Healthcare

Discussion is perking along in my McArdle on rationing thread. For the record: she articulates her general case against national health care here, then follows up here. I think it all adds up to a nice illustration of the point I was making in this post (I wish I had made it more clearly, to judge from comments.) McArdle’s opposition to national healthcare is based entirely on slippery slope arguments, arguments from unintended consequences, and suspicions that those who are proposing national health care really want different things than they say they do. Now, this is reasonable. But only up to a point. Because at some point we need something more, but McArdle is quite strident in her insistence that what she has said is enough.

What does she leave out? Arguing only in the ways she does leaves it unclear what she would think about national health care reform if it worked. And the reason it is important to know that is that we really have to know what McArdle’s values really are – her ideals. Let me show how it goes. [click to continue…]

I’m not writing about the debates over health insurance (as, indeed, I am not writing about most policy debates), because I simply don’t think I’m informed enough to say anything very useful about the pros and cons of the specific options under discussion. Still, this by Alex Tabarrok struck me as a bit odd. [click to continue…]

As governments and the WHO wrestle with the decision on whether to divert resources from the production of seasonal flu vaccines to develop a vaccine against H1NI (swine) flu, I thought I’d repost this piece from 2005, suggesting an expansion of vaccination against seasonal flu, in part to expand production capacity to prepare for problems like this.

Thinking a little more, and with the idea of global public goods in mind, it seems obviously in the enlightened self-interest of developed countries to go beyond domestic vaccination programs and contribute both vaccine supplies and organisational resources to encourage routine vaccination in poor countries, as well as ensuring a further expansion of production capacity.

The same goes, I think, for more extensive use of antivirals like Tamiflu, which apparently have the nice property that the flu virus does not develop resistance to them.

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Donated Kidney is Center of Divorce Dispute:

A Long Island doctor is demanding that his estranged wife give him back the kidney he donated to her seven years ago. Dr. Richard Batista’s lawyer Dominic Barbara says his client would also be satisfied with the value of the kidney: $1.5 million. Newsday reports that Batista married wife Dawnell in 1990 and that he donated the kidney in 2001. According to Batista, their marriage was on the rocks then, but “My first priority was to save her life. The second bonus was to turn the marriage around.” Dawnell Batista filed for divorce in 2005. Dr. Batista told WCBS 880, “She had an affair, then would not reconcile, then handed me divorce papers as I was going into surgery trying to save another person’s life.

All in all the very archetype of a wacky organ donation story, right down to the mandatory quote from Arthur Caplan.

The responses to my recent post about Breast Cancer Awareness Month were interesting. One commenter suggested that instead of addressing specific issues or charities, it would be better to “focus our energy on political action for good national health insurance“. I’ve seen this argument made before, specifically about breast cancer awareness. While you certainly won’t get any arguments from me against better health insurance (I hate hate hate hate the system in the US and I’m among the privileged who at least has health insurance), I’m not convinced that that’s the only issue at hand when it comes to achieving adequate levels of awareness and preventive care.

First, should we give up on incremental action in other realms until the overall health care system gets figured out? Second, even if we do achieve major gains on that front, will that really take care of all associated concerns? Unlikely. One way to approach this is to see whether people in countries that have good universal health care are all educated about various illnesses and preventive measures. The answer is likely no, which suggests that there is room for awareness campaigns. [click to continue…]

I was talking to my Dad last week and he reminded me that it was seven years ago that day that my Mom had been diagnosed with breast cancer. Until then, I’d never made the connection between that event and the fact that October is breast cancer awareness month. As if there hadn’t been enough going on three weeks after 9/11, I now certainly had plenty to keep me up at night. Fast forward seven years and things are going well with my Mom. Although she’s never fully regained all of her energy since the treatments, overall she is back to being herself and has been for years now.

When all this came about, I was very grateful for having spent so many years in the US and how illness (or at least some types by now) is treated here versus many other countries, like Hungary, where my Mom’s diagnosis occurred. In too many cultures and communities, illness of all kinds remains a taboo. Not only is it not okay to tell people about it, often doctors won’t even tell patients their diagnosis. While awareness programs may seem superfluous to some*, it is important to remember that in many communities it is not only not the standard to talk and think about illnesses (and thus, for example, take preventive measures when possible), but it is a topic to be avoided outright due to associated embarrassment.

What struck me as I was talking to friends about my mother’s situation was how many among them had a close family member or friend who’d also had breast cancer. It was very helpful to hear about related experiences. But were it a taboo to discuss issues of this sort, I would have been left on my own to deal with the difficult news. Point being, there is value in talking about things of this sort at various levels: from contributing to prevention efforts to the emotional support that can come of it.

