Tuesday 19th of November 2019

Medicare Gold

PETER COSTELLO: No, Labor said it wanted an even more expensive policy. It wanted free health care – the so-called Medicare Gold – for people over 65. The most irresponsible policy probably put down in a federal election period. So fortunately that policy never saw the light of day.

Expensive? Irresponsible? No and No.

Medicare Gold was one policy Labor got right in the 2004 auction. It could have been, maybe still is, the turning point in Labor's approach to policy. It was based on a principle, and backed up with economic estimates. The modelling that supported free health care for the over-75s is admitted in the Productivity Commission's report on Ageing Australia, but the PC preferred to give weight to data that aligned with Costello's expected conclusions. Who gains in Costello's world? When he says we will have to pay more for healthcare (drugs, investigations, devices), is the pharmaceutical industry pleased, or disappointed?

But, P.Costello could have said any of the following , with equal vigour and arrogance.

"We cannot afford to keep burning oil at the same rate, so we must stop buying Urban Assault Vehicles."

"We cannot afford to keep force-feeding our kiddies with energy-dense foods, so we must decimate the sugar and potato crops."

Instead of ridiculing a policy that was based on well-founded community sentiment, he could have said what he will be saying in other contexts to suit his political purposes. A community with shared values would accept the truth of authoritative statements on the needs to eliminate behaviours that gobble up our health. The community that wants a healthier future will try harder to minimise the damage done by tobacco, alcohol and fattening foods. It would also minimise losses to electronic gambling.

This nation is trapped on the slippery slope of rampant consumerism. The Treasurer has taken the easy step of assuming it can only be like that. He has missed his opportunity to lead reform in several significant areas of our lives. By gutlessly caving in to the will of the big corporates, he has assured himself of a wealthy lifestyle when he leaves politics.

Leadership from public hospitals

The public expect informed leadership. The experts in significant domains of health care reside in our public hospitals. Are our public hospital physicians willing and able to pay their dues to the public interest, and give it top priority?

In New hospital short of cash for equipment The Age reports Austin Health is seeking public support to buy medical gear, despite a $353 million revamp.

In [a fundraising letter sent to thousands of households], the hospital's new chief executive, Brendan Murphy, says despite hundreds of millions of dollars of Government money for the redevelopment, it still needs $275,000 to buy "urgently needed" equipment.

What is going on? The Austin Hospital medical staff are probably treated to half that amount in free meals by pharmaceutical companies in the course of a year of medical "education". Yet the hospital management has the pure arse to dress a minor accounting discrepancy up as a crisis, and go off begging to taxpayers?

Suppose a corporate benefactor, such as Hardies, Tabcorp, Fosters, Altria or Merck make a donation to cover this handy deficit? Would any of the contracted medical experts then be forbidden from speaking out against asbestos, gambling, alcohol, tobacco or bad medicines?

It could be time to put the inner workings of public health care agencies under the knife of democratic principles.

Princess Mary is pregnant

An article by Ross Gittins on healthcare funding is in SMH (Medical miracles that will cost an arm and a leg) and The Age (The bitter pill of our health boom: pay up).

This is at the root of the dilemma.

Health care is quite unlike most industries for two reasons. First, what economists call "information asymmetry" - because doctors and other medical professionals know far more about the subject than we do, the providers of the services have far more say over what's done than the customers do.

The notion of Informed Consent is at the core of ethical interventions. The client must be given enough information to enable informed choices to be made. Such as, in the case of metastatic colon cancer, whether to sit out your days under a tree with a supply of books and street heroin, or subject your living corpse to medical experimentation with new oncology drugs.

But the essential nature of the professions is to guard their specialist knowledge. How does the community construct paradigms that allow it to assign dollar amounts to a priorirised list of interventions? The worst possible way of assigning reimbursement costs is to allow politicians to play their wedging games. This is what is happening right now, with Abbott & Costello feigning to decide how many IVF treatments the government will pay for. In truth, they know the decision will be made by wealthy families that need to secure their assets under the laws of inheritance. There is as much risk that Costello will offend the Howard base in this instance, than there is he will disturb the negative gearing nexus.

We are, once again, letting the commercial media lead us by our noses.

TG's Department of Health Watch

Thanks TG. I wonder if you'd consider running a regular blog on Health issues. A sort of a 'Department of Health Watch'. What do you think?

A very curious headline by the way.

Get some Compassion

First Hamish, people and human beings are NOT clients. They are human beings with pain and suffering. I am one with pain and suffering and I resent people calling me a client and writing about us without compassion. Do people care these day? No!

Clients are just numbers aren't they that make profits for the Health departments and pharmaceutical companies and when we die we are just a dead body that makes money for funeral directors.

Where, oh where is humanity any more. Where is the caring for other human beings?

Hamish the style of writing needs to be changed that we, the ones with ill-health are not numbers or clients for the know-all world to manipulate. The know-all world without them knowing it last humility.

Compassion?

G'day Len, I empathise with your frustration at being catalogued mechanically by bureaucrats, but I'm beginning to think you just criticise people for fun.

Quite incidentally I never mentioned clients - clearly your comment was directed at TG Kerr. Certainly noone mentioned numbers.

But as for "compassion", "humanity" and "caring for other human beings," isn't that what TG is demonstrating as he tries to expose unaccountable practices in the profession that might not be in the interests of, um, people?

The irony is TG said "client" once in this sentence: "The client must be given enough information to enable informed choices to be made." Take issue with the word, but when you scream, "where is the humanity?" I hardly think you're even sincere in your criticism.

What word with equal description? Patient? Customer? Person-at-the-doctor? Is TG (or me, if you must) really such a monster for not using one of these terms, or another, instead?

Most importantly, are you sincere, or are you just here to take miscelaneous pot-shots?

Objectivity

Hamish, I hope the readership here will read my comment with objectivity and not with subjectivity and derision as you have. What do you think readers are?

Customers

Taking issue with use of "client" is OK. I can plead the need for brevity. And I had in mind a more general usage, that could include dealings with lawyers, dentists, accountants and bathroom renovators. I apologise for mentioning the latter. When sufficiently recovered, I may try to describe a painful experience.

The sick are at a profound disadvantage in the doctor-patient relationship. Many people who call on the GP cannot be called 'sick' in the true meaning of the word, that is, unable to deal with the necessities of life because of acute disease, chronic pain, physical or mental disability. In saying that, I do not intend to imply that medicos (or other carers) take advantage of the dependency of the sick. Far from it. And, on the other hand, I know of people who have chronic, even life-threatening, conditions, who are able to function in life and in the consulting room as well as the best of us. The keys are the motivation to find out about their condition, and a nose for trustworthiness and competence on the other side.

ALP Policies

Just a short note to say, at New Matilda -

Don't mention the economy Locked Wednesday, April 27, 2005
'To overcome this obstacle, Labor needs to integrate its policies in a clear vision and set of values - social values - rather than categorising its policies into 'economic', 'social' and 'environmental' headings with their implications of compromise, trade-off, and contradictions.' More by Ian McAuley.

Medicare Gold is referred to in a positive light. (NM is open only to paid-up subscribers.)

The tone of McAuley's article seems in keeping with Barry Jones latest encouragement to his party.

Generational Storm

Nicholas Kristof in New York Times - Greediest Generation.

The solution is not to force the elderly to get by on cat food again. But we boomers need to resist the narcissistic impulse to ladle out more resources for ourselves. Our top domestic priorities should be to ensure that all children get health care and to get our fiscal house in order.

Otherwise, we boomers may earn a place in history as the worst generation.

Editorial, The Lancet, Apr30

This has so much to say about our own health system, I have included the whole article here, in the interests of the common good. I have emphasised some of the text, and hope that does not detract from the message.

The Lancet 2005; 365:1515

DOI:10.1016/S0140-6736(05)66428-8
The unspoken issue that haunts the UK general election

Superbugs. Waiting times. Patient choice. More doctors. New investment. Efficiency savings. Foundation hospitals. National Health Service (NHS) reorganisation. Free personal care. These are some of the issues that have been identified by the main political parties as battlegrounds for
the UK election on May 5. The Economist, more likely, perhaps, to identify financial and business health as key issues, opted instead for the NHS as the “most important

The Ethics of Innovation

I went to one of the Deakin Lectures at Melbourne Town Hall. The topic was The Ethics of Innovation.

Prof Miles Little spoke on the way the ethical framework is built from the community values of the time. He used the example of Colles, an Irish surgeon who experimented with the use of mercury to treat syphilis, in the early1800s. Not only was mercury poisonous (to the person as well as to the bacterium that causes syphilis), but Colles used experimental methods that would appal us. Colles was noticably discriminatory in his publications, cloaking the better classes of patient in anonymity that he denied to the servants. Prof Little reviewed the outstanding medical advances introduced during the period of his life, but suggested we should be looking less to trusted
experts, and more to a collegial method of making decisions.

Prof Fotis Kafatos took us through the looking-glass of modern molecular biology, and opened up some of the many promises for control of diseases, from selection of embryos to tailored drugs.

He reminded us of the dangers, not only in the moral dimension, but also of actual physical harm to experimental subjects. He used the example of vaccines, but he could have said the modern fertility industry (1 million born through assisted conception) is built on the bones of women who died from CJD contracted from pituitary glands. [An Australian book (Cannibals, Cows and the CJD Catastrophe by Jennifer Cooke) suggests some of our eminent scientists and companies were pretty skilful in evading responsibility for the deaths due to HGH treatment.] I would like to have challenged Kafatos on his claim that a measure of what we have to pay for innovations, is the estimate that it costs $800m to bring a new drug to market. This is drug company propaganda, pumped out by an offshoot of pharma, and can be disregarded as blatant bullshit. It's a pity that scientists of that calibre continue to regurgitate nonsense.

Helena Kennedy worked from a Margaret Attwood book, Oryx and Crake.

She talked quite a bit about the perils of discrimination, and the power of the enlightened public to resist. She said there are a number of crucial steps toward adequate information, and one of these is financial disclosure. The people who are being rewarded by corporations, right through the chain from laboratory discovery to promotion of final product, must declare their connections openly. [The Human Genetics Commission in the UK has done that.]

Bob Phelps of GenEthics Network asked a question or three. Gus Nossal, Barry Jones, Alan Trounson and other dignitaries I didn't see, were there.

Disclosure of financial interests is a, er, ahem ... novel ... concept to the Oz medical establishment. 'Novel', as in 'why the hell would we want to do that?'. This nation, under the present regime, could become the last bastion for crooks, frauds and confidence tricksters, in the whole of the West, unless someone with authority takes an urgent stand on principle.

Sam Lipski, the moderator, asked how it was possible to get good legislation on biomedical and scientific matters, when the parliaments
contained so few scientists. Kennedy said she hoped the Lords tradition, of appointing eminent people from all walks of life, will be continued in the democratisation process. She hoped that, while popularelection is desirable, about 20% of members could be appointed for the expertise accumulated during the life's work in the public interest. She cited the Science & Technology Committee as one that does good work of great public significance.

The recurrent theme of the evening was for a process of continuing conversation, under the guidance of Discourse of Ethics, to inform both the public and the law-makers. Community Juries, Constitutional Conventions and Communities of Practice were mentioned as models already working in other countries. The idea is to work in directions, along pathways, NOT with a pretence of offering solutions, and avoiding dogma. The readers of tabloids will want black and white (eg, safe or not safe) answers, but an educated public will learn other ways.

