Medical Professionalism in the New Millennium: A Physician Charter

September 1, 2007 at 11:27 am (Sarah's Posts)

One of my first med school classes assigned this article as reading, and I thought it was pretty darn interesting. It is a pretty visionary viewof the future role of the physician, but it does open up a lot of legal questions about the responsibility of medical professionals both legally and morally. Aside from the responsibilities of an individual physician to an individual patient, they put out that larger issues such as access to care and just distribution of resources are part of the responsibilities of today’s health care professionals.   I haven’t looked to see if there were any responses, but I’d be curious to see how people reacted to being included as stakeholders.

“To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles
of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society.”

Medical Professionalism in the New Millennium: A Physician Charter

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HIV/AIDS documentary link

August 16, 2007 at 12:08 pm (Sarah's Posts)

I just finished watching what I thought was an excellent PBS documentary that follows the history of HIV/AIDS over the last 25 years.  It is 4 hours long, but is divided into sections so you can poke through and see what might be of interest.  If you do scope it out, I’d love to hear what you think.
http://www.pbs.org/wgbh/pages/frontline/aids/

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Another interesting microfinance article

April 24, 2007 at 9:56 am (Sarah's Posts)

http://hbswk.hbs.edu/item/5559.html

I’ll just throw this one out there and see if anyone wants ot bite.

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Patent protection and economic development

April 24, 2007 at 9:55 am (Sarah's Posts)

How Do Patents and Economic Policies Affect Access To Essential Medicines In Developing Countries?

I’ve been working on a project about patent law in India and I stumbled on this article.

It is interesting to me because it goes against the main two positions on patent protection. Big pharma says that IP protection is necessary in order for them to live and activists say that IP protection is preventing people from getting access to essential and life saving medications. This person’s conclusion was that, if you look at the data, patents are granted to so few of the WHO-classified essential drugs that neither side can be right.

That is probably said better in this paragraph:

“These data allow the reexamination of some settled assumptions. There is a belief n the activist community that patents are “a barrier in many [developing countries] to accessing affordable medicines” and, balancing it, a belief in the pharmaceutical industry that it is “necessary to protect intellectual property rights on a global scale” to assure future research and development activities and the industry’s commercial viability. Both of these views are greatly exaggerated. Patents cannot cause essential medicines to be inaccessible in “many” developing countries because they do not exist 98.6 percent of the time; similarly, patents cannot be a “global” necessity of pharmaceutical business because companies forgo them 69 percent of the time. A limited number of exceptions reduce each figure to somewhat below 100 percent, but as an empirical reality those exceptions—and therefore the contentious round dividing these opposing views—are few.”

There are two things that I was thinking (that are partially addressed in the article.) One is that these trends don’t mean that there aren’t specific cases of drugs that need to be examined and their patent status changed. Especially because HIV/AIDS drugs are likely candidates to be on that list as new and novel drugs.

Secondly, this article makes the point (once again) that lack of access to medications is more dependent on economic policy and poverty than on specific obstacles that are blocking access. None of these things are a magic bullet solution.

I just had semi-related thought, on the topic of patents and copyrights. When I/we post articles that are from journals that require a log-in or payment to access, is that technically illegal and breaking copyright?

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Funding for sexual education

April 13, 2007 at 9:25 am (Sarah's Posts)

http://www.latimes.com/news/education/la-na-abstinence8apr08,1,4821225.story

I saw this article today after hearing an NPR segment to the same effect yesterday.  The buzz is about how the federal program for sex education (which is linked to federal funding for health education) limits the scope of what is taught from A, B and C (abstinence, being faithful, condom use) to only A.  This is an issue that most of us have heard about before in the context of HIV or any other STI, but it is back in the US news because five states (Wisconsin, Connecticut, Rhode Island, Montana and New Jersey) have dropped the federal funding in favor of being able to teach kids a more encompassing curriculum.

