Healthcare

I just received an email drawing the (far from original) comparison between terrorism and cancer. It struck me that, to make this metaphor exact we’d need

* attacks on cancer researchers for seeking to ‘understand’ cancer

* even more attacks on anyone trying to find ‘root causes’ for cancer in the environment, such as exposure to tobacco smoke

* lengthy pieces pointing out that the only thing we need to know about cancer cells is that they are malignant

* more lengthy pieces pointing out that criticism of any kind of quack remedy marks the critic as “objectively pro-cancer”

I guess Steven Milloy and other “junk science” types come pretty close to providing the first two. Has anyone seen examples of the third and fourth?

I’ve been meaning to post on the issue of abortion and the European Union. Not to discuss the substantive merits of the case — I’m pro-choice, since you ask — but, rather, to get some reactions. The Portuguese constitutional court has now decided to block a referendum to liberalize the law until September 2006. Naturally, I hope that the referendum, when it is eventually held, produces a majority in favour of reform. But I got to thinking about how outrageous it would be if the EU centrally, or the ECHR, decided what the law in Portugal should be rather than the Portuguese people themselves. It seems, though, that not everyone agrees with me :

bq. Finding ways to force countries such as Ireland, Portugal and Malta to liberalise their abortion laws was the focus of a meeting of 17 members of the European Parliament and representatives of various NGOs who gathered in Brussels on 18 October, LifeSiteNews reported.

bq. At a conference entitled, Abortion – Making it a right for all women in the EU, attendees heard testimony from abortion advocates from countries with restrictive abortion laws.

bq. Held at the European Parliament building, participants strategised about ways to make a right to abortion mandatory for all member states of the European Union. They discussed ways of arguing that guaranteeing the right to abortion falls under the European Union’s mandate because it is a human rights and public health issue.

The EU isn’t structually similar to the US (despite what some commenters at CT appear to believe), but there are obvious parallels here to the Roe v. Wade issue. Personally, I think that the right of a demos to decide these things after intelligent public debate should not be sacrificed lightly in favour of empowering a bunch of (foreign) judges, just to get the substantive result one likes. I would also imagine that if the EU starts to impose a view then that will have very damaging effects on the cohesion of the Union. But I’d be interested to get the views of others.

Jamie Love has an FT op-ed with an interesting suggestion (behind paywall) about solving the incentive problems for anti-flu drugs and similar.

bq. The proposal is to permit governments to acquire medicines freely for stockpiles from generic suppliers, on the condition that if the medicines were used to treat people, the patent owner would receive royalties. This makes it much cheaper to acquire the stockpiles, but also increases the value of the ­patented invention, as long as there is some probability that the emergency use will occur. The price of medicines is related to their expected benefit. But this assumes a nearly 100 per cent probability that someone will actually use them. In the case of stockpiles, on the other hand, there is often a fairly low probability of use. Indeed, the lower the risk of the emergency, the lower the expected benefit of the stockpile. As long as the prices for the medicines are above marginal costs and the ­patent owner insists on a price related to the price of the drug when used, stockpiles will be small. But if governments could freely obtain stockpiles at marginal costs, with only a liability to remunerate the patent owner in the event of use, the incentives to match costs and benefits will be far more efficient.

bq. The amount of royalties to pay in such a system should be generous for higher income countries and much smaller for countries with poor populations. As noted, this works best when the medicine has a parallel commercial market for non-emergency uses. For those drugs that would only have a market in the case of an emergency, such as an anthrax or small pox vaccine, the liability rule could also be used, but in combination with other incentives, such as the medical innovation prize fund approach now being considered in the US, which provides for large cash rewards for developers of new drugs.

I can’t see any very obvious problems with this suggestion – it seems to provide an excellent means of addressing short term crises while solving the problem of long term incentives. Any disagreement?

(slight revisions following comments).

Today’s Guardian has this :

bq. Doctors today called for a change in the law so that graduate medical students do not have to pay fees of up to £3,000 a year upfront.

Which to my mind sits somewhat ill with this :

bq. Accountants believe average GP pay will burst through the £100,000 barrier this financial year for the first time.

Just to emphasise, that’s _average_ GP pay.

