Health for all (once again)

Achieving Health for All: Primary Health Care in Action

From chapter 2 of the book, on life expectancy and GDP (Preston curve)

The list of best-performing countries is still limited because it is often the case that a country looks like it is deriving a high health output from minimal economic growth simply because it has had a prolonged spell of economic stagnation, and health improvements are simply occurring as a result of secular trends set up by past introductions of public health technology. Thus, what often appear to be “top-performing” countries in climbing the Preston Curve frequently appear successful because of stagnant and barely positive economic growth. The project of empirically identifying exemplary countries achieving good health at low cost or “punching above their weight” needs to reexamine foundational assumptions about (1) whether countries are actually engaged in transforming economic growth into better health and (2) what counts as a valid comparison group for a given country at a given time depending on its starting LEB.

 

Cheap crime

Financial Penalties Imposed on Large Pharmaceutical Firms for Illegal Activities

From JAMA: 

Among 26 firms in our sample, 22 (85%) had financial penalties for illegal activities. The combined dollar value of financial penalties totaled $33 billion for 2003 to 2016. Eleven firms with financial penalties exceeding $1 billion in inflation-adjusted dollars accounted for $28.8 billion (88%) of the total penalties (Table 1). The firms with the highest penalties as a percentage of revenues (ie, >1%) were Schering-Plough, GlaxoSmithKline, Allergan, and Wyeth; the number of penalties for these firms varied between 1 (Allergan) and 27 (GlaxoSmithKline). Four firms had financial penalties that totaled less than $80 million and no more than 2 penalty settlements (Actavis [Watson], Roche Group, Genzyme, and Perrigo). All but 1 firm (Perrigo) engaged in illegal activities associated with penalties for 4 or more years. An additional 4 firms received no financial penalties for illegal activities during this period. The most common types of illegal activity involving penalties (Table 2) were pricing violations, off-label marketing, and kickbacks. The firms with the greatest variety in the types of illegal activities involving penalties were GlaxoSmithKline, Bristol Myers Squibb, and Merck. Three firms (Actavis, Allergan, and Perrigo) had penalties limited to a single violation type.

 

That's it.

Prophets and self-fulfilling prophecies

 The Corona Crash. How the Pandemic Will Change Capitalism

Always you may find a prophet around the corner. Fukuyama predicted the end of history, the triumph of liberal democracy and the arrival of post-ideological world. Recently Y. N. Harari predicted the end of liberalism and the arrival of a post-humanism and nothing happened. The history goes on and some of them only may expect that their predictions transform into self-fulfilling prophecies. This is the case of today's book. It distorts reality to adjust to the ideology and desires of the author. I must say that some parts may be true, but on the whole, reading it is a waste of time in my opinion. Just some pieces, and you may judge:

In this context, the suggestion that governments must refrain from ‘interfering’ in the forces of free market competition to create jobs, reduce inequality and increase environmental sustainability is laughable. We do not live in a competitive economy – we live in a planned economy. But the planning is not democratic – it is being undertaken by central bankers, senior politicians and their advisors in big business and finance.

For the rich world, the lesson of the coronavirus crisis is that states can spend to meet the needs of their populations without limit. For the vast majority of the world’s population, this crisis will simply reinforce what they already knew: that the poorer, less powerful members of the international ‘community’ most certainly can’t. Socialists in the Global North must learn the right lesson: that the limits of fiscal policy are determined by political power. International solidarity requires us to return to the issue of debt forgiveness and push for relief for Global South states when this crisis is over.

The free market ideology which serves to legitimise forms of government intervention that support the interests of capital and prohibit state interventions that might increase the power of workers has been placed under significant strain in the period since the financial crisis. As we have seen, the foundation of this ideology is the separation between politics and economics.

You may remember that with the great recession there were voices saying that capitalism was in crisis and there was a need to rebuild it. And?. Any system lives in continous unstability. This is not the end, it needs an urgent fine tuning right now but absolutely different from the book proposal.

 

Digitization and health professionals

 Empowering the health workforce Strategies to make the most of the digital revolution

From the latest OECD report: 

In order to enable a successful digital transformation of health systems and overcome barriers governments need to provide the necessary political leadership and implement a range of policy actions to support three main objectives:

• build trust in the benefits of digital transformation among health workers and patients whileminimising any risks, which requires guaranteeing proper assessment of technology;
• advance the expertise and skills needed for the safe and effective use of digital health technologies;
• adapt the institutional environment – i.e. the legal, financial, and organisational frameworks –to enable the full potential of the technologies

 These messages sound familiar and general, details inside the report. However, there is a long way to go in order to achieve a real digital transformation.

