Saturday, February 23, 2013

Improving the Healthcare System

We all know that a huge chunk of the national spending goes to healthcare. Treatments and visits to physicians have varying cost from region to region, but does that equate to different levels of service and healthcare? The Dartmouth Atlas Project compared medical billing records all of the country and found that there is a huge variation in how much clinics charge patients yet the quality of healthcare they received were more or less the same. The initial speculation is that many physicians give unnecessary treatments to patients; they overkill the patients’ conditions to ensure that they are treated (or, for some, so that they can reel in more money).
I think health is a right, and not a privilege. The most basic general thing that humans have is their health. If they don’t have health, nothing else matters, so if we were to give anything to someone it would be health. Anyone is entitled to and has the right to have better health just because that’s the most essential gift that anyone can receive. How can we deny people of lower income from living their lives in good health? The need for health is more basic than the need for food, sleep or entertainment, because without health or life, food, sleep and entertainment are irrelevant. Of course people of high socio economic levels would have more options available to them in terms of treatments, but everyone is entitled to basic healthcare.
In light of the Dartmouth Atlas project, the documentary US Healthcare: The Good News showcases healthcare systems around the country that has lower than average cost but higher than average services. In Grand Junction, CO, the physicians in the county made a pact in which they promise to charge all patients the same amount of money for the same type of treatment. They do not discriminate between a  patient with private insurance and one with Medicaid. Moreover, a portion of the money received from patients are withheld and distributed among physicians monthly. This system equalizes the cost to visit a clinic, making it affordable for those of lower socio economic levels and ensuring that the poor can get similar, if not the same, quality of healthcare as do the rich.
In Seattle, WA, Group Health is a cooperation of physicians. The physicians are paid a fixed alary and schedule their work day around the patients’ appointments (not the other way around as it is normally). Moreover, they keep electronic records for easy access for both patients and the staff. Patients are given more time to talk with the physicians about their aliments and can contact them by phone or email; this allows the physician to really understand and keep track of the patients’ medical history. The best thing about the fixed salary part of this system is that physicians have no reason to prescribe expensive or unnecessary treatments for patients to make more money, since they are paid the same amount of money either way. This also allows them to take their time with each patient without rushing to maximize the number of patients they see to get more commission.  This system makes the lives of both the staff and the patients much easier.
In Everett, WA, the Everett Clinic is a huge clinic with over 300 physicians working together in it. They strive to eliminate superfluous treatments and costs. They do this by creating strict checklists to approve or deny expensive (and often unnecessary) treatments like CAT or MRI scans. They also use generic drugs and drugs that are the most efficient. They claim that they more money for the community this way by ensuring that the people stays healthy for work.
I think any of these systems could be implements nationally. The main problem is human greed and the lack of strong initiative and leadership. I don’t think convincing all the physicians in a region to voluntarily reduce their income would be easy; moreover, these systems seem to only work if most, if not all, the physicians are receptive to this system. These systems are all or nothing. Either everyone’s doing it in the community or none. I think if we want to see systems like these implemented nationally, it has to be done at a federal level and voted on in the Senate (perhaps making it constitutional iilegal to knowingly prescribe unnecessary treatments). I am sure that this is all possible just as we can evidently see in the cases shown in the documentary, but scaling this up to a national or even state-wide level would deem a challenge.

Friday, February 15, 2013

The Vaccine War: Needs of the many versus the few

Ever since the first vaccine was developed for smallpox was developed, vaccine development have prevented many potential epidemics and is one of medicines greatest achievements. Despite the apparent benefits to mankind, groups that oppose the use, distribution and development of vaccines have sprung up around the country. The Vaccine War is a documentary produced by Frontline that showcases representatives of groups that have different reasons for putting the hate on vaccines and contrasts their opinions with the scientific evidence and opinions of the proponents and developers of vaccines.

The documentary starts off discussing the claim that infant should not be vaccinated because the prevalence of the conditions that is immunized against is very low. For example, this group of people claim that since Polio prevalence is nonexistent, babies should not be given the polio vaccine. The main with this is that the cause of the low prevalence of Polio is because almost every child and adult is vaccinated against Polio, so if there a potential outbreak of polio which could kick start an epidemic, effectively no one gets infected. They also claim that Polio has been eradicated, just as smallpox has been eradicated (smallpox vaccine is no longer required nowadays). Polio is very virulent and can spread extreme quickly. So if there someone who is not vaccine against smallpox happen to come across the polio virus in the jungle or something and return to an unvaccinated population, a crisis would ensue because suddenly there is a spike in infection. Without a doubt, the polio vaccine will no longer be required in the future, but for now, it’s a safe choice to keep the polio vaccine on the schedule.

