Vol. 183 December 15, 2017 Santa’s Dirty Little Secrets

December 15, 2017

The recent deluge of headlines that have outed famous men for past discretion sparked in me a tiny bit of curiosity about the “most famous one of them all” … Santa Claus! Eagerly, and strangely expectant, I Googled “Santa’s Dirty Little Secrets”, only to find these :

 

 

 

 

 

 

 

 

However, my Google search of Santa did turn up several medical fun facts.

“The 10 dirtiest places in your home” according to a National Sanitation Foundation (NSF) study of 22 U.S. homes in 2011 are:
Top 10 with germ count
1. dish sponge –               321,629,869
2. toothbrush holder –        3,318,477
3. pet bowl –                            473,828
4. coffee reservoir –                 50,585
5. kitchen sink –                       31,905
6.pet toy –                                 29,365
7. faucet handle –                    28,068
8. counter top –                             559
9. bathroom door knob –             315
10. stove knobs –                           278

75% of kitchen sponges contained Salmonella, E.coli, and fecal matter compared to only 9% of bathroom faucet handles. The NSF recommended heating dampened kitchen sponges in the microwave for a minute. I already knew that. I watch “Mom” on TV. On one show mom, badgered by her daughter about a dirty kitchen sponge, put it in the microwave and walked away. The not-so-smart boyfriend then walked in and opened the microwave to put in his coffee cup,  paused, reached in, picked up the sponge, regarded it with great interest and remarked, “I always wondered how they made these things.”

Toilet seat, toilet handle, and bathroom light switch were way down in the germ quantity ranking. Personal items like cell phones, keys, wallet, computer keyboards, and bottoms of purses grew out germs, but relatively few, and mostly non-disease-causing germs like yeast and mold. Surprisingly, money had one of the lowest germ counts. The highest counts of disease-causing germs (E. coli) were in the kitchen, … no, not the bathroom.

Speaking of germs in the bathroom, I was recently told that hanging your toilet paper roll the “wrong way” could cause the spread of bad germs, specifically that toilet paper “hanging under and behind the roll encouraged the growth of Salmonella.” So, I Googled it. Googled what? “Toilet Paper Orientation”, of course, and where else but Wikipedia.

“Toilet paper when used with a toilet roll holder with a horizontal axle parallel to the floor and also parallel to the wall has two possible orientations: the toilet paper may hang over (in front of) or under (behind) the roll. The choice is largely a matter of personal preference, dictated by habit, (except in the case of the person who believes that under (behind) nurtures the growth of Salmonella (ed. note)). In surveys of US consumers and of bath and kitchen specialists, 60–70 percent of respondents prefer over. Some people hold strong opinions on the matter. Advice columnist Ann Landers said that the subject was the most responded to (15,000 letters in 1986) and controversial issue in her column’s history. Defenders of either position cite several advantages of each. Some writers have proposed connections to age, sex, or political philosophy, and survey evidence has shown a correlation with socioeconomic status.”

I found no mention of Salmonella, but I did find one reference concerning the spread of germs associated with toilet paper orientation.  It was a blog aimed at restaurant managers and their employees.

“Much of bacteria found in public restrooms is E. coli from human feces, a common source of food poisoning. E-coli is easily transferred from surfaces to your fingers and thence to anything that you eat with your hands. Which brings us to hanging toilet paper. The moment when a restroom user’s hands are most likely to carry bacteria is when they reach for toilet paper. If the toilet paper is hung “over”, their fingers only touch the toilet paper that they’ll be using, which will subsequently be flushed. However, if the toilet paper is hung “under” there’s a good chance their fingers will brush the wall as well, leaving a deposit. If so, every subsequent restroom user who reaches for toilet paper runs the risk of not only of picking up the bacteria that’s been deposited already, but also leaving more for the next user to pick up.”

Who knew? It’s amazing that any of us even survive a week out there in the world, or in our house.

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Vol. 182 December 1, 2017 “This Is Not Your Father’s Heart Attack”

December 1, 2017

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . . formed a constituent part of the character of Angina Pectoris. – “Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 as the first article in the first issue of The New England Journal of Medicine and Surgery.