This issue makes me rather irrationally angry, so I’m trying to be sane about it here at least.  This paragraph from the article highlights what makes me the most angry: “Smith said: “The question state leaders are starting to ask is, ‘How much of this is really about teaching kids, and how much of this is simply pushing forward a social policy favored by President Bush and the conservative right?’ ” ”

I understand somewhere in my head that those who do not want children to learn about ways to protect themselves if they are sexually active believe that they are doing something that is good for children.  But the paternalistic and arrogant attitude that young people should not even have information so that they can decide for themselves makes me bonkers.  I believe that, if even one teenager has decided to have sex, they have the right to know information that will protect them.

Nothing terribly innovative, but I saw this article and got hot and bothered.

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Universal blood created

April 6, 2007 at 6:10 pm (Sarah's Posts)

I’m attaching an article for what I thought was a nifty new technology–universal blood.  It seems that they’ve found enzymes that can convert the sugar molecules that identify red blood cells as A and/or B to O.  Which means that blood in the blood supply could be converted to type O, which can be universally given to any patient without worry about the immune system attacking foreign blood.

This particular article doesn’t mention anything about the affordability of this treatment (probably not very affordable), but it could be an interesting solution to some of the mis-regulation that goes on in blood supplies in the world.  Although this isn’t a solution to all the communicable diseases that can be passed through the blood supply, it could help minimize the deaths that are caused from transfusing the wrong type of blood or from a lack of the right type of blood available when there is a need.

Has anybody heard more about this?

Universal Blood

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Buy (Less). Give More.

March 27, 2007 at 5:53 pm (Sarah's Posts)

Sorry for my absence… I’ll be back and posting soon.

In the meantime, I came across this website that emphasizes how consumerism/corporate greenwashing isn’t the answer to solving the world’s problems, even if it raises money.  They plug into a concept that we’ve kicked around before about whether encouraging consumption as a way to raise money is ethical.

http://www.buylesscrap.org/

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Overestimating the HIV burden in India

March 5, 2007 at 10:04 pm (Sarah's Posts)

Overestimating the HIV burden

I’m once again stealing someone else’s story to tell here because I think it is a fascinating one with a good reminder in it for all of us. Here’s the short version with the corresponding paper attached. For those of you who are geeks like me, take a look at how sexy their methods are. For the non-nerdy, the study itself has some interesting applications.

The folks who wrote this paper are convinced that the burden of HIV in India is highly overestimated. We’re talking a difference of 3-3.5 million people instead of the current estimates of 5.2 million. They are basing this on an intensive study taken on in Guntur District of India. The estimated surveillance in the area was about 4.38%, using data collected by the generally accepted sentinel surveillance method from public antenatal and STI clinics. Doing a very intense population-based survey, the folks writing this paper found that the rate was 1.79%. So, why the difference?

It turns out that the public hospitals where the current country-wide data is collected from contains a higher representation of people from lower standards of living who represent a greater part of the HIV burden. In addition, the second that a private doctor suspects HIV, he refers the patient to the public hospitals so that he doesn’t have to deal with it. So, the public hospitals are (in their view) representing a much larger portion of HIV cases than private hospitals, which wasn’t taken into account in the earlier data.

When I asked Dr. Dandona about the policy implications of this study, his one big comment was that HIV funding represents a disproportionably large part of healthcare funding in India and in the world already, even without these overestimates. I’m loathe to just step up and say that HIV funding needs to be cut because it is clearly a huge problem in India that is mostly being ignored and swept under the carpet. But, it is important to really look at the study methods that are being used when we’re looking at data like this that is used to prioritize health budgets.

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Back to accountability on the local level

February 24, 2007 at 7:21 am (Sarah's Posts)

We had a lecture the other day from a woman from Hopkins who is working on a large-scale clinical trial in Indonesia on the effects of maternal micronutrient supplementation on infant mortality rates (IMR).  It is an area that has been looked at a lot, but with varied outcomes that have left open questions like when supplementation is the most effective and what composition of micronutrients is best.

