Friday, November 9, 2007
Concurring Opinions brings us up-to-date on the latest twist in a case involving the circumcision of a 12-year-old boy. Sarah Waldeck writes,
On November 6, the Oregon Supreme Court heard a dispute between parents over the circumcision of their 12-year-old son. The father, who has recently converted to Judaism and has full custody of the boy, wants him circumcised. The mother is trying to stop the procedure and argues that it is both sexual and physical abuse. The lower court dismissed her challenge but would not permit the circumcision to occur until all appeals were exhausted.
There’s been plenty of talk about this case over at Law Blog. Reading the comments provides a snapshot of the debate over whether the United States should continue its practice of male infant circumcision. Law Blog has comments about the procedure’s health benefits and associated risks; assertions about whether circumcised males experience less sexual pleasure than uncircumcised males; and questions about whether one can criticize male circumcision and avoid being labeled anti-semitic. . . .
An article in the NY Sun quotes Geoff Miller at NYU as stating that he would “be quite shocked or at least surprised” if the Oregon Supreme Court reverses the lower court. Miller has good reason for his opinion, as courts have been unsympathetic to non-custodial parents who seek to prevent the circumcision of infants, and to custodial parents who claim the procedure was done without their informed consent. Still, this case may turn out differently than the rest. The Pacific Northwest has the lowest circumcision rates of anywhere in the county. The boy is 12. The combination of these two factors may mean that judges in Oregon view this case through a different cultural lens.
The case raises interesting questions about child autonomy in addition to the the entire range of issues surrounding male circumcision. An OPB News, an Oregon news outlet discussing the case states, "Circumcision opponents are asking the Oregon Supreme Court to look to a trial court case last year in Chicago. A divorced mother wanted her son circumcised, but the father did not. The judge in that case did not rule on the religious issues. Instead, he blocked the circumcision until the boy turned 18 and could decide for himself."
Thursday, November 8, 2007
The New York Times reports today on the latest toy recall - and it is rather frightening -
The story started with a 2-year-old boy who was taken to a suburban Sydney hospital on Oct. 5 in a shallow coma and suffering from seizurelike spasms. It ended with the latest recall of a Chinese-made toy, as the Consumer Product Safety Commission ordered the recall of 4.2 million Aqua Dots in the United States on Wednesday evening. Bindeez is also sold under brand names like Aqua Dots.
Connecting the two events were four weeks of medical sleuthing by Dr. Kevin Carpenter, a biochemical geneticist in Sydney. Dr. Carpenter discovered that the boy in Sydney had eaten Bindeez beads, celebrated as Australia’s “Toy of the Year.” Once ingested, the beads released a chemical related to GHB, the banned date rape drug. The beads are marketed in North America as Aqua Dots.
Dr. Carpenter’s story demonstrates how recalls come about, in a time when they are becoming depressingly routine.
Doctors at the Children’s Hospital at Westmead, outside Sydney, first believed that the 2-year-old boy, whose name has not been released, had an inherited metabolic disorder. But when Dr. Carpenter checked urine samples the next day for the chemical markers of the disorder, he found GHB, which can render victims unconscious and even cause death through respiratory failure. “We suspected at that time the child had been surreptitiously given” the drug by a family member or friend of the family, he said by phone from Sydney on Wednesday.
A follow-up test two days later showed that the GHB had disappeared from the boy’s body, which confirmed that the chemical had been ingested and was not occurring because of a genetic disorder. It was then that Dr. Carpenter learned that the boy had vomited beads before and after going into a shallow coma.
Dr. Carpenter obtained more of the boy’s beads and tested them in a mass spectrometer, a device that helps identify chemical compounds. “I saw a large peak of a substance I didn’t recognize,” he said. The “peak” was an obscure industrial chemical used to prevent water-soluble glues from becoming sticky before they are needed. But when ingested, the chemical quickly breaks down to become GHB. The United States tightly restricts the chemical’s sale and places GHB in the same category as heroin.
