Health

Healthcare: Not just another business

Ano Lobb — Fri, 20 Nov 2009 16:02:02 GMT

A reader comment on a posting about electronic medical records (EMR) suggests that medicine needs to follow other industries into the digital age. This is likely inevitable: Medical record keeping is bound to become more digitized over time. The primary reasons are monetary: It facilitates the generation of bills to send to patients and payers, the jury is still out on whether it increases quality and efficiency. Individual providers may like the added convenience, but it is still unlikely that EMR will provide the level of care coordination that is hoped for.

President Obama and others have proclaimed that EMR will also bring massive cost savings, but a new study released today sheds doubt on these projections. Harvard researchers analyzed over 4,000 hospitals and found no differences in administrative or overall costs between the most- and least-wired hospitals. More techie establishments did have a faster rate of cost increase, however. As for quality, more wired institutions had slightly higher quality scores for heart attack care, but not for pneumonia or heart failure, and not for all three combined. (These were process-measures, not outcomes measures.)

Another point worth making is that the business of healthcare doesn't operate like other industries, for example:

1. Those providing services (doctors, hospitals) are generally not paid by those receiving the service (patient), but instead by a third party (insurers). So patients don't care how much things cost, and payers trying to be fiscally prudent are easily viewed as valuing profits over human health.

2. It may be a good thing that patients don't know how much services cost, because no one does. There are no fixed prices in healthcare, and those with least ability to pay are charged the most. Insurers negotiate lower rates, but the uninsured are charged full price. And that full price may vary by 100% or more among different providers at different institutions. Have you ever asked a doctor how much something costs? They probably don't know.

3. We don't comparison shop. In fact we will wander into just about any hospital and have a surgeon saw open our chest and yank out an important organ with no knowledge of how good he or she is. Before you buy a pair of shoes you'll take a test stroll down the aisle. Need open heart surgery? There's generally no way to take a stroll with the surgeon first.

4. Generally we let our primary care doctor refer us to a surgeon. But it's unlikely that your primary care doc has any reliable way of knowing how good a specialist is, and referral patterns are generally established around financial arrangements or among colleagues.

5. We take treatment advice from the people that profit the most from providing that treatment. Would you blindly buy a car simply because a salesman recommends it? Never. But you may have your gallbladder removed without a second opinion based solely on the recommendation of a surgeon who will receive thousands for a few minutes work.

Beyond the Drawing Board

Kendra Pierre-Louis — Thu, 19 Nov 2009 09:47:33 GMT

Some days I take a look at the world, and feel an overwhelming desire to give up the superhero gig, pack my bags and wander the planet experiencing as many of its wonders as possible before the Greenland ice shelf melts and turns once peaceful nations into Mad Max styled dystopias.

This does not represent the sort of cheerful thinking that the development world needs.

My frustration stems not from the belief that we can't bring about the necessary changes, but rather from the reality that though there are tens of thousands of amazing ideas on how to create a sustainable planet, most of those ideas seem stuck in neutral. Meanwhile, society en masse pushes forward doing the same old unsustainable things, only faster, bringing us ever closer to the teetering edge.

Take for example cleaner energy. In the places where wind works, for example, it can be price comparable with burning coal or oil when one removes the benefits of government subsidies. Yet, in the United States anyway wind is still struggling to gain a foothold. The government continues to push for continued exploitation of coal and natural gas even when extracting those resources represents the potential destruction of a habituated region (Appalachia), as in the case of coal, or when those resources means exposing a local population to radioactive water supplies (Ithaca, NY) and no clear idea on how to deal with that radioactive waste.

Across the Atlantic Ocean, the European countries that have pioneered the idea that companies should have to take back their products when consumers are done with them seem to have stalled in its application. The idea was simple. If a business has to deal with the full lifecycle of a product, not only its production but also its disposal companies would be more inclined to make products that were easily and fully recyclable and less filled with toxic substances.

This inability for great ideas to really take off I think comes from two main ways of thinking. The first is that people have a tendency to cling to the familiar. As loudly as we complain about the environment, about the limited supply of fossil fuels, for those of us who have access to the fruits of our carbon addiction, the system is working. Not well, or perfectly, but well enough to make leaping into a different technology seem a bit too much like gambling.

The second reason stems from the idea that there is a single solution. There isn't. There is a plurality of solutions some which will work better in some locations rather than in others. Our best bet is likely to throw as many onto the wall and see which ones stick.

We need to move the ideas from the drawing board and into the world.

Electronic health records: Medical miracles or digital disaster?

Ano Lobb — Tue, 17 Nov 2009 19:45:46 GMT

Electronic medical records (EMR) are digitized versions of the paper folders where your doctor squirrels away your health information. They are increasingly being looked to as a solution to what ails modern healthcare. Ideally these digital records can be shared quickly and efficiently among providers, can be programmed to remind doctors about test results or to warn about medication interactions, and can eliminate that ever present problem of illegible handwriting. These are all good things, but it's unlikely that EMR are the solution.

To begin with, evidence suggesting that EMR can increase quality and reduce costs within the US healthcare system comes primarily from studies at flagship institutions such as Intermountain Healthcare: systems that already practiced stellar care, and had the ability, motivation, finances and structure that allowed them to successfully integrate EMR into existing operations. Some of the challenges tarnishing the promise of EMR:

1. Cost: Transitioning from a paper system to an electronic one is expensive. Estimates range widely, anywhere from $20,000 to $70,000 per doctor's office, more if you are a hospital.

2. Where's the system? Let's assume that sufficient safeguards can be built in to ensure that the records are only available to those with permission (a very big assumption in its own right.) In ordered to increase care coordination by enabling quick and easy data sharing, all doctors, hospitals and clinics need to be tied into the same system. That can only happen if all EMRs are linked together. With literally dozens of systems currently available and in operation, that is not the case. Information remains squirreled away in digital silos, inaccessible to the network of providers that deliver modern care.

