Health for humans!

Still raving about Better Access

2011-12-30T18:17:00.001+10:30

From: //blog.artdoxa.com

This blog post is actually a very long comment on the blog by Jacinta Patterson titled "Argument by anecdote in mental health". The anecdote that Better Access money was being wasted on the over-concerned rich and not on the disadvantaged and genuinely mentally ill, seemed to be the main reason put forward in the press, explaining the cuts to Australia's mental health budget for 2011- 2013.

Aha- this post (referred to above) is still getting responses! I dropped in when it was first posted, but my comment doesn't seem to have got through! As a Better Access client and a former mental health researcher trained in public health, I can find many ways of examining the whole scheme!

It's difficult, firstly, to examine Better Access without the stats from the rest of the outpatient mental health sector. As someone said above, many people, mainly with schizophrenia or manic depressive disorder [these names make it clearer as far as I'm concerned; I know the controversy], are covered by Headspace and community mental health clinics [which are hospital outreach disguised]. The NEW cases of psychoses, or those at high risk [pro-dromal; the people who were to receive medications if they seemed on the edge of real psychosis], hopefully benefited from Better Access, but I can't see how I can tease them out of the figures from the govt. I would assume that plenty of these people would not recognise they needed help, just as always happened in the past- the only way I imagine they got into Better Access would be if their GP was alert enough when seeing them for another complaint. How alert are GPs usually? Don't know- no figures. There's no epidemiological data from the past on this and I don't know anyone collecting it, so we can't judge.

Anguish at work- needs help

The figures suggest many new clients for mental health care under Better Access and the sudden proliferation of various therapist groups in the community suggests the same- there are community nurse mental health counsellors, psychology-trained, social-work-trained, [I don't know any] occupational therapy-trained plus more, putting up shingles. Most have few empty slots in their calendars, so someone is filling them. My guess is that new clients who couldn't afford private care before are cashing in on the Medicare scheme to get help they've needed for a long time. I know hardly anyone besides myself who has seen a psychiatrist for more than one session under Better Access and I think that is because psychiatrists won't take merely the Medicare rebate as full payment. Mine agreed to it beforehand, because I asked specifically and because I knew her before she qualified. However, her receptionist didn't know this and when I had received 2 sessions and handed her the rebate cheque for the first one she asked: "How would you like to pay the rest; cheque or credit card?". I told her I had no income, no insurance and no benefits, so she was going to have to accept Medicare or take me to court! My shrink cleared it up with her!

USA, ER visits for mental illness increased

I would suggest that psychiatrists have kept on seeing the same sort of clients they always saw- those referred through hospitals and other professionals, mainly privately insured [the uninsured wait to see their psychiatrist in hospital outpatient clinics every week and get the same doctors as they had privately], a slight leaning towards upper income, definitely more city/suburban people and hardly a trace of indigenous Aussies. However, at outpatient clinics there have continued to be stacks of lower-income clients, young people avoiding parental scrutiny and indigenous and other-cultural-group clients. Because there are virtually no psychiatric emergency "drop-in" centres, the poor old Emergency departments of public hospitals have copped the majority of psychotic, alcoholic and suicidal people, usually in terrible emotional states and which the emergency doctors, nurses, police and ambulance personnel are least trained to handle. Better Access could do with setting up a few Psych Emergency Facilities at least on the outskirts of major towns. I don't think the community is going to suddenly get better at detecting mentally ill relatives and friends before they reach crisis point- they've never seen psychosis etc before, it's scary and they hope it will go away if they ignore it. Maybe the NEW Headspace places can change the culture of stigma and disdain of help-seeking by young men, but I'd like to see it happen before I'd have much hope.

In bed crying? Get help via Better Access

I'm a bit confused about why the change from 10 to 18 sessions in Better Access had to be made and announced because the clients from last year are going to have to see SOMEONE sooner or later. If clients who are still in need of care go back to their previous therapist, which most of us would prefer to do [and that would be therapeutically beneficial], are they suddenly going to say "Bugger off or pay me twice as much?" I can't see it happening except where psychiatrists have hard-hearted receptionists! I'd like to hear from some people about their experiences, since there's NEVER going to be a statistic on this!

As for GPs getting less money for the first consultation under Better Access- I can't work out how the huge amount extra was justified in the first place. The GP gives you a batch of questionnaires to fill in while he/she sees another person, then asks a few brief questions face-to-face, adds up the simplest depression/anxiety scores, gives feedback and may write a standard referral on the computer if you seem to need care elsewhere. Otherwise, if the GP is doing the counseling themselves, people just make regular appointments as they would for anything. I can't imagine that many GPs deduce much themselves from this 1st appointment, even those with special mental health training- mine didn't, that's for sure. Apart from questionnaires, the GP does have some documents to complete proposing a treatment plan, etc, but it's not clear how an ordinary GP could predict what is going to happen with a mental health case anyway- psychiatrists find it hard enough. In my book, the cut in Medicare rebate is justified- doctors just got used to it. Couldn't they feel good about contributing to Public Health with these sessions, rather than through some dubious primary care "health promotion" program? The cuts for ongoing counseling I'm not sure about- halving the rebate seems harsh.

ER will always get self-harm clients

As for the $1.4 billion: Why won't this much be NEEDED for mental health in the future and blow out lesser budgets? You can't hope to "cure" many people, and for the ones fixed up enough to go it alone, another new one will walk in the door & use the Medicare dollars.

Have a look at what happened in California after their mental health budget was slashed. DO we want that in Australia? :
http://disabilityrightsgalaxy.com/2011/10/01/the-system-is-broken/

The USA has even more problems with mentally ill people reporting to ER than we do in Australia:
http://www.msnbc.msn.com/id/25520178/ns/health-mental_health/t/some-psych-patients-wait-days-hospital-ers/
http://vtdigger.org/2011/11/09/frustration-over-upheaval-in-states-mental-health-system-mounts/

Wrong place for mental health care- too tense & anxious

Why self-harm now?: http://thelinc.co.uk/2010/03/self-harm-the-cause-the-facts-the-support/

Moving ahead: http://www.bipolarlifestyles.com/tag/hospitalization/

MS is now a Public Health Concern

2011-12-29T13:23:00.010+10:30

'via Blog this'

Last night on ABC TV [national, free to air, Australia], I saw an interview with a woman who claimed she had been cured of MS by a controversial surgical procedure to the blood vessels draining the spine and brain. I pricked up my ears as I had never heard anything on the topic of CCSVI [Chronic Cerebrospinal Venous Insufficiency]. A neurologist explained that an Italian, Doctor Paolo Zamboni, had discovered that the veins in the neck of MS sufferers were not big enough for the volume of blood coming from the brain, so that back pressure built up, injuring nerves. I assume this guy has done blood flow studies to support this idea of insufficiency in MS vs all clear in non-sufferers- I don't know. The transcript of the interview with various doctors and sufferers is available at: http://www.abc.net.au/7.30/content/2011/s3399100.htm

This sounds reasonable because MS is a progressive condition where muscles throughout the body become weaker due to deterioration in the nerves which carry messages from the brain and spine. There are many theories on why the nerves become damaged, but no one has proven any one cause for all MS people. Some alternatives have included stray measles virus (just as poliomyelitis virus left over from childhood infection can produce post-polio syndrome in adults); toxic chemicals in the environment breaking down nerve coverings; vitamin and nutritional imbalances or insufficiency or above-normal need; damage from leached metals from amalgam dental fillings and good old genetic inheritance.

