The Bottom Buddy is a device which helps the morbidly obese wipe after using the bathroom. I’ll hold my tongue a bit except to say that it probably says something about the state of and concern for public health in this country. *Sigh*
If there’s a bigger single topic discussed in the medical blogosphere than the primary care crisis I’m not sure what it is. It permeates blogs (here and here and here) and the media (here and here and here).
I do believe that the distribution of primary care physicians to specialists in this country is askew but I’ve taken a critical view of some of the claims made by the primary care community. In part there is an argument that the efforts of the organized primary care and the medical blogosphere are merely rhetoric. No one pays attention until there is a ‘crisis’ and the flamboyant and exaggerated claims on the condition of primary care are perhaps merely part of a PR campaign. But in a deeper sense I think that the ‘whining’ coming from primary care is actually contributory to the primary care crisis. I’ve made several posts to that effect.
I thought what was in order was one summarizing post on the issue, something that might stir up some comments. That’s what I’ve put together here: the four myths of the primary care crisis.
The conclusions I reach are based on what I feel is sound data, but the post is obviously far from comprehensive. If there is data from non-interested parties that I didn’t consider or arguments I’ve ignored then let me know in the comments.
Myth #1:There Is A Worsening Shortage of Primary Care Physicians
I’m just going to flat out say it, the fact that physician bloggers and agenda minded think tanks continue to substitute anecdotal evidence of a shortage as a surrogate for the actual figures is distressing. Take this recently touted article from the WSJ. While I won’t speak to the Massachusetts experience the cited study about a nationwide PCP shortage is flimsy.
One of my biggest pet peeves is that these primary care physician-scientists seem to refuse to characterize the evidence they use in their opinions. I would hope that we can all agree that the HSC Community Tracking Study Physician Survey, cited in the WSJ article, falls short of the best evidence on primary care physician numbers. A 6000 physician sample with nearly less than a 50% response rate. Lovely.
The same can be said of the claims for the organized primary care think tanks.
Indeed, the HSC survey is the only original dataset put together by a non-involved entity that I can find that seems to back up a drop in the per capita primary care workforce.
While we have seen a drop in allopathic medical students going into primary care it has more than been offset by IMGs as the GAO says.
There are probably regional deficiencies in the primary care physician workforce but there are regional shortages for physicians no matter their specialty and it does not speak to a systemic problem facing primary care.
Nor is there good data that demand for primary care will grow with an aging population and cause a shortage. Such predictions by organized primary care are pretty low on the pyramid of evidence. While such a deficit may pan out, trying to predict such (even if you think it is just sooooo obvious a conclusion) is notoriously difficult. Predicting the physician requirements of this nation a decade or more out is essentially impossible. See this IOM report from the mid-nineties on efforts to do such. That’s why the major players over the past decade have flip flopped on whether we need to be graduating fewer or more doctors.
Certainly, even if the above scenario plays out, it would be hard to imagine it as a “crisis.”
I think the best evidence says there is not a general primary care shortage. At least not a new one. As I said, I think we have always needed more primary care physicians in this country but the situation isn’t getting worse. The primary care per capita numbers have been maintained and probably even grown a bit over the decades thanks to an influx of international medical graduates. Let that claim rest in peace.
Myth #2: The RBRVS and RUC Are Responsible For The Primary Care Income Disparity
I’ve posted long and hard on the RBRVS and the AMA’s RUC. I admit that I do not believe that primary care physicians are compensated appropriately and I may even buy that the RUC has not done enough to fix the primary care-specialists income disparity. That being said, the evidence clearly supports that the primary care physician has not done worse versus the specialist since the implementation of the RBRVS.
The RBRVS came into existence in 1992. I think a larger review of income data backs me up but for the sake of this post let me take a couple of examples to highlight the condition of primary care before the RBRVS in 1988 versus today. The data sources are the 1988 Health Care Financing Administration’s PPCIS and the 2007 AMGA Physician Income Survey.
I understand the limitations of comparing these two survey datasets, constructed under two different methodologies by two different groups. For example, below I have to use family medicine income as a surrogate for all of primary care. Even today the major physician income surveys show some wide discrepancies but I do believe that comparing this data gives us at least a general idea that the RBRVS has not screwed the primary care physician. In the end, that is the general point of the myth - the RBRVS and RUC have been bad for primary care. Such doesn’t appear to be the case.
