Thursday, December 4, 2008

Medicine for the Job Market -

A central feature of Barack Obama’s presidential campaign was an aggressive plan to expand health insurance coverage by subsidizing low-income Americans and preventing discrimination against the ill. In recent weeks, Senators Max Baucus and Ted Kennedy have been working on a similar plan that might also require people to purchase insurance. Senators Ron Wyden and Bob Bennett are promoting a different approach that would largely replace our employer-sponsored health insurance system with new insurance-purchasing pools.

What all of these plans have in common is the goal of covering every American. And all would require major new spending in the near term — perhaps $100 billion a year or more.

Given the present need to address the economic crisis, many people say the government cannot afford a big investment in health care, that these plans are going nowhere fast. But this represents a false choice, because health care reform is good for our economy.

As the country slips into what is possibly the worst downturn since the Depression, nearly all experts agree that Washington should stimulate demand with new spending. And one of the most effective ways to spend would be to give states money to enroll more people in Medicaid and the State Children’s Health Insurance Plan. This would free up state money for rebuilding roads and bridges and other public works projects — spending that could create jobs.

Health care reform can be an engine of job growth in other ways, too. Most proposals call for investments in health information technology, including the computerization of patient medical records. During the campaign, for example, Mr. Obama proposed spending $50 billion on such technology. The hope is that computerized recordkeeping, and the improved sharing of information among doctors that it would enable, would improve the quality of patient care and perhaps also lower medical costs. More immediately, it would create jobs in the technology sector. After all, somebody would need to develop the computer systems and operate them for thousands of American health care providers.

Expanded insurance coverage would also drive demand for high-paying, rewarding jobs in health services. Most reform proposals emphasize primary care, much of which can be provided by nurse practitioners, registered nurses and physician’s assistants. These jobs could provide a landing spot for workers who have lost jobs in other sectors of the economy.

Fundamental health care reform would also stimulate more consumer spending, as previously uninsured families would no longer need to save every extra penny to cover a medical emergency. When the federal government expanded Medicaid in the 1990s, my own research has shown, the newly insured significantly increased their spending on consumer goods.

Universal health insurance coverage would also address economic problems that existed before this downturn began — and that are likely to linger after growth resumes. In our current system, people who leave or lose their jobs often must go without insurance for months or years, and this discourages people from moving to positions where they could be more productive. Most reform proposals call for the creation of pools of insurance coverage that would guarantee access to high-quality, affordable care for people who are self-employed or out of work, increasing their mobility.

If this coverage focuses on disease prevention and wellness, it could also improve the health, and thereby the productivity, of the workforce.

In the long term, the greatest fiscal threat facing this nation is the growth in the costs of health care. These costs have more than tripled as a share of our economy since 1950, and show no signs of abating. The Congressional Budget Office recently projected that the share of the economy devoted to health care will double by 2050.

Experts have yet to figure out how to restrain cost increases without sacrificing the quality of care that Americans demand. Yet cost control would be easier in an environment of universal coverage. Nations like the Netherlands and Switzerland, which have achieved universal coverage within a private insurance structure, control costs better than we do. And in my home state, Massachusetts, an ambitious plan to cover all residents has focused the attention of all stakeholders on the importance of controlling costs as a means of ensuring the plan’s success in the long run.

These are challenging times. The economic crisis of 2008 has left politicians of all stripes in shock and unsure where to move next. But rather than sit back and lick our wounds, we must move toward healing them. Fundamental health care reform that features universal insurance coverage is an important place to start.

Wednesday, December 3, 2008

Personal Health - Living Longer, in Good Health to the End -

You don’t have to be an actuary or funeral director to have noticed the striking increase in the length of many Americans’ lives. The obituaries in this or any other newspaper show a growing number of people who depart this world in their late 80s or 90s, or even at 100 or older.

The fastest-growing segment of the population consists of people over 85, and by 2050 some 800,000 Americans will have celebrated their 100th birthday.

Doomsayers consider this a terrifying trend, bound to bankrupt Social Security and Medicare and overwhelm the ability of doctors and medical facilities to care for the burgeoning population of the oldest old.

But there is increasing evidence that the societal burden of increased longevity need not be so drastic. Long-term studies have shown that how people live accounts for more than half the difference in how hale and hearty they will remain until very near the end.