3. Electronic prescribing is a practice tied with EMR that has great promise. The computer can check for interactions with existing medications, ensure the dosage is appropriate, automatically remind providers when to stop or renew prescriptions, and eliminate illegible handwriting. These systems are also expensive, resulting in the launch of no or low cost programs from the pharmaceutical industry, who program in various ways of encouraging docs to prescribe their drugs over competitor or generic products. That's a sure route to more expensive, less effective medicine.

4. In an era where you can be denied care based on preexisting conditions, we may not want all data aggregated in one place for all time. Current legislative proposals aim at eliminating pre-existing condition clauses in health insurance, but laws change.

5. Logistics and reliability. How does the doctor interact with the patient when he/she is staring at a computer screen? What if a lab result is coded incorrectly, and stored in the wrong place, will you ever be able to locate it? What happens when the computer crashes?

EMR certainly has promises, but in the free market of American health care, its unlikely to improve quality, lower costs, or improve the health experience of doctors, nurses or patients.

Be rigorous, but don't be fair

Ano Lobb — Sun, 15 Nov 2009 01:30:50 GMT

Last week I was one of about 13,000 people attending the annual meeting of the American Public Health Association. Despite the thousands of scientific, programmatic and policy presentations, mine was one of few addressing the general area of corporate social responsibilities, conflicts of interest, and business ethics. My presentation applied these lenses to the pharmaceutical industry, and just like it was last year, the response was enthusiastic, with organizers requesting more for next year. (I'll discuss some of my paper findings in an upcoming posting.) It seems that the very topics that fuel Justmeans are in great demand in the world of public health.

As in any scientific setting, the role of advocacy can sometimes become strained. There is often a perception that rigorous science is an objective activity steeped in fairness that takes no sides in political or policy battles. This is a misconception in my book. Tam Ormiston, a wonderful man and the chief deputy attorney general for the state of Iowa, once admonished a room of colleagues at a public health meeting that "we must be rigorous, but not fair." Trained as a lawyer, he has advocacy in his veins, and that belief that rigor does not necessarily equal fairness has become one of my central professional beliefs every since I heard Mr. Ormiston utter those words. When objectivity puts arrows in your opponents quiver, its best avoided.

The scientific method is an important process for answering technical questions. But once even-handed inquiry begins to identify worrisome trends, at what point do we stop waiting for more evidence, and instead take action? The answer is closely tied to potential trade-offs. If a treatment formerly thought to be lifesaving suddenly reveals dangerous side effects, then the decision to stop treatment should be backed with very solid evidence, multiple studies, peer review and balanced consideration. In cases of corporate responsibility, marketing, and potential conflicts of interest--practices where the enrichment of a few endanger the health of many, then the threshold for action should be considerably lower. Instead of an even-handed "fair" presentation of data and its limitations, you can favor the evidence that proves your point. Just as reasonable doubt can set the accused free, reasonable suspicion, informed by scientific inquiry that is as rigorous as a timely review of evidence allows, should be sufficient to support actions to end practices that otherwise serve no greater health producing purpose.

I'm a lover of knowledge, and a collector of trivial and often useless information. But I still believe that science for its own sake is something of a waste of time. Knowledge should inform change. Science should guide improvement of health and human kind. And in a world where private corporations can hide harmful acts behind privacy laws, it should be the duty of public health professionals to us science as an advocacy tool to bring some sunshine behind the heavy blindfolds of justice. Rigor is necessary when speaking truth to power, but fairness is not.

Darkside of health data

Ano Lobb — Mon, 09 Nov 2009 18:39:59 GMT

You may take it for granted that you have some level of medical privacy: That a company couldn't, for example, buy a list of all the medications your doctor has prescribed you, the better to entice your doc to change to newer, more expensive drugs that are riskier but no better than the old generics you currently take. You might think you have that privacy, but you don't.

That's thanks to prescriber-identifiable prescription tracking, a marketing practice that sells your health information to commercial interests, spreading handsome profits to everyone but you the patient. To be fair many doctors aren't aware of this practice, and most see very little if any gain from it. Commonly used throughout the US, it is growing in Europe and other markets with computerized prescription drug fulfillment. Each year approximately $20 billion is spent marketing drugs to physicians in the US, and evidence indicates that it is a worthy investment, providing returns on investment of anywhere from $1.23 to nearly $12 for every $1 spent.

This is how it works: When you fill a prescription, the pharmacy's computer system records every detail: The doctor and drug name, your age, sex, any other health conditions on record. Everything but your name. The pharmacy collects this data for every prescription, selling it to Health Information Organizations (HIO) such as IMS Health, Verispan or Wolters Kluwer. HIOs combine it with detailed doctor information gleaned from sources such as the American Medical Association's "master file" of physician members. The AMA sells this database, which includes such information as physician's specialty and contact information. After analyzing the aggregated data, HIOs sell it to drug marketers, who utilize it for targeted sales campaigns. The maker of a new diabetes drug, for example, can identify a doctor with scads of diabetic patients taking a competitor's product, and lavish that physician with attention and gifts in an effort to get them to switch drugs. Gifts amount to far more then pens and coffee mugs: In many cases they amount to $50,000 a year or more. Studies show that marketing works: Prompting physicians to write prescriptions for more expensive, newer drugs that are no-more effective and generally less safe than older, established choices. Bad for health, but good for business.

