Category: Health

Break the link between employment and healthcare!

Cross-posted from Interrobang:

The US Supreme Court ruled along political lines on the 30th of June, 2014 that “closely held corporations”, over 90% of all US businesses, are now free to discriminate against women (and it was specifically women and birth control) if their religion leads them to believe birth control kills babies, or that women who use birth control are Satan’s spawn (the belief does not have to be factual).

The Supreme Court says corporations can hold religious objections that allow them to opt out of the new health law requirement that they cover contraceptives for women.

The justices’ 5-4 decision Monday is the first time that the high court has ruled that profit-seeking businesses can hold religious views under federal law. And it means the Obama administration must search for a different way of providing free contraception to women who are covered under objecting companies’ health insurance plans.

Salon AP coverage

I am not going to debate the wrongness of this decision, the notion that businesses can have religious beliefs, and can use them to discriminate against certain types of people is not up for debate. And, the discrimination is very specific and targeted…

The other, more ubiquitous discrimination is in the notion that the health care you get has anything to do with the work-for-pay arrangement you have with the organization you work for. I am probably the millionth person to mention this, and whole books have been written on the subject, but, the link between healthcare and your employer is wrong because it anchors discrimination. This particular egregious case goes one step further and discriminates based on gender as well, not just work status.

The US had a chance to sever health benefits from employment when they had a three-year debate on expanding health insurance coverage. Thanks to the ability of small political minorities to filibuster and block action, and a corporate-funded reluctance for change, the US kept their employer-based health insurance system in place, and with it, all the discrimination that entails. Uwe Reinhardt reiterated a number of these points recently in the New York Times.

Back Home

Is BC any better? Yes and no. Thanks to Canada’s Medicare, parts of our health care system are universal and not subject to employment ties. But, there are several exceptions making us a two-tier health care system:

  1. The health insurance tax or MSP (what our government cutely calls a “fee” in order to not call the yearly increase in this fee a tax increase): Many employers will pick up part/all of this tax for their employees, whereas one that doesn’t can pay more than 1000 dollars a year for a family. While there is an element of progressiveness to the pricing with very low-income people paying less/nothing, it is weak, families making > 30K per year pay full price.
  2. Drugs: For some reason, drugs are not covered by our “universal” healthcare system and are provided by workplace “supplemental benefits”, as if taking a thyroid pill every day is a “supplement”. The CCPA makes an excellent case for universal pharmacare, if you need more convincing. 10% of Canadians cannot fill prescriptions for financial reasons.
  3. Our public health insurance system assumes people don’t have eyes or teeth. So, if you want your cavities filled, a root canal, or want to see clearly, you need “supplemental benefits”, and these are mostly employer-provided. Oral health is a clear marker of health inequality.
  4. Mental health is not covered, this is inexcusable, as Andre Picard notes.
  5. Treatments that improve overall health, like massages, are not really covered. Once again, your employment status determines whether you have the “luxury” of holistic preventative measures to reduce stress, pain, and many other issues.
  6. Historically and currently oppressed groups, Canada’s indigenous people for example, get a short shrift on the benefits like massage, nutrition, counselling and holistic treatment they need because of disparity in employment availability.

This quote from the Andre Picard article I mentioned summarizes the discrimination.

The well-to-do pay. The middle-class scrape together the money the best they can, sacrificing so their child can get care. And those without the means wait, or do without care.

There are other side-effects. Because “benefits” are expensive, companies have a vested interest in only having certain “valuable” employees benefit. The rest get treated as contractors, have their hours strategically reduced, and much more.

It’s almost as if there’s an unspoken moral argument here, you don’t deserve good teeth or a massage if you don’t work for a living.

Yes, you can buy individual supplemental insurance, or pay per use, but neither of these are cheap because you as an individual have no bargaining power.

We in BC also have a long way to go to break the link between healthcare and employment. Will it cost the average BC resident more money? Let’s consider:

  1. A simpler system with one buyer is administratively efficient. It takes the thousands of decision points every HR administrator or group in every company/union has to make and transfers that to a single entity. Public universal plans are about four to ten times more efficient (pdf) than fragmented private plans.
  2. A bigger entity can negotiate much better rates for you, whether it is for drugs, or for dentistry, or for anything else (a bigger risk pool). If all of Canada administered one simple pharmacare system, we would negotiate much lower prices with pharmaceutical companies. We would also have better funding to run and evaluate effectiveness studies.
  3. Funding preventative, holistic healthcare means fewer hospital visits. In a universal system, there are no artificial barriers between a massage, drug treatment, surgery, stress reduction counselling, or ergonomic counseling for back pain. You don’t have to prove your work injured you in order to get the right treatment, your first point of contact with a medical professional (not necessarily a doctor) decides which path works best. You do not have to get sick enough to go to the hospital before you get treatment covered by insurance.

