Underreported Humanitarian Crises of 2007

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Thanks to Merrill Goozner at GoozNews for calling attention to Doctors Without Borders’  list of the ten most underreported humanitarian stories of 2007.

The global humanitarian physician’s group (Doctors Without Borders/Medicine Sans Frontieres, or MSF) zeroes in on ten horrifying examples of suffering so extreme that it is difficult imagine. At this time of year, it seems appropriate to try to take in at least two examples.

The first story below focuses on the tuberculosis epidemic that, as the New York Times explained last year, “is outrunning us. In the last few months, 53 patients in the South African province of KwaZulu-Natal were found to have a form of the disease resistant to enough existing drugs that it is virtually incurable. All but one of those patients has died. Airborne and deadly, extensively drug-resistant TB is a nightmare disease. It has been found worldwide, including in the United States. . .

“The development of antibiotics had allowed wealthy nations to dismiss TB as a disease of the past. But H.I.V and AIDS have changed that calculus. In Africa, active TB cases are rising by 4 percent a year, largely because H.I.V. activates latent TB infection. TB is the leading cause of AIDS-related deaths. Every patient tested in the KwaZulu-Natal study was H.I.V.-positive and more than a quarter of those who died were taking antiretroviral therapy.

“African health officials gathered in South Africa last week to discuss extreme tuberculosis, but they are hobbled by the world’s indifference . . .

“Money for clinical trials would speed things. But donors have always slighted tuberculosis. According to a new report by Results International, an advocacy group, the World Bank spent only $3.5 million directly on TB in Africa in 2005. The Global Fund to Fight AIDS Tuberculosis and Malaria and the Bill and Melinda Gates Foundation are big donors, but much more is needed. Stinginess created this problem. Generosity is needed to fix it.”

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Open Question: Should Physicians Be Involved in Lethal Injection?

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In the newest issue of JAMA, two authors affiliated with the AMA offer their opinions on physicians’ role in implementing the death penalty via lethal injection. Hint: they don’t approve of it.

The article says that unlike other methods of execution, lethal injection “has elements of medical practice: insertion of intravenous lines, intravenous injection of medicinal drugs, and monitoring vital signs.” Small wonder then, that 35 of the 38 states that allow the death penalty either require or permit physician participation in executions.

Typically the identity of physicians who participate in executions is held confidential by state authorities. Even if they are made known, licensing boards in death penalty states have trouble taking any action against physicians who participate in executions. Since the boards deal with illegal activities, they can’t crack down on physicians who participate in executions that are legal.

But medical societies have more wiggle room. AMA prohibits involvement of physicians in executions, saying that it goes against the physician’s role as a healer. As the authors put it, “any form of participation in causing death by lethal injection is unethical because it violates the physician’s role, thereby undermining trust….the penal system, not the medical profession, is responsible for finding a way to perform executions.”

Obviously this issue has a certain degree of timeliness, given the Supreme Court’s recent agreement to hear challenges to lethal injection on the grounds that the process often gets so mucked up that it constitutes cruel and unusual punishment. But I think the JAMA piece is right in addressing it as a big-picture best practices question. This is primarily a moral question.

And it’s a tough one, even for physicians who might support capital punishment in the criminal justice system. Just because they believe that murderers should die, it doesn’t follow that they feel criminals do or do not deserve a demise that is as painless as possible. Supporting capital punishment and consenting to having a hand in it are two very different things.

So imagine you’re a doctor and the state has asked you to preside over
an execution that will go on with or without a physician present.
What’s your medical duty—to try to ensure that things go smoothly and
spare the inmate unnecessary pain, or abstain from attending because
your presence would mean you were participating in taking a life? Which
choice is truer to the physician’s duty to be a healer?

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Taxes: Weight Watchers for the Health Care System

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A few days ago San Francisco Mayor Gavin Newsom proposed adding a surcharge on soft drinks with high-fructose corn syrup as part of a campaign to combat obesity.

Newsom’s “soda tax” is just the latest development in a series of metropolitan initiatives aimed at promoting healthier living. New York, which pioneered smoking and trans fat bans, has been the most gung-ho city and similar bans now have been passed, or are being considered, by cities across the nation—and the world. 

Efforts like the soda tax are often derided as unnecessary big government intrusions, especially for something like corn syrup (or trans fat) that doesn’t hurt bystanders the way second-hand smoke does. Those who eat or drink poorly only hurt themselves; and the right to self-destruct is a right the government should respect (or at least this is what some say).

But here’s the problem: the cumulative effect of saying that obesity isn’t my problem is to make it everyone’s problem. Newsom’s spokesman, Nathan Ballard told the New York Times that “there’s a well-established nexus between obesity, which is caused by high-fructose corn syrup, and the increased health care costs for the city.” According to a 2004 study in the Annual Review of Public Health, obesity is responsible for between 5 percent and 7 percent of total annual medical expenditures in the United States. Every year excess weight costs our health care system more than $90 billion. Even employers shoulder the burden of obesity: overweight workers require as much a $2,500 extra in health care costs, adding up to almost $300,000 in medical expenses for a 1,000 person firm.