HIOs claim their data is for research, or to ensure rouge docs aren't overusing inappropriate meds. And their databases could be goldmines for the right research. Unfortunately, the cost of accessing them generally exceeds academic research budgets, and I have heard from colleagues who were denied access to the data when it became clear that their research was not in the HIO or pharmaceutical industry's best interest.

Want to know how much your doctor has received from industry? Only a handful of states in the US have laws requiring public disclosure of such information. In addition to being the only ones that are harmed from this practice, patients are being left in the dark about who is being corrupted by it.

How good is your healthcare?

Ano Lobb — Fri, 06 Nov 2009 15:05:11 GMT

Or doctor? Or hospital? Chances are, if you are satisfied with the outcome, you'd say the care was good. If you've had bad experiences then your review would be less positive. Regardless, you probably have little information to evaluate the quality of the healthcare you receive, the doctors providing it, or the hospitals housing them.

How is the quality of healthcare evaluated? On the national level, you can look at key health indicators like life expectancy and under-5 infant mortality. Live in Switzerland or Costa Rica? Life expectancy is around 82 or 79 years, and the under-5 infant mortality rate is 5 and 11 per 1000, respectively. Live in Somalia or South Africa, however, and life expectancy drops to about 53 years, and infant mortality climbs to 154 and 49 per 1000, respectively. Lots of factors contribute to those figures, in themselves they don't tell us what is causing people to thrive or die, and besides moving from Somalia to Costa Rica, they don't help you make health decisions.

National health insurance coverage figures tell us something about ability to pay bills: Only 1% of Taiwanese lack health insurance compared to 20% of Americans under the age of 65. But that doesn't tell us about health or care. Process measures are a good start, and at least in the US these are readily available for hospitals, less so for doctors. These report how often hospitals are doing important things: Giving aspirin to heart attack patients, for example. They are the types of things that have been shown to improve health outcomes, but they are not outcomes themselves.

There are measures of patient satisfaction: Would you recommend this hospital to a friend? Was it clean, and were your questions answered? It turns out that this is a surprisingly good indicator of quality, since the leading reason for care is poorly coordinated care (providers not communicating with each other or you.)

Ideally we'd like to see outcomes measures, and in some cases we have these. Hospital death rates for heart surgery are available, at least in the US. These can be useful, since death rates are relatively high for such procedures. Mortality is not a good measure for something like hip replacement, another common major surgery with a range of possible outcomes, because death is exceedingly rare. Beyond life and death, we have few outcomes measures for hospitals, fewer for doctors. Then there are safety measures: How many patients contract infections in hospital, for example. The availability and utility of these figures varies. All measures must undergo statistical control to account for the age and health of the patients being seen: You would naturally expect worse outcomes from older and sicker folks, regardless of the quality of care they receive. And there is the "problem of small numbers:" in some cases wide variations in quality are statistically hidden because so few procedures are performed.

What do you want to know about your doctor or hospital?

When green choices aren't healthy

Ano Lobb — Tue, 03 Nov 2009 21:03:03 GMT

One of the great things about Justmeans is how it fuses so many interrelated ideas. Whether its climate change, sustainable food, ethical consumption, or social enterprise, it all plays a major role in the health of individuals and populations. But good work can be corrupted, for example eco-labeling occasionally attempts to "green wash" products into seaming more earth and people friendly than they are. And sometimes seemingly responsible choices turn out to be unhealthy ones. A few examples:

Solar panels are one ethical solution to growing global demand for electricity. However, an essential silicon compound created during manufacturing leaves a toxic byproduct, silicon tetrachloride. Extremely damaging to human tissue, it can cause burns, kidney failure, and lesions in the liver and heart. Ethical manufacturing practices call for energy-intensive remediation of this toxin, but unfortunately several documented cases in China, currently the world leader in solar panel production, have found where this toxin was dumped in fields, contaminating nearby communities.

CFL (compact fluorescent) bulbs are popular for their long life and meager electricity consumption. What is rarely mentioned is that they contain mercury. Each CFL contains about a tenth of the amount of mercury found in an old thermometer. That wouldn't be much if you only had one light bulb. But the average house has 20 to 30, meaning a significant amount of mercury. Not only is it likely to up in a landfill, but whenever a bulb breaks, you are exposing yourself and family to a potent neurotoxin.

Clean coal technology is attempting to put a green face on coal powered electrical plants. Most commonly this involves spraying water in smoke stacks to remove toxic pollutants from coal smoke. The upside is that you won't breathe these toxins. The downside is that you might end up drinking them. The toxins don't disappear, they remain in the water, and are corralled into huge, highly toxic sludge ponds where they can leach into ground water supplies, or in extreme cases burst their boundaries and contaminate whole communities.

Methane contributes more to global warming than CO2, and an underappreciated source of this gas is our hunger and thirst for healthy protein in the form of beef and milk. Cows produce tremendous amounts of methane, and they are a growing contributor to global warming.

Eating food grown locally, or within a relatively few miles, ensures that the raw materials for your meals didn't produce CO2 traveling long distances to your plate. There are lots of sensible reasons to want to eat locally produced food, but some question just how eco-friendly it is. Large commercial farms are generally far more efficient than smaller ventures, and the tomatoes in your London salad may have a far larger carbon footprint if grown in a nearby heated Dutch hot-house instead of being shipped in from a more distant Kenyan farm field.

Ethical consuming is a healthy goal, and perhaps we're best advised to consume mindfully, less, or not at all.

Smoking bans: Healthy for non-smokers too.

Ano Lobb — Sun, 01 Nov 2009 23:08:11 GMT

An expert panel convened earlier this year by the Centers for Disease Control and Prevention and Institute of Medicine in the US examined the effect of second hand smoke on health, as well as the reduction in risk associated with smoking bans. Their recently published findings underline the necessity of smoking bans not only to save smokers from their own bad habits, but to save the rest of us as well. In fact, 43% of non-smoking children and 37% of non-smoking adults in the US are exposed to someone else's tobacco smoke.