Recently, I received some notices about interesting pink-themed undertakings going on right now. One is a Pink group on the photo-sharing site Flickr that seems to be raising money for breast cancer awareness in various European countries. Another is an innovative idea by sociologist Dan Myers who has decided to wear pink every day for the month of October to raise awareness and collect donations. Support him if you can.

Of course, there are serious critical ways of looking at the pink ribbon campaign. For a couple of years now, I’ve had the book Pink Ribbons, Inc. on my book shelf, but haven’t gotten around to it yet. Has anyone read it?

I’ve been thinking about a way to contribute to these efforts myself this year and I have an idea. I’m putting some finishing touches on it. I’ll post about it in a bit.

[*] A few months after my Mom’s diagnosis, I still remember that there was an article in The Daily Princetonian making fun of the ribbon campaign. Like I have done above, a response to that piece tried to explain why these do serve a purpose.

This blog post is a shameless plug for a friend’s book. But I wouldn’t be writing it if I didn’t believe that the book is a tremendous achievement, as well as being a very moving personal document. Havi Carel's Illness: The Cry of the Flesh (UK link ) is published tomorrow by Acumen. It is a philosophical meditation on the nature of and social meaning illness, disease and death. It discusses philosophical and psychological literature, Epicurus, Heidegger and Merleau-Ponty. But it is also a personal memoir, it is about Havi’s experience of being diagnosed with a life-threatening illness, about what that meant for her presence in the world, about how she appeared in the eyes of others, and how she felt she appeared. It is about the encounter with medical professionals and their detached and external perspective on another’s catastrophe; it is about the varied reactions of friends, some of whom couldn’t maintain friendship. It is about how to confront the fact that all your assumptions about how your life is going to go: career, relationships, family, old age, can just be taken away. Havi was diagnosed with lymphangioleiomyomatosis (LAM), a rare disease that affects young women, and for which the progosis is about 10 years from the onset of symptoms. The sufferer experiences a progressive decline in lung-function over that time. Life may be extended by a heart-lung transplant, but that’s, obviously, a difficult business.
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Oh how times change! I rather doubt that a piece of 1958 research on how children behave when locked in fridges would make it past a modern university ethics committee!

bq. Using a specially designed enclosure, 201 children 2 to 5 years of age took part in tests in which six devices were used, including two developed in the course of this experiment as the result of observation of behavior. Success in escaping was dependent on the device, a child’s age and size and his behavior. It was also influenced by the educational level of the parents, a higher rate of success being associated with fewer years of education attained by mother and father combined. Three major types of behavior were observed: (1) inaction, with no effort or only slight effort to get out (24%); (2) purposeful effort to escape (39%); (3) violent action both directed toward escape and undirected (37%). Some of the children made no outcry (6% of the 2-year-olds and 50% of the 5-year-olds). Not all children pushed. When tested with devices where pushing was appropriate, 61% used this technique. Some children had curious twisting and twining movements of the fingers or clenching of the hands. When presented with a gadget that could be grasped, some (18%) pulled, a few (9%) pushed, but 40% tried to turn it like a doorknob. Time of confinement in the enclosure was short for most children. Three-fourths released themselves or were released in less than 3 minutes; one-fourth in less than 10 seconds. Of those who let themselves out, one-half did so in less than 10 seconds. One-third of the children emerged unruffled, about half were upset but could be comforted easily, and a small group (11%) required some help to become calm.

I’ll bet they did.

H/t Zoe D.

Martin O’Neill has a characteristically interesting piece in the New Statesman, this time on QALYs (Quality Adjusted Life Years) and their role in the National Health Service decision to provide or deny expensive drugs to patients. Read the whole thing, as they say.

I had one quibble with Martin’s analysis. He writes:

bq. Littlejohns [the clinical director of NICE] has released a preliminary ruling, denying access to the drugs Sutent, Avastin, Nexavar and Torisel to patients with advanced metastatic kidney cancer. These patients will, on average, die months earlier than those with the same condition in other countries in Europe where such drugs are available.

But then later in the same piece:

bq. … if such decisions are made locally rather than nationally, we are thrown into the familiar problems of the ‘post-code lottery’. A patient in Nottingham may find herself denied treatment that is provided to someone in Newcastle. Allowing matters of life and death to depend on the good or bad luck of geographical location seems like the very opposite of finding justifiable policies.

