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Monday, October 29, 2018

Vote like your health care coverage depends on it,

because it does.


Cheryl and I already voted, by mail. 2018 mid-term election day is November 6th. Continuing GOP control of Congress bodes severely ill for U.S. health care policy. Senate Majority leader Mitch McConnell has made no secret of his intent to come after "the Big Three: Social Security, Medicare, and Medicaid." Of those, the first two have historically been non means-tested entitlements available to all who have paid sufficiently into the system across their working lives, irrespective of assets or net worth at retirement. Many on the GOP side long to turn them into penurious liquidate-all-your-assets-first "welfare" programs (e.g., Medicaid).

"We have to come up, and we can come up with many different plans. In fact, plans you don't even know about will be devised because we're going to come up with plans, -- health care plans -- that will be so good. And so much less expensive both for the country and for the people. And so much better.” - Candidate Donald Trump, September 14th, 2016 on the Dr. Oz show.
"You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy." - Candidate Donald Trump, Oct 2016 Florida campaign rally.
"Who knew health care could be so complicated?" - President Donald Trump, 2017.
 No, I don't like the guy. Wonder why?

Some prior KHIT posts on the policy topics:

The Presidential Oaf of Office

What will the 45th President do about health care?

"Overcharged?" Paying for health care

An American Sickness
Population Health and an aging world
The U.S. healthcare "system" in one word: "shards"
ObamaCare is a great mess

Rationing by "Price"

For now. Below, a couple from another blog of mine, nearly a decade ago.

The U.S. health care policy morass

Public Optional

Then there's my 1994 grad school Argument Analysis paper addressing the "Single Payer" proposal published in JAMA [pdf].

Been thinking about this stuff for a long time. I first came to the health care space in 1993 with my first of three QIO stints [pdf]. Again, while the founding core topic of this blog is that of Health IT, I range far and wide as I see fit. As to policy, the finest InfoTech and clinical science we can muster will remain inadequate if health care services are to be predominantly privileges of affluence.


THE BIG 2018 MID-TERMS BUZZ PHRASE: "PRE-EXISTING CONDITIONS"

All the ways Republicans are trying to destroy pre-existing conditions coverage

Do you have a pre-existing condition, like arthritis, diabetes, asthma, or about a million other problems? About one in four Americans (or over 50 million people) do. Even if you aren't personally in that group, it's highly likely one of your friends or family are — and what's more, such a condition can develop at any time.

That's why it's important for each and every American to know that, contrary to what President Trump claims, the Republican Party has made great efforts to snatch health insurance from people with pre-existing conditions. They have tried multiple times to do it through legislation and are trying to do it right now through legal and regulatory efforts…
All of the pols are publicly swearing ad nauseum on the stump and in the media that they will "protect those with pre-existing conditions." Just about all of the Republicans are lying.


ON HEATH CARE "COVERAGE"

All of us, but in particular our politicians, are often sloppy with the use of words. "Universal coverage," "universal access," and "universal health care" are not synonymous. You may buy a "junk" policy to comply with the ACA "coverage" requirement, but actual claims payment for health care services and products may be extremely limited. Tangentially, all us may have unfettered "access" to stroll into any Mazerati dealership in the nation. Whether we can afford to buy any of the vehicles offered is entirely another matter. Beware of political Weasel Talk.

My wife and I are now Medicare benes. We have qualified "universal coverage" and "access" to all clinicians and facilities that accept Medicare payment (i.e., most ambulatory and inpatient providers). As those following this blog know, I've had high utilization this year culminating in hernial surgery and then the Big Show -- my open heart aortic valve replacement "SAVR" operation (happy to report I'm doing fine, and am in my 3rd week of cardiac rehab PT. My cardiologist says it's realistic that I could get all the way back to my absurd full-court hoops obsession).
I should note that, despite my coverage being an "entitlement" (earned via a working lifetime of paying into the system through Medicare taxes), it is by no means "free" (a.k.a., comprehensive "first-dollar coverage"). Between my Medicare Part-B premiums, SureScripts Rx policy, and my high-deductible "Part-F" Humana "Medicap" policy, I pay about $2,400 a year in premiums, plus deductible and co-pay "OoP" expenses. Similarly does my wife. Year-to-date, we're OoP (out-of-pocket) about $7k total (not counting what we spent caring for our late daughter). My latest total year-to-date "chargemaster" (ludicrous accounting fiction) "billed charges" are about $538k, as shown on my current Humana EoB statement. I have no way to know who got how much of the actually reimbursed (and much smaller) percentage of that. 
In short, it behooves us all to critically evaluate health care reform policy proposals, and vote accordingly. It won't be easy. I'm no Pollyanna with respect to this vexing topic.

None of this is exactly news. In addition to the many post links I've cited above, read Elhauge's 1994 "Allocating Health Care Morally" [pdf] to wit:
"Health law policy suffers from an identifiable pathology. The pathology is not that it employs four different paradigms for how decisions to allocate resources should be made: the market paradigm, the professional paradigm, the moral paradigm, and the political paradigm. The pathology is that, rather than coordinate these decisionmaking paradigms, health law policy employs them inconsistently, such that the combination operates at cross-purposes..."
Not a lot has changed for the better in the ensuing 24 years.

NEWS UPDATE

From The Atlantic:
Judges Shouldn’t Have the Power to Halt Laws Nationwide
A court in Texas may put Obamacare on ice—everywhere.


Democrats were ecstatic when a judge in Honolulu barred enforcement of the Trump administration’s travel ban. They were thrilled when a judge in Chicago halted a policy to rescind grant funding to sanctuary cities. In both cases, the judges extended their ruling beyond the litigants to the whole country, issuing so-called national injunctions.

For opponents of Donald Trump’s administration, this legal maneuver has seemed like a godsend. Now it may come back to haunt them, as a single federal judge in Texas considers putting the Affordable Care Act on ice—not only in Texas, but anywhere in the country.

Can one judge really impose his ruling from one coast to the other?

A group of Republican state attorneys general certainly think so. In their view, Congress knocked the constitutional legs out from under Obamacare when it repealed the penalty for going without insurance. They’ve sued to stop the federal government from implementing any part of the law—including its protections for preexisting conditions and the Medicaid expansion—across all 50 states…
No end of stuff to stay on top of. My only pushback thought regarding the foregoing "national injunction" concern is that the ACA ("Obamacare") is not some new, controversial executive order policy, it's a now long-standing law that has withstood SCOTUS challenge.