Apparently a Newcastle [NSW, Australia] general medical practitioner [not a neurology specialist], has been assessing blood flow in MS patients' necks and referring them for stenting or balloon angioplasty procedures to widen the channels inside veins carrying blood back to the heart. Dr Paul Thibault claims that two thirds of people referred have had significant improvement in their muscle function, including the woman on the program [ who has been able to go on a vigorous overseas holiday.

Quote:

KERRI CASSIDY: I actually went on an overseas holiday and I walked halfway around Europe for three weeks. I couldn't believe it that I really didn't think I'd ever be able to do that.

She looked and sounded really good compared with footage of her before the procedure, so I did a little exploration on the Internet.

First, I was quite surprised to see that someone had won a medical award for clinical and research contributions to Multiple Sclerosis because I had thought MS was only a problem suffered by very few people and that the cause was unknown or highly disputed. More surprisingly, it wasn't Dr Thibault from Newcastle, but a Professor Bill Carroll from Perth!

The award announcement says:

"Professor William (Bill) Carroll wins the 2011 John Studdy Award
John Studdy, Multiple Sclerosis Australia (MSA) and Multiple Sclerosis Research Australia (MSRA) would like to congratulate Prof William Carroll on being awarded the prestigious John Studdy Award.
The John Studdy Award is given annually to an individual in recognition of their outstanding,
consistent and selfless provision of meritorious service to people with MS.
... In addition to being one of the country’s most eminent neurologists, Bill performs a
leadership role throughout the world...
...Prof Carroll made a significant contribution in promoting ... and helping to subsequently
establish Multiple Sclerosis Research Australia (MSRA)..."

At various times I heard that there were some promising trials of drugs for MS in Australia, but assumed these measures were supportive but not curative. The national prescribing service [PBS] had approved some new drugs which I understood were very expensive, under their provisions to fund a certain number of treatments for "rare" conditions where the economics of private use were impossibly restrictive. Two people I know personally are taking some of these new drugs and they've told me they are feeling better and can do things they couldn't previously, eg. stand up in the kitchen and prepare food, rather than half-heartedly chopping up the lettuce on a wheelchair tray. However, neither has taken a walking tour around Europe!

The PBS started subsidising oral Gilenya (fingolimod) on 1st September, 2011, bringing the cost of using it down from X to $34 per script. Because this can be taken via the mouth, it is far more convenient than other drugs preceding it, such as injections of Interferon Beta. The latter often caused reactions at the needle site and flu-like symptoms. One friend of mine complained of feeling as though she was getting the flu and having to use her asthma inhaler more, but thought she had improved her muscle strength in her arms for using her wheelchair.

When Interferon was first tried in Australia I can remember it cost a lot- something like $1200 to $2 000 per month, which was not affordable for most people. When the PBS adopted Interferon under their subsidised program, it reduced to between $30 and $80 per month, depending on changing doses in line with improvement/deterioration. The new Gilenya should now be $34 per prescription filled, like any other medication, eg. Ventolin asthma spray [2-pack].

As the ABC program revealed, the surgical procedure to widen the blood vessels in the neck needs to be subjected to the same vigorous trials as the new drugs have been through, to make sure it works for the majority of people with MS. The procedure is moderately dangerous and there have been a few deaths, so it is more than a simple experience with guaranteed good results. Even when performed well, only 2/3 of patients report improvement, so the costs must be considered in proportion to the number of people likely to benefit [this is where Public Health gets into the act].

The MS Society lobbyists and individuals in the community do not fully understand what a dilemma their requests to surgeons create. Many with MS want the procedure right now, before their function deteriorates or before the disease progresses too far, but this is fraught with medical and economic dangers. Economically, since so many requested the procedure when it was subsidised under Medicare, people with other more common conditions (such as blocked veins in the legs or arms) were being pushed further down waiting lists by the perceived urgency of the CCSVI for the MS patients. Surgeons became concerned [and tired from long operating hours] that the Medicare system was becoming "unfair" because more people with rare conditions were receiving procedures than those with common conditions with PROVEN treatments.

Thus, the relevant government authorities have withdrawn support for CCSVI as an MS treatment until good trials have shown that it benefits a significant majority, just as the procedures for blocked veins in the legs do for their sufferers. With leg vein clearing or bypass people gain a lot of function [eg. they can walk again, maybe work], deaths associated with it are very rare, the danger is not high compared with operations on neck veins and the costs per patient are reasonable given the good results achieved.

At this stage I don't feel confident to summarise all the factors we should consider when assessing the "fairness" of public health spending on Multiple Sclerosis, but there are some good articles on which you can base your own assessment:

Benchmarks of fairness:

http://www.who.int/bulletin/archives/78(6)740.pdf

Justice & fairness in Public Health:

http://plato.stanford.edu/entries/publichealth-ethics/#JusFaiPubHea

In the UK a subsidised drug for MS seems to make people worse than no treatment at all. Where's the fairness?:

http://pharmexec.findpharma.com/pharmexec/Europe+Features/Fairness-Risk-Sharing-and-the-European-Price-Cuts/ArticleStandard/Article/detail/676558

A discussion of fairness and provision of subsidies for hyper-expensive treatments:

http://www.nuffieldbioethics.org/sites/default/files/files/Hyper_expensive_treatments_background_paper.pdf

"...Why... does our nation’s health stay bad, even in some areas get worse, and the poor still die younger than the rich?":

http://www.sochealth.co.uk/news/Withoutwalls.html

For summaries of information about MS, read:

Australia; The MS Society: http://www.msaustralia.org.au/aboutms-moreinformation.asp

USA; NINDS: http://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htm

Daron Acemoglu on Inequality | FiveBooks | The Browser

2011-12-21T18:11:00.000+10:30

Daron Acemoglu on Inequality | FiveBooks | The Browser:

'via Blog this'

Public health views economic disadvantage and inequality as the main factors behind poor population health. If the lot of the most deprived in every country cannot be improved, the whole community cannot become healthier.