In 1988 all self employed Family Medicine physicians earned a median of $102,500. In 2007 the median Family Medicine physician earned approximately $185,700. That is an increase of 81% in 20 years.
That is better than the orthopedic surgeon (56%), the cardiologist (61%), the anesthesiologist (78%) over the same time frame. There are medical specialties that made off better over that time frame (see radiology) but in general the RBRVS has been progressive for primary care physician income.
Nor, in terms of hours worked, are family practice physicians working more than they did immediately pre-RBRVS.
If you include all primary care physicians the primary care physician earned 65% of what the medical specialists did in 1988 (i.e. the cardiologist, the gastroenterologist, the pulmonologist, etc) and 44% of the average income of all surgical specialists.
2006 data put together from various sources by the Congressional Research Service says that the primary care physician today earns 70% the medical specialist and surgeon.
No the RBRVS may not have closed the gap in the income disparity completely and/or appropriately but it has made some progress and has not contributed to a worsening of the gap. The income disparity has narrowed since the advent of the RBRVS and the creation of the AMA’s RUC. End of story.
A science fiction writer says we should solve the rising costs of health care by scaring illegal immigrants into not coming into the hospital…sounds like a gre-…wait, what?!
[Larry] Niven said a good way to help hospitals stem financial losses is to spread rumors in Spanish within the Latino community that emergency rooms are killing patients in order to harvest their organs for transplants.
“The problem [of hospitals going broke] is hugely exaggerated by illegal aliens who aren’t going to pay for anything anyway,” Niven said.
“Do you know how politically incorrect you are?” Pournelle asked.
“I know it may not be possible to use this solution, but it does work,” Niven replied.
I don’t even know how you respond to the stupidity of a comment like this, except just to denounce it as such. Larry Niven simply doesn’t know what he’s talking about…or how to write a novel.
I’ve linked to stories concerning black markets for organs in the past. Now we get a story in the Los Angeles Times concerning such a market in Egypt. And it focuses around a terribly tragic story.
Hamed’s 4-year-old son, Mohamed, was dying of cancer and needed an artery transplant that cost $5,000. The only savings Hamed had was what he fished from his pockets at the end of the day.
There was another way, one whispered about for those with nothing. A man could wager part of himself, slip into a hospital gown, and wake up with an incision above the gut.
Hamed sold a section of his liver for a bit more than the price of his son’s operation. The boy died in surgery.
With his scar healing and his son buried, Hamed, whose knowledge of anatomy would perhaps fill a single page, decided that driving a bus was not the fate of the man he wanted to be. He brokered his first liver deal four months ago. He earned $900. Four more sales have followed.
There are virtually no laws governing organ donations in Egypt. Or so the article makes it sound like.
Mohamed Queita, a member of the Egyptian parliament and the ruling National Democratic Party, has been working for 12 years to pass a law to regulate organ transplants and stop an expanding black market that draws patients from across the Middle East and as far away as Europe.
“It’s the worst kind of business in Egypt. It’s worse than slavery,” says Queita, who has no comprehensive statistics but notes that one Cairo clinic had a waiting list of 1,500 people willing to sell their organs. “I don’t want the poor turned into spare parts for the rich. . . . People are coming from all over to buy organs in Egypt. They’re mainly gulf Arabs. If you’re a rich man from the gulf, you go to a private Egyptian hospital that has contacts with organ brokers. Serious cases of poverty in this country are causing an increase in the theft and sale of organs.”
The emphasis is my own. This kind’ve paternalism is just wrong. There are terrible, horrific stories out there but no matter the motives or the life situation that forces someone into selling an organ, it seems something like such is a personal decision without any negative consequences for anyone else. The government has no place regulating such decisions.
It’s real simple - just let people do what they want with their bodies.
It isn’t like western societies’ bans on selling/buying organs are achieving their goals anyway. Protecting the poor? Maintaining some ‘equality’ in the distribution of limited organs? Nonesense.