I guess we'll soon see.


PRESIDENT TRUMP OCT 31ST INTERVIEW WITH ABC'S JONATHAN KARL
JONATHAN KARL: One of the central issues is health care. You’ve been saying Democrats want to take away preexisting conditions. I mean, it’s your administration that’s supporting a lawsuit that would allow health insurance companies –-

DONALD TRUMP: No, but I want to replace preexisting conditions and I’ve always been there. What the Democrats are going to do is destroy our entire health care and you’re not going to have any health care. You would destroy the country. You are not going to have health care. The Democrats are going to literally –- you’ll have to pay three times the taxes and they’ll destroy health care as we know it in this country. You won’t have preexisting conditions. You won't have anything.
Okeee-dokeee, then. Seriously? Yeah, he has "the best words."


UPDATE: BEYOND HEALTH CARE PER SE
What’s at Stake for Science in the Midterms
Scientists-turned-politicians are hitting the campaign trail and appealing for votes based on truth and reason

Bryson Masse
In early October, a United Nations report [KHIT link] warned that humanity has just 12 years to mitigate climate change and save the planet. When, a few days later, “60 Minutes” reporter Lesley Stahl asked President Trump about his position on climate change and the scientists who describe the situation as “worse than ever,” he replied, “You’d have to show me the scientists, because they have a very big political agenda, Lesley.”

Do they ever.

Since 2017, the White House and a Republican-controlled legislative wing have taken shears to environmental protections, reduced the size of national parks, and attempted to militarize space. Such changes have inspired a new generation of STEM (science, technology, engineering, and math) professionals to run for office, and they’re gunning for the midterms.

“There are more talk radio show hosts in Congress than there are chemists or physicists,” said Shaughnessy Naughton, president of 314 Action. “I think part of what running as a scientist brings is an outsider status, but one that actually has credibility in a lot of issues that are important to Americans.”

314 Action describes itself as the pro-science resistance, and it is focused on “aggressively advocating for a pro-science agenda in Washington, D.C., and in local and state legislatures,” according to its website. It’s named for the first three numbers of pi. Since the group put out a call in January 2017 for scientists to run for office, 314 Action has heard from 7,000 scientists seeking help for their campaigns. The group has trained 1,400 of them, and also funds campaigns and puts together financial and communications strategies for inexperienced candidates.

Whether it’s health care, cybersecurity, nuclear weapons policy, or just evidence-based facts, Naughton thinks scientists are equipped to turn D.C. around…
 Indeed. Read the entire article. Excellent. Science! (Notwithstanding that "I am not a scientist.")


Science. Your health depends on it.

UPDATE

From THCB:
We Know We Have to Address the Social Determinants of Health. Now What?
by Rebecca Fogg

In the run-up up to this month’s mid-term elections, health care appears to be just one of many burning political issues that will be influencing Americans’ votes. But delve into nearly any issue—the economy, the environment, immigration, civil rights, gun control—and you’ll find circumstances and events influencing human health, often resulting in profound physical, emotional and financial distress.

Evidence suggests that separating immigrant children from their families could cause lasting emotional trauma. Gun violence and adverse weather events destroy lives and property, and create hazardous living conditions. Structural racism has been linked to health inequities, for instance where housing discrimination leads to segregation of black buyers and renters in neighborhoods with poor living conditions. The list goes on, and through every such experience, affected individuals, their loved ones, and their communities learn implicitly what health care providers have long known: that health status depends on much more than access to, or quality of, health care.

Some of the most influential factors are called social determinants of health, and they include education, immigration status, access to safe drinking water, and others. Society and industry must collaborate to address them if we are to reduce the extraordinary human and economic costs of poor health in our nation…
I've posted on "social determinants" impacts many times. And, we now have to add "exposomics" to the list (epigenetic injury owing to persistent toxic "upstream" factors).

See the work of The Christensen Institute in this regard.

"The Clayton Christensen Institute is a nonprofit, nonpartisan think tank dedicated to improving the world through disruptive innovation. Founded on the theories of Harvard professor Clayton Christensen, the Institute offers a unique framework for understanding many of society’s most pressing issues around education, healthcare, and economic prosperity.
Our mission is ambitious but clear: work to shape and elevate the conversation surrounding these issues through rigorous research and public outreach. The Institute is redefining the way policymakers, community leaders, and innovators address the problems of our day by distilling and promoting the transformational power of disruptive innovation."
I was not aware of this outfit 'til today. My Bad. Have to study up on their work. Ahhh..."disruptive innovation."


CI's health care topics.


"TAKE IT BACK TO THE TOP"
Vote as if the future of of your health care depends upon it. Because it does.
ON DECK

Once the mid-terms hubbub is over, I'll be reporting on a new book I just downloaded.


I got an Amazon email recommendation. I bit. We shall see. A young man on the move. Recall my prior post "Data Science?" Will have to triangulate with other relevant texts.

CODA: MIDTERM COUNTDOWN UPDATE

President Trump during his MAGA Rally in Chattanooga on Sunday Nov 4th:
“They [the Democrats] want to take away your health care [and] they want to impose socialism on our country;”

“If Democrats gain power on Tuesday, they will try to raid your Medicare to fund socialism, you know that.”


“The Democrat health care plan would obliterate Medicare and eliminate Medicare Advantage for more than half a million Tennessee seniors.


“The Democrats’ plan to destroy health care also includes giving away your benefits to illegal immigrants, you know that.”


“As we speak, Democrats are openly encouraging millions of illegal aliens to break our laws, violate our borders, and destroy our nation in so many ways, and they want to sign them up for free welfare, free health care, free education and, most importantly, the right to vote. They want them to vote. Come on in and vote. They love them voting.”


“And Republicans will always protect patients with pre-existing conditions. Please remember that.”
Right. BTW, from the source Atlantic article:
None of those claims is hard to debunk—but the last one, about Republicans always protecting pre-existing conditions, speaks to a president and many other Republicans running for Congress who have simply become unmoored from the truth on health care, which polling shows is by far the number one issue among voters.

