I started, about two weeks back, with a radio interview that I listened to which had to do with health and health service provision. The particular interview was concerning the state funding of herceptin for women at risk of breast cancer.
Hot on the heels (heals?) of that came a tv doco on the international drug companies and the “invention is the mother of necessity” principle. Included here was the “invention” of new diseases such as ADHD, used to provide a market for drugs such as Ritalin; “bipolar disorder” – not to be confused with “manic-depressives”? -; cholesterol “imbalances", used to provide a market for beta-blockers etc; right through to the current favourites of “restless leg syndrome” and “FSD”. Now that last I recommend as a piece of quiet research – there should be some fascinating results.
In Sunday’s paper is a further article, very pertinent to the line of thought I was developing myself. It has not been put out on the paper’s website as Part 2 is being published next weekend.
Fundamentally the question is “How much is enough?” I had no idea of the examples that SST brought to light –
- An elderly lady undergoing surgery “to clear intestinal blockages”. She died next day, not from the operation directly – it was totally unrelated. She died from terminal bowel cancer, which was not in any way connected with the blockages.
- A person of 104 receiving his/her third hip replacement.
- A person of 80 plus scheduled for kidney transplant.
At the other end of the scale was the GP who told the story of a patient of his who was admitted to hospital for the fourth time with a more than passing heart attack. The patient had gone out, after his second, and made arrangements with the local undertaker even to the point of selecting and buying his coffin. “What are you doing in here?”, the GP asked. “Buggered if I know”, was the reply, “It’s you guys who keep sending me in here.”
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There seem to me to be three separate questions in this;
First and the most challenging is;
When and where does “curative and restorative” treatment justifiably stop and “palliative care” commence?
From the same paper, same day…
The political viewpoint, expressed by the ACT health spokeswoman, Heather Roy –
The public health system of the future may perform only emergency surgery, Act MP Heather Roy believes.
…
Every country in the western world was grappling with the rationing questions, Roy said.
"We need an intellectually honest debate on how we can pay for health into the future," she said.
The problems of the Hawke's Bay District Health Board, which last week pared 1800 patients from its waiting lists, were not isolated, she said.
Roy says about 40,000 people would be sent back to their GPs if the other 20 district health boards were to do what Hawke's Bay District Health Board had done, and remove everyone who had been waiting longer than the prescribed six months to see a specialist.
She said there needed to be a transition towards an emergency-only public health system - a service the system already performed exceedingly well - by introducing means tested part charging for elective operations and greater use of the private sector.
So, the PC term is obviously “rationing”. I submit that tends to hide the fundamental question; as I have stated it.
Add to this the fact that several other DHB’s have since “fessed up” to trimming waiting lists, and the continual political pumping of waiting lists as a “health scandal”, and one can but wonder that the public health system in this country has lasted as long as it has. But that, truly, is not where I want this article to go.
Then, again in the same paper, was this article -
Surgeons want taxpayers to pay for weight-loss surgery for children as one solution to New Zealand's ballooning obesity epidemic.
Obesity among children is becoming a major problem. Starship Children's Hospital in Auckland recently treated a 12-year-old weighing 182kg and often sees adolescents over 100kg. One in 10 Kiwi kids is obese but no publicly funded surgery -such as a lap-band operation which reduces the stomach size or gastric bypass - is available to treat them.
Surgeons say other children are being bumped from surgery in favour of obesity-related cases.
"In one month alone we had three cases where we probably ended up cancelling eight kids to do more urgent (obesity-related) surgery," said Wellington paediatric surgeon Brendon Bowkett. One child was five and weighed 52kg.
Obese children often have alarming adult conditions including type-2 diabetes, heart disease, gall bladder infections, obstructive sleep apnoea, hip problems, and skin abscesses.
Surgical treatment is a last resort. Only a handful of adults are given publicly-financed gastric bypass surgery, which costs about $20,000. So far only a few 15-year-olds have had the operation, but paediatric surgeons say children could benefit too. America has paediatric surgeons dedicated to obesity surgery and in Australia, an estimated 50-60 children as young as 12 have had lap-band surgery.
Surgeons agree diet and exercise are the best way to combat excess kilos, but losing 50-100kg is often unachievable.
"It appears if you've got a person who's morbidly obese at 12 or 13, you've got a body that's programmed to be overweight," Bowkett said.
Now, to use Heather Roy’s question, “Where is the intellectual honesty in that?”
I want to ask the question this way;
“If a child is morbidly obese, should the ‘cure’ be a palliative in the form of ‘We understand that your life has been hell because you have lived on tv and chippies so we will operate to take away the cause’?
Or should it be honest in the form of telling the parents “If you want your child to live, then you are going to have to change your lifestyle; diet, attitudes, recreation… When you make that commitment to change we will provide the resources to help. Your right to free treatment and assistance will remain as long as your commitment is followed.”
As for the argument that a 12 or 13 overweight person is “programmed” to be obese, I can accept that is so in some instances. I would suggest fairly rare instances. I can not accept that metabolic and endocrinal changes in the human species are proceeding at such a rate that statistics from 50 years back are no longer valid. In the four different schools I attended, from when I was 9 to 17, in contact with perhaps 1000 other kids in that time, there are only three, perhaps five, that I can think of who would fall (anywhere like remotely) into the morbidly obese category. They were known as the “school fatties”, the Billy Bunters, the ones who never played sport unless they were forced to. Yet now we have an “epidemic” of obesity, the only ‘cure’ for which is an advanced form of surgery developed in the past thirty years.
