Reform at the NHS England

The recent overhaul of the American health care system, which has been inappropriately referred as “Obamacare” by the media, and the frantic efforts of the new American administration to dismantle it—so far unsuccessful but time will tell—has brought some forced comparison with other care systems; some policy pundits have insolently dubbed it as the “Anglicisation” of our highly fragmented health care delivery system.

Since the health care reforms of Premier John Major—who enacted the “internal market”—and Premier Tony Blair—who instituted the “patient choice”—the health policy experts in the United Kingdom have been talking non-stop about the ongoing “Americanisation” of their venerable National Health Service (NHS). In 1948, the UK authorities created a universal health care coverage for every Briton, who were mostly impoverished after the World War II and the loss of their colonies. Citizens and pundits alike have denounced those modernization drives as a “Trojan horse” to force the entry of the “private sector” in an extremely revered and popular British institution.

What the two health care systems have in common is the following: their citizens live longer and are consuming a higher percentage of public and private financial resources in a technologically-driven medicine. In the USA the Medicare and Medicaid systems have been slowly replacing the fee-for-service system for a more integrated and efficient system of “managed care” that must be accountable. In Britain, the timid introduction of some kind of accountable care has sparked a vivid rebuke of organized citizens groups and the media that have denounced it as illegal because voters had not approved it.

James Meeks wrote in the “London Review of Books” an excellent review of the present reform in the United Kingdom with the forthright description of two universe. “In universe one, the NHS will be upturned to give most of the healthcare people need at home or on their doorstep and admit to the big hospitals only patients with major trauma, or suffering diseases that demand intensive care, or complex surgical or biochemical expertise. Big hospitals are to become centers of research, high technology, rare skills and dramatic, life-saving interventions.” In contraposition to that ideal, clean environment the author describes the other universe. “In universe two a counter-reality prevails: the reality of winter, the reality of need, the reality of an ever increasing number of frail, elderly people converging on the help of last resort, the emergency hospital.”

In the United Kingdom the combination of a providential welfare state and a good universal health care system has led to the marked prolongation of life expectancy for men and women alike. However the entry into an ever older age has brought the emergence of “multiple co-morbidities” in their clinical condition. Nowadays a patient that has a peak of high blood pressure must be treated taking into consideration that he/she might be also diabetic, or suffering form renal diseases, or a neoplasia. As a result, efficient and comprehensive long-term care for the elderly and disabled is a high time and resources-consuming endeavor. Sadly, even though elderly people might elicit compassion and understanding at an individual or family level, they are mostly ignored by the younger generations that work and fill the purse with their salary deductions. That commiseration does not translate into the civic approval of more funding. Younger citizens are usually in a state of “self-denial” about their own future fragility in old age.

Meeks studied the reform in Leicestershire, a miniature expression of modern England: densely populated, a dynamic economy and a younger population, many of them immigrants and students. It’s on the south-eastern rim of the Industrial Revolution of the 19th century, it has three Labor elected representatives and it narrowly voted to stay (Remain) in the European Union. The counties surrounding Leicester are very different as they comprise extremely well-off areas where the country gentlemen live and run-down districts that could not recover from the modernization. It is a whiter, older world where the need for home health services and ancillary support is stronger. The Lansley reform—named after the Conservative health secretary Andrew Lansley—created seven local organizations as the point of delivery in Leicestershire.  The “Clinical Commissioning Groups” (CCG) are aggregation of general practitioners located at the city of Leicester and the east-west ends of the area. The Royal Infirmary Hospital, which has the largest Emergency department in England, is run by the “University Hospitals of Leicester Trust.” The “Leicestershire Partnership Trust” runs all the community care services, including Mental Health and the Prisons.

Meeks found that the authorities of Leicestershire have implemented a virtual system 256 bed “hospital” called “Intensive Community Support” (ICS) where the convalescent patients are being treated by nursing and ancillary personnel in their own residence. There is an integral, holistic approach to the patients that are discharged from the hospital as the home health personnel, social workers and ancillary personnel are being scheduled and supervised by the same administration. The author found that the altruistic objectives—like being able to access a local doctor until 8 PM seven days a week—are not completely attained, with some district areas worse than others. The push for cuts in services that are prodded by the central authorities of the NHS could not prosper.

