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A study just released by the Urban Institute finds that insurance reforms will not work unless they include mandates that individuals must obtain health insurance. Without the mandate many people will not purchase insurance. Those that are likely to purchase may be the sickest who will use more resources and prevent savings to allow enrollemnt of the poorest members of the population.
According to an article in this month's American Journal of Public Health investments in state tobacco control programs are independently and significantly associated with larger and more rapid declines in adult smoking prevalence, according to a study by researchers at the Centers for Disease Control and Prevention. The study covers the period from 1985 to 2003. However it depends what you mean by tobacco control programs. Much of the credit is probably due to increasing taxes on cigarettes and public programs to reduce public smoking, particularly in restaurants, offices and stores. I believe the behavioral programs that occurrred concurrently had minimal effect.
Yet another study, this one from the University of Rochester, has demonstrated rapid clearance of ethyl mercury from the body and total lack of harm from use fo thimerasol in vaccines. The study showed that blood levels of ethyl mercury in children who received vaccines with thimerosal were "only a tenth as high as expected." While we do not know the cause of autism yet, it is time for parents of children with autism to stop blaming the health system for causing it.
In the New York Times today is a story that President Bush will call for "large cuts in the growth of Medicare, far exceeding what he proposed last year, and he will again seek major savings in Medicaid, according to administration officials and budget documents." Both "health programs account for nearly one-fourth of all federal spending, and their combined cost -- $627 billion last year-- is expected to double in a decade." While the details are the important issue it is unlikely this will be more than fiddling with the fringes. Until we get the will to set up a single payor system which focuses on "Need" instead of "Want" and puts a premium on proven generic drugs there will be no halting the upward spiral of medical costs.
In a new report from the NCHS; approximately half of 1 percent (0.47 percent) of the U.S. household population between the ages of 18 and 49 are living with HIV, according to estimates from CDC’s National Center for Health Statistics (NCHS) based on surveys conducted between 1999-2006. This is still too many, since the behaviors resulting in the infections are for the most part preventable.
Sub groups within the overall population shows:
Men ages 18-49 are more likely to be infected (0.7 percent) than women (0.2 percent).
Two percent of non-Hispanic black adults ages 18-49 were infected with HIV compared to 0.23 percent of white adults and 0.3 percent of Mexican-American adults.
Adults aged 18-49 who are infected with the herpes simplex type 2 virus (HSV-2) are more than 15 times likely to also be infected with HIV. An estimated 2 percent of HSV-2 positive adults ages 18-49 also have HIV.
The latest version of political correctness is that Doctors are biased aganst the obese. Obesity is an eating addiction. For doctors to ignore this when treating patients is poor medicine. So long as we keep giving patients a pass for adverse behaviors we will never change them. Today's article in the Washington Post is typical of selective journalism. The issue should be whether doctors need to be trained better in dealing with all kinds of addiction including those due to smoking, and excess use of alcohol, and prescribed medicines, poor dietary habits and lack of exercise. This diatribe in the Post is one of diverting any personal responsibility for health outcomes. It is easier to blame the doctor.
In a commentary in this week's JAMA Drs. Goodman and Grumbach from Dartmoutb argue that more physicians do not lead to improved health care outcomes, other than in physician shortage areas when more primary care services are introduced. The current rush by the AMA and AAMC to produce more doctors will only increase the cost of medical care in the U.S. without improving the undelying defects in the system. The members of the choir wll appreciate this article, the heathens will ignore it. [JAMA, January 23, 2008—Vol 299, No. 3, p335]
Yesterday I noted the potential impact of gastric banding for all obese persons. Today the Diabetes Association tells us that Diabetes costs $174 billion a year. When you add each special disease interest group's prognostication the costs are far more than the total spent for disease care each year.
Do we really need another poor study on how coffee can harm us? All the previous studies, on further follow-up showed such studies were flawed. Coffee consumption is almost universal, the use of recall is inneffective, biological plausability is minimal, and controlling for varied use while mathematically possible does not work in practice. Of course it makes headlines for activists who want something to shout about, and wastes resources in replication with better studies which will fail to show any effect.
One more blow for complementary medicines beloved by liberals. Many low income people go to 'Nature foods', 'Herbal' and 'Vitamin' stores in belief that these relatively cheap 'traditional' pills, powders and salves will help them. Here is another piece of evidence that they can cripple and kill, particularly children but often adults. It is really time for federal oversight of 'Herbal' and 'traditional' remedies sold across the counter without any controls.
An article in this week's JAMA [JAMA. 2008;299(3):316-323] and an accompanying editorial [JAMA. 2008;299(3):341-343] are worth reading. They a provide a balance to the newsmedia hoopla. We all know that Type 2 diabetes is mainly the result of obesity. With stomach surgery to restrict food intake it is hardly surpriing that diabetes tests should indicate rapid improvement. Prior intervention included sromach stapling which is more intrusive than banding.As expected, the surgical group lost more weight than the medical/behavioral group (20.7% vs 1.7%), and the amount of weight lost was the dominant predictor of diabetes remission. The percentage weight loss generally required for diabetes resolution was 10%, which was achieved in 86% of surgical patients but in only 1 patient in the medical group. Behavioral intevention continues to be disappointing. The JAMA editorial notes that It is time for a major shift in the way the health care community considers diabetes treatment goals.
This is an instance in which surgery may be more effective and lasting than medical treatment.
The AMA is supporting a Senate bill to improve health literacy! We are told this is because patients need to understand how to take care of themselves. Is that not what we were supposed to learn in medical school? Isn't that also part of the expectations of CME and the medical literature? Why do we need a new law to carry out the objectives of medical education? I thought the LCME which certifies medical schools and the ACGME which approves residency training, and the Boards of Medicine which oversee podstgradiuate practice were supposed to perform this function. Is the AMA hierarchy really this much out of touch with reality? It appears that training is focused too much on technology and examinations are focused on abilty to answer multiple choice questions, not on performance. Yet even more emphasis is being placed on the wrong competencies in CME programs, which train the wrong way, and are associated with new state and federal mandates being pushed on state boards of nedicine. Those who decry a recipe-based approach to medical practice are prescribing such a practice to avoid law suits, rather than fixing the problem in medical school. I am sure this is not what the IOM intended when it published "To Err is Human". The fixes are worse than the problem.
The Brazilian Ministry of Health has called for travellers to Brazil to be vaccinated aganst Yellow Fever. This is not the only country with Dengue problems. Dengue fever killed 407 people in Cambodia last year [2007], the highest number of fatalities in nearly a decade, a health official said on Friday. Most of those who died from the disease were children. More than 40 000 dengue patients were admitted to Cambodian hospitals last year.
A total of 3380 people were killed in China by rabies last year [2007], according to statistics from the Ministry of Health. A joint statement issued by the Ministries said that owners who refuse to get their dogs vaccinated will face "serious punishment," while legal action will be taken against owners whose dogs cause the spread of the disease.
Today a new Guttmacher Institute census of U.S. abortion providers is released. The abortion rate is now at its lowest level since 1974. There are many theories about why, including more use of contraceptives, more types of contraceptives available, changing attitudes of young women, and maybe men. Whatever the cause many in public health have argued for years that we would all be better off if the anitabortion activists focused on better education on the vakue of contraception. Abortion should be as avoidable as most STIs. An unwanted pregancy really is an STI!
A new study at Johns Hopkins Chidren's Center suggests that people exposed to toxoplasma had a 24 percent higher risk of developing schizophrenia. The study was small. Not an unbiased population sample, and needs repicating in a large population that is representative. Don't rush out to kill all the cats yet.
Activists cause all kinds of harm. They always want proof that nothing happens, although there is no way to provide such "proof". As infants deaths and deaths from infectious disease decrease world-wide, and longevity increases these factors contribute to population expansion. This leads to a need for additional food, both vegetable and animal. It seems reasonable to increase anmals and plants in the food chain by cloning. But, just as nuclear power is an answer to energy needs, activists prevent distribution of plentiful foods and safe power. Have we let freedom of speech go too far, or do we just have wimps as politicians?