Pitfalls

There are concerns with a universal single-payer system:

  1. As Vox points out, if a government administering the single-payer system decides not to pay for contraception, then no one gets it. So, getting good universal healthcare is about constantly winning political battles. The good thing about universal healthcare in Canada is that it is incredibly popular, polling near 90% approval (pdf). So once quality is improved, governments will find it hard to cut back.
  2. Like any other public system, the quality of the institutions drafting policy and administering the system is vitally important. Well run public systems are efficient. But conservative movements in the last 30+ years have worked hard to dismantle the quality of public institutions and trust in such institutions. In this reality of shrinking budgets and staff levels where bureaucrat is a term of insult, ensuring that public system expansion is handled efficiently is no given. There is an entire industry of political parties, think tanks and media devoted to tearing down the concept of a publicly administered good, and ready to pounce on every little misstep (Remember the Obamacare roll out anyone?)
  3. Will employers raise wages from all the savings they get from not providing health benefits, and will these raises cover the increase in taxes we will pay for universal healthcare? Probably not right away, but it will happen eventually.

Transitions

Clearly, we can’t transition tomorrow. A public system would need to be in place and functioning before our employers get out of the health insurance business. I would phase universality in the following order:

  1. Drugs
  2. Teeth and eyes
  3. Preventative and palliative care.

We would also need to rethink the”fee for service”, where healthcare providers are paid per widget, and think about a different system closer to a salaried model, more on that in future blog posts.

Stalking my walking.

image

Google Now tells me I have walked 74 km in February (one of the last meaningful acts of my phone before it passed away). That’s mostly me walking from my bus stop to work and back, 3.6 km everyday, something I don’t consider exercise to the point that I undergo serious bouts of self-criticism about “not exercising enough”. I post this because I, like many around me, am very concerned about the amount of digital surveillance in our society. Everyday, Snowden’s document dump brings new revelations. Yahoo webcam images, anyone? But the benefits of benign surveillance are potentially big. I would like my phone to remind me that I am exercising, that my bus is scheduled to arrive in 5 minutes (of course, BC Transit does not have real-time information, so this is theoretical), that I am near a grocery store that has my favourite cereal on sale (this would need open data on retail prices), that my neighbour on the bus is reading the same book that I am (okay, too much!).

Cellphones are now intelligent, location and context aware. They can do a lot of good. Hell, I’ll even tolerate the use of some of my metadata for advertising and information gathering as long as it is transparent. But the data is also used by governments non-transparently to track my movements and actions, and I am deeply uncomfortable with it. Till now, my gee-whizness and fairly high belief in the value of a trust-based open information commons keeps me from closing off these data streams. If we stop trusting in the good of an open internet and stop contributing, the internet is seriously harmed.

Lasers shooting into irises

I did not think my first minor surgery would involve someone shooting lasers to make holes in my iris. It sounds like more fun than it actually was, but was mostly painless and here I am, looking at a computer screen 3 hours later. My eyes feel like they’ve had about 5 hours of sleep, which is good considering they’re now sporting two brand new drain holes.

Laser iridotomy is also performed prophylactically(preventively) on asymptomatic individuals with narrow angles and those with pigment dispersion. Individuals with a narrow angle are at higher risk of an acute angle closure, especially upon dilation of the eye

http://www.surgeryencyclopedia.com/La-Pa/Laser-Iridotomy.html

I also just started reading Bad Science by Ben Goldacre, which is about the use and misuse of the banner of science by a large group of people including nutritionists, pharmaceutical companies and “alternative” treatment specialists. It has a great chapter on the “placebo” effect, how much of it is culturally mediated, and how much doctor demeanour and confidence in their skills and outcome affects results. The doctor shooting holes in my eye was extremely confident in their skills and their results, and normally, my brain would be sending off all kinds of hubris warnings. In this case, their confidence reassured me a bit, and Bad Science definitely helped. It was also interesting to see a large section on homeopathy in the book, since I’ve written about my contact with homeopathy and felt that the cultural practices of a good homeopath can be of some use to people as long as they don’t go too far. The book confirmed some of that.

