Back from hiatus (studying long enough to get distracted and update)!

Pop quiz: What’s the difference between the people living on the left side of the yellow line and the people living on the right side of the yellow line?

If you’re thinking “Well damn, I have no idea. It looks like somebody just arbitrarily drew a line across the land” you would be nearly right. Specifically, it’s the border between modern day Kenya and Somalia — a border that (to my limited knowledge) was arbitrarily drawn by European colonialists carving up Africa. Granted there are significant cultural differences between Kenyans and Somalis, but these people never recognized a strict border drawn across the land.  The people living on either side of the line were nomads who frequently crossed back and forth without even knowing a line had been drawn.

As Kenya and Somalia transitioned from colonial rule to self-government, the line grew in importance. Somalia suffered under the nightmarish-rule of Siad Barre and later dissolved into near anarchy, whereas Kenya remained relatively stable, though it also had its share of corrupt and inept government bureaucrats. While religious factions, rival clans, and warlords (some of which were supported by the USA) fought a for control of Somalia, hundreds of thousands of Somali refugees fled to Kenya. The border has now become increasingly militarized and immensely important for Kenyans and Somalis living near it — but it has also remained porous as the ill-equipped Kenyan border patrol is unable to police the 400+ mile border.

The conditions in the Kenyan refugee camps along the Somali border are atrocious. Malnutrition is rampant. Lack of clean water commonly leads to massive outbreaks of water-bourne illnesses such as cholera. Ayaan Hirsi Ali writes about her encounter with one of these camps — she writes of children dying of dehydration and people getting stung by snakes and scorpions. It’s a testament to how terrible conditions must be in Somalia that people come to these camps at all. I can’t imagine the suffering that they’ve been put through.

That’s part of the reason why this article irked me. I don’t have time to post my full reaction today, but I’ll get to it soon..

Debating Paul Farmer

The UW SMPH Ethics Committee, a group of mostly M1 and M2 students, met for the first time last week. We talked a bit about a snippet from a paper entitled, “Anthropologist to activist: Paul Farmer’s changing perspectives on cultural difference and human rights,” Anthropology Southern Africa, 2008, 31(1&2).

“Farmer also argues that medicine, medical ethics, and biomedical
research have inequality as their foundation since
these erase poor people in their research and practice, for
instance spending millions on research in hair replacement,
while tuberculosis treatment, because it is an illness affecting
predominantly the poor, is hardly worth researching. Similarly,
he criticises medical ethics for its preoccupation with
questions such as brain death and organ transplantation, but
hardly noticing the suffering of millions from treatable diseases.

One gets the sense, in attending ethics rounds and
reading the now-copious ethics literature, that
these have-nots are an embarrassment to the
ethicists, for the problems of poverty and racism
and a lack of national health insurance figure only
rarely in a literature dominated by endless
discussions of brain death, organ transplantation,
xenotransplantation, and the care at the end of life
(Farmer 2003:205).

I agreed with Paul Farmer. Look at the hot-topic medical issues of our time — abortion, euthanasia, offering a public health insurance option, other healthcare reforms, etc — most deal with providing too much healthcare. When is it appropriate to stop sustaining somewhat who is permanently brain-dead? How can we control healthcare costs without decreasing the amount of care we receive (rationing)? These are questions that come to the fore in a nation in which the majority receive heaps of healthcare.

I don’t want to trivialize the importance of considering these issues of too much care: they deserve the full attention of bioethicists as well. However, the issues of inequalities in health outcomes, inequalities of healthcare provision, racism, sexism, and other forms of structural violence are typically pushed aside and not given the full attention they deserve. The number of people who will die of easy to treat, preventable diseases far outnumbers those who are grappling with the issues of too much care. It’s not even close.

This distinction between issues of too much care and too little care is by no means only issue of rich countries vs. poor countries. It’s true that many of the largest health disparities exist between rich and poor countries, but the gap also persists within rich inegalitarian countries such as our own. People here in the USA suffer from HIV, tuberculosis, and malnutrition — but perhaps we as a society are better at hiding the suffering of these people than poorer countries. This provides a basis for the charity starts at home point of view: there are plenty of people in need here in the USA, so why travel halfway across the world when valuable service can be provided at home? Besides, health interventions at home are more feasible and perhaps more likely to succeed — as this argument goes.

I think the charity starts at home perspective has two major flaws. First, poverty is relative. If we choose to use an absolute measure of poverty such as household income, people living in poverty in the USA earn about $11,000 per year + another $3000 per year for every additional person living in the household. Contrast this to the approximate 1.4 billion people living on less than $1.25 per day (about $450 per year). Granted there are differences in cost of living, but I think the point still stands that being poor in the United States is vastly different than being poor in an impoverished country.

Second, ‘home’ isn’t what it used to be. The world continues to globalize as technology improves and countries become more and more interconnected. A team of doctors can now reach even the most remote places on earth within 48 hours to deliver healthcare. The healthcare interventions do not need to be large, expensive, or complicated to achieve better outcomes in health — delivering oral rehydration therapy to a child suffering from life-threatening diarrhea is cheap and easy to administer. We are more capable of delivering healthcare on global scale now than we have been at any other point in human history.

Ghostwriting: Here at UW and Everywhere Else

Ghostwriting has been getting a fair amount of press in the past few months (for good reason). The NYTimes ran an article last week about it, PLoS Medicine published an editorial, and a quick search revealed ghostwriting is common here at UW. What exactly is going on? Ghostwriters are medical writers (read: NOT authors or researchers) typically sponsored by pharmaceutical or medical device companies that conduct research or supply writing that is slipped into papers authored by academic researchers. The medical writers’ contributions are not acknowledged, and their work is passed off as the academic’s own.

So how widespread is this? It’s pretty damn common. Look at the rates of ghostwriting in the top medical journals (as reported by the NYTimes):

“The study also reported a ghostwriting rate of 7.9 percent in JAMA, 7.6 percent in The Lancet, 7.6 percent in PLoS Medicine, 4.9 percent in The Annals of Internal Medicine, and 2 percent in Nature Medicine.”

Holy crap. Does this mean that one out of every twenty articles in the top medical journals are slanted towards drug companies? PLoS medicine recently redacted 1500 ghostwritten articles. They don’t mince words either:

”..quite simply, the story told in these documents amounts to one of the most compelling expositions ever seen of the systematic manipulation and abuse of scholarly publishing by the pharmaceutical industry and its commercial partners in their attempt to influence the health care decisions of physicians and the general public.”

Even worse, it’s happening right here at UW. A drug company, Wyeth, paid the UW $1.5 million to educate doctors about hormone replacement therapy, using five ghostwritten articles that downplayed the risk of and overstated the benefits of therapy. The articles were written here at the UW.  The ghostwriters played a role in developing topics, writing the text, and submitting the papers. Doctors practicing in Wisconsin are required to complete a minimum number of continuing education, so in effect Wyeth had a captive audience for its fake media.

Dr. James Stein, a cardiologist at UW, takes the right approach. He should be commended for refusing to put his name on educational material sponsored by drug companies — twice within a single week. Here’s what he has to say:

“Frankly, it’s plagiarism.”

“If an undergraduate did this, he would be expelled,”

Amen. Take a look at the articles. It’s well worth knowing what’s going on.

The hidden public-private cartel that sets health care prices

Slate published an interesting article today on how medicare determines the cost of various procedures. They use a system which assigns “relative value units” to every procedure based upon the mental effort and stress required of the doctor. This fancy-schmancy procedures like CT scans are worth many RVUs whereas more simple procedures are worth less. Every RVU is worth about $40 right now, so RVUs*$40 how much medicare doles out.

Who determines how many RVUs the procedure is worth? A panel of doctors made up of mostly specialists — those people who profit most by charging more for big fancy procedures. Two things strike me immediately —

1. Is the cost of the equipment or time required for the procedure factored in at all?

2. What about the patient’s need for the treatment? Is a simple life-saving treatment worth less than a complicated yet less important treatment?

It seems like the RVU system sets up a perverse incentive scheme that rewards big fancy procedures performed by specialists over more simple care provided by a family practice doctor. I could easily see how this contributes to the current healthcare mess we’re in.

New PHR Report Examining Torture

Physician’s for Human Rights Report: Aiding Torture

“These techniques used alone or in combination may meet the definition of torture under US and international law. Legality aside, they are associated with high risk of physical and psychological harm, including harm that is enduring, in those subjected to these techniques. They also represent clear violations of well-established medical ethics governing the behavior of health professionals.”

“Not only were health professionals involved in designing and monitoring the CIA interrogation program, they also played an indirect but essential role in the legal justifications for the program prepared by the Office of Legal Counsel (OLC).”

“Health professionals who were involved in this program should be the subject to independent investigation for both criminal and unprofessional conduct. Professionals who have violated professional ethics or the law must be held accountable through criminal prosecution, loss of license and professional society membership, where appropriate.”

New Report: Aiding Torture

Listen: Speaking of Faith - The Ethics of Aid, One Kenyan’s Perspective