Vol. 152 August 1, 2016 It’s Not the Screen Time, It’s the Content.

August 1, 2016

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“Playing rapid action video games benefits the mental skills of processing information, switching between tasks, and visualizing the rotation of an object.”
                 Scientific American, July 2016


What?!
“Shooting zombies and repelling aliens can lead to lasting improvement in some mental skills.” (1)

Bavelier while a graduate student in the 1990s developed a computerized psychological test of the ability to see an individual shape in a busy visual scene. He tested it first on himself, expected to get an “average score”,  and  got a perfect score. He next tested Green, his mentor who also unexpectedly got a perfect score. They figured something was wrong with the computer program, but they could not identify a bug. After a number of Green’s non-psychological buddies also scored perfect results they spent some time in looking for the reason. The only common denominator among the group was that each had spent more than 10 hours a week playing the video game Team Fortress Classic. That discovery launched them, and others, into 15 years of investigations into the cognitive effects of playing fast-paced “shooter” video games.

According to various studies video game playing can boost a variety of cognitive skills:

  • improve focus on visual details (like reading fine print in a contract or on a prescription bottle)
  • heighten awareness of visual contrast (help drive in a thick fog)
  • enhance mental rotation of objects (get that odd-shaped couch through the door)
  • improve audio and visual multitasking (read a menu while conversing with a dinner partner)
  • improve reaction time to unexpected events by 10%
  • increase the number of correct decisions made under pressure
  • improve specific attention in fast changing visual fields (better control of attention)

One study found that laparoscopic surgeons who were also game players could complete surgery faster with the same precision or quality as non-gamers . I remember many years ago learning that the Israeli Army realized that video game players made the best tank commanders.

Obsessive game playing (“binging”) is NOT needed to boost the brain, and the American Academy of Pediatrics has made recommendations for preventing excessive use of all media by children.   Short, daily intervals of play on fast-action games can reap cognitive benefits. Many so-called “brain games” marketed for improving cognitive skills do not live up to their claims. According to these researchers fast-action video games can because:
1. they are fun,
2. they have careful pacing and levels of play (reduces frustrations of early failures),
3.they require increasing attentional control as the game proceeds,
4. they consistently challenge the player,
5. they provide the successful gamer rewards on different time scales (promotes planning for short and long-term objectives).

The content of the game is very important. Violent, aggressive action games can adversely influence children’s attitudes and behavior. Games involving action sports, real-time strategy (like StarCraft), 3-D puzzles (like Portal 2),or “Prosocial” games that involve cooperation rather than competition are listed as examples of “brain-boosters” by these researchers.

They did not include their opinion of Minecraft , an open-ended, creative game that has captured the imagination of millions of children. This fast-paced, multi-level, 3-D building block game is too hard for this adult to understand or follow. One grandchild agrees and has started an instructional website “Minecraft4Momz” . Take a look on YouTube.

References:
1. The Brain-Boosting Power of Video Games, Sci Am; July 2016, D. Bavelier, Prof. of Psychology, University of Rochester and C.S. Green, Asst. Prof. of Psychology, University of Wisconsin


Vol. 151 July 15, 2016 Heroin Users Don’t Need To Lie Down To Kick The Habit.

July 15, 2016

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“It is how you act, not what you take, that defines you as an addict.”

 

 

Much is being said and written about our current “opioid use/abuse epidemic”, “heroin addiction epidemic”, “opioid dependency problem”, “opioid crisis”, or other politically-correct term that catches your fancy. Speculation, and some good data, is abundant about causes, prevention, treatments, and consequences. Today’s blog will restrict itself just to treatment, Medication Assisted Treatment, or MAT. Outpatient MAT using Suboxone (1) has proved to be effective  treatment for the disease of opioid dependency. Opioid addiction is a disease that we can treat, just like we can treat diabetes with insulin.

Many popular press articles and consultant’s reports are calling for “more opioid treatment beds”, BUT you don’t need a bed to detox from heroin dependency. In fact, most heroin dependent patients don’t even need to “detox”, in the traditional sense of abstaining from a substance for days, going through withdrawal symptoms for days, and coming out “clean” at the other end.

