Morning Fog

Crisis In Childbirth Death?

ABC News reports, with considerable excitability, a California study documenting increased rates of death, almost triple what it was ten years ago, among women who have recently given birth.  Two reporters got to the point of nearly screaming -- "unacceptable!" -- " how can this happen in America?." 

Still, I guess they should be given credit for at least admitting that the "trend" is probably statistically insignificant.  It reflects 95 deaths out of 2 million or more deliveries.  The trend, it is explained, may be explained by two factors, an increase in obesity of expectant mothers, and an increase in Caesarean sections.  Both increase risks, but the former cause was mentioned only to be dropped; while the reporting focused on C-sections.  (No way we would want to make overweight patients feel responsible for their own problem, now is there?)

I'm no doctor, but it seems to me there is probably another good explanation, too:  More women having more babies late in life, when risks are higher; possibly even more women taking risks of the kind we see on TV - any risk acceptable (or ignorable) in hopes of bringing that baby into the world. 

Either way, another "big news" story is born, as long as you can pick the facts you want to emphasize.. 

Claimed Link Between Autism And Vaccinations Debunked

Today, low key reports like this one revealed that the British medical journal Lancet has "retracted" a study published twelve years ago whose author, Andrew Wakefield, suggested that a certain vaccine might cause autism in children.  

The article, because it appeared in an authoritative, reputable medical journal, had been a mainstay of parents and parents-to-be desperately seeking an explanation for autism; it had caused amazingly high percentages of parents to deny vaccination of their children for common childhood diseases. 

The retraction unfortunately comes too late for many, and perhaps too late for the good conscience of the editors of Lancet.  It would be nice to think that this simple step would correct the misconceptions, but a whole industry has grown up around the idea of blaming (and more important, suing) a drug company for "causing" autism.  Lawyers won't let it rest; and these times of recession-driven paranoia, others invested in the unproven link between vaccine and autism will simply believe that this overdue step by the British journal is a conspiracy.  (Check out the "comments" on the Washington Post story linked above.)

By the way, it's interesting to note that Wakefield is reportedly practicing (what?) in the U.S. now.

Cancer Screening

The U.S. Preventive Services Task Force has issued new recommendations that routine screenings for breast cancer should be done only every two years rather than annually, and starting at age 50 rather than 40 for most women.  To the layman, this seems like news to be welcomed.  Reduced frequency of a painful and dreaded screening, with no difference in health outcomes for most patients?  What's not to like?  And indeed, some experts have already applauded these findings. On the other hand, very quickly after the announcement, other voices were raised in a chorus of protest.  Those early negative reactions seem baseless. 

First, the recommendations don't mean "doing away with screening," as one radiology professor complained.  In fact the PSTF's spokesman was at pains to point out the changes relate only to routine screening.  As with other diseases, a patient's history, doctor's advice, and other factors will continue to determine when the "standard" recommendations need to be ignored.  So it seems self-evident that some patients, who might need or want screening earlier than age 50, based on self-examinations, or on a doctor's recommendation, or even just a preference, will obtain it.

Second, the reasons provided for changing the "rules" seem rational:  Data suggest that more is lost under current norms (once a year after 40) in anxiety, false positives, and needless costly/painful procedures, than is gained by the screenings.  In this respect, breast cancer and prostate cancer are similar.  The real message here is that current screening tests for both diseases really don't work very well, and need improvement.

Third, I don't see politics in the situation.  Some have professed to see the PSTF's announcement, coming from a government agency, no less, as a harbinger of "denial of care" or "rationing" that's in store for us under health reform legislation.  But to me, that's seriously paranoid.  You can believe that the government is plotting to ration care and would make that public before any legislation is passed, or you could choose the more likely conclusion that only those opposing health care changes might hope to benefit from announcing these changes now.  In fact, making this announcement before reform bills are passed strongly suggests that the changes are proposed for sound health reasons.

Last, a word about cost.  Some who bemoan the changed recommendations worry that insurance companies might refuse to pay for any screening before age 40.  Undoubtedly that's at least a possibility.  But this complaint also reflects the distorted nature of "cost" perceptions in our health care system.  Existing bills, as many experts have pointed out, may result in more people being insured, or in fewer abuses of policy coverage, but they don't truly deal with the rising costs of most health care.  Here's a case where things do need to change.  When all care is essentially free (ie. covered by insurance), the consumer has no incentive to worry about the cost of what he "wants."  If consumers were focused on costs, a switch that would reduce the frequency of an expensive screening by half would be a no-brainer.  That's the next, and bigger task, for health care reformers.

