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Health Policy

An Environmental Activist’s Thoughts on GMOs (and How He Was "Converted")

There’s a lot of talk these days about eating genetically modified organisms (GMOs). GMOs are any organism whose genetic material has been altered using genetic engineering techniques.

For about 14,000 years humans have been using selective breeding, a form of genetic modification, in our raising of domesticated plants and animals. So, basically everything we eat has been selectively bred, thus modifying the genes over time.

How are GMOs intrinsically different? They may or may not be: whereas selective breeding depends on choosing among naturally occurring genetic variation within a population or species, genetic engineering can, but does not necessarily, involve the intentional introduction of genes from different species, a technology first developed in 1972.

And is this intrinsically “good” or “bad”? Mark Lynas, researcher at the Cornell Alliance for Science, mulls this over in “How I Got Converted to G.M.O. Food.” Lynas, a self-described lifelong environmental activist, notes that though he was initially opposed to GMOs, he now believes that genetically modified foods are safe, and points out a major gap between scientists’ and the public’s perception on the issue: per the Pew Research Center and the American Association for the Advancement of Science, while 88 percent of association scientists agreed it was safe to eat genetically modified foods, only 37 percent of the public did. Lynas, through his research at Cornell, tries to bring a more informed context to this gap. In sum he notes:

No one claims that biotech is a silver bullet. The technology of genetic modification can’t make the rains come on time or ensure that farmers in Africa have stronger land rights. But improved seed genetics can make a contribution in all sorts of ways: It can increase disease resistance and drought tolerance, which are especially important as climate change continues to bite; and it can help tackle hidden malnutritional problems like vitamin A deficiency.

Celebrating 60 Years of Polio Vaccinations!

Sunday April 12th marks 60 years since the polio vaccine, developed by Dr. Jonas Salk, was declared “safe, effective, and potent.” April 12th also marks 70th years since of the death of President Franklin D. Roosevelt, whose paralysis was generally believed to be caused by polio.

Prior to 1955 the dreaded disease afflicted 600,000 people around the world each year, including about 50,000 children in the U.S. There is still no known cure for the disease which could cause various degrees of paralysis and is sometimes fatal. The testing of the vaccine, known as the Francis Field Trial, was the largest medical experiment in history up at that point, involving more than 1.8 million children from Maine to California.

Polio was officially eradicated in the United States in 1979. However, worldwide there still remain occasional outbreaks. In fact, in 2014 the World Health Organization declared polio’s renewed spread a “world health emergency” and the civil in Syria has led to more than 90 cases reported in that country. There have also been at least 20 cases reported in Pakistan in 2015.

Given recent measles outbreaks in the U.S. — another preventable disease with an effective vaccination — a 2010 documentary on the polio vaccination is receiving extra attention these days. Carl Kurlander, CEO of the company which produced the film A Shot Felt ‘Round the World reports increased interest in the film from groups interested in promoting the importance of vaccination. The World Health Organization hopes to eradicate polio worldwide by 2018.

“There’s no technical reason why there should be cases anywhere in the world by the end of this year,” said Oliver Rosenbauer, communications officer for the World Health Organization’s Global Polio Eradication Initiative. “It’s a question of political will and societal will.”

New Measles Case Reported in Oklahoma

According to the Centers for Disease Control and Prevention, measles was effectively wiped out in the U.S. in 2000. From the CDC website: “The United States was able to eliminate measles because it has a highly effective measles vaccine, a strong vaccination program that achieves high vaccine coverage in children, and a strong public health system for detecting and responding to measles cases and outbreaks.”

According to the Centers for Disease Control and Prevention, measles was effectively wiped out in the U.S. in 2000. From the CDC website: “The United States was able to eliminate measles because it has a highly effective measles vaccine, a strong vaccination program that achieves high vaccine coverage in children, and a strong public health system for detecting and responding to measles cases and outbreaks.”Yet in 2014 there were 644 cases in the United States, and thus far in 2015 there have been 178 reported cases. 74% of these were related to a much publicized outbreak linked to Disneyland. Today a new case was reported in Oklahoma, which had experienced no reports of measles in 18 years.

Worldwide measles is a serious problem, infecting 20 million people each year and claiming 146,000 lives. According to the CDC, 1 in 4 people in the United States who get measles will be hospitalized; 1 or 2 out of 1,000 will die. The 2015 outbreaks are attributed in large part to parents not having their children immunized. Dr. Gil Chavez, deputy director of California’s Center for Infectious Diseases, noted at a news conference in January during the Disneyland-related outbreak that the park would be “perfectly safe” if you’ve been immunized.

MCNTalk has frequently blogged on the anti-vaccine movement. It’s been specifically noted by multiple international public health experts that the original 1998 study involving eight children which erroneously tied autism to the measles-mumps-rubella vaccine was just that, erroneous. 