Then the documentary shows a group that claims that children should be raised naturally without any medical intervention. “Children are supposed to get sick,” says one lady.  While I agree that it’s important for the child to develop the adaptive immune system (i.e. chickenpox, colds), I don’t think allowing a baby to get tetanus, whooping cough or measles is any good for the baby’s development and wellbeing. Sure, it’s good that if a child can develop his or her immune system by getting a little cough or fever, but putting the child at the risk of a lethal condition is in no way a good idea or natural.

The last and the biggest group of opposition claim that vaccines cause autism in children. This group managed to get a huge following because celebrities got involved as well. People whose children because austistic some time after the children were vaccinated had huge demonstrations and rally. They claim that certain components of vaccines are causing austism in children. The documentary then showed that there has been many epidemiological studys done on seeing if there were an association between vaccines and autism; All of the studies concluded that there is no correlation between vaccine use and autism. The main spokesperson of this group, Jenny McCarty, said “I don’t need scientific evidence, [my autistic son] is evidence,” is an example of the group’s disregard of the facts and their penchant for gut feelings and unsupported claims. I think the problem here is that the parents of autistic children are simply finding something and someone to blame (it’s just human: My child is autistic. It can’t be my fault. It’s the vaccine he had last month. That must be it.). As the documentary points out, autism usually comes about at the same time frame children are scheduled to get their vaccines. This is just another cause of correlation doesn’t mean causation.

 The documentary was obviously more biased towards the proponents of vaccines, since it always had a commentary or a speaker who would essentially debunk and humble the claims of every single anti-vaccine speaker. So watching this documentary didn’t sway my opinion on vaccines at all, since I’m all for vaccinations.  But I wasn’t aware that the anti-vaccine moment is based on such unsupported claims and theories. I thought that they may have legitimate and rational reason to oppose vaccines but no. Moreover, they are stubborn in their opinions  even after they were given scientific evidence that they were wrong.

Vaccines has a positive externalities; in other words, the consumption/use of vaccines have indirect benefits to people around the consumer as well as direct benefits to the consumer. If person A is vaccinated, his roommate benefits as well because person A is unable to be infect and get his roommate sick as well. If we scale this up, the more vaccinated people there are, the more people benefit from not having sick people around. This increases the general health of society and economic productivity because people have less sick days. This is called herd immunity. If an unvaccinated person were infected, the spread of the disease is easily contained because there are less vectors of transmission, preventing an endemic. But if we decrease the percent of vaccinated people in the population, there is a tipping point where herd immunity not longer exsist; At this point, if a person were infected, there’s not enough vaccine people to contain the spread which would result in worldwide panic and tumult.

Unless they have known allergic reactions to the vaccines, ideally all infants should be vaccinated not only for their own health but also for the health of their family and society. But I still believe that people have the right to choose if they want a vaccine or not based on religious, cultural or personal reasons.

I think one of the reasons why people don’t want vaccine is because they really know about the diseases they prevent. If they don’t know the full extent of the problems the lack of vaccines would cause, they can’t possibly see how the benefits outweighs the consequences. The public needs to be educated of the time when there was no vaccines, the time when small pox probably killed one or more person in your family, and the jubilant time when the vaccine for smallpox was distributed. People take vaccines for granted now because they just don’t know what the world would look like without them (and it would probably be a scary world due to the higher transmission rates caused by modern transportation and connections).  Though, I believe in time most people will see how the benefits of vaccines greatly outweigh the consequences just as how most people now see that the earth revolves around the sun rather than the inverse.

Saturday, February 9, 2013

The Smoker's Wife

In Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan, a paper published in the British Medical Journal in 1981, Dr. Hirayama set up an observational study to see if second hand smoking is related to lung cancer. From 1966 to 1979 (14 years), Dr. Hirayama tracked the prevalence of lung cancer in 91,540 non smoking wives aged 40 and above. He categories the smokers (and non smokers) into groups of different amounts of cigarettes and compares the prevalence of lung cancer in the wives of these smokers between these different categories of cigarette usage. With a p value of 0.00097, Dr. Hirayama concludes that the wives of smokers have a statistically significant higher risk of lung cancer than the wives of non-smokers do; sequentially, he reports that, although not as much as first hand smoking, second hand smoking causes lung cancer.