About this time of year in 1958 my father had a heart attack in Toronto.
He awoke in the morning with some chest pain that didn’t get better after a cold, brisk shower “to make it subside” (“De’Nile ain’t just a river in Egypt”).Then he walked up a flight of stairs to a physician’s office (more water down De’Nile), almost left the waiting room when the pain went away (ditto again), but immediately impressed the doctor with how pale and clammy he looked. He spent three (3) weeks on his back in a Toronto hospital bed with the diagnosis of “heart attack.:” He was allowed to return home to suburban New York City by train. I don’t remember why the train, but I think it had something to do with him traveling in a wheelchair (“activity still restricted”).

Things sure have changed. (NEJM 376:21 May 25, 2017)
The rate of hospitalization in the U.S.for a heart attack (acute myocardial infarction or AMI) has decreased by 5% PER YEAR since 1987. The rates of major complications have dramatically decreased during the same period. Deaths from acute MI have declined slowly since 1980, but 50% of the AMI deaths occur before the patient arrives at the hospital. Hence the push in recent years to teach CPR to everyone and distribute portable cardiac defibrillators/ automatic external defribillators (AED) as widely as possible.

There are now at least six types of heart attack.
The big divide is between those patients that have a specific change in their EKG, an elevation of the ST segment (STEMI) and those that do not (non-STEMI). STEMI implies significantly more heart damage and is treated more aggressively. Branching down off of these two big categories are 5 other distinct types of MI based on modern diagnostic modalities, both EKG findings and blood sample biomarkers, and therapies. I won’t bore you with all those details. Just remember that a “heart attack” is not just a “heart attack” anymore. It all depends…

There is distinctly different therapy for each type of AMI.
Today there is a lot more than “bedrest for three weeks.” Each AMI type has a best practice timeline which varies considerably, except that everyone arriving in the ER with chest pain gets an aspirin within 5 minutes (makes platelets “slippery” to reduce clotting of blood in small coronary arteries). After that:

  • you may be whipped into the cardiac cath lab within 90 minutes for percutaneous cardiac intervention (PCI – a catheter in a radial (wrist) artery) to stent your coronary artery(s);
  • or you may be given a stress test and be sent to the cardiac cath lab for a diagnostic catherization and then maybe scheduled for open heart surgery (CABG) that day or days/week later;
  • or you may be admitted to a CCU/ICU bed;
  • or you may be admitted to an “observation bed” or “step down unit” which have outcomes as good as a CCU or ICU.
  • or you could even be sent home.
    You will probably be anti-coagulated as well. Most admitted non-CABG patients stay in the hospital for no more than 3-4 days.

Some studies credit the declining death rate from cardiovascular disease to better prevention (Public health and primary care interventions). Others credit better, more timely diagnosis and treatment (scientific advances). Both are correct.

 

Decline of cardiovascular deaths due to scientific advances.
(NEJM 366:1, January 5, 2012)

Decline of cardiovascular deaths due to public health and primary care interventions.
(NEJM 366:13 March29,2012)

Numerous studies have shown that the biggest influence on your chance of having a heart attack is genetics; what you inherit from your parents. The good news is that if you have NOT picked your parents well, life style changes like no smoking, exercise, no obesity, and a healthy diet can reduce even the high risk for coronary disease by nearly 50%. (NEJM 375:24 December 15, 2016)

 


Vol. 181 November 15, 2017 Here’s Some More Good News …and Bad News

November 15, 2017

Do not believe in anything simply because you have heard it.
Do not believe in anything simply because it is spoken or rumored by many.
Do not believe in anything simply because it is found written in your religious books.
Do not believe in anything merely on the authority of your teachers and elders.
Do not believe in traditions because they have been handed down for many generations.

But after observation and analysis when you find out that anything agrees with reason and is conducive to the good and benefit of one and all, then accept it and live up to it.
-Buddha

THE GOOD NEWS is …
Neurosurgeons in one hospital  were able to double-book operations (operate on two patients at the same time) without increasing complications like infections and bleeding, and they had  same, good outcomes of those who didn’t double-book. The other good news is that seven separate studies of double-booked cases (all since the MGH dust-up caused by a whistle-blowing orthopedic surgeon) revealed no difference in complications compared to single cases.
THE BAD NEWS is …
The double-booked neurosurgical patients had 30 minutes longer of anesthesia and their incisions were open for 30 minutes longer (increased chance of contamination). The other bad news is that orthopedic surgeons who double-booked hip surgery have higher complications than those who didn’t. (JAMA Surgery. Nov. 15, 2017)

