Hope On A Global Scale

At a time when the global economy is sagging and headlines are filled with reports of conflict and death, it is critical to keep in mind programs working to improve the health of mankind.

Of all the issues we have dealt with at the Institute of Federal Health Care, few seem more globally significant than immunization. Vaccines provide a nucleus around which public health efforts orbit in symbiosis. Vaccines have tremendous ROI in terms of avoided health care costs, and they can relieve or prevent suffering on a massive scale, as numerous studies have demonstrated.

If you want statistics, visit the Sabin Vacccine Institute’s website: www.sabin.org. The Sabin Institute works closely with the Bill and Melinda Gates Foundation to reduce the burden of vaccine-preventable diseases, both by increasing immunization rates and by developing new vaccines. The GAVI Alliance brings together developing countries, donor governments and organizations (including the Gates Foundation) and industry to bring immunization to the poorest parts of the world.

And now, a new organization reports happy news: the potential for a vaccine against dengue within two to three years. According to the Dengue Vaccine Initiative (of which the Sabin Institute is a member), several vaccine candidates are in various stages of advanced development, with clinical trials in progress on five of them.

A three-dose vaccine under development by Sanofi appears especially promising, with predictions that it could be available for widespread use by 2015. Dengue, also known as break-bone fever, kills about 20,000 individuals each year, many of them children.

So, things are happening that can relieve morbidity and mortality on a global scale. Let’s not forget that.

Birth Control A Complex Issue

By Harold M. Koenig, MD
Vice Admiral, US Navy (retired)

Recently a Georgetown University law student testified before a congressional committee about the high cost of contraceptive services.  She stated that contraceptives would cost her $3,000 during the three years she was in law school and so she supported the recent administration mandate that all health insurance programs provide contraception at no cost.  Georgetown is a Catholic university, so her testimony drew the immediate attention of the Church, the administration and the media.  She even received a phone call of support from the President after he saw her televised comments.  This delicate issue rapidly became more polarized and enflamed.

Birth control (BC) pills can cost nearly $1,000 per year or well under $100 per year, depending on the brand.  They all work pretty much the same and have similar ingredients, efficacy and safety.  The difference in cost is in the packaging and advertising and depends on whether the formulation is still on patent.  The most expensive ones are on patent and are advertised in slick, full-page color adds in magazines widely read by sexually active young women.  The women talk with each other about this, believe the advertising and demand the brand name prescription from their doctor — and most of them get it.  I checked with a large local health care group that provides birth control pills at no cost as part of their program, and they do provide the highest-cost pills to women who demand them.  They do this because they got so many complaints from patients when they tried to provide the less costly variety, it just became easier to give them what they demanded than to try and educate them.  The provider just spreads the costs between all of their program enrollees.

Individual providers in this program want to give these same young women the HPV Vaccine to prevent them from acquiring this ubiquitous virus that causes nearly all cervical cancer.  But some rules and regulations prevent them from giving it to an emancipated minor without parental consent.  Many of these underage girls have not told their parents they are sexually active and, for various reasons, don’t want them to know.  So, unless they are also using effective barrier or virucidal protection, they are at risk of acquiring HPV.

Another problem is the risk of acquiring STDs.  Many young people just becoming sexually active don’t understand that BC pills offer no protection from STDs, and perhaps give them a false sense of security about sex.  Most people have heard of gonorrhea, syphilis and HIV and know that the first two are curable and the third manageable if detected early enough.   The most common STD, though, is Chlamydia.  This less well-known infection can later on in life cause inability to conceive because of scarring in the fallopian tubes.  A young woman may not want to get pregnant now, but some day most of them will.  When they get to the time they feel their biologic clock is running out, they get desperate.  Unable to get pregnant the “natural” way, they resort to artificial methods that may work but are very expensive, tens of thousands of dollars per pregnancy.

Many doctors caring for young, sexually active women with multiple partners advise the use of condoms also to prevent getting an STD or acquiring HPV.  There is a lot more to the BC pill issue than just making them available to women at no cost.

Caring for Those Who Decline Vaccines

Vice Admiral Harold M. Koenig, MD
Former Surgeon General
US Navy

Some physicians are starting to decline caring for children whose parents refuse to allow their children to be immunized.  I would never refuse to continue to care for a child because a parent made what I thought was an unwise decision regarding their child's health care.  

I would document that the parent had been informed about the need for immunizations and refused.  I would continue to care for the child and try to help the parents deal with this and other difficult decisions. People do change their minds as they gather more facts.  By continuing to provide care and establishing trust and confidence some will change their minds.

When a physician refuses to continue to care for a child because their parents object to a recommended course of care, the parents will be forced to find care somewhere else.  Unless they can find a physician with the above attributes, they will default to physicians who focus on episodic illness care and not preventive care and education.

We know the latter provides far better outcomes than the former.

The Promise in Big Data

The next big thing in health care appears to be “Big Data” — the voluminous amounts of information spewed from new technologies and electronic health records. Big Data can tell us which treatments work and which don’t, how best to deliver care and how to make care more accessible. A report last year by McKinsey and Company estimated that the U.S. health care sector could add more than $300 billion in value a year by plumbing secrets amassed in Big Data.

Big Data also is seen as advancing personalized care, with the cloud and supercomputers such as IBM’s Watson able to store and process huge amounts of information to reveal which treatments work best for the genomic makeup of a particular individual.

“If Watson can already observe tons and tons of data — and it sits there day after day, it doesn’t take breaks, it doesn’t take lunches — these computers when given enough data can actually find patterns that might lead to real cures or better treatments,” Shahid Shah, CEO of the IT consulting firm Netspective Communications, said in an article in Health Care IT News.

A challenge will be to pair mined data with information captured in the electronic health record, the article notes.

A November article in Forbes observes that new sources of information are proliferating:

“New types and sources of health care data have become available – or soon will – and in overwhelming quantity.  The federal government is investing $20 billion in Electronic Health Records; industry is developing new electronic transaction standards; and innovators like PatientsLikeMe, 23andMe, Fitbit and Zeo are helping people generate and share their own data.  The era of Big Data in healthcare has arrived.”

Can all these efforts dovetail for maximum benefit?

“We must start producing better evidence faster and on a large scale,” the Forbes article asserts.  “Before we can reduce costs and deliver meaningful improvements in outcomes, we must have meaningful evidence.  Without it, we can never know what works, and for whom.”

The promise of Big Data can be seen in the Veterans Health Administration, where mined data from its VistA electronic record — generally agreed to be the most successful such EHR in the nation — has produced such advances in care as the National Surgical Quality Improvement Program (since adopted as a national program of the American College of Surgeons).

The future of Big  in health care is enticing. Advances in computing allow us to view massive amounts of information, and to use it in new ways. The trick will be to make sure we do it wisely, and well.