And yet parents continue to forego getting their children vaccinated. With a highly contagious disease such as measles there are consequences for opting against vaccinations. People who are unvaccinated for any reason, including those who refuse vaccination, risk not just their own infection, but spreading the disease to others, including those who cannot get vaccinated because they are too young or have certain health conditions.

Sadly, just last month Susan Mendez, education director for immunization services with the Oklahoma State Department of Health, said it could just be a matter of time before measles entered Oklahoma.“It just takes one person traveling into Oklahoma…If you’re not vaccinated, you are taking a risk.”

 

Making up for Medicare Shortfalls?

Do hospitals need to make up payment shortfalls from Medicaid and Medicare by charging higher prices to privately insured patients? That theory, known as cost shifting, has been discussed considerably over the past few decades.  But many recent studies have in fact suggested something else: lower medicare hospital payment rates for inpatient care might just lead to lower private payment rates.

Cost shifting is based on the notion that a hospital’s costs (staff, equipment, supplies, space) are fixed, with an event requiring a specific set of resources. Therefore when reimbursements don’t meet the hospital’s expenses the cost must be met in some other way. However, in reality hospitals as with any other industry face and respond to various market forces.

As was reported to Congress in 2011, it’s been hospitals’ underlying costs, not cost shifting, that have led to differences in prices charged to insurers and to Medicare shortfalls or profits. In fact, as noted in this New York Times editorial:  “Today, hospital cost shifting is dead, and the spillover effect reigns. A consequence is that public policy that holds or pushes down Medicare and Medicaid prices (or their growth) could put downward pressure on the prices hospitals can charge to all its customers and, in turn, on the premiums we pay to insurers.” Good news indeed for consumers of health care and especially for those concerned with the long-term potential shortfall effects of reduced payments to Medicaid and Medicare.

$30 Billion and Counting

Since 2009 the American taxpayer, according to Kaiser Health News/NPR/Montana Public Radio, has spent about $30 billion on the installation of electronic records systems in hospitals and doctors’ offices. However, right now the ability of the systems to converse with one another — so that patient records can be tracked from one facility to another — is at about a 2 or 3 on a scale of zero to 10, according to Robert Wachter, a hospitalist at UC San Francisco, and to technology entrepreneur Jonathan Bush.

Wachter has authored the upcoming The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, on information technology in health care.

Up until now, he says, there has been a financial disincentive for doctors and hospitals to share information. For example, if a doctor doesn’t have a patient’s record immediately available, the doctor may order a test that has already been done – and can bill for that test. Keeping EMRs [electronic Medical Records] from talking to each other also makes it easier to keep patients from taking their medical records — and their business — to a competing doctor.

Karen DeSalvo, the federal government’s health IT coordinator, is now working on standards for how to share digital information. 2015 might just be the time to move medicine more into the digital age. Wachter notes that as about a dollar of every $6 in the U.S. economy is spent on health care, a new IT boom in that sector means there are billions of dollars to be made.

One Procedure, Many Prices

A new report from Blue Cross Blue Shield, The Health of America analyzed the cost of hip and knee surgeries in 64 areas across the US and found that the amount charged for the same procedure in the same city varied by as much as 313%.

The amount charged by the hospital is different from the amount negotiated by an insurer, which is itself different from the amount owed by a patient. That’s one reason deciphering hospital bills can be complex. It’s also a perfect example of why people can end up buried under a mountain of confusing medical debt if they are uninsured, lack good insurance, or simply don’t understand what their insurance plans actually cover.

“If you are in a plan that charges a $30 copay to see an orthopedist, that is your cost,” explained Dan Mendelson, the CEO of consulting firm Avalere Health and a former associate director for health at the federal Office of Management and Budget. But if you have a high deductible, if your surgery isn’t covered, or if you are uninsured, your already high costs may end up being three times higher just because you chose the wrong hospital.

Would these differentials in price exist if the patients had some skin in the game and they rather than their carriers were paying the bulk of the charge? Or if “skin in the game” meant more than meeting an annual deductible.  Though higher deductibles and co-pays do prompt patients and families to track expenditures and self-ration when possible, it’s not a step in the direction of making prices readily available or easy to understand.  And the disparities begs the question of why carriers like the Blues are willing to pay the higher prices when one of their insureds choose one of those hospitals.

60,000 Additional Deaths a Year Attributed to Smoking

A study entitled “Smoking and Mortality – Beyond Established Causes” appeared in the New England Journal of Medicine last week. The study followed almost a million people over the course of ten years. Researchers found that compared with people who had never smoked:

  • Approximately 17% of the excess mortality among current smokers was due to associations with causes that are not currently established as attributable to smoking.