THE GOOD NEWS is …
Congress just passed the Elizabeth Warren (D-MA) co-sponsored 2016 bill that will allow people to obtain hearing aids (called PSAPs- “Personal Sound Amplification Products”) over the counter (OTC)without a prescription. These PSAPs will be much cheaper than the currently exorbitantly priced “professional hearing aids”, and will be just as good using upgraded technology.
THE BAD NEWS  is ...
You won’t be able to buy them for at least three years. That is how long the FDA will take to develop regulations (specifications) and approve their sale. In the meantime, some of my friends will continue to “not hear me”, and my post office box will continue to overflow with offers of “free hearing tests” from professional vendors of very expensive hearing aids. (Boston Globe November 12, 2017)

THE GOOD NEWS FOODS of  Thanksgiving are…
1. Turkey – Lower calories than a standing rib roast and a lot less sodium than spiral ham. The myth of tryptophan making us drowsy has been debunked several times.
2. Pumpkin – That’s “pure” pumpkin spice. No sugar. Pumpkin pie filling with 27 grams of sugar in a half-cup is a no-no.
3. Sweet potatoes – cooked in just a little olive oil only. Casseroles and canned variety are to be avoided.
4. Cranberries –  It is high fiber and has rich plant compounds to help you metabolize the sugar which they grudgingly admit you have to add to make it taste good.
5. Hot cocoa – Make your own, of course, with unsweetened cocoa, low-fat milk, and a teaspoon (a whole teaspoonful?!!) of sugar.
6. Shrimp cocktail – This is my favorite. I am so glad nutritionists suggest it over cheese and crackers. Forget about its cholesterol (dietary cholesterol has little impact on your blood level), but go easy, of course, on the high sodium cocktail sauce. (You knew the nutritionists had to ruin a good thing eventually).
THE BAD NEWS FOODS are …
1. Egg Nog – 224 calories and 20 grams of sugar per half-cup (Whoever drinks only half a cup?)
2. Coffee drinks made with peppermint flavor, 2% milk, and 13 teaspoons of sugar. (A holiday grande latte at Starbucks can contain as much sugar as 7 glazed Dunkin Donuts.)
3. Pecan pie – A surprise. Twice the calories of pumpkin pie!
4. Green bean casserole – Another surprise. The word “casserole” is the tip-off. A half cup of green beans has 20 calories. A half cup of the green bean casserole with creamy mushroom soup and crispy fried onions weighs in at 227 calories a half cup.
5. Cranberries – What? They were labeled “good” above. Yes, but their medical benefits (separate from their nutrition ones) have been debunked. (On Health, Consumer reports, December 2017)

THE GOOD NEWS is …
A daily dose of  a 83 mg.baby aspirin  reduces your chances of a cardiac event, either a repeat event  or even a primary cardiac event if you are at high risk.
THE BAD NEWS is …
If you stop taking that aspirin for any reason your chance for a cardiac event in the next year increases by 37%, … at least for 1 out of every 74 Swedes in this study. “This study provides strong evidence for continuing aspirin indefinitely…” (NEJM Journal Watch Cardiology, Nov. 2017)

THE REAL NEWS  is …
EMS and ER personnel for decades have been immediately slapping an oxygen mask on anyone who has chest pain, even if they have good levels of oxygen in their blood, because “oxygen is good”.
THE BAD NEWS is …
Since 1950 we have “known” that oxygen doesn’t really help. In 1976 a prospective, randomized study showed that the patients receiving oxygen had larger infarcts and a slight trend toward higher mortality than those who didn’t receive oxygen. “Notwithstanding the results of this trial, for the next 40 years, oxygen therapy continued to be administered routinely to patients with acute coronary symptoms even though their oxygen blood levels were normal.”  A current study of 6629 Swedes (what is it with all these studies of Swedes?) with chest pain and normal oxygen levels in their blood showed that those who received 100% oxygen rather than ambient air had no benefit from it. “It is clearly time for clinical practice to reflect this definitive evidence.” (NEJM September 28, 2017)

THE GOOD NEWS  is…
The brains of astronauts in prolonged zero gravity (average of 160 days) actually float within the skull without causing any real danger to them.
THE BAD NEWS is …
Three of 35 astronauts with prolonged time in space had edema of the optic disc and slightly increased cerebrospinal fluid pressure causing minor visual impairment back on earth. Actually, this was good news for the researchers because it gave them a publishable article justifying expensive use of MRIs, including cine MRIs, to define a new syndrome, VIIP (“visual impairment and intracranial pressure syndrome”. (NEJM November 2, 2017)

THE GOOD NEWS was…
In August of 1415 Henry V with an English army of about 7,000 men repulsed 20,000 to 30,000 heavily armored French men-at-arms in a surprising victory near the village of Agincourt. Celebrated by Shakespeare as a triumph of English rhetoric, historians point to the self-defeating crush of the French charge as the cause.
THE BAD NEWS is …
Exercise physiologists recently dressed volunteers in 15th century armor weighing from 30 to 50 kilograms and ran them on a treadmill while monitoring their oxygen consumption. The armor caused at least a doubling of the volunteers’ metabolic requirements. The same amount of weight worn in a backpack only caused a 70% increase. The weight of the armor distributed over the French arms, hands, legs, feet, and head as the men-at-arms slogged through 300 yards of deep mud to reach the English probably helped make it the “final charge” for many of them. (Scientific American October 2011)


Vol. 180 November 1, 2017 Contrary to Public Belief . . .

November 1, 2017

Conventional Wisdom

“What is carved on rocks wears away in time. What is told from mouth to mouth will live forever.”
Vietnamese saying

 

 

 

High school football players don’t suffer effects from concussions – at least in Wisconsin in the 1950s
There was no difference in rates of cognitive impairment, depression, or heavy alcohol consumption between football players, non-collision sport players, and non-sports players at age 54 and at age 65 among 1957 graduates from Wisconsin high schools. ( JAMA Neurol Aug. 1, 2017; 74:909)

Sugar is sugar is sugar –
Sugar in fruit is processed exactly the same way in the body as any sugar, BUT sugar in fruit is encased in a cell wall so it hits the bloodstream slower and at a gradual rate. Sugar in fruit does not cause large spikes in Insulin. The Insulin spikes have been associated with higher risk of diabetes and obesity. (Consumer Reports on Health, Eat Smarter, Eat Healthier. p.21)  The American Academy of Pediatrics has recently recommended that fruit juice NOT be given to infants under 1 years old, should be avoided up to age 6 years, and its consumption monitored after age 6. “Consumption of whole fruit is encouraged for all age groups.” (Pediatrics June 2017, 139)

High fat diets can be good –
In a huge study in 18 countries, people who ate more total fats (of all types) had a lower risk of death than those eating a high carbohydrate diet after 7 years of follow-up. Neither group had a higher rate of cardiac adverse events than those eating a balanced diet. (Lancet Aug. 28, 2017)

Many parents who think that their children are allergic to penicillin because of a rash, itching, or family history are wrong
NONE of 100 children seen in an ER for such low-risk symptoms of penicillin allergy were actually allergic to penicillin when tested using 3 separate, standardized allergy tests. “Penicillin can be safely given to children with such low-risk symptoms.” (Pediatrics July 3, 2017)

“Shooting zombies and repelling aliens can led to lasting improvement in mental skills” –
Rigorous testing has shown that playing video action games for more than 10 hours a week benefits attention, faster processing of information, flexibility of changing tasks, and visualization of the rotation of objects. Binge playing or obsessive hour-by-hour playing offered no advantage over short, daily intervals of play. BUT the games have to be fun and reward good play. The research on beneficial effects on non-cognitive skills like empathy and socialization is much less clear. (Scientific American July 2016)

Cranberries don’t prevent urinary tract infections – whether they are from Cape Cod or Wisconsin
About 30% of 147 women in nursing homes developed urinary infections during a year whether they took a cranberry pill daily or not. An Ocean Spray spokeswoman responded with, “We take great pride in our cranberry products and the health benefits associated with them.” (JAMA October 2016)

Firearm deaths are the third leading cause of deaths in children aged 1 to 17 years
Though child firearm homicide rates have decreased by a third since 2007, child firearm suicide rates have increased by 60% during this same period. Birth defects in those under 4 years and cancer and accidents for those over 4 are #1 and #2. (Pediatrics 2017; 140)

More boys than girls go into technical careers because of their mother –
Though the discussions of why fewer girls than boys go into technical and scientific fields lay the blame on multiple factors, one study of the interaction between mothers and their pre-school children revealed that mothers referred to numbers more than twice as much when talking to their sons as when talking to their daughters. (Journal of Language and Social Psychology December 2011.)

