Tag Archives: Health Policy

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Health Risk and Pleasure

I thought I would post this one from The Physician Executive because Val was once my favorite internet buddy. My Canadian ex-compatriate is now remarried and has moved to South Carolina. But one thing has not changed: the timeless notion that people somehow view healthcare as a way to dodge the consequences of overindulging their little pleasures. In this case we are talking about something relatively innocent: unpasteurized dairy consumption. Our health officer in Clark County gets upset every time he hears about another place selling raw milk in Clark County. The latest I found was Camas Produce selling raw goat’s milk.

It’s easy to condemn the practice of consuming raw dairy on its scientific basis. Trouble is I love artisanal French cheeses. Many are raw and were outlawed int he US at the time this post was written in 2007. I am a happy camper now that I can get unpasteurized cheese. I hope Dr. Melnick will forgive me this one indulgence.

 

Dr. Val at the Voice of Reason posted an article on the hazards of raw milk. She grew up on a dairy farm, so her observations are particularly cogent. The article raised two questions in my mind.

First, our clinic’s practice is heavily Latino, dominated by Salvadoreans who have a tradition of consuming raw milk products. In fact, Salvadoreans consider yogurt made from raw milk one of the healthiest foods for young infants. My patients tell me it is usually introduced at around two or three months of age.

Of course, this goes against the usual recommendations for baby feeding in the US, which appears to me to be based on bowel maturity and propensity for allergies, as much as on healthy nutrition. There have been sporadic cases of bovine mycobacteria amongst Hispanic infants in our area, which is a stone’s throw and a ferry ride across the Potomac from Dr. Val’s stomping grounds (so much for anonymous blogs, eh?)

My classic and rigorous medical training causes me to carefully counsel my patients against the consumption of anything other than breast milk and formula for the first four months and to avoid raw milk products until they are old enough to choose for themselves. My cultural sensitivity makes me wonder if this is truly appropriate.

Yogurt, perhaps reserved for later infancy, is probably a great source of nutrition to have become an important staple in El Salvador. Culture is important to everyone who has one, and food and child-rearing are important aspects of culture. The documented number of infections in our County was 4 in 2005. Is that enough to intrude on culture and tradition, or can we just remain sensitive to the fact that these children are at risk an intervene early? I’ve never had to treat an infant with cow tuberculosis in their gut, but I wonder… I just wonder…

The second thought that came to my mind is about the French! No I’m not getting political… I just like French cheese. One of my favorites is Camembert from Normandy made from raw milk. Perhaps there is something in the process of making cheese that I am missing, but raw milk cheeses taste better and have been really hard to find because of the Department of Agriculture’s import restrictions. I just found a really smelly cheese store nearby and I’m in heaven. The first thing I asked is if they had raw cow’s milk cheese and the guy behind the counter smiled and nodded knowingly. He probably figures me for a connoisseur for asking!

Raw milk products have inherent hazards, but this isn’t like eating a puffer fish prepared by a novice sushi chef.

Just wondering…

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Disruptive Innovation

This is based on an old post from The Physician Executive when I first started thinking about the place of disruptive innovation in health care delivery.

 

The problem with disruptive innovation in health care is thinking twice about how it applies.

A couple of precepts before we begin, just so we’re all on the same page, or at least the same library:
1) First the technology can exist for a long time before it is adopted, if at all. It is in the application that an innovation potentially becomes disruptive.
2) Adoption is likely to come from smaller players as new technologies are frequently overlooked by the big players.
3) The innovation is not disruptive to the consumer. It is disruptive to other producers. The consumer adopts it because it is simpler and cheaper than the alternative.

In my world, the innovation will come from changes in the way health care is delivered, not about a sexy new scanner or robotic procedure or even a new iPad app for diabetics. And here, observations about how slowly such innovations are taken up become pertinent.

I would argue against big business. Lately, consolidation has caused health care to be delivered out of monolithic medical systems incorporating primary care, specialty, allied health (physical therapy, audiology, optometry among others) and imaging services. This creates a few problems:

1. Like big government, big business generates an entrenched bureaucracy that is resistant to change, difficult to navigate and primarily interested in perpetuating itself.

2. Incentives are skewed to generate more testing and services. Primary care, when properly delivered, reduces downstream costs to the system, meaning less revenue for the organization.

3. There is less choice (see availability of reproductive services in areas dominated by large Catholic health systems) and the cost advantages of scale initially required to reap the benefits of the technology deployed are rarely manifest.

Carving primary care out of the health care delivery system and providing a special place for it with better revenue, greater legal protection (e.g. tort reform, voiding non-competes) and subsidizing an infrastructure to allow small, personal, relationship-based practices would be a tectonic shift on how we think about health care.  Now that would be disruptive; and just as the iPhone disrupted the PC market, it is only primary care that can disrupt the medical tech (specialty/referral/imaging) sector.

Maybe this is why Clayton Christensen believes health care is ripe for disruptive innovation, although the comments confirm to me that he has not yet found the right disruptions. It will be up to people like Dave Chase, Rob Lamberts and Brian Forrest to figure it out. I could include others, but why take sides?

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Immigration and Health Care Costs

Impressions from a cross-country road trip dominates this
Physician Executive post from 2008. The cultural diversity of the country made a big impression on me. It is ironic that while we argue today about Immigration Reform, the pressure from immigration has been dissipated by new economic realities. Net migration from Mexico is now negative. I suspect it is only a matter of time before xenophobia rears its ugly head again in the healthcare debates.