This cry to “increase beds” as the answer to opioid dependency sounds to me a bit like the cry to increase hospital beds in the 70’s and 80’s. In hindsight that urge looks misguided at best as we marvel today at replacing heart valves without surgery with 2 days in the hospital rather than 2 weeks, delivering high potency intravenous medications from the ICU formulary to patients in their homes, and the sprouting up of numerous networks of hospital-run ambulatory diagnostic, treatment, surgical, and urgi-centers. It is getting to the point where they barely let us lie down for some procedures before we are out the door.

Most substance abuse detox centers are based on the alcohol detox model with a bed in a protected residence, help with alcohol withdrawal symptoms by IV or IM or oral medications, IV hydration if necessary, and behavioral support. That model is NOT relevant to heroin dependency treatment, and, as we now know, it does not work very well.

Heroin or opioid detox centers could be described as “revolving doors” as revealed in numerous studies and as depicted in a recent HBO film. Studies have shown that people with substance addiction undergo an average of 3-4 detox stays over a median of 9 years before staying free of substance abuse for 12 months. Each stay may be as long as 3 weeks and cost about $550 a day. Heroin detox stays may, in fact, increase the chance of a fatal overdose for a patient since their tolerance of heroin decreases, and their “usual dose” before detox, if they relapse and take it, may be too much for them. “Recent abstinence is a major risk factor for fatal opioid overdose.” (2)

Today a heroin or opioid user seeking treatment for his disease can walk into a health care provider’s office and receive his first dose of Suboxone in as little as 12-24 hours after his last dose of heroin. That is how fast heroin “washes out” of the body. (Unlike alcohol withdrawal symptoms, like the DTs, which may not start until 2-3 days after the last drink.) Most heroin users starting on Suboxone experience only mild withdrawal symptoms like jitteriness or changes in bowel movements which can be treated with numerous oral medications “on the hoof”. They do not have to lie down. Their behavioral support system, required by all high quality MAT programs, can be initiated and nurtured “on the hoof.”  After the first week or 10 days the Suboxone prescriptions (filled at the local pharmacy and covered by most insurance plans) are issued on a monthly basis while the outpatient mental health visits and behavioral support groups continue. A patient on Suboxone can be treated both medically and behaviorally for a year for about the same total charge as a 3-week detox center stay.

“Treatment of drug use does not require lying down.
Stand up for yourself!”

Our current thinking about the urgent need for more opioid treatment beds may be part of an outdated, knee-jerk response by legislators and policy makers to “do something” about the opioid crisis. Policy changes and public funds might be better focussed on effective, ambulatory Medication Assisted Treatment (MAT) rather than “more beds”.

References:
1. Suboxone is taken daily in tablet or sub-lingual form and contains two drugs: Buprenorphine relieves pain like opioids but does not produce euphoria plus Naloxone which causes immediate withdrawal symptoms if taken intravenously or intramuscularly.
2. New England Jour of Medicine 373;22, November 26, pg. 2015, 2095-7;  an excellent brief history of a century of Federal drug control.


Vol. 150 June 1, 2016 Blockers of Sun and Bugs

June 15, 2016

Hub thumbnail 2015It is that time of year again.
The 4th annual review of sunscreens (can’t call them “blockers” anymore per the FDA) and insect repellents was just published by Consumer Reports (July 2016 issue). For those of you who don’t wish to read all that chaff-like verbiage under the new editor here are some bullet points to guide your purchases. (If you wish to wade through all the CR words,  the July issue also has recommendations about beach umbrellas that don’t blow away, replacing 15-year-old furnaces with a central heating and A/C unit, and the coolest coolers of them all.