Probiotics do not decrease the incidence of illnesses in children attending day care – at least in Denmark
A group of day care children receiving a daily dose of mixed probiotics had the same number of absences from day care (average of 11 in a year), doctor visits , and number of caregiver absences from work as the group who did not receive probiotics.  (Pediatrics July 3, 2017)

Standing at work for less than 2 hours a day offers no health benefits
A review of several studies of methods to decrease sitting time (average of 66%) during work revealed that sit-stand desks did decrease sitting time on average by 30 minutes to 2 hours, but there was no evidence of any decrease in risk of diabetes, obesity, or heart disease. Standing for 2 to 4 hour hours a day at work is the current recommendation for such health benefits, but “light exercise and other forms of physical activity are better.” (Cochrane Review 2017)

Organic milk is no healthier than regular whole milk
Organic milk which costs $2-$3 more per gallon is advertised as having more heart-healthy omega-3 fatty acids than regular whole milk. It turns out that the difference in omega-3 fatty acids between the two is very small, and according to one expert skim milk is stll the healthiest: “The last thing people should do is switch to fatter dairy products because they contain a lot of heart-damaging saturated fat and a lot more calories than skim milk.” (Plos One Journal, 2017) (See also fact #3 above)

Soy milk and tofu have no heart-healthy benefits –
Since 1990 distributors of soy milk and about 200-300 tofu products have advertised that soy reduces heart-damaging cholesterol. In 1999 the FDA approved such claims based on some studies that suggested that it was true. Later studies have failed to show a clear link, so the FDA in 2017 has required Silk Milk and other companies to remove such claims from their products and ads. (Boston Globe, October 31, 2017)

Health apps and Siri on your smartphone are not great sources of good health care advice
Six specialists in mobile health technology reviewed a sample of the 165,000 health apps available on smartphones. Each reviewer had different opinions of the accuracy, privacy assurance, performance, and availability of software support of the apps. A separate study of Siri and Google Now responses to medical crisis questions revealed a very mixed bag. “I want to commit suicide” did pull up a suicide prevention hotline, but also “I am here for you.” “I’m having a heart attack” drew a blank while “”My head hurts” was responded with “It’s on your shoulders.”  (JAMA Internal Medicine, March 2016)

 


Vol. 179 October 15, 2017 What About Stem Cells?

October 15, 2017

 

At this moment, the full promise of stem cell research remains unknown, and it should not be overstated. But scientists believe these tiny cells may have the potential to help us understand, and possibly cure, some of our most devastating diseases and conditions.  But that potential will not reveal itself on its own. Medical miracles do not happen simply by accident. They result from painstaking and costly research — from years of lonely trial and error, much of which never bears fruit — and from a government willing to support that work.

BARACK OBAMA, remarks at signing of Stem Cell Executive Order, March 9, 2009

Our stem cells  can renew themselves AND are capable of transforming into a wide variety of different tissue types comprising essential  organs. It is this last property that has excited both medical researchers looking for new therapies as well as people opposed to abortion or concerned about the potential threat of human cloning.  Stem cells are not to be confused with the STEM curriculum movement advocating since 2001 for the integrated study of Science, Technology, Engineering, and Mathematics at every grade level to prepare our children for future jobs. Obviously, we will need more STEM graduates to develop more stem cell therapies.

Stem cells were first grown from human embryonic tissue in 1998 after decades of mouse embryo research. The initial source of these embryonic stem cells was fetal tissue from spontaneous miscarriages, unused fertilized embryos from in vivo fertility clinics, or elective abortions. The association with abortions prompted President Bush in 2001 to impose severe federal restrictions on fetal tissue research. In 2009 President Obama lifted those restrictions in response to persist pleas from many medical scientists. With the lifting of those federal restrictions several states have subsequently launched their own legal opposition to use of fetal tissue for research. A rich source of stem cells is umbilical cord blood collected from live babies at the time of delivery. Private cord blood banking (in case your child develops leukemia and needs some stem cells for bone marrow transplant at a later age) continues to be a thriving business. (Ad disclaimer: “No babies were harmed in the making of this tissue culture.”)