Twenty Republicans-led states are awaiting a federal court ruling on a lawsuit aimed at demolishing the vestiges of the Affordable Care Act that remain in existence, including the hugely popular provision that prohibits insurance companies from denying insurance to people with serious medical problems or “pre-existing conditions.” The Trump administration has filed a brief in support of the lawsuit. And just the other week, the administration issued a rule that makes it easier for states to begin offering watered down insurance plans that do not include pre-existing conditions, which some have begun doing.

But none of this has stopped Republican candidates for Congress in those 20 states, or the president himself, from claiming that Republicans will always protect the very thing they are now in court to abolish...
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More to come...

Saturday, October 27, 2018

Six months of mourning

Twenty years and six months, to be precise...

Danielle Leigh Gladd, July 27, 1970 - April 27, 2018




This (2nd photo) is now my iPhone wallpaper. We shot this "selfie" in the family room after returning from the final ER trip, where Danielle had decided to commence home hospice care.

She died six weeks later. Peacefully, just stopped breathing at about 9:25 pm, April 27th.

My girls, 1974, Seattle, the year I got sole custody.

"A tale of two sisters"

Still largely at a loss for words. Hard to wrap my head around losing them both. I lived for those kids.


I do OK, but I can tell a lot of it is the Zoloft talkin'.
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Tuesday, October 23, 2018

"An American Sickness" update: a conversation with Elisabeth Rosenthal


An excellent expenditure of 36:15. After which, see my posts on "An American Sickness."


Hat tip to THCB for the podcast link.

See also "Overcharged?" Paying for health care. And, perhaps my "Shards" post.
___

UPDATE: TECH ERRATUM


Apple Watch. Yeah, I have one. Use it principally as a watch (though the "Dick Tracy Wrist Radio" phone feature can be handy).

 

In the wake of my recent aortic valve surgery, I have a heightened interest in useful real-time cardiac monitoring. I looked into this Apple stuff and decided nah...

NEW BOOK COMING SHORTLY

Just read a great Wired article, "Meet the Carousing, Harmonica-Playing Texan Who Just Won a Nobel for his Cancer," an excerpt from this soon-to-be-released book.

JAMES ALLISON LOOKS like a cross between Jerry Garcia and Ben Franklin, and he’s a bit of both, an iconoclastic scientist and musician known for good times and great achievements. He also doesn’t always answer his phone, especially when the call arrives at 5 am, from an unfamiliar number.

So when the Nobel Prize committee tried to reach Allison a few weeks ago to inform him he’d been awarded the 2018 Nobel Prize in medicine, Allison ignored the call. Finally, at 5:30 am, Allison’s son dialed in on a familiar number to deliver the news. The calls have not stopped since.

Allison’s breakthrough was the discovery of a sort of secret handshake that cancer uses to evade the immune system, and a means to block that handshake—what the Nobel committee hailed as “a landmark in our fight against cancer,” which has “revolutionized cancer treatment, fundamentally changing the way we view how cancer can be managed.” (Allison’s co-recipient was Tasuku Honjo of Kyoto University.) Advances in cancer typically come in 50-year increments; the science that Allison and Honjo helped advance, cancer immunotherapy, has made a generational leap seemingly overnight…
Having now lost both of my daughters to cancers, I am keenly interested in these developments for others. I'm sure the Biden Cancer Initiative people are on top of this news.

I look forward to the book's release.

SETH MEYERS ON THE GOP AND HEALTH CARE

 
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More to come...

Wednesday, October 17, 2018

Global warming: the ultimate mental health issue?

Follow-on update to my prior post "Global warming: the ultimate health issue?"

“My uncle was a great professor at MIT for many years. Dr. John Trump,” he said. “And I didn’t talk to him about this particular subject, but I have a natural instinct for science, and I will say that you have scientists on both sides of the picture.”

So Trump’s claim to scientific competence rests on his belief that science is a matter of instinct, and this instinct is passed on genetically, as evidenced by his uncle. Those lucky few possessed of this gift can look at two competing hypotheses and know which one is correct, without needing to study the evidence, or even having a clear understanding of what “evidence” means...
From New York Magazine this morning.
Trump: My ‘Natural Instinct for Science’ Tells Me Climate Science Is Wrong
By Jonathan Chait

…The president of the United States styles himself as a man of science, willing to follow the facts wherever they go. In yet another of his current spate of lunatic ramblings he has decided to share with various media, this time the Associated Press, Trump was asked about the report again, and gave an even crazier response.

Trump asserted that, contrary to the scientific conclusion that pumping heat-trapping gases into the atmosphere has caused an upward ratcheting of temperatures, he sees it as random unexplainable variation: “I agree the climate changes, but it goes back and forth, back and forth.” When the interviewer noted that scientists have concluded otherwise, Trump asserted his own scientific credentials…
Elect a clown, expect a circus. But, hey, what do I know? "I am not a scientist."

From the Chicago Tribune:
Physicist U.S. Rep. Bill Foster says Trump has 'inability to understand the importance of science'

Stay tuned. This is likely to be another accruing long one. There's just so much to consider.


Above, see in particular Trump administration flack Myron Ebell at 3:52. A Google search turns up some stuff characterizing him as a "scientist." Right. He's with the Competitive Enterprise Institute, and a transparently partisan"markets-uber-alles" apologist for incumbent dirty energy extractive industries. He is no scientist. His argument here is basically an circumstantial ad hominem fallacy attacking the IPCC participants of practicing "Soviet Science" -- i.e., that they're UN stooges for an anti-US environmental policy position.

Calls himself the "#1 enemy of climate change alarmism."

But, hey, he lists a "Master of Science" degree from the London School of Economics.

The increasingly popular refrain among politicians, “I am not a scientist,” is just another formulation used to avoid an intelligent discussion of climate. It is not in any way a coherent response because logically the follow-up would be “so I will defer to the consensus of people who are scientists.” 

But the politicians never seem to get to that part. They instead act as though unless there is 100 percent unanimity among scientists, nothing can be known. But they are also contradictorily fully willing to assent to a tiny minority of scientists who happen to be saying what they want to hear. As often as not, the scientists in question are not even climate scientists, but who cares?

Mann, Michael E.. The Madhouse Effect: How Climate Change Denial Is Threatening Our Planet, Destroying Our Politics, and Driving Us Crazy (p. 9). Columbia University Press. Kindle Edition. 
An actual, accomplished scientist.

In His Own Words.
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More to come...

