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The Year Of Health And Politics

January 4th, 2010, 04:01 am admin Leave a comment Go to comments

No, this isn’t yet another Top 10 list. But looking back at 2009, I do think it’s worth looking at a few of the major health stories we covered here.

One thing I won’t list is the efforts on the health reform bills currently making their laborious way through Congress. It was one of the most important health stories of the year, but we don’t have an ending for it yet.

The other health story of the year, and no surprise to anyone who reads Daily Kos regularly, was the 2009 H1N1 (aka swine flu pandemic), the first in 41 years. Oh, it’s not just me saying so. It’s also HealthDay, CNN, and news editors in Canada:

The H1N1 virus was the top Canadian news story of 2009, according to 70 per cent of the country’s editors and news directors in The Canadian Press’s annual survey of newsrooms.

“It was a coast-to-coast story that people followed with interest no matter where they lived in Canada,” said Lesley Sheppard, managing editor of the Moose Jaw Times-Herald, in Moose Jaw, Sask.

But equally important, especially for the contrast and the long term implications was this story: On Cancer Screening, Politics, and Communication. As I wrote on the Arena today:

This past year has two particular health stories outside of the health reform efforts: pandemic (excellent reviews by the bloggers and the press) and mammogram guidelines. Both have deep implications for how our health system functions. But the most interesting observation is how the former (pandemic preparedness) has thankfully not been politicized. Alas, the same cannot be true for the latter. Despite that, evidence based medicine and the need to establish guidelines for what works and what does not are essential to health quality improvements as well as cost control (doing well by doing good), and good sense will prevail. All political parties and persuasions should be pushing for that, and in the end, we will adopt evidence based medicine and improve the system in the next year and years to come.

I want to highlight some of the work done at Flu Wiki by our volunteer bloggers and newshounds, who chase down stories from all over the world, but I also want to point out this excellent summary of how the pandemic seemed to those who were looking for it to happen (Real-world lessons learned.)

Interestingly, in his year-end summary, Donald McNeil writing for the NY Times notes some things that were tough decisions, but decisions that panned out:

…the relatively cautious decisions by the nation’s medical leadership contained the pandemic with minimal disruption to the economy.

For example, in the early days, they ignored advice to close the Mexican border and pre-emptively shut school systems. They released part of the national Tamiflu stockpile, but did not give it to millions of healthy people prophylactically, as Britain did. They ordered vaccine made with a 50-year-old egg technology rather than experimental methods. They bought adjuvants — chemical “boosters” — that could have stretched the first 25 million vaccine doses into 100 million, but did not use them for fear of triggering a backlash among Americans made nervous by the messages of the antivaccine movement.

To alert the public without alarming it, a stream of officials — from doctors in the navy blue and scrambled-eggs gold of the Public Health Service to a somber President Obama in the White House — offered updates, at least twice a week for months.

But the last paragraph is the important one:  

Dr. Frieden said he thought a victory over the antivaccine movement had been scored. Nearly 60 million people have been vaccinated, including many pregnant women and children, with no surge in side effects.

John P. Moore, an AIDS researcher at Weill Cornell Medical College, was less sure. Dr. Moore, who spent years fighting AIDS denialism, has called skepticism about flu vaccine “an unholy alliance of the left and right” because it joined the liberal natural-medicine proponents with anti-big-government conservatives.

“It’s hard to say if it hurt or helped,” Dr. Moore said, pointing out that polls still show a large minority of Americans rejecting the vaccine. “As with AIDS, people have to die before others understand the consequences of ignoring science-based medicine.”

Dr. Frieden is, alas, wrong, if he thinks facts will simply trump opinion, at least not without effort. Only day to day discussions in doctors offices and by officials on a recurring basis will fight the well-funded anti-vax misinformation machine. Well informed people have the right to be skeptics, but the organized for-pay misinformers do us all a disservice, particularly high risk patients who need their vaccines. This one was a publicly paid for vax, no extra charge, but the billions invested in novel manufacturing techniques are yet to pay off, though they are getting closer to reaching fruition.

Was this a less than feared outbreak? Absolutely, though it hit children especially hard. H5N1 (bird flu) is the mother of all flu strains (greater than 60% mortality at the moment), and worse things than swine flu are still out there. But complaints about hurricane warnings because the storm wasn’t as bad as feared are equally misplaced. Well, at least those that deny the possibility of pandemics have been quiet for a few months (don’t count on it lasting any longer than that.)

As for mammograms and guidelines, nothing highlights the dangers of politicizing medicine like that topic does. But what’s important is the concept that everything we do in medicine is right because it’s the US and we do everything best. This “medical exceptionalism”, as highlighted by National Geographic with their “cost of care” graphic, is simply not true.

The United States spends more on medical care per person than any country, yet life expectancy is shorter than in most other developed nations and many developing ones. Lack of health insurance is a factor in life span and contributes to an estimated 45,000 deaths a year. Why the high cost? The U.S. has a fee-for-service system—paying medical providers piecemeal for appointments, surgery, and the like. That can lead to unneeded treatment that doesn’t reliably improve a patient’s health. Says Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health who studies health insurance worldwide, “More care does not necessarily mean better care.”

But how do we get control of costs? By not spending it on things that don’t work, just because we always have. That means taking hard looks at futile end of life care, looking at cheaper ways to do things (like importing drugs from Canada), relying less on antibiotics that are inappropriately used. In other words, using evidence based medicine to determine what works and what does not (P.S., vaccines work and are very cost effective.) That’s exactly what the new mammogram guidelines do: suggest recommendations based on currently available data, even as they ruffle entrenched interests and entrenched thinking.

The reaction and blow back, which has been considerable, are less aimed at the actual guidelines (”talk to your doctor if you are woman under 50, because we really do not know what’s best”) than the way they were presented (somewhat naively in the midst of health reform debate, immediately hijacked by the “death panel” faction of the Know Nothing Party.) But if you really are serious about quality improvement and cost control, task forces like the U.S. Preventive Services Task Force (USPSTF) are essential in sorting through facts and opinion. And the more the process is politicized, the worse the country is served.

Don’t expect that to change any time soon. But serious health reform proposals will incorporate evidence based medicine to enrich and improve our lives. And get used to being challenged about what you think you know. That’s going to become an everyday part of our lives.

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