Ok, perhaps now would be the time to increase our product safety enforcement, oh, I forgot - Nancy Nord, the acting chairwoman of the Consumer Product Safety Commission does not want more money and other tools for enforcement. Silly me, I forgot that having one full-time employee to check on toys is sufficient. Ezra Klein has a video urging action.
Medpage Today has the solution for our current health care crisis - the Robo-doc:
Specialists at University of Louisville Health Care on Thursday began using a robot to remotely treat patients at Owensboro Medical Health System in western Kentucky, the Louisville Courier-Journal reports.
Specialists in areas such as neurology, cardiology and maternal-fetal medicine can use InTouch Technologies' RP-7 robot to consult with patients, observe vital signs on monitors and check heart rates, blood pressure readings or sonograms. The specialists in Louisville control the system using laptops and joysticks and receive help from doctors or nurses in Owensboro.
The robot system is the first in the state and one of about 130 being used worldwide, the Courier-Journal reports. University of Louisville Health Care officials did not disclose how much they paid for the system, but InTouch officials said each control station costs $2,500 and robots can be leased for five years for $5,000 per month.
Officials said the robot system could help counter Kentucky's physician shortage, specifically in rural areas. While 43% of the state's population lives in rural areas, just 23% of physicians practice in rural areas, according to the Courier-Journal. In addition, most medical experts and specialists practice in urban areas like Louisville and Lexington.
I think this is a really cool idea. Just replace us with robots! If you look at the lease rates, it really is affordable - especially when they have "double dollar days" at the robot dealership. At this rate, the pay is actually even less than you pay a midlevel provider ($60,000 per year), plus you don't have to worry about benefits, vacations, sickness, or even CME.
The downside is that you have to have real physicians at the other end controlling the joy sticks. This reduces the overall efficiency of the process and really cuts into the cost savings of having an independent robot doctor. Dealing with cranky human doctors is just a nuisance that we should not have to deal with.
So here is my solution. Train a bunch of Grade School kids on Trauma Center: Second Opinion for the Nintendo Wii. Then they can control the robots remotely. This is a great idea because kids are far better at this kind of thing than are adults. My kids can cream me at driving games, even though I am a better driver in real life than they are. They can transform into a wolf and get enough jewels to open a magic trunk better than I can, but in real life I am far better at doing this. They can get their Bulbasaur to successfully defeat someone with a high-level Toxicroak using a vine whip attack, when...well, they are actually better at that in real life than I am. I was never good at the vine whip.
The rest of the article and suggestions are also quite fun. I wonder if this idea will catch on . . . .
Wednesday, November 7, 2007
The Washington Post reports today on a new study in JAMA showing that
Being overweight boosts the risk of dying from diabetes and kidney disease but not cancer or heart disease, and carrying some extra pounds actually appears to protect against a host of other causes of death, federal researchers reported yesterday. The counterintuitive findings, based on a detailed analysis of decades of government data about more than 39,000 Americans, supports the conclusions of a study the same group did two years ago that suggested the dangers of being overweight may be less dire than experts thought. . . .
"The take-home message is that the relationship between fat and mortality is more complicated than we tend to think," said Katherine M. Flegal, a senior research scientist at the Centers for Disease Control and Prevention in Atlanta, who led the study. "It's not a cookie-cutter, one-size-fits-all situation, where excess weight just increases your mortality risk for any and all causes of death." The study, published today in the Journal of the American Medical Association, was greeted with sharply mixed reactions. Some praised it for providing persuasive evidence that the dangers of fat have been overblown. . . .
But others dismissed the findings as fundamentally flawed, saying an overwhelming body of evidence has documented the risks of being either overweight or obese. "It's just rubbish," said Walter Willett, professor of epidemiology and nutrition at the Harvard School of Public Health. "It's just ludicrous to say there is no increased risk of mortality from being overweight. . . . From a health standpoint, it's definitely undesirable to be overweight." . . . .
