Can We Really Eliminate a Virus? The Polio Puzzle

On Wednesday a milestone was established in the fight for the eradication of polio. It has been one year since the last reported case of the childhood disease in Myanmar (data usually takes a month or two to collect so this may change). That makes two countries this year, the other being Somalia, who have surpassed a year without an outbreak in 2008. Currently polio is endemic in four countries: Pakistan, India, Afghanistan, and Nigeria. The organizations who fight the disease encounter a two-fold challenge in each of these countries; immunize all children under 5 with enough doses to be effective, and contain the disease within the country until it can be eliminated. These challenges are further complicated by war, political insecurity, famine and distrust of medicine. To overcome these roadblocks and eliminate the disease will require supreme diligence and innovative ideas from those on the ground in these last few strongholds which continue to spawn cases of polio.

The press to eradicate polio across the globe started in 1988. The World Health Organization (WHO), Rotary International, UNICEF, and most developed countries (with the US far and ahead with greater than $1,000 million US donated so far) set out to conquer the disease that was endemic to over 125 countries. 20 years later only 4 countries suffer through a constant battle to interrupt transmission. 10 other countries reported infections in 2007 and all but 2 have had cases this year (the total cases to-date in 2008 is 453 globally).

One major factor standing in the way of success in many of these countries is political instability and war. Afghanistan and Somalia, as well as parts of Pakistan and Ethiopia, suffer from armed conflicts that make "vaccination logistically difficult and unpredictable at best." But the will of the people on the ground, doctors and volunteers who want to make a difference in their home countries, finds ways to operate around such dangerous situations. Negotiations for 'days of tranquility' (the suspension of hostilities in order to allow for vaccination) have been successful in Sudan and previously in Somalia and Ethiopia. These individuals show great courage and determination in the face of a major roadblock. Many times simply receiving and delivering vaccinations with the workers is a strain on the patience with multiple searches and questions. Soldiers don't take to kindly to strangers, especially those who create large crowds of citizens. But there are success stories from countries with far worse conditions than any face today. Bangladesh, Vietnam, Rwanda, and Zimbabwe all offered serious problems. Polio was eradicated from Angola in the midst of a civil war. In 2002 an outbreak in Kandahar was stopped by a WHO-led mop up crew despite the Afghan war. Currently Afghanistan faces challenges with a power struggle happening in the country. Basic supplies are in short order, many parts are barren or hard to reach by vehicle, and regional conflict has made most villages wary of any outsiders. This final roadblock presents a whole new challenge for the eradication efforts.

Once the organizations have been allowed to organize a vaccination effort the ground campaign must begin to recruit trained medical personnel and volunteers to monitor and administer the vaccine. A huge part of this effort is to inform citizens of the intentions and purpose of the operation. Dr. Atul Gawande, a surgeon from the United States, traveled to his family's native India after his residency to volunteer in the fight against polio. In his book, Better: A Surgeon's Notes on Performance, Gawande writes,

One difficulty came up repeatedly--from local doctors, from villagers, from workers trudging house to house. The question was: Why? Why this huge polio campaign when what we need is--fill in the blank here--clean water (diarrheal illness kills 500,000 Indian children per year), better nutrition (half of children under three have stunted growth), working septic systems (which would help prevent polio as well as other diseases), irrigation (so a single rainless season would not impoverish farming families)? We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in?

There are no simple answers to this question because truly the access to clean water, or good nutrition would save a larger number of children than polio eradication ever will. I know I would have trouble answering questions like that, I know I would explain I was there to do what I could, and polio eradication has been decided as what I can do. An old saying explains a better reason maybe; if you're starving, becoming paralyzed certainly isn't going to help. While it is harsh it is true, the doctors on the ground are just following what they can do to help. These guys are truly what makes the eradication goal a feasible one, the ability to organize and convince the population of the importance in the face of true struggle is a skill that a large organization cannot achieve, only in small step swill individuals gain the trust of an entire population.