High fructose corn syrup makes you fat

This well designed and well executed study provides rather conclusive proof that High Fructose Corn Syrup, the sweetener most commonly used in North America, makes you gain weight in a way not explained by calories alone. These rats gained more weight on HFCS compared to a sucrose (regular sugar) diet even though they were fed the same calories. The effect was seen in the short term and in the long term, and abdominal fat increased the most. Gut fat, if you did not know is related to the infamous metabolic syndrome, causing diabetes, hypertension, coronary disease, etc.

High-fructose corn syrup (HFCS) accounts for as much as 40% of caloric sweeteners used in the United States. Some studies have shown that short-term access to HFCS can cause increased body weight, but the findings are mixed. The current study examined both short- and long-term effects of HFCS on body weight, body fat, and circulating triglycerides. In Experiment 1, male Sprague–Dawley rats were maintained for short term (8 weeks) on (1) 12 h/day of 8% HFCS, (2) 12 h/day 10% sucrose, (3) 24 h/day HFCS, all with ad libitum rodent chow, or (4) ad libitum chow alone. Rats with 12-h access to HFCS gained significantly more body weight than animals given equal access to 10% sucrose, even though they consumed the same number of total calories, but fewer calories from HFCS than sucrose. In Experiment 2, the long-term effects of HFCS on body weight and obesogenic parameters, as well as gender differences, were explored. Over the course of 6 or 7 months, both male and female rats with access to HFCS gained significantly more body weight than control groups. This increase in body weight with HFCS was accompanied by an increase in adipose fat, notably in the abdominal region, and elevated circulating triglyceride levels. Translated to humans, these results suggest that excessive consumption of HFCS may contribute to the incidence of obesity.

Miriam E. Bocarsly, Elyse S. Powell, Nicole M. Avena, Bartley G. Hoebel. High-fructose corn syrup causes characteristic of obesity in rats: Increased body weight, body fat and triglyceride levels. Pharmacology Biochemistry and Behavior, 2010; DOI: 10.1016/j.pbb.2010.02.012

For a more layman friendly summary of the article, read the sciencedaily release.

Do reconsider your food habits to avoid HFCS. Note that this whole corn syrup boondongle is made possible by the US government’s insistence on providing billion dollar subsidies to its farmers to grow corn while imposing tariffs on cane sugar from the tropics to make it less attractive. Free trade, my A$$.

Thanks to Tom Laskawy at grist for the blog post.

Al Franken is good for health

You know what's in your food and many beauty products. Senator Al Franken wants to make it possible to see exactly what's in your household cleaning products as well.The Minnesota Democrat introduced a bill in the U.S. Senate requiring producers to fully disclose all ingredients on their product labels, including those suspected of causing long-term harm. Currently the warnings on cleansers are designed to prevent immediate harm due to swallowing, splashing in eyes or other unintended uses.

via Kare 11

It would seem common sense to have information on labels, especially on the harsh and powerful chemicals we use every day. You may not understand what they mean, or how to pronounce the chemical names, but you don’t have to! Organizations such as the Environmental Working Group have extensive information on common high volume chemicals so people can match what they see on the label with what they would like to avoid.

But it is not the law of the land in the US, or Canada for that matter. Al Franken, comedian, talk show host and an intelligent man turned senator would like to change that in the US. Of course, we in Canada would benefit as well.

Chemical manufacturers aren’t having any of this.

There’s always a concern about turning labels into encyclopedias,” Brian Sansoni of the Soap and Detergent Association, in Washington, D.C., told KARE Tuesday.

Pretty insulting, claiming that your consumer does not like encyclopedias, or is not capable of reading and googling.

Information helps drive consumers to safer alternatives. If you see two cleaners, both of which claim to work equally well, a quick read of the ingredients will drive you to the safer (or simpler) choice. Clearly, sale by obfuscation is the preferred marketing strategy here.

If I were American, I would call my senator/congressperson and ask them to support Al Franken.

Sugar Pills, now more effective!

Well, all sugar is not bad for you. Apparently, when given to you in pill form by someone wearing a white coat with a pleasant demeanour, it can cure all kinds of ills.

It’s not that the old meds are getting weaker, drug developers say. It's as if the placebo effect is somehow getting stronger.The fact that an increasing number of medications are unable to beat sugar pills has thrown the industry into crisis. The stakes could hardly be higher. In today's economy, the fate of a long-established company can hang on the outcome of a handful of tests.