Hmm. So in the first-quoted paragraph, Martin presents the supra-national geographical variation as a troubling datum, to which the adoption of a sensible national drug-evaulation policy is a response, whereas in the second, he presents sub-national geographical variation as a decisive reason for rejecting local discretion. But why not say that local variation is OK, just so long as it is backed up by good reasons, or, alternatively, that we should have European (or even global) standards that treat like cases alike?

… and, increasingly, fat British too.

For Europeans, one of the really disconcerting things about visiting the United States is the size of the meals. Ok, there’s the phenomenon that the restaurant staff will let you take home what you don’t or can’t eat (and that’s an idea that many Europeans feel uncomfortable with), but there’s still the fact of the sheer volume of stuff that gets put on your plate. It seems it wasn’t always this way. Via someone in my del.icio.us network, I came across this article on how portion sizes have changed in the US over the past twenty years. And not only are American meals bulkier, they’ve also increased two or three times in calorific value. That can’t be good.

Nancy Folbre, who is widely considered to be one of the most knowledgeable economists on issues of care work, has recently started a new blog, called Care Talk. It’s a research blog that aims to bring together interdisciplinary insights on issues of care — child care, care issues related to primary education, elder care, care for disabled, and health care. Care is a neglected issue in several disciplines and subdisciplines, including economics and political philosophy, and I can only applaud this initiative. I hope that this will become a genuine international blog — much can be learnt from looking at how care work is organised and divided in other countries.

Folbre published earlier this year her new book Valuing Children which I have here on my desk. I promise our readers a review of that book sometime in June.

The BBC has a feature on my friend, the philosopher Havi Carel, and the way in which philosophy has helped her come to terms with the diagnosis of an incurable disease. Havi has a book _Illness_ (US, UK) forthcoming in September, in which she draws on her own experience and tries to give a philosophical account of the meaning and significance of illness.

A kind reader alerted me to an article in last Sunday’s Guardian, on the proposal by the Conservative Party to introduce the Dutch system of Kraamzorg in the UK. As I briefly mentioned in an earlier post, under this system a qualified maternity nurse cares for mother and the newborn child at home in the first week after the birth.

The article gives a fair account of what these nurses do, and of the advantages of this system. Yet I’m surprised by the claim that the system would be too expensive to be introduced. Of course the question is ‘expensive in comparison with what’. In the Netherlands, one reason why mothers who give birth leave the hospital so quickly after the delivery (if they go to the hospital at all, that is), is the cost; a maternity nurse at home is much cheaper than the cost of keeping mother and child in hospital (as is the case in Belgium, for example). I don’t know what the kind of care is that is currently provided to newborns and their mothers in the UK – yet it is self-evident that if the comparison is made with no care for the newborn and mother at all, then the system is relatively expensive. But how under a system of no care at all the mothers can take the rest that they need is a mystery to me. The days that this could be provided by family members are, for most of us, long gone. Hence not a bad plan from the Tories, if you ask me.

There’s a long-standing urban legend about where you meet an attractive person in a bar, they buy you a drink, and the next thing you know you wake up in a bath of ice with a pain in your lower back and a note telling you to get to a hospital. One of the reasons this story is just a story is that in order to usefully extract someone’s kidney for transplant, a whole lot of stuff has to be organized beforehand, and you need to have a lot of skilled people working together against a hard time constraint — too many, really, to quietly and reliably pull something like this off.

On the other hand:

Mr. Mohammed was the last of about 500 Indians whose kidneys were removed by a team of doctors running an illegal transplant operation, supplying kidneys to rich Indians and foreigners, police officials said. A few hours after his operation last Thursday, the police raided the clinic and moved him to a government hospital. … Many of the donors were day laborers, like Mr. Mohammed, picked up from the streets with the offer of work, driven to a well-equipped private clinic, and duped or forced at gunpoint to undergo operations. Others were bicycle rickshaw drivers and impoverished farmers who were persuaded to sell their organs, which is illegal in India.

Although several kidney rings have been exposed in India in recent years, the police said the scale of this one was unprecedented. Four doctors, five nurses, 20 paramedics, three private hospitals, 10 pathology clinics and five diagnostic centers were involved, Mohinder Lal, the police officer in charge of the investigation, said. “We suspect around 400 or 500 kidney transplants were done by these doctors over the last nine years,” said Mr. Lal, the Gurgaon police commissioner.

I’d be interested to see how many suppliers were straightforwardly lied to about what they were getting into, or otherwise forced to undergo operations, and how many were offered money first (and paid afterwards). Unlike some other documented cases of organ sales, this seems less like an illegal but functioning market and more like a criminal racket founded on fraud.