Ray Moynihan has written this one so I don't need to

2011-10-18T09:54:00.000+10:30

We should stop pharmaceutical companies from dealing directly with practising physicians/doctors. An accountable government-approved/appointed group should be the party to recommend drugs for use by a country's doctors. I'll keep saying it and I guess, so will Roy Moynihan. His article:

It’s not you, it’s the patients: why doctors should tell drug firms it’s over

Doctors' wining and dining by drug companies distort prescribing patterns and may influence them to recommend less-than-ideal drugs. PhillipC/Flickr

This week Radio National’s Background Briefing looks at how pharmaceutical companies market their products to doctors.

The program is presented by Ray Moynihan, an award-winning journalist, columnist at the British Medical Journal and conjoint lecturer at the University of Newcastle.

You’ve written and researched extensively about the business of medicine – what is it that attracts you to this area?

It’s a good story. I’m essentially a journalist and the corruption within the medical world is an incredible story to follow and investigate.

The extent of the financial entanglement between doctors and drug companies seems to know no bounds and I think it’s vitally important that there’s more scrutiny of these relationships.

The reason people are interested in doctor-drug company relations is not because of the desire to expose doctors wining and dining habits, the reason to expose this is because it distorts prescribing patterns and it means doctors are more likely to prescribe the latest and most expensive medicines. Sometimes a good thing but other times, wasteful and dangerous.

The example we use in the program is the antidepressant Cymbalta. Here’s a drug that is getting the thumbs down from a number of independent educational groups but is being ferociously promoted by drug company reps who stand to get a sizeable bonus if they can get a certain number of patients taking this drug.

And it’s being promoted by specialists, who are being paid generous fees secretly to present company slides about it at “educational events” to their peers.

Rennett Stowe

This is an extremely unhealthy aspect of the Australian health-care system, and I think one of the most frightening aspects of what Petra Helesic [a former drug company insider] says is how she became aware in recent years of how aggressively anti-psychotic drugs were being marketed for depression.

That, in itself, is worthy of a great deal of public scrutiny.

What can be done to ensure the independence of the medical profession?

There are many ways in which doctors, professional groups, universities, hospitals and other players in the health-care system can roll back their interaction with some of the unhealthy marketing practices.

A classic example comes from Christchurch, New Zealand, where many doctors have stopped seeing pharmaceutical company sales representatives and have replaced that kind of interaction with independent education.

In the same town, the college of general practitioners has stopped taking drug company sponsorship for their annual conference.

This is one of many examples around the world where there are small-scale attempts to engender a more independent relationship between health professionals and the pharmaceutical industry.

One of the simple things that every single university could do tomorrow is to mandate all of their staff to declare their financial relationships with drug and device makers and make that available on a publicly-searchable website.

That’s the sort of thing University of Sydney’s Professor Martin Tattersall and others have been suggesting. It’s going to become standard practice around the world and I would love to hear an argument about why it’s not possible for Australian universities to do that.

There’s also a great opportunity here for the tertiary education sector to offer genuinely independent education to our health professionals.

The industry appears to fund the lion’s share of ongoing professional education either directly at these dinners or indirectly through their sponsorship of conferences, seminars and meetings.

But there’s an abundant amount of evidence that industry-funded approaches are not in the best interest of patients or the public.

There’s a real, genuine, timely opportunity for the tertiary education sector to play a bigger role in this kind of education.

The AMA strongly opposes having a public register that names doctors who receive benefits or attend events sponsored by pharmaceutical companies, instead favouring disclosure of the cost of meals and names of restaurants.

AMA president Steve Hambleton says, “bringing it down to an individual level is going too far”. Why do you think the AMA is resisting transparency?

One of the things that Steve Hambleton says very clearly in the program is that one of his concerns is that being on a public register could besmirch a doctor’s reputation.

ArtBrom/Flickr

But if there’s something wrong with being associated with these marketing events, then why are doctors going to them?

If doctors believe that attending drug company lunches and dinners or accepting those generous speaking fees ($750 to $1500) are in the interests of their patients and in the public interest, then they should have no problem at all with that information being transparent and publicly available.

But there’s huge resistance from the AMA in Australia and its very much behind thinking around the world on this.

In fact, one of the senior executives of one of the companies in Australia has already publicly flagged the potential desirability of much greater transparency, in terms of disclosing the names of doctors who attend dinners and the amount of money that drug companies pay to individual specialists.

And Medicines Australia, the industry body for pharmaceutical companies, has said greater transparency is one of the things they will be looking at in their review of their voluntary code.

But more importantly, the United States has a law called the Sunshine Act, which is sitting there as a policy option for the Australian government.

It would be great to hear the argument for why such transparency isn’t appropriate in Australia but is in the United States.

What ways could doctors be learning about medicines that are independent or not emanating from drug companies?

There are three that were mentioned in the program – the National Prescribing Service, which is Australian; the Drugs and Therapeutic Bulletin out of the United Kingdom and; Prescrire which is a very reputable French journal.

There are many other sources, such as the Cochrane Collaboration, and there are many ways in which doctors can educate themselves.

But the truth is that going along to a dinner in a fancy restaurant in your local area is easy, and it’s fun. And you’re treated like a bit of a VIP.

A small but growing number of other doctors are absolutely horrified by the fact that their colleagues are still going in their thousands to these promotional events – which are described as “educational” in an extremely disingenuous way.

This article was originally published at The Conversation. Read the original article.

If you would like to hear from the other side, there is an account here: http://circ.ahajournals.org/content/121/20/2221.long

China adopts Western obesity.

2011-07-08T18:22:00.002+09:30

In PubMed, I came across this interesting article about body weight trends in China:

Emerging disparities in overweight by educational attainment in Chinese adults (1989-2006). from the International Journal of Obesity [London]

It appeared to be a great naturalistic study of the effect of increasing capitalism on body weight. Since China dropped strict communism and allowed individual financial enterprise, there has been a gradual division of their society into the more and less educated and the more and less well-off. Some scholars from California analysed the China Health & Nutrition Survey data and discovered that well-educated Chinese women have become slimmer and well-educated Chinese men have become much larger than their less educated fellows.

I haven't delved into the methodology to see were the sample came from and how severe the differences in education or income, but it is an interesting result for the Chinese to follow the Western pattern, rather than that of a society where bodily bulk means power and money, eg. in some African groups & formerly in the Pacific Islands.
From Robert Lindsay's blog, this photo of a Western, Caucasoid, Chinese man:

We seem to accept in Australia that people from lower SES groups become more obese than their high-SES neighbours due to eating too many high-fat, high carbohydrate foods and not enough fruit, vegetables and lean meat (protein). Would the same mechanism have emerged in China or does their different dietary tradition insulate them from this effect? Perhaps the Chinese have adopted Western-style meals and fatty take-aways as the norm these days (it didn't seem to be the norm when I visited a few years ago, but youngsters obviously relished their KFC and McDonalds when they had enough money for them)?