The recent review of evidence found a 25-30% increased risk of coronary heart disease among non-smokers regularly exposed to second hand smoke. They also found that the exposure increases the risk of heart attacks by anywhere from 24% in non-smokers exposed 1-7 hours of exposure a week, to 62% for those exposed 22 hours a week or more. The International Agency for Research on Cancer classifies second hand smoke as carcinogenic in humans, and other evidence suggests a 24% increased risk of lung cancer among chronically exposed non-smokers. That's not surprising considering that the noxious brew contains over 4,000 chemicals including 40 known to cause cancer. While the 11 studies that met the CDC/IOM panel's inclusion criteria were not of highest quality, they were in general agreement: Anywhere from 6 to 47% reduced risk of heart disease among non-smokers associated with smoking bans.

Second hand smoke risks are especially troubling among children, who suffer increased rates of everything from asthma to ear infections, to say nothing of dramatically increased risks for starting the habit themselves. In Britain it's estimated that 17,000 children under age 5 are admitted to hospital every year with illnesses attributable to their parent's smoking. Public smoking bans have been enacted in several countries--including England, Sweden, Ireland, Italy, Norway, Thailand, Vietnam, Bhutan, and several Canadian provinces and US states--but we need more. For example, at what point does a parent's willingness to unnecessarily expose their child to known toxins become abuse? In the state of New Hampshire a commendable law was recently drafted that sought to outlaw smoking in private cars when children were also riding in them. Unfortunately in that case, the freedom of parents to make poor health decisions trumped the rights of children to good health, and the law never passed. Perhaps that state should consider changing its current motto of "Live Free or Die" to "Live Free and Die," or even more fittingly "Living Free While My Children Die."

Swine Flu in the United States

Justmeans Staff — Sat, 31 Oct 2009 06:34:05 GMT

During the first few months of the swine flu causing havoc in the United States, approximately 5.7 million Americans got infected with the H1N1 virus. According to estimations made by the scientists at the Centers for Disease Control and Prevention, from mid-April to July between 2 to 5.7 million people were already infected with the virus and more than 21,000 people had to be admitted for immediate healthcare. Health experts have estimated that approximately half of swine flu cases in the world are present in the US with more than 127 deaths and 3,065 hospitalizations. There has been a significant increase in the number of people getting hospitalized due to infection from the H1N1 virus since July.

Based on reports it was found out that 12 is the average age of swine flu patients, 20 for hospitalized patients and approximately 37 for people who died due to swine flu. The virus is more deadly for old people (65 and above), especially patients who are suffering from asthma, immune system problems, diabetes and chronic heart diseases. Health officials in the United States are urging people to get the swine flu shot without fail, whenever required. The vaccination is usually given in two shots with a difference of 21 days. Vaccines being made public for use are first being tested and licensed.

Health officials from the United Nations have formally declared swine flu as a pandemic which will not only increase the production of vaccine but also affect the government spending in controlling the first global flu epidemic that has taken place in the last 41 years. According to the World Health Organization, the H1N1 virus is not lethal anymore but it will be very difficult to stop it from spreading further. It was in late April that the early cases of swine flu were reported in the US and Mexico and since then it has spread to approximately 74 countries, infecting 30,000 people. One can't deny the fact that the virus is spreading rapidly and if we continue being so complacent, the epidemic might take a more frightening form in the coming years.

Healthy mothers, healthy kids, healthy societies

Ano Lobb — Thu, 29 Oct 2009 08:38:53 GMT

How do we reduce infant mortality? In a nutshell: Take better care of mothers. In two nutshells: Gender equality and reproductive self-determination.

Several recent postings have discussed the global death toll among children and youth from malaria, diarrheal disease, and accidents. Such staggering numbers could crush the spirit if we had no ideas about how best to improve them. Exhaustive research, including a recent 100-page review of the literature by researchers at Aga Khan University, Save the Children and Johns Hopkins University, has provided evidence of what works.

From a social and political perspective, increased maternal autonomy (recognition of gender equality, and women's rights), and increased maternal education have both been proven to decrease infant mortality and increase health. Societies that are matriarchal, for example, have lower infant mortality than equivalent societies that are patriarchal. Mothers in full control of their reproductive rights are healthier. And there's a dose response relationship between a mother's education level and reduced infant mortality: Each added year of maternal education increases survival for her children. Such steps are ideal in that they address underlying causes of ill-health while strengthening human rights and social development. But they can be difficult to improve in a timely fashion, since they require changing social mores and developing an educational infrastructure.

Improvements in healthcare and public health can be implemented more rapidly, but often have large price tags. A recent analyses estimated that delivering 16 interventions proven to reduce childhood mortality to 90% of the population in the 60 countries with greatest need would save an estimated 35%-66% of deaths among children under 5, that's somewhere between 1.33 and 2.45 million children a year. The cost: $3.89 billion. (Or about 3% of the $123 billion that the US government used to rescue investment giant AIG.)

What types of interventions are proven to reduce death and increase health among children? Many are surprisingly basic: Anti-malaria treatment for mothers could reduce 10%-20% of neonatal deaths, clean childbirth practices (such as hand washing and clean umbilical-cord cutting) could prevent another 60%-80% of death due to infection, keep the room warm and dry the baby immediately and you save another 40%.

Tricia Edgar recently talked about the sustainability concerns surrounding breast feeding, and the neonatal consequences are equally great: exclusive breastfeeding could reduce deaths by 10%, while kangaroo care, having mothers carry the baby close to their skin, cuts infection rates in half.