It was strange to hear Prof Little remind us that we all have to die, at the same time Peter Costello was trying to tell us we could all live long and happy lives, as long as we work harder and pay less tax. Prof Little confronted our consumerist mentality with the sobering reflection that we will have to account for the cost of extending the lives of the wealthy, in terms of services taken away from the less well-off, especially among our indigenous peoples, and most horribly in the developing nations.

Snowman.

Ethics

So what did you learn about ethics. At the end of your story you seem to have a conundrum between Professor Little's theory and Peter Costello's words. Is it that the word "ethics" looks nice and sounds nice from someone's lips, that it can be framed into a short story, and pushed and prodded and molded but in practical terms people don't use ethics as using ethical decisions costs money . . . and money is a scarce commodity not to be wasted on periferals such as ethics because if ethical decisions are used progress is impeded. What is progress with no ethical decisions?

safety net conspiracy

They were the last words from Julia Gillard, in her response to the Budget.

In a budget that is a record post-election spend it was health that missed out. It was Minister Abbott who could not secure sufficient funds for his portfolio to make good his word. That will count against him for all time. No-one in this country will again believe any promise he ever makes about our health system. We will get to the bottom of the Medicare safety net conspiracy.

Earlier in the speech, she promised:

Let me assure you, Mr Deputy Speaker, we will never let this matter rest until we get to the truth of it. We will never let this matter rest until the truth is in the public domain, and that will spark Minister Abbott’s resignation. He ought to have resigned already for breaking his word to the Australian people. He has not done the right thing, but we will pursue this matter until he does.

I thought Ms Gillard did a good job of laying out the reasons why Mr Abbott knew all along, even before he made his 'ironclad guarantee', that the excessive expenditure under the Medicare Safety Net was flowing straight into the pockets of AMA members and the private health industries.

But let me predict - Mr Abbott will not resign over this failed promise. Ms Gillard will get more value out of following the money trail, instead of seeking 'the truth'. She will have to show she can confront the AMA, and the special interest groups, at some stage.

In pursuit of the truth

Julia Gillard in pursuit of Tony Abbott, Hansard for May 31st:

We know that Minister Abbott has not broken his word—he has smashed it. We know there is a conspiracy which lies behind the breaking of his word, because of what Minister Abbott has said on the public record. He has tried to justify this broken promise by saying that when he gave the promise he had not the ‘slightest inkling’ that the Medicare safety net would be changed after the election. There are reasonable grounds to believe that in making that ‘slightest inkling’ statement Minister Abbott was not really being frank with the Australian community on yet another occasion. It is those matters that the opposition are pursuing and will pursue in Senate estimates, through freedom of information requests in this parliament, and in any other forum available to us until we get the truth.

This will come up Senate
estimates committees
in the next few days.

There was some hope the PM's own review of the health system, under
Andrew Podger, would provide incentive for the government to be more
interventionist. Ms Gillard thinks that is not going to happen.

The one thing the Howard government was going to do—and it was not the
minister for health who was going to do it; it was the Prime
Minister—was to have Mr Podger review the health system and have the
outcomes of the Podger review go to the Council of Australian
Governments meeting. We were very critical of the Podger review. It was the ultimate black box review—a bureaucrat literally sitting in an
office and not seeing anyone, not talking to anyone, not consulting
with anyone and not asking anyone with expertise what they thought
should be done next. It was the ultimate black box review, but it was
the only thing going. And now we understand that even that is off the
table, that the Prime Minister has indicated that the Podger review
document is now cabinet-in-confidence and will not be made available to the states, and that whilst he is willing to discuss some issues in
health reform there will be no system-wide health reform. That failure
by the Howard government is going to continue to cost our health system over $1 billion each year in waste. It is not good enough. It is an abandonment of the single biggest thing that needs to be done in
health. That is what more than 40 professional health organisations
say, as do I. It adds to the Howard government’s track record of
failure in the area of health.

Advertising for health

A submission to Inquiry into Health Funding (Standing Committee on Health and Ageing), by Professor Stephen R Leeder of Australian Health Policy Institute, University of Sydney (288KB PDF), is published in the August edition of  'About the House', the House of Reps magazine, as 10 fixes for our health system.

It isn't quite fair to reduce Leeder's piece to anything less than the full length, but for the sake of it, his main claims are for (1) enhanced primary care (2) efficient and effective information flows between the population, providers, policy makers and payors.

Leeder makes the subsidiary, but highly significant, remark that a people's health is seen in their teeth. This was dwelt on in a recent New Yorker article by Malcolm Gladwell, The moral-hazard myth.
The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

Leeder: Currently, by subsidising private health insurance, which covers dental services to some extent, the government provides a 30 per cent rebate for dental care only to private health insurance holders.

Leeder: A central ambiguity resides at the heart of the health insurance debate and it is this: Australia has a universal public health insurance system, Medicare, underpinning the majority of health care. Yet $2.3 billion of public money is now spent subsidising private health insurance. This ambiguity expands when private health insurance is commended to the electorate, who demand Medicare’s continuation, as taking “pressure off the public system

No Free Lunch

Following an outcry from among its members, the American Academy of Family Physicians has reversed its earlier decision to deny a booth to No Free Lunch and has invited the organization to exhibit at its meeting next week in San Francisco.
In August, The AAFP rejected No Free Lunch’s application to exhibit at its annual meeting—which will be attended by some 5,000 family physicians and slightly fewer exhibitors—stating that No Free Lunch’s position was “not within the character and purpose of the Scientific Assembly.

great news story .....

Still room for the noisy little guy.

A great reminder of the fact that it ain't over 'till it's over.

Abbott's Gold-plated medicine

From Doctors With Ties to Device Makers (NY Times)

While health reformers are struggling to curtail undue influence by drug companies on the prescribing practices of doctors, a comparable problem has surfaced in the field of medical devices. An article by Reed Abelson in The Times on Thursday reveals that many surgeons have ties to manufacturers, ties that are often not revealed to their patients or to hospitals. These connections raise questions as to whether some doctors are choosing devices primarily for the good of their patients or primarily for the benefit of their own bank accounts. ...
... Ties between manufacturers and doctors are surely a factor in driving up spending on medical devices. Hospitals, insurers and patients have been squeezed as such costs have soared and companies have earned profits of nearly 20 percent a year. ...
... Perhaps the most important reform would be full disclosure by doctors - to their patients, their colleagues and their hospitals - of their lucrative contracts with the manufacturers. That would alert patients and institutions to look hard at whether the devices recommended by a doctor-consultant were really the best to use.


Is this type of scam happening in Oz, with surgeons, private hospitals and the private insurance industry helping each other along? Why not? How would we know? We can be pretty confident that the Tories will not bother to look too hard into commercial transactions. Meanwhile, they hammer away at the principle of universal health insurance. Labor's Medicare Gold policy is the vestige of universality. MG receives a battering every week in parliament, eg on Sep 14th,
QUESTIONS WITHOUT NOTICE: Health > Haase, Barry, MP; Abbott, Tony, MP > 14:36:00.
... I call on the Leader of the Opposition to prove he is a tougher leader than the member for Lalor by getting her policy off his web site.

The latest barrage was delivered by Christopher Pearson, in The Weekend Australian for Sep 24-5, Deluded by the flame.
... Whether she can be persuaded to abstain from bold social policy is another question. I doubt it myself. Her biggest claim to fame was Medicare Gold. It was Whitlamite in its boldness, an extravaganza of geriatric welfare, perhaps the single most irresponsible exercise in public policy since the 1970s. The Department of Finance predicted its costs would blow out to $7 billion in the first two years of operation. Econtech, the private consultants, warned of longer-term troubles. Within weeks Barry Jones called it "a turkey". Peter Botsman, a Left-Labor policy analyst, described it as "a hoax ... the head of a donkey ... on the body of a wombat". Various health economists and the Australian Medical Association concluded that it couldn't possibly deliver on its promises. But it was her brainchild, beyond criticism, and not once, in all the intervening months, has Gillard made any concessions to reality on the matter of Medicare Gold.

Nice one, Chris, quoting the AMA as an authority on containment of healthcare costs.

The sustained attacks on MG suggest it may not be such a bad idea. Gillard must know, by now, where the excesses, the graft and the greed are placing burdens on the system. If she wants the job, she will have to face up to the power elites and medical specialist colleges, sooner or later.

Medicare, prevention and the media

The underlying principle of Medicare Gold is universality, where citizens are insured (by the State) for treatment of a defined set of conditions. Universality is non-controversial for some things, including children's diseases, accidents and cancer. Why shouldn't all families have the same access to treatment for sick children? Why shouldn't all the elderly have free access to the same standard of treatment, after hip fracture? The point is that entrpreneural healthcare is diametrically opposed, in crucial aspects, to the requirements for universal care.

There are some gold standards for prevention of illness, too, but these are often swamped in the market state, where value is equated to cost. The current discussions about our national plans for the influenza pandemic are swirling around in some murky waters, so it's important to tease out the relevant strands before the heat is applied. The same type of lobbying that wants a two-tier system for care of acute problems also threatens the foundations of that programs and plans that seek to prevent ill-health. I guess it is self-evident why that should be so. In case an example is needed, think about a surgeon who has made a nice living from cutting out lung cancers, whose offspring is training to carry on the family business, and their likely responses to laws that limit the sale of tobacco.

For this post, I should lift a corner of the flimsy veil of pseudonymity, and disclose a professional interest, and maybe a couple of personal ones, too. My day job is a medical microbiologist (a breed of pathologist) in a diagnostic laboratory of one of Melbourne's public hospitals. The first time for many years, I did not bother with the annual influenza vaccination, because there aren't schoolkids in the household. There was more influenza in the community, than last year, but we were not affected. And, despite the intimations of interviewed virology experts, I have not tried to buy stocks of anti-influenza medicines.

Lisa Allen has an article in The Australian Financial Review for Sep 26th, page 5, on responses to the current epidemic of Highly Pathogenic Avian Influenza in Asia. She writes that there is evidence of some Australians buying antiviral medicines (Roche's 'Tamiflu') to take on their tours of Asia. Allen also writes about the government's decision to seize imports of Asian poultry meat and other poultry products. The vaccine maker CSL is quoted as saying it will have a human vaccine for "bird flu" ready by August '06. (Read the history of the one-time competitor to Roche's product, zanamivir, and the troubled relationship between the Melbourne group Biota, and GlaxoSmithKline, which also has a manufacturing plant in Melbourne.)

That wealthy citizens would be buying Tamiflu, to preserve their assets, should not be a surprise. A couple of the nation's leading experts in infectious diseases have admitted that they keep enough private stocks of the drug for their own household, just in case. The interviewers forgot, of course, to ask the medical professors if they had any sort of commercial relationship with Roche, GSK or CSL.

While there is a trend to place all hope in future technological developments, it is worth asking about basic measures that help to protect against influenza, or other infections. We should not expect medical experts to be able to give a balanced account, because medicos are trained to look after their own interests first, including their shareholdings. Hang on, you may say, what about their roles in performing lifesaving procedures, and prescribing lifesaving drugs? Simple answer. If the medicos were not there, people would die. So, medicos have to stay healthy, and be able to feel happy about preserving their property values and access to good private schools, otherwise we will all suffer. QED.

From Centers for Disease Control and Prevention (USA) -
The most important thing that you can do to keep from getting sick is to wash your hands.

A search on Google News for 'hand hygiene' turned up a list of articles, including -

Women Better At Hand Hygiene Habits, Hands Down
Science Daily (press release) - 21 Sep 2005
... to have on hand.". Among those observed, fans at Atlanta's Turner Field had the worst hand hygiene habits.

Ferry Plaza called haven for hand hygiene
San Francisco Examiner, CA - 22 Sep 2005
San Francisco — Along with fat heirloom tomatoes and fresh oysters, Ferry Plaza foodies have something else to be proud of: squeaky clean hands.


Hand hygiene guidelines to fight MSRA
IrishExaminer.com, Ireland - 19 Sep 2005
By Evelyn Ring. GUIDELINES that emphasise basic hand hygiene to stop the spread of the hospital superbug MRSA have been welcomed by lobby group Patient Focus

Other Views
Chicago Sun-Times, United States - 13 hours ago
... Through rigorous hand hygiene, meticulous cleaning of equipment in between patient use, testing incoming hospital patients to identify those carrying dangerous


Athletes! Prevent the spread of MRSA before it starts!
North Texas e-News, Texas - 21 Sep 2005
... parents should encourage good hygiene among players, and they should be taught to administer proper first aid, practice appropriate hand hygiene, and implement


Washing Up
Monitor, TX - 11 Sep 2005
... more information on promoting a culture of proper hand hygiene can visit www.ItsASnap.org, a Web site promoted by the CDC. "It’sa Snap encourages students to


These refer to the central part of good hand hygiene in all parts of living, but especially in schools, hospitals and food preparation.

Here's an example of the depth of work going on in schools in the USA, to prepare kids for healthier living.
Washing Up 
September 12,2005 Rose Ybarra The Monitor
Clean hands often translates to staying healthy
On any given school day, children are exposed to millions of germs. Classroom door knobs alone have the hand residues of about 20 students and two or more teachers and these germs can live for a long time. "Viruses can live six hours on an inanimate object, such as a door knob," said Martin Garza, M.D., who practices at DLC Pediatrics in Edinburg. "Those viruses are transferred when a student turns a door knob and then later touches the face." The U.S. Centers for Disease Control and Prevention (CDC) estimates that nearly 22 million school days are lost every year due to the common cold and one of the most ways to catch colds is by rubbing their noses and eyes after touching something or someone that is contaminated. Hand hygiene is the first line of defense against many illnesses, according to the CDC. "We’ve always said that hand washing is one of the most important things you can do to keep from getting sick," said CDC spokesperson Julia Smith-Easley. Educating the public about hand washing is the mission of the Clean Hands Coalition, a partnership of public and private entities working together to create and support coordinated, sustained initiatives to significantly improve health and save lives through clean hands, according to the organization’s Web site. The Clean Hands Coalition designated Sept. 18-24 as National Clean Hands Week, during which they are asking the public to make hand washing a higher priority in their lives and the lives of their children. Though colds are at the top of the list of communicable illnesses, some serious diseases like hepatitis A, meningitis and infectious, diarrhea-causing illnesses, such as the rota virus and shigella can also be prevented by correctly washing the hands. Experts agree that parents play a huge role in teaching the importance of hand washing to their children but sometimes grown-ups are poor examples. Washing your hands after using the bathroom, before cooking or eating food and after doing yard work or playing with pets might seem like basic common sense for adults but the statistics prove otherwise. A study by The American Society of Microbiology found that one-third of people passing through major airports in the United States don’t wash their hands after using the toilet. The CDC also estimates that about one in three people don’t wash their hands after using the restroom. "Parents have to set a good example," Smith-Easley said. "They need to help their children make washing their hands a routine part of the day. Reminders are also effective. A simple, ‘Don’t forget to wash your hands,’ helps." Garza added that parents should teach their children the proper procedure for hand washing and remind them to keep their hands away from the face. "If you notice in public restrooms, most people wash their hands for about five seconds but we should rub the hands vigorously for 15 seconds and ideally, 30 seconds. It’s also important to dry the hands well." Washing the hands with soap and water is best, Garza added, but said that using alcohol-based anti-bacterial gels or wipes are "better than nothing." The CDC suggests washing the hands regularly throughout the day, but especially before, during and after preparing food; before eating and after using the bathroom; after handling animals and animal waste; when the hands are dirty and more frequently when you or someone in the home is sick. Parents and educators looking for more information on promoting a culture of proper hand hygiene can visit www.ItsASnap.org, a Web site promoted by the CDC. "It’s a Snap encourages students to create their own hand washing campaign in their schools," Smith-Easley said. "It raises awareness and reminds students, educators and parents about the important role hand washing plays in keeping healthy. The ultimate goal is to help students to have less sick days and be in school learning." ——— Rose Ybarra covers features and entertainment for The Monitor. You can reach her at (956) 683-4425.


The side-bar on the ItsASnap website has a pointer to Handwashing Links from the National Agricultural Library with dozens of examples of excellent educational projects.

So, the question is forming - what can we expect in Oz? Is there any of the same quality of educational material about? If there is some way to go, before we take the matter as seriously as the Americans, who should be leading?

It's my opinion that none of the infectious diseases establishment, in Melbourne, can be trusted to give an unbiased opinion on ways to meet the coming influenza pandemic. All of them are compromised by connections to the biotech industry, either as grant-begging researchers, as sponsorship-grasping conference attendees, as agents of pharma in drug trials, as employees, or as shareholders.

Why would someone with a commercial interest in a vaccine be unlikely to give due weight to primary prevention? Easy. Take the example of the virus, Rotavirus, that causes diarrhea in infants around the world. Like all diarrheal diseases, Rotavirus infection starts when the germ gets into the mouth, in food and water or on the hands, and goes down into the stomach and gut. If African infants had access to clean water and food, and were able to practise good hygiene, there would be no need for a Rotavirus vaccine. Put it another way - makers of hand hygiene products, like soaps, will promote basic hygiene, because there is a unending market for their products. But, if diarrheal diseases can be controlled by clean water and soap, why would a vaccine maker draw attention to that simple equation? That is, would Melbourne's CSL, or the Victorian biotech industry, or Victorian politicians, or Melbourne's The Age, promote primary prevention, if there are megabucks to be made from a vaccine or drug?

GlaxoSmithKline, which makes the less popular Relenza, has also stepped up production, with big government orders from Europe in recent weeks. Relenza was developed in Australia, and drug company Biota earns a royalty from sales. Its share price has doubled in the past eight weeks.

If medical leaders cannot give honest, straight, evidence-based accounts, who can? How about the nurses who work in big public hospitals, don't they practise superb hand hygiene? Nurses would be ideal role models, except for a couple of random observations I have made. Recently, I sat by the bed of a sick relative in a big hospital. One of the nurses came to adjust a piece of apparatus, and her fingernails were objects of amazing "glamour". I thought the standing rule for nurses' fingernails was 'clipped short and clean', and that artifical nails were banned. I thought it was understood that vast numbers of bacteria collect and breed in the moist spaces under and around fingernails. I know it is impossible to decontaminate the hands, with any assurance, unless the nails are short. Has nursing administration has lost its power to uphold standards? The photo of a newly-appointed chief nurse, Denise Heinjus,  in The Saturday Age on page 33, shows clearly that she has long nails. What hope, then, of insisting ward staff adhere to world's best practice?

Vaccines and antiviral medicines have a limited place in the anticipated influenza pandemic. Those products should be reserved for essential personnel, like the ambulance service and police. For example, if we had doses of Tamiflu at my workplace, they would be held for use by those scientists who are more likely to be exposed to the virus. If we had limited stocks of an effective vaccine, it should be given to mothers of young children, first.

Why do I persist, in what may turn out to be a one-man crusade, for widespread community action for better hand hygiene? Why, indeed, when Joe and Jill and the little Averages can be seen in any food mall, transgressing grandmother's dictum to wash hands before coming to the table?

Australians will be sitting ducks (also here) for the pandemic, if they believe quarantine of imports (Quarantine officials warn of bird flu threat) and imperfect medical technology can substitute for personal reponsibility. But there are smart people in the business world, and, as reported in AFR, Wall Street is taking notice. A pandemic will ruin businesses, full stop. The corporate moguls may come to see those great gaps in public health practice, that reduce our collective ability to deal with any epidemic of infectious diseases. They may see that prevention is a job of education and leadership, that costs almost nothing to keep a population protected. The chiefs of industry may then tell the pork-barrelling politicians, the conflicted medical experts, the self-serving healthcare sector, and the gutless media, to stop pissing in each others' pockets and start giving out good information to the public.


Nuggets

With Fiona Wood at the National Press Club, a bit more rational thought may be directed at national health policy for a few minutes.

The Australian Financial Review for Sep 28th has an editorial on the government's desire to sell Medibank Private, and the effect of the PHI 30% subsidy.
... Medibank Private accounts for 30 per cent of the market and should not need the drip-feed of taxpayers dollars. If the government wants to subsidise the health sector, there are plenty of more equitable ways to distribute the nearly $2.5 billion involved. And if the government wants to encourage private insurance, ther are better ways than a subsidy, which is an effect a penalty on those too poor to take private cover, or who choose not to do so for other reasons. ...

Also worth reading are two web articles on the pharmaceutical business. (This AFR mentions that a feeler put out by Abbott & Costello, to further discount me-too drugs, is being white-anted by pharma and its allies, because it would be 'bad for our business'.)

Jeanne Lenzer in Drug Secrets at Slate.
... The use of trade-secret laws to conceal deaths and serious side effects linked to drugs has the obvious flaw of putting profits before public health. It also subverts the covenant between researchers and study volunteers. Subjects like Traci Johnson are told that even if they do not personally benefit from a new drug, the scientific knowledge gained from the study in which they've participated will benefit others. The volunteers should be told instead that scientists will learn about their experience only if it's good news for the drug they're helping to test.

Richard Smith in Curbing the Influence of the Drug Industry: A British View at the current PLoS Medicine.
... The consequences of all of these incestuous relationships, says the committee, are bad decisions on the regulation and prescription of drugs, over-reliance on drugs rather than on other interventions (such as dietary change, exercise, or counselling), and the “medicalisation

Innovations

The Victorian government is setting up a Health Service Management Innovation Council. (Want the job?)

Health service management is crying out for more measurement of outcomes and processes, so that the innovations that improve safety and quality can be identified on the basis of actual evidence.

Measurement relies on electronic messaging, so it is reassuring the Telstra is committed to providing broadband access.

The days of trying to count health events, on a population-wide spectrum, by transfers of paper are long gone. It's intriguing that politicians are jumping up and down about the risks of avian influenza being transmitted onto mainland Australia. But our mechanisms for counting occurrences of the perennial influenza, or any other significant infecious diseases, are grossly deficient. As far as I can tell, reports on incidence of specific infections are issued by the Communicable Diseases Intelligence branch at DoHA. I know, for a fact, that the data that supplies these charts is garnered from individual diagnostic laboratories that voluntarily send copies of their results, by post in A4 envelopes. Good enough for the season just before the pandemic? I don't think so.

The Forbes report on the Queensland health system has been published and the government is promising to spend lots of money to fix it. Report seeks $1.5b reform of Qld health system How much of the $1.5b is going to spent on more effective IT systems?

Labor, today, is suggesting more taxation will be have to be lifted, in order to support our growing national expenditure on health. Labor warns health spending may push up taxes How much will be shifted into better IT systems, before anything else?

An article at Forbes.com ( Fixing Hospitals) shows that in the US, the financial services sector spends 9% on IT, while the health sector spends 5% of revenue on IT. See also Electronic Medical Records Push Could Spur More Deals. Australian comparators would be worth a look.

When one giant US health insurer recently bought out another (WellPoint to Buy WellChoice in $6.5 Billion Deal), the comment about a key component was -
The companies also say that by raising money from investors, they can finance the heavy costs of information technology.