  • Smokers were about twice as likely to die from infections, kidney disease, respiratory ailments not previously linked to tobacco, and hypertensive heart disease, in which high blood pressure leads to heart failure.
  • Smokers were also six times more likely to die from a rare illness caused by insufficient blood flow to the intestines.

The study also found small increases in the risks of breast and prostate cancer among smokers. Dr. Brian Carter, an epidemiologist with the American Cancer Society, notes that those findings were not as strong as the others, adding that additional research could help determine whether there were biological mechanisms that would support a connection.

According to the Centers for Disease Control and Prevention, about 42 million Americans smoke — 15 percent of women and 21 percent of men.

 

Chronic Fatigue Syndrome Becomes Systemic Exertion Intolerance Disease

We have now seen another example of the medicalization of distress and the emergence of a new “disease” (as opposed to a group of symptoms) according to the linked article.

While we have not yet read the report and reserve full conclusions, the release suggests nothing new in terms of science, etiologic agents, or new findings that lend meaningful clarity and a path to recovery from the symptoms of Chronic Fatigue Syndrome (CFS). Rather, the deciding panel appears to have largely achieved a political goal of validating a syndrome of various symptoms that do not lean to any conclusions as to cause or cure. That those who claim to have CFS or whatever new name may be ascribed to it are suffering is not in question. What remains unknown is why, and whether this syndrome is caused by a lesion of some sort, a viral or bacterial pathogen. What is going on with this action?

Likely a number of things. One is that it addresses the anxiety and perceived stigma that often applies to experiences that are ill-defined and may be considered to have an emotional component, implying lack of validity for the sufferers. Noteworthy is that the panel is seeking responsive treatment and diagnostic codes. By validating a syndrome as a disease, the conversation changes to one of obligations and rights for the sufferers that they believe they lacked before.

And it implies and may create duties by others in the industry of treating diseases, including insurance carriers, employers, courts and the culture to increase the level of payment, support, acceptance and accommodation to those claiming the disease. And let’s not forget members of the medical profession, drug companies, hospitals and other parties who have a strong vested interest in adding to the list of issues for which they may/will receive payment.

The list of syndromes, new diagnoses or disorders with expanding numbers and those claiming them are many. In no particular order they include: Post-concussive syndrome, “Low-T,” erectile dysfunction (with a recent ad featuring a beautiful woman claiming that over 50% of men over 40 suffer from some form of it), Epstein Barr Virus, Autism, Post-traumatic stress disorder, Fibromyalgia, ADHD (attention deficit hyperactivity disorder), Lyme Disease, and others. Common to many are claims of financial, educational, occupational or legal entitlement, partial exculpation from responsibility, expensive and proprietary medications, strong advocacy groups and heated arguments in the media and professions.

In short, recent “clarification” on Chronic Fatigue Syndrome likely fits more into the realm of politics than science.

The Top 8 Jobs with the Highest Injury Rates

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Four of the top eight are medical workers: orderlies, nursing assistants, personal care aids, and registered nurses.

According to the Bureau of Labor Statistics, more than 35,000 nursing employees are injured each year severely enough that they miss work.

Some hospitals have report that they have reduced lifting injuries among nursing staff by up to 80 percent — using an approach often called “safe patient handling.” They use special machinery to lift patients, similar to motorized hoists that factory workers use to move heavy parts. The hospitals also conduct intensive training among the staff.

Yet the majority of the nation’s hospitals have not taken similar action. The injuries are often so severe that they’re career-ending, a problem compounded by the fact that many of those injured are relatively young. To help address the problem, on Jan. 1, 2012, the Hospital Patient and Health Care Worker Injury Protection Act went into effect in California. This NPR article follows several injured medical workers and their stories.

New Year’s Resolution: Don’t Have an Annual Physical

It may sound a little odd to suggest not going to the doctor. But this editorial does just that. About 45 million American adults have a basic annual check-up. However, a study has indicated that those check-ups for adults — with no specific symptoms to discuss — are not particularly useful. In fact, the Canadian guidelines have recommended against these exams since 1979.

In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years. Their findings? Regardless of which screenings and tests were administered, studies of annual health exams dating from 1963 to 1999 show that the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.

There are many reasons why the annual physical is not productive; it does little to avert death or disability from acute problems; it does little for chronic conditions without significantly useful interventions; and, sadly, an early diagnosis might extend the time patients know they have cancer but is unlikely to extend their lives.

This is not to suggest skipping doctor visits altogether: get your flu shots, stay up-to-date on vaccines, discuss symptoms with your doctor.

But consider this from Dr. Ezekiel J. Emanuel, oncologist and vice provost at U. Penn: Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam. That will free up countless hours of doctors’ time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance.