Friday, August 24, 2007
Setting an ethical agenda for health promotion
An interdisciplinary conference on the ethics of health promotion and public health
18 – 20 September 2007, Ghent University, BELGIUM
REGISTRATION CLOSES 7th SEPTEMBER!
Norman DANIELS (Harvard University)
Angus DAWSON (Keele University)
Ronald BAYER (Columbia University)
Nancy KASS (Johns Hopkins University)
Luk JOOSSENS (ECL)
Marcel VERWEIJ (Utrecht University)
Maurice MITTELMARK (University of Bergen)
Lea MAES (Ghent University)
Ted SCHRECKER (University of Ottawa)
Andrew TANNAHILL (Health Scotland)
Details, full programme and registration forms available from the conference website at: http://www.healthpromotionethics.eu
The Lancet (free registration) released data showing that the United States having the best survival rate for cancer. This is great news! Ezra Klein analyzes further what this information really means. He writes,
Andrew Sullivan is quite pleased that the US is #1 in cancer survival rates. So am I! Problem is, we don't know what that means. The US has the most aggressive tumor screening in the world. That means we find some tumors earlier, but we also find many tumors that would have been non-lethal, or proven so slow-growing that something else would have killed the individual before the cancer did. In those cases, our treatments are, at best, an enormous waste of money, and at worst, more damaging than the disease. The question is how many otherwise lethal cancers we're curing, not merely how many cancers we're curing (or slowing).
Moreover, simply having the highest survival rates isn't a particularly useful metric of whether we're getting good value for our money. Our 5-year cancer survival rate, according to the study Andrew links, is 62.9%. Italy's is 59%. Italy spends about $2,532 per person. America spends about $6,100. And these numbers, incidentally, are adjusted for purchasing power parity. Then there's the question of who our treatment is best for. Not the poor. Studies show significantly lower mortality rates for the low-income cancer patients in Canada than in the US. Is this all a good deal? Maybe. But Sullivan should explain why we should believe that. . . .
For a different take, see the Ayn Rand Institute.
Wednesday, August 22, 2007
For a quick de-bunking of the health insurance as a moral hazard, Lawyers, Guns and Money (what a combo), has a good post,
Repeating a frequent argument, a commenter to this thread says:
Frankly, this gets us to one legitimate critique libertarians have of universal health care: it can be used to bootstrap lots more nanny statism. I can live with that given the net positives of having a better health care system, but it's regrettable.
For this reason, however, it's worth noting that the argument is lousy, a subset of the utterly bizarre belief that medical care works according to similar incentives as markets for consumer goods. As Malcolm Gladwell notes with respect to the claim that having health insurance (rather than paying for doctors out of pocket) represents a major moral hazard:
The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick. “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?” . . . . .
None of this surprises me, because the argument also strikes me as illogical on its face. The thing is, being healthy is its own powerful incentive. Maybe I'm unusual, but even though I have decent health insurance I don't actually enjoy being sick, bedridden, in physical pain, spending time in doctor's offices, etc. Do people really think it's common -- even subconsciously -- for someone with a relatively healthy lifestyle to get health insurance and see that as an opportunity to go on that all Popeye's, deep-fried HoHos, and Cutty Sark diet they've been hankering for? I don't understand this reasoning at all. There may be room for some minor disincentives at the margin, but the idea that universal healthcare won't work because the possibility of being bankrupted by medical bills is the major incentive people have to be healthy is bizarre.
The structure of a universal care system should somehow promote and reward healthy living.
How does one deter the freeloaders who take poor care of themselves and then overuse the system for years on end (as sort of mental health therapy)? "It will not happen" is a questionable response - it happens now.
Just in time, The Next Hurrah has blogged about the Australian flu season and provides some insight into whether the United States is prepared for the flu season. . . . The site states,
Severe flu seasons can be as bad or worse than a mild pandemic. Here's a post from our colleague Revere, one of the epidemiologists at Effect Measure, the pogressive public health blog, outlining exactly that. From Effect Measure:
Given our posts (here, here) on the particularly severe flu season in Australia, we thought it useful to remind ourselves that a bad flu season can be really bad -- worse than the 1918 pandemic in some locations. Here is a post we did back in April 2006 about an interesting paper (see link in post) by Cecile Viboud and her colleagues at NIH that looks at historical records on flu mortality. Flu is a bad disease, pandemic strain or not. Why some flu is worse than others we don't know.
The hospital diversions and capacity overflow is a reminder that health issues in this country (not just Australia) need to be kept front and center as a priority. A bad flu season would overwhelm our own EDs
A  study to be published in the April 2002 Annals of Emergency Medicine on emergency department use and capacity in California, sheds light on the overcrowding problem nationwide and provides the first objective data on this crisis in the United States. (Trends in the Use and Capacity of California's Emergency Departments, 1990-1999).
The study finds that in the past decade (1990-1999) emergency departments in California decreased by 12 percent, while the number of emergency department visits at each hospital increased 27 percent to about 25,778 annually.
and the efforts to prepare for a flu pandemic (whatever strain of virus) only highlight the health infrastructure issues here in the US that are every bit as ignored as crumbling bridges... until they collapse. To their credit, California is trying to address surge capacity issues in their hospitals. Is that happening in other states, with backing from the legislatures?
The SCHIP program's proposed expansion to cover underinsured children (and Bush's virulent and mean-spirited opposition) is in the news now, and other health care issues need to stay in the news through the primaries and right up to the election. Government has an important role in rebuilding our health infrastructure, and we need to make sure the candidates from both parties articulate what they see that role as. . . . . (See Gene Sperling's evaluation of SCHIP).
Tuesday, August 21, 2007
I am not sure why the President decided to issue these new standards for State Children’s Health Insurance Program (SCHIP) late, last Friday (oh, wait - they look like they might be incredibly unpopular so perhaps he hoped no one would notice . . . ). The New York Times reports on the President's battle to prevent expanding the coverage of SCHIP:
The Bush administration, continuing its fight to stop states from expanding the popular Children’s Health Insurance Program, has adopted new standards that would make it much more difficult for New York, California and others to extend coverage to children in middle-income families. Administration officials outlined the new standards in a letter sent to state health officials on Friday evening, in the middle of a month-long Congressional recess. In interviews, they said the changes were aimed at returning the Children’s Health Insurance Program to its original focus on low-income children and to make sure the program did not become a substitute for private health coverage. After learning of the new policy, some state officials said today that it could cripple their efforts to cover more children by imposing standards that could not be met. . . .
The poverty level for a family of four is $20,650 in annual income. New York now covers children in families with income up to 250 percent of the poverty level. The State Legislature has passed a bill that would raise the limit to 400 percent of the poverty level — $82,600 for a family of four — but the change is subject to federal approval. . . . .
In the letter sent to state health officials about 7:30 p.m. on Friday, Dennis G. Smith, the director of the federal Center for Medicaid and State Operations, set a high standard for states that want to raise eligibility for the child health program above 250 percent of the poverty level. Before making such a change, Mr. Smith said, states must demonstrate that they have “enrolled at least 95 percent of children in the state below 200 percent of the federal poverty level” who are eligible for either Medicaid or the child health program.
Deborah S. Bachrach, a deputy commissioner in the New York State Health Department, said, “No state in the nation has a participation rate of 95 percent.” And Cindy Mann, a research professor at the Health Policy Institute of Georgetown University, said, “No state would ever achieve that level of participation under the president’s budget proposals.” The Congressional Budget Office has said that the president’s budget, which seeks $30 billion from 2008 to 2012, is not enough to pay for current levels of enrollment, much less to cover children who are eligible but not enrolled.
When Congress created the Children’s Health Insurance Program in 1997, it said the purpose was to cover “uninsured low-income children.” Under the law, states are supposed to make sure public coverage “does not substitute for coverage under group health plans;” but the law did not specify what states must do. In an interview today, Mr. Smith said: “The program was always meant for children in lower-income families. As states move higher up the income scale, it’s more likely to substitute for private coverage.”
Monday, August 20, 2007
The Associated Press reports on the latest struggle for scientists: defining life. The story states,
In suburban Washington this summer, prominent scientists at the J. Craig Venter Institute, who were key players in mapping the human genome, switched DNA from one bacterium into another, changing its genetic identity. That put the world on notice that man's ability to manipulate life is dancing around the point of creation.
Now Venter is asking for a patent for a completely new bacteria that would be created by inserting genes into a hollowed-out cell of what once was a urinary tract bug. Venter doesn't view that as creating life, just "modifying life to come up with new life forms."
At least half a dozen other research teams around the world are going farther, trying to create life out of chemicals, mimicking the beginnings of life on Earth. They're somewhere from three to 10 years from success, they figure.
For them, and Venter, new man-made life forms mean new energy sources, environmental clean-up mechanisms and life-saving medicines. For others, such a breakthrough would mean understanding how life began on Earth by trying to recreate it. . . .
Many scientists familiar with these challenges of defining life say the answers won't be easy to find. "It's an important but ultimately frustrating question if one expects to come up with a nice clean shiny answer; it ain't going to happen," said Francis Collins, a prominent Christian scientist and director of the National Human Genome Research Institute.
That talk about life is going to get uncomfortable as dreams of creation, from Frankenstein's monster on, get closer to reality, said University of Pennsylvania bioethicist Art Caplan. "This issue of 'what is life' has been at the core of biology for about 400 years," Caplan said. He said it leads to the more theological questions about whether life is special and whether we are special. Later this century, the definition of life will be at the heart of a political and societal debate as heated and divisive as abortion and embryonic stem cell research, Caplan predicts.
Look for changes in religion, too.
"As knowledge has (been) added, religions have adapted," Venter said. "I don't see why this is any different. We're pushing the frontiers of knowledge, understanding life on this planet."
Venter dismisses suggestions that scientists are playing God as media sensationalism. And Collins, a scientist who talks at length about his faith, said he finds it interesting that the people who most often use the phrase "playing God" usually don't believe in God.
