Generally, I lack the time to follow much TV, so it’s been a while that I watched Lost, but I thought the show’s basic and primordial premise – being lost on an island, where no one really knows how they got there, or how to get away (ok, for those who are up to date on this, people seems to have gotten off the island in Season 4) – seems so befitting our current economic situation. Now, I am a physician and not a economist, but most analysts seems to agree with me that the current world economic situation is quite similar to the TV series: we seem utterly lost, every day brings a new turn (together with a 500 up or down in the Dow), no one fully undertsands how we got here (some of the villans, subprimes, clearly not being everything), no one really knows how to get out of the hole.

But that is not the only thing lost. Although I just learned that Ed Kennedy is working on comprehensive heallth care reform (bless him, I wish him well but this may be his parting gift to Congress and the American People), I think that people like Bean, Gingrich and Kerry, who just out forward a suggestions to run medicine like baseball, should do a reality check. Here are some things they wrote that bug me:

Studies have shown that most health care is not based on clinical studies of what works best and what does not, be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition (…)  We can do better if doctors have better access to concise, evidence-based medical information (…)  Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.

First, apart from the fact that a baseball player can hardly be compared with a doctor, it is not like Evidence Based Medicine is a new concept. It has been around for decades. And the barrier to findings new evidence is not primarlily the lack of will of doctors to accept it, it’s the lack of evidence, caused by a lack of studies, especially unbiased studies. The US government and public have sat back, NIH funding has been insufficient, and we have left it to the drug industry to go and find the evidence. Thus there is a lot of (often biased) evidence of the most lucrative conditions (although the FDA’s orphan drug program has made some difference), like the new diseases everybody seems to have (restless legs, social anxiety, ADHD). Meanwhile, it has become more and more expensive to get a medical education, there is a shortage of physcians, particularly in primary care, the doctors that do work often have no time, and sometimes no funds, for continuing education. Furthremore,  the number of un- and underinsured people is at an alltime high. Although I think it is a great idea, adequately funding the NIH, or some new institution, to run large unbiased clinical trials will have no immediate impact on clinical care: evidence will take years to accumulate and be transplated into practice and it will cost billions that Americans unfortunately are not willing  to pay (more taxes, anyone?).

Everyday I deal with the checkbox mentality of doctors: patient has condition X, so I must check Y and order Z. If I don’t, my hospital gets poor marks on the statistics used to judge their performance, and soon will determine their reimbursement. Furthermore, doctors are trained to think that if they do yet another test, they will not get sued and risk their livelihood and job as a result. Meanwhile, they have not time to talk to the patient, take a good history and review the chart. There is little, if any, evidence that increaseing the ‘batting average” of a doctor to run test Z does anything to make a patient better.  What we need NOW (notn in 5 to 10 years), is to get off the island. Not mb checking boxes, or more tax breaks, but by comprehensive health care reform. Let’s get Un-Lost!

At the Presidential Debate on Tuesday, the candidates were asked a direct question: Do you think health care is a right, privilege or responsibility? McCain responded that it is a responsibility. Barack Obama answered that it should be a right.

This is the first time that I’m aware of that a Presidential candidate in the general election has been so explicit as to say that health care a right. However, if you listen to the answers of both candidates, you’ll realize that there are different kinds of of “rights”. In the United States, the common understanding of rights is based in limitations upon what the government can do: rights restrict government actions. Some rights are inalienable (life, liberty, pursuit of happiness), while other rights pertain to being a citizen of a wealthy nation.

Rather than re-hash debates and discussions about health care as a right (and what kind of right it is), I want to refer you to a very thoughtful discussion at HealthBeat and Moving Meat.

Is health care an inalienable right to all people? Reasonable people can disagree based on the semantics of “rights”. But let’s not get lost in that forest — even if we disagree on those points, I believe most Americans support the ideals represented by the NPA’s Secure Health Care for All Campaign:

1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. The health care coverage strategy should be affordable and sustainable for society.
5. Health care coverage should enhance health and well-being by promoting access to high-quality, effective, safe, timely, patient-centered, equitable care.

Now is the time to have the discussion about how to achieve those goals, not a dorm-room bull session on negative and positive rights (however fun those actually are).