You can’t make direct payments, but those with resources are still open to bettering their odds of getting an organ by doing everything just short of paying the previous owner of the organ.
There seems to be something of a little backlash in the war to prevent obesity. Or maybe the skeptics are just getting more vocal or more coverage.
According to some experts whose views are public health heresy, the jury is still out on how dangerous it is to be fat. “The obesity epidemic has absolutely been exaggerated,” said Dr. Vincent Marks, emeritus professor of clinical biochemistry at the University of Surrey.
Moreover, [obesity skeptics] point to research showing the benefits of a few extra kilos (pounds).
In 2005, Katherine Flegal of the United States’ Centers for Disease Control and Prevention published a study in the Journal of the American Medical Association, finding that overweight people typically live longer than normal-weight people. More than a dozen other studies have come to the same conclusion.
You might remember that 2005 report from the CDC researcher. It made a little bit of splash in the mainstream media as the most prominent study to announce that being overweight (BMI between 25-30) was actually associated with decreased all cause mortality.
In our analysis, we did not find overweight (BMI 25 to <30) to be associated with increased mortality in any of the 3 surveys. Our results are similar to those of a previous analysis of NHANES I and II data that found little effect of overweight on life expectancy.30 Our finding is consistent with other results reported in the literature, although methodologic differences often preclude exact comparisons. In many studies, a plot of the relative risk of mortality against BMI follows a U-shaped curve, with the minimum mortality close to a BMI of 25; mortality increases both as BMI increases above 25 and as BMI decreases below 25,31 which may explain why risks in the overweight category are not much different from those in the normal weight category. Some studies have found that overweight was associated with a slightly increased risk of total mortality compared with the normal weight category.32-34 Other studies have suggested that overweight (BMI 25 to <30) is associated with no excess mortality, particularly in older age groups.35-37,39
But even in Flegal’s study the relative risk of mortality for those who were obese (BMI >30) was clearly higher.
Using relative risks from the combined survey data, we estimated that 111 909 excess deaths in 2000 (95% CI, 53 754 to 170 064) were associated with obesity (BMI ≥30).
Certainly the study had critics concerning its methodology. While there is data (most of it older, such as from NHANES) which has found the same as that 2005 study; but there is a much larger dataset which finds an increased relative risk of mortality both with being overweight and obese.
Consider Adams’ 2006 look at all cause mortality in the middle aged overweight and obese,
In this large prospective study, obesity was strongly associated with the risk of death in both men and women in all racial and ethnic groups and at all ages. After we accounted for potential bias owing to preexisting disease and residual confounding by smoking status by using midlife BMI values and restricting the analysis to participants who had never smoked, we found that even moderate elevations in BMI conferred an increased risk of death. The risk among participants who were overweight at the age of 50 years was 20 to 40 percent higher than that among participants who had a BMI of 23.5 to 24.9 at that age. The risk among obese subjects was two to at least three times that of participants with a BMI of 23.5 to 24.9. The risk of death among underweight participants was attenuated.
[…]
[W]hether moderate elevations in BMI (i.e., overweight) truly increase the risk of death is controversial.2 Several studies reported no increase in the risk of death among overweight subjects even after those who died during the initial years of follow-up were excluded or subjects were stratified according to smoking status.25,26,27,28,29 Recently, Flegal et al. reported that overweight was not associated with an excess risk of death in the nationally representative samples of U.S. adults drawn from the National Health and Nutrition Examination Survey.29 They speculated that possible causes for their finding might be improved medical management of obesity-related chronic disease or differences between the U.S. general population and populations in other studies.29 Others have suggested that inadequate control for the combined effects of smoking and chronic illnesses could be the explanation.30 Smoking is associated with both a lower BMI and an increased risk of death and can therefore distort the relation between BMI and the risk of death. Statistical adjustment for smoking status does not fully address the problem; the adjusted findings represent a potentially complex combination of the associations between BMI and the risk of death among current smokers, former smokers, and those who have never smoked. Restriction of analyses to persons who have never smoked is a powerful tool for addressing this potential bias. Our cohort included more than 186,000 men and women who had never smoked. When we restricted our analyses to these persons, the relation of obesity to the risk of death was substantially strengthened, and significant increases emerged in the risk of death, even among overweight participants.