Tuesday, October 16, 2018

Get your flu shot!


Get your flu shot. I'm getting mine tomorrow. My cardiac rehab PT manager asked me today about it. Off to CVS I go in the morning.

Wednesday update: Done. "Senior high dose."
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More to come...

Tuesday, October 9, 2018

Global warming: the ultimate health issue?


"THIS REPORT responds to the invitation for IPCC ‘... to provide a Special Report in 2018 on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways’ contained in the Decision of the 21st Conference of Parties of the United Nations Framework Convention on Climate Change to adopt the Paris Agreement.

The IPCC accepted the invitation in April 2016, deciding to prepare this Special Report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty.

This Summary for Policy Makers (SPM) presents the key findings of the Special Report, based on the assessment of the available scientific, technical and socio-economic literature relevant to global warming of 1.5°C and for the comparison between global warming of 1.5°C and 2°C above pre- industrial levels. The level of confidence associated with each key finding is reported using the IPCC calibrated language. The underlying scientific basis of each key finding is indicated by references provided to chapter elements…"
President Trump (who admits, unsurprisingly, to not having read the IPCC report) has repeatedly dismissed global warming as "a hoax, a money-making industry."


"Trump suggests the climate may actually be 'fabulous' after an ominous UN report on looming disaster"

Right. Google "IPCC global warming report findings" to see extensive reporting and analysis of the 2018 IPCC findings. I am particularly interested in the IPCC findings regarding likely human health impacts (and the impacts on all life more broadly). 

Stay tuned. According to the IPCC, time for averting large-scale prolonged calamities is getting very short. According to our President, we need to burn more coal.

As I post the first cut of this, we're less than a day away from the Florida panhandle landfall the rapidly strengthening of Hurricane Michael. Recall my prior post on Hurricane Florence. "Anthropocene Era," anyone?

Below, a sculpture/statue in Berlin entitled "Politicians discussing Global Warming."


UPDATE

Not much on "health" in the Report, with one exception (Chapter 3):
3.4.7 Human health
Climate change adversely affects human health by increasing exposure and vulnerability to climate-related stresses, and decreasing the capacity of health systems to manage changes in the magnitude and pattern of climate-sensitive health outcomes (Cramer et al., 2014; Hales et al., 2014). Changing weather patterns are associated with shifts in the geographic range, seasonality, and intensity of transmission of selected climate- sensitive infectious diseases (e.g., Semenza and Menne, 2009), and increasing morbidity and mortality are associated with extreme weather and climate events (e.g., K.R. Smith et al., 2014). Health detection and attribution studies conducted since the AR5 provided evidence using multi-step attribution that climate change is negatively affecting adverse health outcomes associated with heatwaves; Lyme disease in Canada; and Vibrio emergence in northern Europe (Mitchell, 2016; Mitchell et al., 2016; Ebi et al., 2017). The IPCC AR5 concluded there is high to very high confidence that climate change will lead to greater risks of injuries, disease and death due to more intense heatwaves and fires; increased risks of undernutrition; and consequences of reduced labor productivity in vulnerable populations (K.R. Smith et al., 2014)…
This paragraph is followed by several pages of topical "detail." That's about it. There's one brief allusion to "Population Health," but lacking any ensuing illustrative particulars (see my prior post).

Notwithstanding that accelerated and serious health adversities will surely result from the various other characteristics of global warming -- e.g., air and water pollution, heat waves, persistent droughts, increased poverty, food shortages, climate-induced migration, political instabilities, etc. -- I was hoping for a more substantive discussion of health impacts per se.

OCT 12TH UPDATE

CNN just published an article addressing the foregoing:
How climate change will affect your health
By Arman Azad, CNN


A new report from the UN Intergovernmental Panel on Climate Change warns of dire consequences if governments don't make "rapid, far-reaching, and unprecedented changes in all aspects of society" to stem global warming. But the planet isn't the only thing at risk as temperatures rise; your health might be in danger, too…

An increase in disease-carrying mosquitoes and ticks 

Hot and humid climates provide a perfect breeding ground for critters, and experts say that a warming world might put us at greater risk for vector-borne diseases, which are those transmitted by ticks, mosquitoes or other organisms…

Contaminated water sources and dangerous bacterial infections
Extreme weather and rainfall have contributed to the spread of bacterial infections through contaminated water, especially in summer. Warmer temperatures will only make those storms worse…

An increase in mental health issues
Even a modest rise in temperatures is associated with an increase in mental health issues, according to a study published this year that surveyed nearly 2 million US residents. The research, in the journal PNAS, looked at individual cities and found that warming of just 1 degree over five years was linked to a 2% increase in mental health issues…

An increase in Type 2 diabetes
Rising temperatures are associated with an increase in Type 2 diabetes, according to a 2017 study published in the journal BMJ Open Diabetes Research & Care. However, researchers looked only at the correlation between temperatures and diabetes, so the study didn't establish that temperatures necessarily caused the disease…

Respiratory problems and stroke

Most scientists agree that greenhouse gases like carbon dioxide are contributing to global warming, but those emissions aren't just hurting the planet. Fossil fuel pollutants can also generate a mixture of solid particles and liquid droplets in the atmosphere that can enter your lungs and even your bloodstream…

More car crashes and fewer food inspections
Even small changes in climate can impact human behavior, leading to an increase in fatal car accidents and a decrease in food safety inspections, according to a study published this year in PNAS…

…the MIT Media Lab research scientist who co-authored the study, noted that "hot temperatures are basically bad for human functioning." The crux of the idea, he said, was that "weather affects how we perform our duties and how we go about our daily lives and the risks that we experience."
Read all of it.
One thing that will be centrally important will be the applied "Data Science" elements of large scale public health "big data" disparate-source collation and analytics. Moreover, at the primary care outpatient clinic level, we will have to finally get beyond all of the endless "interoperability" happy talk and derive appropriate and effective means of EHR data sharing for epidemiological "early warning" sentinel purposes.
___

