Friday, May 23, 2014
Two decades ago, David Walmer went on a volunteer mission with his church to Haiti. He was sent to paint walls at a hospital in the seaside town of Léogâne, but when the people there learned that Walmer was a doctor — he was a fertility specialist at Duke University — they asked him to spend the week with a local obstetrician-gynecologist named Jean-Claude Fertilien. Walmer was shocked by what he saw: Fertilien finishing a hysterectomy with the aid of a flashlight when the hospital generator failed to restart, for instance, or when an anesthesiologist wasn't available for an emergency C-section, the doctor just numbing the skin and cutting. At one point, Walmer was called to the bedside of a young woman in her mid-20s with undiagnosed cervical cancer who had gone into septic shock. There was nothing to be done for her, and she died right in front of him. Walmer was appalled. In the United States, cervical cancer is considered a preventable disease.
"You have 10 years to detect this disease before it becomes untreatable," Walmer says. "And it's easy to detect. It develops on the outside of the cervix, which you can see."
At the end of his week in Haiti, Walmer, who is a boyish 61, put a question to Fertilien: "I'm a busy guy. But if there's one little thing I can help you out with, what would it be?"
"Cervical cancer," Fertilien said.
Walmer had no expertise with the disease — he divided his time between seeing patients and doing lab work, analyzing the biology of the uterine lining — but he told Fertilien he would do his best.
Back at Duke, he pressed colleagues to let him work alongside them and learn about the disease. He knew that an effective screening program would be the biggest single fix he could propose. In the U.S., screening is typically done with Pap smears — a quick swab of a woman's cervix to screen for the cellular changes that foreshadow cancer. If abnormal cells are found, a doctor will usually perform a colposcopy, in which the cervix is examined using a specialized magnifying lens, a colposcope, to see if disease is visible. Before the widespread adoption of Pap smears in the 1950s and '60s, cervical cancer was the top cancer killer among women in the U.S. Now, when caught in time, the diagnosis and treatment are pretty straightforward: Paint the cervix with acetic acid — essentially vinegar — which turns abnormal areas white. Confirm the presence of disease with a biopsy. Then freeze or remove the abnormal cells.
Thanks to early detection (and helped by the vaccine for HPV, or human papillomavirus), the mortality rate for cervical cancer in the U.S. is relatively low. Not so in developing countries, where it kills almost 250,000 women every year. Haiti has one of the highest rates of cervical cancer in the world. Walmer knew that a national screening program would save countless lives, but deploying colposcopes across the impoverished nation was not feasible. They're expensive, they require reliable electricity and they're too big to be easily carted around to the ramshackle clinics throughout the country. A battery-powered, portable and affordable alternative was needed.
At the time, in the mid-1990s, Walmer was teaching young doctors how to reverse sterilization surgeries by repairing women's fallopian tubes. He used loupes, or surgical glasses, to see the tubes properly. "I realized, I've got these magnifying lenses right here, and they don't require any electricity," Walmer says. A solution began to take shape in his mind. He bought a halogen headlamp at a bike shop and a green filter at a camera store. He figured that by switching back and forth between green and white light he would be able to provide the contrast needed to identify precancerous lesions on the cervix and the pattern of blood vessels that indicate something suspicious.
Thursday, May 22, 2014
Most health care plans ask that you spend some money out of your pocket whenever you use the health care system. This is known as cost-sharing, and it exists because research has shown us that people are, in general, less likely to spend their own money than someone else's. Cost-sharing works its way into insurance today through co-pays, deductibles and co-insurance.
Cost-sharing works for most people, because most people are healthy. Healthy people who use health care are often doing so inefficiently. They often don't need the care they ask for, because they're well. One way we use cost-sharing poorly, though, is that we apply it to all insurance beneficiaries equivalently. We treat them all the same, no matter how sick or healthy they are.
A study just published in JAMA Pediatrics looked at how children with asthma obtained care under different levels of cost-sharing, and how much stress their families were under financially because of their child's illness. It's important to understand that children with asthma, by definition, require care.
Wednesday, May 21, 2014
When poor teenagers arrive at their appointments with Alan Meyers, a pediatrician at Boston Medical Center, he performs a standard examination and prescribes whatever medication they need. But if the patient is struggling with transportation or weight issues, he asks an unorthodox question:
"Do you have a bicycle?"
Often, the answer is "no" or "it's broken" or "it got stolen."
In those cases, Meyers does something even more unusual: He prescribes them year-long memberships to Hubway, Boston's bike sharing program, for just $5 per year—a steep discount from the regular $85 price.
"What we know is that if we are trying to get some sort of exercise incorporated into their daily routine, [the bike] works better than saying, 'Take x time every day and go do this,'" Meyers told me.
The bike-prescribing program is paid for by the city. For patients without bank accounts, Boston even puts up its own city credit card. Meyers thinks the two-wheeled solution tackles several problems at once.
Tuesday, May 20, 2014
Many years ago I spent a lunch hour in a doctors' dining room eavesdropping on two white-coated men of a certain age idly discussing a colleague who worked at the city hospital next door.
While they themselves saw mostly insured patients, she worked exclusively among the destitute, a de facto one-woman charitable health organization. Most of the hospital community thought she was a saint. These two doctors, to put it mildly, were not impressed.
"It's easy to do that kind of work," one concluded, putting down his napkin and standing up. "The hard thing is taking care of patients who are exactly like you."
New generation of sensors
Drug therapy alternatives
How it works
We believe that it might be possible to treat breast cancer— the leading cause of female cancer death — with a drug that can already be found in nearly every medicine cabinet in the world: Aspirin.
In 2010, we published an observational study in The Journal of Clinical Oncology showing that women with breast cancer who took aspirin at least once a week for various reasons were 50 percent less likely to die of breast cancer. In 2012, British researchers, by combining results from clinical trials that looked at using aspirin to prevent heart disease, found that aspirin was also associated with a significantly lower risk of breast cancer death.
And yet, until now, there have been no randomized trials (the gold standard of research) of aspirin use among women with breast cancer.
It's not hard to see why: Clinical trials are typically conducted on drugs developed by labs seeking huge profits. No one stands to make money off aspirin, which has been a generic drug since the Treaty of Versailles in 1919, and which costs less than $6 for a year's supply.