While questions may remain, the studies seem to trend that being overweight or obese increases your all cause mortality. But in turn that increased risk of death has drawn criticism over the campaign to document how much obesity is costing western societies.
Notably, Daniel Engber (aka The Slate Explainer) has a recent column entitled, ‘It’s time to shut up about “the cost of obesity”‘.
I have definite mixed feelings about this. 10 nurses conspired hurt their employer by walking off the job without notice. Now they’re facing criminal charges for endangering the lives of their patients with their sudden resignations.
Prosecutors say the nurses’ resignations — without notice — on April 7, 2006, jeopardized the lives of children at Avalon Gardens in Smithtown, where some of the patients are on ventilators and required constant monitoring.
None of the patients suffered ill effects, but an indictment alleges the nurses knew their sudden resignations would make it difficult to find replacements. Their trial is scheduled to begin Jan. 28.
Defense attorneys say they are perplexed why the case is proceeding to trial because two separate state-agency investigations cleared the 10 nurses. [Prosecutor] Spota said the legal standards for a prosecution differ from those of the state agencies.
While, not knowing the specifics of the incident, in general I would say something like this should be far from a criminal matter…in a just society.
It was fun, especially on trauma call. But beyond trauma call it was a pretty repetitive service. My home surgical residency program, admittedly merely through faculty report, has the single highest average number of lap choles performed per graduate. I’m not sure that’s really a selling point (although the laparoscopic cholecystectomy is one of the most popular operations in this country), but I do believe it.
On the slowest general surgery service (one to two ORs depending on the day, one fifth year, one second year, two interns) in the hospital (average probably 8-12 cases a week) and with three other students to split up the cases I probably was scrubbed into 12-15 lap choles in six weeks or about two a week. I think a disproportionate number fell to me. While lap choles probably did literally make up the majority of our service, it wasn’t like they represented 90% of the operative load. Even so that seems like there were a lot of choles.
Indeed, I’m pretty sure with my attending on the other side of the table I could perform a lap chole right now with the complication risk about the same as when my junior resident on the service did it.
I will mention one health policy issue which I’ve come to appreciate and it concerns the way we handle trauma. I’m really naive about the issue, but I think as long as we’re throwing around proposals for further government funding of health care that we might also consider the way we fund trauma in this country. It goes beyond EMTALA. We need to seriously consider some kind’ve national trauma insurance pool (I’m sure there are proposals out there) and even consider further mandates to hospitals for Medicare participation (I’m being serious, despite the complications of doing such).
The Healthcare Economist links to a recent paper which makes a nifty point.
“How much uncompensated care do doctors provide?” comes to the conclusion that private physicians make more money per uninsured patient than per insured patient.
45-59% of physicians actually provide negative uncompensated care
[…]
Compared to all insured, physicians deliver [as little as] -$2.10 in uncompensated care per visit by the uninsured.
How is this possible? Physicians have fees they charge patients for every office visit, every procedure. When third party payers come into the picture they set their own fee schedules. The insurer basically says, we’ll pay you 40% of what you would “normally” charge for an office visit and in return we’ll allow patients on our insurance to visit you. It’s quantity.
But when someone without insurance comes in for a visit or a procedure, they typically get billed the “full” amount (or at least more than what is billed to the insurance company). So even though some large percentage of visits by the uninsured go unpaid (result in no or little compensation), the physicians are charging more than they would get with an insured patient and so physicians actually make more money per patient when you compare the whole of the two populations.
Also of note, most private physician “charity” care doesn’t arise from physicians offering it…but instead by the bills they level onto their uninsured patients not being paid.
[M]ost uncompensated care arises from the uninsured not paying their bills…Only 13% of the uninsured were billed less than the insured; only 7% were billed nothing…on the other hand 87% of the uninsured were billed more than the insured
To be fair, private physicians represent a tiny fraction of the total charity care provided in this country. For instance my county hospital and clinics, staffed largely by salaried physicians (both employees of the county and through contractual arrangement with the medical school), obviously provide the vast, vast, vast majority of charity care in this area. The same is likely true the country over.