Implementing other interventionssuch as having a trained midwife present at birth, access to emergency obstetric care, appropriate medications, and quality nutritionfurther enhances the health of mother and child. Once again there are opportunities among the despair. We don't need to find the one solution that saves every child. Provide weatherproofand therefore warmerhousing, some way to clean water and medical-scissors, ways to promote breastfeeding or kangaroo care. Encourage human rights and education. Breed a better seed or sustainable protein source. These steps are as life- saving as anything a doctor provides.

Private thoughts on a public option

Ano Lobb — Wed, 28 Oct 2009 08:56:12 GMT

A previous posting on competition garnered lots of interest and a question about the logic of a government sponsored health plan in the US, the so called "public option." The specifics of this particular pudding are still baking in the unreliable oven of Washington politics, but some general assessments can be made about a potential role of government:

1. The central problem with paying for healthcare over a person's lifetime is that the same entity collecting premiums when you are a healthy 20 year-old needs to be the one paying for your care when you're an unhealthy 70 year-old. In the US, health insurance is coupled with employment, guaranteeing that no insurer will cover you for long. So the company collecting premiums when you are a healthy youngster will not be the same company paying for your care when you are old and sick. This means unpredictable risk for private insurers, who respond in various creative ways that are not good for patients. Governments seem much better suited to managing this type of life-long coverage.

2. Rhetoric aside, Americans seem generally comfortable with current public options: Few suggest eliminating Medicare, Medicaid, and Veteran's Care. They realize that government doesn't provide care, so "government run healthcare" means government is guaranteeing your ability to pay your doctor to see you. And American's overwhelmingly support government-run essential services such as fire departments, police, libraries and road maintenance.

3. Government plans allow a couple of things that private plans don't: Data gathering and transparency, and the ability to force quality improvement. It's not a fluke that so much research in the US focuses on the Medicare population: The government gathers data on them, which is available to researchers at no or low cost. This is the type of research that is fueling and informing the current round of health reform. It's also no accident that the only national, publically accessible database reporting on hospital quality is run by the government. A government plan can also hold providers accountable to better outcomes in ways that private payers rarely have.

4. While most countries provide universal access to healthcare using a single government payer, those that provide access with a private focus use government as a super-regulator to ensure that the private marketplace stays focused on health and not profit. The political viability of having government play a more vigorous regulatory role is not clear.

5. If private competition is going to dominate, there needs to be reliable, universal and publically accessible outcomes reporting, so that consumers of healthcare have the ability to choose services based on quality. That could be where government is involved: Being the neutral party that gathers and reports trusted data. (I'll discuss the topic of hospital quality reporting in an upcoming posting.) Currently, consumers can learn more about the quality of their car, toaster, or a pair of shoes than they can about their heart surgeon or hospital.

How safe is H1N1 Vaccination for Infants?

Justmeans Staff — Wed, 28 Oct 2009 05:38:28 GMT

Health studies have proved that H1N1 vaccination is not very safe for toddlers and infants. Even though doctors are recommending children to get the swine flu vaccination, age and food allergies are some of the basic factors due to which some babies should not take the vaccine. Thimerosal is a preservative used in swine flu vaccines. This vaccine contains mercury that can be extremely harmful for small kids.

Recently, the federal government in Canada ordered 50.4 million vaccine dosages which contain adjuvant (substance used for giving the effect of vaccine the much required boost). Out of this dosage, approximately 1.2 million doses are for pregnant women and it doesn't include any adjuvant. Since there are no evidences as such on how toddlers would react to this substance, the government is not planning to use adjuvant-free H1N1 vaccine for small babies. Pregnant women and babies are being considered the two most important groups that can get affected due to this virus. However, precautions are being taken to make sure that young children should be given adjuvanted vaccine only when required.

There is no doubt that H1N1 virus can cause serious health hazards on children under the age of five but the proposed vaccination can not be used on them for various reasons. If babies under 6 months are directly vaccinated with H1N1 vaccine, there are chances of sever health complications and even death in some cases. Therefore, as a precautionary measure health experts have recommended the required dosage for caregivers who take care of babies (6 months and below). This will provide protection to them from any possible infection. Infants can also be protected from the H1N1 virus if they are kept away from infected people and if pregnant women receive the vaccine before delivering the child, chances of the new born contracting swine flue after birth will decrease.

Doctors also don't recommend the vaccine for children who are allergic to eggs because the swine flue shot contains a small amount of egg protein that can trigger the allergic reaction in them.

The competition conundrum: Can better care cost less?

Ano Lobb — Mon, 26 Oct 2009 00:31:21 GMT

Kevin Long introduces the argument that more competition might actually increase healthcare costs in the US. The logic: Competition opens the field to more players, but having fewer players endows each with larger market share, and therefore greater leverage to negotiate lower prices. This line of reasoning is extended to discourage the entry of not-for-profit healthcare.

The central problem with competition in healthcare is that the wrong metrics are currently used to assess winners. Competing on price guarantees that costs will not decline, and in many cases will actually increase. How? Cost is driven by two variables: price and volume. Evidence has shown, and good business practice dictates, that when you decrease the amount that you pay for a service, providers will compensate by increasing volume. Currently in the US, contractual negotiations between insurers and providers tend to focus on the price of services, not the volume. Quality is an afterthought. Volume is left at the discretion of doctors and hospitals, which is bad for costs and for health outcomes.

The likelihood that you will receive discretionary services such as non-emergency hospitalization has nothing to do with your underlying health, but on the availability of hospital beds, or doctors available to perform procedures. Once hospitals build more beds, they must keep them filled to get paid, and over 30 years of research by the Dartmouth Atlas of Healthcare, and others, shows that is exactly what they do. Have a new operating room and a top notch surgeon? The same business logic applies: You have to feed the surgeon patients to maintain revenue stream. The irony is that regions of the US with the highest costs tend to have the worst outcomes, even after you control for the health of patients.