Perhaps the goal of global eradication of polio is an absurd ambition, India alone creates a new pool of potential polio victims the size of Venezuela's entire population. Staying caught up means organizing a mammoth campaign to immunize every child under 5, and the cost has been overwhelming. So far about $3 billion has been spent worldwide, more than six hundred dollars a case. To put that in perspective the total health care budget for India's government in 2003 amounted to four dollars per person. The truth is, no cost-benefit analysis calculus can assure us just now that the money is well spent. But this remains a task that as a civilization we can do that would benefit mankind forever. The eradication of smallpox was a gift from the previous generation to all who are to come, and now, perhaps, the eradication of polio can, too. But it will be achieved on the backs of those on the ground who represent a monument to the perfection of performance, showing what can be achieved through diligent detail coupled with great ambition.

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What Does the Hannah Poling Case Prove?

I figured I'd take a minute to address the Hannah Poling case since it deals with a topic I've covered here multiple times; the link (or non-link) of vaccines and autism. Earlier this year the Department of Health and Human Services (DHHS) was sued by the Poling family under the Vaccine Injury Compensation Program (VICP) and won. They successfully argued that vaccines Hannah had received, specifically diphtheria-tetanus-acellular pertussis, Haemophilus influenzae type b (Hib), measles-mumps-rubella (MMR), varicella, and inactivated polio, caused her to develop autism spectrum disorder.

Ok, that's a lot of medical mumbo jumbo, here's the important part; the Vaccine Injury Compensation Program (VICP). This program was created in 1986 because lawyers had sued almost all pharmaceutical companies out of existence, claiming vaccines were the reason for cases of sudden infant death syndrome to epilepsy. By the time it came into existence there was only one manufacturer of the diptheria-tetanus-pertussis vaccine left in the market. The government stepped in with the National Childhood Vaccine Injury Act, which included the creation of the VICP. The Act called for an excise tax on every vaccine and the VICP compiled a list of compensable injuries. If studies supported the notion that vaccines caused a negative reaction -- thrombocytopenia after receipt of measles containing vaccine -- children and their families were given a fair reimbursement quickly and fairly. The number of lawsuits against vaccine makers decreased.

Unfortunately the VICP has recently turned its back on science. In 2005 a woman successfully claimed that a tetanus vaccine caused her optic neuritis. Although there was no evidence, published or otherwise, to support her claim, the VICP ruled that if a petitioner proposed a biologically "plausible" mechanism by which a vaccine could cause harm, as well as a logical sequence of cause and effect, an award should be granted. This opened the door to compensation being given for a whole new host of conditions which have no set of data to prove or disprove the claims.

In 2006 the VICP deviated farther from its original standards than it ever had before when Dorothy Werderitsh successfully claimed that a hepatitis B vaccine caused her multiple sclerosis. By the time of the ruling, several studies had shown that the hep B vaccine neither caused nor exacerbated the disease, and the Institute of Medicine even concluded that "evidence favors rejection of a causal relationship between the two." But the VICP was less impressed by the scientific literature than it was with an expert's proposal of a mechanism by which hep B vaccine could induce autoimmunity (an ironic conclusion, given that Dorothy Wederitsh never had a detectable immune response to the vaccine).

Here are some facts: Natural infections will exacerbate autism spectrum disorder in patients with mitochondrial enzyme deficiencies (what Hannah Poling has), vaccines haven't shown the same. Children with this disorder are especially susceptible to infection so it is recommended they receive all vaccines.

A belief that multiple vaccines overwhelm the immune system is floating around the anti-vax camp. But a century ago children received one vaccine, smallpox, which contained 200 structural and nonstructural proteins. Today, the 14 vaccines given to children contain a total of 150 immunologic components.

Maybe the most important point of this case is that the government has eroded the confidence in the vaccination system without any concrete evidence of mass panic. The problem with letting a few kids skip out or having parents opt out of vaccination compromises herd immunity, a pillar of the vaccination theory. Consequences should be weighed next time a decision like this is made instead of caving to media and political pressure, a precedent has been laid down.

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Senate Passes Genetic Information Nondiscrimination Act

This last week has seen a small victory in healthcare coverage for consumers. The Senate, on a 95-0 vote, passed the Genetic Information Nondiscrimination Act of 2008 (GINA, H.R. 493). The bill's goal is to "prohibit discrimination on the basis of genetic information with respect to health insurance and employment," filling what was considered a large gap in coverage protection of employees' and patients' rights.