Bill Brandt 

The time to stop recreational testing has come

 Direct-to-Consumer Genetic Testing: Value and Risk

Piecing together information from a variety of sources, one reporter concluded that by early 2019, more than 26 million people worldwide had been tested by the four leading companies, 23andMe, Ancestry, Gene By Gene, and MyHeritage (1). That volume was fueled by aggressive marketing, including discounts in the lead-up to major holidays to promote gifting of test kits. As of May 2020, the  undiscounted price of the basic test offered by the leading companies was $59–$99.

This is an example of what should not had happened. Recreative genomics doesn't add value and increases uncertainty and anxiety. 

Although many consumers of DTCgenetic testing express an intention to modify their lifestyle to address risk factors, studies typically show no changes at follow-up (15, 30). In the PGen Study, 59% of participants said that test results would influence their management of their health (31). However, an analysis of the 762 participants who had complete cancer-related data found that those who received elevated risk estimates were not significantly more likely to change lifestyle or engage in cancer screening than those who received average or below-average risk estimates (44). It may be relevant that no participants tested positive for pathogenic variants in highly penetrant cancer susceptibility genes. As for population health, the Centers for Disease Control and Prevention identify three conditions—hereditary breast and ovarian cancer syndrome,Lynch syndrome, and familial hypercholesterolemia—that are poorly ascertained despite the potential for early detection and intervention to significantly reduce morbidity and mortality (45). The hope is that DTC genetic testing could improve the situation (15). However,DTC genetic testing as currently carried out is likely to fill gaps in haphazard fashion, given the characteristics of purchasers, the scope of available products, and integration issues.

One message. Right now and until we don't know the implications of recreational genetic testing, direct to consumers testing should stop.

Banksy

 

Q&A COVID-19, economics and health

 Diálogos en la interfaz de la economía y la salud a propósito de la covid-19

A new book of interest has been released on economics and health perspectives on COVID-19. One message from the introduction: 

En definitiva, resulta controvertido el juzgar la bondad de nuestros sistemas de salud, puestos hoy a prueba con el stress test de la COVID-19. Algunos apuntan a que los recortes presupuestarios son los responsables de que España gaste poco en sanidad. Esto es erróneo; los recortes son coyunturales y responden a procesos normales de consolidación fiscal. El problema es estructural de baja financiación del sistema sanitario, desde la interpretación política de qué parte de la recaudación tributaria se ha de dedicar a cada  una de las parcelas del gasto social o, en su falta, el compromiso a articular medidas complementarias de financiación. Como consecuencia de todo ello, se ha instalado en el sector cierta resistencia contra la contención del gasto sanitario público. El modo en el que los profesionales sanitarios han respondido a la pandemia avalaría dicha posición. Otros piensan que más allá de los recursos disponibles, la razón fundamental de nuestros déficits es la gobernanza con la que las instituciones sanitarias desarrollan su actividad: es la rigidez y no la falta de musculatura lo que dificulta adaptaciones flexibles a las diferentes coyunturas. Dicha percepción pone el foco en la diferente genética de los sistemas públicos, ya organizados como servicios nacionales de salud o como sistemas de aseguramiento social sanitario. Por otra parte, las cifras de gasto como indicadores de buen o mal funcionamiento ofrecen a menudo falsas pistas que no permiten resolver por esta vía las bondades relativas a través de simples indicadores cuantitativos.

There are many more messages in a Q&A format. Inspiring.

 Banksy

Health reform zombies (2)

 THE NEXT GENERATION of HEALTH REFORMS

Three years ago in a OECD Health Ministerial meeting, everyone accepted the statement on the criteria for next health reforms. Now, 3 years later, we can confirm that nothing happened about it.

Inside the document there was also a recommendation on health data governance. And the same, nothing happened.

That's it, an extraordinary built narrative that leads to nowhere. Death and taxes remain as only truths.