These possibilities need to be explored before accepting that the Chinese change in the distribution of obesity is due to Westernisation of the diet. There is also the racial mixture of the people in the study sample to consider. In the East of China, especially the giant cities of Beijing & Shanghai, most people are the larger-boned Han Chinese, but in the West most are more Caucasoid with finer bones and fairer hair. The diets tend to be different as well, with higher fat, more protein in the East and less variety, less fat and less food overall in the West.

From Fotopedia, a Han Chinese child:

However, we still haven't explained why rich women are thin and rich men are fat (on average, compared with other SES groups). Is there more to it than diet and psychology?

Trying new Blogger in draft

2011-07-08T10:07:00.002+09:30

I'm hoping the new version of Blogger will solve my problems with publishing my blog. I've written an awful number of posts that have just disappeared into the ether. I learnt to save each paragraph, but really that's not often enough at the moment- I am so pissed off I get all stabby and bang all the keys at once!

Half the time I forget a week later what I was so interested in because I've got equally worked up about naughty Blogger and/or another health topic that's incensed me!
Do you think I could "Add this" for a simple abstract from PubMed- no, not even that- as soon as I tried to add an illustrative photo from Google images, it disappeared all the writing! Arrgghh!!
Now let's see if this appears and is also editable...
Otherwise I may stop blogging about health here and go over to my personal blog at WordPress. Hear that Googlybobs?

6 Principles for Averting Collapse | Living Climate Change

2011-06-18T13:30:00.000+09:30

6 Principles for Averting Collapse | Living Climate Change I really go for the first one. In fact I've been trying to live this one since I was about 15!

Keep your germs to yourself. If others can't, then get vaccinated!

Cancer from plastics vapors?

2011-06-14T20:32:00.002+09:30

Hmm... nothing here now- must have been disappeared by the old Blogger. Anyway, I had an article referenced on firefighters being denied claims on cancer.

Firefighter cancer risk study would be interesting as they are exposed to possibly damaging vapors from plastics and petroleum derivatives. Here's another item from Melbourne's The Age, with a call by unions to allow firefighters to claim cancer on insurance for work.
Union wants firefighter cancer law
Ben Schneiders
June 16, 2011

It seems logical that with modern homes and buildings containing plastics, that firefighters could inhale a lot of toxic fumes and particles if they are not wearing sealed suits on arrival at fire scenes.

Australia's firefighters union discovered that there was actually a campaign against their claims!

NOT public health: Fantastic visualisation of the brain's nerve pathways

2011-06-04T21:18:00.000+09:30

Researchers map, measure brain's neural connections

This technology might help me explain what I think goes wrong with the development of an autistic brain. It's very hard to figure out the parts formed at various embryological stages when you can't see inside the brain. Now I can see how the mirror neurons fit the picture.

The article mentions autism- I must explore the associated articles in the journals.

14 000 cases of Whooping Cough! Australia

2011-05-26T10:16:00.000+09:30

Department of Health and Ageing - National Notifiable Diseases Surveillance System current CDNA fortnightly report

Cut the bullshit and get your kids immunised!

2011-05-23T14:06:00.001+09:30

This post has been appearing and disappearing constantly! I can't get it to appear in editing, then it disappears in the real post, so I have to start again!! I think Blogger is still having digestive troubles.

First of all, I spotted an article in GOOD about how 8 kids from one little church community died from measles in 1991.

"In 1991, nobody from First Century Gospel Church was prosecuted for failing to give measles vaccinations to the congregation’s children, a decision that resulted in eight of the kids dying from an outbreak of the illness."

They died because their parents falsely believed that vaccination was unnecessary because faith in God could fix their kids instead. Imagine if eight children who attended one church in your neighbourhood all died over a short period of time! How would any Australian community let those poor victims of religious delusion die from a disease which is totally preventable? I'm sure most people these days have NEVER seen anyone with measles. You probably don't have any relatives who are deaf or have lifelong brain damage from measles, either. This is all good. BUT some people who have never seen the symptoms think it isn't a risk any more and so DON'T vaccinate their kids. Do they realise that one of their kids' could easily catch it from a visitor or another unvaccinated child?

Now the US Centre for Disease Control is releasing some alarming statistics about the current rash of measles cases.

It's happened with Whooping Cough (pertussis) where many middle-aged adults whose childhood vaccinations have worn off, get nasty attacks of Whooping Cough that lay them low for weeks. Some cough for months, making work impossible or difficult- imagine being a miner? Note though, that adult Wooping Cough is easily stopped in its tracks by the antibiotic erythromycin, which you can get from your GP or local 24-hour clinic. It works quickly- I've had Whooping Cough as an adult and had to convince the old GP to do a swab to prove I had it.

From unvaccinated people and the expired immunity in adults, babies are starting to get Whooping Cough again. People may not realise that babies can catch it because the immunisation for this doesn't begin until 2 months of age (I think- please correct me if incorrect). This means that newborns who have doting grandparents as babysitters are completely open to infection and at high risk of serious illness or death! My efforts to encourage new grandparents to become re-vaccinated have been surprisingly unsuccessful. Some say- "I'd know if I was infectious, so I wouldn't babysit that day", or, as many nurses say about influenza, "I'm too healthy. I'd never get whooping cough". It's noticeable these days that people continually question public health advice as though the experts don't know anything. Now this sort of advice is based on so many years of work- generations in fact with some diseases (like smallpox), it needs to be accepted at face value. People should regard it as solidly as they would regard injunctions against punching out strangers in a crowd! But no. I keep plugging away, having a word in an ear here or on Facebook another day, hoping the message is persistent enough it will trick.

There is a great chart at this site you can print off that tells you what needles babies should get at what ages. It also has a handy guide to the main physical abilities of babies at those ages:

http://www.gpnnt.org.au/client_images/305400.pdf

Visit these other more erudite blogs for more info, esp. if I haven't convinced you:

http://www.australianimages.com.au/opinion/vaccination.php [Has a video of a child with Whooping Cough just to show how awful it is].

Roald Dahl (yes, the story book guy) had a baby who died from measles- too young for the vaccine. Here's an interview with him talking to Cory Doctorow (yes, another book guy...):

http://boingboing.net/2009/06/03/roald-dahl-on-vaccin.html

Dancing with disruption - Panel on Public Sector Innovation

2011-05-23T10:16:00.000+09:30

Dancing with disruption - Panel on Public Sector Innovation

We really need to have some conversations about involving the community in designing and lobbying for changes in the way health care reaches them. A few citizens' juries on limited topics are great, but there's a lot more scope for people to influence policy and delivery of health!

David Chalmers

2011-05-01T13:22:00.000+09:30

David Chalmers

This guy sounds as though he'd be very interesting to read in relation to my interest in autism and the salience of visual perceptions. Wow- he's worked with Doug Hofstader as well! I'd better read his online material and see if I need to delve into his book: The Conscious Mind: In Search of a Fundamental Theory . I found this gem of a bloke in the list of speakers for TEDx Sydney for May 28th 2011.

