Friday, May 29, 2009

The business of news

When I was growing up in the 1970s (yes, in fact it was last century, thank you very much), news was different. And I do not think that this is just the everything-was-better-in-my-day nostalgia. News was about news. News was not sexy (heck, newspeople were not sexy!). What has happened to the news? Well, if you have read Robert Reich's Supercapitalism, the answer is obvious to you: competition. Interestingly, economic theories suggest that competition is good for the consumer -- it drives quality up and prices down. That may be true for toilet paper (although even here I am not sure this idea has held water), but it has not panned out for such consumables as news and healthcare. Instead, what happens is that all of the market moves in the same direction, applying the same strategies and tactics to maximizing value to their investors. By definition, a high bottom line comes from only two sources: low expenditures or high returns, and preferably both. Since commercial news channels are supported through advertising, their market share of our eye ball and ear time are critical to investor value. Thus, the slippery slope to the lowest common denominator (here we go again with the denominators). 

With the advent of constant news the competition for market share became far stiffer than we could have ever imagined in the 1970s. In order to distinguish one Constant Chatter Channel from another, marketing ideas had to be applied; and they were. The anchors are now for the most part younger, prettier and more friendly-appearing than in the days of yore. They keep us glued to the screens with a constant barrage of headlines and sound bites designed to tantalize, terrify and titillate, and ultimately sell more products: hospital services, safer (gas guzzling) cars, home alarm systems, etc., to keep us wrapped in a cocoon of comfort and ignorance.

It is interesting to think of our healthcare system in this context as well. A mammoth enterprise generating staggering returns for many involved (this includes some physicians, academic researchers, manufacturers, insurers, and, yes, investors), it has not promoted health, but disease maintenance. Why is this? Well the simple answer is that health does not generate income, disease does. And furthermore, think of the economic consequences of cleaning up such promoters of disease as tobacco, certain forms of pollution, as well as the way we produce food... In fact, think of the financial and thus political muscle behind these industries, a Goliath that can easily stamp out any grass-roots efforts to set disease prevention agenda. Add into the mix the at once frightened and phlegmatic populace expecting to be entertained by the news, and how we got here becomes obvious. The less obvious issue is how we move out of this morass of mis-information. 

As I have already mentioned, I do not believe that premeditated evil is a common human practice. In fact, I have to conclude that our slide into the current situation is a result of chaos. Further, it is a result of the unopposed stakeholders with too much to lose and thus too many personal agendas. The healthcare system has been like a symphony orchestra without a conductor -- each excellent musician making excellent individual music with the end-result of painful cacophony. If you buy my theory, then you much agree that it is disingenuous for us to maintain that the government does not belong in this discussion. We must think of our elected officials as a political group that represents precisely the interests of the populace, and thus balances out all of the other voices at the table. 

I do not hold out much hope for the business of news -- after all, keeping us informed is the job of serious news outlets like the New York Times, the Wall Street Journal and the BBC. And since these alternatives are still widely available, I personally do not care what others do -- these are the choices that we still have in America. As for the healthcare system, we must hold our politicians responsible for representing our interests and stopping this disease juggernaut in favor of promoting a healthy society.  

Saturday, May 23, 2009

Whom are we killing?

We are a society obsessed. Everywhere we go, there are soaps and detergents with antibacterial agents in them. Some of our food is irradiated to kill micro-organisms. Our milk is ultra-pasteurized in the name of sanitation. At the first sign of the sniffles, our healthcare providers eagerly prescribe antibiotics that today can cleanse your native flora with great efficiency. Our food animals, which are raised on factory farms in conditions that should be considered torture, are given antibiotics routinely, so as to prevent disease from galloping through their overcrowded quarters. Because of all these measures we are healthier today than ever before, right?

