Preventive care

Preventive care. Good, right? Prevent diseases from occurring in the first place instead of treating those conditions once they occur. Sure, sounds great! And it probably saves money too, right? Wrong.

While prevention makes good sense, and should happen (in most cases, anyway), prevention does not save money. (See this Kaiser article.) There are some exceptions. Childhood immunizations by and large save money, as do smoking cessation programs. But Pap smears, screening for prostate cancer, and other preventive care programs do not save money.

Many involved with health care reform mistakenly tout that these new prevention measures will save us money in the long run. That simply isn't true. Adding prostate cancer screening, for example, will cost Medicare $2.8 billion over 10 years.

Please don't misunderstand me. I am a big proponent of cost-effective preventive care. Stressing the cost-effective part. Cost-effective doesn't necessarily mean cost saving. If the intervention costs less than, say, $50,000 per life year saved, it may be deemed cost-effective. (This is an arbitrary figure that just illustrates how cost effectiveness is measured. An intervention may cost $1 per life year saved - pretty good! - or $1 million per life year saved - pretty bad! - and the cutoff point is VERY subjective.

Let's take the example of cervical cancer screening. Screening women (who have had a normal Pap smear) for cervical cancer every 3 years costs $262,800 per life year saved vesus the $1.1 million screening every year. (Russell's "Educated Guesses") Indeed, the Agency for Healthcare Research and Quality (AHRQ) does not recommend annual screening, because there is no evidence "that annual screening achieves better outcomes than screening every 3 years."

So, in sum, preventive care is not always cost-effective. Sometimes it is. Sometime it's not. But the determination of when something is cost-effective is extraordinarily subjective. Screening your mother for breast cancer may be worth $1 million to you but only $1 to someone else. It's a very tricky business.

More articles about prevention:
Health prevention often costs more than it saves
Do prevention or treatment services save money? The wrong debate
Preventive care and cost savings
Preventive care not always cost effective
Does preventive care save money?

News links

Several interesting articles from the weekend that may be of interest:

• Keeping healthy while flying - Spreading germs on a plane can be mitigated by keeping your hands clean (duh) and using common-sense public health practices.
• Possible vaccine controversy with the coming H1N1 vaccine - The author discusses the importance of a public education campaign around vaccine safety.
• Our very own Lisa had an article published in a recent MMWR! This article discusses the paper about the National Electronic Disease Surveillance System (NEDSS).
• The House passed a food safety bill - This bill will require more frequent FDA inspections.
• Mental health is an important issue in the military - This article discusses suicide rates among soldiers.
  
• And, just for fun, Michael Pollan had a recent article discussing the changes in American cooking habits in light of the new Julia Child movie, "Julie & Julia." I thought it was an interesting article.
  

H1N1 Vaccine News

CDC has released the latest H1N1 vaccine news and the priority populations for receiving the vaccine. The Advisory Committee on Immunization Practices (ACIP) met yesterday and determined recommendations. Priority populations include:

• pregnant women,
• infant caregivers,
  
• health care and emergency workers,
  
• those 6 months - 4 years old, and
  
• those 5 - 18 years old who have a complicating health condition such as a compromised immune system or chronic health disorder.

Before the vaccine is widely released, it will go through a series of clinical trials to test for safety. Officials are hoping the vaccine, made by 5 companies, will be available in October. It is important to note that there will be two influenza vaccines this fall: one for the H1N1 virus and one for the 'normal' seasonal virus. Each protects against a separate strain, and you will need to be vaccinated against both for full influenza protection.

Atlanta Journal-Constitution article
MMWR article about seasonal influenza vaccine

Obesity & Upstream Issues

Essentially, obesity boils down to one issue: People take in more calories than they expend. But of course we know there are many other issues that contribute to this: cost of food, access to healthy foods and environments, media and advertising, school lunch programs, agricultural subsidies, and more.

According to CDC, obesity costs the U.S. $47.5 million, and that's a 1998 figure! This USA Today article puts that figure much higher, around $147 billion. And check out this website to see a chronological view of how obesity has spread throughout the U.S. from 1985 to 2008 - it's disgusting how widespread it is!

The new movie Food, Inc. hits on some upstream issues associated with obesity, some of which are mentioned above in this posting. Cost of and access to healthy foods and environments are a huge issue; healthy foods cost more than unhealthy foods.