A quartet of solutions to reduce costs while increasing the quality of care:
1. Competition based on cost-effectiveness. This requires measuring and reporting doctor and hospital outcomes. Doctors and hospitals providing the best outcomes at the lowest cost are the winners.
2. Reward evidenced-based treatments. US patients receive care that is scientifically shown to be the best choice about 55% of the time. The rest of the care provided is based on theories, habits, and doctor's preferences. Encouraging the use of care that actually works reduces wasteful treatments that don't work, aren't necessary and can only bring harm.
3. Informed patient choice. Studies show that when given sufficient information to compare treatments, patients overwhelmingly choose the most effective treatments, which are generally the least invasive and least expensive. Not only does informed patient choice make business sense, it's usually the most ethical approach.
4. Pay doctors a salary. Most American doctors are paid on a per-procedure basis. This incentivizes over-use of procedures, driving up costs and putting patients in danger. Those who argue that this would lead to unmotivated doctors providing shabby care might not realize that this is the payment model at the Mayo Clinic in Rochester Minnesota, arguably the best medical center in the world.

Calling for reform

Sam Wertheimer — Sat, 24 Oct 2009 20:46:24 GMT

Volunteers across the nation sent a strong message in support of American health care reform this week. Motivated by distaste for a broken system, thousands of friends, neighbors, and strangers gathered in living rooms and community centers to call other voters and encourage them to back reform. The callers, collected through President Obama's Organizing for America (OFA) - the updated version of his community-based campaign organization, Obama for America - aimed to place 100,000 calls by the end of the day on Wednesday 10/21. They reached that number by 2:30pm. By midnight volunteers not only phoned over 300,000 voters, they also reached a wider audience because their efforts grabbed the attention of CBS News, the Huffington Post, and other news outlets. On Thursday night, I joined this good work. Below is my not-so-live blog of the event.

7:11pm - The event started at 7 but I'm stuck in parking lot-style traffic on the 405. I'm still learning how to navigate the freeway system in L.A., but I'm pretty sure that rush hour lasts until 10pm every night.

7:30 - Finally arrive and meet my host. Four other volunteers sit in her living room. They discuss strategy and peruse OFA-provided briefing materials. Only two have ever called other voters in support of a political issue.

7:31 - Skipped dinner, so I grab a cookie from the impressive snack spread in the dining room before joining the rest of the group.

7:35 - Along with a page describing common misperceptions about health reform, another detailing the broken health system, and two listing voter names and numbers, OFA provides a script for callers. The script suggests asking recipient to call their senator and solicit their support for the President's reform proposals. Callers are also directed to ask for a letter sent to Congress on behalf of the President, a volunteer obligation, and attendance at a future OFA calling event. One volunteer, overwhelmed with all the requests, announces plans to make up his conversations on the fly. He doesn't want to memorize the script nor bore callers with a canned speech. The OFA regional organizer suggests he stick to the script.

7:40 - Volunteers spread throughout the house to place their calls. Some head for the porch, another sits in the stairway. I remain in the living room and call the first number on my list. A woman answers and tells me to call back later - not an inauspicious start.

8:00 - After realizing that politely questioning if recipients, "have a few moments" before starting my pitch only results in a flat "no," I stop asking permission and jump right to the request for their support of health reform.

8:25 - Most of the people on my list so far are busy (or are screening my calls). None have been rude. Two of the first 30 agree to call Senator Feinstein. I give them her number and feel like my efforts aren't in vain.

8:30 - First really excited recipient.

8:40 - First rude recipient.

8:45 - Time for another cookie.

9:01 - After a string of no-answers, the OFA organizer calls time. Most callers are only ¾ through their list of names. He says that phone solicitations become increasingly irritating after 9pm. Is there ever a good time for phone solicitations?

9:13 - Staying late for a few moments to help clean gives the organizer a chance to coerce me into attending the next event. OFA volunteers will continue calling voters throughout the week and regional groups will hold a second round of national health reform phone gatherings next Wednesday.

9:15 - I called 46 phone numbers, left 14 messages, and spoke to 5 people. Three promised to call their senator the following day. Supposing I follow my own advice, staffers on Capitol Hill can expect at least 4 calls tomorrow. Every little bit helps.

9:20 - I must have done some good work since karma intervenes and there's no traffic on my way home.

Search for a malaria vaccine continues, despite challenges

Ano Lobb — Tue, 20 Oct 2009 16:49:44 GMT

My six year-old son is fascinated with monsters, dinosaurs, and vicious killers of all types. But he has a hard time understanding why, whenever he asks me to name the deadliest creature on the planet, I tell him it's the mosquito. If we lived in sub-Saharan Africa, he'd understand that what I'm referring to is the global plague of malaria.

A previous posting looked at new research into the main causes of death for adolescents and young adults, but death rates among those younger than 5 years are an often-used metric for population health.

Of the 3 billion people threatened by malaria each year, some 250 million become infected, and nearly a million die, 85%--800,000-- are children under the age of 5. Anti-malarial efforts center around four basic strategies: Insecticide treated nets, anti malaria drugs, indoor spraying with insecticides, and intermittent treatment of pregnant women. Studies have found that effectively implementing these measures can quickly cut infection and death rates in half. Vector control is also key: Eliminating or reducing the environmental factors that harbor the mosquito that transmits the disease. This includes appropriate sanitation, proper drainage to prevent standing water, and suitably bug-proofed housing.