The most surprising finding was that being overweight but not obese was associated only with excess mortality from diabetes and kidney disease -- not from cancer or heart disease. Moreover, the researchers found an apparent protective effect against all other causes of death, such as tuberculosis, emphysema, pneumonia, Alzheimer's disease and injuries. An association between excess weight and nearly 16,000 deaths from diabetes and kidney disease was overshadowed by a reduction of as many as 133,000 deaths from all other deaths unrelated to cancer or heart disease. Even moderately obese people appeared less likely to die of those causes.
Although the study did not examine why being overweight might guard against dying from some diseases, Flegal said other research has suggested that extra heft might supply the body with vital reserves to draw upon to fight illness and aid recovery. . . . .
Now for the downside -
"I think it would be very unfortunate if these findings made us complacent about becoming overweight," said JoAnn E. Manson, chief of preventive medicine at Brigham and Women's Hospital in Boston. "We know being overweight is linked to increased incidence of major chronic disease, including diabetes, hypertension and cardiovascular disease," she said, adding that it "impairs physical function and decreases quality of life." In fact, another paper published in the same journal found that obesity is increasing disabilities among the elderly, making them less able to do simple things such as walk a quarter-mile, climb 10 steps, bend over or lift 10 pounds. Flegal stressed that the findings should not encourage people to be overweight or change any public health recommendations. "This doesn't mean being overweight is good for you," Flegal said. "But it is associated with less mortality than expected."
Professor Lawrence O. Gostin has an interesting article in the most recent issue of JAMA discussing the global spread of tobacco products and how best to regulate their use to protect the poorest from the harms of smoking. He argues:
With stricter regulation and an increasing anti-tobacco culture, smoking rates in North America and Western Europe have plummeted. Tobacco executives have aggressively sought new markets in developing countries. The industry has been astonishingly successful as smoking worldwide is expected to massively increase, along with industry profits. The forces of globalization—unparalleled communication, transportation, and commerce—propel this trend.18 . . . .
The industry's success in exploiting poor people will have enduring, harsh health and economic consequences in low- and middle-income countries. However, civil society is fighting back through global regulatory strategies and new global initiatives by Michael Bloomberg and the Gates Foundation to prevent 100 million deaths from tobacco by 2020.2 The imperatives of science, ethics, and human rights oblige society to reduce the burden of smoking, particularly among the disadvantaged. Tobacco marketing and commerce, with all their destructive force, do not deserve sociolegal protections, such as freedom of trade and speech.
Tuesday, November 6, 2007
According to a recent story in AMNews, the Senate's passage of a $479 billion HHS appropriations bill, achieved the necessary majority to help override a potential presidential veto. AMNews reports that the House and Senate expect to reach a compromise HHS bill later this month. The Senate bill contains the following:
The Senate measure generally resembles the House version. Both would boost funding to the National Institutes of Health, prevent the president's proposed virtual elimination of the Title VII medical education loan program and increase federal community health center funding.
The president's 2008 budget proposal would reduce Title VII medical student loan assistance to $10 million from $184.7 million in 2007 and would freeze funding for community health centers at $1.99 billion. It proposes reducing the National Institutes of Health budget by $310 million (2%).
The Senate budget measure would head in the other direction. It would add $5 million (2.7%) to Title VII and $250 million (12.5%) for community health centers. It would boost NIH funding by $1 billion (3.5%).
The health center increase would allow facilities to see nearly 2 million more patients, according to Dan Hawkins, senior vice president for programs and policy at the National Assn. of Community Health Centers.
"This bill will continue the vital expansion of health centers into more medically underserved communities across the country," he said.
The NIH increase would pay for an additional 400 grants, compared with fiscal 2007 and 700 more than the president's budget.
Even the Senate bill's increase wouldn't keep pace with today's biomedical inflation rate of 3.7%. The NIH needs $1.9 billion (6.7%) annual increases from 2008 to 2010 to restore it to the spending ability it had in 2002 before a series of flat budgets, said Jon Retzlaff, director of legislative relations for the Federation of American Societies for Experimental Biology.