Per the IPCC report, I found this interesting (Chapter 5):
Well-being for all (Dearing et al., 2014; Raworth, 2017) is at the core of an ecologically safe and socially just space for humanity, including health and housing to peace and justice, social equity, gender equality, and political voices (Raworth, 2017). It is in alignment with transformative social development (UNRISD, 2016) and the 2030 Agenda of ‘leaving no one behind’. The social conditions to enable well-being for all are to reduce entrenched inequalities within and between countries (Klinsky and Winkler, 2018), rethink prevailing values, ethics and behaviours (Holden et al., 2017), allow people to live a life in dignity while avoiding actions that undermine capabilities (Klinsky and Golub, 2016), transform economies (Popescu and Ciurlau, 2016; Tàbara et al., 2018), overcome uneven consumption and production patterns (Dearing et al., 2014; Häyhä et al., 2016; Raworth, 2017) and conceptualise development as well-being rather than mere economic growth (Gupta and Pouw, 2017) (medium evidence, high agreement). 
Trump and his kleptocrats will simply scoff. I am reminded of Peter Frase's "Quadrant IV" -
Hierarchy and Scarcity: Exterminism
But if we do not arrive as equals, and environmental limits continue to press against us, we come to the fourth and most disturbing of our possible futures. In a way, it resembles the communism that we began with — but it is a communism for the few.

A paradoxical truth about that global elite we have learned to call the “one percent” is that, while they are defined by their control of a huge swathe of the world’s monetary wealth, they are at the same time the fragment of humanity whose daily lives are least dominated by money. As Charles Stross has written, the very richest inhabit an existence in which most worldly goods are, in effect, free. That is, their wealth is so great relative to the cost of food, housing, travel, and other amenities that they rarely have to consider the cost of anything. Whatever they want, they can have…

…In Tropic of Chaos, Christian Parenti makes the case that we are already constructing this new [exterminism] order, as climate change brings about what he calls the “catastrophic convergence” of ecological disruption, economic inequality, and state failure. The legacy of colonialism and neoliberalism is that the rich countries, along with the elites of the poorer ones, have facilitated a disintegration into anarchic violence, as various tribal and political factions fight over the diminishing bounty of damaged ecosystems. Faced with this bleak reality, many of the rich — which, in global terms, includes many workers in the rich countries as well — have resigned themselves to barricading themselves into their fortresses, to be protected by unmanned drones and private military contractors. Guard labor, which we encountered in the rentist society, reappears in an even more malevolent form, as a lucky few are employed as enforcers and protectors for the rich…
 The online article is fine. The book is better. Much more in-depth.

"As things stand now, even if every country met the commitment it made in the Paris Agreement, the temperature would still increase to three degrees Celsius above pre-industrial levels by the end of the century. If the world continues burning fossil fuels and emitting greenhouse gases at the current rate, it could rise by four degrees—a fact that the Trump Administration, which withdrew the United States from the Paris Agreement, in June, 2017, acknowledged with language buried deep in an August draft report issued in support of eliminating Obama-era fuel-economy rules. Representatives from the Trump Administration were in Incheon and had to approve the conclusions of the report. Whether President Trump will respond to its findings remains to be seen…" [From The New Yorker]
In my email inbox
"...if a smoke alarm rings in the kitchen and everyone’s watching “Fox & Friends” in the den, does it make a sound? Asked about the report last week, Donald Trump said, “I want to look at who drew it—you know, which group drew it.” The answer seemed to indicate that the President had never heard of the I.P.C.C., a level of cluelessness that, while hardly a surprise, was nevertheless dismaying. The next day, as a devastating hurricane hit Florida—one made that much more destructive by the warming that’s already occurred—the President flew to Pennsylvania to campaign for Lou Barletta, a climate-change-denying Republican congressman running for the Senate..."
WaPo OpEd
As the climate worsens, wealth inequality will, too
David M. Lodge is Francis J. DiSalvo director of the Atkinson Center for a Sustainable Future at Cornell University.


Disasters often bring out the best in Americans — cooperation, kindness and dogged perseverance supersede political and provincial ideologies. One need only look back to the warm greeting between President Barack Obama, a Democrat, and Republican New Jersey Gov. Chris Christie two days after Superstorm Sandy devastated the Garden State in 2012.

But these disasters also serve to separate Americans, widening the gap between the “haves” and the “have-nots” and increasing wealth disparities. Fortunately, environmental policy changes can help close that gap…

Without changes in federal and state policies, the economic divide will grow even faster as climate-induced flooding ravages our country. A host of federal and state environmental and development policies exacerbates this disparity, including Environmental Protection Agency policies that allow increased greenhouse-gas emissions and state regulations such as those in North Carolina that allow development in locations increasingly prone to flooding.

…Let’s hope political amity in the aftermath of this season’s hurricanes will last long enough for lawmakers to pass meaningful reforms. By allowing current science to inform policy, legislators would also be protecting the most vulnerable in our country and reducing the growth of the wealth gap.
atkinson.cornell.edu
Yeah, but the breadth of focus of the Trumptocracy is on that of the margins separating the "haves and the have-yachts." Again, Frase's "Quadrant IV."

On a brighter note, see the Atkinson Center "FOCUS: ONE HEALTH" page:
"Human health, animal health, and ecosystem health are inextricably linked. One Health or planetary health research emphasizes the connections between these elements to promote, improve, and defend the health and well-being of all species. This research focus often involves collaboration among clinicians, natural scientists, and social scientists working in universities, health institutions, and environmental organizations. Cornell boasts a top-ranked vet college, medical school, and environmental sciences across several colleges. Project teams have demonstrated success in working together in innovative combinations to tackle the complex, interlinked issues of species health, sustainable populations, and ecosystem functioning..."
Yes!

UPDATE:



I cited him once before (his book The Madhouse Effect) in my post "Update on the March for Science."
"By 2030, it is estimated, climate change will cause as many as 700,000 additional deaths a year worldwide.14 By comparison, each year 443,000 people currently die prematurely from smoking or exposure to secondhand smoke. One could well argue, from this standpoint, that the industry-funded campaign to deny the effects of human-caused climate change has and will cost even more lives and constitutes an even greater crime against humanity than the tobacco industry’s campaign to deny the health effects of tobacco.

Malnutrition kills more than 7 million people a year, many of them children. More than 2 million people a year die from complications arising from lack of access to clean drinking water, such as diarrhea and waterborne diseases. The vast majority, again, are children. The adverse impacts of climate change on food and water will magnify the fatalities. The developing world, with its weak health-care infrastructure, will be least able to cope.

A warmer Earth means more extreme, dangerous heat and more fatalities from heat stroke and heat exhaustion. In the United States, there has been a doubling of record daily high temperatures in the past half-century, and this increase has taken a toll. As many as 10,000 people perished in the Chicago heat wave of 1988, which affected a very large portion of those most vulnerable: the elderly and infants. Fortunately, with increasingly widespread air-conditioning in homes, buildings, and vehicles, we in the United States are insulated from the full impacts of heat extremes, and fatalities from complications related to intense heat are limited to fewer than 1,000 a year. (But, of course, the down side of air-conditioning is that it requires large amounts of electricity, which in turn require the burning of more fossil fuels.)

Other countries that have less of this infrastructure aren’t as fortunate. The record heat wave in Europe in 2003 took a toll of 70,000 human lives, and the record heat in Russia in 2010 took another 56,000. The heat wave in India and Pakistan in 2015 claimed several thousand more. The elderly, the very young, outdoor workers, and those who lack access to shelter are most vulnerable…

Climate change brings not only death but pestilence, too. We can expect to see infectious diseases such as Dengue fever and malaria spread into the extratropics as the globe continues to warm. West Nile virus was first detected in New York City following the record warm year of 1998, and dangerous Hantavirus appears to be spreading north in the western United States.

Then there’s the issue of air quality, allergies, and asthma. Higher atmospheric CO2 favors weeds such as ragweed, whose pollen triggers allergies and worsens asthma. Rising temperatures increase ground-level ozone smog, which also worsens asthma. The number of pollen allergy and asthma sufferers appears to be increasing in recent decades as the globe continues to warm..."
Mann, Michael E. The Madhouse Effect: How Climate Change Denial Is Threatening Our Planet, Destroying Our Politics, and Driving Us Crazy (pp. 40-42). Columbia University Press. Kindle Edition.
UPDATE: THE "PINATUBO STRATEGY?"

From NBC News:
…The international panel charged with reining in climate change said this week that the world needs to take "unprecedented" steps to remake its energy, transportation and agriculture systems to avoid the worst effects of global warming.

What the Intergovernmental Panel on Climate Change did not discuss was an even more radical potential response — one that would re-engineer Earth’s stratosphere to create a massive heat shield by effectively duplicating the fallout that follows a volcanic eruption.

This kind of revolutionary “solar geoengineering” — known by some as the “Pinatubo Strategy,” after a volcano whose 1991 eruption shrouded the planet in a sulfurous cloud — was once relegated to a far corner of academia. But a number of scientists and environmental advocates said this week that the IPCC report — punctuated by Hurricane Michael, which hit the Florida panhandle and may have been intensified by global warming — argues for speeding up the study of the once unthinkable…
Planet-wide "geo-engineering?" Good luck getting world-wide international political agreement on that.

MORE NEWS...
GOP senators from hurricane-ravaged states mock UN’s climate change warning
Trump says climate change may be 'fabulous'. Dire UN report says otherwise.
Mexico Beach FL after Hurricane Michael
ANOTHER UPDATE

Good material here via this organization:

MEDICAL ALERT!
Climate Change Is Harming Our Health
[pdf]
ADDENDUM

Yet another resource.

Website link.

BTW, I've touched on the climate change stuff before:
The ultimate population health "Upstream" issue? (2014)
 Upstream, downstream; what happens to health when there IS no more stream? (2015)
As I Google around searching out activity and further resources, it's becoming clear that there will have to be a follow-on post.



And, the hits just keep on comin'...

Climate-driven declines in arthropod abundance restructure a rainforest food web
Bradford C. Lister and Andres Garcia

Significance
Arthropods, invertebrates including insects that have external skeletons, are declining at an alarming rate. While the tropics harbor the majority of arthropod species, little is known about trends in their abundance. We compared arthropod biomass in Puerto Rico’s Luquillo rainforest with data taken during the 1970s and found that biomass had fallen 10 to 60 times. Our analyses revealed synchronous declines in the lizards, frogs, and birds that eat arthropods. Over the past 30 years, forest temperatures have risen 2.0 °C, and our study indicates that climate warming is the driving force behind the collapse of the forest’s food web. If supported by further research, the impact of climate change on tropical ecosystems may be much greater than currently anticipated…
 Hat tip to the Naked Capitalism blog for the heads-up. "6th Extinction," anyone? (Scroll down in linked post.)

CODA

This book is scheduled for an October 30th release. I read a review in my latest Science Magazine.

"America's leading nutritionist exposes how the food industry corrupts scientific research for profit."
I'd like to see the folks at Science Based Medicine review this one.
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More to come...

Friday, October 5, 2018

Population Health and an aging world


I first used the above photo in my recent post on "The Silver Tsunami." Then, in a subsequent post on "The Biden Cancer Initiative" I cited an article I ran across at STATnews.
More research on ‘dying healthy’ will also help us live healthier
By GEORGE J. ANNAS and SANDRO GALEA, OCTOBER 3, 2018


Helping people live longer has been a central goal of medicine for decades. The quest to extend life raises an interesting question: Should we keep investing in research aimed at adding even more years to the already impressive gains in the average life expectancy that occurred during the 20th century?

We can only go so far. There’s likely an unalterable biological limit to the human life span, somewhere around 115 years (though there are, of course, occasional outliers). Virtually all humans die before reaching that age, most of them before they turn 90.

This limit should give us pause…

Advances in medical treatment, including cancer treatments, are increasingly unlikely to provide further significant gains in human longevity. An analysis of 71 cancer drugs consecutively approved between 2001 and 2012, for example, suggests that their overall contribution to survival was just 2.1 months; the gains attributable to personalized cancer medicine have, so far, also been minimal.

Lacking evidence that the human life span can be radically increased by new medical technologies, we believe it’s time to shift our country’s investment priorities away from medical research that aims to extend life and instead focus on the same social, cultural, and political factors that successfully prolonged life in the last century.

That means more public investment in education, transportation, and housing. That kind of investment would directly contribute to the prevention of chronic diseases such as diabetes, heart disease, and many cancers, and would do more to improve the quality of life of the population than additional medical research aimed at treating individuals with specific diseases…

One way to preserve quality of life throughout the life span is to compress aging-related illness and disease into as short a time as possible.