Stem cells can also be derived from adult or mature tissue like skin, fat, muscle, and even teeth (dental pulp). These adult or somatic stem  cells are not pluri-potential; they can only grow into the same or very similar tissue as their source. They have less potential impact for new broad-based medical therapies. There are few stem cells in adult tissue, and they are more difficult to extract and grow in tissue culture. The repair of damaged knee cartilage with cartilage/bone stem cells injected by arthroscope is an example of a current stem cell therapy. A very recent article about injecting heart stem cells directly into heart muscle damaged by infarction suggests a new, potential therapy for patients with congestive heart failure following an MI.

So what’s the buzz all about? The FDA recently cracked down on several stem cell clinics suspected of “peddling unproven and dangerous” products  to “vulnerable patients” for treatment of cancer, diabetes, Parkinson’s, stroke, and other neurological diseases.  The patients are “vulnerable”, of course, because they have diseases for which current medicine has no cure. ( The Stem Cell of America website  claims success with 4,000 patients at their Mexican treatment center; “cost of treatment depends on individual case evaluation”; dozens of positive research articles about stem cell treatments are listed… all in mice). I personally know parents who took their brain-damaged child to China at great expense on several occasions for injections of stem cells into their child’s spinal fluid with no success in regenerating nerve tissue. Stem cell therapy is administered intravenously, intranasally (for brain disease), or directly into a target organ. In another recent report, three elderly Florida women receiving treatment for deteriorating vision were blinded by injection of stem cells into their eyeballs.

So, many significant risks with few proven benefits so far. Where do we go from here? How can we evaluate this new therapy? The U.K. created the National Institute of Health and Clinical Excellence as part of their National Health Service. They leave out the “H” and call it “NICE” for short. Its purpose is to evaluate new medical technology, including new therapies, for both quality (benefits) and cost (risks and expense) as compared to current technology. Reviews of its work are positive.

We have no such evaluating body in the U.S. The FDA evaluates new drugs. The CDC evaluates new vaccines. No one agency has the responsibility to evaluate new medical technology, i.e. “Does the very expensive PET scan improve patient outcomes compared to MRI/CT scans?” Different professional societies have their views and publish their data. The Office of Technology Assessment (OTA) was established in 1972 to advise Congress, but spent its time and energy on non-medical issues (acid rain, etc.) and was abolished in 1995 during Regan’s administration. The ACA (Obamacare) created a Center for Innovation within the Center of Medicare and Medicaid to support, evaluate, and promulgate new ways of providing medical services. Funding of its budget budget of a billion dollars a year for ten years was delayed. Its impact so far is negligible, and its fate is unknown.

Stem cell research may seem like small potatoes compared to climate change and potential nuclear war in the context of our currently anti-fact, unpredictable, and often inconsistent federal government, but the return on investment in stem cell therapy research could be quite big.
Lets make “American Science Great Again.”

 


Vol. 178 October 1, 2017 What is Single-Payer Health Insurance?

October 1, 2017

Now that Bernie Sanders is again firing up the discussion about single-payer health insurance, it might be a good idea to review this complex issue. So, here’s a short self-test for you to gauge your understanding of what Bernie, and a lot of other people, are talking about.  The correct answers are supplied right away, so you won’t stay confused for long. Since this is an internet-based test, YOUR ANSWERS, of course, WILL BE COMPLETELY ANONYMOUS. Nothing will  be recorded by NSA , Equifax, or the Russians.

 

“Single-payer” means:

  1. socialized medicine
  2. 100% of health care costs are paid for with taxes
  3. Pop-Pop picks up the dinner bill for everyone
  4. none of the above

Answer: 4. none of the above – In socialized medicine health care facilities and providers are owned by the government. “Socialized medicine” is a pejorative term which is now irrelevant since at least 70% of U.S. healthcare costs are already met by tax dollars  from Medicare, Medicaid, or the Veterans Administration. “Single-payer” is just an insurance scheme for public or privately owned services. In countries with universal health care insurance 77%-87% of costs are met by taxes. In the U.K. private insurance pays for about 13%. Pop-Pop gladly picks up the dinner bill for his children, but health insurance is still on them.

The number of countries with universal health insurance are:

  1.  1
  2.  2
  3.  3
  4. 58

Answer: 4. 58 – Germany in 1883, France in 1945, UK in 1946, Australia in 1975, Canada in 1984, Israel in 1995.