SUNSCREENS 

  • An SPF (Sun Protection Factor) of 30 blocks 97% of UVB rays (the cause of sunburn)and is the minimum SPF recommended by the American Academy of Dermatology. An SPF of 50 blocks 1% more for more money. SPF 100 blocks 99%.
  • Almost half (48%) of the sun screens tested by CR actually provided LESS SPF then stated on the package. This has been true over the four years of CR analysis, and this year CR is sending their results to the FDA and asking, “How come you guys don’t test this stuff?” Use SPF 30 product as a minimum.
  • Mineral sunscreens (those with titanium or zinc oxide in them) were the poorest UNLESS the sunscreen left a whitish glow on your skin. Nano-particle mineral sunscreens do not leave a whitish glaze (customers prefer that), but they don’t work well. The FDA is “still studying the unknown unintended consequences of nano-particles in skin lotions”. Non-mineral manufacturers are jumping on this uncertainty by promoting “no nano-particles” advertising, just another meaningless advert phrase.
  • “Broad-spectrum” sunscreens penetrate deeper into the skin to also block UVA light which is associated with increased risk for melanoma and accelerated aging of the skin. UVA rays pass through clouds and glass. There is NO SPF number for UVA ray blockers. CR used a “standard from Europe” in judging UVA blocking ability.
  • “Natural sunscreens” (as opposed to “chemical sunscreens”) are labeled as such because they contain natural minerals, aka “chemicals from the earth”, like titanium and/or zinc oxide. All of them came in under SPF of 15 in CR ratings unless they left white streaks on your skin when applied.
  • The only real difference between kids’ and the adults’ sunscreens are the cartoons on the package. Sprays are NOT recommended for kids because of inhalation occurrences. If you want to use a spray, spray it on your hand and rub it on.
  • No sunscreen is waterproof and reapplication is recommended after coming out of the water. “Waterproof” and “sweatproof” are terms prohibited to sunscreen manufacturers by the FDA.
  • Most sunscreens lose effectiveness after three years in their container, and the FDA requires them to date them now.

CR’s TOP PICKS?
No-Ad Sport SPF 50: super protective, non-greasy, fragrance-free, no white streaks, at a great price of 63 cents an ounce.  (“No-AD” means the company does not run ads on TV; it does not refer to “no additives”.)
Coppertone Water Babies SPF 50: $1.31 per ounce

HIGHEST RATING?
#1 – La Roche-Posey Anthelios 60 Melt-in Sunscreen Milk SPF 60: $7.20 per ounce
#2 – Pure Sun Defense SPF 50 Disney “Frozen”: 79 cents per ounce! (go figure!?); other models with different Disney names like “Avengers”, “Spiderman”, etc. should be equally good.

WORST?
CVS Kids Sun Lotion SPF 50:
an actual SPF of 8
Banana Boat Kids Tear-free, Sting-free Lotion SPF 50: is also apparently sunscreen-free with an SPF of 8

BUG REPELLENTS

Choosing a mosquito and tick repellent is easier. Just buy one with either 20% Picaridin or at least 15 % DEET. Both provide protection for 5-8 hours.  Repellent concentration is key. 30% DEET gives a full 8 hours protection. 5% Picaridin (found in some OFF products) gives less than an hour protection.

  • 5 of 6 “Natural ” plant-oil-based repellents tested did NOT work. Burt’s Bee Herbal gives you a scant 1 hour protection.
  • The “natural” 30% oil lemon eucalyptus “Repel” DID work for 7 hours, but should be used only on people over 3 years of age.
  • Picaridin 20% is safe for pregnant women and children over 2 months of age. Canada restricts its use to children over 6 months.
  • “Avon Skin So Soft” works only when it contains 20% Picaridin, but NOT without it.
  • DEET 15-30% is safe for children over 2 months of age.
  • Children under 2 months should be protected with mosquito netting and clothes.
  • Products including Vitamin B1, garlic, wristbands, or ultrasonic devices have no evidence of effectiveness.
  • Like sunscreens, don’t spray your face. Spray on your hands and rub on your face.

OFF, CUTTER, REPEL are familiar brand names, but buy the repellent with the right concentrations since some of these brand products have insufficient concentrations of either Picaridin or DEET to afford adequate protection.

Have fun at the beach … or the Olympics… or wherever!

 


Vol. 149 June 1, 2016 Jargon Update, Placebo Prices May Count, and Visual Acuity in Kids and Baseball Players

June 1, 2016

Hub thumbnail 2015Jargon Update

Babylag” : the sleep deprivation symptoms experienced by 50% (gender not identified) of new parents; worse than jet lag because they can be cumulative.

“Brobats” : Robots, six times the size of human sperm cells, that move and turn by wriggling their tails; aka MagnetoSperm; may eventually be used to deliver drugs through the bloodstream.

Connectomics” : the study of “connectopathies” like Alzheimer’s, schizophrenia, depression, and autism spectrum disorders; spurred by the increasing use of functional MRIs (fMRI) as a non-invasive brain imaging.

Placebome” (pronounced Pla-SE-bom): the network of 10 genes that predisposes people to respond to a placebo; moving forward on personalized medicine is a long-standing goal of he Human Genome Project.

Placebos believed to be expensive may work better than those believed to be cheaper.