Via Wired

An interesting article that takes the reader through a recent history of placebos, why they seem to work better now than they used to, and tangentially, why the competitive research paradigm of the pharmaceutical industry delayed recognition, and continues to delay possible fixes and therapies.

A few things about the placebo effect:

  1. There appears to be a physiological and neurological basis to the effect, something that can actually be turned off by deactivating the body’s natural production of opioids.
  2. This effect is triggered by various patient stimuli, including exposure to advertising, faith in the medicine, doctor bedside manner, etc. It appears that for minor ailments, these effects could be as strong as the medication prescribed.
  3. It is not short lived, the effects can linger well after consumption of sugar pills.
  4. Despite all this, the article states that we are no closer to finding the most appropriate way to administer placebos (Hmm, or are we? Read on!).

Pharmaceutical companies conduct hundreds of clinical trials every year. They are not required to publish them in most countries, so negative results, failures, etc. which reflect badly on the company’s stock price are routinely hushed up. This means that the mounds of data that show tested drugs as no better than placebo are not accessible for research. This is one of the greatest drawbacks of competitive research paradigms, the lack of cooperation, the inefficiency that comes from duplication of negative results, and the lack of statistical power that comes from inability to use all the data available. In a milieu where knowledge = stock price, this is the logical approach, but something to note next time an Ayn Rand acolyte comes bleating to you about the beauty and perfection of the market. You might ask “What are some options to the current patent exclusivity driven regime”? My favourite economist Dean Baker of the Center for Economics and Policy Research has written extensively about the drug development process and alternatives in his excellent (and free to download) book The Conservative Nanny State, I suggest reading at least the chapter on drug development and patents!

Anyway, back to placebos, what to do? How to administer sugar pills in a quasi-official setting for minor ailments. It’s almost like you need a parallel paradigm of medicine that dispenses sugar pills that did not have to go through double blind randomised clinical trials. it would help if this paradigm uses vaguely scientific terminology while doing very little harm. It would work in conjunction with the conventional approach, not in competition so there is little danger of people taking sugar pills for malaria!

I give you, Homeopathy!!! This blog(ger) is no stranger to this wonderful form of medicine, involving concepts such as the memory of water, similars, dilution, etc. When I wrote about homeopathy last year, it was more in relation to the psychological aspects of my experience with it. I (and I assume you did not click through to read!) wrote about my parents’ great and enduring relationship with their homeopath, and the benefits it brought them. Back in India this time around, it was suggested that I take some homeopathy for a cold I was developing, which I did (yum, sugar!). The cold went away in a few days 🙂 There was some swine flu medicine being passed around as well (I did not partake), which worked too, nobody at home got swine flu 🙂

So, how to make it work? It already works in India because belief in the efficacy of homeopathy is well established. As long as the homeopath is well qualified in basic diagnosis, and crucially, knows when to punt the patient into conventional therapy, the system works to a certain extent. But what about a society with no such foundation? Do you go to a clinic with both an allopath and a homeopath, and if your ailment is one where placebo works about as well, let the homeopath make some well diluted similars for you to consume? How to settle turf wars? Would it be better for the allopath to feign develop an expertise in homeopathy and make that work for her in treating the patient? Would they apply the most important lessons in homeopathic treatment, Listen, Empathise, Soothe?

I don’t know. It is not my nature to believe in sugar pills, faith, or advertising. So it is hard for me to say what would work. But given that sugar pills work well, it is vital for society to find a way.

Soda = Fat

Sodat Fat

From The New York Department of Health

Try this experiment at home: Take two and a half cups of water, add 15-20 teaspoons of sugar and stir to dissolve. If you haven’t broken your wrist with all this action, take a sip or two, or gulp it down. No worries, you’ve just had all the nutrition in a typical soda!

That’s the message the NY Department of health is sending out with its new PR campaign against soda. Pretty gross and effective, I must say, though I would go one further and put it on every label of Coke, now wouldn’t that be nice!

NC Smoking ban now inevitable?

Well, it has taken less than a decade (I am a pessimist), but looks like smoking in bars and restaurants may finally be over and done with in my old home state of NC.

Note that there is currently a HUGE loophole in the senate version of the bill, it permits smoking in “private clubs”. Many bars in NC designate themselves as “private clubs” to circumvent prohibition era (or thereabouts) laws that mandate liquor serving establishments to get a certain percentage of their revenue from food. So, my favourite Chapel Hill drinking establishment, The Dead Mule (no website, sorry!) is supposedly a “private club” – You supposedly pay a one time membership fee (usually less than 5 bucks), and are supposed to “sign in” any members and guests. This was all a farce anyway, and the Mule got extremely smoky, it was quite disgusting after a while.

