Saturday, July 11, 2009

When public health becomes a public nuisance

The bizarre advice given to British doctors on how to deal with swine flu confirms that top-down scaremongering is destroying medical practice

The combination of speculative scaremongering by Britain’s health authorities and increasingly absurd directives to general practitioner (GP) surgeries in response to the current flu outbreak confirms that public health has become a public nuisance.

On 3 July, the UK health minister Andy Burnham (the fourth since the last General Election) announced that the swine flu pandemic could no longer be contained and that there could be 100,000 cases a day by the end of August. In response to the suggestion from a TV interviewer that this could mean 40 deaths a day, the chief medical officer Liam Donaldson agreed that this was possible, and that it could be higher.

Burnham conceded that his figure was ‘a projection’, not a fact - he meant that it was a speculation based largely on ignorance, similar to previous (unfulfilled) predictions of catastrophic mortality from AIDS, mad cow disease and bird flu. Though leading public health authorities cling to the belief that proclaiming nightmare scenarios is useful in raising public awareness of disease, in reality this provokes anxiety out of all proportion to benefit.

On the same day we received in our GP surgery, by fax and email (and no doubt shortly also by post), the latest of the almost daily pandemic flu briefings from the local primary care trust (PCT). The headline barks: ‘PPE procedures to be used for every patient.’ The bulletin continues in the now familiar tone of an exasperated infant school teacher spelling things out for children who suffer from a combination of learning difficulties and attention deficit hyperactivity disorder (though it never goes so far as to explain that PPE stands for ‘personal protective equipment’):

‘GPs are reminded that on seeing a patient with flu-like symptoms they need to follow all guidance on PPE, including wearing a surgical mask, gloves and apron.’

This is the sort of advice that could only be given by somebody who has never set foot in a GP surgery, certainly not since the onset of the great swine flu scare. The simple fact is that many patients who have been alarmed by the pandemic propaganda take no notice of the advice to stay at home and come to the surgery (and bring their children) and - quite understandably - expect to be seen. So, after they have sat in the waiting room for hours, coughing and spluttering, we are then expected to scrub and gown up as though we were performing open-heart surgery - and then repeat this procedure for the 20 other patients in the queue? Dream on.

I am torn over what has been the most useful guidance we have received from on high. Is it the diagram showing a cross-section of the nasopharynx illustrating how to take a throat swab? Or is it the picture of the container showing how to package the swab for transport to the laboratory? It was also very helpful to receive ‘real examples’ of ‘what not to do’ detailing just how stupid some local GPs have been in misinterpreting simple guidelines. It is shocking to hear that some GPs have even confused World Health Organisation (WHO) pandemic alert algorithm S5a (for dealing with suspected cases) with algorithm S5b (for sporadic cases). Is it any wonder that the pandemic is out of control? Can revalidation come a moment too soon?

GPs who were instructed - as I was - by the Health Protection Agency (HPA) to visit a suspected case of swine flu solely to do a throat swab may be alarmed by the proposals for home visiting in the grand pandemic flu contingency plan. This anticipates that 28.5 per cent (note the decimal place precision) of a predicted 30million cases in the UK (based on a 50 per cent ‘clinical attack rate’) will require visiting at home. By my humble calculations, assuming a four-week period (and assuming, improbably, no GP absenteeism), this would mean about 10 visits a day for every GP working seven days a week. Whether or not this would be of any benefit to these patients, it would certainly bring primary care services to a halt. But, if the epidemiologists want swabs, why not ask patients to do their own? (They could be sent pictures to help them locate their noses and throats.) We do this already with suspected cases of measles and mumps, so why not for flu? Patients are quite capable of doing their own genital swabs for chlamydia. Indeed this suggests another role for the ‘flu friend’: why not ask them to do your chlamydia swabs as well and get even friendlier?

The unfolding swine flu fiasco raises some hypothetical questions. What if the WHO, the HPA, the Department of Health and the rest had declared an embargo on press conferences and public statements? What if they had encouraged the virologists to concentrate their energies in the laboratories (where their achievements have been impressive) and stay away from the TV studios (where their pronouncements have often been ill-judged and alarmist)?

What if the PCTs had simply let GPs respond in the familiar way to cases of flu apparently occurring in an unfamiliar season? Given the evident mildness of the vast majority of swine flu cases (often milder than seasonal flu), it is difficult to believe that this approach would have resulted in any higher morbidity or mortality. It would certainly have led to less anxiety, to a much lower number of confirmed cases and to a vastly lower consumption of marginally effective anti-viral drugs. It would also have prevented much distress to patients, and much disruption to schools and workplaces (not to mention to surgeries, out-of-hours services, and hospitals).