The national government should convene COAG and get a moratorium on all current projects for health IT, and find out what the heck is going on. There is no doubt that some legislatures have committed, very unwisely, to technologies that rely on the synapses occurring in a single brain. There is no doubt, also, the first result of rationalising the spend on IT is going to be ugly - more dough from the punters. But that's what Infrastructure Partnerships Australia is for.

Food Politics

From 'Food politics' by Marion Nestle. (some scanning artefact, omitted superscripts and other errors have crept in)

CHAPTER 5
CO-OPTING NUTRITION PROFESSIONALS
THE EFFORTS OF FOOD COMPANIES TO INFLUENCE DIETARY advice to the public and to establish an image of their products as nutri­tious extend well beyond lobbying Congress and government agencies. They go right to the heart of nutrition as a profession. Indeed, co-opting experts - especially academic experts - is an explicit corporate strategy. A guide to such strategies explains that this particular tactic "is most effectively done by identifying the leading experts ... and hiring them as consultants or advisors, or giving them research grants and the like. This activity requires a modicum of finesse; it must not be too blatant, for the experts themselves must not recognize that they have lost their objectivity and freedom of action. At a minimum, a program of this kind reduces the threat that the leading experts will be available to testify or write against the interests of the regulated firms."'

Food companies apply this strategy to engage nutritionists as allies in various ways, some evident but some less so. They routinely provide information and funds to academic departments, research institutes, and professional societies, and they support meetings, conferences, journals, and other such activities. Most nutrition professionals depend on such support, and some actively seek it. At issue is whether doing so corrupts academic and professional integrity.

This question is not so easy to address as it might seem. As an aca­demic nutritionist, I cannot fail to recognize that the industry has created a plentiful, varied, readily available, relatively safe, and relatively inex­pensive food supply that is the envy of people throughout the world. Many - perhaps most - of my colleagues sincerely believe that the only way to improve the diet of Americans is to work with industry to pro­duce more nutritious food. Nevertheless, although accepting support from a food company does not necessarily mean that we endorse its products, the public may perceive us as doing so. Thus people outside the field who observe partnerships among nutritionists and food companies might wonder how we can possibly maintain objectivity and critical judg­ment when engaged in alliances with industry - and they would wonder with good reason, as this chapter suggests.

SPONSORING EDUCATION AND RESEARCH
Food companies routinely sponsor the educational activities of nutrition professional societies as well as the research of individual investigators, and nutrition academics routinely consult for food companies on these and more product-oriented matters. In my own experience, it is impossi­ble for nutrition academics not to be involved with food companies in one way or another. This issue is not new; a survey by the Center for Sci­ence in the Public Interest in the mid-1970s identified frequent payments by food companies to agriculture and nutrition faculty for consulting services, lectures, membership on advisory boards, and representation at congressional hearings; this same group now reveals academics' ties to industry on a Web site that provides hundreds of examples of nutrition researchers and educators who receive funding from food companies. Nor are the apparent conflicts of interest in such interactions confined to the United States; a recent British study found 158 of 246 members of national committees on nutrition and food policy to consult for or receive funding from food companies. Table 13 lists a few examples of food company sponsorship of professional societies. Inevitably, such connec­tions raise questions about the ability of academic experts to provide independent opinions on matters of diet and health.
Journals and journal Supplements

Nutrition societies publish journals and supplements to journals. These are expensive to produce, and corporate sponsorship helps to defray costs. Thus the Journal o f Nutrition Education acknowledges 8 "corpo­rate patron friends" and 4 "corporate sustaining friends ... who make an annual financial contribution to support the goals of the society and its journal." The more research-oriented Journal of Nutrition lists 10 food and drug companies as sustaining associates of its parent society, and the  American Journal o f Clinical Nutrition lists 28 such companies support­ing "selected educational activities of the Society." Sponsors of nutrition journals include such companies as Coca-Cola, Gerber, Nestle/Carna­tion, Monsanto, Procter & Gamble, Roche Vitamins, Slim-Fast Foods, And the Sugar Association, as well as others that make baby food or formula vitamin supplements, functional foods, diet products, sugar­sweetened breakfast cereals, and genetically modified crops - virtually all ,)l them products with nutritional attributes considered controversial and . currently under debate.

Some journals go to great pains to erect a "firewall" between their edi­torial and business functions, but this barrier is all too easily breached. ( One reason for the breach is that advertisers contribute to the financial health of academic as well as popular journals. The American Dietetic Association, for example, reported an income of about $3 million from its journal in 1999. Its April 2000 issue carried 12 full-page advertise­ments, mainly from companies selling diet supplements or nutrient-analy­sis software a separately bound 20-page "educational" insert from the I Dannon Institute; and another 8 pages of classified advertisements. An Account of the advertising practices of the two leading U.S. journals - the New England Journal of Medicine and the Journal of the American Medical Association - both of which publish the "hottest" of nutrition research, observed that both have business as well as academic functions and "are beholden to drug makers for their economic viabil­ity;" each takes in about $20 million annually from drug company adver­tising. At the very least, this sponsorship causes considerable discomfort to the editorial side of the firewall.

Papers presented at conferences sponsored by food companies are sometimes published as supplements to nutrition journals, and the com­panies also underwrite the costs of publication. In 2000 for example, companies such as Wyeth Nutritionals, Bristol-Myers Squibb, Mead John­son, and the International Nut Council helped support publication of sup­plements to the American Journal o f Clinical Nutrition. Researchers on drug company sponsorship have shown it to be highly correlated with publication of articles favorable to sponsors' products, and nutrition jour­nal supplements also tend to highlight the benefits of particular foods or diets in which the sponsors have some interest. A rare exception was a supplement to the Journal o f Nutrition on the role of soy foods in disease prevention and treatment. Although the sponsors included Archer Daniels Midland, Cargill, and a host of other soy producers, product manufac­turers, and promotion boards, the editors introduced the supplement with this caveat: "With few exceptions, considerably more research is required before a good understanding of the health effects of soy can be realized ... [and] there is some lack of confidence about the validity of some of the effects that have been observed ... [A]lthough most delegates considered soy foods to be absolutely safe, not all were in agreement on this point." 6
I can speak from experience about the difficulties inherent in spon­sored supplements: I edited one for the American Journal o f Clinical Nutrition in 1995. The papers came from a conference on the health effects of Mediterranean diets for which the principal sponsor was the International Olive Oil Council - a group that might be expected to have much to gain from favorable publicity about the health benefits of diets in which olive oil is the principal fat. After much discussion, the editor and I dealt directly with problems of conflict of interest. We agreed that the sponsors would not participate in the editorial process, pay authors for their contributions, or pay me for my editorial work. The entire supple­ment was peer-reviewed, and the sponsorship was fully disclosed: "Spon­sor: Oldways Preservation & Exchange Trust through a grant from the International Olive Oil Council, Administrator of the United Nations Olive and Olive Oil Agreement." This journal requires such disclosure; like others, it adds the letter "s" to supplement page numbers - a signal to readers that the articles may not have undergone as rigorous a peer review as is customary. Not all journals are this scrupulous, however.
Conferences
Professional meetings normally take place in hotels; they are expensive to run but can produce substantial income for nutrition societies. The American Dietetic Association, for example, reported revenues of nearly $900,00o from its 1998 annual meeting, a figure that surely must exceed expenses. To generate such income, nutrition societies routinely seek corporate sponsorship, and companies willingly comply. Food, beverage, and supplement companies buy space at exhibits; place advertisements in program books; underwrite coffee breaks, meals, and receptions; sponsor research awards and student prizes; and provide bags, pens, and other meeting souvenirs - for which they are thanked in program books. This phenomenon is not confined to the United States. In 1998 I attended a meeting of the British Nutrition Society where the program book thanked Nestle UK and Sainsbury's for receptions, Coca-Cola and Mars for refreshments, and the Meat and Livestock Commission for barbecue and banquet meat. I also attended a meeting of the Community Nutrition Society of Spain sponsored by 20 groups representing vitamin supple­ments, juice, margarine, olive oil, and beer.

In the United States, the annual meeting of a leading nutrition research group, the American Society for Nutritional Sciences, sets aside time for a Kellogg-sponsored breakfast meeting for heads of university nutrition departments; an especially memorable one featured samples from the com­pany's line of psyllium fiber-supplemented foods, which were then under­going test-marketing. That same conference offered research sessions spon­sored by trade associations such as the National Dairy Council and the National Cattlemen's Beef Association. The program book for the Amer­ican Dietetic Association's annual meeting in 2000 acknowledged session sponsorship by more than 30 food, beverage, or supplement companies, some with commercial interests in the topic under discussion. The Dis­tilled Spirits Council, for example, sponsored a session on the risks and health benefits of alcohol consumption, Slim-Fast sponsored talks on obesity prevention and treatment, the company that makes Benecol mar­garine underwrote a session on its cholesterol-lowering ingredient, and Quaker/Gatorade supported lectures on athletes' dietary supplements.
 
Does sponsorship influence the content of conference sessions? In my experience, speakers at sponsored sessions are offended by such a ques­tion. Sponsorship is so ubiquitous and is considered so helpful that hardly anyone can imagine that it might have harmful consequences. A study of pharmaceutical industry practices, however, has reported that physicians who accept travel funds, meals, or gifts from drug companies, or who attend conferences sponsored by them, are more likely to write prescriptions for the sponsors' medications. Another study described how a drug company used a medical conference as a public relations strategy to generate interest in vitamins as "potent agents of health"; it concluded that if nothing else, critics of the products were excluded from the debate. 9
Such research suggests that to avoid undue influence, nutritionists should refuse sponsorship or decline invitations to attend or speak at sponsored meetings. Perhaps so, but if we take this ethical high road, we end up talking only to ourselves. To give a personal example: Should I have declined an invitation to debate food biotechnology at a sponsored session at the American Dietetic Association's annual convention? The association offered airfare, meals, and hotel expenses and an honorar­ium of $1,500 - all paid for by Monsanto, the leading U.S. producer of genetically modified crops. Although the company approved the pro­gram in advance, it is "innocent" of buying influence; Monsanto's funds go to the association, not directly to the speakers. If I refuse such invita­tions, I lose an opportunity to explain my views to an influential audi­ence. If I decline the funding, I am out the considerable costs of travel and hotel accommodations. But if I accept the invitation, will my views be compromised by the sponsorship? Will I feel that I am being impolite if I criticize Monsanto for its opposition to labeling of genetically modi­fied foods? This ethical dilemma is not easily resolved, even by people sensitive to the issue.