Little old loudmouth!

2011-04-26T21:35:00.000+09:30

This content also appears at: http://www.reportingonhealth.org/blogs/little-old-loudmouth

This morning I decided I needed to let off some steam because I had far too many possible comments circling my brain to get them out in one session! Luckily, I was reading Virginia Hughes talking about a review of treatments for autism. After trying hard to get a very lonnng comment accepted and being told my email address was a crock, I decided I needed to join a forum where I could comment at leisure as a registered contributor. So, here I am.

As I've delved into the health field while doing an MPH, I've found I am quite passionate about a whole range of issues. I'm sure half of it is mere ego- but who cares in blogs? Aren't they a great spot to let the ego run free? My irrepressible impulse to write several pages of response to Virginia Hughes' blog entry is built on 35 years worth of thought about the origins of autism and quite a bit of empirical research, but many years ago. Meanwhile, I have kept up my reading on the topic of my abandoned PhD and I still feel that no one has exactly pipped me at the post and I want to let it all out!

I think I can explain why most autism treatments don't seem to work very well, as well as why traditional drug trials will never show the worth of various anti depressants for major depression. I'd really like to put forward my ideas on possible neurodevelopmental problems behind visual perceptual difficulties that autistic people suffer, especially in relation to social cues. For instance, the review of the work on mental rotation by researchers such as Soulieres et al, 2011, was quite logical and reasonable- but I think there is a totally different way to explain it which links to a lot more research on characteristics of ASD people. Hopefully, over the next few days, I'll be able to log in on the relevant websites and make some comments with my alternative explanations for the findings reviewed.

Then there's the topic of public vs. private payment/hospitals/clinics in health care. Australia has had a fairly good universal health coverage system for many years in Medicare, although lately the gap between the scheduled fee and what an individual doctor names as his/her fee has grown so much that ordinary people find it difficult to get appointments and/or pay at all. The government covers everyone for the scheduled fee, which varies with the length and complexity of the consultation. When the fee gets higher, I certainly visit the doctor less and I know many others are similar. The trouble is, if I give in and visit after some illness has become quite nasty (eg. I get a chest infection and my asthma flares up suddenly), firstly the doctor chastises me, then I have to have a swathe of tests, then I get medication and the illness lasts up to 4 times longer than it would if it hadn't worsened within the first few days. So this episode ends up costing so much that I go into debt with my partner and/or friends in order to pay for the treatment. So the system doesn't really work for certain classes/groups of Australians.

In the UK and USA, recent financial and political changes have meant the health funding in those countries is being cut across some areas. There is obviously huge debate about whether cuts should go ahead in health (could cuts be made in other budget areas?), and then which areas to cut first, should everything be cut equally, will private practitioners cut costs by shedding poor patients? etc The health systems in most Western countries do not set priorities across the board for treatment of certain conditions, ages or use of procedures (such as stenting the heart). Therefore, even with cuts, some specialties are going to go over budget by doing what they did last year, or overspend on questionably necessary procedures and underspend on vital ones. Of course, there is good old health economics weighing in with making assessments of years of quality life gained from treatments and arguments about what a quality life consists of and how can you value a life in dollars! I can have heaps to say on articles about these topics, but I keep using time that should be spent on other things!

Having been a researcher in eating disorders for many years (where most of my publications came from) I also find I have plenty to say about articles and media reports on young children hating their bodies from very young ages and on how "the media" and "advertising" are making kids sick!

I'd better button it up at this point as my partner is crying for stewed quinces and yoghurt, but I could rave on, naming endless topics I want to blether on about!

Lucky Spotrick got hungry, eh?!

Too late I see we are too large

2011-04-02T22:37:00.000+10:30

As everyone knows by now, health authorities across the planet have been getting in a terrible lather about increasing obesity. More people are becoming larger and their largeness is even larger than it was before!
I attended a charity event where people contributed delightful, multicoloured cupcakes for sale in a bid to raise funds for Australian Flood Relief.

[We've had shocking floods over a large proportion of the inhabited mass of Australia and that is a very big expanse of country to be under water. Some of it is still flooded after 3 months, other parts have had monster cyclones and been inundated again and again. People have lost the land their houses sat on, never mind the actual houses!]

Back to the topic at hand:

As I stood back after depositing my [dairy free] cupcakes on the sales table I observed the line-up of mainly women, many accompanied by youngsters in push-chairs. I was really quite shocked because just about every female over the age of 15 appeared to be overweight.

In contrast, I felt like a tiny, skinny little pimple on the face of the

earth. My GP has said I'm overweight for more than 12 months now, but I haven't made a major effort to do much about it. I'm just sitting on BMI= 25 and whenever I try to eat less and exercise more I lose track of myself while concentrating on something else- like study or having fun with friends; and then I end up eating as I always did, so the weight stays the same. At least it doesn't increase all the time these days! What's more, I'm revelling in having got rid of that horrible Black Dog of depression over the past 10 months and I'm not too keen on making anything I enjoy now into a negative experience. If I enjoy my food and don't balloon out, I'll just leave it be for a while.

However, what I saw with my own eyes was quite disturbing. I happen to know that people weren't nearly this big during the late 1980s and early 1990s because I really did measure them then! My work mates and I were doing research on women's attitudes towards their own bodies [you might call it body image]. We wanted to see how much of a role your actual size played in opinions about your body, eg. If you said "I feel fat when I look in the mirror", were you honestly overweight, or were you judging yourself too harshly? Of course it partly depended on weight, but in plenty of people real-world weight seemed to have very little to do with their miserable self-opinion. [I'm "Walker" among the authors]

When we measured height and weight, we found that about 20% of women were classed as overweight or heavier. That's one fifth of the population and when you looked at a crowd of people, it was believable. Eighty percent of women were normal weight or below, ie. BMI 25 and under, with mildly underweight around 18.5 to 20 and really underweight, continuing down to anorexic emaciation from 18.5 downwards. I met people whose BMI was only 13- just skin and bone, poor creatures.

Today, just before writing this blog entry I thought I'd better consult the current statistics so I could see what the government had been getting their knickers in a knot about:

Self-reported data from the AIHW (Australian Institute for Health & Welfare):

"Data from the 2004-05 National Health Survey showed that 47 % (7.5 million) of Australians aged over 15 years were overweight. Of these, one third (2.5 million) were obese.
Males were more likely than females to be overweight. Some 56% of males aged 15 years or over had a BMI of 25 or more compare to 39% of females [overweight and obese].
For both males and females, the highest rates of those who were overweight were aged 55-64 years, 68.5% and 52.2% respectively." [I am certainly not alone, with more than half of people my age overweight or obese by earlier standards]

Notice those stats are from 6- 7 years ago. There are more recent stats, but on much smaller numbers of people- so let's be kind and stick with the old numbers, because I haven't found a nice table with the new ones!