One or two of those 10 genes may be associated with what’s in your wallet.   The Washington Post (1/29/16, Bernstein) “To Your Health” blog reports that investigators “found that the patients performed better on motor skills tests when they believed they were on the expensive drug, an effect that increased when they were given the expensive placebo first.” The Los Angeles Times (1/29/16, Kaplan) “Science Now” blog reports that investigators “also used functional MRI scans to assess the patients’ brain activity and found that the ‘cheap’ placebo prompted more action than the ‘expensive’ one.” The blog adds that “to the researchers, this was a sign that the patients expected less from the placebo they believed cost less, so their brains responded by doing more work.” (Huh ???) There is much more to the placebo story; a story too complex to tell in a single paragraph or understand from a single study..

Outdoor activity for prevention of myopia in children (at least in Chinese children)

The prevalence of myopia (nearsightedness) increases throughout childhood, particularly during and after puberty. Myopia often progresses as children grow older and high levels of myopia are associated with an increased risk of sight-threatening complications later in life (eg, myopic macular degeneration and retinal detachment). In a study published in JAMA; 314, October 2015 , 1913 school children in China were randomized (by school) to an additional daily 40-minute outdoor class or usual activity . The cumulative incidence rate of myopia over three years was lower in the intervention group compared with the control group (30 versus 40 percent). This is the first study to suggest an effective preventative strategy.

Increasing the amount of time children spend outdoors is a simple intervention and could be a strategy to reduce the risk of developing myopia and/or slow its progression. The effect was related to just being outdoors and had nothing to do with sports or activity.This is yet another good reason to reinstitute recess periods in elementary schools. The mechanism of the preventative effect of being outdoors is unclear. Some think that lack of exposure to sunlight for long periods is associated with myopia. Myopia is more common in high-income regions of the world presumably because those people spend less time outdoors.  “Myopia, once believed to be almost totally genetic, is in fact a socially determined disease,” and is increasing in prevalence. (SciAm June 2016, p.80)

Speaking of outdoor eyesight

Wade Boggs, whose number was just retired by the Boston Red Sox, shared “better than normal” visual acuity with fellow Baseball Hall of Famer Ted Williams. “Normal vision” (20/20) is being able to see at 20 feet what most people see at 20 feet. As the letter size increases going up the Snellen chart (designed in 1862) the denominator number increases. If you have 20/100 vision you can see clearly at 20 feet what most others can see at 100 feet. Wade Boggs’ visual acuity during his baseball career was 20/12. He could see the blue dot of the MLB logo on the ball as it rotated toward him! That and several other factors apparently accounted for his superb hitting. (Wade’s favorite game as a child was the early video “Pong” which was one of several hand-eye-coordination games that he played.)

Ted Williams, the other fantastic Red Sox hitter, had 20/15 vision. He could see the stitches on the hurtling baseball. The two had very different batting stances and styles, but were good friends. After several attempts by Ted to “correct” young Wade’s stance and swing they resolved to mostly talk about fishing.

Speaking of video games

PCs are apparently passé to babies. Most are using smartphones or tablets. In a 2013 survey of nearly 1500 U.S. parents 40% of children UNDER 2 years of age used a mobile device, an increase from 10% in 2011. (66% watched TV – no increase since 2011) Most of this was probably due to the rapid increase in smartphones in those families. Smartphone use of educational media for children up to 8 yo. in lower-income families tripled between 2011 and 2013 while PC use decreased. The same study revealed that 28% of parents felt that children’s device use decreased the time they spent with their kids while 12% felt it increased their time with them.

A study of over a thousand 13-17 year olds by the same Common Sense Media organization revealed that in 2012 the  vast majority of teenagers had their own cell phone (82%) including 41% who say they have a “smart” phone, meaning they can use it to “check email, download apps, or go online.”  Cell phone ownership varied by age (74% of 13 to 14-year olds, compared to 87% of 15 to 17-year-olds), and by income (74% of lower-income youth, compared to 84% and 86% of middle- and upper-income youth). There were no significant differences in cell phone ownership by race or by parent education. Surprisingly, the teenagers who were surveyed preferred face-to-face communication (49%) over texting (33%), but other studies have shown that the fear of being “left out” seems to compel the use of social networking via devices.

Read the rest of this entry »


Vol. 148 May 15, 2016 Fun Facts About U.S. Presidents

May 15, 2016

Hub thumbnail 2015Since we are fully immersed in the Presidential primaries, and I just happened to see an illuminating PBS documentary on the death of President James Garfield, I thought that this week’s blog should be about some U.S. Presidents.

President Garfield was not assassinated. He died of medical malpractice.

On September 19, 1881 a disgruntled office seeker who was denied the post of Paris Consulship shot President Garfield twice as he walked through the Washington, D.C. railroad station. This was 16 years after Lincoln’s assassination but secret service protection for the President did not yet exist. A passing policeman wrestled the shooter, Charles Guiteau, to the ground before he could fire a planned third shot. Garfield died 79 days later from overwhelming infection from the one bullet retained in his body.

Though Lister had been writing about anti-sepsis techniques to prevent infection for twenty years, the wound was repeatedly explored by bare hands and unsterilized metal probes in unsuccessful attempts to locate the bullet for removal. Dr. Willard Bliss, an experienced surgeon who had served during the Civil War, took personal charge of the case, refused access to any other physicians, and steadfastly insisted that the bullet was lodged in the President’s right side. He continued to probe the wound looking for it. Alexander Graham Bell designed a metal detector expressly for finding the bullet. Dr. Bliss allowed him to scan the right side only since “that was where the bullet was.” The metal detector scan was ambiguous, perhaps due to the metal bed springs, but Dr. Bliss declared that it showed that he was right, ” the bullet is in the right side of the back”. Dr. Bliss declared the persistent pus as a “sign of healing”, the raging fevers as caused by malaria (which Garfield’s wife did have), and issued several press releases describing Garfield’s “improvement”. Dr. Bliss denied other physicians’ requests to examine the patient in order to help with the treatment. He clearly did not believe in anti-sepsis and the germ theory, both of which were in the medical literature since the 1860’s. Dr. Bliss also rejected the new fangled stethoscope and listened to Garfield’s terminal pneumonia by pressing his ear to the patient’s chest. Emaciated, septic, and covered with carbuncles and abscesses Garfield finally died when his splenic aneurysm burst.

An autopsy revealed that the bullet was lodged in Garfield’s left side of his back, had missed all vital organs, and it was not considered to be a lethal wound. Dr. Bliss was roundly criticized by prominent physicians and the press “for practicing not in accordance with well-defined and acknowledged surgical precepts.” Garfield’s death is considered by some to be a water shed or dividing point in American medicine with subsequently more positive journal articles about anti-sepsis, the development of nurse educational standards (trained nurses were rare and Cabinet wives provided most of his nursing care), and the beginning of the trend toward medical specialization.

Ronald Reagan got his nickname because in those days no one was routinely testing children’s vision before starting school. (1)

President Reagan got his nickname “Dutch” because his parents knew he could not see straight and had his hair cut so that bangs fell over his eyes. The “little Dutchman haircut” gave him his nickname. Reagan was severely near-sighted and developed hobbies involving close-up things like butterfly collecting. He sat in the front row of the classroom to try to see the blackboard. No one picked him for their baseball team because he was a lousy hitter and often got hit by the ball when at bat. When he was thirteen and riding in the country with his family one Sunday he picked up his mother’s eyeglasses which she had left on the car seat. The shout of amazement when he suddenly saw the rest of the world for the first time almost caused his father to crash the car! The next day the eye doctor measured his vision as 20/200 and gave him some thick lenses in ugly frames. His new-found confidence led him to work as a lifeguard for 7 summers, and he saved 77 people, by his count, while wearing his glasses.

Ulysses S. Grant was a horse whisperer long before Nicholas Evans ever wrote a word or Robert Redford ever acted.

When Ulysses was very young a traveling circus came to town and the ringmaster issued a challenge to all the youngsters to try to ride a miniature pony. Ulysses immediately volunteered, but was skipped over for several older boys. When they were all thrown by the pony Ulysses got his chance. Despite the pony’s rearing, kicking, and pawing at the sky Ulysses dug his heels in and held on to the mane until the pony quieted. Ulysses guided him quietly around the ring as the crowd went wild! By the time he was five he could stand up on a trotting horse holding the reins in his hand. By 7 he found a job hauling wood in a horse-drawn wagon. With the money saved from the job he bought his own, first horse. He was not a savvy “horse-trader”, paid a bit too much, and was dubbed by his friends as “Useless Grant.” By age 9 farmers were hiring him to break their unruly colts. His early reputation in the Union Army was based largely on his superb horsemanship. As President he expanded the White House stables and sheltered more horses than any other President. He preferred riding a horse in Washington, D.C. rather than being chauffeured around in a carriage and once got a $5 ticket for speeding while President.