More Pseudo-Science

Scenario:  A couple of reporters want to show the physiological effects of eating some of the country's fattiest, saltiest, sugariest, highest calorie, baddest-for-you fast foods.  Reporter has blood, heart rate, liver function, and other vital indicators measured at some unspecified point just before eating, eats four of these badboy dishes, and then gets the same tests run again.  

Results:  Amazing!  Various vital signs are off the charts in various ways; heart racing, blood full of fats, etc.  Return to normal takes several hours.

What we learned about the effects of bad junk food on our bodies:  Absolutely nothing.  Are we so poorly educated in scientific method after eight years of kowtowing to ignorance, that our intrepid reporters think this demonstrates anything?  One of the keys to any test is to minimize the variables.  Here, the two tests were taken (apparently) at different times of day, one when the subject had eaten nothing recently, the other when she had just eaten a huge meal.  How can we tell what are the effects of eating bad food, and what might resultl just from eating any meal?  We can't.

Proper procedure:  Day 1, reporter eats normal lunch and gets the tests done.  Day 2, same time of day, reported eats the terrible fast food lunch and gets the tests done.  Compare results.  Then we might learn something.  University of Maryland, be ashamed.

Just A Little Gardening

With so much rancor in the political arena these days, it's nice to call attention to a great project with a lot of benefits, which to my knowledge no one has criticized -- namely, the White House vegetable garden.

Even if you live far from Washington D.C., you are probably aware that First Lady Michelle Obama decided back in March to create a vegetable garden on the White House grounds, the first such garden since the days of Eleanor Roosevelt.  One stated purpose was to provide the White House kitchen with more locally (very locally) grown fresh produce for the First Family and for White House guests.

The greater impact, though, was through Obama's decision to involve a group of fifth graders from a DC school in digging and planting the garden.  Last week, the same group returned to the White House for harvest time.  Like most of us in urbanized America, these kids are a long way from our farming tradition, but the entire experience -- wrapped up with a lunch utilizing the foodstuffs they grew, and a talk about the importance of fresh food and good nutrition, must make a huge and hopefully positive impact on them.  And because it's the White House, of course, the publicity for the effort creates ripples that will touch a lot more young people than just the few dozen who participated directly.

The timing is interesting.  Planting gardens has long been associated with hard economic times.  During both World Wars, "victory gardens" were encouraged in several countries, including the U.S., not just for the food that could be grown, but as a morale booster.  No one seems to have dubbed the current effort "victory garden" yet, but clearly at a time when the demand for garden seeds is outstripping demand, the time is ripe. 

Speaking of morale, one last positive effect of the White House garden goes far beyond lettuce or nutrition.  The vegetable patch was one element of a much broader effort both Obamas have made to get involved in the local community - out for a burger at lunch, serving food to the poor, planning events in schools.  Never before has a President or First Lady connected with the people of the Washington area in this direct a fashion; this, I think, is appreciated especially here in D.C. with its orphaned, "taxation-without-representation" status.   

Leprosy

Suddenly yesterday, I was beset by tales of leprosy, or Hansen's disease, as it is now called.  First, the local paper reported a heartwarming story about a group of women in Falls Church, Virginia, who were knitting bandages for lepers in Vietnam - a worthy cause, indubitably.  Later in the day, a speaker at an event I attended happened to refer to an incident in his past when a prominent American visitor to a foreign country was asked publicly to lay hands upon a sufferer from Hansen's.  And that made me reflect on my own experiences of lepers in Africa years ago.  I recall at one time buying grilled skewered meat from a leper in Sierra Leone, but more vivid was New Year's day of 1974, when a couple of friends and I spent a day visiting a leper "colony" in Liberia, basically a village to which  lepers were banished to keep them isolated. 

The colony was also a mission at which the medical and spiritual needs of the afflicted were treated by a U.S. Episcopal missionary and a small local staff.  It was an enlightening experience; I learned that the disease is caused by a bacterium, that it carries a very low risk of contagion (such that people who work in leper treatment facilities like this do not generally fear contracting the disease); and that it is treatable with what we might now call a "cocktail" of drugs.  One last, very noticeable fact:  I found, as did the prominent citizen mentioned earlier, that lepers very much long for the touch of those who don't have the disease.  I suppose it's a validation of their human dignity, and a confirmation that the disfiguring disease is not completely repulsive to "others."  So yes, we shook hands with many of the inhabitants that day, and attended a worship service with them.