This vote has been a long time in the making, with multiple votes coming up on it, but never in the same congressional session. This year, Senate Majority Leader Harry M. Reid (D-Nev) determined that the bill needed to be on the front burner and its about time. Francis S. Collins, director of the National Human Genome Research Institute and leader of the Human Genome Project said, "this is a day for celebration...I think the American public can breathe a sigh of relief that the fear of genetic discrimination, which has basically been a cloud over our future, has been dealt with." (Washington Post, April 24)

This doesn't seem like a big deal now but a big reason of that is due to the doubt citizens had about their coverage if genetic tests were performed. A January survey conducted by the Genetics and Public Policy Center found that 93 percent of respondents would not participate in genetic research projects unless it were illegal for employers and insurers to use the results against them.

And for those of us like myself who work with DNA research and clinical samples, a long standing problem has been solved. During my research many times it is necessary to confirm that my own DNA has not contaminated the samples that I have been working with. The only way to do this is to perform a genetic fingerprint on my own sample and compare it to the working samples. Although I am the only one who uses the information it is written down to document the full procedure. If my employer or insurer happened to find an underlying genetic problem, such as a risk of cancer, heart disease, or diabetes, previously they would have had the right to terminate my employment or coverage in order to save themselves the problem in the future.

There are still some questions that were not answered in the bill including life insurance, but a gaping hole in employee and patients rights has been closed.

The bigger debate surrounding this issue should be under what circumstances should it be right for health insurers to decline coverage? Under a more sophisticated and consumer friendly system, such protection would be completely irrelevant, as nobody could arbitrarily be declined care. The Congress has put a band-aid on a system that needs a complete reconstructive operation, but until there is an administration in the White House who cares to acknowledge the damage a market-driven system has inflicted on America's health and pocketbooks, this looks to be all Congress can do.

I'll take a quote from Barack Obama's new book, The Audacity of Hope, to explain a pragmatic way to look at the healthcare problem for those that really think accessible, affordable healthcare should be spurned in favor of a pay-or-die attitude.

"Given the amount of money we spend on health care (more per capita than any other nation), we should be able to provide basic coverage to every single American. But we can't sustain current rates of health-care inflation every year; we have to contain costs for the entire system, including Medicare and Medicaid. With Americans changing jobs more frequently, more likely to go through spells of unemployment, and more likely to work part-time or to be self-employed, health insurance can't just run through employers anymore. It needs to be portable." (The Audacity of Hope, p. 184)

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McCain's Healthcare Debacle

Ok, so I know this is becoming a common theme here at StifledMind, but I'm going to hit it again anyway. John McCain is a fucking moron.

I know, I know, we're supposed to be talking about how OUTRAGEOUS the distraction issue between Obama and his former pastor has become. How Obama's statement of disagreement with some of Wright's opinions is THE SURE AND FINAL SIGN that Barack just doesn't have what it takes to be the president.

/sigh

Ok, but in the real world, children are still missing necessary checkups, the ill are not able to afford their medication, and people are actually dieing because they can't pay to live. Obviously, we are talking about the more impoverished segment of the population, for if a person can afford to provide their children or themselves with healthcare, I would imagine they would. So McCain has devised a solution, and is anyone surprised that its a near mirror-reflection of Bush's laughable proposal in 2007? McBush strikes again. This dottering fool wants to offer tax breaks to individuals who purchase their own health insurance. Sounds good, huh? Except the majority of people who do not have insurance now, do not pay taxes either due to their income levels. A tax break for people who don't pay taxes isn't much of a break is it? And by removing the tax incentives for companies to provide insurance for their employees, those employer programs will also suffer, if not vanish, as a result.

McDumbass, like the modern GOP, is disastrously out of touch of the needs of Americans. We don't need crumbs-from-the-table tax deals to help us afford private insurance. Hell, we don't need any damned insurance at all. What we need is heathcare. We need the profit calculations to be removed from decisions about our physical well-being. We need a government which advocates for the People, not the corporations. Take a look at McSame's proposal, and guess which of those two it favors...

Yeah, I'm sad too.