Obama’s early writings predicted the future.

In response to a third grade teacher’s request to write about “What I Want To Be in the Future” Barrack Obama wrote the following:

“My name is Barry Soetoro.
I am a third grade student at SD Asisi.
My mom is my idol.
My teacher is Ibu Fer. I have lots of friends.
I live near the school. I usually walk to the school with my mom, then go home by myself.
Someday I want to be president. I love to visit all the places in Indonesia.
Done.
The eeeeeeeeend.”

Hm-m-m??   I-N-N-teresting.

References:
1. All three of these stories about Presidents as kids are from “Kid Presidents: True Tales of Childhood from America’s Presidents” by David Stabler and Doogie Horner, Quirk Productions Inc., 2014;  www.quirkbooks.com


Vol. 147 May 1, 2016 Why UnitedHealth Group Is The Poster Child For What’s Wrong With Our Health Care

May 1, 2016

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UnitedHealth Group, the nation’s largest health insurer, said Tuesday
that in 2017 it will exit most of the 34 states where
it offers plans on the Affordable Care Act insurance exchanges.

                                                          –Washington Post, April 16, 2016

 

The creation of state health insurance exchanges were incentivized by the Affordable Care Act (ACA) in order to encourage the offering of health insurance policies at competitive prices to individuals not covered by employer plans. Individuals that earned just enough to be ineligible for Medicaid coverage (aka “the working poor”)  could apply for federal subsidies to help pay for exchange health insurance policies. Health insurance companies anticipated that many uninsured people would become premium-paying people resulting in a significant revenue increase to the health insurance companies.  Like any insurance scheme, all the companies had to do was to set “competitive rates” (based on their actuarial estimates) that would bring in more revenue than the expense of what they would pay out for claims.

UnitedHealth Group (UHG) is withdrawing from 34 state health insurance exchanges because the company lost $650-720 million on their exchange policies (aka “marketplace polices”);i.e. claims for medical care received exceeded the premium revenue. Speculations about the reasons for this include:  the companies priced their policy premiums too low in response to the competitive nature of the exchanges (“They screwed up”);  the people who took out these policies were inherently “high-users” of medical services; or the higher than estimated use of medical care represented a backlog of unmet need for medical care.

The fact that the ACA has decreased the uninsured and underinsured in America by 36 million is uncontested.  About 12 million or 33%  of these people gained access to medical services from policies available from the health insurance exchanges.  Close to 87% of those were eligible for and received partial subsidies for the cost of premiums. Most of the rest of the increased access came from expanded state Medicaid insurance subsidized by the federal government under ACA. But 11 million individuals remain uninsured,

“…Depicting the Affordable Health Care Act as a “slippery slope” to single payer is bizarre, given that it relies on private insurance.” (1) Health insurance policies have tremendous influence on medical care delivery by determining who is eligible for what medical service and where. Differential rates, deductibles, and co-pays can favor one type of delivery site (hospital bed, ER, ambulatory center,  provider’s office, home care, or nursing home) and even the type of provider (MD, NP, or PA). Specific coverage for selected medical services (named and unnamed when you buy the policy) can be denied. Coverage of prescribed drugs and even procedures can be unilaterally changed annually by the insurance company simply by mailing to policy owners a fine-print booklet that lists what will be available and at what price for the coming year. In a more positive vein, one study showed that in states that expanded their Medicaid programs under ACA the number of newly diagnosed cases of diabetes increased by 23% as opposed to less than 1% in states not choosing to expand Medicaid. Early diagnosis can be life-saving and cost-effective in a chronic disease with effective treatments like diabetes .

The effect of UHG’s withdrawal will have little real effect on the insurance offered by the exchanges. Premiums for policies from the remaining companies may only increase by 1% or $4 a month. But the UHG withdrawal brilliantly spotlights the profit motive as the basic driver of our health insurance system. Private health insurance has a place in any medical care system, and does exist in most, if not all, of the state-based universal health insurance programs in other developed countries, but only in the U.S. do the profit-motivated health insurance companies have such profound influence on to whom and how medical services are delivered.

