Last week, we learned that placebos were more common than we thought. Today, we learned that many more doctors were in fact prescribing a placebo, but didn’t know (and certainly weren’t about told it): Zetia adds nothing to the known benefits of a statin.

As you’ll recall, this study was finished years ago, and was to be released in March 2007, but it was not. There was a mini-scandal when the companies tried to change the end-point measures, and then Congress got involved.

So, how much money was spent on Zetia and Vytorin last year as we waited for the results? Let’s see …

Regarding Merck’s cholesterol franchise with Schering-Plough Corp. combined quarterly sales of Zetia and Vytorin rocketed 30% to $1.3 billion. Zetia sales grew 21% to $578 million, while Vytorin sales increased 38% to $686 million.

Wow … $1.3 billion is a big incentive to squash those results.

This is another reminder that companies are beholden to their shareholders to maximize profits. Doctors have a different goal: to use science to benefit our patients. These goals do not always align, and as in this case, can be diametrically opposed.

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Listen to Maphosa report

A new study reveals that more African doctors and nurses are working abroad than at home, which it says is contributing to the worsening shortage of health care professionals in Africa. From London, Tendai Maphosa has more in this report for VOA. 
 

Patients fall asleep in the long line of Tintswalo Hospital in South Africa, waiting for the doctor to attend them, 26 Aug. 2007 (file photo)

The new study says some 65,000 African-born physicians and 70,000 African-born professional nurses were working overseas in developed countries by the year 2000. It says this represents about one in five African-born physicians and about one-tenth of African-born professional nurses.  According to the British government, more than 17,000 doctors and nurses from Africa were recruited in 2007 to work in Britain.  

Co-author of the report, Gunilla Pettersson of Sussex University in the UK, tells VOA that the brain drain is cause for concern.

“The health situation in Africa is dire, so we are very interested in the impact of these emigration flows,” she said.

Pettersson says working conditions for African medical professionals must be improved to encourage them to remain in their own countries.

Analysts have long stressed an obvious link between economic and political instability and a brain drain.

The new health care study cites several examples of countries beset by civil war in the 1990s such as Angola, Congo-Brazzaville, Guinea-Bissau, Liberia, Mozambique, Rwanda, and Sierra Leone.  It says those countries lost more than 40 percent of their physicians by 2000. The report says Kenya, Tanzania, and Zimbabwe, which went through decades of economic stagnation, lost more than half of their physicians.
 
The United States and the UK are among the top destinations for African health professionals.

Britain’s National Health Service has a policy against directly recruiting medical personnel from sub-Saharan Africa, but it does accept African health professionals through recruitment agencies.

Abi Smith, a spokesperson for the British Medical Association, says her organization is concerned about the medical brain drain in Africa.  She says the association is encouraging African governments to improve training, working conditions and salaries for medical professionals in order to get them to stay at home.  But, she says there is also a human rights issue, the right of individuals to move about as they wish.

“People do have human rights to move, and I wouldn’t like to see any policy infringe that,” she noted.

Mason Ford, a spokesman for the international humanitarian group Medecins Sans Frontieres (Doctors Without Borders), says donor governments are throwing hundreds of millions of dollars a year at HIV care in Africa.  But he says developed countries and international donors can also do more to make it more attractive for medical professionals to stay in Africa. 

“Next to nothing goes into improving the working conditions of healthcare staff,” he said.  ” Donors have been very, very reluctant to pay salaries of health workers or pay for training through medical college.  These measures really, really ought to be funded by the international community as well.”

Ford says such assistance would provide long-term benefits for Africa by helping to stem the brain drain.

Experts compiling the new health care study acknowledge that the brain drain is not the only problem facing health care in Africa. 

“For example, in South Africa two thirds of the physicians serve only about one-fifth of the population in the private sector,” said report co-author, Gunilla Pettersson.  “Another example in Mozambique, 70 percent of the physicians live in the capital Maputo so they are thousands of miles away from the most remote parts of the country where health conditions are worse.”

The study, titled “New Data on African Health Professionals Abroad,” was published by the online journal Human Resources for Health.

In a recent opinion piece (or here), Betsy McCaughey, former lieutenant governor of New York and current adjunct senior fellow at the Hudson Institute, raves against mandatory health insurance, in fact she claims to know the “Truth About Mandatory Health Insurance”! This is accompanied by a caricature by Chad

Crowe, worthy of a feature in ‘How to Translate Polemics into Art’.

“Requiring catastrophic coverage (our parents called it major medical) probably is smart“, Betsy muses, but, in brief, comprehensive coverage would not solve overcrowded emergency rooms, and anyway many uninsured are immigrants (and – sarcasm intended – we know most of them are illegal = do not deserve health care) and healthy people should not be made to pay premiums covering the risk of sick people.

First, I doubt (and for her sake I hope) that Betsy has set foot in an ‘overcrowded’ ER in an inner city hospital recently, other maybe for a brief cameo appearance. I am not saying that giving everyone health insurance tomorrow would make this problem go away. But as someone who has trained at institutions running such ERs, I can attest to the fact that many (not all) visits are due to lack of preventive care, proper education and the availability of health care providers that actually see patients (the one’s that cannot pay beaucoup $$$).