Considering that the population of Britain is growing in overall number and longevity, there is dire financial need for more staff, more material resources, more distributive planning. Besides the demographic inflation, there is the salaries’ inflation to account for as the health care system is run by persons with increasing needs in a modern economy. In order to compete in a tight labor market for talent and expertise, the health care organizations must offer better benefits and good pay. The “Baumol cost disease”—named after the economist William Baumol—describes the asymmetry between industries like manufacturing that can be automated and require less workers with the ones like health care that cannot be readily automated and still require large number of employees.

Many citizens of modern societies like the UK and the USA (certainly not all and not in the same degree) are enjoying one of the biggest prolongations of their average life spans with an ensuing ability to continue enjoying their activities, including postponing their retirement and working into their late 70s. But they certainly are afflicted by chronic diseases like high blood pressure, diabetes, arthrosis, which require regular medical check-ups and proper long-term treatment. Young people will eventually reach that stage too and if they now refuse to fund the existing long term care services for elderly people, they will be dismantled by myopic bureaucrats that only know how to count beans. Watch out, Millennials. Those services take years to design and put up; they will not be available for you in your golden years if you don’t protect them now with your voices and votes. But there is a positive economic variable at play.  William Baumol considered that the efficiency savings in the manufacturing sector will eventually liberate more funds to invest in health care. Let’s hope that politicians don’t squander those funds.

What do you think? Please tell us.

Don’t leave me alone.

 

 

 

Disparities in access to Palliative Care

Access to good, timely and comprehensive Palliative care is one of the great advancements in modern medicine as it has improved the quality of life of patients and their families. However, there are still major disparities in its access, especially for members of vulnerable communities like Minority populations in the USA.

One of the most disseminated and fallacious “truths” circulating in the hospital corridors and medical offices in this great country is that Minorities, i.e. Blacks and Hispanics, do not care much about Palliative Care for socio-cultural reasons. It is true that disadvantaged members of society usually fear, with good reason, that they will be summarily treated and later abandoned by the medical establishment. They view the possibility of Palliative Care as an excuse to withhold necessary care. To complicate matters worse, many minority patients are deeply religious, for which they are confounded by the mixed messages emanating from their traditional churches.

Faigle et al. published an online article where they suggest that the culprit for this glaring inequity of access is actually the systems implemented in certain hospitals, using the data from the ICD-9-CM codes stored in the Nationwide Inpatient Sample (part of the Healthcare Cost and Utilization Project) They found that Minority patients received less PC than whites but also discovered that the same was true for all the patients admitted to largely Minority-serving hospitals.

In predominantly white hospitals., the researchers found that the median rate for the use of Palliative Care in post-Stroke patients was 8.5 per 100 ICH admissions but in mixed or largely Minority-hospitals the median usage rates were 6.3 and 2.5 per 100 ICH admissions respectively. The usage of Palliative Care after Ischemic Stroke was 2.2 per 100 admissions but it lowered to 1.5 in mixed facilities and a dismal 0.5 in largely Minority-hospitals. This data was controlled for demographics, comorbidities, socio-economic factors, hospital features and stages of the disease.

Important variables in the system were the implementation of sound institutional algorithms that could alert the medical personnel that the services were available.

What do you think? Please tell us.

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Medical kits for prenatal care

Sometimes “a little” can mean “a lot” in the daily lives of long ignored, underserved communities.

In under-developed countries the rates of maternal and newborn morbidity and mortality are scandalously high in spite of longstanding intervention by the public and private agencies, especially in the Sub-Saharan countries. The critical factor is to engage the pregnant women at the point of care entry. The lack of adequate supplies of medical kits is of humongous importance.