The reason why obesity costs so much is obvious. Individuals who are carrying too much weight are at an increased risk of hypertension, osteoarthritis, high cholesterol, type 2 diabetes, heart disease, stroke, gallbladder disease, respiratory problems, and cancer. And it’s only getting worse. A RAND study from earlier this year found that from 2000 to 2005 the obesity rate in the U.S. (, i.e. the number of people with a body mass index of 30 or above,) increased by 24 percent. Meanwhile the number of people with a BMI over 40 grew by 50 percent, and the number of people with a BMI over 50 grew 75 percent.

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How Soon Can We Expect National Health Reform?

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On this blog, we have debated how soon Americans will be ready for national health reform.  Many observers believe that we’ll only get reform when more people are uninsured—specifically when more middle-class and  upper-middle-class families find themselves “going naked.”

The chart below comes from a new Commonwealth Fund Report which shows that while two-thirds of low-income adults (earning less than 200 percent of the federal poverty threshold) were uninsured or underinsured in 2006, just 17 percent of those earning more than 200 percent of the federal poverty level (FPL) were either underinsured or uninsured at some point during the year.

 

Uninsuredandunderinsured_2

“Underinsured” is defined as someone who finds himself spending 10 percent or more of his income on out-of-pocket medical expenses. (For those earning less than 200 percent of FPL, the number is 5 percent.)

The report observes that employers are continuing to back away from offering health benefits:  “Between 2000 and 2005, the proportion of workers receiving employer-provided health insurance declined from 74.2 percent to 70.5 percent,” and again “middle- and lower-wage workers,” suffered most, with “the largest decreases” hitting this group.

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Are Americans Working Health Care into the Ground?

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We Americans are proud of our work ethic. We work longer hours, and more productively, than any other nation. Our industriousness has long been cited as a source of strength of our economy—but it just might be a source of some of our health care woes as well. 

According to a just-released study from Wake Forest University, professional flexibility is an important contributor to better health. Employees at all levels who have, or feel they have, more job flexibility (e.g. the ability to work from home, choose their hours, etc.) engage in healthier behavior than those that don’t. The study found that employees with flexible schedules exercised more, attended more employer-sponsored health classes, were more likely to describe themselves as living a healthy lifestyle, and reported getting more sleep. When the researchers checked in a year later, they found that as job flexibility improved, so did healthy habits: more flexibility meant more sleep, more health classes, and a healthier lifestyle.

This study deserves attention. Changing behavior is the single most powerful way to prevent health problems. As experts from the Robert Wood Johnson Foundation noted in a Health Affairs article earlier this year, “behavioral issues represent the greatest single domain of influence on the health of the U.S. population,” with 40 percent of early deaths in the U.S. due to behavioral patterns. Anything that promotes health behavior needs to be seriously considered as a strategy for making America healthier—and by extension, health care costs lower. 

Obviously, somehow ensuring that everyone in America had more flexible hours wouldn’t cut early deaths by 40 percent. And there’s no guarantee that more flexible hours will translate into better sleep, more exercise, or more education on a national scale. Any movement for universal job flexibility would have to be coupled with a concerted effort to translate free time into healthy time.

But this study gets us thinking about behavior as more than just the usual spate of no-nos like smoking or eating poorly. Work is behavior. Work is relevant to health—more so even, than the Wake Forest University study suggests. There’s an argument to be made that more job flexibility can translate into a shift away from medication in two big arenas: childhood disorders and depression.

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Donating an Organ: Should It Be A Gift?

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A story in yesterday’s New York Times Magazine raised some very thorny questions about organ transplants. I spent the afternoon reading more about transplants; by evening I had stumbled onto what seems to me at least a partial solution.

The NYT piece tells the story of Sally Satel, a 49-year-old psychiatrist in need of a kidney transplant. In 2004, her kidneys suddenly, quite inexplicably, began to fail. (The cause may have been a medication she had taken in her twenties.)  She had no living relatives except a couple of cousins whom she rarely saw. A close friend came forward, was tested, found that her blood was a match, volunteered to donate a kidney–and then reneged. (It turns out that when she went to chorus practice one evening, “a fellow alto” talked her out of it. The fellow-alto was, of all things, an organ transplant specialist. Satel was enraged: “a transplant surgeon should know how hard it is to get a donor.”)

A second friend volunteered, and again proved a match. But then she, too, got cold feet– though she didn’t tell Satel right away.

Finally, a 62-year-old stranger in Canada saw Satel’s message on an organ match website, called and offered to help her.  He was the right blood type, he seemed “steady” and “honest,” and after a few weeks of phone calls and e-mails, they set a date to do the operations in early January. Then, just before Thanksgiving, he went dark. “Everything turned to radio silence as my e-mail and phone messages went unanswered,” Satel recalls. When her transplant coordinator contacted him, he waffled. He wasn’t sure he would be able to make it in January; he was too heavily involved in a political campaign…

“I was astonished at the Canadian’s . . . what? Negligence, cowardice, rudeness?” Satel writes. “It was a sickening roller-coaster ride: hope yielding to helpless frustration, gratitude giving way to fury. How dare he reduce me to groveling and dependence? Yet I assume he intended no such thing. I think the Canadian was actually quite devoted to the idea of giving a kidney — just not necessarily now or to me.”