Leprosy continues to crop up in the world.  The U.S. Department of Health and Human Services reports about 700,000 new cases per year worldwide, with 70% of those occurring in just three countries: India, Indonesia, and Myanmar.  But it still exists in the U.S. (see the National Hansen's Disease Clinical Center near Baton Rouge, Louisiana, which offers diagnosis, information, and treatments).  It's less widespread than it was, and it's better understood (though still not well understood).

Overall, I believe the Hansen's story is "good news."  The disease is less prevalent now than it was five decades ago; with increased understanding, progress is being made, and it's no longer so scary, either for those who have it, or those who don't. 

Health Reform Dialogue

"Health Reform Dialogue" is a disparate group of insurance companies, doctors, hospitals, consumers, employers, and other groups.  They all have stakes in the U.S. healthcare system.  They've been meeting for six months or more, brought together by private facilitators, away from day-to-day public scrutiny, to discuss possible changes to the system, and have now issued a report on their discussions. 

The actual report seems to have been released only to the press.  By all accounts, it could be a positive step in achieving meaningful change to U.S. health insurance and care.  As one article put it, it's the first time that all major players have "coalesced around significant changes." That's certainly good news; just getting the parties talking would be good news.  But from what I've seen so far, there is less here than meets the eye.

There are little red flags that I think ought to make us all very cautious about premature elation.  For starters, I note that there's no indication anyone from government took part in these discussions; that professional facilitators (with a built-in interest in making the results of their work look positive) presumably crafted the report; and that the few bits of wording that appear in quotes are very carefully phrased.  

One key quote is this one: "We should seek to ensure coverage for all."  Really?  Duh! And this revelation was reached after only six months?  I suppose there are participants in the Health Reform Dialogue for whom that statement is a radical change of view, but it's a long way from where we need to go.  The more contentious issues, however, aren't dealt with. 

The hang points are where they have always been, on the money and the mechanism.  Of course there will be a lot of debate about how to pay for universal or expanded coverage and we will need agreement on that, but in a society as rich as ours, in the long run it's not a financial problem but a political one.  More disappointing is the failure even to agree that coverage should be universal.  We don't need to "cut in half" the number of uninsured Americans (as one media source reports), we need to devise a system that leaves NO uninsured Americans.   Step by step change is one way to get there, but it's extremely disappointing to think that the HRD group couldn't even agree that should be our goal.

The question of how to deliver expanded (or preferably universal) health insurance has also been complicated by the "refusal" of insurance companies to accept any government-operated plan that would provide insurance for those left out of the private system.  We should utterly reject the notion that insurance companies can "refuse" anything.  Who elected them?  Of course they are major players, and of course their views will be taken into account.  But the provision of a social safety net (in health insurance as in social security or food stamps) is a government function, if anything ever were.  By definition, private business interests do not put the public interest first.

Insurance companies say they are concerned about a government program that would be so generous that people would start migrating out of private plans.  Nonsense. There are many ways to craft a government plan to deal with that.  The usual model for a "government plan" is the plan that federal civil servants (and Senators) have.  The key elements of that are transferability and a choice among different plans, but all insurance coverage is still provided by private insurers.  A safety-net plan would not have to offer all the bells and whistles of coverage that the government employees plan has, however; a more basic level of services would easily encourage people to move up to private insurance when/if they could. 

The proposed alternative to a government-based plan is the Baucus suggestion for a "mandate" - requiring that people obtain health insurance (as drivers now must have liability insurance).  For those least able to pay for insurance, the government would then have to pay insurers to offset costs in those cases, or offer tax breaks to the insured.  I guess that might work, but why complicate things?  Elsewhere in business, it used to be conventional wisdom to "eliminate the middleman."  I guess it makes a difference if, as in the case of the health insurers, you ARE the middleman. 

None of this is to suggest that the HRD isn't a step forward.  Positive developments include a consensus that change is needed, that more people need to be insured, and that insurance companies could get by without charging more for people who have existing health problems.  The HRD discussions will undoubtedly help advance the process of change.   