Research Studies
Whether nutrition professionals are compromised by support from food companies is a troubling issue, but an even more troubling question is whether corporate sponsorship affects the conduct of nutrition research or its results. Research funds are scarce, and researchers are always look­ing for funding sources. Given the cautious interpretation required for most nutrition research, any study, review, or commentary with conclu­sions favorable to sponsors may give pause, as indicated by the selected - but quite typical - examples offered in Table 14. So might the actions of the National Academies' Food and Nutrition Board (FNB) in recom­mending higher levels of intake of vitamins C and E when the board's work is funded in part through a foundation supported by companies such as Roche Vitamins, Mead Johnson Nutrition Group, Daiichi Fine Chemicals, Weider Nutrition Group, and the Natural Choice Vitamin E Association - all with vested interests in having nutrient standards set so high that people can meet them only by taking supplements. The FNB itself is supported directly by food and supplement companies such as G. D. Searle, Monsanto, NutraSweet, and Nestle.
Nearly everyone believes that the first step in preventing sponsorship from influencing research is to disclose it. One notable exception is the prestigious British journal Nature. Its editors dismiss concerns about research sponsorship and explain that they persist in the "stubborn belief that research as we publish it is indeed research, not business." This view may explain why the journal was "pleased to acknowledge" the financial support of The Roche Group - a company that makes a drug used in obesity treatment - for a "Nature Insight" section containing six scientific papers on this condition. Roche advertisements introduce the Insight section: "There is no doubt that, in addition to lifestyle and behaviour changes, innovative new drugs will play an important role in managing obesity. We take pride in sponsoring this special issue." The filial Insight article concludes that current drugs have a useful place in the I treatment of obesity; one of its authors works for Millennium Pharma­ceuticals a Roche partner "in attempting to understand the underlying cause of obesity and diabetes."" Although the quality of the sponsored papers may be excellent, this section cannot help but appear more as .advertising than as science.
The most important consideration is whether industry sponsorship influences research results and opinions. This question demands careful consideration if for no other reason than sponsorship by industry is so common A 1996 survey found that nearly 30% of university faculty members accept industry funding; 12 another found 34% of the primary authors of 80o papers in molecular biology and medicine to be involved in patents to serve on advisory committees, or to hold personal shares in L companies that might benefit from the research."
Some self-selection surely is involved in these relationships. Most research on this question concerns sponsorship by drug or tobacco com­panies Those studies demonstrate that investigators who support the use of drug or tobacco products are more likely than neutral or critical authors to have financial relationships with such companies. They also demonstrate that favorable attitudes toward the product are associated with favorable research results, whether or not the companies can be proved to exert influence. Other studies demonstrate an even stronger association with research results that minimize negative effects of these products on health. Researchers on such relationships do not suggest that industry-sponsored research is always biased, just that there is a higher probability that it will draw favorable conclusions. 14
As indicated by the examples given in Table 14, it seems entirely likely that investigations of sponsored nutrition research would arrive at similar conclusions. No matter how carefully the research is conducted, its parti­san sponsorship conveys the impression that the results were purchased.

TABLE 14. Quotations from selected research studies, reviews, or editorials supported fully or in part by food, beverage, or supplement companies
"High-fibre breakfast cereals may help to reduce risk of cancers that are asso­ciated with poor fibre intakes." (The author is employed by Kellogg's, UK. )a
"Eating two eggs daily for 12 weeks ... resulted in no statistically measurable effect on plasma LDL-C [low density lipoprotein-cholesterol, the "bad" kind] in HC [high-blood-cholesterol] subjects" (funded in part by The Egg Nutrition Center).
"Margarine intake compared with butter intake lowered LDL-C levels 11 % in adults ...and 9% in children." (Sponsors included the United Soybean Board and the National Association of Margarine Manufacturers.)
"The prepared meal plan is a simple and effective strategy for improving dietary compliance and CVD [cardiovascular disease] endpoints." (This study was funded by Campbell Soup, maker of the prepared meals.)d
"Scientific findings indicate that the prevalence of lactose intolerance is grossly overestimated." (One of the authors is an officer of the National Dairy Council. Lactose is the principal sugar in dairy products.)e
"Zinc gluconate ... significantly reduced the duration of symptoms of the common cold by 40% compared with placebo." (One of the authors is reported to have earned nearly $145,000 from sale of the product's stock before the paper was published. A later study by the same group found zinc to be ineffective against colds.)f
"Substantial evidence indicates that intakes greater than the recommended dietary allowances (RDAs) of ... calcium, folic acid, vitamin E, selenium, and chromium reduce the risk of certain diseases for some people." (The author of the review is a scientist/official of the Council for Responsible Nutrition, a supplement-industry trade association.)g
"The possible risk of pulmonary hypertension associated with dexfenfluramine [an anti-obesity drug] is small and appears to be outweighed by benefits when the drug is used appropriately." (The authors consulted for the drug manufacturer. )h


TABLE 14. (continued)
"For most patients [with blood cholesterol levels above 130 mg per deciliter] an LDL-lowering drug will be required." (The chair and 5 of 13 other members of the committee responsible for this recommendation consulted for or received honoraria or grants from pharmaceutical companies making cholesterol-lowering drugs.)'
"There is reason to be concerned that lowering NaCI [salt] intake may have long-term metabolic risks that have not been fully identified ... we do not have solid evidence that lower NaCI intake prospectively will prevent or control high blood pressure." (The review in which this appears was funded in part by The Salt Institute, a trade association for the salt industry.)j
"A moderate intake of wine (2-5 glasses per day) was associated with a 24-31 % reduction in all-cause mortality." (This study was funded in part by The French Technical Institute of Wine.)k
"The symposium reviewed ... the new evidence suggesting that certain cocoa flavonoids may have cardiovascular health effects ... the research to date suggests that chocolate lovers may obtain more than a sensory benefit from their indulgence." (The journal supplement in which this was published and some of its studies were sponsored by Mars, Inc., United Kingdom.)'
Sources: a O'Sullivan KR. In: Smith G, ed. Children's Food: Marketing and Innovation. London: Blackie Academic & Professional, 1997. 'Knopp RH, et al. J Am College of Nutrition 1997; 16::551-561. `Denke MA, et al. JAMA 2000;284:2740-2747 Metz JA, et al. Am j Clin Nutr 1997; ~,6e373-385. `McBean LD, Miller GD. J Am Diet Assoc igg8;g8:67c-676. fMossad SB, et al. Annals of ( Internal Medicine tgg6;iz5:8r-88. Hilts PJ. New York Times February 1, 1997:6 Macknin ML, et al. JAMA rgg8;z7gag6z-tg67. g Hathcock JN. Am J Clin Nutr tg97;66:4z7-437. hManson JE, I,vch GA. N Engl J Med i996;335:659-660. Hilts PJ. New York Times August zg, rgg6:Dr8. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA -,,oi;z85:z486-z497. 'Muntzel M, Drueke T. Am J Hypertension 1991;5:1s-41s. 'Renaud SC, et al. I pirlcmiology r998;ga84-i88. 'Erdman JW et al., eds. J Nutrition zooo;t3o(8 suppl)zo57s-ztz6s.

This impression is reinforced when sponsors use the results to advertise or publicize their products. Following publication of the margarine study cited in Table 14, for example, a trade group identified only by its Web site (www.margarine.org) placed a full-page advertisement in the New York Times (December 8, 2000): "4G families end the margarine vs. butter debate A groundbreaking study in the Journal of the American Medical Association proves that using margarine instead of butter significantly lowers cholesterol. The debate is over . . . the results proved once and for all that soft margarine is clearly the healthier choice ... everyone in your family can feel good about eating it."
The advertisement, of course, says nothing about the caloric equiv­alence of butter and margarine, nor does it particularly emphasize that the margarine must be soft in order to avoid cholesterol-raising trans­saturated fatty acids. Industry publicity about the finding of beneficial flavonoid phytochemicals in chocolate and wine also rarely mention their dietary context.

Flus and flaws

While the USA's HHS Secretary, Mike Leavitt, tours our part of globe looking at the influenza situation, it is worth checking some of the things he has been saying about IT.

Eg, HHS Accelerates Use of E-prescribing and Electronic Health Records.
... These new proposals would allow hospitals and certain health care organizations to furnish hardware, software, and related training services to physicians for e-prescribing and electronic health records, particularly when the support involves systems that are “interoperable

Lifestyle vaccines

This topic was introduced to Parliament on Tuesday, by Labor's Julia Gillard in Speech: NATIONAL HEALTH AMENDMENT (IMMUNISATION PROGRAM) BILL 2005: Second Reading
... We are concerned that the increasing predisposition by the Howard government - and this has in fact been stated in briefings to us - is to view the future of vaccines not as great new breakthroughs to be made on the universal provision of vaccines as a public health matter but as lifestyle vaccines - that is, highly targeted vaccine populations who require the vaccine because of some particular set of circumstances. We are concerned that we are now at a stage where the Howard is looking at vaccines through that prism.  Over the coming period, this country will be required to make some decisions about the provision of vaccines, which I would say are decisions that ought to be made through the prism of universality and public health measures rather than through the prism of the provision of highly targeted vaccine provision - the so-called lifestyle conditions that then attract a predisposition to needing a vaccine. ...

It is a new concept, briefly addressed earlier this year in Cancer prevention | Lifestyle vaccines | Economist.com.
... The idea of a nicotine vaccine is to stop the drug getting to the brain in the first place. People who are vaccinated should develop antibodies that bind to the nicotine in their bloodstreams, disabling it. If no nicotine reaches the brain, there will be no pleasurable reward for having a cigarette. So vaccinated individuals should - in theory - be less likely to relapse. This approach is not unique to nicotine. Vaccines against cocaine, another addictive recreational drug, are also being developed. But the results announced in Orlando suggest that Cytos's nicotine vaccine is now the closest to being deployed. ...

In this case, of a nicotine vaccine, we may wonder who would be keen to attract public money into both doing the R&D, and using taxes to pay for smokers to get it. Could it be governments, who rake in billions of excise from tobacco sales, or tobacco merchants who resist the attempts to curtail sales of their nicotine-addiction-inducing products?


The World Vaccine Congress Lyon 2005 had one talk in one session on 'Are lifestyle vaccines the more profitable option?'.

Ms Gillard went on
... One example of that - and I think it is a very critical one - is the vaccine that is now under development for the human papilloma virus, which we know is implicated in a number of cancers, but most especially cervical cancer. This is a great Australian invention and we should be incredibly proud of it. Every year in Australia, 700 cases of cervical cancer are diagnosed and there are about 270 deaths. We know that this vaccine appears to have the potential - when used as a population health measure, viewed through the prism of universality for young people - to eradicate that kind of cancer in our population. Girls growing up in the current generation and girls born this year will never have to think about cervical cancer in the same way the women in this parliament throughout their lives have had to think about it. They will not have to think about risk factors in relation to it because a vaccine will be available. It is a complete medical miracle. ...

Miraculous indeed, since HPV is but one of several common microbes that cause sexually transmitted infections. What is she proposing - that vaccination for HPV will also magically engender respect for the easy passage of the little buggers between conjugated condomless couples? What if the intemperate waft about 'miracles' somehow increases the risk that young women will be less able to insist on barrier protection?

And what about a vaccine for HIV-AIDS? If one was developed, would there be a political argument for vaccinating all children at birth? Or could there be a better argument for leaving those who want to take the 'lifestyle'  risks, to pay for it out of their own pockets? What was it that so effectively minimised the transmission of HIV in Australia? Condoms, and continuous emphases on the need for education about safer sexual behaviour!! Now that we are starting to recognise the extent of HIV infections in PNG, would Ms Gillard as Health Minister be encouraging and paying for 'safer sex' campaigns - lecturing the people of PNG to act on proven first principles about sex, and at the same time promising miraculous protection for Australians? Maybe the HPV vaccine will prevent AIDS, too? But, if condoms prevent HPV transmission, wouldn't a fraction of the money be much better spent on effective government advertising, today?

A clue was injected in the continuation of the debate, the following day. Speech: NATIONAL HEALTH AMENDMENT (IMMUNISATION PROGRAM) BILL 2005: Second Reading > Hatton, Michael, MP > 10:08:00
...  One thing that foreign pharmaceutical companies acting in Australia as regional units of overseas entities have a good track record in doing is developing new drugs that are useful not only in Australia but worldwide. These new drugs are invented and proven effective in Australia but then get worldwide approval and are developed for worldwide distribution from Australia. A number of such drugs have been developed by the Merck Corporation in the electorate next to mine, the electorate of Reid, by their group in Granville. The work force largely comes from my electorate of Blaxland. The Merck Corporation have built a very substantial business on the basis of their own research and development. Under Labor’s policy, they took one of their drugs from nothing to $4 billion of income for the company. They made $400 million a year, year on year, and averaged out that is $4 billion over a decade. The second drug they did that with, Vioxx, has been taken off the market because of deleterious consequences associated with it, but the same company have just announced that their vaccine trials in relation to cervical cancer have proven to be utterly effective. The vaccine has been shown to be 100 per cent effective against cervical cancer in women. ...