Although an interesting study, I think the policy implications for such are limited. Healthcare is a business but there are a lot of physicians out there doing really incredible work for the public good. Don’t draw too many conclusions from this paper.
A proposal to create a new class of drugs, to relabel the risk aversion this country has with medicines, is before the Food & Drug Administration. Call them “semi-over the counter” drugs.
[T]he Food and Drug Administration is considering creating a different option, a class of medicines dubbed behind-the-counter drugs. It would let consumers purchase routine medicines that could include birth control pills, cholesterol drugs and migraine medicine without a prescription — as long as they discuss it with a pharmacist first.
I’m more than comfortable with this. The response I imagine from most physicians is…well, as you would imagine.
Dr. Anmol Mahal, a Fremont gastroenterologist and president of the California Medical Assn., said the federal agency’s proposal was ill-conceived and unsafe for consumers.
“Patients are not clinicians,” he said. “Allowing people to self-diagnose and self-treat is not in their best interest. Nothing could be farther from the truth.”
Meaningless words from the CMA that miss the real debate. The debate always is and always will be how much risk is acceptable. True there’s some evidence that the populace doesn’t swallow risks associated with medications real well. They don’t understand them and they’re not willing to accept them it sometimes seems like.
That’s merely a matter of education and process, not a hard core limitation to access. I think the behind the counter class is a good idea that has worked well in other parts of the world.
Those wrong hands namely being some parents. A Boston Herald reporter goes off on pediatricians asking kids about their parent’s substance abuse habits and gun ownership.
I send my daughter to the pediatrician to find out if she’s fit to play lacrosse, and the doctor spends her time trying to find out if her mom and I are drunk, drug-addicted sex criminals.
We’re not alone, either. Thanks to guidelines issued by the American Academy of Pediatrics and supported by the commonwealth, doctors across Massachusetts are interrogating our kids about mom and dad’s “bad” behavior.
We used to be proud parents. Now, thanks to the AAP, we’re “persons of interest.”
The paranoia over parents is so strong that the AAP encourages doctors to ignore “legal barriers and deference to parental involvement” and shake the children down for all the inside information they can get.
What type of crap-ass characterization is this? It gets worse once we he gets on gun ownership.
Last year, my 7-year-old was asked about my guns during his physical examination. He promptly announced to the doctor that his father is the proud owner of a laser sighted plasma rifle perfect for destroying Throggs.
At least as of this writing, no police report has been filed.
“I still like my previous pediatrician,” Debbie told me. “She seemed embarrassed to ask the gun questions and apologized afterward. But she didn’t seem to have a choice.”
Of course doctors have a choice.
They could choose, for example, to ask me about my drunken revels, and not my children.
They could choose not to put my children in this terrible position.
They could choose, even here in Massachusetts, to leave their politics out of the office.
But the doctors aren’t asking us parents.
The emphasis is my own.
Politics? This is paranoid, deluded gun ownership lobby talk. Look, there is no bigger supporter of gun rights than myself but that is in spite of the public health risk firearms represent. To present this as a political position of the AAP and the medical community is to deny that fact. Which I think is insane whenever I hear such. Every piece of legitimate data supports that firearms are a public health disaster. There’s no systemic bias in the research leaving out gun protection incidents, there’s no miscounting, there’s no grey area. Guns kill way more innocent people than they protect.
Children in this country are more likely to die by firearm than leukemia. And there’s something wrong, there’s something political about asking your children in private about gun residence in the house and their understanding of gun safety?
Like it’s appropriate to have parental influence on the answers to these questions. Sorry they didn’t ask you to your face. *rolls eyes*
The reporter throws out a story where some parents were reported to the police (without consequence) merely for legally owning guns. To begin with we know nothing about the facts of this case beyond what this reporter chooses to grace us with and second, a single story of an overzealous pediatrician is not data. On the whole how can anyone think it’s appropriate to let a child walk out of the office without asking about firearms or about other home safety issues?
The op/ed ends with the most ridiculous of comments concerning questioning children about sexual abuse.
Worst of all, they’re asking all kids about sexual abuse without any provocation or probable cause.
The American Academy of Pediatrics has declared all parents guilty until proven innocent.