Ah yes, but it could have been worse, comes the doomsday chorus from WHO, HPA, and all the rest. No doubt, the H1N1 virus could mutate to become the most virulent strain since the 1918 flu pandemic that killed 20million people. It could even be worse than the Black Death of 1348 that reduced the population of Europe by a third. Or maybe not. The public health authorities appear to have become incapable of distinguishing between sensible contingency planning and scaremongering propaganda. But instead of quietly admitting at the outset that very little was known about H1N1 and discreetly getting on with the job of preparing a vaccine and testing drugs, they reached for the megaphone. Better, according to the official mantra of twenty-first century risk aversion, ‘to prepare for the worst and hope for the best’. But even if swine flu had turned out to be a more serious illness, it is difficult to see how scaremongering, swabbing, PPE and Tamiflu would have made much difference.

The ascendancy of public health over primary care revealed in the swine flu scare is an ominous trend. The statements of both national and local public health practitioners confirm attitudes of condescension, even contempt, for the individuals traditionally regarded as being at the centre of primary care - patients and GPs. For public health specialists, our patients are merely people committed to unhealthy lifestyles. Their risk factor epidemiology repackages old prejudices: people get ill because they are idle, promiscuous, gluttonous, drunken, and as the spread of swine flu confirms, dirty. They regard GPs as sadly lacking in the moral fervour required to transform the deviant behaviour of our patients.

The outlook of public health would not be of much consequence were it not for the fact that it has, over the past 20 years, acquired a growing influence over primary health care. This is confirmed by the prominent role of public health specialists, who often have little knowledge or experience of General Practice, in primary care trusts. It is also reflected in the shift in the focus of primary care away from the diagnosis and treatment of the illnesses presented by patients towards the attempt to manage the health-related behaviour of the practice population. The burgeoning activities of check-ups and screening are resulting in what might be called an epidemic (perhaps not yet a pandemic) of overdiagnosis and overtreatment particularly in relation to cancer, heart disease and diabetes.

The moralising propaganda of public health has a generally demoralising effect on society, encouraging fear and anxiety - and attendant sentiments of stigma and blame. It has a degrading effect on medical practice and is corrosive of good relations between doctors and their patients. As the swine flu scare confirms, it is also disruptive of day-to-day medical practice.


Insuring you won’t cut costs

Health care "reformers" keep talking about getting us more health insurance. Then they talk about cutting costs. This is contradictory nonsense. Insurance, whether private or a government Ponzi scheme like Medicare, means third parties pay the bills. When someone else pays, costs always go up.

Imagine if you had grocery insurance. You wouldn't care how much food cost. Why shop around? If someone else were paying 80 percent, you'd buy the most expensive cuts of meat. Prices would skyrocket. That's what health insurance does to medical care. Patients rarely even ask what anything costs. Doctors often don't know. Often nobody even gives a damn. Patients rarely ask, "Is that MRI really necessary? Is there a cheaper place?" We consume without thinking.

By contrast, in areas of medicine where most patients pay their own way, service gets better, while prices fall. Take plastic surgery and Lasik eye surgery: Because patients shop around and compare prices, doctors work hard to win their business. They often give customers their cell-phone numbers. Service keeps increasing, but prices don't. "In every other field of medicine, the price is going up faster than consumer prices in general," says John Goodman of the National Center for Policy Analysis. "But the price of Lasik surgery, on average, has gone down by 30 percent."

This shouldn't be a surprise. What holds costs down is patients acting like consumers, looking out for themselves in a competitive market. Providers fight to win business by keeping costs down and quality up. Yet politicians keep telling us the solution is more insurance. And they mean insurance not just for catastrophic diseases that could bankrupt us but also for routine treatments.

The politicians are so oblivious to reality that they are on course to make things worse. Obama would force every business to either give workers health insurance or pay a fine into the public system. Why is that something we should want employers to do? Premiums come out of our salaries, but insurers are accountable to our bosses, not to us. Why not just have a free market where people can buy whatever kind of health insurance they want? Competition would then bring prices down.

Obama and his Senate allies would limit competition by requiring insurers to cover everyone for the same "fair" price. No "cherry picking," the president says. No charging healthy people less.

They call this "community rating," and it sounds fair. No more cruel "discrimination" against people who have a preexisting condition, obese people or smokers. But such simple-minded one-size-fits-all rules take from insurance companies their best price-dampening tool: Risk-based pricing encourages people to take better care of themselves, just as car-insurance companies reward good drivers. With one-size pricing your car-insurance company must give the town drunk the same deal it gives you. Insane, but the health-insurance industry is playing along. Insurers say that if government forces everyone to have insurance, they will accept all customers regardless of preexisting illnesses.

