Saturday, November 29, 2014

Uncertain Health in an Insecure World - 12

“Terror’s Toll”

The greatest weapon in a terrorist’s arsenal isn’t a hijacked airplane or a ground-to-air missile or an explosive vest.

It’s fear.

When humans are subjected to the threat of terror, and nothing deadly actually occurs, the terrorists are still winning.

Their victims feel powerless.

It is not surprising that individual survivors of terrorist attacks (9/11, 7/7, The Boston Marathon bombing, Mumbai, etc.) experience early post-traumatic stress disorder (PTSD) at rates twice that among motor vehicle accident survivors (38% versus 19% in a 2005 study). A minority develop chronic PTSD, often in response to continuing stress. Repeated terror acts in countries such as Israel cause psychological distress in the affected communities, with measurably elevated PTSD prevalence.

The World Health Organization’s (WHO) 2005 analysis of 57 million global deaths tallied 35 million deaths from chronic diseases, 17 million deaths from infections (HIV/AIDS, malaria, tuberculosis) and 5 million deaths from terrorism, civil war and one-sided violence (i.e., genocide).

I did not know that!

There is a growing body of evidence that another long-term consequence of being chronically fearful and powerless is higher mortality & morbidity related to substance abuse in conflict-affected populations.

Why is that?

Terrorism & violence damage health and economic infrastructures. Health care services are disrupted (electricity, water, sanitation) and health care workers often flee. During armed clashes in Somalia in 2013, basic health services such as polio vaccinations suffered. Agriculture and food rations (other than home brewed alcohol) dissipate. Forced resettlement marches and refugee camp overcrowding exacerbate these strains.

Not surprisingly, witnesses to extreme personal or family violence are deeply traumatized.

A 2013 report comparing pre-2000 to 2002 substance abuse disorder disability-adjusted life years (DALY’s) in 182 WHO member countries showed that a 1% increase in deaths due to terrorism & violence was associated with a 0.1% increase in alcoholism and a 0.12% increase in drug abuse. If there were 50,000 more terrorism & violence deaths beyond the baseline, there would be 220,000 more DALY’s lost due to alcoholism and 83,000 more DALY’s lost due to drug abuse.
Fifteen to 44 year old males are most negatively impacted by terrorism & violence.

While the alcoholism and drug abuse gender gap continues to close in episodic terror-afflicted affluent nations (Europe, U.S., India, etc.), the gap in terror-afflicted developed nations like Syria, Pakistan and Indonesia remains wide. In these continuously violent countries, the diminished social status of women seems to perversely favor their health.

All this begs the question, “Does the war-on-terror body count consider terror’s indirectly affected victims?”

Of course not!

To walk in The Square, we must confront these terrifying paradoxes.

Without fear...

Sunday, November 23, 2014

Uncertain Health in an Insecure World - 11

“The Agony and the Ecstasy”

In both 15th century art and modern bio-medical research, these are inseparable.

In 1410 Florence, Donatello revealed his wooden crucifix at the church of Santa Croce to his contemporary Brunelleschi, who countered with his own creation in the Santa Maria Novella. Michelangelo saw both carvings, preferring Donatello's plowman Christ to Brunelleschi's more ethereal figure, which "was so slight that it looked as thought it had been created to be crucified".

With great art, the eye of the beholder is the crucial variable.

Whether in the film adaptation of Irving Stone’s 1961 Michelangelo biography, or in the translation of fundamental laboratory research into new treatments for patients, transformation is fraught with few successes and many failures.

True genius is rare.

Just what does the world get for its annual US$240 billion investment in science? Not much, according to Nobel Prize winners and high-impact research journal publishers. A 2009 Lancet article claimed that 85% of this investment is wasted.

Does science need a forensic audit?

In a rush to generate a "health dividend", thereby achieving profit or re-election, the private and public sector sponsors of bio-medical research pervert the slow deliberate process of discovery.

Science is a marathon, not a sprint.
Academics assume that bio-medical literature publishing is methodologically sound… innovative… reproducible. However, the 2013 Nobel Laureates in Medicine & Physiology have recently boycotted so-called “luxury journals” (i.e., Nature, Science, Cell) due process integrity issues.

That’s a troubling sign.