"Playing God" is a secular, not religious, term, said Ted Peters, a professor at the Graduate Theological Union in Berkeley, Calif., and author of the book "Playing God." He said people who worry about that are really talking about tinkering with nature. "What Craig Venter is doing is an extremely complicated form of animal breeding," Peters said. "We're going to be changing the face of the planet no matter what. The question is do we want to do it responsibly or not?"
C. Ben Mitchell, a bioethicist connected with Trinity University, an evangelical Christian college in Illinois, worries about entrusting such monumental developments with scientists.
"Human history is enough; it is sufficient to remind us of the problem of hubris," Mitchell said. "It is at least a cautionary note, to caution us to be aware of unintended consequences.". . . .
Oops! The headlines on this Associated Press article are a bit misleading when one reads the article and discovers the reasons for the increase in use of pain medication (it is not because people are deeply depressed over the stock market woes, the entire Bush Presidency, or the latest Britney Spears rehab debacle). The Associated Press reports,
Retail sales of five leading painkillers nearly doubled over the last eight years, reflecting a surge in use by patients nationwide who are living in a world of pain, according to a new Associated Press analysis of federal drug prescription data. The analysis reveals that oxycodone usage is migrating out ofto areas such as , and Fort Lauderdale, Fla., and significant numbers of codeine users are living in many suburban neighborhoods around the country. The amount of five major painkillers sold at retail establishments rose 90 percent between 1997 and 2005, according to Drug Enforcement Administration figures. More than 200,000 pounds of codeine, morphine, oxycodone, hydrocodone and meperidine were purchased at retail stores during 2005, the most recent year represented in the data. That is enough to give more than 300 milligrams of painkillers to every person in the country. . . .
Dr. Jeffrey Gordon, director of the blood and cancer center at Day Kimball Hospital in Putnam, Conn., said Vicodin is a popular painkiller to give patients after surgery, and many doctors are familiar with it. "Over the past 10 years, there has been much better education in the medical community to ... ask if people are having pain and to better diagnose and treat it," Gordon said.
An AP investigation found these reasons for the increase:
_The population is getting older. As age increases, so does the need for pain medications. In 2000, there were 35 million people older than 65. By 2020, the Census Bureau estimates the number of elderly in the U.S. will reach 54 million.
_Drugmakers have embarked on unprecedented marketing campaigns. Spending on drug marketing has zoomed from $11 billion in 1997 to nearly $30 billion in 2005, congressional investigators found. Profit margins among the leading companies routinely have been three and four times higher than in other Fortune 500 industries.
_A major change in pain management philosophy is now in its third decade. Doctors who once advised patients that pain is part of the healing process began reversing course in the early 1980s; most now see pain management as an important ingredient in overcoming illness. Retired Staff Sgt. James Fernandez, 54, of Fredericksburg, Va., survived two helicopter crashes andover 20 years in the Marine Corps. He remains disabled from his service-related injuries and takes the equivalent of nine painkillers containing oxycodone every day. "It's made a difference," he said. "I still have bad days, but it's under control." . . .
"I'm concerned and many people are concerned, that the pendulum is swinging too far back," he said.
_More people are abusing prescription painkillers because the medications are more available. The vast majority of people with prescriptions use the drugs safely. But the number of emergency room visits from painkiller abuse has increased more than 160 percent since 1995, according to the government.
_Spooked by high-profile arrests and prosecutions by state and federal authorities, manynow say they offer guidance and support to patients but will not write prescriptions, even for the sickest people. The increase in painkiller retail sales continues to rise, but only barely. There was a 150 percent increase in volume in 2001. Four years later, the year-to-year increase was barely 2 percent.
_People who desperately need strong painkillers are forced to go long distances — often to a different state — to find doctors willing to prescribe high doses of medicine. Siobhan Reynolds, widow of apatient who needed large amounts of painkillers for a connective tissue disorder, said she routinely drove her late husband to see an accommodating doctor in .
The article goes on to discuss some of the prosecutions that have occurred and some of the evidence of abuse. Although it appears some may have distributed pain medication in an illegal manner, many doctors now fear prosecution for helping their patients manage their pain.
The New York Times reports that Medicare will no longer pay hospitals for costs deemed the result of " treating preventable errors, injuries and infections that occur in hospitals." The Bush administration claims that this change will help save lives and lots of money. The Times reports,
Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.” Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder. In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products. . . .
The new policy — one of several federal initiatives to improve care purchased by Medicare, at a cost of more than $400 billion a year — is sending ripples through the health industry. It also raises the possibility of changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission. Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case.
The Centers for Disease Control and Prevention estimates that patients develop 1.7 million infections in hospitals each year, and it says those infections cause or contribute to the death of 99,000 people a year — about 270 a day. . . .
Consumer groups welcomed the change. And while hospital executives endorsed the goal of patient safety, they said the policy would require them to collect large amounts of data they did not now have. Lisa A. McGiffert, a health policy analyst at Consumers Union, hailed the rules. “Hundreds of thousands of people suffer needlessly from preventable hospital infections and medical errors every year,” Ms. McGiffert said. “Medicare is using its clout to improve care and keep patients safe. It’s forcing hospitals to face this problem in a way they never have before.” . . .