Since malaria is primarily a disease of the poor and underdeveloped, these strategies are severely hampered by funding and infrastructure shortfalls, as well as under-investment in human capitol. In fact, according to the WHO, "Lack of human resources or capacity at country / inter-country level is the key constraint to developing, implementing and sustaining malaria control."

These are all good reasons to work on a malaria vaccine. Recent research is shedding light on why such a vaccine is proving so difficult to concoct. The basic vaccine development strategy aims to identify proteins from malaria-causing parasites that, when injected into humans, would arm the human immune system with antibodies capable of fighting off infection from the parasites themselves. Unfortunately, new genetic analysis of P. falciparum, the most dangerous of the five potential malaria-causing parasites, has found that the bug wears a constantly-changing protein coating with 214 possible mutations. This makes it potentially much more challenging to identify which proteins to isolate for vaccine development.

Efforts continue despite these technical difficulties, backed by resources and expertise from organizations including the WHO, USAID, and the Jenner Institute at Oxford University. With the most promising vaccine candidate about to enter large scale, "phase 3" human trials, I'm hopeful that the lowly mosquito will soon be reduced to the villain status attributed by my son: Nothing more than an itchy nuisance of damp summer evenings. Of course that's what they are in wealthier nations, and the accusation has been raised that diseases of poverty, such as malaria, do not receive sufficient attention specifically because there is no profit to be made in combating them (unlike HIV, for example, which is a scourge among the wealthy as well as the poor.) Would you agree with that assessment, that business models drive treatment innovation and disease eradication strategies?

Stomping on a cigarette company job ad

Sam Wertheimer — Tue, 20 Oct 2009 03:24:08 GMT

Although I'm employed, job ads still catch my attention. After a year-long search for employment, it's hard to turn off the job-seeking reflex. This is why I found myself drawn to a simple, text-only magazine ad during a recent visit to the dentist. The ad - displaying only red and black lettering against a white background - stood out amidst the waiting room coffee table clutter because of its claim that early career workers "can't beat the experience." With my interest piqued, I brushed aside a few glossy US Weeklys and picked up the outdated magazine for a closer look.

A quick scan of the ad only increased my interest. Phrases like, "creating value," and "aligning with society," appealed to my inner social entrepreneur. Mention of leadership development inspired me to read further. Just as I grabbed my phone to text an unemployed friend the website for resume submissions, I finally noticed the name of the company that posted the ad and stopped short. Small print at the bottom of the page displayed the name, "Altria Group Inc."

Those less familiar with Altria might not have hesitated to pass on the job info. After all, the company is a member of the S&P 500 and boasted $5 billion in operating income during 2008. And while the ads mention "satisfying adult consumers" (emphasis added), a casual observer might be forgiven for thinking that the company with the friendly title of "Altria" offers pharmaceuticals or cars to mature shoppers with discerning tastes.

But I hesitated because I know differently. During my public health training I learned that in 2008, Phillip Morris Companies Inc. renamed itself Altria Group Inc. and spun off its tobacco brands. Despite a new moniker and some restructuring, little else changed. The company still sells harmful products that increase mortality and morbidity throughout the world. This knowledge stopped me from passing on the job listing. I didn't want my friend to lend his talents to a company that kills its customers.

So, my subterfuge should qualify as good work, right? Perhaps not. In this era of 9%+ U.S. unemployment, my friend probably won't appreciate that I screened the job ad (sorry Niko). And Altria will likely argue that they lawfully peddle smokes and chew to adults only within clear a regulatory framework. To strengthen this argument critics would point to new, tougher regulations that installed the Food and Drug Administration (FDA) as overseer of Altria and other American tobacco companies.

Nevertheless, I'm unashamed that I chucked the dentist's back issue of Sports Illustrated. Altria might offer "big challenges" for young leaders, but these involve finding new ways to push products that harm. The world would be a better place without tobacco-related death and disease, and talented people should avoid lending their abilities to companies like Altria. Niko, you're going to have to keep looking...

If you want to learn more about efforts to weaken the tobacco industry, visit www.tobaccofreekids(dot)com.

And, if you want to know where you should not send a resume, check out www.cantbeattheexperience(dot)com.

What's killing our youth

Ano Lobb — Mon, 19 Oct 2009 20:44:18 GMT

A new study in the venerable medical publication The Lancet has for the first time systematically analyzed the principle causes of death among adolescents and young adults around the globe. This may seem like a rather pessimistic topic for discussion, but before investigating solutions that bolster health, we need to understand what threatens health.

This will be the first in a series of entries here at Justmeans and at our companion health blog that will look at global threats to children's health.

The Lancet study analyzed death rates among people aged 10 to 24 years in 78 countries during 2004. Countries were divided into two groups: high-income countries, and low- and middle-income countries. Worldwide, 2.6 million deaths occurred among the 1.8 billion people in this age group, 97% in low and middle income regions, and roughly 60% in sub-Saharan Africa and southeast Asia.

The principle killers? Diseases (primarily HIV/AIDS, tuberculosis, lower respiratory tract infection, cardiovascular disease, cancer, and neuropsychiatric disorders), and injuries (the major ones being traffic accidents, fire, drowning, violence and suicide). Communicable diseases were a leading cause of death among females, responsible for 48% of deaths in this age group (7% were maternity related). Among males, injuries were the leading cause, responsible for 51% of death. Unintentional and intentional injuries accounted for more than 2 in 5 deaths among males and females.

For both sexes, in all regions, death rates increased substantially with age, anywhere from 2 to 4 times. And rates were higher among males than females, especially in high-income nations where male behavior, combined with lower disease-related female death, leads to 2.4 times more death among males than females. As has been shown in other health research, geography plays a heavy hand in health destiny, with the death rate in wealthier nations about one-third (among males) to one-fifth (among females) the rate in the rest of the world.