Others before us have suggested that the U.S. is now at the point of diminishing returns in high-tech medicine. Unfortunately, calls to redirect resources away from research into extending life and toward quality of life have been ignored in the past, and the same will likely happen now. We believe that is a mistake…
I immediately tangentially thought of "A Good Death."

I looked into the authors of the foregoing STATnews piece, both faculty members of the Boston University School of Public Health.

Sandro Galea, MD is the author of this intriguing book:
Introduction
HEALTH MATTERS. A CONCERN with our health and well-being crosses national, partisan, and ideological divides. Our concern with health has led us to remarkable achievements that have made for a healthier world during the past century. Life expectancy worldwide is higher than it has ever been. In the past century alone, we have increased life expectancy by a mind-boggling 30 years after centuries during which life expectancy was more or less stagnant. We have dramatically reduced death from infectious disease, and large numbers of people worldwide have access to quality medical care when they need it. Yet, our health achievements leave much to be desired. Although life expectancy has increased overall, billions of people continue to die prematurely, and substantial healthy life years are lost worldwide due to disease or disability. Our collective health achievement is marred by tremendous gaps, with global life expectancy ranging from a high of 83 years in Japan to a low of 47 years in Malawi. The United States has worse health metrics than nearly all other high-income countries, even as the country spends far more on health than any other country worldwide. Population health in the United States is characterized by racial/ethnic and socioeconomic gaps, despite decades of study and effort to narrow these disparities. These successes, and failures, are all the remit of public health.

At heart, public health is concerned with the social, economic, cultural, and political conditions that shape the health of populations. The vast majority of health achievement during the past century is attributable to an improvement in these conditions: to better living conditions in cities, improved educational status for women and men, safer water and sanitation, availability of nutrient-rich food, stable housing and shelter, and reduction in violence and injury. Conversely, our shortcomings represent our failure to tackle the social divides—across countries and within countries—that become health divides. This is compounded by our mis-investment of resources in curative care and away from education, physical and social conditions of cities, social justice, and efforts at disease prevention that create the conditions for healthy populations…
1. The Aspirations and Strategies of Public Health 
DURING THE PAST century, public health has been responsible for an extraordinary number of achievements. Going forward, the field stands to make similar contributions to health in this century. Our rapidly changing world continually presents us with new challenges, including chronic diseases, increasing income disparities, the threat of bioterrorism, and climate change. In the face of these concerns, public health is well positioned to lead the way.

Yet, despite its record of achievement, organized public health appears to be on the defensive. High-profile initiatives such as the burgeoning precision medicine agenda and the continuing war on cancer have captured attention at the highest levels of politics, diverting resources into individualized efforts at disease prediction through genomic approaches, at the expense of population-based public health action geared toward the foundational drivers of health [2, 3]. Given that much public health scholarship arises from academic public health institutions that are heavily dependent on federal funding agencies, our national preference for cutting-edge technology and expensive treatment over less eye-catching prevention measures threatens to monopolize the direction of public health scholarship for decades to come. Public health is not alone in this financial uncertainty. We share funding and infrastructure deficiencies with transportation, education, and almost all other endeavors that are reliant on public funding and leadership. Investments in much of this infrastructure have been declining, or barely keeping pace with needs, for decades [4]‌. In this context, every extra dollar spent on medical care comes at a high opportunity cost, at the expense of public health [5].

The difficulties we face do not center on disagreements about the core goals of our field, which have always been, and remain, broad and aspirational. According to the American Public Health Association, “public health promotes and protects the health of people and the communities where they live, learn, work, and play” [6]‌. This statement captures public health’s goal of shaping the conditions that enable healthier populations, with a key emphasis on the prevention of disease…


Galea, Sandro (2017-06-20T23:58:59). Healthier: Fifty Thoughts on the Foundations of Population Health (Kindle Locations 184-258). Oxford University Press. Kindle Edition.
OK. More stuff to have to study up on. I have to confess I don't know much about the nuts and bolts of "public health" as an academic and/or professional domain. I spent my three tenures with the HealthInsight Medicare QIO first as a Nevada acute care hospitalization outcomes analyst (pdf), and then as an EHR implementation and workflow analyst (DOQ-IT, Meaningful Use REC) working the ambulatory primary care space (Family Med, Internal Med, Peds, OB/GYN). In that arena, mention "population health" to the harried docs on the enervating productivity treadmill would just get you eye-rolling, grumpy, dismissive responses -- "If we each provide the best care for our patients, 'population health' will take care of itself."

Not that simple, by a long shot. But, then, none of us in the trenches had time for debating abstract macro policy issues.
"Yet, despite its record of achievement, organized public health appears to be on the defensive."
In particular given the priorities of the Trump administration. And then there are the competing economic priorities and chronic misalignments revealed in Rosenthal's excellent book "An American Sickness." 
An Aside: where might "Data Science" fit in to this? And, broadly, the "Upstream"? In that regard, "Your ZIP code matters more than your genetic code."
And, let us not forget the "exposome."
Take a Deep Breath and Say Hi to Your Exposome
Researchers begin to explore the unique cloud of airborne microbes and chemicals that surrounds each of us


In the past few decades, researchers have opened up the extraordinary world of microbes living on and within the human body, linking their influence to everything from rheumatoid arthritis to healthy brain function. Yet we know comparatively little about the rich broth of microbes and chemicals in the air around us, even though we inhale them with every breath.

This struck Stanford University genomics researcher Michael Snyder as a major knowledge gap, as he pursued long-term research that involved using biological markers to understand and predict the development of disease in human test subjects. “The one thing that was missing was their exposure” to microbes and chemicals in the air, Snyder says. “Human health is clearly dependent not just on the genome or the microbiome, but on the environment. And sampling the environment was the big hole.”…
 Add one more discipline to the "Omics." 

ALSO OF INTEREST AT BU-SPH

Roaming around their website led me to this:
Health Law, Ethics & Human Rights Research

The Affordable Care Act
Constitutionality, implementation strategies, Medicaid expansion, role of private health insurance companies, coverage of public health screening, and patient-oriented research.
 

Clinical Bioethics
Analysis of clinical case consultations performed at Boston Medical Center dealing with end-of-life care, reproductive health, patient capacity to participate in decision-making, and resource allocation.

Genetics & Genomics   
Genetic screening and counseling strategies, including fetuses, newborns, children, and adults. Introduction of whole genome screening into the clinical setting. Role of government mandates and informed consent. Genetic privacy, genetic transfer experiments, and regulation of synthetic biology.