It's one thing for public figures to talk up the stock of biotech companies. It's another to ignore the fact the good public health can be far more cost-effective than vaccines, especially vaccines that are years away from general use.

Merck, and CSL, would dearly love this government to commit to paying for every young girl to be vaccinated against HPV. That's, say, $100 a pop, for 200,000 12-year-olds every year. We don't know how much Merck will charge, but the price is sure to be pitched on top of plenty of PR about how expensive it was to get the product 'on the shelf'. That starting point will be at least US$1billion, on today's spruiking, so $20m a year will be handy. A little nudge up to, say, $105 per dose, will more than cover the incidentals, like paying for [*****] to go on a study tour of the plants.

I hope Mr Abbott and Mr Pyne have more sense, than that shown by Labor, on this matter.

The next World Vaccine Congress is in March 2006 at Washington DC.

On of the 'Cocktail sponsors' at the 2005 Congress was SAFC Biosciences. This business was bought from CSL, for some hundreds of millions. (Acquisition of JRH Biosciences). If promotion of local industries is a good thing for politicians to be doing, despite the trashing of good public health campaigns, then I'd recommend the Hawaii stopover on the way to the Congress.

(BTW, I enjoyed Dr House shaft pharma, in Episode 17 of Season 1, see the Fox site.)

Good bye Medicare?

Short extract from a very lengthy but very good article in the New York Times

""""""How did things get this bad?

Most health care in the United States is fragmented and profit-driven, a system in which everyone but the patient is meant to benefit financially.

"Fragmentation is a fact of life in health care, and people consider that to be one of the most fundamental problems," Dr. Brailer said. "We pay by the piece. Everybody gets paid individually to do something: to see a patient, to admit someone, to do a lab test, to do a prescription, so health care is swamped by detailed, line-item bills." """""""

Gus option: Fight tooth and nail tp prtecty what you have before it's too late!

Fertilising fairness

In a letter to The Australian, Oct 15th, from Julia Gillard,
[...] The truth is that savings to the taxpayer would have been achieved on the private health insurance rebate due to Labor's Medicare Gold policy, a policy Mr Abbott obviously still fears. Medicare Gold meant older Australians would no longer need to have private health insurance, and consequently, would not have needed the private health insurance rebate. The savings on the rebate from Medicare Gold were made clear in the election policy document. [...]

Medicare Gold rested on an understanding of root-and-branch reform of healthcare, and the way it is funded. Other statements by Labor in last week's Parliament suggest Ms Gillard needs to keep testing herself on what she really means to achieve. What would she say in response to this, from Background Briefing Oct 9th, Getting Older, Getting Cosmeceuticals?
[...] David Le Couteur: The large pharmaceutical companies, which are huge multinational billion-dollar companies, have moved out of doing early phase drug development and really only start to develop drugs when there’s a short-term horizon in the order of three to five years. So any drug that looks like it’s going to be a genuine therapeutic advance is taken up by the big companies at that point. So most of the early-phase drug development is being done now by small start-up, often biotech companies, and these are high risk companies, analogous to the gold and mining exploration companies of decades gone by. So that’s one force. On the other hand there’s a competing force which is the fact that the universities now are being forced to consider themselves as being economic entities whose role is to generate profit rather than education and research that benefits society. So there is enormous pressure on scientists on all areas to be involved in some aspect of commercialisation of whatever they’re doing research in, and it’s the pressure on these scientists that is probably fuelling the start-up companies as well. So you’re getting a meeting of the two forces: the academics that are being forced to be shown to be commercialising their products, and small start-up companies that are wanting to look like they’ve got a product, or want to convince the share market that they’ve got a product.
Stan Correy: And if that product is for age-related disease, then there are special problems for biopharmaceutical companies who are trying to develop new treatments. Professor David Le Couteur:
David Le Couteur: The companies working on age-related diseases are a very big area simply because that’s a huge market. Ageing is the major risk factor for every disease that you can think of: heart disease, bone disease, cancer, diabetes, dementia, the lot. So obviously, if you want to produce a product for a big market, you’ve got to be producing drugs for diseases of older people. The big problem with drug development in older people however, is that the drugs are tested on middle aged people, people in their 50s and 60s, and then used often with considerable problems in terms of side effects, in much older people who can’t tolerate the medications nearly as well.
Stan Correy: That’s very interesting, so you say there are particular factors in dealing with drug development for older people?
David Le Couteur: Very much so. The risk of side effects of medications increases exponentially as you get older. The probable cause of the diseases, the underlying mechanism for the diseases changes as you get older. Yet much older people, and I’m talking people in their late 70s and 80s and 90s, are the ones that have all the disease and are by far and away where the medications are used the most. And what I can tell you is that information on their usefulness in those age groups is almost non-existent, yet information on the harm caused by those medications is well established. So we really have a major problem here that drug development is done in younger adults, the market is in much older people and these people are often being harmed by the inappropriate use of drugs in these groups, and I think they’re being exploited. [...]

Big pharma is more than capable of looking after itself. With pressure on the government to ensure supply of effective anit-influenza vaccines, companies like CSL will be able to name their price, more or less. Why do CSL and Merck need sponsorship from politicians?

In her speech about the HPV vaccine, Ms Gillard called it a "miracle". An advertisement by Ian Frazer's employer, University of Queensland, in the weekend papers, used the same terminology about Frazer's foundational work that enabled the vaccine to be produced. Frazer, himself, says the "miracle" happened 20 years ago, in basic research.

All the work on the vaccine since then, has been to industrialise and commodify it. It's odd that Labor is beating up a commercial product, another commodity that will be offered to buyers according to market rules. Merck and CSL, and all their employees, are solely about giving maximum return to shareholders. On an influenza vaccine, CSL "[...] will make it a commercial product but we'll certainly not be looking to make it an obscenely profitable product." No, but the compensation will be based on figures cobbled together by CSL insiders, without the benefit of public audit. The spirit of commercial-in-confidence will ensure that details about production costs are not disclosed, and CSL will be able to call on industry competitors to vouch that a figure of around $1billion will be appropriate.

Why does Ms Gillard, or any other Labor MP, need to get on the bandwagon in praise of Merck? (See Lifestyle vaccines.)

The message about Australia's investment in basic research, and the broader R&D effort, is that we are not putting enough into it. And we can't simply focus on giving better laboratories for today's researchers. Our involvement in the discoveries of the future begins with our children, and more specifically the smart kids from families who do not have access to the best private schools. This is what Labor should be about, if it still believes in the underpinning philosophy of Medicare Gold. Industry giants can look after themselves, as can the Scotch Colleges. Labor's future is in people who need assistance to reach their potential. The sooner Labor gets back on track, the better the chance of giving a helping hand to a young person who can make a huge difference to humanity.

But Labor must be careful, as well as adventurous. From Pylori pioneers: a long and Nobel journey (only available to subscribers):
[...] The discovery by Warren and Marshall that ulcers were caused by infection posed a major challenge to the pharmaceutical industry and there is no doubt that acceptance of antimicrobial therapy for ulcers was slowed by a reluctance of companies to include the hypothesis in their educational activities. To put this in perspective, it has to be appreciated that at this time the anti-ulcer therapies were the biggest-grossing products on the market, bringing in millions of dollars annually. Ten per cent of the population could expect to suffer from ulcer disease in their lifetime. The antisecretory drugs were the perfect pharmaceutical for a company. They caused instant and complete symptom relief for ulcer patients, acid secretion was stopped quickly and thus the ulcers would rapidly heal. However, should this wonderful treatment with huge patient satisfaction be stopped, the duodenal ulcers recurred in most patients within a year. Thus many patients were put on maintenance therapy for life. This continuing usage contributed greatly to company profits. These profits were jeopardised by the discovery of H pylori. Ulcers could now be cured by a two- to four-week course of therapy. The ulcers did not come back and so maintenance therapy was not needed. Until the evidence became overwhelming, it was not in a salesman's best interest to promote the new discovery. [...]

The HPV vaccine isn't going to keep sexually active women (or, more to the epidemiological point, women who had multiple partners in unsafe sexual practice) from the need for regular Pap smears, or equivalent, for the next 50 years, even if it is licensed today. There are at least three different areas where good money could be put down for more research, to remove the necessity for those ugly gynaecological examinations. They are:
1) A blood test for antibodies to HPV, could show that a mature woman has no evidence of previous infection with the strains of HPV that are associated with cancer.
2) Self-administered test (vaginal swab) to detect the specific HPV DNA.
3) New generation fibre-optic (not traumatic) inspection of the cervix for microscopic changes due to HPV.

Labor should be thinking, also, in terms of the lucrative cytology industry, and how changes to the taxpayer-funded status quo will be resisted.

In general, Labor should be redefining the practical outworkings of social democracy, and learning about new ways to apply them, while pitting Labor thinking against market-driven philosophies. Rolling along with the spruikers and lobbyists will keep Labor in opposition.

Medicare Gold revived

From Commonwealth should run hospitals: expert (Financial Review, Oct 29th):
[...] The man the Prime Minister asked to review the health system has gone public for the first time and called for the commonwealth to take over public hospitals. Former public service commissioner Andrew Podger is at odds with Prime Minister John Howard, who has ruled out taking over the health system from the states. "Clearly the Prime Minister has got a view that he would prefer not to go down the path of systemic [wide] review now, and I guess I can understand that," Mr Podger told the Weekend AFR.  "But I would like both levels of government to see that the commonwealth taking over would be a sensible option and to start looking at it seriously." Mr Howard commissioned MrPodger to report on the health system. While Mr Podger's report was handed over before the last meeting of the Council of Australian Governments in May, the government has not released its findings. [...]

From Secret Howard health plan matched Labor's (Weekend Australian, Oct 29th):
THE author of a secret report for John Howard on health reform has recommended a plan for caring for the aged that resembles Labor's Medicare Gold. Former public services commissioner Andrew Podger says there is a strong case for a single funder for the health needs of the aged - inevitably the public sector. [...]

From Latham man to tackle state health crisis (Courier Mail, Oct 29th):
A KEY architect of the Federal Opposition's discredited Medicare Gold policy has been hired to implement the State Government's health reforms.Former senior Commonwealth health bureaucrat Professor Stephen Duckett will head Queensland's new Reform and Development Unit, charged with putting in place the $6.4 billion five-year health plan. Professor Duckett, who is pro vice-chancellor and dean of health sciences at Melbourne's La Trobe University, was one of the health analysts behind former opposition leader Mark Latham's Medicare Gold policy. [...]

From ALP offers business tax cuts (Australian, Oct 28th):
[...] Shedding its image of having a "small target" policy approach, the Labor Party has also revived plans to use private hospital beds to take the pressure off the public system. Health spokeswoman Julia Gillard said she was convinced of the merits of the principle, which underpinned the much-maligned Medicare Gold policy at the last election. [...]

Costs of medicines

After the recent change of name from Health Insurance Commission to Medicare Australia, consumers should try not to confuse that government body with Medicines Australia (the lobby group for the pharmaceutical industry).