Like Renaissance artists competing for a wealthy patron’s eye or critical acclaim, scientists see the selective peer-review vetting process as noble… cleansing… robust…  The 2013 Nobel Laureate in Physics described himself as an “embarrassment” to his university for having so few research papers published.

Several funding fundamentals are wrong.

The average age of researchers receiving their first National Institutes of Health (NIH) operating grant is now over forty years. Only 60% of NIH-sponsored clinical research trials are published within 3 years of completion, at a cost to publish of more than US$200,000 per paper. The impact of a research paper is measured by the number of times it is cited by others - the cost of generating a citation now exceeds US$11,000!

Increasingly, academic rewards are misdirected and difficult to connect to true quality.

The very essence of top quality bio-medical research – what renders it important work – is often lost in the seeing for a lack of careful looking.

So whether you're standing in Piazza Santa Croce or in The Square, keep a critical eye!

Thursday, November 20, 2014

Uncertain Health in an Insecure World - 10

“Bored to Death”

Circa 2000, a groggy post-Millennium world awoke to a chronic disease pandemic.

Unless you’re a global public health maven, there hasn’t been a lot of excitement about this rapidly expanding threat.

The World Health Organization (WHO) calls chronic diseases ‘non-communicable diseases’ (NCD). Dr. Douglas Bettcher, WHO Director of NCD Prevention & Control, recently warned us that, “In this globalized world, we cannot isolate ourselves… from either Ebola or NCD’s”.

Unlike Ebola, you can’t “catch” a chronic disease.

Chronic diseases are defined as incurable illnesses present for >1 year that require ongoing medical care and that may affect a person’s daily life. The main chronic diseases are coronary heart disease & stroke, type-2 diabetes, cancer and chronic lung disease.


But in 2005, the Agency for Healthcare Research & Quality (AHRQ) reported that 80% of American >50 years old had one chronic disease – that adds up to >60 million Americans. In 2005, the World Health Organization (WHO) estimated that 35 million people would die of chronic diseases, and projected that figure would increase to 41 million by 2015!

Once a chronic disease causes organ damage, it’s almost impossible to reverse.

The longer people around the world live, the greater their proclivity towards one or more vital organs – heart, lungs, pancreas, liver and bone marrow – failing them. We have discussed “brain failure”. More than 83% of dementia patients also suffer the profound effects of co-existing chronic medical conditions during the average 7-10 years before death.

Associated health care costs adversely affect undeveloped country economic growth & development, thwarting aspirations of developed nation status.

Once largely the selective burden of developed nations, chronic diseases are now negatively transforming the less developed world. This growing scourge visits 80% of global chronic disease deaths on low and middle income countries. In poor countries, maternal-fetal malnutrition and low birth weight predict future chronic diseases.

Of Americans aged >70 years, 90% have at least one chronic disease.

Developed nation health care systems burdened with the rising cost of caring for patients living with chronic diseases are actively exploring the potential benefits of chronic disease prevention. Singapore spends only 5% of GDP on health care by focusing on social interventions in their 70 year old “Auntie Jane” population.

Nepalese public health educator/advocate, Lonim Prasai Dixit, espouses the WHO ‘ABCDE’ life plan for reducing the burden of chronic disease – Avoid alcohol, Be physically active, Consume limited salt & sugar, Don’t use tobacco, and Eat plenty of fruits & vegetables.

Sounds quite simple…

But it’s incredibly difficult (and often financially unfeasible) to motivate seemingly un-sick, asymptomatic people to adopt these lifestyle changes.

Other experts call chronic diseases “lifestyle diseases”.

Wherever you live on Earth, the wear & tear of life (high blood pressure, type-2 diabetes, environmental & ingested toxins, and obesity) is taking its toll.

The chronic disease behemoth is steadily advancing on The Square.

High time to wake up!

Uncertain Health in an Insecure World – 9

“Brain Failure”

Forty million people world-wide have some form of what Dr. Sube Banerjee of Brighton & Sussex Medical School calls “brain failure” – more commonly dubbed dementia. The World Health Organization (WHO) estimates the global dementia prevalence doubling time at twenty years – from 35.6 million in 2010 to 115.4 million in 2050.

Sadly, many Gen ‘Y'ers’ will become the fodder for Gen ‘D’… the Dementia Generation.

The burden of "brain failure" is being acutely felt by global economies.