Well, not exactly. As a nation, our health is in the bottom third of all of the developed countries in the world. Despite the most expensive healthcare system on Earth, we have the biggest problems with access, and the quality of the product when we do access it is not that great. But aside from that, all this cleanliness has made a positive difference, of course... Well, no again! Some scientists think that our over-sanitized life style has contributed to the escalating rates of asthma and other allergic conditions. We know for certain that overuse of antibiotics is responsible for creating a cadre of superbugs that threaten to bring us back to pre-antibiotic era (if you don't believe me, just check out the FDA and the WHO web sites). The use of antibiotics in animal production (incidentally responsible for roughly 70% of all antibiotics utilized in this country) has not stemmed the tide of food-borne outbreaks, and has likely contributed to antimicrobial resistance that is affecting the human population. And yet, even healthcare providers by and large have bought into the benefits of sterilizing everything.

A small handful of scientists and authors are working hard to debunk this myth. The Union of Concerned Scientists, the Infectious Diseases Society of America, the Alliance for the Prudent Use of Antibiotics are just a few organizations struggling to bring the issue of antimicrobial agent overuse to the forefront of the political and legislative arena. Books by Michael Pollan and Barbara Kingsolver are raising awareness among lay public and driving the interest in returning to more humane and sustainable approaches to food production.

We as consumers must take matters into our hands. We can vote with our feet when it comes to what foods we choose to purchase and where. Locally produced whole foods are as a rule better for you, your family and the environment than foods grown thousands of miles away in dubious conditions. If your doctor urges you to take antibiotics for a minor cough, just say "no" (unless there is a solid reason to think that you have a serious bacterial infection) -- you will be doing both yourself and the society a favor by limiting the opportunities for superbug development. Finally, in this technologically advanced age, there is still one very low-tech intervention that can make all the difference in disease prevention: soap and water, just like mom said.

Since bacteria have been on this Earth orders of magnitude longer than humans, and have had the chance to evolve reliable mechanisms to evade our assault on them, would it not be smarter for us to learn to live with the ones that do not cause disease peaceably instead of trying to decimate them? Although we seem to be killing them with drugs, heat and radiation, are we really killing them? Or are we creating a more resilient race that is able to do ever increasing amounts of harm to our species? 


Wednesday, May 13, 2009

Some thoughts about denominators

Let's face it: denominators keep numbers (and people reporting them) honest. Imagine if I said that there were 3,352 cases of a never-before-seen strain of flu in the US. To be sure, 3,352 cases is a large enough number to send us rushing to buy a respirator mask! But what if I put it slightly differently and said that out of the population of roughly 300,000,000 individuals, 3,352 have contracted this strain of flu. I think this makes things a little different, since it means that the risk of contracting this flu to date is about 1 in 100,000, a fairly low number as risks go. Now, I am going to give you another number -- 86. This represents the number of the novel H1N1 flu-related deaths in Mexico reported on April 25, 2009, by the health minister of Mexico, and at that time this flu had been thought to have sickened 1,400 people. This gives us the risk of death with the flu of roughly 6%, a very high risk indeed! Well, that was then. Now that we have all steadied our pulses, and the health authorities have gone back and done some testing, as of yesterday Mexico had confirmed 2,059, cases with 56 fatalities, equating to a 2.7% risk of dying with the disease. Still a high number, to be sure, but lower than what was though before.

In the US, we have had 3 fatalities among 3,352 cases reported as of yesterday, yielding the risk of death from H1N1 in this country of about 1 in 1,000. But, of course, the denominator of 3,352 persons represent only those who sought medical attention and got tested, so probably it is an underestimate of the true burden of this strain of flu, and necessarily also an over-estimate of its attendant mortality. Now, apply this to the situation in Mexico, and it's likely that the risk of death from H1N1 is also lower than what we have observed precisely due to the under-estimation of the denominator. 

So how could we get a true estimate of the numbers of people afflicted with the H1N1 influenza? Well, we could screen absolutely everyone (or more likely a large and representative group of individuals). Then what? Do we treat them all with anti-virals? Do we observe them? Since the Centers for Disease Control and Prevention recommends testing only severe cases and treating only persons at a high risk for complications, universal testing does not seem like a practical approach. So, the bottom line is that we are not likely ever to get at the correct denominator for the risk of dying with this disease, and any number that we get is likely to be an over-estimate of the true risk.