Immunization and Contagion

I recently read about several new cases of Hib (Haemophilus influenzae Type B) bacterium in Minnesota and was struck by the similarities between this situation and the problems that have been experienced in the eradication of polio (see my earlier post).  It is not yet clear whether this is a pattern that is occurring elsewhere in the U.S., or if it's unique to Minnesota.

Hib can cause fatal infections; immunization is effective against it.  Minnesota health officials speculate that reluctance of parents to have children immunized may play a role (the vaccine is in somewhat short supply too).  Parental refusal has also played a role in Pakistan, India, Nigeria and other countries where new cases of polio still occur (the other obstacles to progress are war and the remoteness of some areas).  It's also been reported lately that in some areas of the U.S. and Europe - notably, those where a high percentage of parents have declined immunization - measles is cropping up again. 

In light of evidence that incomplete immunization of the population can open the door to a resurgence, the trend of parents refusing to permit their children to have immunizations disturbs me.   We've got new diseases to worry about, from HIV to ebola and BSE, but we can't afford to be complacent about the older ones.  Perhaps we take too much for granted today.  Most parents today don't recall how prevalent diseases like smallpox and polio were just fifty years ago, and how many victims they claimed. They're not much in the news any more but they could very rapidly become threats. 

I know there's some concern about side effects or future complications, but as far as I'm aware, these are mostly unsubstantiated or extremely rare (depending on the disease), while the effects of neglected immunization are well documented, and often potentially fatal. 

Universal immunization against preventable diseases is the one contagion we should want to spread.

Dangerous Docs

A very late act of the Bush administration was a regulation to prevent employers from disciplining health care workers who refuse to participate in medical procedures that offend their ethical, moral, or religious beliefs.  It's scheduled to go into effect Tuesday, January 20.  Bravo to the seven states and two organizations that have filed in court to block this regulation; it's totally nonsensical.

I'm all for freedom of religion but it's a matter of individual conscience, and should remain in the personal sphere.  No one should be able to impose his/her beliefs on others who may not share them, especially in a field like health care, where it might be dangerous or fatal to do so.  David Stevens, of the Christian Medical and Dental Association, claims the proposed regulation protects patients who have religious reservations about certain medical procedures, but the patients whom society really needs to be concerned about are the ones who might want these procedures and who consider them completely acceptable.  How would such people be protected from mistreatment or neglect at the hands of medical caregivers who might refuse to provide the treatment or even suggest it?  Mr. Stevens doesn't seem to worry about them..

In politics, the usual solution would be some compromise for religiously-correct health care workers.  We are already familiar with options such as private practice and denominational hospitals.  One seemingly viable suggestion: Any physician who opposes a practice on religious grounds should be required to inform his patient of the existence of this conflict of interest.  Stockbrokers are required to do this; should we expect less in the medical care field, where lives are at stake?

Even so, I'm doubtful that there is any middle path that can protect everyone.  One example: What about emergency care when the religiously motivated physician is the only doctor around?  All in all, the proposed regulation attempts to codify individualist views about abortion or other procedures into generic "rules" affecting us all.  It is a camel's nose that could threaten to bring down the tent of our civil society.

The concept of professionalism posits the existence of a common set of standards independent of the individual's personal preference.  People who won't offer a client a full range of options aren't living up to their professional responsibilities, and those who refrain from performing elements of their work out of moral repugnance define themselves automatically as amateurs.   A professional soldier might have moral qualms about killing, but if he finds he can't do it, then he needs another line of work.  It's the same in health care.   Hospitals and other public institutions don't have the option of employing people who might refuse to do parts of the work they were hired for; they'd be rightfully subject to lawsuits (and the non-performers should be accountable). 

I also have difficulty justifying the opt-out approach ethically.  Most religions preach tolerance and understanding for the views of others.  I'm not a doctor (I don't play one on TV, either, if you were about to ask); but if I were, I'd find it difficult to refuse a certain treatment to another human being only because it offended my sensibilities. That would be dishonest and immoral.

The CMDA website says its goal is  'to motivate, educate, and equip its members to...glorify God.'  (Not to practice medicine!)   I'd prefer that CMDA members glorify God by giving up their own lives or health, not mine.  My radical but inescapable conclusion:  These are "dangerous docs" who really shouldn't practice medicine at all.  There may be openings in the ministry, where they could do less harm.