The current annual global cost of caring for dementia patients’ dependence & disability tops $600 billion, or 1% of global GDP. Dr. Banarjee notes that this “bucket of money” exceeds that being spent on more cost-effective killers – cancer, stroke and heart disease.

Previous posts have introduced you to a political leader who died of Alzheimer’s disease.

You may have a relative who is afflicted or who has succumbed to some type of progressive illness that has sapped cherished memories and cognitive functions. The fear of such a terrifying neurological decline contributed to the world’s greatest comic, Robin Williams, tragically taking his own life.

For centuries, doctors have studied other organ failures.

Heart, liver, kidney, bone marrow, and pancreas failure research have led to new medicines and to the capacity to safely transplant failed organs with healthier donor organs that prolong and improve lives.

But “brain failure” is a medical brick wall – essentially untreatable and uniformly terminal. There is no near-term likelihood of solid organ brain transplantation, although stem cell therapies hold great promise for regeneration of selective areas of damaged neurological tissue.

Dementia patients stay at home to avoid the confusion & panic of being out in the world.

Their unspent disposable income impacts the economy. The British have calculated that the unspent “dementia pound” amounted to £11 billion in 2014, and project that this figure will double to £23 billion by 2030. Financial institutions recognize the risk of dementia, betting that memory chip & personal pin cards will allow customers to bank independently for longer.

Dementia disrespects the boundaries between health care and social services.

The U.K. Alzheimer's Society has created 'dementia friendly communities' where taxi company employees are trained to recognize confusion and panic attacks among their customers. U.K. prime minister David Cameron launched a Challenge on Dementia to improve care and fund research.

Whether your granny calls a taxi at 1 AM to get to breakfast with old friends, or your president can't recall the name of his secretary of state, our world's security - writ small or large - is at risk.   

So wear your wrist watch upside-down... and pray.

The Square can be a unfamiliar, scary place.

Wednesday, November 12, 2014

Uncertain Health in an Insecure World - 8

“The Needle and the Damage Done

Neil Young’s 1972 song decried the overdose death of a Crazy Horse roadie and the heroin use by the band’s guitarist – signs of a troubling time in America, when inner city blacks were being decimated by the needle.

The developed world imports nearly all the opium and heroin that the less developed world produces. Despite decades of international police incursions, narco-terrorist threats and murders abound in Mexico & Central America. And despite Gulf wars and extended Southwest Asian military tours, the Taliban and others harvest the raw material unmolested. In 2013, Afghanistan produced more opium than the rest of the world combined (see Afghan heroin bag label).

But the gateway drugs to heroin have changed. In 1995, Purdue Pharma began marketing prescription oxycondone as OxyContin™, ostensibly to treat chronic pain. Prescription opiates quickly became the dark, slippery path to heroin addiction and death, particularly in affluent health-insured suburbia.

By the millennium, heroin was also a white persons’ problem.

In 2007, three senior Purdue Pharma executives pleaded guilty in U.S. federal courts to misleading doctors and patients by representing OxyContin™ as being less addictive than similar opiates. As Purdue’s “responsible corporate officers”, the execs bore responsibility for five years of addiction and abuse that brought billions of dollars of sales to the company. U.S. Department of Health and Human Services banned the Purdue executives from doing business with its health care payer (Medicare) for twenty years – a ruling that was recently unsuccessfully appealed.

Pick your poison.

Since 1999, U.S. prescription painkiller sales have quadrupled, and related overdose deaths have tripled. Last year’s 16,000 pain pill-attributable deaths were double those from heroin and cocaine. According to the U.S. Centers for Disease Control & Prevention (CDC), there are now >100 U.S. all-cause overdose deaths per day, making this the leading cause of injury death. The CDC reports that for every death, ten people are admitted to hospitals for substance abuse treatment.

Public outrage and policy responses have kicked in.

Grassroots local campaigns to make the opioid antidote naloxone (Narcan™) available to first responders have blossomed, saving some 3,000 lives per year in the U..S. Official state and federal efforts to regulate the number of prescription painkillers ordered via more restrictive narcotic drug schedules and a 30-day dispensing limit have received little traction.

These sobering statistics miss the point.