For example, in GPs attack drug regulator over Bayer ad (in Financial Review, subscription required):
Doctors have criticised the confidentiality protocols of Australia's drug industry self-regulator after complaints about the marketing of Bayer's popular impotence medication Levitra. Australian Medical Association president Mukesh Haikerwal said yesterday he would ask Medicines Australia to realign its review process for breaches of its code of conduct. [...]

Medicare has issued a pamphlet, TGA and PBS listing process information sheet that states:
1. Research & development takes an average of 8 to 12 years and may cost more than $300 million for each product that reaches shelves.

Was that a misprint? $300 million, only?

Medicines Australia: The latest independent research shows that it now costs about $1.2 billion to bring a new medicine on the 12 year journey from discovery to market.

Various guestimates are bandied about, depending on relationships with Big Pharma. For instance, in The dearth of new antibiotic development: why we should be worried and what we can do about it:
[...] The cost of researching and developing any new drug is generally in excess of US$500 million, and it usually takes about 8–10 years from the time a drug is first developed to the time it is released for sale. [...]

And, from Antibiotics A shot in the arm:
[...] The cost of drug development adds to the pressure for high-return products. According to the Tufts Center for the Study of Drug Development in Boston, it costs some $800 million on average over 10–15 years to bring a new drug to market. [DiMasi, J. A., Hansen, R. W. & Grabowski, H. G. J. Health Econ. 22, 151-185 (2003)]. [...]

Steven Projan (Wyeth Pharmaceuticals): Wyeth Pharmaceuticals is one of the few companies researching new antibiotics. The company has a new drug that should hit the market in a couple of years. It has taken the company 12 years and more than $1 billion to develop the drug and show it is safe.

In The $800 million pill: The truth behind the cost of new drugs by Merrill Goozner, reviewed here

From an online review of Marcia Angell's The Truth About the Drug Companies: How They Deceive Us and What to Do About It
[...] She describes how, even though the drug companies claim that it costs them an average of 802 million dollars per drug to develop new medicines, that figure is obscenely inflated since it factors in marketing as well as expected interest the company would have received had they invested the money in the open market. Meanwhile, Angell says, most of the R & D work is done by colleges and universities funded by the government. [...]

There's no doubt the bill for drugs under Medicare, based on a $300 million estimate for R&D, would be a lot less than one based on pharma's own sums.

The pamphlet makes Medicare Gold more feasible, so how long will it be before someone from the Bennelong Group has a quiet word with the member for Warringah?

The pamphlet is on the reverse of a page on SSRIs, mailed to all providers. It may become a collectors item, like one of those stamps with the queen's head upside down.

Healthy deceptions

The major medicines we should now develop are organic foods...

Most obesity and such problems as hyperactivity in children can be started by "junk" foods. Many chemicals will disturb our metabolism in small but incremental ways...

Organic food used in a balanced diet can restore the natural flow of energies to the body. No extra beefed up this or that in the produce. No artificial this or concentrates that to upset our natural processing.

Many of our simple ailments are stemming from the simple lack of certain trace elements or from the accidental replacement of some good trace elements with dangerous ones. Iodine, copper and iron are good ... We know that .... But too much of these can also lead to biorhythmic imbalances. Manganese is BAD. Aluminium is not good. Lead and mercury are crook.

Substances like Caffeine is beneficiary to a point at which it can concentrate our focus to fanaticism, more can stop us from performing a task and caffeine can be fatal above a certain amount.

Element like Uranium and plutonium are catastrophic. The atomic experiments of the 50s may have killed more than 20,000 children in this country alone. Most of the dead kids' bone have shown major traces of unnatural radio-active isotopes (still classified). The fall out of the little war games that used depleted uranium in Queensland will be felt for thousand of years to come...

Tar in cigarette and that we use on the roads is highly cancerogenic. So is most emission from the burning of petroleum products... Many substances are addictive and some of these have been added in some food, in cigarettes and in some beverages. Many drugs and medicines are oversubscribed in replacement of behavioural education or management — especially to children, creating a "next" generation of pill-popping individuals. All great news for designer pharmaceuticals...

The development of vaccines is not as costly as it can be made out. In many ways we can assess that pharmaceutical companies spend a lot of research on the big ones... The secret work on medicines like the little blue pills, the ultimate cancer treatments and other arcane philosophical alchemies — all to be copyrighted and jealously guarded. So most of the expenditure is spread across the board, with mega-growth sucking the cream. What better medicine than a fully paid holiday under the sun... ? The cost of things is always relative...

Thus it is basically impossible to know the true cost in the development of new targeted cures to ailments we haven't got yet, many pills that we do not "need" but are told we "want" and the "on-going research" on many fronts... Many substances are tested, copyrighted and stored for properties "that are not needed" yet. More Prozacs and Valiums... or specific amphetamines for soldiers on the battlefields and sleeping pills when the troops come back from combats 36 hours later...

In the meantime natural and alternative remedies that often work with greater efficiency, like raw honey for skin sores and sore throats don't rate a mention... No money it it... It's the money that drives the research, and that's were the PBS can be (is) being taken for a ride...

In the mean time the CSIRO government labs — that do public research to be shared for all — are about to sack nearly 200 more workers... I'm sure they'll find places in private enterprises with better pay... and our PBS will cover the cost... out of our pockets.

Medicare- Universal health care?

I reflect back, about 22 years ago, when medicare first came out? It was good at the time and a mantra of "Free and Universal Health Care" was provided. Why is it that medicare has eroded? Why? Our taxes paid for it, and it should be free.

Why can't dentistry be bulked billed? A toothache does affect your health, and people have died from it. You might think it is a minor thing, but when your gums become infected, I dont think it will be a minor thing.

I am working and I cannot afford a dentist, so what should we do? I can't wait at a dental hospital where there are cuts to the service, why can't bulk billing for dentist be done? So how can medicare be a universal health care?

Padding

In the US, a system of rorting is described by David A. Andelman in Padded Care?
... The fact is, eventually we all pay. And that's just the problem. Two doctors instead of one. Huge markups on the use of hospital equipment and facilities. But none of that matters, does it? I only got bills totaling $248.48. My insurer got a bill for $1,407.52. By the way, I'm fine. One nurse told me, "Well, that's most important, isn't it?" It probably is. But it misses the point. If I weren't fine, the bills would have been a whole lot higher still. ...

Gold, pure gold. 

More padding

In 'Unhealthy practices at health funds' (Financial Review, Dec 8th), by anaesthetist Elliot Rubinstein:
... Under the guise of "tackling the rising cost of benefits", Medibank Private is going to drive patients away from Epworth because it is offering a superior service. The fund has looked at Epworth and noted that its costs are above average, so Medibank will save money by reducing the benefits it pays for its subscribers. If it is allowed to bring everyone back to average, we will end up with a less than average health service. But if it so damaged Epworth that it closed, Medibank really would save a lot of money. ...
... What it has done is to show that health funds, which are supposed to offer us insurance against adverse health events, have the power, through the contracts they offer, to control the provision of services. It's another form of managed care, the application of business principles to medical practice. As occurs with some health maintenance organisations in the US, funds could get to the point where doctors and patients would have to ring them for a clerk to organise where and when their procedures or admissions would take place. Control hospitals, take doctors and patients out of the equation and we will see the end of a once great health system. Hospitals should not have to cherry-pick and health funds should not be allowed to.


Weasel words. This sounds like code for "it's better for patients that doctors be allowed to set rates for their own services". They can, and do, especially anaesthetists.

Murky

Recent revelations about the way Merck manipulated data in rofecoxib trials support arguments for vigilance.

Slashdot: Merck's Deleted Data (links back to very interesting Forbes article).
NYT: Editorial: Manipulating a Journal Article
NYT: Doctor Suggests Merck Trial May Have Led to Demotion
ABC (US):Vioxx Editorial May Bolster Merck Suits

From the New England Journal of Medicine editorial:
Expression of Concern: Bombardier et al., "Comparison of Upper Gastrointestinal Toxicity of Rofecoxib and Naproxen in Patients with Rheumatoid Arthritis," N Engl J Med 2000;343:1520-8
Curfman G. D., Morrissey S., Drazen J. M. Abstract | PDF 
... Lack of inclusion of the three events resulted in an understatement of the difference in risk of myocardial infarction between the rofecoxib groups. It also resulted in the misleading conclusion that there was a difference in the risk of myocardial infarction between the aspirin indicated and aspirin not indicated groups.
In addition, the memorandum of July 5th, 2000, contained other data on cardiovascular adverse events that we believe would have been relevant to the article. We determined from a computer diskette that some of these data were deleted from the VIGOR manuscript two days before it was initially submitted to the Journal on May 18, 2000.
Taken together, these inaccuracies and deletions call into question the integrity of the data on adverse cardivascular events in this article. We have asked the authors to submit a correction to the Journal.


From Prescription rates fall as pill poppers give up their drug habits
... Medical leaders believe the drop in drug use reflects a more cautious approach by doctors and patients, triggered by better pharmaceutical education and findings of potentially lethal side effects in some drugs, including the once popular pain-killer Vioxx. Sales of that drug, which previously cost about $150 million a year in subsidies, have plunged after it was linked to an increased rate of heart problems. ...

Citizens on health

From Citizens singing a whole new health song (Anne-marie Boxall and Stephen Leeder):
... A revolution in health care is possible but it may take an unpredictable form if the public is consulted. Recent work with citizens' juries in Western Australia, by Professor Gavin Mooney and colleagues, may provide the inspiration. They invited a cross-section of people, chosen randomly, to participate in citizens' juries and, after educating them on the dilemmas and limitations of the health system, asked them to set priorities for health. Their recommendations were groundbreaking. Contrary to expectations, they consistently ranked high-tech and high-cost hospital care at the bottom of the list of priorities. Mental health, Aboriginal health and access to community-based health services were ranked at the top. Citizens' preferences will vary from region to region, but in the juries conducted so far, the priorities have been clear: acute, curative care - no; preventive and chronic community-based care - yes. The public's ideas on the health system are revolutionary and form the basis of a new composition in health care. A song set to these new words would be the anthem we need to replace the clapped-out ballad we have sung for decades. ...

Saving Pfizer

From Pfizer to Finance $100 Million Safety Study of Celebrex:
... Dr. Nissen announced yesterday that the clinic's cardiovascular research center would coordinate the study of about 20,000 patients. He called it the first large-scale trial to compare the safety of a cox-2 painkiller with older nonsteroidal anti-inflammatory drugs in high-risk patients. ...

The article at Forbes has details not mentioned by NYT. From Saving Celebrex:

... To head off any criticism based on conflicts of interest, Nissen is taking the unusual step of forbidding the nine researchers planning the trial from taking consulting or speaking money from the companies that make the drugs, Wall Street or law firms. Financial relationships related to Wall Street, hedge funds or Vioxx lawyers will likewise be forbidden. "The controversy and the issues have been so intense that I just think it's necessary," Nissen says. ...
...
Already, the study is facing criticism. The trial will be conducted in Australia, the U.S., Eastern Europe and Switzerland, but not in most countries in the European Union, where Celebrex's labeling says it should not be given to patients at risk for heart attacks. ...

The restriction, on researchers being free of financial entanglements, should make it almost impossible to do the study in Australia.

Gold in cloning

When the debate about therapeutic cloning comes round again, (More stem cells backed), the current scandal regarding Dr. Hwang Woo Suk and his team will be mentioned. From Clone Scandal: 'A Tragic Turn' for Science:
"We depend entirely on the truthfulness of the scientific community," Dr. Zoloth said. "We must believe that what they are showing us and what they say has been demonstrated is worthy of our concern and attention."