Despite what some members of my Monday night pool group may say of me,  I think capitalism is great. It has produced multiple “wonder drugs”, nurtured the widespread distribution of fantastic medical technologies, and can provide the best medical care in the world… for many… but not all.   I also think that is silly to think that profit-motived health insurance will ever be able to provide universal access to medical care, a universal access that could enhance the continued physical and economic good health of our country.

References:
1. The Virtues and Vices of Single Payer Health Care, NEJM 374;15, April 14, 2016; 1401; J. Oberlander, Ph.D.

 

 

 


Vol. 146 April 15, 2016 The Bathroom Bill and Another Unintended consequence

April 15, 2016

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“Bathroom Bill passes the House and goes to the Senate next month.
Governor Baker still on the fence.”

Gender politics are currently heating up in North Carolina, Massachusetts, and other states about proposed bills banning discrimination against transgender people “in public accommodations”. Many states have already passed laws or issued Executive Orders banning discrimination against transgender people in government and other jobs. The lightening rod in these new bills is the clause allowing transgender people to use the public restroom appropriate for what “they look like”.  This effort to “ban transgender discrimination in all public accommodations” has been succinctly reframed as “which restroom are they allowed to use”, hence the name “bathroom bill”.  Groups in favor of letting transgender people use the bathroom “that matches how they look” advocate passionately for the rights of transgender people. Opponents raise the specter of men masquerading as women assaulting women in public bathrooms. If it weren’t for the strong emotions swirling throughout this largely symbolic conflict these discussions might be another source of “comic relief” in this election season.

Screen Shot 2016-04-15 at 10.50.35 AMAs previously blogged  different kinds of gender-benders can look the same.  These proposed laws will set rules based on how people LOOK, but transgender people define themselves by how they think. “Transvestites, transexuals, and cross-dressers can be defined by who they go to bed WITH. Transgender people are defined by who they go to bed AS.”

These bills mark our continuing evolution of trying to deal with the changing views of gender identification. In 2014 ABC News found 58 possible gender identifications allowed by Facebook, though many of them are just slight variations of the same term; ex: “Male to Female” and “MTF”, “Cisman” and “Cisgender Man”. The list also includes “Other” and “Two Spirit”.  In 2015 California colleges in response to a 2011 California law started giving 6 choices for voluntary gender identification on student applications: “male; female; trans male/trans man; trans female/trans woman; gender queer/gender non-conforming; and different identity.”   They also added a question asking the student to voluntarily identify their sexual orientation. All of this apparently for state government data collection purposes, and, perhaps, to help make appropriate roommate assignments. The California colleges have stated repeatedly that the new information does not enter into the admission decision process itself. 

Not surprisingly a demand on a number of college campuses has risen for more “gender neutral” restrooms as one logical solution to this gender conundrum.. In Europe, and in select small public facilities in the U.S., they are  called “Unisex” restrooms. If you are wondering how you could identify such a facility, you might just look for this sign.:gender neutral symbolwpid-167_4817_6960

UnCHOF
My most recent nomination to the Unintended Consequence Hall of Fame (UnCHOF) goes to the Novartis pharmaceutical company. They make Voltaren (diclofenac) a non-steroidal anti-inflammatory drug commonly used  for joint stiffness and pain when simple Advil doesn’t help. It has been associated with a small risk of cardiac toxicity in humans.

Years ago farmers in India started giving diclofenac to their aging, limping, stiff cows in hopes of getting another year or two of use out of them. When the cows died their carcasses were left in the fields as was the custom in India and millions of vultures quickly reduced them to piles of bones. The vultures of India have been providing this necessary and efficient service for centuries.  But, the vultures ingested the diclofenac remaining in the cow carcasses, and it so happens that vultures lack the enzyme that metabolizes diclofenac. The rising blood levels of the drug were toxic to their kidneys.  Millions of vultures in India and Pakistan, as in ALL of them, had died by 2008 of renal failure. “Today there are many young Indians who have never seen a vulture.” (1)

When the “vulture clean-up service” died out the cow carcasses were trucked away to dumps. Feral dogs found the dumped carcasses to be a ready source of food, and the feral dog population in India exploded. Recently there have been more frequent sightings of leopards, yes leopards, in some Indian urban areas. The leopards are there to eat the dogs.

So, veterinarian use of a very common non-steroidal drug consumed by millions of humans has in India killed off a whole species and has produced a new type of urban danger, hungry leopards!  QED

References:
1. A River Runs Again; India’s Natural World in Crisis;  by Meera Subramanian, 2015


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