While searching for the above stats I came across the program of a conference in Australia during last week: The Australian Obesity Summit. In amongst the speakers I found the TV personality, Dr John Tickell, who is a doctor in real life and who runs expensive weight and exercise programs for a living. He always sounds (and looks) good but he hasn't shown me any longterm outcomes that stick with the ordinary adult in the community. It also struck me that nowhere in the conference program was there anything about people's attitudes and feelings, which are surely the factors behind the success or otherwise of a weight control program. He seems to recognise the magical value of food for women in the link, but I haven't heard what goes on in his sessions to confirm any psychological input.

In my webby travels I also came across the grim news that Australians are ranked third in the developed world's fattest population. What a [dis]honour.

Obesity: Australia ranked in global top three

And the delightful announcement that, yes -

Obesity Australia's biggest [sic] health challenge say experts

OK, so 39% of Australian women and even more men have their size rated above the norm- either overweight, obese or morbidly obese. Isn't it odd that men have a much higher rate of obesity than women, but women are the ones who worry about it AND get dumped on by men for being overweight. Hmm...pot calling kettle black here!

Sorry if you were at that function today, but I saw a room full of very worrying female bodies. Many of these overweight women were quite young- late teens to late thirties and I could see they had potential to become even larger because they were so much taller than the older women (like me). This photo was the only one I saw. I didn't take it, so faces are disguised to protect the innocent. I have no feelings either away as far as liking or not liking these people- it's just an illustration of what alarmed me.

Just for comparison, I'm only 150cm tall (about 5 feet) and my BMI is 25, giving me a weight of 56.2kgs or 8 stone-8lbs. Yes, I am verging on being too heavy for my height, and certainly a lot heavier than when I left school, a tiny, sickly streak of misery at about 32kgs [!! and never had anorexia nervosa in my life, just a bit weight-challenged as well as being height-challenged]. To see what I would have to weigh to be classified as obese (BMI 30 plus), I'll calculate a projected weight at BMI=31. That's 69.75 kgs [where would I put that??] or nearly 11 stone.

I can remember our chubby little admin officer at work in the Weight Disorder Unit was 12 stone and she didn't look good while she puffed going up stairs. To be morbidly obese I would have to weigh over BMI=34, so let's calculate for BMI 35. That would make me 76.5kgs and 12 stone on the dot. That's another 20kgs on top of what I weigh now, which is roughly 40kgs heavier than when I left school or more than TWICE my teenage weight. OMG!!

Thinking about the young women I saw today, some would have to be 100kgs or more as they looked very large, plus they were up to 1.80metres tall [nearly 6 feet]. That's a huge worry, plus I already worry about young friends who are already a bit overweight (from observation) and who tell me on Facebook what they had for dinner or lunch. Thinking to myself I cringe how close their size and eating habits are bringing them towards diabetes.

Ordinary people [and even some in health profession] seem to speak of diabetes far too casually. It fairly terrifies me and I think it would terrify them if they just contemplated it for a bit. I had the misfortune for my closest cousin to die at 19 from uncontrolled diabetes [I was also 19]. Sure, she overate when her parents weren't looking and hated having insulin and cortisone injections- but her mum had deliberately fed her to be huge (plus the younger two cousins). It was some strange neurosis borne of a poor family and the 1930s Great Depression. I also had two friends in their early 20s who suddenly got severe diabetes after participating in marathons and triathlons for a few years. Both were skinny guys who couldn't be told anything about looking after themselves, but they both became very ill and ended up on regular insulin injections. Such a shame- both had their PhDs by the age of 23 and had brilliant careers ahead of them but had to slow down when their diabetes hit and made them feel tired and ill.

This has been such a serious post- but it really struck me that the world has just been bumbling blindly into this obesity epidemic yet most individuals are completely unaware of the horrors that real obesity and diabetes can bring on a personal level. I'm not using scare tactics- it's really nasty to suffer the health consequences of obesity.

My idea of neighbourhood exercise and fitness programs part run by experts and volunteers may not be so pie-in-the-sky after all. However, in the real world we would have to do 1000% better than these hard-working guys: The Impact of a Community-Based

Heart Disease Prevention Program in a Low-Income, Inner-City Neighborhood by Jennifer L. O'Loughlin, PhD, and Gilles Paradis, MD, MSc, Katherine Gray-Donald, PhD, and Lise Renaud, PhD.

There won't be a cure for autism

2010-12-14T17:04:00.000+10:30

I came upon an article in the Huffington Post about Dr Mark Hyman's account of a child who seemed to have been "cured" of his childhood autism: "Autism Research: Breakthrough Discovery on the Causes of Autism". (December 11, 2010 11:37 AM). Dr Hyman attributed the child's "cure" to intense nutritional intervention aimed at correcting gut flora and metabolic functions concerning absorption. In making this connection, he referred to this exploratory research by Dr Cecilia Giulivi and colleagues of University of California, Davis.
I note that it is titled by the authors as a "Preliminary Communication" only and was not meant to be the final answer to any specific problem.
The paper is about "Mitochondrial Dysfunction in Autism", which means it's about how the cells of the body process energy or nutrients which are absorbed from the blood, after they enter the body via the gut. Dr Giulivi and colleagues did a laboratory experiment with some white blood cells belonging to autistic and normally developing children- they didn't use their brain cells. In autism research the processes that happen in white blood cells are used as an analog or model of how brain cells work. So their research is NOT on autistic children who are present in the lab, and is only about cells, not the whole living, breathing child. You should note that none of the authors work in a clinic or school for autistic children, so they are certainly not claiming they have even the beginnings of a cure. Their basic research conclusion is "In this exploratory study, children with autism were more likely to have mitochondrial dysfunction, mtDNA overreplication, and mtDNA deletions than typically developing children."

Please, dear readers and parents, don't put too much hope on this piece of research. There has been 50 years or more research on possible metabolic influences on autism- I was involved in some myself on serotonin/dopamine metabolism.

My own conclusion from the research is firstly that I am not very confident white blood cell metabolism is a very good representative of the areas of the brain I believe may be damaged pre-natally in autism spectrum disorders. Also, I imagine that the damage to the developing brain occurs to varying degrees and reaches different projections of nerve pathways in each child's brain, interacting with the rest of their potential for brain development, making it very unlikely that any one "treatment" or combination of strategies could ameliorate autistic thought and behaviour.

The appealing little boy featured in Dr Hyman's video seems rather normal and delightful and he also resembles several children I have interacted with who were similarly autistic when they were toddlers. As several people commented on the Hyman post, brain development reaches a certain level of maturity around 6 years old and kids become able to learn in class groups rather than alone or one-to-one. After this time lots of connections are possible between areas of the brain, but hardly any more new cortical cells develop or migrate. I think this little guy was rather bright originally and was able to benefit from his brain maturation plus good therapy.