I feel like my head is going to explode. I love how he mixes the legal terms of popular culture/understanding into a situation on which they shed no light. Probable cause…to ask a question? Even in the right situation that doesn’t make sense. Like the police need such to ask you…anything.
Pediatricians stamping parents as guilty? That assumes a question is equatable with an accusation. I don’t know how this guy got hired as a columnist with that kind’ve logic. Seriously, my advice to him is to go take a rhetoric class. You have to be a paranoid nutjob to write this op/ed. Or take it seriously.
Oh well, that’s the joy of this system Mr. Graham, go find yourself another pediatrician who won’t ask all these personal, intrusive, inappropriate questions.
You can scratch pediatrics off my list, if I have to deal with morons like this.
Dr. Rangel takes up my pet peeve.
For example, obesity alone is calculated to decrease US life expectancy by 0.3 to 0.75 years and the US has the highest rates of obesity in the world. Notice that Japan has one of the lowest rates of obesity and is among the countries with the highest life expectancies. The WHO report acknowledges that other variables like higher HIV rates, higher tobacco abuse rates, higher rates of risk factors for coronary artery disease (including obesity), and higher rates of homicides in the US compared to other industrialized countries combine to decrease the life expectancy for Americans.
The generally poor life style choices of Americans are more likely to have a causative effect on health care spending than the other way around. I.e. more health care spending is needed to take care of the conditions like heart disease that result from our poor health habits. This is more logical than to assume that high health care spending has anything to do with rates of obesity or smoking.
This blog is a broken record on this point but again: the United States has some of the sickest people in the western world independent of access to healthcare and 2/2 lifestyle choices. This poor health: a) raises the health care spending and b) contributes to poorer outcomes across all those imprecise measures which international ratings of health care systems are based on.
While it remains the U.S. runs one of the least efficient health care systems in the world, how about everyone have their kids put down the Big Mac, get some exercise and see what happens to our life expectancy before they start complaining that Americans are dropping over younger than the rest of the first world.
Oh well, good to see someone else echoing this point. He also goes on into other reasons the WHO rankings are garbage; some of which I’ve made before on this blog. Strong work Dr. Rangel.
A little bit of a chilly and sad story as N fowleri has claimed the life of an Arizona boy. That brings the total for the year throughout the country to 6 deaths. Over the decade before 2007 the average had only been approximately 2 deaths/year.
A 14-year-old Lake Havasu boy has become the sixth victim to die nationwide this year of a microscopic organism that attacks the body through the nasal cavity, quickly eating its way to the brain.
Aaron Evans died Sept. 17 of Naegleria fowleri, an organism doctors said he probably picked up a week before while swimming in the balmy shallows of Lake Havasu.
The amoeba typically live in lake bottoms, grazing off algae and bacteria in the sediment. Beach said people become infected when they wade through shallow water and stir up the bottom. If someone allows water to shoot up the nose — say, by doing a cannonball off a cliff — the amoeba can latch onto the person’s olfactory nerve.
The amoeba destroys tissue as it makes its way up to the brain.
Naegleria is a scary disease. Here’s the CDC fact sheet. One day you’re swimming in typically still, warm, fresh water and 1 to 2 weeks later you’re dead.
Once infected, most people have little chance of survival. Some drugs have been effective stopping the amoeba in lab experiments, but people who have been attacked rarely survive, Beach said.
“Usually, from initial exposure it’s fatal within two weeks,” Beach said.
That being said, realize how rare this is. I’m not trying to spread this public health efforts as terror, which has become so popular in the mainstream media.
A review of the studies which have shaped the policy, questions the all-cause mortality benefit of vaccinating everyone over 65 years old.
Influenza vaccination may save many fewer older patients’ lives than generally claimed, according to researchers here.
The reason is that estimates of a 50% or greater reduction in all-cause mortality have emerged from cohort studies fraught with selection bias, asserted a review article in the October issue of The Lancet Infectious Diseases.
The “illusory” estimates arose primarily from methodologically weak cohort studies, the GWU researchers said.
These studies used nonspecific endpoints, typically all-cause mortality and non-laboratory-confirmed influenza outcomes, while attempting to adjust for selection bias in multivariate models with health-status covariates defined by diagnostic codes.