Pilar Betrán, Bergel et al. designed a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten prenatal care clinics in Mozambique that followed at least 200 pregnant women per year and had specialized nurses. The Public Health interventions were composed of these components:

  1. Component 1: provision of prenatal care kits with basic medicines laboratory supplies and materials approved by the Health Ministry
  2. Component 2: a place to store the kits was provided at each clinic
  3. Component 3: a login sheet was used to register the usage
  4. Component 4: a training session and refresher course for the nurses

Ten practices were chosen initially for primary and secondary outcomes:

  1. Screening for proteinuria
  2. Screening for anemia
  3. Treatment of parasitic women with mebendazole
  4. Screening for high blood pressure
  5. Screening for syphilis
  6. Preventive treatment for malaria
  7. Screening for HIV
  8. Treatment for syphilis

For the three primary outcomes—proteinuria, anemia and parasites—the interventions produced clinically and statistically significant improvements. “5519 (14.6%) of 37826 women were screened for anemia in the control period, compared with 30,057 (97.7%) of 30,772 women in the intervention period…3739 (9.99%) of 37,826 women were screened for proteinuria in the control period compared with 29,874 (97.1%) of 30,772 women in the intervention period…17,926 (51.4%) of 34,842 women received mebendaazole for treatment of parasitic worms in the control period compared with 24, 960 (88.2%) of 28,924 women in the intervention period.” In four of the six secondary outcomes there were also clinically and statistically significant improvements; a small improvement was measured in HIV screening and treatment but it was not statistically significant.

The design and implementation of a woman-centered prenatal supply-chain made a big difference in Mozambique, which sets an example for the rest of Africa.

What do you think? Please tell us.

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The PURE study

In modern nations the importance of consuming fruits and vegetables in order to prevent cardiovascular diseases has been studied extensively. However the same does not hold truth for the rest of the nations until the “Prospective Urban Rural Epidemiology” (PURE) study, a prospective cohort study that involved 135,335 participants aged 35 to 70 years without cardiovascular disease in 18 low, middle and high income countries. Dietary guidelines recommend a minimum of 400g/day of fruits and vegetables but it has not been truly achieved on a global basis due to the cost limitations.

Victoria Miller et al. enrolled participants between January 2003 and March 2103 that responded to standardised questionnaires about socio-economic, lifestyle, personal health and family histories. They studied outcomes like major events related to cardiovascular disease (myocardial infarction, stroke, heart failure) and mortality rates produced by those conditions. Cox models were created to study the association with fruit and vegetables consumption. Potatoes and other tubers, fruit-vegetable juices were excluded; the legumes were beans, black beans, lentils, peas, chickpeas and black-eyed peas.

The authors wrote: “during a median 7.4 years (5.5-9.3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex and centre…Higher fruit, vegetable, and legume consumption was associated with lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day)”

The researchers also found that participants that consumed more fruits, vegetables and legumes had higher education, higher levels of physical activity, lower rates of smoking, and higher energy, meat consumption and were more likely to live in urban areas. There was an 11% lower risk of major cardiovascular disease for the highest fruit intake category compared with the lowest category intake; there was a minimum benefit from a higher vegetable input. The authors hypothesized that given that vegetables can be consumed raw or cooked, the latter might have degraded nutrient contents.

What do you think? Please tell us.

Don’t leave me alone.

Tuberculosis and HIV

Tuberculosis is one of the leading causes of chronic disability and death in the developing world and is the first one killer of people infected with HIV. The risk of contracting TB increases with HIV, especially after the CD4 counts start to fall and even after the institution of anti-retroviral therapy. Preventive therapy with isoniazid—a cheap and well-tolerated drug—has been instituted for more than five decades with good, measurable results.

Several clinical trials have confirmed the usefulness of the preventive use of isoniazid in people already infected with the HIV virus, even without the availability of proper anti-retroviral therapy for all those patients. A large cohort study in Brazil showed that the use of isoniazid had a synergy effect in patients treated with ART, with a 76% reduction in the TB incidence. However only a million of the approximately eligible people to receive this drug, have been duly treated due to several operational handicaps, including the erroneous perception that it might interfere with the ART efficacy.