Reference may be made to commercial applications of cloned cells, and difficulties that one or two Australian scientists may have had with their business interests.

There is a gold standard for up-front declaration of private interests, at the UK's Human Genetics Commission. One example from HGC's Register of members' interests:

Registrable shareholdings

GlaxoSmithKline
Unilever
Bernard Matthews (family)
Boots (family)
Diageo (family)
Elan Corp. (family)
ICI (family)
J Sainsbury (family)
Nycomed Amersham (family)
PPL Pharmaceuticals (family)
Zeneca (family)

Which Australian Commission or Board requires that depth of disclosure? Easy - none.

A demonstrably high standard of conduct should be high on Labor's list, for the biomedical sciences.

Lockhart review

Paul Krugman's Drugs, Devices and Doctors at New York Times Dec 15th, is still on pay-to-read, by the look of it. It will become free, soon, I hope. Here's a taste:
... The point is that the whiff of corruption in our medical system isn't emanating from a few bad apples. The whole system of incentives encourages doctors and researchers to serve the interests of the medical industry. The good news is that things don't have to be that way. Economic trends gave rise to the medical-industrial complex, but only because those trends interacted with bad policies, which can be fixed. In future columns I'll talk about how serious health reform can reduce the conflicts of interest that taint our current system.

The "conflicts of interest that taint" need to be ripped out of our health system, too. As the NHMRC's Lockhart inquiry completes its review of the legislative controls on stem cell research, some of the concerns being aired by Krugman may come to the surface.

Financial dealings of directors of the Australian Stem Cell Centre don't exactly leap off the page. According to ASCC's Corporate Governance Best Practice document, the directors are required to make personal judgments on whether or not they may have conflicts of interests, and are able to conceal any declarations they make under the Privacy Act.

Since, according to ASCC's Submission to the Lockhart Review Committee, their business plan is 'commercial in confidence', it would be correct to discount any public assertions made on behalf of the ASCC, by any of its directors or key researchers, on the grounds that their motives are purely for private gain.

There are 1035 submissions to the Lockhart review. How many of them raise the issue of management of conflicts of interests, religious and financial?

Let's do Safety, Quality and Prevention - first.

A bit of commentary on health records in the UK, at More focus on research needed in NPfIT, says report.

This could be a worthy topic at The AFR's 8th Annual Health Congress.

Another one to keep an eye on - Patient Safety 2006.

AIHW wants more information to flow IN, to keep the army of inquisiteurs and data-munchers happy.
National Public Health Information Plan 2005
The National Public Health Information Plan sets out priority activities aimed at improving the quality, coverage, utilisation and coordination of public health information in Australia.

How about getting some information OUT, to the public, on things they can do to be healthier? Could AIHW put any pressure on governments to spend less on advertising their own political ends, and more on public health advertisements for prime-time TV?

Pills for obesity

An excellent look at the anti-obesity drug SR141716A (also known as Rimonabant), by Fred Gardner at Counterpunch, makes a useful supplement to 2 Approaches to the Nation's Obesity Epidemic Coming Up for Review at NY Times.

Gardner referred to the sucrose and fructose in Coca-Cola.

US thirst for Mexican cola poses problem for Coke
Hidden sugar's the real foe 

The Controversial Secret Ingredient of Coca-Cola

you've got it TG .....

The average Australian consumes 52kgs of sugar per annum, whilst their figure-looking-good counterparts in the "land of the free" consume, on average, 75kgs.

Our bodies can source energy from two sources: carbohydrates & fat. If we give our bodies both, they will consume the carbohydrates 1st & store the fat. With our increasing intake of sugar (carbohydrate) & other highly refined foods (white bread etc), along with our increasingly sedentary lifestyles, we just keep getting fatter. To boot, our increased weight generates not just an obesity epidemic but also a diabetes epidemic (the curves match perfectly in all western countries).

So why isn't there a backlash against sugar (carbohydrate) intake?

Simple really. Sugar is the cheapest ingedient that food manufacturers can put in their products. The cheaper the cost of production, the higher the profits. That's the main reason that the CSIRO's "Welbbeing Diet" was recently attacked so viciously.

With the big corporate food manufacturers whacking as much sugart into their "healthy" products as they possibly can & then advertising them with the endorsement of "sports stars" (little johnnie must have a plate of coco-pops when he gets home from school), what chance does the consumer have?

Kill the sugar, cut-down on the other highly-refined carbohydrates, including bread & potato, exercise a little & eat a 'balanced diet' & you'll live to be a zillion ..... the only other relevant question that you need to ask is: would you want to?

Cheers.

more please ......

‘To do so, starting in the early 1970s, the researchers followed more than 15,000 people, ages 45 to 64 years, from two towns in the Glasgow area. At the beginning of the study, less than half of the subjects had a body mass index (BMI) of 18.5 to 24.9, which is considered to be within a normal weight range. Over 2000 had a BMI of 30 or higher, which is considered to be obese. 

 

In the subsequent 20 years, the obese subjects had an increased risk of a variety of cardiovascular problems compared with normal weight subjects, according to the report in the European Journal of Cardiology.  

 

Compared with the normal-weight subjects, obese subjects had 1.6-times the risk of death or hospital admission; 2.0-times the risk of heart failure; 1.4-times the risk of stroke; 2.3-times the risk a blood clot; and 1.8-times the risk of developing an abnormal heart rhythm.’ 

 

Obesity-Related Diseases 'A Burden'

Uniform views on health

The previous Australian Council for Safety and Quality in Health Care has morphed into the Australian Commission on Safety & Quality in Health Care, with Diana Horvath as inaugural CEO.

John Horvath, Chief Medical Officer and husband of Diana, was a member of the original ACSQHC and was on the Review Team that orchestrated the changes. The selection committee that chose the CEO for the new body included Jane Halton, the renowned citizens' advocate who restrains marauding ministers and compels public servants to do their duty in the public interest. See Consumer presentation (a Powerpoint) at this page.

The Horvaths also shared an association with the late Kerry Packer.

An amalgam of healthcare people have been lobbying Canberra to take more control of funding and administration, eg total care for the aged, and all of mental health. With such an auspicious beginning to the revitalised ACSQHC, and a remarkable coincidence of views in those that have his ear on health, the PM could drive his reforms through this Commission without needing to set up another one. And do it without bothering Tony Abbott, either. Mr Abbott could then concentrate on the finer moral matters, like womens choice in reproduction.

So, here's a task for the new body, replicate this - GP creates searchable database of NHS quality data.

But, too many of the pivotal decisions in health are allowed to be made by the specialist groups with closed memberships and vested interests.

From Doctors Urge Ban on Gifts From Drug Makers (New York Times):

Dr. David Kessler, dean of the University of California at San Francisco School of Medicine, agreed. "Everyone know that drug marketing is out of control," he said. Dr. Kessler said his university's rules regarding free gifts and classes have "been under discussion for several years." He did not know whether The Journal's article would lead to rule changes. The deans of medical schools at Columbia and Harvard universities were unavailable for comment. Kaiser Permanente, the huge California-based managed-care group, is one of the few medical organizations in the United States that has implemented nearly all of the recommendations suggested by The Journal's article. Kaiser physicians have very different prescribing habits from doctors nationally. "We thought it was critical for us that our patients never had a doubt that the decision made about a drug or a device was based on the best interests of the patient and not the financial interest of the physician," said Dr. Sharon Levine, associate executive director of Kaiser Permanente Northern California.

 

Perhaps the Drs Horvath could strike a blow against the undue influence of the pharmaceutical industry.

Fattening

Juan Cole has a list of Top Ten things Bush won't Tell you About the State of the Nation. Bush is expected to say a lot about health care, instead.

Nicholas Kristof (NY Times, pay for view) in 'Take a Hike' has ideas, including:
... Sell cigarettes only in pharmacies and raise cigarette taxes. Smoking still kills 440,000 Americans a year, including 50,000 nonsmokers. One study found that raising the federal excise tax on cigarettes by 75 cents a pack would generate $13.1 billion in additional revenue per year and cut youth smoking by 13 percent and adult smoking by 3 percent, saving 1.2 million lives. Let's do it. ...

Bush is unlikely to upset the tobacco lobby, though, or the companies marketing junk food to preschoolers. He will make a big noise about the need to spend money to get an electronic health record. One of his cousins is in that line of work. See Health Care's Electronic Elixir?:
... But one electronic-health entrepreneur will watch the speech with special interest: the President's 36-year-old first cousin, Jonathan S. Bush. That's because he runs athenahealth Inc., a technology outsourcing outfit that will be a huge winner if efforts to improve health-care record keeping through technology take off. ...

All in a good cause. But nowhere near as useful as hearing the President implore his subjects to "eat less and walk more". And it wouldn't be good enough for Oz, the Biotechnology Hub of the Universe, either. We should be lobbying for a vaccine to prevent obesity - Obesity Might Be Catching.

Bright future for lap-banders

Christopher Pearson, writing in The Australian March 11th, (Something about Julia) had a good rip into Julia Gillard and Medicare Gold. If it wasn't for detractors like Pearson, and Tony Abbott, Medicare Gold might have slipped from the radar. But, as they cannot explain why it won't work, it's probably safe to assume it is a sound and attractive health policy, while they continue to decry it.

In Operation safety, we learn about the work of the newly established Safety and Quality Commission, that replaced the Australian Council for Safety and Quality in Health Care. The SQC's chief executive is Diana Horvath, medical adminstrator and the former chief executive of the Central Sydney Area Health Service and Sydney South West Area Health Service. The article does not mention that Diana is married to John Horvath, the Chief Medical Officer of Australia. Whatever the Horvaths tell John Howard about the needs of the health system, he can be assured the advice supports the medical establishment and is not confused by breadth of opinion.

The SQC is featuring at a seminar in Melbourne on April 10th, Monitoring the quality of care in hospitals in 2006. (See the brochure.)

A couple of today's headlines illustrate the complexity of issues related to the obesity crisis - Fat surgery in public hospitals set to rise and Diet soda may help teens shed pounds. I wonder how many of the lap-banding doctors have shares in sweetened fizzy drinks?

I might pop along to the above seminar, and try them on. Reform of the healthcare system requires both informed consumers, and a vastly improved electronic informatics backbone. So, how many of our top policy wonks keep personal records of their own health events? How many keep their own data on blood pressure measurements and basic test results? Hmmm.

Hair does matter

Leon Beswick, of Australian Institute of Political Science, writing in The Australian March 20th (Make way for our leading ladies)

Medicare Gold is no more Left than the Government's 12.5 per cent tax on new medicines to fund more welfare for seniors.

Orphan kilojoules

Another one for the shredder:

Letters editor, The Age

Nikki Barrowclough's Good Weekend article on obesity in children ('Chips with everything', 15/7) was very good, but it missed a chance to be a lot better. It is important to know the energy count of any food, but what does it mean to say there are 1063 kilojoules in three cookies? How does that number relate to total daily needs, and how much exercise is needed to burn off any excess intake?

Facts about foods and nutrition are becoming more complicated. It would help to lessen confusion if consumers had easily understood scales on which to balance their purchases. For instance, the Glycemic Index is a helpful way of rating the differences between sources of carbohydrates.

Going on about the basic facts may be boring, but it is far less intrusive than the surgery being performed on obese children.

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Anyway, who wants to know how many Mars bars will fuel a 10km walk?

With the current problems

With the current problems that our medical care system has, you can have a higher chance of getting in an alcohol rehab than actually managing to convince our political leaders to improve the medical system.