And we're not following the media on this issue today, here's a post from March 11th featured on StifledMind detailing why McCain's plan will fail.

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Wal Mart Does The Right Thing

I don't think we've covered it here yet but this is a pretty disturbing story. In short, Deborah Shank was an overnight shelf-stocker at Wal Mart who was broadsided by a semi truck. She suffered horrendous injuries including permanent brain damage. Unable to walk without help, she lost the ability to care for herself or interact meaningfully with her family. Now 52, she lives in a nursing home.

Deborah, through an agent, settled with the trucking company and set up a trust to ensure her long-term care. But Wal Mart lawyers, citing a clause in her health benefits, sued for all money their health plan had covered after her accident. Even though they were technically right, morally it is wrong to take this woman's only means of ensured care. They even sued for court costs and won! The case went all the way to the supreme court and they didn't even hear the case, giving Wal Mart the decisive win.

But today Wal Mart executives say they do not plan to collect on their court winnings. In a humane and unexpected turn of events the huge corporation has decided to swallow their pride and give this woman a means of survival, hell they even ate all of their court costs. So I guess chalk one up for big corporations, the score should be about 3,945,489,283 to 1 now.

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McCain's Healthcare Nightm...excuse me, Plan

Lets take a look at the state of our Healthcare system really quick. Yale Professor Jacob Hacker sums it up pretty well:

"Among insured Americans, 51 million spend more than 10 percent of their income on medical care. One out of six working-age adults—27 million Americans—are carrying medical debt, and 70 percent had insurance when they incurred it. Of those with private insurance and medical debt, fully half have incomes greater than $40,000, and of this group a third are college graduates or have had postgraduate education." - Professor Jacob Hacker, Testimony Before the Committee on Health, Education, Labor, and Pensions, United States Senate, Washington, D.C., 01/16/07

Or maybe we can turn to Harvard Medical School Professor David Himmelstein who says:

"'I think the message that we take away is, really, nobody is safe in our country. Short of (Microsoft Chairman) Bill Gates, if you're sick enough long enough, you're likely to be financially ruined,' cautioned study author Dr. David Himmelstein, an associate professor of medicine at Harvard Medical School. 'We're all one serious illness away from bankruptcy,' he added." - Karen Pallarito, "Health Medical Problems Cause Half of Personal Bankruptcies," Forbes.com, 02/02/05

That is absolutely crazy, one is six INSURED American have substantial problems paying their medical bills. So what's McCain' plan?

McCain's main healthcare ideas are increased corporate competition to supposedly limit rising costs and tax credits to encourage the uninsured to buy insurance. Neither will do any more than perpetuate the dismal status quo.

Once-a-year tax credits benefit the same people who benefit from Bush's tax cuts, the moderately wealthy. Those who need coverage most will still be unable to afford premiums that now average over $12,000 per family, not including skyrocketing deductibles, co-pays, drug and hospital charges, and other fees.

The idea that corporate competition will curb spending is pretty ludacris. Under the stewardship of a market friendly administration the past decade, premiums have jumped 87 percent, far outpacing inflation and wage increases. Insurance companies don't compete by delivering more care or lowering prices. They compete by harvesting more customers and slashing their costs.

Employers continue to slash coverage as their two largest spending items are wages and health benefits. As their cost increases the employer responds by either passing the higher costs to the employee or discontinuing coverage options.

This is another incident of our politicians laying in bed with big corporations. John McCain will do nothing to ease the burden of medical costs for the poor, middle class and working Americans. This plan is ignorantly short-sighted. While other countries around the world are finding ways to protect and cover all of their citizens McCain's plan has no mention of providing coverage for those who live below the poverty line. Hell, his plan won't even benefit the normal American, so why the fuck is it a good plan? Its not, its a fucking disaster is what it is. Take a look at the big oil companies because the pharmaceutical and insurance companies are about to join them in the news with record breaking profits and exhorbinant CEO salaries. I wish I could stick my foot as far up McCain's ass as he's about to do to us.

