ''open access,'' meaning that terminally ill patients can continue chemotherapy and other treatments and still get hospice benefits through Medicare. The idea began in the 1980's, when AIDS patients started enrolling in hospices and weren't quite ready to give up all medical options. Today hospice workers are also aligning with doctors in a field known as palliative medicine -- an approach that emphasizes pain relief, symptom control and spiritual and emotional care for the dying and their families. With hospice becoming so inclusive, and with palliative care on its way to becoming a new medical subspecialty with its own licensing exam, the natural, machine-free deaths we say we want are starting to look a lot like the medicalized deaths they were meant to replace.
The trend reflects society's deep ambivalence about dying. During the long and public agony over the death of Terri Schiavo, debate centered on the right to make end-of-life decisions. But underlying the political posturing was a shared assumption that was barely acknowledged: the belief that dying is something over which we have some control. This death-denying culture has led to a system of care for the terminally ill that allows us to indulge the fantasy that dying is somehow optional.
In many ways, we act as if we can avoid death indefinitely if only we're quick enough or smart enough or prepared enough. Even hospice workers call their field by a new name that accentuates the positive: they used to say they specialized in ''death and dying,'' but today the umbrella term is ''end of life.'' The shift is subtle but significant -- an emphasis on ''life'' rather than ''death.''
What we have, then, is a medical system for the dying that is as ambivalent about dying as we are ourselves.
The accompnaying photographs are really gripping. [tm]
August 9, 2005
Adult Guardianship Project
For those of you in Chicago looking for a worthwhile way to spend your free time,
Loyola University Chicago's Elder Law Initiative recently announced The Adult Guardianship GAL Project. According to the press release, this project
"aims to increase the number of pro bono guardians ad litem (GALs) available to investigate adult guardianship cases and to develop a pool of other professionals to assist in guardianship cases in Cook County, Illinois Circuit Court ". . .
The project provides training for attorneys and other professionals who are interested in serving as GALs. In return for the training received, the volunteers are expected to participate in 3 adult guardship cases or devote 40 hours (whichever comes first) over the next year to such cases.
For more information or to apply, please contact: Professor Marguerite Angelari at (312)915-6775 or by email at firstname.lastname@example.org. [bm]
Law Review Publication Concerns
Since many of you may be working on getting out a publication this Fall (or perhaps have already submitted one), Crooked Timber has an interesting post about the world of law review publications. The editor notes:
Now I know that there are a lot of complaints among legal academics about the dominant role of student-edited law reviews. But (if this is at all representative), I hadn’t realized quite how bad the problem was. It’s not (as Micah has argued previously ) the fault of the students editing these reviews – when you have so many article submissions that you’re literally unable to read them all (thanks to the practice of multiple submissions), you’re inevitably going to have some more-or-less unfair metric for deciding which ones to read, and which ones not to. The problem is a structural one. But it does suggest that it’s going to be a lot more difficult for a smart legal academic in a second or third tier school to improve her position by publishing material in good journals, than it would be if she were, say, a political scientist or a sociologist. If her school’s position in the rankings counts against her chances of getting published, she may find herself in a Catch-22 situation; the only way to get published in good journals is to improve her personal name-recognition (since her school won’t help), but the only way to improve her personal name-recognition is to get published.
This observation rings true to me. I had a colleague who sent around an article. After receiving an offer of publication, he called other schools attempting to obtain a better placement. He mentioned in one phone call that he was from UC. The student editor became very excited - University of Chicago! "Um, no," my colleague answered, "University of Cincinnati." Needless to say, my colleague was not greeted with quite the same enthusiasm after he made the correction. I am not sure what the answer is to the rankings roulette, but blind reads does sound like one potential solution. [bm]
August 8, 2005
Michael Schiavo Guardianship Award
BlogBioethics reports on Orlando Sentinel article discussing Michael Schiavo's recent award.
The Florida State Guardianship Association bestowed its Guardian of the Year Award on Schiavo for carrying out his wife's wishes not to be kept alive artificially despite a drumbeat of withering criticism.
. . . .
Association members, most of whom are appointed by judges to represent people who have been declared incapacitated, acknowledged Schiavo was a controversial choice and they anticipate a backlash. After all, Gov. Jeb Bush joined world leaders from the president to the pope in aligning themselves with Bob and Mary Schindler, the Pinellas County couple who fought their son-in-law's effort to remove the feeding tube that kept their severely brain-damaged daughter alive for 15 years.