In the way and manner this paper is written, finding out that second hand smoking can cause harm seems to be shocking and somewhat cutting edge. This study probably reached headlines and causes many a smoker to quit on behalf of the health of their loved ones; this, of course, is a good thing because it most likely reduced the number of smokers in the world, decreasing the potential years of life lost globally. On top of that, companies can produce and develop alternative methods for nicotine addict to get their fill of nicotine without lighting up and causing second hand smoke (which I think could have stimulated the economy).

Of course in order to include so many subjects in the study, Dr. Hirayama had to do an observational study. He couldn't, with relative ease, create a true experimental study. Doing an observational study would have been the best choice economically and logistically.

But the main problem of doing an observational study is that there are many more variable which are not controlled which causes the association to not immediately mean causation.If we look at Hill Criteria for causation, all the criteria checks out (strength of association, consistency of association, high number of subjects). Just like the study that concluded that coffee caused pancreatic cancer with a significantly low p value (when it was really caused by tobacco), the association found in this study may be cause by a confounding factor(s). For example, husbands who smoke may be more depressed, and this depression is shared with the wives, which in turn causes a pathway that leads to lung cancer; or perhaps, smoking husbands have less disposable income, so the wives are more stress in the accounting department, which causes lung cancer. I do believe that that second hand smoke causing lung cancer seems to have a logical biological pathway, but there could still be a middle man factor that is the actually cause of lung cancer.

In any case, it may be better for wives, kids, husbands to reduce cigarette consumption for their own and the health of other. If needed be, those who really needs the buzz or effects from nicotine have many alternatives to cigarette to chose from nowadays; There are electronic cigarettes, nicotine patches, and gums. Of course they are relatively new and the long term effects of using them are not known yet, but, without a doubt, they don't produce second hand smoke that causes harm to people other than the user.

Saturday, February 2, 2013

Binge Drinking Among Women and High School Girls

             Binge Drinking is a problem among the women of America. According to the Morbidity and Mortality Weekly Report, excessive consumption of alcohol in women is accounted for "an estimated average of 23000 deaths and 633000 years of potential life lost among women and girls in the United States each year."  Citing the BRFSS survey, the report found that 12.5% of women aged above 18 binge drink. Women tend of binge drink less as they age(24.2% for 18-24 year olds and 2.5% for over 65 year olds); more educated women had a higher prevalence of binge drinking (14.1% of college graduates) compared to women with less education(8.5% of high school dropouts); women with higher income levels(16.0% in >$75,000) binge drink more than their lower income subjects (11.4% in <$25,000). One alarming data point is that 19.8% of high school girls binge drinks.

This is a problem because underage drinking may cause irreparable damage to the girls’ body and growth. The report also points out that alcohol consumption by high school girls is "strongly correlated with alcohol consumption by adults.” Explanations for this correlation include the youths’ desire to be like “the adults”, cultural factors, and new alcoholic beverages marketed to appeal to underage girl among others. Regardless of what it is, reducing the prevalence of binge drinking in adults may reduce that of underage girls, safeguarding their health.

The worst part is that the numbers that we have on the prevalence of binge drinking are all voluntary surveys and suffer from reporting bias. Those who indulge in binge drinking may report that they do not if they agreed take the survey at all (because of negative stereotypes of alcoholics). This survey then omits a lot of binge drinkers and under-reports the prevalence of binge drinking in women, meaning that there is actually a higher prevalence of binge drinking than the survey may show.

The trends between binge drinking and age, income and education level are not too surprising. Older women binge drink less because they are more mature; women with higher income binge drink because they can afford to do so; more educated women binge drink more because they are more stressed. However, I find the high prevalence (37.9%) of alcohol consumption among high school girls to be surprising. It really shows that the drinking age and the reinforcement of it is not very effective.

If we can lower alcohol consumption and prevalence of binge drinking in adult women, we would also reduce that of high school girls. Increasing the drinking age won’t do anything but cause inconveniences and a lot of opposition from the public. Lowering the drinking age allows easier access to alcohol (which makes a lot of people happy but doesn't solve the problem at hand). Limiting the amount of alcohol supplied or increasing the tax on alcohol in the market will without a doubt lower sales and reduce consumption, but it would result in dead weight loss in the alcohol market (economically undesirable). The best way to reduce alcohol consumption would be to educate the public of the dangers of alcohol overconsumption and the joys and merits of moderation. On top of that, the public need to suppress the popular media’s implication that getting wasted or passed out drunk is the hip and cool thing to do.