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Mental Health Coverage Parity Bill Passes House

Today H.R. 1424, the Paul Wellstone Mental Health and Addiction Equity Act was passed by the US House. This is a major development in the struggle for sane, fair healthcare for Americans. Until this bill becomes law, insurance companies are able to deny coverage for most mental health and addiction issues, leaving millions of Americans, who give hard-earned dollars to these corporations for their policies, out in the cold if their medical crisis comes in the form of a mental illness. The merits of this bill are debatable, particularly in light of competing bills in both the House and Senate. But this marks the first time Republican efforts to deny health insurance to the mentally disabled, and shield the Heath Corps from the financial burden of actually providing meaningful coverage, has been thwarted by Congressional Democrats.

Hey, I know it’s a baby step, but any progress is a good thing, and a freakin’ miracle to boot in this era of Pax-Republicana.

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Universal Healthcare?

For what its worth, in about 2-3 months the Presidential race is going to heat up and hopefully some real issues will cross the table. Healthcare will definitely be one of these issues and the big debate will be on whether to keep our current system or switch to a publicly managed insurance system.

I make no secret that Universal healthcare should be a pillar of modern society and public health. With the amount of travel and personal exposure due to rising population density it is important that we value the health of our neighbors and fellow citizens.

So my question is why is there such an upwelling of support against a universally accepted insurance program? Currently in the US we have 2 different publicly managed insurance programs. One is Medicare/Medicaid and the other is the for national children's health insurance. Currently most Americans are happy with this system and believe that it is right to help insure those with fixed incomes and those too young to care for themselves.

In 2001, the median income for Medicare receiving families was $20,000. The cost of Medicare is 15% of the cost for private coverage which means many of these families could never afford private insurance. It is estimated that 43 million individuals who are not on a fixed income receive Medicare benefits, that is over 10% of the nation (most in the working population) that would not be covered if not for the public system now in place.

Another concern is exactly how we're going to pay for this. And that is a good question that policy makers will have to address going forward. One fallacy of universal healthcare is that we will have to pay to insure those who aren't contributing to the healthcare fund. While this may be true and another roadblock to universal coverage, the truth is that many people today are receiving treatment at our public hospitals and not paying for it. Many of these people contribute very little to no tax revenue and are still receiving services at no charge. These services and time logged by physicians and nurses still have to be paid, they are not a pro-bono service, and will receive payments whether the patient can pay or not. This payment comes in the form of increased insurance premiums and elevated cost of service.

If a hospital can expect 60% of people receiving CT scans to be able to pay, the cost of each CT scan is going to rise as the cost of unpaid service has to be ameliorated through a concurrent price increase in each individual procedure. Now that a CT scan price has increased any insurance company with a client receiving a CT scan will now have to pay more for the procedure than previously. The rise in price is not absorbed by anyone other than the patient themselves as their premiums and most likely deductible will continue to rise as the insurance company is responsible for higher procedural payments. To compound the problem, the insurance company is not seeking good faith and word of mouth advertising, they are looking at their profits.

Here is another reason why healthcare here is so expensive. If a procedure costs $100 and the insurance company is responsible for $80 your copay is $20. That doesn't sound too bad, but why do you have to pay $300 a month to maintain your coverage? The answer is profits. In order for the insurance company to make money the consumer must pay above and beyond the cost of care received. Its really a simple equation, if the insurance company has to pay X you can be sure that you will be contributing X + Y to the insurance company in order to feed its profits. So you are paying both for your coverage and services received and the profit margin for the company. This is ridiculous, and add to it the cost of the doctor's profits and you are looking at a steep price with hidden profits behind every procedure you have done. If these companies are allowed to reap in huge profits it is not coming from the hospitals, physicians, or government, its coming from our pockets!

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NEJM Blasts Bush on S-CHIP Stance

In the latest edition of the New England Journal of Medicine, Sara Rosenbaum writes a scathing article detailing why Bush's opposition to S-CHIP (State Children's Health Insurance Program) isn't based on economics, but rather Bush's right-wing dogmas.

This is just another example of the administration putting the screws to those who aren't in their party. How can you withhold care to millions of children because you're afraid of exposing huge corporate machines in the insurance industry. Its time that the power in this country get out of the pockets of large corporations. It is insane that healthcare in this country costs more for every single product or procedure than those countries we count among our peers.

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