The Woodrow Wilson School at Princeton has launched a new initiative to make available audio and video recordings of academic lectures and events. For now, the University Channel is focusing on public and international affairs, because, as the site claims, “this is an area which lends itself most naturally to a many-sided discussion”. Perhaps the idea is to have people link to the material on the site and then host discussions on their own blogs or classrooms as I do not see a place for the suggested “many-sided discussion” on the UC site itself. The scope of materials that will be included seems quite broad judging from what is already available (IT, religion, politics, etc.).

It is certainly nice to have one central repository of such materials. If the project succeeds in getting lots of places on board and hosting material from all over then it has the potential to be a great service. In fact, the collaborators it already has lined up are already a good sign of its potential. (Then again, some people have suggested [see first comment] that “text is the only useful information on the Internet”.;)

Kelly Bedard and Olivier Deschênes have an article forthcoming in the _American Economic Review_ providing strong statistical evidence that service in the US military is bad for your health – but not (only) for the obvious reasons. Even apart from combat mortality, old soldiers tend to die younger; 2 million veterans from the 1920-1939 cohort (generation) died prematurely. The effects of this, measured in terms of “years of potential life lost,” were roughly as bad as those of the total number of combat deaths in World War II and the Korean War combined. Why so many dead? The authors’ evidence points to one key factor: smoking. During World War II and the Korean war, soldiers were issued cigarette rations, and could buy more cigarettes at subsidized prices. Tobacco companies donated cigarettes to the troops, in part so that soldiers would get hooked on their product, building a long term customer base. Excess veteran mortality after the age of 40 is most pronounced for lung cancer and heart disease, both of which are strongly linked to smoking. Bedard and Deschênes calculate that 36-79% of the excess veteran deaths through lung cancer and heart disease can be attributed to military-induced smoking for veterans from World War II and Korea. The military no longer supplies cigarettes to soldiers as part of their rations. However, tobacco products continue to be sold at subsidized prices at army base PXes. As Bedard and Deschênes argue, this is very bad policy indeed.

(thanks to Erik for the link).

Yesterday, the Pew Internet and American Life Project released its latest research report, this one on health information-seeking online. The study finds that 80% of users have searched for some type of health information online (it’s worth noting here that “health information” is defined broadly by including searches for diet and exercise or fitness in this category). Regarding material pertaining to a specific disease or medical problem, the survey of 537 users found that two-thirds have used the Internet as a resource.

One of the topics of interest to me in my research is seeing how different types of Internet access may result in different types of Web uses. The report shows that while 87% of those with a broadband connection at home sought some health information online, only 72% of those with a home dial-up connection did so as well. Also, Internet veterans (in this case people who’ve been online for six or more years) are considerably more likely to have engaged in such activity (86%) than those who have 2-3 years of online experience (66%).

Of course, we would need more information about all these users to draw any conclusions regarding the independent effects of certain factors. People who went online later and who don’t have high-speed connections at home may differ from others in various ways (e.g. lower income, lower education), which may then be related to their propensity to search for health information in the first place. Nonetheless, these relationships are interesting to observe. They support my arguments about the potential implications of connectivity quality and experience for types of uses.

The author of the report is Susannah Fox, Pew’s resident expert on the topic. She has been working in this area for several years and has put out other related reports in the past, e.g. one dealing with prescription drugs online and another looking at how users decide whether to trust online information when it comes to health matters.

A sad story in the Times today about a woman from Limerick who died following a facelift at the hands of a self-promoting New York surgeon:

Mrs. Cregan had left her home in rural Ireland two days before, telling her husband, a farmer and part-time plumber, that she would be attending a business course in Dublin. In fact she had flown to the United States to have a face-lift performed by Dr. Michael E. Sachs in his offices on Central Park South. Hours after surgery she went into cardiac arrest and was rushed to the hospital. … Examining Mrs. Cregan’s knapsack after her death, her family found a folded copy of an article from The Sunday Independent of Ireland. It was a glowing account of a face-lift performed by Dr. Sachs, “a leading cosmetic and facial reconstruction surgeon” in the United States, the article said, with a “highly confidential client list.”

Sachs appears to have drummed up interest in Ireland via a story in the Sunday Indo Magazine about a facelift he performed on an Irish woman for free, in exchange for the publicity. Sachs seems like a dodgy character:

Dr. Sachs is among the most sued doctors in New York State, having settled 33 malpractice suits since 1995 … last year the State Health Department took the extraordinary step of banning Dr. Sachs – an ear, nose and throat specialist – from performing complex nasal surgeries without the supervision of another surgeon; … the operating room in his office is not accredited … [and] while he states on his Web site that he has been affiliated with the New York Eye and Ear Infirmary “for the last 23 years,” he is not affiliated with that hospital or any other.