Many very old people have assumed “bragging rights” about their age and what they can still accomplish despite it, as Michael Kinsley wrote in The New Yorker in April.

At a pool in downtown Los Angeles, Mr. Kinsley encountered a stranger who interrupted his laps long enough to say, “I’m 90 years old.” The man, Richard Ibañez, a retired judge, died in November at age 97, but swam every morning until the last week of his life, his grandson, Christopher A. Karachale, wrote in a letter to the magazine.

A friend’s father, Irving Weinig, who lived in an assisted living facility in New York, requested new clothes for his 104th birthday so he could look spiffy when he had lunch with “the girls,” an activity he enjoyed until his death at 108.

And last spring the Island Nursing and Rehab Center in Holtsville, N.Y., boasted about a new resident, Nora Elizabeth Wright, who was turning 106.

All of these examples speak to a concept proposed in The New England Journal of Medicine in 1980 by Dr. James F. Fries of Stanford University: that adult vigor can be extended well into the ninth decade of life, with illness and disability compressed into a period that shortly precedes death.

Who Lives the Longest?

Many studies have examined the factors that predict the length of people’s lives, with nearly universal agreement that about 35 percent is determined by genes over which we have little or no control.

Dr. Nir Barzilai and colleagues at Albert Einstein College of Medicine found, for example, that individuals “with exceptional longevity” and a low incidence of age-related diseases have significantly larger HDL and LDL particles in their blood, a genetic characteristic that reduces their risk of developing cardiovascular diseases.

Scientists are searching for ways to extend healthy life spans by manipulating “bad” genes, but the potential exists now for modifying many of the environmental factors that account for the other 65 percent of longevity. And I suspect that most of us who hope to join the ranks of the oldest old would like to do so in a manner similar to that of Richard Ibañez and Irving Weinig — in rather good shape physically and mentally almost to the very end.

“Longevity is a Pyrrhic victory if those additional years are characterized by inexorable morbidity from chronic illness, frailty-associated disability and increasingly lowered quality of life,” Dr. William J. Hall of the Highland Hospital Center for Healthy Aging in Rochester wrote in The Archives of Internal Medicine in February.

New Habits Are Effective

Dr. Richard S. Rivlin, an internist and director of the nutrition and cancer prevention career development program at Weill Cornell Medical College, said in an interview that it was never too late to adopt habits that predict a healthy old age.

“While measures started early in life are most likely to have the greatest health benefit,” he said, “older people should never feel that turning over a new leaf at their age is anything but highly effective.”

He said there was clear evidence that measures taken in one’s 70s could help prevent “several important categories of disease, such as hypertension, heart disease, osteoporosis and even cancer.”

In The American Journal of Clinical Nutrition last year, Dr. Rivlin noted that changes in body composition, like loss of bone and muscle and accumulation of body fat, typically accompany aging and can affect health in a variety of ways: poor posture that impairs breathing; falls and fractures; loss of mobility; a reduced metabolic rate; and weight gain that can lead to diabetes, heart and blood vessel disease and some forms of cancer.

But these changes in body composition, he added, “are not an invariable accompaniment of aging.” Much can be done to limit and even reverse them, he said, including restricting calories and following a diet of high-quality protein and limited saturated fat and replacing simple sugars with whole grains rich in fiber.

The Importance of Exercise

A second critical measure for the “young-elderly,” as he calls 70-year-olds, is to “make regular exercise a part of their daily lifestyle,” including aerobic activities that raise the heart rate; weight-bearing activities that strengthen muscles and bones; and stretching exercises that reduce stiffness and improve flexibility and balance.

Another age-related concern is cognitive decline, which is more likely in people with metabolic syndrome, a cluster of modifiable risk factors that includes abdominal obesity, high blood pressure, insulin resistance and abnormal cholesterol levels. Dr. Hall cautioned against therapeutic nihilism in treating older people with such risk factors.

“Chronological age is a very imperfect determinant on which to base medical decision-making,” he wrote.

Dr. Hall’s comments were based on a 25-year study by Dr. Laurel B. Yates of Brigham and Women’s Hospital and her Boston colleagues of 2,357 men who were healthy at an average age of 72 when the study began. Of the 970 men who survived to at least age 90, the primary modifiable predictors of longevity were not smoking; preventing diabetes, obesity and high blood pressure; and exercising regularly.