By now Satel is desperate. She realizes that her only alternative is dialysis “three days a week, for four debilitating hours at a time, I would be tethered to a blood-cleansing machine… I had an especially morbid dread of dialysis,” Satel admits.  She was haunted by what she had read about “the playwright Neil Simon [who] received a kidney from his longtime publicist in 2004 . . .but before that he endured 18 wretched months on dialysis, suffering cramps and vomiting spells that kept him largely confined to his house. His memory deteriorated, and he hated the time away from his writing. Shortly before his donor came forward (unsolicited, it should be noted), Simon’s doctors said he might have to start spending more time on dialysis. If that were necessary, he said, he had decided, ‘I didn’t want to live my life anymore.’ Neither, I thought, would I.”

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Pilots Use Checklists. Doctors Don’t. Why Not?

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This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist” is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long” but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. “She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.” By then “she has a body temperature of 68 degrees—and no pulse.” A helicopter takes her to a near-by hospital. 
There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. “Her right leg and left arm [are] partially paralyzed.  Her speech [is] thick and slurry.  But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.” 

“What makes her recovery astounding,” Gawande writes, is “the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running” all the while “orchestrating each of these steps in the right sequence, with nothing dropped . . .”

This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

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Complaints about Medicare Advantage Mount…While Congress Contemplates Slashing Fees Traditional Medicare Pays Docs

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Recently I argued that eliminating the private insurance industry would not suddenly make health care affordable. But this is no reason to gratuitously overpay private insurers to provide health care to Medicare patients—while simultaneously planning to slash the fees that Medicare pays physicians.

Begin with the insurers. When Congress created Medicare Advantage, the program that allows private insurers to offer Medicare to seniors, it agreed to pay for-profit insurers about 12 percent more per patient than traditional Medicare would spend if it were covering those patients directly.  Add up those extra payments and they amount to a $16-billion-a-year subsidy for the health insurance industry.

Why the sweetener?  Lobbyists argued that the government would have to pay more to persuade for-profit insurers to join the Advantage program.  Moreover, they promised that the insurers would use the $16 billion to offer patients extra benefits like acupuncture and eye exams that they would not receive under traditional Medicare.  And Congress agreed. Now, think about this for a minute: legislators agreed to use our tax dollars to help for-profit insurers draw customers away from a government program that most people liked—and that cost taxpayers less.  This is not about saving money by transferring Medicare to the supposedly more efficient private sector. This is about the conservative agenda: some politicians are determined to try to outsource government to for-profit corporations.

Predictably, private insurers structured their plans to siphon off the healthiest seniors.  In New York City, for example, Oxford included free memberships to some pretty posh gyms as part of the package. They called it the “Silver Sneakers” program. Unfortunately, a year after seniors signed up they discovered that the number of gyms involved in the program had suddenly shrunk. The options that remained weren’t nearly as tony, and most were no longer located in upper-middle-class residential neighborhoods. Is this “bait-and-switch”? You decide.

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The Drug War versus Health Care

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Yesterday President Bush gave a speech on the success of his drug policies in celebration of a new report showing that teen drug use has continued a decline that began in 1997. But it is not entirely clear that there is much cause for celebration: use of some of the most hardcore stuff—such as cocaine, crack, LSD, and heroin—has held steady over the past five years or so. True, recently the use of marijuana, amphetamines, and methamphetamines has dropped, but that’s hardly reason to declare victory in the war on drugs.

Like any good president, Bush wants to take credit for good news. But as the lack of progress in the battle against heroin and crack suggests, the U.S. is on the wrong track when it comes to drugs. Our institutional bias is still to see drug use and drug control as criminal justice issues when we should really be thinking about them as public health concerns.

Just take a look at history. According to a Health Affairs article from earlier this year, since 1987 public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. From 1987 to 2003, the average annual total growth rate for SA treatment was 4.8 percent, while U.S. health care spending grew by 8.0 percent each year. Because of this mismatched growth rate, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Compare this drop in treatment spending to the increase in drug arrests: according to the Bureau of Justice Statistics, in 1987 drug arrests were 7.4 percent of all arrests reported to the FBI; by 2005, drug arrests had risen to 13.1 percent of all arrests. Our spending on SA treatment and the volume of drug arrests are moving in opposite directions. And for all the political pageantry surrounding yesterday’s report, President Bush’s FY 2008 budget calls for cutting $158.7 million from the Substance Abuse and Mental Health Services Administration (SAMHSA) budget and $278.9 million from the Safe and Drug-Free Schools and Communities (SDFS) program. 

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