Blame does not lie solely with the heroin dealers, Afghan war loads or Pharma executives, but with some doctors and their professional governing bodies. Physician prescribing patterns and government-run drug coverage payment plans contribute to >12 million Americans admitting to using opiates like OxyContin™ for non-medical reasons in 2010. And doctors running illegal pill mills need to go to jail!

Most doctors are not trained to treat chronic pain.

2011 estimates were that suffering & disability from chronic back pain and cancer, fairly cited as a medical necessity for these drugs, topped 100 million Americans. In 2014, the U.S. Agency for Healthcare Research and Quality (AHRQ) concluded that the long-term use of prescription opiates for chronic pain increases the risk of “serious harm” to patients (i.e. overdose deaths, fractures, heart attacks and sexual dysfunction), with little evidence in support of a health benefit.

So, Neil Young was prescient when he stated the obvious about narcotic addiction, “I’m not a preacher, but drugs killed a lot of great men”.

The developed world has come full circle.

Sadly, the damage is being done all over The Square.

Wednesday, November 5, 2014

Uncertain Health in an Insecure World - 7

"What’s in a Word?"

The counterpoise of chronic disease management with acute Ebola outbreaks confuses developed world health systems.

The emerging Hobson's choice question for their patients is:
Q: Would you rather die in hospital at age 75 after thirty years of chronic disease, or die acutely in a hospital at age 45 within three weeks after contracting Ebola?

The unsatisfying answer to this tricky question is:
A: Most of the >750,000 staffed U.S. hospital beds are configured for acute (not chronic) patient care, and there are currently only 11 U.S. hospital beds judged Ebola care ready by the CDC.

To health care systems in the developed world, and now in the less developed world, there is no question as to which type of death is more cost-effective... It's Ebola.

Degraded in common usage by medical half-truths and media spin, health care confusion abounds.

So let's clear up a few of the words in the cloud...

Contamination: Medical providers who don gowns, gloves & masks for routine patient care face an immense risk of self-contamination when removing similar gear after caring for an acutely ill Ebola patient. Daily use of acute (intubation, surgery) and chronic (dialysis) life-saving measures are known risks for Ebola virus spread via contaminated body fluids. Complex decontamination protocols are much more robust than simple aseptic techniques (hand washing) for acute and chronic patient care.

Isolation: Protective isolation of medical care providers against acute (meningitis) and chronic (tuberculosis) infections is not the same as reverse isolation of patients with weakened immune systems. The near-certainty that an Ebola-infected person walking into the emergency room of a nationally-accredited metropolitan hospital will be promptly ‘isolated’ is ironically coupled with high probability that these less specialized medical facilities cannot reliably treat this illness.

Transmission: Unlike the obvious blood splatter from an open wound onto surgical scrubs, Ebola transmission is typically subtle – the virus unwittingly borne by caregivers and their personal contacts – coworkers, families, passengers (and yes, possibly their pets). Most Ebola victims cannot say how they became infected. Public health experts’ disease control and index case containment efforts are not the same as government-mandated or self-imposed personal quarantine.
Spending: Some of the world’s most expensive (cost per capita) health care systems struggle to control their ever-escalating acute & chronic care expenses (by “bending” national cost curves) through purchasing groups (by 'commissioning' in the UK) and incentives (by 'pay-for-performance' and 'accountable care' in the US). Looking in the mirror, the public health care system reality sounds more like, “We just buy things… We don’t do quality”.

Investing: Some of the world’s most improved and cost-effective public health care systems, such as New Zealand, have “devolved” their cost-control strategies. Their new modus operandi reflects a national belief that “Spending is palliative, while investing is hard-nosed”. Private sector investing in public health care is controversial. However, it is undeniable that such strategic partnerships - with the partners sharing financial “skin in the game” - are a powerful incentive for value creation.

The forecast is for word cloud clearing!

Plain talk is echoing across in The Square.

Tuesday, November 4, 2014

Uncertain Health in an Insecure World - 6

"We’re From the Government and We’re Here to Help"

Paraphrasing Ronald Reagan’s nine “most terrifying words in the English language”, health care has become a raison d’ĂȘtre for most jurisdictional governments. Even the most hardened trickle-down health care funders now acknowledge that the connection between socioeconomic supply factors and medical care services demand is neither nuanced nor opaque.