Summary of a recent talk by Dr. Anthony Fauci at the Bloomberg School of Public Health is worth reading as he notes that treatment seems to have reached a stone wall where the only way to improve to battle against HIV is through prevention. Those of us old enough to remember the advent of penicillin and the battle against STIs remember similar progress. It is important to remember history, even recent history.
With our distored medical marketplace the FDA does not force a drug off the market, even it is not as effective as other drugs, or even ineffective. The hope is that no-one will pay for it. With the news that ZETIA may not reduce risk of heart disease will the various third party payers refuse to reimburse for its use? What about all the other me-too drugs? There is no agency, even AHRQ, that reviews effectiveness of drugs and recommends not reimbursing for their use.
A study published in the January/February issue of the journal Health Affairs by a team led by University of Michigan and Harvard University researchers shows that rather than increasing co-pays for medicines, particularly for chronic diseases, better compliance with medication takes place when co-pays are lowered, which in turn should lead to better control of chronic diseases.
The "AMA News" today tells us there are 12 new medical schools coming into beng with 7 being accredited by the LCME last year. While there are concerns about lack of physicians the lack is in primary care practitioners and preventive interventions, not in specialty practice. More medical schools will not change the imbalance while the current payment schemes remain unchanged, and training focuses on specialty care and procedures. Just like the old Hill Burton Act, this is one more case of perception failing to match reality. These new schools will continue to escalate the cost of health care.
CDC "urges all women -- and particularly young women -- to make sure" that they incorporate "400 micrograms of folic acid" into their diets "daily . The value of folic acid in prevention of neural tube defects in newborn has been known for decades, but it is only in the last decade that serious efforts have been made to encourage the use of folic acid among women. In spite of the educational efforts less than 50% of women of childbearing age are taking such supplements regularly
The above is the title of a boook I recommend. Written by epidemiologist Madelon Lubin Finkel, the book is made up of a series of essays demonstrating how public policy is often made when scientific data shows the policy is absolutely wrong. This morning the AP reports that Bernard Vallat, director general of the World Organization for Animal Health, said that "[f]ears of a flu pandemic from the deadly H5N1 bird flu virus were overblown." According to Vallat, the "concerns a few years ago that a flu pandemic from H5N1 might be imminent lacked scientific proof." Vallat said that the "H5N1 virus has proved extremely stable, despite concerns that it could mutate into a form that could spread easily among humans." Support of pandemic influenze in the U.S. seems more driven by dollars given to public health than the likelihood of a real epidemic. Yet, if this money had been given as a block grant to improve public health infrastructure it might have done more good. The latter however is not nearly as politically appealling as preventing a non existent threat. Dr. Finkel's book is available at Amazon.com
Forty years ago Anne Somers and Lester Breslow published an important study carried out in Alameda County which showed the relationship between longevity and habits among men wiht an increased longevity of 11 years.. Now a similar study has been carried out at the University of Cambridge Institute of Public Health with similar results; four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 years in chronological age. These behaviors were not smoking, moderate use of alcohol, regular exercise and eating 5 servings of fruit and vegetables a day. Even after forty years, as a population we cannot learn to change our behaviors.
In an article in Health Affairs this month; Health Affairs, 27, no. 1 (2008): 58-71, the authors from the London School of Hygiene and Tropical Medicine compared 30 conditions in the European Union and the USA that were responsive to preventive interventions. As might be expected in a country where technology is more important than prevention, the U.S. came in last among the 19 countries studied! In a previous study 10 years ago the U.S. was only 15th. It is high time that those suggesting changes in the health care system focused on prevention of diseases that become more prevalent as the population ages, or we will soon bankrupt the health care system..
A fascnating article in the BMJ this week focuses on the large amounts of money spent world wide on drugs for acid reflux indigestion when there are better, cheaper and safer drugs readily available. The drugs in question include nexium. prilosec, prevacid and other widely advertised drugs. The article questions why, after extensive education aimed at prescribers, there was no change in prescribing behavior. For fifty years doctors have been prescribing antibiotics for viral infections on demand by patients. Why should their prescribing for indigestion be different? It may be time to limit drug advertising. There is little evidence that it has benefitted the public. Politicians cannot be trusted to protect the public; the drug companies pay for their elections. The insurance programs need to refuse to pay for medications when there is little evidence for their benefit compared to medications already available.