One of the areas that she mentioned as particularly controversial was their policy of creating a certification program for all people involved in the project, including the local community facilitators (CFs).  They realized realy on that the local workers didn’t understand the larger focus of the project beyond their specific assigned tasks.  So, they started a program that evaluated everyone based on three categories: head (understanding of the project), heart (empathy and ability to communicate with the mothers), and the hands (ability to record and keep track of data).  If a CF fails three times, he is asked to leave the project.  Both the expat and the academic communities said that this wasn’t a practical, realistic or necessary expectation, but the program coordinators insisted.

When they started looking at the data, they found some interesting things.  Firstly, there was a 20% decrease in IMR with micronutrient supplementation, with the most important time being during the last trimester.  More interestingly, when they compared the IMR for women assigned to excellent CFs as compared to those who were rated as good, there was an additional 17% decrease in IMR.  Among women who were initially assigned to a CF who had to be dismissed due to failure to pass the certification, there was a 20% increase in IMR, essentially elimitating the positive effects of micronutrients.  If seems that there was a synergistic effect of having micronutrient supplementation and an excellent CF.

Sometimes in public health work here, I see the mentality that just because we’re doing good work, it means that we don’t have to do a good job.  Outcome measurements that look at numbers of people trained or number of women reached sometimes gloss over whether the project effectively trained/communicated/reached the target popultion.  Instead, these projects need foster the idea that everyone involved is going to be held accountable because they are all responsible to the community.  It is a method of empowerment, of telling CFs that their skills and understanding are valued, particularl if it becomes clear that these skills have an effect on health outcomes.

On a site note, someone brought up the point that all these programs are merely drops in the bucket, and that any given intervention-specific project is too small in scope to make any real difference.  This lecturer felt that the greatest increases in health have come from economic development, not from any health research or specific program.  How would we begin to address the question of whoether all the money that goes into health specific interventions and research could be used more effectively if directly invested in economic development of the community?

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Ethics of scarcity

February 10, 2007 at 1:40 am (Sarah's Posts)

 

My university is undergoing a fairly large survey (2,400 kids) in the city of Pune to determine polio vaccine coverage during the most recent national immunization day (NID). The city is broken up into wards, and each ward is covered by an immunization officer. We’re finding pretty high overall coverage rates (I don’t have the exact numbers yet, but it is somewhere around 95%), although the survey is a little self-selecting because we’re using houses as the starting points which misses out on all the migrant workers. For polio, they are the ones that are of most concern and are responsible for most disease spread. But, at the least it has been a very informative and interesting exercise that brought us to an ethical dilemma.

The chief immunization officer for the city wanted to hear about our survey and started asking questions. Now, from his point of view, he would love to have information on exactly which children haven’t been vaccinated because then he could make sure to cover them in the next NID. So, is it ethical for us to give him that information?

My first response was a Big No Way. People underwent the survey with the understanding that we are university students who are trying to determine coverage rates, not that we would send immunization officers to their houses. I think that you’d be sent packing by any ethical review board in the states based on not getting consent to give out personal information.

On the other hand, my professor felt strongly that we should give him the information. In her mind, it is unethical to waste the money of an already stretched public health system by keeping the information to ourselves, leaving children who could potentially spread the disease. To that end, I didn’t come into contact with anyone who thought that immunization was wrong or didn’t want it. People mostly just missed the NID and thought that they would get covered in the mop-up sessions where volunteers go door-to-door with the vaccine. Still, even if nobody would protest in this case, I think that it could be dangerous to set the ethical precedent that individuals don’t have a right to their personal information.

In my mind, there is a balance in this situation where we could give out the information about any wards that weren’t well covered, but that still leaves a huge number of people that need to be combed through in order to ensure high coverage. Does scarcity affect the right of the individual to their privacy when it comes at the expense of the public good?

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