But, group members said, Michael Schiavo's unwavering commitment to honoring his wife's wishes in the face of public scrutiny and enmity embodied the professionalism and compassion with which court-appointed guardians quietly carry out their duties every day.
New Theories about Autism
Today's New York Times containes an editorial by -Simon Baron-Cohen concerning new research on some of the causes of autism. He writes,
Males obviously produce far more prenatal testosterone than females do, but levels vary considerably even across members of the same sex. In fact, it may not be your sex per se that determines what kind of brain you have, but your prenatal hormone levels. From there it's a short leap to the intriguing idea that a male can have a typically female brain (if his testosterone levels are low), while a female can have a typically male brain (if her testosterone levels are high). That notion fits with the evidence that girls born with congenital adrenal hyperplasia, who for genetic reasons produce too much testosterone, are more likely to exhibit "tomboy" behavior than girls with more ordinary hormone levels.
What does all this have to do with autism? According to what I have called the "extreme male brain" theory of autism, people with autism simply match an extreme of the male profile, with a particularly intense drive to systemize and an unusually low drive to empathize. When adults with Asperger's syndrome (a subgroup on the autistic spectrum) took the same questionnaires we gave to non-autistic adults, they exhibited extreme Type S brains. Psychological tests reveal a similar pattern.
And this analysis makes sense. It helps explain the social disability in autism, because empathy difficulties make it harder to make and maintain relationships with others. It also explains the "islets of ability" that people with autism display in subjects like math or music or drawing - all skills that benefit from systemizing.
People with autism often develop obsessions, which may be nothing other than very intense systemizing at work. The child might become obsessed with electrical switches (an electrical system), or train timetables (a temporal system), or spinning objects (a physical system), or the names of deep-sea fish (a natural, taxonomic system). The child with severe autism, who may have additional learning difficulties and little language ability, might express his obsessions by bouncing constantly on a trampoline or spinning around and around, because motion is highly lawful and predictable. Some children with severe autism line objects up for hours on end. What used to be dismissed by clinicians as "purposeless, repetitive behavior" may actually be a sign of a mind that is highly tuned to systemize.
One needs to be extremely careful in advancing a cause for autism, because this field is rife with theories that have collapsed under empirical scrutiny. Nonetheless, my hypothesis is that autism is the genetic result of "assortative mating" between parents who are both strong systemizers. Assortative mating is the term we use when like is attracted to like . . .
The editorial is very interesting and provides new thought for the causes of autism.
On Friday, I posted an article from a reader concerning California's autism rates and what the article noted was apparently a decline in autism rates. Another reader alerted me to articles that show that California has not experienced such a decline. See the following two cites: http://citizencain.blogspot.com/2005/07/kirby-flubs-autism-data.html
http://autismdiva.blogspot.com/2005/07/this-just-in.html. Much of what causes autism is as yet unknown, leading to much disomfort and heartbreak. In addition, the many statistics used can be quite frustrating and diffcult to understand. I apologize for adding to the confusion. [bm]
August 7, 2005
Bird Flu Vaccine
The New York Times reports that there has been a successful testing of the vaccine for a strain of bird flu. The Times article states,
In interviews over recent days, Dr. Fauci has said that tests so far had shown that the new vaccine produced a strong immune response among the small group of healthy adults under age 65 who volunteered to receive it, although the doses needed were higher than in the standard influenza vaccine offered each year. The vaccine, developed with genetic engineering techniques, is intended to protect against infection, not to treat those who are sick.
Further tests are expected to be conducted among two groups - people 65 and older, and children - over the next several months. Dr. Fauci expressed confidence that they would confirm the success of the first tests and answer remaining scientific questions.
Because the vaccine is made in chicken eggs, "a potential major stumbling block" to successful mass production is the number of eggs farmers can supply manufacturers, Dr. Fauci said.
If manufacturers can overcome such hurdles, the new vaccine could go far in averting a possible pandemic of human influenza, Dr. Fauci said.
Before you get too excited about the good news, Effect Measure has some concerns that you may want to take note of:
Apparently the New York Times got an exclusive from NIAID Director Tony Fauci over the weekend and the other MSM outlets are playing catch-up, citing the NYT story. But why now? The results are only partial, preliminary and very hard to interpret. It appears that the Administration has finally awakened to the bird flu threat--as a PR problem. With stories all over the media about an impending pandemic, many noting the shocking lack of preparation on the ground, the spin machine was put into action, with Fauci again the water-carrier (it is sad to see a good scientists brought so low).
You should read the entire Effect Measure article for an overview of where we appear to be in terms of the development of a vaccine. [bm]