“Compared with nonsurvivors, men with exceptional longevity had a healthier lifestyle, had a lower incidence of chronic diseases and were three to five years older at disease onset,” the Boston team reported in February in The Archives of Internal Medicine. “They had better late-life physical function and mental well-being. More than 68 percent rated their late-life health as excellent or very good, and less than 8 percent reported fair or poor health.”

Other long-term studies have also pinpointed exercise as the single most potent predictor of healthy longevity, in women as well as in men. It is not that very old people like Judge Ibañez can exercise because they are healthy, these findings indicate. Rather, they achieve a healthy old age because they exercise.

Medicins Sans Frontieres doctor performs amputation following instructions sent by text - Times Online

A doctor volunteering in war-torn Congo performed a complex amputation to save a boy’s life by following instructions sent by text message from a colleague in London.

David Nott, 52, a vascular surgeon, was working for a Medicins Sans Frontieres hospital in the eastern town of Rutshuru, an area ravaged by bloody battles between Congolese and rebel troops.

Among the hundreds of wounded soldiers and civilians brought into the hospital in October was a 16-year-old boy who had been caught in the midst of a gun fight between advancing combatants in a forest in the Nyanzale region.

The boy said that he had felt a heavy blast beside him, and woken up later with his brother screaming beside him and his arm “totally destroyed”.

A doctor had performed an amputation, but the stump had become gangrenous.

When Dr Nott saw him, what remained of his upper arm was severely infected. “He had about two or three days to live when I saw him,” he said.

He knew the boy’s only hope of survival lay in a forequarter amputation, a huge operation which involves removing the collar bone and shoulder blade. It usually requires much careful planning and a well-equipped operating theatre.

“In the best hands (it) carries huge risks,” he said. “I had never done this operation before but I knew a colleague in London who had so I texted him. He sent me two very long text messages back explaining how to do the operation step by step.”

Dr Nott was unsure that he should operate. “I had to think long and hard about whether it was right ot leave a young boy with only one arm in the middle of this fighting,” he said.

“In the end he would have died without it so I took a deep breath and followed the instructions to the letter.”

He felt able to understand precisely what his colleague meant in each text message, having operated with him many times before on a more immediate basis.

He was equipped with a pint of blood and an elementary operating theatre. The boy has now made a full recovery.

“It was just luck that I was there and could do it,” said Dr Nott, who works at Charing Cross Hospital and volunteers for MSF for a month every year.

“I don’t think that someone that wasn’t a vascular surgeon would have been able to deal with the large blood vessels involved. That is why I volunteer myself so often, I love being able to save someone’s life.”

Tuesday, December 2, 2008

Young adults hit by mental health issues --

Nearly half of college-age adults struggle with a mental health disorder, from alcohol dependency to depression and anxiety. But only a quarter seek treatment, according to a study published today.

"This study gives a picture of the magnitude of the problem and the extent to which these disorders go untreated," said Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University Medical Center and lead author of the study. "It really lays out the challenge of providing services to meet the need, particularly of alcohol use disorders."

The study found similar rates of psychiatric illnesses among college students and those not enrolled in college, suggesting that the stressful transition from adolescence to adulthood can trigger the onset of a mental health problem regardless of setting. Olfson said he hopes the data will provoke discussion about how to get more young people into treatment.

Researchers analyzed results of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a sweeping national survey of 43,093 adults of all ages conducted by the U.S. Census Bureau and the National Institute on Alcohol Abuse and Alcoholism. Olfson's study, which appears in this week's Archives of General Psychiatry, focuses on the responses from about 5,000 people between the ages of 19 and 25. It compared findings in two groups, those enrolled in college - 2,188 - and those who were not - 2,904.
Among college students, alcohol abuse and dependency were the most common at 20 percent, followed by personality disorders such as obsessive-compulsive and paranoid disorders at 18 percent. Non-college students were most likely to report personality disorders and nicotine dependence.

The rates of mood disorders, such as depression and bipolar disorder, were 11 percent for college students and 12 percent for non-students. The same rates were found for anxiety disorders in each group.

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Monday, December 1, 2008

Consensus emerging on universal healthcare - Los Angeles Times

The prospect of bold government action appears to be accepted among players across the ideological and political spectrum, including those who opposed the idea in the 1990s.

After decades of failed efforts to reshape the nation's healthcare system, a consensus appears to be emerging in Washington about how to achieve the elusive goal of providing medical insurance to all Americans.