Some high-functioning autistic children learn the rules, or how to simulate the rules, of normal social interactions and communication during the early school years, particularly if they have had attentional training and helpful parents. I remember a youngster whom I used to collect from his home to travel to the Flinders Medical Centre laboratory where we asked him to do some attention-grabbing tasks while recording his EEG/brain waves. He was a nice, quiet young boy (around 10 to 11 years old) and would talk during our journey if I spoke to him. He had very few twitchy movements or strange habits and could have been taken for "normal" by anyone we met. However, until he was about 8 he was the weirdest kid his parents had ever met! His habits, noises, bizarre reactions to people and situations had held the household to ransom since he was about 8 months old and became mobile! He had received a lot of individual speech, cognitive training and behavioural therapy so he could attend a mainstream school, because he could read and count at age level. His brain activity during the tasks was very similar to the other autistic people we tested, and was unlike that of the "normal" kids we had matched to them on several criteria. I'm sure Dr Hyman would have considered him "cured" given his everyday behaviour, just as his teachers did; his mum could still see his little quirks.

If you're interested in the idea of pre-natal brain development problems as an explanation for different degrees of autism, have a look at some early work from 1982 and some much more recent work in Italy which recaps the same theme, but with greater detail.

I love the work done by Simon Baron-Cohen on "theory of mind" and autism. While I agree with it up to a point as I can see that most autistic people behave as though they have no idea how the world appears from my point of view. However, my own pet theory is that the brains of autistic people are damaged sufficiently to leave them with a deficit in understanding what is important to attend to in the world, in order to function and survive. I call this a problem with "salience"- I think there is something wrong with the connections amongst the parts of their brains responsible for visualising movements and relating what they can see others doing, to their own body in motion. To me they seem as though they don't get the idea that speech is for communicating and that there is a lot of information in other people's faces that they should be using to decipher what happens. It's as though a basic biological connectedness is missing or damaged, so that they don't really "get it" the same way as ordinary people. They experience the world in different ways to the rest of us- it is quite difficult for us to explain to anyone how WE experience the world (we take it for granted; it's natural)- so how can we expect them to convey to us how THEY experience it? A super BIG ASK! All we can do is try to teach them to behave and reason about things like the rest of us so they and their families can have a calmer time.

There is a lot of research and therapy development at the Autism Research Centre in London, UK, which has a whole website devoted to it.

NB. It might be a little hard to include this as a "public health" post, but to me it is important that we balance the spending of health dollars amongst things which are likely to have an effect on a lot of people versus on special programs we might ration amongst only those likely to derive maximum benefit. It can be a cruel reality for parents when their autistic child is rated as "too impaired" to enter a special social skills or language program. For higher functioning kids, this sort of program might enable them to eventually live independent lives in the community whereas there is little hope of this for the children with the worst symptoms.

Out damned paradigm!

2010-08-07T10:53:00.000+09:30

I have decided that whatever double blind crossover placebo-controlled# trials can do for sorting out the good treatment from the bad, they're completely beyond the pale* in mental health!
My starting points are roughly these:
1. Taking major depression as an example:
a) every case has individual real-life occurrences as contributing factors: maybe being totally neglected emotionally as a child, or having a string of teenage relationships ending in "betrayal".
b) every case happens to a different brain

c) every case has a certain set of present/absent, good/bad liver enzymes
d) whatever the age, size or shape of the person, they have a different "felt response" to the same dose of a drug
e) everyone has different ways of reasoning
f) we all afford differential salience to "stimuli" such as words, happenings, situations and other people's moods.
g) if interpersonal therapy happens, each person will have a different first impression (therapist AND client), which will influence the course of the relationship;
h) therapists all have different interpretations and ways of implementing different therapies (their "style")
i)different client vs. therapist personality combinations either work or don't work in particular therapies, no matter what the therapist thinks about their own "objectivity" in the interaction.
j) clients have differing "stickability" in their regularity and timing of visits to a therapist.
k) additional contributors may/may not occur DURING treatment by any mode eg. parent dies, husband leaves etc.
l)many factors contribute to what "dose" of therapy or medication will alter core symptoms, regardless of liver enzymes etc.
m) many people on medication never get a good therapeutic effect because of recommended dosing levels, especially if they are not referred to a specialist after partial response. Specialists can observe the person while pushing the medication to the biological limit and achieve complete remission (or rule out that medication).
n) people have different "feeling criteria" of when they are "OK" again after an amount of treatment- it may be quite different to what a therapist concludes.

Anyway, having committed heresy, I'll slink away to gather some evidence!

I'm starting to get worried!

2010-07-10T11:54:00.000+09:30

Here comes the good old Lancet with the latest look at risk factors for stroke, worldwide:
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study by Martin J O'Donnell & multiple colleagues. [If you create an identity and password you have access to this article even if you don't subscribe].
Although I wish they'd come up with something different, the verdict was:

"Phase 1 of INTERSTROKE suggests that hypertension, smoking, abdominal obesity, physical inactivity, and diet are the most important modifiable risk factors for stroke. These important findings should help to inform stroke prevention strategies around the world and to reduce the global burden of stroke." (Comment: Reducing the global burden of stroke: INTERSTROKE by Jack V Tu, The Lancet, Volume 376, Issue 9735, Pages 74 - 75, 10 July 2010)

Yeah sure mate- "help inform stroke prevention strategies"- I think most moderately health-conscious societies are quite well informed on this already- but how the hell do you get us (the at risk people right now) to exercise against that awful, ingrained "physical inactivity". We are NOT MOTIVATED YET!! I think someone has to come up with something new to get us all off our bums!

Quite honestly, I have been exhorting myself to exercise regularly since the age of 15 when my family doctor handed me the old XBX exercise paperback and said "Start here!". For no more than 14 days of my life have I exercised vigorously EVERY DAY- and that's when I have gone on holidays specifically to walk at least 10km/day over someone else's hills! I have plenty of photos to prove it, too!
Here I am at the famous Beseggen Ridge in Norway in mid 2004, a cardiovascular treat if ever there was one!

I see absolutely nothing in my neighbourhood, which is full of middle aged and older citizens, prominently encouraging us to come along to exercise sessions or enrol in a government-sponsored walking program. I have deliberately sought out suitable programs on the internet and discovered a Heart Foundation Walking Program, but I haven't managed to get along yet. There is also an early morning exercise class for "Seniors" at a local community centre, but it's at 7am and that is just dumb for most people who have blood pressure medication to take with breakfast!