The generality of the findings may not contribute much to our overall assessment of specific programs that may be needed, but a few conclusions can be reached. While global emphasis has been placed on HIV/AIDS and maternal causes of ill health among the young, these findings make it clear that equal emphasis should be placed on injury prevention. Worldwide, accidents and injuries, whether the intentional acts of violence or war, or the unintentional misjudgments of traffic pile-ups, are claiming over a million young-people every year.

Lack of Sleep Causing Hypertension in Women

Justmeans Staff — Thu, 15 Oct 2009 07:24:21 GMT

Did you know that women are more prone to insomnia than men? Health studies have related this condition in women with premenstrual phase, reproductive and menopause cycle. Even sex hormones have been held responsible for causing insomnia in women to some extent. Health risks associated with sleep deprivation in women is also more in comparison to men. If they sleep for less than 7 hours per day, they become more prone to hypertension which leads to cardiovascular problems.

It has been proved that the level of Interleukin-6 (marker related to coronary heart disease) is usually lower in women who sleep for approximately 8 hours. But the level of high-sensitivity C-reactive protein (hs-CRP) that predicts future cardiovascular morbidity is high in women who get to sleep for five hours or less. Due to the rise in stress levels, people are either facing difficulty in sleeping, waking up at night or waking up very early in the morning. Several psychiatric disorders are linked to difficulties in getting proper sleep.

Lack of sleep in some women also emerges secondary to menstrual symptoms such as headache, bloating, tenderness of breasts or cramps. Premenstrual syndrome (PMS) also affects the chances of getting sound sleep. Some studies reveal the side effects of sleep deprivation in women while other studies reveal the negative effects of sleeping more than nine hours. If postmenopausal women sleep for more than nine hours, there are chances of them getting ischemic strokes. The risk is 60-70% higher in women who have gone through menopause as compared to women who sleep less than nine hours.

In yet another interesting study conducted on women, it was found that older women sleep for longer hours as compared to men. This certainly breaks the misconception of women having poor sleep than men. It was concluded that women aged between 59-79, slept 16 minutes longer and their sleep was less fragmented. However, the difference in few cases was caused due to the consumption of liquor and use of medicines. Even though different studies reveal different results, the end result remains the same - sound sleep of approximately 8 hours is required for good health.

Sticking to Meatless Mondays for Health

Justmeans Staff — Thu, 15 Oct 2009 07:10:50 GMT

Health experts believe that risks related to curable chronic diseases such as diabetes, cancer, obesity and cardiovascular problems can be reduced by avoiding meat products once every week. For people like me who consume meat in their daily diet, it might be a difficult task to follow. However, one can't deny that fact that one meatless day followed by millions of people across the world can help save essential resources like fossil fuel and fresh water. Sticking to fresh and healthy vegetables instead of meat can have several benefits.

Did you know that approximately one-fifth of greenhouse gas emission caused by human activities is generated from the meat industry? Even more than the pollution caused by vehicles, emission from the meat industry is causing serious issues. With the annual demand for meat products rising all over the world, the situation may worsen in the coming years. In order to make consumers aware of the benefits to skip meat consumption for a day, an international campaign named, Meatless Mondays have been started. It encourages consumers, especially meat lovers to not have meat on Mondays so that they enjoy the benefits of healthy vegetarian food and also protect the environment.

But why choose Mondays? This day marks the beginning of the week when people move back to work. According to various studies it has been proved that behaviors adopted on Mondays are more likely to be maintained throughout the week. So, if one Monday passes without meat, it will be easy to follow the same in the coming weeks. We Americans consume almost 8 ounces of meat in a day, therefore if we take a small step and replace it with green vegetables one day per week, we will remain healthy and also support environmental sustainability.

The effects of global warming and rising carbon footprint are not hidden from us. Temperature is rising, habitats are getting destructed and mankind is one the verge of extinction if the current climate change hazards continue to cause more damage. The choices we are making at present may be affecting some family in Africa but very soon we will also bear the brunt of it directly. So why not follow initiatives like 'meatless Mondays' that are within our capacity and create a better future for our coming generations?

Do You Suffer From Constant Muscle Pain?

Justmeans Staff — Wed, 14 Oct 2009 13:11:41 GMT

Did you know that musculoskeletal disorders (MSDs) such as joint and muscle pain account for more sick leaves in UK and Europe than any other health condition? Based on health studies it has been proved that musculoskeletal disorders cause 60% permanent incapacity at work and 49% of all absence from work. This in turn costs EURO 240 billion to the European economies annually. In the UK, absence from work due to joint and muscle pain costs 7 billion pounds every year to the economy.

Besides joint and muscles pain, musculoskeletal disorders also include arthritis, strain injuries and back pain. Approximately one million people in the UK suffer from these problems and take frequent leave from work. Annually, so many leaves result in the loss of 9.5 million working days. The negative impact of MSDs on the European workforce and economy needs to be avoided. At a time when Europe is trying to stimulate its economy from the impact of global recession, decrease in labor productivity can mar the efforts of its quick revival. The present need for policy makers is to develop methods through which issues related to labor productivity could be addressed in companies at all levels.

Health experts are of view that early intervention will be required to deal with this problem as ageing workforce; rise in obesity and less physical activities can aggravate this issue further in the coming years. If business organizations implement effective health measures at work it will not only reduce the burden on government's health budgets but also bring down the rate of sick leaves. With early intervention in such cases, companies can also ensure better employee performance.

Chronic pain is also a major health issue in the United States due to which a large number of Americans become totally or partially disabled for few days or weeks. The second highest symptomatic reason is back pain due to which many people visit physicians in the US. As compared to major diseases, health problems like back and joint pain may not seem to be a serious issue but its impact can be felt on economies across the globe.