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You take your kid to the specialist to talk about persistent symptom x and he says, “Well it’s probably harmless thing A, or maybe harmless thing B. And there’s a very small chance it’s the horrible and ultimately fatal genetic disorder C.”

If I were rational, this conversation would not have upset me as much as it did.

_Update:_ Given all the parents in the world who really do have serious child-health problems to deal with, and worse besides, I now feel ashamed for even bringing this extremely remote possibility of bad luck up here. It wasn’t even meant to be the point of the post, just a springboard for an observation. Don’t be surprised if the post disappears altogether soon, having died of embarassment.

Avian flu sounds pretty nasty, and a pandemic would be a disaster. But John Sutherland, writing in the Guardian , is in the grip of statistical confusion when he asserts that it could kill 70 per cent of the population. As I understand it, the virus kills 7 out of 10 people that it infects, and the number infected is far below 100 per cent. Moreover, the 7 out of 10 figure may well be an exaggeration, since people who recover and don’t die are less likely to be be included in the figures than those who do. The WHO impact assessment isn’t encouraging (2 to 50 million dead, but could it be worse than that). I’m sure we have some epidemiologists among our readers. Any thoughts?

Kash on the comparative waits for health care services in Western democracies.

Washington Monthly’s piece about VHA hospitals.

The New Yorker’s excellent medical writer Atul Gawande on how a doctor is paid.

I’m going to be writing about what deregulation of health care might mean¹, but I think that I’ll end up coming back to how an American doctor gets paid by insurance companies². This is not the best way, or the only possible way, but it’s where we’re starting from. From the New Yorker article:

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Everyone else is talking about health care this week, so here’s a reprise of an old post of mine. Below is a figure showing the relationship between the “Publicness” of the health system and the amount spent on health care per person per year. Data points are each country’s mean score on these measures for the years 1990 to 2001.

You can also get a nicer PDF version of this figure. As you can see, health care in other advanced capitalist democracies is typically twice as public and half as expensive as the United States.

When I posted this before, I made the mistake of not emphasizing a key point: these data *do not include* any health-related Research and Development spending, so it’s not the case that the U.S. is way up in the top left simply because it’s generously subsidizing everyone else’s research costs.

The figure doesn’t show it, but it’s worth noting that despite not having a national health system, U.S. public expenditure on health in the 1990s was higher in terms of GDP than in Ireland, Switzerland, Spain, Austria, Japan, Australia and Britain.

It’s easy to see that mainstream debate about health care in the U.S. happens inside a self-contained bubble, and that one of its main conservative tropes — the inevitable expense and inefficiency of some kind of universal health care system — is wholly divorced from the data.

When the world was young, I wrote a long post about single-payer health care. As it’s the new hot topic, I’ve reposted it under the fold. Enjoy, or don’t.

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I wish I could have been a fly on the wall for this Reason party. Matt Welch:

What I still can’t understand, is how anyone — seriously, anyone — can think a system where it is extremely difficult for a perfectly healthy young person untethered to an insurance-providing job to obtain health insurance without lying, or without giving up the possibility of having childbirth covered, is a good system…

What I understand even less is how some of these same people will tell you with a straight face how terrible French health care is. Last Thursday-thru-Saturday, we spent a really wonderful time at “Reason Weekend,” which is what my employer does in lieu of a celebrity booze cruise. It’s a great event, filled with smart donors to the Reason Foundation, various trustees, and a few people from the magazine. Great speakers, panels, walks on the beach, etc. Anyway, we had some small discussion group about De Tocqueville, and someone (naturally) brought up France’s high taxes and thick welfare state. “Well, the thing is,” Emmanuelle said (quotes are inexact), “some of the things the French state provides are pretty good. For instance health care.”

“Wait a minute wait a minute,” one guy said. “If you were sick — I mean, really sick — where would you rather be? France or the U.S.?”

“Um, France,” we both said.

Various sputtering ensued. What about the terrible waiting lists? (There really aren’t any.) The shoddy quality? (It’s actually quite good.) Finally, to deflect the conversation away, I said “Look, if we made twice as much money, we’d probably prefer American health care for a severe crisis. But we don’t, so we don’t.”