One hopes that the final bill will make the ban universal. Bans like this work best when they don’t favour one group of establishments over the other for no real reason. The people who work at the Dead Mule are equally entitled to clean air.

1.5 cautious cheers, let’s see what happens in the end…

The state Senate voted Thursday to ban smoking in bars and restaurants in North Carolina. It set the stage for what would be a historic prohibition of a product that created thousands of jobs, built Duke and Wake Forest universities and has long been an integral part of the culture in the nation's top tobacco-producing state.

House members passed a tougher version last month, meaning that lawmakers will still have to work out a compromise, assuming the Senate passes the measure in a second vote on Monday. The bill passed Thursday by an eight-vote margin, 26-18, so that seems likely.

via State Senate OKs smoking ban – Politics – News & Observer.

Circumcision and AIDS – Revisited

condom.jpg

A post I wrote quite a while back on circumcision and AIDS remains my most commented post ever. In it (if you’re too lazy to click) I said that while research indicating a reduction in HIV infection in circumcised men was promising, there were a couple of concerns. One, that this could be a distraction from the single most effective prevention measure (no, not abstinence!), condom use. And two, that in certain cultures, especially among Hindus, this would be an absolute no no because circumcision is identified with being Muslim.

Anyway, in a review article, the Cochrane Centre in South Africa summarizes results from a meta analysis of a number of trials indicating a 50% reduction in HIV incidence among circumcised males. At this point in time, it is clear that circumcision is effective in reducing HIV incidence among heterosexual males. Based on this, the institute encourages the widespread use of circumcision as an AIDS prevention strategy.

So, am I still circumspect? Absolutely. I am still concerned that this research will be misinterpreted in a way that discourages condom use. In fact, the authors note that circumcised men indulged in more risky behaviour. Also, the incidence of HIV in the women these men were sleeping with increased from 9.6% to 13.8%, a 40% uptick. This increase was not statistically significant. No arguing with that, though the study was stopped early once it was clear that the men were helped, never mind the women, or reaching statistical significance in their case.

Given that it is very unclear what the effects of circumcision are on anything other than circumcised penises, which are only one half of the equation (or less!), I don’t think it is responsible to call for widespread use of circumcision as a public health strategy for the prevention of HIV until its effects on the other parties are known. While people are aware of this issue, I don’t think the science or the cultural landscape promote the use of circumcision as a HIV prevention strategy until its proven that women are not at risk from increased HIV incidence either biologically from a yet unknown mechanism, or socially from increased risk taking.

Men have more power in most societies to demand and receive sex on their terms. So the male centric nature of this research, and the conclusions drawn are disturbing. How irresponsible is it to encourage a public health strategy that appears to increase risk taking behaviour among men when the effects on the women are yet unknown, with only a statistically “insignificant” 40% increase in HIV incidence among women being observed?

I am. for very good reason, still circumspect on circumcision.

Whisky flavoured condoms courtesy bruno  girin’s photostream used under a creative commons license. Now how’s that for a turn on, whisky!

Health Canada report ties asbestos to lung cancer

Health Canada sat for more than a year on a report by a panel of international experts that concludes there is a “strong relationship” between lung cancer and chrysotile asbestos mined in Canada.

Health Canada received the report in March 2008, resisting calls from the panel chairman to release the findings despite his plea last fall that the delay was “an annoying piece of needless government secrecy.”

Canwest News Service obtained the report under Access to Information legislation, but the request took more than 10 months to process.

Vancouver Sun

Yes, dog bites man anywhere else except Canada, which has a hard time accepting that it routinely exports products that kill people. The “annoying piece of needless government secrecy” is neither needless or annoying. It protects a dying industry with a few, powerful stakeholders in Quebec, an important swing political province, so there’s need for it! Annoying – your seat “buddy” on the bus yammering on their cellphone, cancer, well, I don’t know, you tell me!

Expect little to change from this report. It does mention that there is little danger from “Canadian exposure levels”, conveniently forgetting that 90% of the export is to developing countries where there are fewer safeguards. This feeds into the Canadian government line that “chrysotile” is safe if used correctly. If you think this line of reasoning is familiar, it is. The tobacco industry used it routinely till recently.

Shame.
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