Second, the notion that healthy young people should not pay more for healthcare than they consume is exactly the problem that has been bogging down the US system. Other countries have widespread or mandatory insurance – backwards places like Western Europe, you know – many of which the WHO rates better than the US on healthcare (France is No 1, Italy No 2, Spain No 7, Austria no 9, Netherlands No 17, UK No 18, Germany No 25, Canada No 30…. the US is a distant 37th). And by the way, the US also is not top of the list when in comes to fairness of financial contribution, as stated in the same report (the front runner here is Colombia, and there are 7 European countries in the Top 10). In Germany, for example, everyone shares the cost of healthcare, insurance is mandatory – the underlying principle here is called solidarity. And no, Germany does not have socialized medicine, and if you think solidarity sounds socialist, then read its definition here and un-wash your brain! It is basically risk sharing. If only the ones with the risk end up paying for it then healthcare can never be affordable for anyone even with a decent income – unless your are young (i.e. low risk) and healthy, which is not the majority of US citizens. Thank goodness that in the US, most young people will become old people later in life and thus consumers of healthcare (it would probably help if you could take your insurance from job to job). And yes, if you make lots of money and do not buy health insurance, you are probably either extremely shortsighted or fatalistic.

However the mean household income in the US is a somewhat meager $40+ k, and provided you do not have insurance through your employer, according to the Kaiser Family Foundation, an average family plan will run at ~ $11,000 (Oh, and a few thousand on top of that may be your deductible/co-insurance). Does that sound affordable?

That is not to say that healthcare consumers should not share responsibility , i.e. live healthier lives, for which many may need incentives (not punishments).
I think if US citizens – and their leaders – are not able to think out of the box of their Suum Cuique (“to each his own”) mentality, we are heading for healthcare Armageddon. And it won’t matter if we start with 23.7 million uninsured (Betsy, how is that number any better than 43 million?) or more, it’s going to go up, fast.

Crossposted at Stupor Cordis

There is a significant ongoing blogger discussion about health care reform, particularly the battle between those physicians who want patients to take responsibility more of their health care (and the costs) and physicians who want universal health care system to cover everyone. Over at the Happy Hospitalist, he pounds home the message that Free=More. PandaBearMD lays out the Free Loader worries. Meanwhile, Grahamazon responds about Social Justice.

It strikes me that “patient responsibility” has a similar flaw to the “get tough on crime” line: the vast majority of people don’t make rational decisions about their health care or their criminal tendencies. We’re trying to apply rational-thought theory to a realm where people aren’t rational. It’s as crazy as trying to encourage people to make rational decisions about who they are going to marry. Even though society places value in marriage, and gives it tax and legal benefits, we leave it up to the individuals to decide with whom to get hitched. Even though it is clear to practically everyone that some people are not marriage material, we still confer the same legal benefits of marriage. And as for who makes a good parent, we’ve decided to let just about anyone reproduce (see above) and we’ll work with the consequences as best as we can.

People don’t think rationally about their health. And I don’t think we could make them. We could try to estimate the value that patients place on their own lives, and provide that level of care. Obviously, we couldn’t ask patients to put a dollar sign on their lives (“Priceless, you jerk!”), but we can make assumptions based on their actions.

Seat belt are estimated to be cost less than $100 per Quality Adjusted Life Year (QALY). Airbags cost $44,000 per QALY. Mammograms? About $175,000 per QALY.
So, if you have a patient who buys a car with airbags, but refuses mammograms, then they must value their life at somewhere between $44,000 and $175,000 per year.

But what if the patient doesn’t use a seat belt, but gets her mammogram? Or what about two similar patients who present with breast lumps, one who gets annual mammograms and one who doesn’t? Does the first value her life more, so she should get more treatment than the second for the same cancer?

Yes as a physician, I’m frustrated when I have patients who smoke, and yet are worried about the possibility of bisphenol-A in their Nalgene bottles. It isn’t rational, but people don’t make rational decisions based on cost/benefit analyses about their health care. Instead of trying to parse how much each patient values their own life, and provide a level of care corresponding to that, social justice demands that we place the same value on all lives.

And, that, I suspect, is what annoys commentators like Panda Bear — why should society place the same value on Panda’s life as that of a drug addict?

Well, it seems to me that the whole 3/5ths thing went out of style in the 1800s.

Human rights dictate that all humans are equal. Yes, some people make poor decisions because of lack of education, bad environments and, well, generally being bad people. But as a physician, I don’t take a moral inventory when I assess my patients. I treat all patients who need my skills based on their medical needs, not their social or financial “value”.

If you are concerned about patients who are draining the system with their poor decisions, then maybe you should help them to make better decisions — provide education, change their environment, discourage bad decisions. This extends beyond the exam room — funding schools, creating jobs in underprivileged areas, limiting corporations from profiteering from people’s bad decisions (excessive eating, gambling, drinking, gun-fighting), etc.

And you should support providing a basic level of health care to everyone, regardless of ability to pay.
Arguing that patients should have more responsibility for their basic health, and that health insurance should be limited only to catastrophic events seems backwards to me, especially from the conservative point of view. Conservatives should be arguing that everyone is given the same opportunity for basic health care and information (especially as children), but then they are responsible for what they do with that information. If they choose to smoke, then no catastrophic coverage for COPD. If they do drugs, no coverage for endocarditis.

Heck, no one (except infants) should be covered for AIDS since that is the ultimate disease of personal irresponsibility.

Limiting care to only those who have done the “right” things (including obtaining their own insurance) seems like a grand idea, but I dare any physician to determine which patient, without a doubt, developed pancreatitis because of alcoholism and which one has familial pancreatitis. Or what percentage of diabetes is due to obesity versus a genetic tendency.

Physicians are not God (despite what some may think). We cannot make those determinations, nor should we decide who is “worthy” of health care. We have two options: 1) deny care to the “unworthy”, but also include those who lack the education, money or skills to make good decisions. Or 2) provide care to everyone, knowing that some free loaders will be included.

I believe in an America that does not punish the innocent, even if it means letting a few of the “guilty” slip through. That is why America should have universal health care.

(Cross-posted at medipol.livejournal.com)