Archive for the ‘Public health’ Category
Liberals, Conservatives, Joan Baez and the Nation-State
The other night I saw a reprise performance of the recent American Masters episode on the life of folksinger and political activist, Joan Baez.
It was a good program and showed what a remarkable person Joan Baez is. She walked the walk, even to the point of voluntarily accepting incarceration several times because of her (nonviolent) opposition to the Vietnam War.
But one detail that caught my attention was a brief remark by Joan in a film clip from an early 1970′s protest: she was exhorting people to “end the nation-state”.
End the nation-state? Sounds like a good idea to me — where do I sign up?
And here was Joan Baez, one of most visible “liberals” of the second half of the 20th century, saying something I agree with, even though I am a political libertarian — which most people consider a conservative position.
But there was no mistake. Joan Baez wanted to end the nation-state. That was the wish of liberals in the 1960′s (as with John Lennon’s song, “Imagine there’s no countries; it’s easy to do….”). It seemed obvious to anyone with good sense that governments were the cause of wars, and that governments served generally to suppress what is best in human nature.
To liberals, the government was the problem, not the solution. The government was causing the war in Viet Nam, and hurting everyone. Liberals wanted to reduce government power and to end the cultic worship of governments.
But roll things forward 35 years. Now so-called liberals are supporting massive government-run healthcare.
They’re militant about it, insisting that “poor people have a right to healthcare, and the government
should supply it, whatever the cost.” This is not only different from the liberalism of the 60′s, it’s really the complete opposite.
In the 60′s and 70′s, the view was that if governments would get out of the way, people could sort out their own problems. I can say that for sure, because, at least in the 70′s, I was there marching and singing “give peace a chance.” People were thinking, “Life is good. If governments would get out of our lives the natural impulse to enjoy life and to love and help others would manifest itself spontaneously.”
That’s still my view. If John Lennon were alive today, I’d like to think that would be his view, too. Somehow I just can’t imagine him singing, “Hooray for government! Let’s give them more power! Let them pick our pockets and design aversive, government health programs, so we can all stand in line, put up with terrible service, and be at the mercy of arrogant public officials.” No, that’s not how a working class hero would see things.
So the great irony is that true conservatives and true liberals are on the same side: both groups want a world which affirms human values, welfare and happiness. And opposed to these things is an ever expanding “statism” — a vast, inhuman, oppressive machine.
This is a rather important idea, and bears further thought. Consider how much the media makes of the supposed opposition between “conservatives” and “liberals.” What if this turned out to be all bunk! Could it be that human beings are in basic agreement about core values — and in an instinctive aversion to abusive government power? And could it be that the dominant economic institutions try to invent a false conflict in order to divide and conquer the population?
The Individual Mandate is A Radical Alteration of the Social Contract
Part of the health care reform bill currently being debated by the House of Representatives is the individual mandate. By this provision, everyone would be required — by law — to have health insurance, or else be charged with a criminal offense and face fines or possible imprisonment.
This would be a radical and unprecedented change in relationship between citizens and government. The government would be saying, “you must be part of the system — our system — or we’ll fine or imprison you.” That violates your basic freedom as a human being.
At face value, the arrangement seems no different than mandated car insurance, which already exists. But there’s an important difference. Nobody has to drive a car. If you don’t want to be forced to buy car insurance, walk or take the bus. You aren’t compelled. You retain your freedom to participate or not.
Similarly, everyone is required to pay income tax – but only if you have income. If you really don’t want to pay income tax, you can, in theory, quit your job and just live off the land. Few do this, but the possibility of choice has a major implication. Since you’re free to opt out of the system, your participation is voluntary. That’s the essence of the social contract, and the basis by which governments are accountable to citizens. Without the voluntary aspect, there is no social contract, because a contract cannot be compulsory. If you’re forced to participate, your condition is that of slavery and servitude to the state.
A further implication is that you’d be effectively forced to have a job so that you can pay for health insurance. True, nominal programs would help the unemployed buy insurance, but these would likely be inconvenient and complicated. Most Americans would feel it necessary to work and to buy insurance.
People should work because they want to, not because they have to. When they have to work, it affects the workplace: companies then don’t need to supply good benefits or working conditions to retain employees. So with the individual mandate, not only would you be a slave to the state, but to the corporate system as well.
The individual mandate’s closest analogy is military conscription. But at least the draft — itself controversial — applies to a dire emergency — war. The individual mandate is, at best, a convenience of the government, not a social necessity.
Thus, as with 9/11 and the ensuing Patriot Acts, the government is trying to use problems in the health care system to justify an expansion of power – at the cost of your freedom.
What we have in the United States is a health crisis, not a health insurance crisis. Legislators seem unable to comprehend the difference. The problem is not that many Americans lack health insurance, but that health-care costs are too high. We should be focusing on new ideas for reducing costs – based on technology, innovation, competition, and individual initiative – not trying to expand the current insurance-based system that has produced the crisis.
Seven arguments against a doctor’s office visit for flu
1. Unless the patient has *serious* pre-existing conditions the flu will pass by itself.
2. After two days of symptoms, pharmaceutical treatments (i.e., Tamiflu or Relenza) will probably have little or no benefit.
3. The best treatment for flu in any case is to stay in bed. A trip to the doctor’s office places serious and potentially unnecessary stress on the patient and his/her immune system.
4. The patient exposes others to flu virus.
5. In principle, a prescription for Tamiflu or Relenza could be made without a physical examination. Patients can accurately take their own temperature and report their symptoms by phone.
6. The best reason for an office visit is indirect: to take a throat or nose swab/sample for flu virus confirmation, either via a rapid (immediate) test or by sending it to a lab for culturing and more accurate testing. This has public health value, because it helps track flu in the community, but does not benefit the actual patient.