 

In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.

I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.

All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.

So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!

If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.

Our immigration laws are not only ineffectual; they are economically and socially counter-productive.

I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.

It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.

Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)

The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.

In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.

If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.

The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.

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Response to Michael Cannon

More on Cannon and the USA Today article from 2007.

I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that’s a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?

I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.

First let me direct some comments directly to Michael’s defense of the USA Today Op-Ed:

  1. To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
  2. To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
  3. Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.

There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country’s health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who’s never walked a day in clinic.

The first step in crafting health care policy is articulating a role for government. If you don’t believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.

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USA Today Health Reform Editorial

Here is one Michael Cannon would prefer to forget. The problem with the ideologues is that they learn to reference their papers after they’ve written theM. So often, the articles do not say anything about what is being referenced. This is why I do not often use material from think tanks unless it is clear to me they do not have a political agenda and treat facts respectfully, with reason and an absence of rhetoric. From The Physician Executive in September in 2007. I will never delve this deeply into ideological clap-trap ever again! 

 

Dear readers, I need your help.

As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.

Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.

Here is a systematic breakdown of what I found:

1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.

2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.

3. The next link is used to support the phrase “As many as 20% of the “uninsured” are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.

4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.

5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.

6. A rapid sequence of references asserting that expanding health coverage will not

a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.

b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.

c. Affect life expectancy: A New York Times article about education being related to longevity.

d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon’s argument is nearly circular.

7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.

8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.

Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon’s references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.

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The Economics of Mid-Levels

Another old post from The Physician Executive with currency in today’s environment. 

 

I was once a family physician delivering babies in an East Coast big city.

No, I am not a masochist, I was a family practice residency faculty.

Given the intense turf wars caused by an oversupply of competing specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?

Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)

I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.

On the other hand, Jason’s post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman’s assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.

I’m not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.

On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.

I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.

I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.

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Health Care: The Blind Men and the Elephant

From The Physician Executive in August of 2007.

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don’t believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners… Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn’t understand why the clinical staff didn’t follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that “protocols” and “guidelines” are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It’s too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat… These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists’ regressions, economists’ differentials and executives’ spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don’t yet know what it looks like. Let’s just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.

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Employed Physicians Becoming More Common

I am on a roll finding old posts from The Physician Executive that are still relevant today. In fact, this post is more relevant today than it was in August 2007.  We now must need to be concerned about how physicians are being managed and in the face of large integrated health systems with an incentive to encourage increased testing and referral. This will still be a major policy issue for the next decade.

Interesting post by Dr. Reece about physician-hospital collaborations at medinnovationblog. There is no question that community hospitals exist in a challenging environment, but each specialty now has its own financial realities that can color the relationship between physician groups and hospitals. My comment, is the most recent trend towards hospital-employed physicians accomplishes two things:

1) it puts physician executives in greater demand
2) it may put more hospital functions under greater physician influence or control.

Surely there are numerous other forces at work here and only the smartest and best informed physicians will win. I don’t believe the golden age of medicine was very good for patients, at least on a population basis. However physicians are often well-positioned to consider the patients’ best interests. Hopefully, the current grass-roots push towards more accountability and better quality-of-care data will combine with a strong physician perspective and professional management skills at hospitals to improve health outcomes overall.

Then again, the landscape may prove just too complex to navigate.

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Envelopes and the Greek Medical Business

This post on informal payments from The Physician Executive was one of my most popular. Originally published Aug 15, 2007. Dangerously, I have to note it is one of my favorite jokes. 

 

If you think we have problems in the US, you should try Greece.

There had been talk of a socialized system several years and a couple of prime ministers ago. There seems to be a modicum of a centrally funded, insurance-based system now. However, the WHO’s description of Hellenic healthcare tells me it still runs the old-fashioned way:

[Informal payments] are especially prominent in the case of in-patient care, and are made to doctors, mainly surgeons, in public but also in private hospitals. These payments are also made in the case of outpatient care. The rationale is to jump the queue or to secure better quality services and greater personal attention by the doctor. Unofficial payments are considered to be a major problem in the Greek health care system. It is estimated that about half the total private expenditure on health care involves informal payments. There is no really reliable estimate of the size of the unofficial market, partly because it is so widespread, and partly because of the complexity of the Greek health care system.

Almost 60% of total out-of-pocket payments (official and unofficial) are made to doctors and dentists (especially those in charge of facings), 20% go toward pharmaceuticals, with the rest being mainly expenditures on private diagnostic centres and private clinics. Out-of-pocket payments (both official and unofficial) represent roughly 6% of household income (1990 figures).

So these informal payments are made under the table, usually cash stuffed into an envelope and they are fairly common, even in the out patient arena. Traditions die hard, and the tradition of the “fakelaki” (the Greek word for envelope) is alive and well. I believe these payments are outlawed in the government-run clinics, but common prejudices take effect: Greeks are nearly Italian in their disregard for authority and let’s face it, doctors can’t be any good if they works for the government! You and I may know it’s not true, but there’s no accounting for consumer decisions.

My suspicion is that the lowest risk way of buying a stake in Greek Healthcare is to buy a stake in an envelope factory.

Aide, gela!

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Vaccine Objector Backlash


In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  



Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory — the paralysis, death and suffering wrought by a horrible disease — it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.

[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.