I could follow the same line through a different tack; and use ADHD and Ritalin as the “cause” and “cure”. Or one could follow a man my age into “sexual disfunction” and “Viagra” or “cialis” or the next flavour of the month.
To close this part of my thoughts, I must concede that there are health and appearance problems where major medical intervention is both warranted and perfectly justified. Fifty years back it was cleft palate reconstruction, then surgical techniques were developed to correct “club feet”, it went into orthodontry (my daughter benefited from this at the cost of some $3,000 or 10% of my gross wage at the time) and the surgical correction of heart defects, the care of neonatal and premature birth children, and in more recent times there have been advances in the correction of scarring from burns and accidents, and birthmarks.
So to the second question;
What right should we grant the drug companies to market their product direct to the perceived market?
I am in my late 50’s. I suffer from many of the minor aches, pains and ailments that have plagued men of my age for centuries past. I get the gout from time to time, I have a genetic predisposition to it. I have very poor blood circulation in my legs, again a genetic predisposition. I do not get enough exercise, affecting blood pressure, heart, muscle tone and strength, right through to sexual performance and the “dramas” that go with that. If I listened to my wife and my doc, I would be taking three different drugs for my heart and blood pressure, anti-coagulants because the bp drugs can cause clotting, I would probably be looking at anti-cholesterol drugs as well… a veritable pharmacopoeia. Statistically I am no different to 70% of men of my age. If I listened to the drug companies you could add drugs for sexual performance, to retard the onset of alzheimers (which my grandmother had), depressants to counter the side effects of the steroids I would be taking to prevent the gout, the list is near endless…
I am not that gullible, or at least I would hope not. I fear that the rest of society, a goodly part thereof at least, is otherwise. Why else would sexual performance enhancers, mood modifiers, baldness cures, weight loss programmes and drugs, laxatives, antiseptics (external antibiotics), age inhibitors, youth enhancers… have such a major part of the advertising time on television, on newsprint, on the internet. How often do we read of a “new” disease, at the same time as a drug is discovered to “cure” it?
As an aside, I can not get health insurance for any of these "complaints" - I have had the veins since I was 22, the bp since I was 35, the dodgy heart valve is from the age of about 8... they are all "pre-existing conditions" and fall directly into the exclusions of every policy I have been shown. About the only thing I can get cover for is avian flu and watch the exclusions flow into the market over the next two years on that one...
Is it a case of not having the ability to care for ourselves any longer?
The third question is at the personal level, and it comes from both my personal attitudes, and those of the guy I mentioned back at the beginning – the one who after his second heart attack went and purchased his coffin. It is this –
Are we, as a species, as a civilization, as individuals, so scared of dying that any pain, any other agony is preferred.
As a species, I would have to answer “No. I do not believe so”. I base that (quite empirically I admit) upon the differing “value” placed on human life in different societies. The attitude to death as seen in NZ, Australia or US is considerably different to India, or Chad, or Bangladesh or Thailand. I do not belittle the emotion and grief of families in those countries on the death of a loved one; not at all. It is a matter of acceptance. It is a matter of death being the final stage of life.
It is seen in so many different ways too. An elderly Chinese gentleman in his 80’s would smile contentedly, and would be congratulated on his age. A western person of the same age might wish that they were 30 or even 60 years younger. Some undergo extensive surgery to try and create or maintain that personal falsehood.
As a civilization, I am far less certain. Just in this one area alone, the numbers from that radio interview I mentioned at the beginning –
Total global drug sales – NZD900 billion per year
Drug sales in continental Africa – NZD25 billion per year
Drug sales (pharmaceuticals remember) in the US – NZD225 billion per year.
That is before we get into elective surgery (which seems to have a different meaning to different people). To me, getting my veins done is elective. They are not (yet) threatening the quality of my life. For a baby with a major heart defect, corrective surgery would not be elective; it is essential to the baby’s survival. My daughter’s orthodontic treatment may have been elective, given that at the age of six I could touch her palate with my little finger with her mouth closed so bad was her overbite. The extreme, in my view, is the use of surgery to maintain a pretence of youth and beauty.
On the matter of elective surgery, this from the first of the articles I quoted above –
Health Minister Pete Hodgson said that although the private sector played an important role, the government believed "the private provision of health is always more expensive in the long run". For that reason, he said, it wanted the public health system to dominate.
He did acknowledge the public system falls short by nature. "No public health system in the world that is free of charge can deliver the real or perceived public need for elective surgery."
The critical word, the one that makes the statement bulletproof is “perceived”. There is always someone who feels (because they have disease ‘A’ which is not subsidised when disease ‘B’ is) that the system has failed them, or that the latest drugs on the market should be given by right.
As for my personal medical woes – first get more exercise. That should help bp, circulation, muscle tone. Watch diet – Vitamin B group seems to be one of the personal triggers for the gout. Then start working on the elimination of stressors. Further improvement in bp. More sex, more often – I am a practicing heterosexual; practice makes perfect as they say… That reduces the likelihood of prostate cancer by keeping things working… self maintenance is the key.
If it doesn’t work, well I guess that I will be finding out the truth about gods sooner rather than later. But, as an article in yesterday’s Listener points out, given the choice between ten more years with the ability to have sex, bladder control, and having an operation now to stop prostate cancer with the consequences of no sex, no bladder control and perhaps another ten more years after that, most men would chose the no operation route.
I know that I would.
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I mentioned FSD. - Female Sexual Disfunction or post-menopausal loss of libido. It is quite the subject of discussion at present in the circles my wife follows. The general feeling at the (womens’ section of) tennis club seems to be “Wish the old man was able to keep up with me”…
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