The answer, say leading groups of businesses, hospitals, doctors, labor unions and insurance companies -- as well as senior lawmakers on Capitol Hill and members of the new Obama administration -- is unprecedented government intervention to create a system of universal protection.

At the same time, those groups, which span the ideological and political spectrum, largely have agreed to preserve the employer-based system through which most Americans get their health insurance.

The idea of a federal, single-payer system patterned on those in Europe and Canada, long a dream of the political left, is now virtually off the table.

Rejected as well is the traditionally conservative concept, championed by Sen. John McCain (R-Ariz.) during the presidential campaign, of reforming healthcare mainly by giving incentives for more Americans to buy insurance on their own.

There also is a widespread understanding that any expansion of coverage must be accompanied by aggressive efforts to bring down costs and reward quality care. And key players in the healthcare debate increasingly back a massive investment of taxpayer money for healthcare reform despite the burgeoning budget deficits.

Beyond those areas of basic agreement, the details of what would be one of the most momentous changes in domestic policy since World War II remain vague. 

As a presidential candidate, Barack Obama embraced both expanded insurance coverage and preservation of the job-centered system, but since he won the White House he has provided few specifics about his plans once he takes office.

Disagreements over specifics could again lead to a stalemate. Even the most sanguine advocates of sweeping reform concede that difficult negotiations lie ahead.

But what is taking shape is a debate very different from previous discussions about what America's healthcare system should look like.

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Sunday, November 30, 2008

Pro-Anorexia Groups Spread to Facebook | Newsweek Health |

A Web page labeled "Ana Boot Camp" recently offered its members a seemingly irresistible proposition: a 30-day regimen designed to help them drop some serious pounds, no exercise needed. The catch was that the group's members were to vary their daily caloric intake from 500 (less than half the daily minimum requirement for women recommended by the American College of Sports Medicine) to zero. They were supposed to track their progress, fast to make up for the days they accidentally "overate" and support each other as they worked toward their common goal of radical weight loss.

Pro-anorexia, or "pro-ana," Web sites (with more than one using the "Ana Boot Camp" name) have for years been a controversial Internet fixture, with users sharing extreme diet tips and posting pictures of emaciated girls under headlines such as "thinspiration." But what was unusual about the site mentioned above (which is no longer available) was where it was hosted: the ubiquitous social networking site The (largely female) users who frequent pro-ana sites have typically done so anonymously, posting under pseudonyms and using pictures of fashion models to represent themselves. Now, as the groups increasingly launch pages on Facebook, linking users' real-life profiles to their eating disorders, the heated conversation around anorexia has become more public. Many pro-ana Facebookers say the groups provide an invaluable support system to help them cope with their disease, but psychologists worry that the growth of such groups could encourage eating disorders in others.

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U.S. 'Not Getting What We Pay For' -

Talk to the chief executives of America's preeminent health-care institutions, and you might be surprised by what you hear: When it comes to medical care, the United States isn't getting its money's worth. Not even close.

"We're not getting what we pay for," says Denis Cortese, president and chief executive of the Mayo Clinic. "It's just that simple."

"Our health-care system is fraught with waste," says Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. As much as half of the $2.3 trillion spent today does nothing to improve health, he says.

Not only is American health care inefficient and wasteful, says Kaiser Permanente chief executive George Halvorson, much of it is dangerous.

Those harsh assessments illustrate the enormousness of the challenge that awaits President-elect Barack Obama, who campaigned on the promise to trim the average American family's health-care bill by $2,500 a year. Delivering on that pledge will not be easy, particularly at a time when the economic picture continues to worsen.

Senate Finance Committee Chairman Max Baucus (D-Mont.) has already warned that improving and expanding health care will cost money in the short run -- money that his Republican counterpart, Sen. Charles E. Grassley (Iowa), argues the government does not have.

Yet among physicians, insurers, academics and corporate executives from across the ideological spectrum, there is remarkably broad consensus on what ought to be done.

A high-performance 21st-century health system, they say, must revolve around the central goal of paying for results. That will entail managing chronic illnesses better, adopting electronic medical records, coordinating care, researching what treatments work best, realigning financial incentives to reward success, encouraging prevention strategies and, most daunting but perhaps most important, saying no to expensive, unproven therapies.

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