7. There’s no logical reason not to sell rapid influenza test kits in pharmacies (without a prescription) and to let patients use these at home. Note that these tests have relatively low diagnostic sensitivity (50-70%): they produce many false-negative results. However the tests have diagnostic specificities of more than 90%: they produce few false-positive results; thus, if a positive result occurs, the patient probably has flu and Tamiflu or Relenza can be prescribed. This could be done by phone or fax based on a patient’s self-test. Thus, for 50-70% of patients with flu, an unnecessary and counterproductive office visit could be avoided by means of a self-administered rapid test.
The above just outline some of the obvious considerations. The main point is that this subject needs to be examined at the level of public health policy and some sensible guidelines established.
More information on flu testing:
Protect Yourself from the Flu
A leading flu vaccine producer, GlaxoSmithKline (GSK), has generously released this audio-visual presentation, originally developed for their employees, to the public:
When the new window opens, press the “Next” button on the lower right to continue.
This is the best presentation of its kind available today. Watch it yourself and show it to your family and friends.
If enough people follow the simple, common-sense steps outlined here, it can have a significant effect on reducing the swine flu pandemic. Because pandemic disease transmission follows an exponential pattern, even minor preventive steps like those explained here can have a major impact on total disease incidence.
This post follows up on an earlier one concerning the value of mathematical models, computer simulation, and operations research in dealing with pandemic and inter-pandemic (seasonal) influenza.
There’s a lot that can be done to control flu, once its known to be spreading. We can shut down a school, for example. But the key is to suit an intervention precisely to the need, and not to overreact. We can shut down *a school*, and not all schools in an entire city or country.
To accomplish such tailored intervention, information is crucial: we need to know who actually has the flu, and what strain of flu they have.
A current problem is that the majority of flu cases are not formally diagnosed. People get flu-like symptoms; they suffer for a week; they get better — and that’s that. Then they tell people “I had the flu”. Yet many of these people might not have had the flu at all. They may have had a cold, or food poisoning, or some other infectious disease.
Fortunately, fast, simple, and potentially inexpensive tests exist to diagnose flu and to identify viral strain class (e.g., A or B strain) exist. However, currently, these tests usually require a visit to the doctor.
As a result, only a minority of people with the flu receive a test. First, why visit a doctor in the first place? You’re sick in bed, suffering from symptoms. The last thing you want is to get into a car (much less a bus) and visit a doctor. Besides the inconvenience, that stress is harmful (remember, the classic treatment of flu involves staying in bed getting lots of rest). Further, by traveling and sitting in a doctor’s office reception area one risks contaminating other people.
Many doctors will not request a flu test anyway. Why should they? It’s added cost and inconvenience. And from a clinical management standpoint, a confirmed diagnosis of flu is of little value. In most cases the treatment is the same: stay home, rest, and drink fluids.
Note this is different than for bacterial respiratory tract infections; there one wishes to identify the bacteria in order to select an optimal antibiotic.
Potentially a flu test could be of value in deciding to prescribe Tamiflu. However, Tamiflu has a short window of efficacy. If a doctor suspects flu, then the logical thing would be to prescribe Tamiflu immediately, rather than wait for the results of a lab test.
Recall what happens with a flu test. A cotton swab is inserted into the nasal passages, collecting a mucous sample. The sample is then sent to a lab for processing. It could take a day or longer for the sample to reach the lab. Then it might wait several hours before processing. And then it might take another several hours for someone to phone or fax the results to the doctor. By that time the window of opportunity for Tamiflu would have potentially passed.
A Paradigm Shift
What we need to recognize is that the real value of flu testing is not to benefit an individual patient, but society. That is, the main value is epidemiological, not clinical.
A flu test should be routinely performed so that we can track the spread of flu virus during an outbreak and to make judicious interventions on that basis.
Because of this, we should consider paying for flu tests out of the public coffer, instead of billing patients individually. Further, we should consider streamlining the flu assay process. Here are some suggests towards that end:
1. Develop even faster, cheaper tests. The tests are already simple. A flu antigen test can be performed in 15 minutes, using paper tabs, analogous to a home-based pregnancy test. However, currently these are performed in a lab, by a trained technician. The costs are not currently stated online, but a reasonable guess would be at least $50. What would be ideal is a home-based test, purchasable at a local drugstore. With many more test units being sold, one could easily imagine the price dropping to $10 or even $5 without loss of total revenue to manufacturers.
2. Mobile flu test units. It might take a while to overcome institutional resistance to a home-based test. In the meantime, we could in the US develop something that is already common in Europe: lab courier. Lab couriers are people who can come to your home and pick up a something like a urine sample and take it to the lab for processing.
Option 1 a no-brainer. Eventually this will likely happen. The only question is when. Again, there is probably institutional resistance to overcome. In a sense, this takes work away from doctors and labs.
Option 2 requires a little analysis however. All the parameters involved are straightforward. We can estimate how many people would use such a service (hopefully, if the cost is low enough, nearly everyone with suspected flu). We can also estimate the potential value to society. By tracking the spread of a flu outbreak with almost complete accuracy, we could issue local alerts, close schools, etc. We could optimally distribute antiviral drugs, and launch rapid-response immunization programs. We could also prevent hysteria and unnecessary closures. By tracking an outbreak with complete precision, we could potentially prevent a pandemic.
How much would that be worth? To judge from government investments in bird flu contingency plans, billions of dollars.
The question is whether a publicly financed mobile flu-test units, or some other innovative program, would be cost-effective, in terms of saving money and reducing morbidity and mortality. These are, in principle, simple calculations to make, and perhaps someone at a public health school or the CDC will run them!