Yesterday, N. Gregory Mankiw , a former adviser to George Bush, and current adviser to Mitt Romney, has an article in the New York Times business section discussing the future of health care in America and the need to examine the facts before considering reform efforts. He then repeats and debunks what he believes are some false facts about America's health care system - a system that he believes works fine and will get better. For example, he takes issue with the 47 million uninsured number that has been in the news for quite some time. He states,
Some 47 million Americans do not have health insurance.
This number from the Census Bureau is often cited as evidence that the health system is failing for many American families. Yet by masking tremendous heterogeneity in personal circumstances, the figure exaggerates the magnitude of the problem.
To start with, the 47 million includes about 10 million residents who are not American citizens. Many are illegal immigrants. Even if we had national health insurance, they would probably not be covered.
The number also fails to take full account of Medicaid, the government’s health program for the poor. For instance, it counts millions of the poor who are eligible for Medicaid but have not yet applied. These individuals, who are healthier, on average, than those who are enrolled, could always apply if they ever needed significant medical care. They are uninsured in name only.
The 47 million also includes many who could buy insurance but haven’t. The Census Bureau reports that 18 million of the uninsured have annual household income of more than $50,000, which puts them in the top half of the income distribution. About a quarter of the uninsured have been offered employer-provided insurance but declined coverage. . . .
Concurring Opinions commentator Frank Pasquale disagrees with Mr. Mankiw and cites to a recent article by Professor Timothy Jost drawing some opposite conclusions about the stability and desirability of our current health care system.
But for now, I'm inclined to agree with the perspective of Tim Jost. He is a health law scholar who has thought seriously about comparative health systems, and does not share Mankiw's tendency to "look on the bright side:"
[A] series of studies over the past decade have shown that the quality of health care in the United States is seriously deficient, and, in particular, that medical errors are common and often have serious consequences. Indeed, the quality of the health care Americans receive is no better, and in some respects worse, than that provided in many other countries that spend far less on health care and yet provide it for all of their citizens.
DailyKos commentator Tonyahky also contains a sharp critique of the facts used by Mr. Mankiw. Here is the response to the 47 million number:
Even if 10 million of the uninsured are illegal immigrants, what about the other 37 million? He doesn't tell you that 9 million of the uninsured are children. He also does not tell you that in general, the only adults who even qualify for Medicaid in most states are people receiving TANF and individuals who are eligible for SSI.
And what about those who declined coverage offered by their employers? I thought we could do a little bit of second grade math to illustrate why so many of these individuals opt out of employer sponsored health insurance I'm going to use a friend's earnings, living expenses, and her employer's insurance premiums to illustrate why many people opt not to receive health insurance: (see here for rest of discussion of cost of health insurance) . . .
In 1950, about 5 percent of United States national income was spent on health care, including both private and public health spending. Today the share is about 16 percent. Many pundits regard the increasing cost as evidence that the system is too expensive.
Brian Leiter's blog has a review of hypothetical responses from the Bush Administration to the question of whether the rack constitutes torture. Some examples:
Mukasey: I haven’t been read into the details of the Rack, and I
understand that these details are classified. I am firmly opposed to
torture, torture is illegal, but I do not know whether the Rack is
torture. To comment further would be to expose sincere and loyal
Inquisitors to the possibility of retro-active condemnation.
Bush: I am not going to give aid to our enemies by disclosing details of
our interrogation techniques. But if we do expose detainees to the Rack
it is not torture, because we do not torture.
Cheney: A little stretching never hurt anybody. I understand it’s
actually recommended before exercising. . . .
Gonzalez: I cannot recall what the Rack was. Nor do I have any
recollection about whether I ever discussed it with the President. The
testimony of some that they heard me mention the Rack in a meeting on
March 23rd -- a meeting which I do not remember --may have been a
confusion of Rack with Iraq.
Daniel Levin: I cannot say since I have never been exposed to the Rack.
I do have an appointment next Friday for a 50 minute session in Seville.
I find nothing funny about the current waterboarding debate but this shows how ridiculous the Administration's response to torture has become.