So, what are the lessons here? First, don't let anyone get away with only giving you the numerator, as that is not even a half of the story. Second, even when the denominator appears known, be skeptical -- does it really represent the entire pool of cases that are at risk for the event that the numerator describes? The likely answer will most of the time be "no". Clearly, it is the denominator that is the key to being an educated consumer of health information.

Tuesday, May 12, 2009

Writer's block

Here I am sitting at my computer trying to write a review on MRSA in the intensive care unit, and all of a sudden I cannot write -- everything is distracting me, I cannot figure out what I want to convey, or how I should structure the paper. This may well be a manifestation of information overload. When I type "MRSA" in the search engine PubMed, I get 12,214 hits! When I narrow it to "MRSA+ICU", it becomes a much more manageable, but probably not particularly comprehensive and still daunting 326. 

And herein lies the conundrum of evidence-based medicine: There are nearly 700,000 medical papers published annually, according to William Miser, MD, MA, who wrote that a clinician reading 2 articles per day in 1 year would fall over 9 centuries behind in his/her reading (Prim Care 2006;33:839-62)! Furthermore, the quality of these studies is far from uniformly good. So how does a busy clinician sift through this gargantuan amount of information in order to provide up-to-date care to their patients? Well, the answer is that some, probably more than any of us care to admit, don't; I call the type of medicine they practice the "15-years-of-experience-based practice". This is an insidiously dangerous type of practice, since from an early age we are taught to trust the greying temples and the confident and condescending demeanor. 

Unfortunately, the only recourse for us as patients is to be educated consumers of healthcare. Now, I am not implying that everyone needs to start reading the 700,000 studies that come out annually. I am not even implying that all of us need to follow the "breaking news" stories about health and disease; in fact, I would steer clear of those, since the sound-bite format lends itself to sensationalist half-truths. My view is that every patients needs to be empowered and unafraid to ask certain simple questions of their healthcare provider. "Why" is the most important question to ask (as in "Why do [that is what makes] you think I have this condition?" "Why are you ordering this test?"), followed by "What are the chances" (as in "What are the chances that the test will tell us what we need to know?" "What are the chances that the information from the test is trustworthy?" "What are the chances that the test will give us the wrong information and send us down the wrong path?"), finishing with "What actions will we take?" (that is, "What actions will we take based on the results of the test?" "What are the possible consequences [both positive and negative] of these actions, and what are the chances of each happening?") If we start with a somewhat skeptical attitude and expect to have our questions answered respectfully and completely, we may be able to weed out the up-to-date from the outdated experience. But that doesn't really help me with my writer's block, does it?

Monday, May 11, 2009

Too little too late?

The Washington post today reports that several stake holders in our healthcare system (the AMA, PhRMA, AHA, AHIP, to name a few) are meeting with President Obama today to discuss their commitment to cost-containment in healthcare (  Indeed, to someone who has been an observer of this area it seems a bit disingenuous, albeit a strategically obvious move. I don't know how many readers will remember the multi-million dollar campaign mounted by the same stake holders in the early 1990s during the Clinton administration against the then proposed overhaul of the system (the famous "Harry and Louise" ads were a part of this campaign). The idea was that introducing the kind of regulation into this industry would not only be un-American, but also might lead us onto the path of limited access and rationing.

Interestingly, this was not the first time in American history that a proposal to change how we deliver healthcare engendered such rhetoric. During the Truman administration, in mid-to-late 1940s, there was a strong movement afoot to reform medicine. Framed initially as "compulsory health insurance", it became better known as "socialized medicine", a moniker that to this day brings goose pimples to our necks along with the drab grey images of Communist demonstrations in the Red Square. That campaign was in fact so effective precisely because it implied that, should we pass such legislation, we would become either the Nazi Germany or the Communist Russia, the paragons of un-Americanism. With large amounts of money spent on effective advertising (a little known but affable and convincing actor by the name of Ronald Reagan was featured in many of the ads), the measure was gutted and forgotten until 1993, when similar tactics were once again employed by the opposition.