They also offered to stop charging higher premiums to sick people. They're even giving up on gender differences. Sen. John Kerry huffed, "The disparity between women and men in the individual insurance market is just plain wrong, and it has to change." The president of the industry trade group, Karen M. Ignagni, agreed that disparities "should be eliminated."

Give me a break. Women pay more than men for health insurance for good reason. Despite being healthier than men, they incur higher costs because they go to doctors more often, and they take more medicine. Kerry is pandering. I don't recall him demanding that men be protected from higher life-insurance and auto-insurance premiums.

"Community rating" hides the cost of health care. It's as destructive as ordering fire insurance companies to charge identical premiums for wood frame and stone houses. Universal health insurance with "no discrimination" pricing will make health care costs rise even faster. When politicians interfere with free markets, unintended consequences harm everyone, except the companies that lobby hard enough to protect themselves. Is it too much to expect our rulers to understand this?


Health care is not a right

Amidst all the health care debate, there is one underlying assumption that hardly anyone challenges: the notion that people have a right to health care. The truth is that it’s a nonsensical notion. People no more have a right to health care than they have a right to education, food, or clothing.

After all, what does a right to health care mean? If I have a right to something, then doesn’t that mean that you have a correlative duty to provide it? If you’re a doctor, then it means that you are required to serve my needs, like it or not. If I need an operation, then you cannot say “no” because that would be denying me my right to health care.

Thus, isn’t the right to health care actually a power to force doctors to provide people with medical services?

Now, the proponent of health care as a right might say, “That’s not what I mean. Why, to force doctors to provide health care services to others would be akin to slavery, especially if it’s for free. I think that doctors deserve to be paid for their services.”

Fair enough. But then doesn’t the right to health care entail the power to force someone else to pay for it? Let’s assume, for example, that I need hip-replacement surgery that will cost $25,000 and that I don’t have the money to pay for it. Since I have a right to health care, that means that I have a right to get the money from you to pay for my operation. It also means that you can’t say no because that would be interfering with my right to health care.

Thus, the right to health care entails the power of everyone to get into the pocketbooks of everyone else. That’s not only a ridiculous notion of rights but also a highly destructive one. Since obviously people can’t go and take the money from others directly, it inevitably entails converting government into an engine of seizure and redistribution. Or to paraphrase Bastiat, such a concept of rights converts government into a fiction by which everyone is doing his best to live at the expense of everyone else.

Meanwhile, while everyone is using government to get into everyone else’s pocketbook to pay for his health care expenses, he is simultaneously doing his best to protect his own income and assets from being plundered by the government to fund everyone else’s health care bills.

Over time, it is easy to see how such a system devolves in everyone’s warring against everyone else. It is also easy to see that such a system obviously does not nurture friendly and harmonious relations between people. This is especially true when these types of “rights” expand to such areas as education, food, clothing, and housing.

The true nature of rights — the type of rights the Founding Fathers believed in — involved the right of people to pursue such things as health care, education, clothing, and food and that government cannot legitimately interfere with their ability to do so.

Thus, the right to life, liberty, and the pursuit of happiness, as described in the Declaration of Independence, doesn’t mean that someone else is forced to provide you with the means to sustain or improve your life. It means that government cannot enact laws, rules, or regulations that interfere with or infringe upon your right to pursue such things.

When Americans began looking upon rights as some sort of positive duty on others to provide them with certain things, that was when the quality of health care in America began plummeting. That was what Medicare and Medicaid were all about — the so-called right of poor people and the elderly to health care. It is not a coincidence that what began has the finest health care system in the world has turned into a system that is now in perpetual crisis.

There is one — and only one — solution to America’s health care woes — and it lies not in a government takeover of health care. In fact, the solution is the exact opposite: It is the end of all government involvement in health care — a total separation of health care and the state. That would entail not a reform or improvement of Medicare and Medicaid but rather their total repeal.

At its core, the solution to America’s health care crisis lies in the abandonment of the notion that health care is a right. Once people reach this fundamental realization, as our American ancestors did, the nation can get back on the road toward to a healthy, prosperous, and harmonious society.


1 comment:

Anonymous said...

It seems to me that people in a democratic society, where the government pledges to look after the citizens in a basic sort of way, DO have a right to health care. The problem is that the public think each and every one of them have the right to the most advanced and expensive care from ages 0 to 101. We need to get real and rational, decide what the basic allocations of health care are FOR ALL and what are the trimmings and luxury items- like IVF for instance and aortic stents for 88-year-olds...
We need to make some difficult decisions, implement them, get called "paternalistic bastards" and succeed. It might help if we translated what we're doing into words of one syllable and kept repeating them loudly as well.