Anani Badje et al. published the results of the TEMPRANO study—a randomised clinical trial that focused on the effects of the use of isonaizid in HIV patients with CD4 counts of less than 800 cells per ul but above the threshold for starting the anti-retroviral therapy. The initial results showed that both the use of isoniazid and anti-retroviral therapy reduced the grave clinical consequences of HIV infection and the use of both had the greatest benefits. After 6 months of the use of isoniazid in HIV patients, there was a 37% reduction in the mortality rate that was independent of the ART use.

The results of the TEMPRANO study are encouraging for HIV patients because:

  1. People with high CD4 counts had good survival rates over 5 years
  2. Benefits were noted for people with and without positive tests for TB
  3. Adjustment of baseline covariates did not change the final results
  4. Benefits of the use of isoniazid were independent of the ART

There should be a more forceful design and implementation of isoniazid delivery for the HIV patients who are at high risk of contracting TB and who would benefit the most.

What do you think? Please tell us.

 

Don’t leave me alone.

End of the cholera pandemic?

Cholera is one of the most ancient scourges of Humankind with periodic appearances in regions of extreme poverty and/or devastated by war or natural disasters. Transmitted by the faeco-oral route, the Koch bacillus spreads when the disadvantaged populations lack good water and proper sanitation services; it disproportionately affects children and their mothers.

An editorial in “The Lancet” stated that “the global annual cholera burden is estimated at around 2.9 million cases per year, resulting in 95000 death. In 2017, these estimates could be far exceeded due to a number of devastating outbreaks, including those in Yemen and northern Nigeria. So far this year, 750000 possible cases, causing over 2000 deaths, have occurred in Yemen.”

This deadly disease is endemic in more than 40 countries where the water, sanitation and hygiene (WASH) infrastructure is completely inadequate. At present the biggest incidence occurs in endemic areas of Africa, which has been worsened by the accelerated urbanisation that created slums in cities.

The design of an oral cholera vaccine (OCV) and the scientific study of the acquired immunity in humans have fostered the implementation of better and safer vaccination campaigns to control the epidemics; the WHO has stockpiled a good supply of vaccines in strategic depots in the affected areas.

Since 2013, 13 million vaccines have been used on an emergency basis. The Global Task Force on Cholera Control (GTFCC) has pooled the resources and know-how of contaminated countries, private donors and academicians in order to develop a multi-faceted strategy to eradicate the disease for good.

The GTFCC designed a three-pronged approach to combat the disease:

a) Rapid response to outbreaks with good community surveillance and delivery of control kits, oral vaccines and WASH supplies in depots.

b) Create a sustainable WASH infrastructure and health care systems.

c) Coordination of the regional and international systems of support

We have the scientific know-how and technical capacity to end the cholera pandemics with the proper sanitary measures, as long as we protect the “equality” of the access of vulnerable communities to the right services and therapies. Why aren’t we doing more to eradicate this scourge from the face of our planet?

What do you think? Please tell us.

Don’t leave me alone.

Stop this vile abuse of the poor in the BRSF

“Un élu, c’est un homme que le doigt de Dieu coince contre un mur.” Jean-Paul Sartre

-“Doctor…This woman with the asthmatic child… Is she on food stamps?”

The seemingly innocent question made by the assistant in Rick Scott’s office exuded deep disdain and discrimination against, let’s talk clear, the poor in the modern USA.

There is a silent, yet relentless war to displace the poor to the outer fringes of urban areas like Miami-Dade in order to make way for an out-of-bounds gentrification.

That question awakened the wild tiger that I have been carrying inside me since birth.

-“WHAT?!!! What are you saying? This is an American, A-M-E-R-I-C-A-N child that is being badly abused by a greedy landlord and might die as a result…You can’t be this insensitive…Besides, I don’t think that Governor Scott would approve of this language…What’s the matter with you?”