Banksy

Health expenditure at a glance, or how Bulgaria spends the same as Catalonia

 Health at a Glance: Europe 2020. STATE OF HEALTH IN THE EU CYCLE

Health expenditure as a share of GDP, 2019 (or nearest year)

Catalonia spends 7,5% of GDP in health, like Bulgaria

Health expenditure as a share of GDP, EU27 and selected countries, 2005-19

Health expenditure by type of financing, 2018 (or nearest year)

Health expenditure from public sources as share of total health spending, 2018 (or nearest year)

Mazzucato as a supplier of a flattering narrative for politicians

 The Myth of the Entrepreneurial State

Some delicious words by Deirdre McCloskey on Mazzucato recent contributions:

Mazzucato, a loyal daughter of the left, is suspicious of private gain, of the sort you pursue when you go shopping, say, and is therefore suspicious of people doing things for a private reward. She wants the State, advised by herself, to decide for you. Yet the private entrepreneur, she would concede, gets a reward if she pleases her customers. And it is in fact what Mazzucato in her own trade has done. She has parachuted herself into the center of the debate about the role of state planning as against private profit-making for innovation and allocation. It is not because she is innovative herself (though that is what her brave rhetoric suggests), but because she is, market-style, giving people what most of them want: magical thinking, mythical certitude, free lunches all around, wise and loving parents guiding the people in a coerced routine from on high. Modern “statism.” Her theory is the illiberal one that has dominated economics since John Maynard Keynes eight decades ago spoke out loud and bold.

 The statists imagine that it is always COVID-19 time, for anything: the legitimate actions by a State to suppress a plague or a forest fire or a military invasion are to be applied to all manner of private matters, always, with no such persuasive claim to legitimacy as fighting plagues, forest fires, or invasions, being technically speaking public goods. Braiding hair for a living is to be regulated by the State. Innovation and allocation, says Mazzucato in particular, are to be socialized.

And we could say that Deirdre is a loyal daughter of the right. And no problem. However, you may imagine what follows...in her book. I have read Mazzucato and part of her arguments are convincing. However, there is a need for a balanced perspective according to the current trends. Deirdre provides such perspective. A book that deserves to be read.

The claims of reason and the imperative of power

The Professor and the Politician. For Max Weber, only the most heroic figures could generate meaning in the world. Does his theory hold up today?

Charisma and Disenchantment: The Vocation Lectures

For Max Weber:

The professor and the politician are not figures to be joined. Each remains a lonely hero of heavy burden, sent to ride against his particular foe: the overly structured institution of the modern mind, the overly structured institution of the modern state.

 The politician needs to convert effort into effect, to “make an impression” on the world. But there’s a fine line between molding the world into a shape and needing to see one’s signature at the base of it. The politician is always at risk of swapping out “actual power”—power tethered to purpose—for “the brilliant appearance of power”—power untethered from purpose. The first is the aim of the true politician; the second, the temptation of vanity, which is “the deadly enemy of any commitment to one’s goals.” When a politician gives in to vanity, amending or adapting his aims in order to perform effectiveness, his power is drained of its design.

 The spectre haunting Weber is neither bureaucracy nor capitalism (although capitalism does play an under-remarked role in these lectures). Instead, it’s an ancient tension between hero and fate, transposed to modern life. Where classical tragedy sees the hero felled by a destiny that he resists, the nemesis of the Weberian actor is absorption in the institutions that he’s meant to oppose. Society is a siren, forever tempting us to forsake our tasks and seek the smaller goods of reputation and status. The scholar becomes a scribe; the politician, a hack. The danger is not defeat of the opposing self from without but corruption of the self from within, where the self’s diminishing desire to oppose comports all too well with society’s needs.

Great op-ed by Corey Robin at The New Yorker.

Joana Biarnés

 

Prioritising the vaccine

 Framework for Equitable Allocation of COVID-19 Vaccine

Health equity is intertwined with the impact of COVID-19 and there are certain populations that are at increased risk of severe illness or death from COVID-19. In the United States and worldwide, the pandemic is having a disproportionate impact on people who are already disadvantaged by virtue of their race and ethnicity, age, health status, residence, occupation, socioeconomic condition, or other contributing factors.

Framework for Equitable Allocation of COVID-19 Vaccine offers an overarching framework for vaccine allocation to assist policy makers in the domestic and global health communities. Built on widely accepted foundational principles and recognizing the distinctive characteristics of COVID-19, this report's recommendations address the commitments needed to implement equitable allocation policies for COVID-19 vaccine.

If vaccines are coming in the next months and we all agree that supply will not fulfill demand, then we need to prioritise. This publication of the National Academy of Medicine provides some usegul insights. However, the most important is to have a concrete application in specific contexts.

Joana Biarnés

Health Reform Zombies

 Better Now. SIX BIG IDEAS TO IMPROVE HEALTH CARE FOR ALL CANADIANS

Morris Barer and Bob Evans first coined the term “health care zombies” in 1998. A health care zombie is a terrible idea about health care that refuses to die. No matter how many times you drive an evidence-based stake through its heart, it rises from the (un)dead to confront you in the newspapers of the nation, ruining a perfectly good morning cup of coffee.