Schlundt and his colleagues at Meharry Medical College in Nashville, Tenn.
examined 2002 data from the U.S. Centers for Disease Control’s Behavioral Risk Factor Surveillance Survey. Seatbelt use declined as BMI increased, with approximately 55 percent of extremely obese individuals reporting they did not use a seatbelt. The connection between increased body mass index and decreased seatbelt use held even when controlling for other factors, such as gender, race and seatbelt laws in the respondent’s state. Maybe accident report forms used by EMS and police need to include obesity as a factor to be coded when investigating accidents.
For most Americans mosquitoes are linked to Malaria. A few may think of equine encephalitis with its periodic outbreaks seen mostly in the Southwest, or West Nile Virus. The newest disease starting to spread, more so than avian influenza, is Chikungaya which has appeared recently in Italy and has symptoms similar to Lyme disease. Dengue fever, also spread by mosquitoes has been increasing in Brazil with more than 60,000 cases in 2007. Rather than worrying about Avian influenza, a darling of the media and politicians, we should be concerned about both Dengue and Chikanguya spreading into the US.
In the BMJ this week (page 7) Nicole Lavery, Community Adviser, Northern Ireland believes we have now reached saturation point as to how many studies and articles it takes to convince us that we are too fat as a nation. What good does it do to advise people that they need to walk, cycle and swim when the infrastructure is doing its best to prevent exactly this, she asks? These comments could just as well apply to the United States and our own communities. The planners who work for city & county boards spend their time explaining how builders should be rewarded for new developments. They do not focus on whether the infrastructure of the new development is good for its planned residents. Are there sidewalks that provide walking and cycling paths? Are there exercise areas that do not force people into gymnasia? What swimming resources and athletic fields are available? Without readily available exercise areas, and the ability tio walk to the local shops, we will not change obesity with lectures. Health departments should become part of community planning.
People can be their own worst enemies. In a fascinating report from the MMWR is a case of multiple exposures ro rabies from a stray kitten picked up and petted at a mutistate softball turnament. 27 persons were identified as having exposures that warranted PEP: one from South Carolina, 15 from Georgia, and 11 from North Carolina. In New Hampshire, in 1994, approximately 600 persons received PEP after potential exposure to a single rabid cat, at a cost of approximately $1 million for biologics alone. Measures to reduce rabies exposures among humans by promotion of responsible pet ownership and routine vaccination of cats remain public health priorities. Children should be taught to be cautious in their interactions with animals, especially those that are unfamiliar, to avoid potential exposures to rabies and other infectious diseases.
It all depends. A report issued jointly by the AAMC and the ACGME, reported today in the Washington Times suggests more doctors are needed to deal with the expected aging "boomers" which is fueling the epidemic of chronic diseases. The study is seriously flawed because its fails to address the need for primary care physicians instead of just training more specialists. We seem to learn nothing from watching the rest of the world. The training system sponsored by the medical professionals who make up the AAMC and ACGME arrogantly assume they know best, yet agian continue to lead us to one more medical disaster after another by training the wrong type of physician/medical team for the tasks ahead of us. Further, they make their proposals in the abscence of changing the medical-health care system for the better and failing to address the millions of citizens without health and medical coverage.
A wonderful satire just published in the Seattle Post-Intelligencer, written by a resident and an MPH student in Seattle is worth reading by all interested in the health care system. I would cut and past rather than provide the link, but that would be illegal. Have a chuckle over their new year's thoughts.
Commnentary from JAMA this week in world wide approaches to the problem of pain treatment is worth reading in this article by by Larry Gostin et aL on the legal, policy and cultural issues associated with effective treatment oif pain [Ensuring Effective Pain Treatment: A National and Global Perspective: Allyn L. Taylor; Lawrence O. Gostin; Katrina A. Pagonis; JAMA. 2008;299(1):89-91.],
Also the commentary by Peter Burdetti on the rise and fall of "market justice" and US Health Care over the last century. [Market Justice and US Health Care: Peter P. Budetti; JAMA. 2008;299(1):92-94]