After the Socialist Revolution started in Cuba in 1960, scores of its middle and upper classes citizens fled to the safety and comfort of the USA, initially settling heavily in what then was another undeveloped resort town: Miami. Toiling hard, they set up new businesses and raised beautiful families. Sadly this success story has a dark undertone as a stowaway hid in their luggage.  As in all Latin American countries, they had inherited the authoritarian streak and lack of civic virtues that the Spanish Empire imposed on them. Eventually most of them evolved to appreciate and accept the precious defense of basic individual rights that an Anglo-Saxon society grants. But a few of them remained reactionary holdouts that did not accept individual, let alone women’ rights; they do not understand that in our complex society single working women are the norm, and not the exception, as I have already explained in my blog “The single Mom.” Sadly many of these recalcitrant individuals have bought residential complexes along the Calle 8 axis.

Mariela X. is a single working mother of four beautiful children that I met a few months ago as I regularly ordered take-out food from the resto in Calle 8 where she works. She goes to work at 6 PM and slogs relentlessly in the kitchen and counter until the wee hours, always treating her customers well. Occasionally we informally discuss the care of her 8 years old daughter that has severe Bronchial Asthma and is being regularly treated by a pediatrician. Last week she told me that a tree had fallen on top of her roof and was slowly eroding the foundation with the real possibility of bringing it down.Her daughter recently had a worsening of her symptoms due to the lack of proper air conditioning. When I asked her why she hadn’t contacted her landlord to fix the problem, she replied:

-“I did many times…He told me that he wished the roof would collapse so he could make a bigger claim to FEMA and then rent it for a higher amount…He didn’t care if my children were hurt…He told me to go away.”

When we were hunkered down in a small closet with my son during the height of the Hurricane Irma’s strike on Miami a few days ago—amidst the clatter provoked by the maddeningly swirling winds outside the windows with frighteningly sudden lulls that heralded an even bigger onslaught by those demons to bring down the top floor apartment—we decided to pray to our Creator asking for forgiveness for our sins and acceptance into Heaven. When we finally made it out, both Gian Luca and I were different persons. My son decided to finish his first feature film and make it an artistic work to remember. Myself, I decided to fight for the poor and deprived of this city.

My street sources tell me that Mariela’s plight is common in that neighborhood as the unscrupulous landlords are taking advantage of the post-hurricane chaos and, abetted by the corrupt politicians and their lackeys in the City of Miami, are harassing the poor. Before Mariela had the chance to finish her story, I could already feel the finger of God Almighty pushing me against the wall to command me: you have to help her.NOW.

With all the details of her dire situation, I first contacted the 311 number staffed by members of the local office of the “Florida Division of Emergency Management”; befitting the long tradition of civic indifference and laziness of the bureaucrats from this “Banana Republic of South Florida” they said it was not their business (sic) and only provided me with a state help line. After doing the tiring phone rounds of public offices that were only jerking me around, I was almost ready to give up. Suddenly the memory of the departed Charlton Heston valiantly riding a horse in “El Cid” sprung to my mind.

Governor Rick Scott of Florida showed remarkable stewardship during the worst moments before, during and after Hurricane Irma that was a monster storm ready to level out all traces of civilization in the Florida peninsula. My son and I listened watched his conferences in CNN, which gave us hope.  Exhausted and disillusioned I called his office a few days ago. After the horrible first impression that you saw in the beginning of this posting, his aide understood the severity of the situation and gave me the right contact. Danilo Flores, a good-natured employee of the “Division of Agriculture and Consumer services” helped me file the necessary complaint. Thank you very much.

When I called Mariela to relay the good news that help is coming, she said:

-“Doctor…Do you know what that crooked landlord told me today? That he couldn’t discuss with me cause I’m a woman…That I should get a man!” Oh really, dude?

Cid Campeador-Rick Scott, come down with your gallant army to the  rescue of these poor, defenceless women and children in the BRSF. God will be riding on your side.

What do you think? Please tell us.

Don’t leave me alone.