Health Promotion
Legal and ethical issues in health promotion programs among employers, health care payers, government, and communities as well as the constitutionality of state and federal laws designed to change health behaviors (e.g., cigarette labeling laws, container size limits for sugary drinks, etc.)

Health & Human Rights
Development of a theory linking health to respect for human rights, including the meaning of the international “right to health.”

Patient Rights & Patient Safety

Defining the legal rights of patients, including the “right to safety” and the role of evidence-based medicine in setting the standard of care.

Medicine & the Holocaust
Study of the role of medicine during the Holocaust, focusing on racial hygiene, eugenics, euthanasia, and genocide. Care of Holocaust survivors, research on perpetrators and bystanders.

Military Medical Ethics
Study of existing military doctrine, application of civilian medical ethics to the military; special emphasis on ethics standards at Guantanamo, including hunger strike protocols, and the concepts of “dual loyalty” and “dual use.”

Reproductive Rights
Constitutionality of new state laws that restrict abortion services.

Research on Human Subjects
Study of the changes needed in federal research regulations and methods to improve subject understanding of research and improve the consent process and its documentation.

Religion & Public Health
The role of religion in public health policy and the First Amendment limits on governmental interference with religion and religious practices.

Emergency Preparedness
An examination of how public health should work with national security agencies, including the relationship between epidemics and bioterrorist attacks.

Medical Privacy
Privacy of medical and genomic records, quality assurance studies, and electronic health records, as well as the access the government has to private health information.

Legal & Ethical Implications of Wellness Programs
An analysis of the reciprocal interactions between corporate wellness programs and the laws governing health insurance and employment.

Forensic Medicine
Forensic evaluations of refugees and asylum seekers, as well as victims of abuse and torture. Setting standards for same.
Wow. Makes me want to move to Boston and apply.

My interest in these areas has been abiding ever since grad school [pdf] in the 1990's ("Ethics and Policy Studies"). apropos, see my prior post on "Information Ethics."

Oh, and I've alluded to this a couple of times:


I reached out to these folks, and gently pointed out that their "Ethical Framework" pdf download document had no definition of "ethics." The email reply I got blew me off -- "we all know what we mean, we're not gonna get bogged down in abstract academic jargon."

Right. In Silicon Valley-speak, just "Don't Be Evil" while you "Fail Fast and Break Stuff" in your Agile Scrums.

Dudes, I'm not talkin' obtuse ivory tower "Dialectical Hermeneutics,"or hypothetical "gotcha" moral dilemma "Trolley Problems," etc, just a common-sense primer of sufficient detail. e.g., from a book I got onto via Science Based Medicine:

Ethical Frameworks and Principles
Ethical considerations of any problem or issue can be divided into two major categories: (a) nonconsequentialist and (b) consequentialist approaches. 1 Nonconsequentialism considers that the action (or even just the motivation behind an action) is the crucial ethical factor. In other words, the action itself is more important than the actual outcome (consequence) of the action. By contrast, consequentialism holds that outcomes (as opposed to actions) should be the crucial determinants of ethical decisions…

Principlism
The inherent subjectivity of ethics presents a problem: even when reflexive and uncritical responses (such as the ‘gut reactions’ of tabloid readers) are excluded, along with religious outlooks, medical ethicists still do not all agree on which ethical principles are best.

It was in response to this reality that an approach to ethical analysis known as principlism was developed. Principlism attempts to factor in both nonconsequentialist and consequentialist approaches. The standard version is based on four core principles:

(1) Respect for autonomy (a nonconsequentialist principle—but one that utilitarianism also supports).
(2) Nonmaleficence (‘first, do no harm’—a nonconsequentialist principle).
(3) Beneficence (increase overall utility—a consequentialist principle; it is essentially utilitarianism).
(4) Justice (fairly distribute benefits, risks and costs—a nonconsequentialist principle). 
Principlists apply this approach to an ethical case by examining how each of the four principles (in turn) applies to the issues raised by the case. It is quite common for medical ethics committees to use this method to reach decisions. Principlism can be very useful as a structured ‘checklist’ method to address ethical problems and therefore finds favour amongst laypeople or non-ethically trained professionals, who predominate on ethics committees…

Ernst, Edzard. More Harm than Good?: The Moral Maze of Complementary and Alternative Medicine (Kindle Locations 83-208). Springer International Publishing. Kindle Edition.
That entire chapter is excellent. One need not, however, even go to that much trouble. Any quick Google search will get you tons of relevant, succinct definitional information on the topic of Ethics.

Below, a good, accessible, inexpensive resource:


I still have all of my many grad school texts, but I keep this in my Kindle as a handy refresher.

It was emphasized to us in grad school early on that "Ethics" was not about some lookup cookbook of "right/wrong," but rather a frequently arduous process of rational moral deliberation comprising evidence (including accrued wisdoms), logic, and -- yes -- "values" fused in honest attempts to derive just decisions and policies.

UPDATE: ON HEALTH RESOURCE ALLOCATION

My latest issue of Science Magazine arrived today. This therein is relevant to the discussion in this post:
Cancer prevention: Molecular and epidemiologic consensus

Prevention of any disease can occur at two levels: (i) avoiding or reducing risk factors coupled with increases in protective factors (primary prevention, which is preferable when it can be practiced) and (ii) detection and intervention early in the course of disease evolution (secondary prevention). But despite substantial epidemiologic data showing that a large proportion of cancers and cancer deaths are preventable, decreases in cancer mortality rates in developed countries have lagged far behind decreases in mortality rates from heart disease (1), another major disease amenable to prevention (for example, 18 versus 68% decrease, respectively, between 1969 and 2013 in the United States) (2). We believe that one main factor explaining the relatively modest reduction in mortality is the limited support for cancer prevention research, which receives only 2 to 9% of global cancer research funding (3). As a United Nations (UN) High-Level Meeting begins this week to review efforts to combat noncommunicable diseases, a key question is how to prioritize resources to realize the potential of cancer prevention…
'eh?

CODA

Off-topic erratum: I drove today for the first time since my August 23rd SAVR aortic valve surgery. I start cardiac rehab PT next Tuesday. Doin' OK. Can definitely hear/feel that new valve thumpin'.
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More to come...