Recently, in a very quiet manner, the Bush Administration updated its vaccine requirements for immigrants applying for their greencards, or permanent residency.  At least two of the vaccines have been on the market for less than two years, have no generic availability, are high-cost, and are heavily backed by the pharmaceutical lobby.  In particular, Gardisil, a vaccine for the human papillomavirus (HPV) is now required for adolescent girls and women entering the country.   In addition, this mandatory vaccination will not be accompanied by health education or screening for cervical cancer — effective approaches to steming the spread of the HPV virus.

One has to wonder – Is PhRMA setting our public health agenda for our Administration, and further burdening the health care system?

A Think Progress column “http://thinkprogress.org/2008/09/15/immigrant-gardasil/“>Bush Administration Forcing HPV Vaccine on Immigrants” and a Wall Street Journal article, “Gardasil Requirement for Immigrants Stirs Backlash“, both look at the disparity this could create within our health care system.

THINK PROGRESS 
Bush Administration Forcing HPV Vaccine On Immigrants

In July, U.S. Citizenship and Immigration Services quietly amended its list of required vaccinations for immigrants applying to become citizens. One of the newest requirements? Gardasil, which vaccinates against the human papillomavirus (HPV). From the agency’s press release:

    CDC’s revised Technical Instructions to Civil Surgeons for Vaccination Requirements require the following age-appropriate additional vaccinations to adjust status to legal permanent resident:

    * Rotavirus
    * Hepatitis A
    * Meningococcal
    * Human papillomavirus
    * Zoster

This regulation goes directly against the advice of Dr. Jon Abramson, chairman of the CDC’s advisory committee on immunization practices. In Feb. 2007, Abramson said that he and other committee members advised that Gardasil should not be mandatory because HPV is not a communicable disease like chicken pox.

The problem with this regulation is that the HPV vaccine is not mandatory for U.S. citizens. Therefore, U.S. citizens are allowed to weight the costs and risks associated with Gardasil, but immigrants are forced to pay-out-of-pocket for a vaccine they might not want to take. Some of the problems with this scenario:

Cost: Without health insurance, the three-shot vaccine can cost $162 per dose, making it the most expensive vaccine on the market. Gardasil manufacturer Merck, which lobbied heavily for state mandates for school girls, would profit greatly from the new regulations

    Testing on underserved populations: WOC PhD writes how immigrants and women of color have historically been used as human test subjects: “[Although] Gardasil has already been approved by the FDA recent complications in patients using the drug, 3500 major complaints in a single year and 8000 since the approval, as well as multiple deaths, could indicate that more testing is needed. Why pull the drug off the market when you can study the results through a mandated population?”

Immigration barrier: Jessica Arons, Director of the Women’s Health and Rights Program at the Center for American Progress, expressed concerns to ThinkProgress that this mandate will block women from immigrating: “Given Gardasil’s high cost, and the fact that there does not seem to be a public health justification for this particular mandate, I’m concerned that its real purpose is to create a financial barrier for immigrant women who seek to lawfully enter this country.” 

OCTOBER 1, 2008, Wall Street Journal

Gardasil Requirement for Immigrants Stirs Backlash
by Miriam Jordan

Even as the medical community debates the widespread use of Gardasil, a vaccine that helps prevent cervical cancer, the government has made it a mandatory treatment for young women seeking to immigrate to the U.S.

The policy, which went into effect Aug. 1, has angered some immigrant advocates, who say that forcing foreigners to take the costly vaccine saddles them with an unfair financial burden. The decision has also upset health policy experts in the U.S., who see the requirement as excessive.

The addition of Gardasil as a mandatory vaccine is the result of a 1996 immigration law, which states that any vaccination recommended by the U.S. government for its citizens becomes a must for green-card applicants. After the immunization committee of the Centers for Disease Control and Prevention advised last year that Gardasil be given to females ages 11 to 26 in the U.S., the recommendation became an automatic requirement for prospective immigrants when the government updated its list of vaccines in July.

However, even some of the CDC physicians and experts who promoted Gardasil in the U.S. say they never intended to make the vaccine mandatory for young female immigrants.

“If we had known about it, we would have said it’s not a good idea,” said Jon Abramson, who was chairman of the CDC’s Advisory Committee for Immunization Practices when the body recommended the vaccine for U.S. citizens last year.

“We don’t want someone coming into the U.S. who hasn’t been vaccinated against measles or chickenpox,” said Dr. Abramson, who is currently chairman of the department of pediatrics at Wake Forest University School of Medicine in Winston-Salem, N.C. “HPV can only be communicated by sexual contact….This is not something that endangers kids in a school setting or puts your population at risk.”