But, in one study, adjustment for diagnostic codes indicating severe illness and frailty was found to increase the mortality difference between vaccinated and unvaccinated groups even before the flu season. This suggested that the method left uncontrolled bias.
Indeed, two studies revealed that most influenza-related deaths occurred in small subsets of older adults with low vaccine coverage who were hospitalized in autumn.
Without cohort studies, “the remaining evidence is not sufficient to show that vaccination substantially reduces the risk of influenza-related mortality among elderly people,” they wrote.
Perhaps the most damning evidence,
Age-adjusted estimates for influenza-related mortality in excess mortality studies showed no reduction in flu-related deaths during a period when vaccine coverage increased by 50%. Nor was there any increase in mortality during the 1997-1998 flu season when the vaccine completely mismatched circulating strains.
When it comes to public health and vaccinations the health community has already thrown out the premiere-ness (and that is a word) of non-maleficence in favor of utilitarian measurements of benefit. The point is even if the benefit of vaccinating all of the elderly is less than expected it is almost certainly still greater, I imagine, than the complications or bad reactions that come with giving the vaccination. This review, even if confirmed by better designed studies in the future, probably contributes little to the public health policy concerning who gets vaccinations.
And it isn’t like there are other subsets of the population who could benefit more from the vaccine during periods of shortage. As long as it is the providers and the markets doing the rationing (and not the government) I have no problem with it, even if the evidence (as above) doesn’t support the rationing as strongly as we might have once believed.
Disappointment as Merck’s live recombinant vaccine fails in its Phase III trial,
Executives at the company, based in Whitehouse Station, N.J., said 24 of 741 volunteers who got the vaccine in one segment of the experiment later became infected with HIV, the virus that causes AIDS. In a comparison group of volunteers who got dummy shots, 21 of 762 participants became infected.
More on Merck’s HIV vaccine efforts here and more on HIV vaccine efforts in general at the WHO.
I’m really fascinated by when public health comes into conflict with personal liberty. You can image where I fall in the debate. The public health risk needs to be remarkable to infringe upon personal liberty. There may be a place for criminalizing knowingly exposing people to a dangerous health risk, but acting preemptively is a slippery slope.
I bring this up because we have a story of a scared teenager with TB trying to return to his home in Mexico and instead ending up in a Georgia prison.
They put Santos in jail Friday evening, in a rare act of a government agency confining a sick person. Santos is the only inmate in a special medical isolation cell designed for inmates with contagious conditions. The cell, which measures about 15 feet by 20 feet, has a special ventilation system that keeps the air from reaching other inmates.
The 5-foot-5 teenager has a toilet, sink, bed and a mirror made of polished metal. Two deputies guard him and the other medical inmates.
[T]he county health attorney, said Santos was detained because he is a public health threat.
“He has active, contagious TB,” Will said Saturday. “He is at risk of communicating that with anybody he comes in contact with.”
Will said Santos is being held under a court order for confinement. He’ll stay in that cell until either he starts cooperating and accepting treatment, or a judge makes some other decision at a Sept. 5 hearing. At that commitment hearing, the judge could decide to place him in a hospital with security.
In a bit of a surprise I’ve actually cared for my share of TB patients since I’ve started my rotations (here is hoping my ppd doesn’t convert next year) and I think I’ve got a sense of the public health risk.
While ‘casual’ contact is a risk factor for catching TB from someone who is contagious (see here and here) the odds of getting a really bad disease from such are still remarkably small. The role forced treatment, observed treatment has played in killing the great TB epidemics in the first world is minimal. The applause for that instead goes to education, to the fact effective treatment now exists, to sanitation.
Would there be more cases of TB in this country if the government didn’t commit TB patients against their will; if the government didn’t force TB patients to be registered; if the government didn’t force observed treatment on TB patients? Of course. But the speed limit could be 15 miles per hour as well to save lives. We could always be safer at the expense of something else in life.
A third of the world is infected with TB. Unless they’re immunocompromised only 5-10% will ever become symptomatic.
Even with that out there this kid got to sit in a prison cell because he didn’t want to swallow some pills? Hear the sarcasm: It’s wonderful the value we put on people’s liberty.