These ideas have often been proposed as solutions to the pressures on our health care system. But they’ve all been shown, time and time again, to weaken health care quality and sustainability. They also undermine our shared values.

These words sound familiar in our context. However it comes from a canadian book.

A canadian physician reflects her views in a well written book about the health reform. It says:

When care is necessary to improve health, every Canadian deserves reasonable access to it. That means solutions to wait times that help everyone, not just people who can afford to pay for their care. And it means finally bringing medicines under medicare. Across the country, people like Ahmed the taxi driver are forced to sacrifice their long-term health because of the short-term crunch of prescription drug costs. Alongside that profound inequity lives the uncomfortable truth that we pay some of the highest prices in the world for our prescription medicines. Only our governments can take the necessary steps to establish a national pharmacare program that would ensure access, safety, and appropriate use of medicines at a cost that is affordable not just for governments, but also for citizens and for employers.

It is quite incredible that canadians don't have drugs in the benefits package. And this is the outline of the book:

THE BASICS

Dr. Martin Goes to Washington

Getting Our Facts Straight

Taking the Pulse of the System

Health Care Zombies

BIG IDEA 1 Abida: The Return to Relationships

Primary Care: When It Works, It Works

Three Relationships for Health

Rewarding What Matters

BIG IDEA 2 Ahmed: A Nation with a Drug Problem

Medicare’s Unfinished Business

The Price Is Wrong

Prescribing Smarter

BIG IDEA 3 Sam: Don’t Just Do Something, Stand There

The Compulsion to Cure

Slow Medicine

BIG IDEA 4 Susan: Doing More with Less

The Revolving Door of Health Care

What Better Looks Like

The F-Word

BIG IDEA 5 Leslie: Basic Income for Basic Health

Sick with Poverty

Curing Income Deficiency

BIG IDEA 6 Jonah: The Anatomy of Change

From Pilot Project to System Solution

Data: The Brain of the System

The Heart of the Matter

Feet to Do the Walking

CONCLUSION Worthy Action

 

Paying for (Artificial) Intelligence

 The US Government Will Pay Doctors to Use These AI Algorithms

The US Centers for Medicare & Medicaid Services (CMS) recently said it would pay for use of two AI systems: one that can diagnose a complication of diabetes that causes blindness, and another that alerts a specialist when a brain scan suggests a patient has suffered a stroke. The decisions are notable for more than just Medicare and Medicaid patients—they could help drive much wider use of AI in health care.

The incentives for technology adoption are related to professionalism, organizational, and economic. In this case are the latter one.Though, FDA must have cleared both algorithms, and this is the case. 

We could also think on using AI for reducing radiation exposure in CT scans for example..

EU is lagging behind developed countries in this (and many other issues)...

Prioritising population health or the economy (2)

  The Pandemic Information Gap. The Brutal Economics of COVID-19

Joshua Gans has updated his former book on covid economics. And says:

Pandemics are an information problem. Solve the information problem and you can defeat the virus. There is a big difference between knowing someone you interact with is infectious and having to make a guess as to whether that person is infectious. In the former case, you can act and limit the interactions. In the latter case, you have to take a risk. And, in evaluating that risk, what we care about is not just whether you become infected but also whether you might pass that infection on to others.

 The difference between perfect knowledge and no knowledge is what causes an infectious disease to have an impact on social and economic interactions. With perfect knowledge, some people get sick, they are isolated, and life is (for most of us) essentially unchanged. With no knowledge at all and no interventions to prevent infections, then for COVID-19, at its peak, about 21 million people in the United States alone would likely be infectious at one time. With no restrictions on activity, the probability that you interact with one of the infectious people on a given day is 21 million divided by 327 million (the US population), or 6.4 percent.4 However, suppose you interact with only 10 people per week. In that situation, the probability that you are able to avoid any of those infected people is about 50-50. When going to public spaces, you may interact with over a hundred people per week. In that case, your probability of avoiding an infected person becomes close to zero. In other words, perfect knowledge allows you to avoid all infected people. No knowledge makes it near certain that you will encounter at least one infected person.

 Without knowledge of how many people are infected and whether particular people are carriers of thecoronavirus, we are forced to take drastic actions.

True. Pandemics are an information problem but information will never be perfect and complete. Uncertainty sorrounds us. And pandemics are more than an information problem. Because you may know who is infected, and not "act and limit interactions". Therefore, emotions, incentives and expectations count. We do have also a behavioral problem. And if it is behavioral, it has ethical implications. And finally, that's life, decisions with or without information and behavioral and ethical implications of such decisions.

Anyway, a useful introductory text.