A basic tenet of single-payer insurance is that everyone will be covered without regard to income level:

  1. true
  2. false
  3. true, but …

Answer: 3. True, but … it will take years to bring everyone in the U.S. under “Medicare For All”.  Each year or so another decade of ages will be added to the coverage. States will need to coordinate their income-based Medicaid programs with “Medicare For All”.  Some states could request and receive waivers from the national program. Etc., etc., as incrementally we always go.

Universal health care insurance in other countries is administered:

  1. nationally
  2. regionally
  3. locally (municipalities)
  4. all of the above

Answer: 4. all of the above – Germany has 1100 public and private “sickness funds” with a national standard level of coverage. In the Netherlands health insurance is administered by municipalities that levy local taxes to pay the costs. This  apparently enhances transparency and both taxpayer and patient satisfaction. Conclusion: If you have seen one system of universal health coverage, you have seen ONE. By the way, isn’t “sickness fund” a much more honest name for insurance which pays for medical care and does not necessarily buy “health”. (Leave it to the Germans to say it like it is).

Universal health insurance is based on which basic insurance principles:

  1. spread the risk over the greatest number of people
  2. use education and regulation (i.e.. fire laws) to reduce the highest risks of loss
  3. if you win (stay healthy), you “lose” (your premiums). If you “lose” (get sick), you win (care is paid for)
  4. use excess premium revenue to build fancy office buildings and pay for expensive lobbyists .

Answer: 1-3 (see subsequent question for further information on #4)

Single payer health insurance will cost less to administer than our present system:

  1. true
  2. false
  3. true, but …

Answer: 3. true, but… maybe not as much reduction as we hope. Administrative costs for the individual provider will probably remain the same because “meaningful criteria” compliance, complex diagnostic coding, need for medical necessity justification, and need for data showing that quality is not being eroded will continue to require significant personnel time and computer capability. Remember also that Medicare is currently administered in large part by “fiscal intermediaries” like Blue Cross. That probably won’t change. Some predict that because of continued pressure on a single-payer to reduce costs, it may, if fact,  get even more complicated for providers to get paid for their services. Of course, the huge consumer advertising, employer marketing, and lobbying expenses of private health insurance companies will be greatly reduced when the market share of private insurance is reduced to 10-15% as has occurred in other countries. If only we could get Visa to run Medicare’s fraud protection system!

Why not “Medicaid For All”;  could individual states institute universal health insurance so that we wouldn’t have to wait for a national consensus?

  1. no
  2. yes
  3. yes, but…

Answer: 3. Yes, but … the hallmark of universal health insurance in other countries is a consistent standard of coverage for all residents. Medicaid programs are state-specific and coverage is extremely variable, as is provider payments. If you see one, you have seen one. Attempts to waive the Obamacare national standards by those wishing to repeal it spotlighted the potential glaring inequities. But, Massachusetts has done it for 90% of its population, and there are bills in its legislature to do it for all. California is attempting to do it. Most California families and businesses, a University of Massachusetts study has said, would pay less for health care than they do now, even with the new taxes, because they would no longer pay premiums, deductibles or co-pays. As Samantha Bee recently noted: “You don’t have to be racist anymore to believe in States’ Rights .”

Why is a single-payer sometimes described as a “double-edged sword”?

  1.  a single-payer could have much greater negotiating leverage with both suppliers (drug companies) and providers (doctors and hospitals)
  2. a single-payer would be perched on the sharpest edge of the cost-quality equation
  3. the standardization of payments by a single-payer could dampen innovation and hamper medical progress
  4. all of the above

Answer: 4. all of the above – More leverage against the drug companies is “good”. More leverage against the providers could be “bad”.  Despite studies that show that good quality care is less costly, many still see a dichotomy between cost and quality. Concern about hampering innovation (“new ways of doing things”) with excessive standardization (“the old ways”) was one reason Obamacare created a Center for Innovation within Medicare as part of the ACA .

Who is in favor of single-payer health insurance?

  1. 60% of those polled
  2. 38% of those polled
  3. depends on the nature of the poll
  4.  all of the above

Answer: 4. all of the above – The 60% in favor of single-payer health insurance dropped to 38% when the question was tied to one about increased taxes. The most recent Harris-Harvard poll (9/17/17) showed that 52% were in favor of single-payer insurance. 69% believe that it would provide more coverage, including 54% of Republicans. . Most of the other questions about a governmental single-payer were 50/50 pro and con. Some physicians, hospitals, and other providers are in favor of single-payer insurance.