The International Social Survey Programme (ISSP) of public attitudes in 33 countries shows that the economy (25%), health care (22.2%) and education (15.6%) were the top ranking concerns among people around the world between 1993 and 2013.

Not surprisingly, modern political parties repeatedly run on one of two policy planks – economic growth or better health care. The interplay between the public’s desire for better health and the mounting cost of health care as a percentage of GDP is undeniable.

The average political election cycle length of between just 2-4 years does not help matters. Inevitable political transitions spawn endless acronym-laden health care policy and process reforms.
Beyond serving up easy fodder for health care watchdogs and the press, continuous governmental cycles of re-invention, re-organization, re-purposing and re-positioning often culminate in vote pandering and organizational change fatigue. 

Here's what we know to be true...

The common thread of publicly-financed health care system breakdowns is a lack of courageous governmental health policy. The private sector profitably manages the related collateral damage.
The unifying threat is massive health care system bureaucracies parsing banal governmental policies. Entrenched bureaucrats quickly conclude that they can hunker down and survive most changes.

The antithesis of real progress – institutionalized risk aversion – renders situational hopeless-helplessness the new norm. People sick of hearing alarm bells simply turn them off.

Unlike in Reagan Country, your government has not likely “signed legislation outlawing the Soviet Union. The bombing begins in five minutes”. (1985 President Reagan mike-check quip)

But like in Reagan Country, your government is probably at the heart of the problems with your public health care system.

Welcome back to The Square!

Sunday, November 2, 2014

Uncertain Health in an Insecure World - 5

The Boogeyman

In Dr. Khaled Hosseini’s acclaimed first novel ‘The Kite Runner’, the protagonist's polio-afflicted family servant, Ali, had a “twisted and atrophied” right leg. The children of Wazir Akbar Khan neighborhood called him Babalu – The Boogeyman. Ali gamely navigated the dangerous streets of Kabul, until he died after limping onto a landmine in Hazarajat.

With the recent observance of the 100th anniversary of Dr. Jonas Salk’s birth and World Polio Week, it is worth noting that while hundreds of millions have been vaccinated world-wide over the last sixty years, polio remains endemic in Afghanistan, Pakistan and Nigeria. The World Health Organization (WHO) has declared a wild polio virus exporting emergency in several countries, including Pakistan, Afghanistan, Syria, Iraq, Cameroon and Equatorial Guinea.

Yes… polio myelitis… febrile crippler of young bodies, diabolical spawner of the iron lung, has made a terrible resurgence in the war torn and teeming cities of southwestern Asia and Africa.

Polio is a stigma – a national mark of Cain – symbolizing the breakdown of a society.

Worldwide, the widespread use of oral polio vaccine has reduced cases from >350,000 per year in 1988 to just 416 in 2013. With only one in 200 cases resulting in paralysis, and only 5-10% of those experiencing respiratory symptoms, polio is more of a lurking health threat than a deadly epidemic. 

In his Pulitzer Prize winning treatise ‘Guns, Germs and Steel’, Jared Diamond chronicled civilization’s ascent in the face of decimating plagues and contagions, including epidemic polio which was first documented in 1840.

The same disease that struck fear into the hearts of parents for generations until the 1950’s (see the photo of 1954 vaccinations in Canada), sparing neither the rich nor the poor, has since been essentially eradicated in the developed world. Type-2 polio has been absent since 1999.

Unlike the yearly influenza vaccines that must tack to the unpredictable shifts and drifts of hyaluronidase (H) and neuraminidase (N) mutations, there is no polio “season”. In fact, polio is one damn boring virus – the three polio virus types have not mutated since the days of Salk and Sabin.

But polio is not just another debilitating childhood disease. The recent resurgence of polio, a disease preventable through childhood vaccination, is an indictment of the public health systems of the worst afflicted countries.

More modern “great vaccinators” who boldly predict the availability of millions of anti-Ebola vaccine doses by 2015, must also privately cringe at the thought of millions of children at risk failing to be immunized against polio.

 Human rights workers and relief organizations alike are eternally frustrated by embargoes and threat lists that prevent the delivery of inexpensive vaccine doses into the hands of enemies of their polio-free states.

Regional strife is the greatest impediment to the global eradication of polio.

Polio, not poor Ali, is The Boogeyman for many of the world's children.

Let's stop polio from stalking The Square.