Agricultural subsidies are a huge part of this. The U.S. government pays farmers to grow tons upon tons of corn and soybean crops which lead to tons upon tons of high fructose corn syrup, hydrogenated soybean oil, and feed for beef and pork. I did some fascinating research on this subject in grad school and found that many, many issues are intertwined to make this issue very complex.

Some links to get you started:
A report from UC-Davis
A NY Times article
A British Medical Journal article
"The Fat of the Land"
Food and Water Watch - a watch-dog type group
A Michael Pollan article

Happy reading! Now you'll see why I try to eat organic or grass-fed beef and chicken now. And why the Farm Bill should be called the Food Bill.

It's all connected. A very interesting topic.

Public health in Africa Part 1: HIV

My trip to Africa was amazing! Beyond the huge number of animals we saw, interacting with the people was an especially wonderful component of the trip. We went to Botswana, Namibia, and Zimbabwe, with a stop in South Africa.

Africa is a complex continent, especially when it comes to HIV. The HIV rates are staggering. In Botswana, 23.9% of adults are infected with HIV, an unbelievable figure. Namibia, Zimbabwe, and South Africa are slightly lower, but not much. This article published in today's NY Times details South Africa's lag in circumcision and fighting their high HIV rate.

While in South Africa for the day, my family and I visited a public hospital in Johannesburg. It was a sobering visit. We saw overcrowded wards, almost 100 children in a pediatric ward that is supposed to house many fewer patients. The neonatal intensive care unit was also overburdened, a unit whose patients need critical personalized care. The hospital was in need of supplies and staff. One nurse told us that they have a big problem with orphans whose parents have died of AIDS. It was very eye-opening.

We saw several ads for HIV prevention, in the form of posters and billboards. We also saw a free condom dispenser. One of our tour guides wore a T-shirt that said "We are getting tested in Caprivi", a walking advertisement for prevention.


So there is some progress being made. But it is slow. It was quite a trip.

Cancer screening

One of the most interesting classes I took in grad school examined the cost effectiveness of various public health interventions. We discussed prostrate cancer screening, cholesterol screening, and cervical cancer screening. It was fascinating to learn that many public health prevention interventions make sense but are not always cost effective. That's another story.

Today, the issue is cancer screening. According to this article in the NY Times, screening the entire population for certain types of cancer is not cost effective and can even be harmful. Certainly cancer screening generally is positive - and screening for some types of cancer is very useful. Don't get me wrong, I'm not down on screening generally. But blanket screening is not helpful and "do come with medical risks" as well as economic costs.

This article states that there are several possible bad outcomes, including "needless anxiety," "unnecessary procedures that can lead to complications," and false positives, to name a few. "Screening is useful only if, on balance, the deaths prevented by treating cancers outweigh the harm done by treatments that are not medically necessary."

For example, the federal recommendations for cancer tests include cervical cancer screening - but the catch is that the recommendation is to screen every 3 years. Many women are told to come in annually. Part of this is to get women in the door to make sure they are healthy overall, but part of this is needless screening. Women who have had 3 normal Pap smears in a row can receive cervical cancer screening every 3 years, not every year.

The bottom line: Talk to your physician about which screenings are appropriate for your age, lifestyle, risk factors, and family history. You may need some, but you may not need all.

WHO to stop tracking H1N1 cases

Wow, it's been awhile! I've been out of the country (Africa!) and we've been busy here at the office. I will post a public-health-related posting about Africa, which was fascinating, but for now, here is a little H1N1 update.

Apparently, WHO says it will stop tracking H1N1 cases. Very interesting. It said in a "briefing note" posted on the website late Thursday that tracking would cease. One of the reasons indicated is that poorer countries are having a hard time keeping up with the load on their epidemiologists and laboratories. The website says that "there is still an ongoing need in all countries to closely monitor unusual events, such as clusters of cases of severe or fatal pandemic (H1N1) 2009 virus infection, clusters of respiratory illness requiring hospitalization, or unexplained or unusual clinical patterns associated with serious or fatal cases." New countries with H1N1, however, will still be reported on the WHO website.

It is unclear what the agency will track exactly now. Dr. Michael Osterholm, quoted in the NY Times article, says that "bad measures can be worse than no measure at all" and that he hopes this "will force the public health community to come up with better [measures]."

Very interesting. We'll have to keep an eye on this.