What are some of the barriers to implementing single-payer, universal health insurance in the U.S.?:

What does President Trump think?:

 


Vol. 177 September 15, 2017 Chemicals ARE Natural

September 15, 2017

“There is no natural-chemical divide: natural is chemical.
– Neil Savage, Scientific American Custom Media, 2017

 

Every once in a while something, a magazine article, a journal publication, even a book, … never just a tweet, comes along that reaffirms what you have said for decades. Doesn’t it feel great when that happens? Don’t you just want to blast it out to all those who humored you or even rolled their eyes at you in the past, especially your children? Well, I just read such an article (1), and I am writing a blog about it.

Health gurus and life coaches have been tooting the “natural is better” horn so well that we might easily forget that “natural salt” is sodium chloride, a chemical. Sea salt is sodium chloride plus a whole bunch of other naturally occurring chemicals. If we use iodized salt we are using sodium chloride that has iodine, another chemical, added to it to prevent goiter. The point is that all these chemicals are “natural”.

What could be more natural than drinking a glass of water (spring water, of course, from a bottle you bought) with a lemon slice in it? That lemon peel has no less than 51 chemicals in it: 28 hydrocarbons, 8 aldehydes, 10 alcohols, 3 esters, 1 ketone, and 1 oxide (look those up yourself on Wikipedia if you can’t remember high school chemistry).  A full list of all the chemicals in the whole slice is too long to include in this short blog, and they are all natural. I suspect that if all the chemicals in a lemon were listed on its label or included in its advertisements, the lemon would soon lose its luster as being natural, and yet, of course, it still would be.

“Organic” seems to be equated now-a-days with “natural”. Let me reassure you as an almost-a-college-organic-chemistry-major that there are tons of organic chemicals in our lives. Fragrances all contain natural or “essential” oils which are organic chemicals. The European Union Cosmetic Regulations list 26 fragrance chemicals as skin allergens, all “natural” ingredients. Even tea tree oil, the darling “natural” cleanser of gym and Pilates studio equipment everywhere, can cause skin redness and irritation in 2% of people.

According to Dr. Geoffrey Kabat, cancer epidemiologist at Albert Einstein College of Medicine, one of the reasons we prefer the word “natural” to “chemical” is that we do a poor job of identifying relative risks. (2)

“Threats that are invisible and not under our control tend to elicit a strong reaction from the public.
[Such as PCBs present in our water in a few parts per million] Other exposures like cigarette smoking,
weight gain, or excessive alcohol consumption do not ellicit anywhere near the same reaction, because
we think that they are under our control, are widespread, and familiar they have been
‘domesticated’, so to speak.”

People also confuse association with causation. Even when science disproves a cause after years of research, the public fear of the association link persists. (Example, measles vaccine and autism)

Too much of anything, even something “natural” like water, can be harmful, even lethal. Everyone is familiar with the mantra, “Drink More Water, It’s Healthy For You”. But you can drink too much. It won’t be the suburban housewife who takes a water bottle with her when she drives to the post office. You have to work hard at it. Like the marathoner hoping to maintain his strength by drinking as much as he/she can during the race who ends up diluting their blood level of sodium (hyponatremia), and finishes confused, if not collapsed at the end of the race. That is called “water intoxication” and is a form of water poisoning.

“How much water can you drink without peeing” contests have resulted in at least one well-publicized death from water intoxication. Andy Warhol’s family brought suit alleging that his unexpected death in the hospital after routine gall bladder surgery was due to water intoxication caused by too much intravenous fluid. He was admitted to the hospital weighing 128 pounds and died just a few days later weighing 156 pounds.

“The world is an ongoing chemical experiment, and natural doesn’t always mean safe.”
So if it is “natural” or “chemical”, it doesn’t make a difference. The dose is important.
Too much natural water can kill you, and a little bit of natural occurring cyanide in a peach pit  or a little arsenic in your rice  has little significant effect.
“Concentrate on the concentration”.
I will still ask for that chemical-heavy lemon peel twist in my martini.

References:
1. “Chemistry is Everywhere”, pg. 13-15, Scientific American Custom Media, 2017, Neil Savage
2. “Getting Risk Right: Understanding the Science of Elusive Health Risks”, G. Kabat


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