Now, with a strong Democratic leader in the White House, along with a near-veto-proof majority in Congress, and a staggering deficit, the former nay-sayers are eager for a place around the table. But is this enough? Are they hoping to replace legislative mandates with unenforceable commitments? To be sure, the issue is very complex. Many people and groups bring divergent agendas to the issue. And while I truly believe that there is no fundamentally evil intent to deceive the American people, we need to be wary of these agendas. Since the primary goal of a business is to make money, and since early in our history we chose to allow healthcare to fit a business paradigm, many of the stakeholders meeting with President Obama today will be looking out for their best interests (the AMA for the physicians, PhRMA for the pharmaceutical manufacturers, AHA for hospitals and AHIP for the insurance companies). On the other hand, since the healthcare industry is one of the major employers in this country, at least to some degree their interests overlap with those of the public as a potential engine of economic growth, a particularly relevant issue in this recession. 

So, the President and his team will be walking a tight rope in order to balance industry agenda with the interests of the American people. It would be easy to say that the current efforts of these industry groups are, in fact, too little too late. However, we have an accomplished politician in the White House, who seems to be able to negotiate important compromises without giving away the store. I am hopeful that Obama will make a good faith effort to work with these groups, and that this effort will result in strong legislative action that will create durable and enforceable regulations to ensure sustainable, equitable and high quality healthcare for all. 

Saturday, May 9, 2009

On trade-offs

Remember how your mom made you choose between a cookie and a piece of chocolate for dessert? Remember how shocked you were the first time it happened? "You mean I can't have both?" Now as an adult you stand in front of your closet packing for a trip and deciding between the brown loafers and the black heels, because surely you do not have room for both in your luggage.

Every day we make hundreds of choices, and by choosing one thing we are giving up something else. We mostly do this almost subconsciously (tea or coffee? paper or plastic? hot dog or hamburger?), though with some choices we need to think a little harder (vacation or a new roof?). On the other hand, some ostensibly simple decisions may have far-reaching consequences: should I take up smoking, should I watch TV instead of going for a walk, should I grab that greasy cheeseburger for lunch again?  

As citizens of a nation founded on self-determinism, we view the opportunity to make these choices as our inalienable  right. But with any right comes personal responsibility. Oddly, we seem to leave this right/responsibility doublet at the door when dealing with our health choices. Indeed, for many it is precisely the choice to have that cheeseburger while sitting in front of the TV or to pick up that cigarette or to put exercise at the bottom of the priorities list that leads to the logical trade-off between health and disease. But because the steps between that cigarette and heart attack are many, these choices, as if moves in a chess game, are removed from the check mate. Nevertheless, by picking up that cigarette, you have made a health trade-off.

Of course, today the medical science can pull us out of the abyss of near-death like never before. We have drugs and surgeries and other procedures to deal with the consequences of the choices we make. In fact, where is the trade-off in that? So, maybe mom was wrong (heavens!), and I can have both a cookie and a piece of chocolate? Not so fast. The treatments themselves represent a trade-off. That is, every time a pill or an injection or a scalpel invades your body, there is a chance for an adverse consequence. Also, we are now spending over 2 trillion US$ on healthcare annually in the US! And this represents that trade-off, that decision to have a cigarette. By choosing to smoke, we have implicitly decided that we would rather be spending all this money on healthcare rather than on, I don't know, a baseball game. Like with any budget, if you spend money on one, you may not be able to afford the other -- your choice!

So, unless we see no better way of spending our money than on the consequences of our near-sighted health choices, we had better make smarter decisions and think about trade-offs far down the road. And by the way, perhaps this means that we don't need a bigger and more costly healthcare system, but one that is more efficient. Who knows, perhaps we can provide everyone with access to quality healthcare that will not bankrupt our children. And with a piece of chocolate (or a cookie).   

Virgin blogger

Well, I have been contemplating starting a blog for some time, but was not sure how to approach it. Being a health services researcher, I obviously wanted to blog about healthcare in the US and elsewhere, but with so much already being written about it... well, what's the point? Nevertheless, I will try to take on some of the popular topics in the news and the literature and look at them from a different perspective, or devote some time to stuff that in my opinion is important, but is not getting the attention it deserves. That is, given that I have enough time to do this. And well.