At the other end of the spectrum, my neighbour has a 13 year old girl who rather fancies herself as Australia's answer to Paris Hilton (without the hotels, unfortunately), but I haven't seen her doing regular exercise around the neighbourhood, either. Isn't there a school health and fitness program to get these kids enjoying regular exercise as a normal part of their daily routine? Evidently not! This young lady HAS been attracted into a program where appearance is important- a cheerleading team- where some calisthenic moves are combined with a great deal of ribbon-waving and strutting around in glittery costumes! Are we missing something in the marketing department about what motivates regular exercise these days? Obviously, the promise of a glittery costume is not going to get me to the community centre at 7am any time soon, but I wonder what would?

I daresay I have quite a few risk factors for a stroke later in life:

1. I have had elevated blood pressure all my life, even during childhood.

2. Both my parents had high blood pressure- mum from her 50s, dad from his 70s.

3. I'm on some medication for another problem which actually CAUSES elevated blood pressure, but I have no alternative at the moment.

4. My mum started having mini-strokes/TIAs [transient ischaemic attacks] from her late 60s and died as the result of a stroke during an unrelated operation at 81.

5. I am rather physically inactive, though not as much as most people my age who I know.

6. Although currently at the upper limit of normal weight for my height, my weight is concentrated around my middle.

7. I weigh 157% of my weight on leaving highschool!

OK- I have a few helpful factors going for me- I've been prescribed (and take) a pill for hypertension and it works moderately, but not all the way back to "normal"; I haven't used sodium salt sprinkled on food for nearly 40 years- we used to have a container of 50/50 sodium/potassium salt for me to use on potatoes (the only thing I liked a bit of salt on), but it took 10 years to use it up!; I eat a diet which others would regard as fairly healthy and I rarely eat anything prepackaged like sweet biscuits, frozen meals; I have never had artificial sweeteners as I thought they might be bad for my liver- I had weird ideas that they must be taking up a metabolic pathway that should have been utilised by another foodstuff, goodness knows what- and I figured if I didn't like an unsweetened version of something I could just give it up!; my diet is almost vegetarian but I believe I need animal meat because I am an animal born to utilise eaten muscle to maintain my own muscle; my diet is also rich in raw fruit and vegetables containing lots of anti oxidants, plus I eat raw, fresh nuts of various sorts for lunch every day- also a 30-year habit. The only cheese in the house is low-fat and I drink plenty of water and black tea, rarely coffee or soft drink. Lastly, my father lived to the age of 95, despite having a congenital heart valve problem, which did lead to heart failure in the end- but you'd hardly say he had the usual kind of cardiovascular disease!

SO!!! What will persuade me and others like me to exercise regularly? I know that when I went to aquarobics twice a week with friends, it was the social contact and the regular expectation that got me there. Now I don't earn a living and don't qualify for government assistance, paying $40/week to attend is out of the question. However, this would be a good way to go for people with a normal income. I still like my idea of having community fitness trainers/leaders who are paid out of the national health budget to get people into regular exercise programs to the extent of thumping on the front door and yelling at them to come out!

The National Heart Foundation walking program for seniors should be what I attend, as it's free (mainly), but I haven't managed to get there despite several tries! I haven't seen the new video publicising the walks on TV, either- where is it?? Since it's about dog-walking, it's not really for me, but might encourage plenty of others.

I keep returning to the research on depressed young people, where researchers found that regular exercise was quite therapeutic and wonder how this sort of program could be financed and monitored locally. It could be quite attractive to public health campaigners as it literally kills two birds with one stone! There is plenty of good research on psychological health and exercise for older people as well, even for those who already have heart disease!

Goodness knows why I'm still here, sitting on my proverbial and not out there treating myself to a dose of free depression treatment while lengthening my expected life span!

Gout- a very ouchy problem!

2010-02-25T23:02:00.000+10:30

I hadn’t ever expected to blog about gout, but a few things have pushed it to the forefront of my attention lately.

One- I discovered that a friend my age has it quite badly and two: I didn’t realize this is just one of the many forms of arthritis (there are more than 100- yikes!)!

Having decided to inform myself, I found it was a timely topic- The Lancet has just had a leading article on it and most of it is pretty readable for an educated person, not just for medicos. Here’s a link to the Abstract, but you’ll have to use your connections in the business or a science library to read the whole caboodle:
Richette P and Bardin T (2010) Gout. Lancet. Jan 23;375(9711):318-28.

The docs have provided a beaut explanation of the current state of gout knowledge and how to treat it and relieve the symptoms. Sufferers are [rightly] much more vocal about the symptoms themselves- gout hurts to high heaven wherever you get it! [Insert loud groans and screams here]. It certainly laid low my friend on several recent occasions when he would far rather have been out enjoying himself. It also seems to make him and others quite depressed- which I guess can also be the result of taking a lot of pain killers.

All I knew before researching this topic was that some crystals accumulated in the joints somehow; that they were sharp, and that they maybe scratched the bones and thus hurt a lot! Apparently, that’s almost true, except for the fact that gout is really a form of arthritis, (meaning inflammation of joints: Greek ‘arthro’= joint and ‘itis’= inflammation), and that the crystals irritate the joint linings which makes them swell up and produce pain- it’s not the physical scratching from some great chunky quartz-type crystals, but tiny little pointy things in spaces they shouldn’t be. Here’s a pic from the internet:

Monosodium urate crystals

The traditional spot for gout to show up is in the big toe- here’s a diagram to show where the crystals deposit.

Now I know why I saw a lot of old guys with the toe cut out of their shoes when I was a little kid growing up in a country town! The pain is felt all over the toe and really gets bad if your shoe rubs the end of it.

Unfortunately, gout can cause arthritis in most joints- my friend has it in the knees, for instance. What can add to the pain and discomfort is the occurrence of swelling and heat around the joint such that ice packs are very welcome, as well as pain killers and anti-inflammatories (like aspirin).

I wondered where the crystals came from or why they accumulated in the joint spaces, rather than in the kidneys (like other crystals I’d heard about, eg. kidney “stones”). Well the uric acid crystals actually come from processing proteins we eat- I won’t explain the whole process as you can look it up. The folklore about gout being caused by a diet that is “too rich” and “having too much to drink” is not all true.

Most gout has some inherited component- it “runs in families” and researchers are identifying some possible target genes. It is a metabolic problem where the usual pathways though and out of the body for the urate crystals are disrupted or diverted. Instead of all the extra uric acid we don’t need getting ferried out through the kidneys, too much of it hangs around in the blood permanently. With ageing, the concentration is more difficult for the body to cope with and the crystals percolate out of the blood and into the tissues, accumulating in the joint spaces where they hurt. Also, if it isn't treated properly you could end up with permanently damaged joints and need joint replacements. Alternately, if you become dependent on steroids to control the symptoms, you get all sorts of nasty side effects which wreck other aspects of your health! Bad scene- better to change your diet!

Most of the foods that contain the protein that causes uric acid build-up are also nice tasty, popular foods like: red meat, shellfish, other popular fish, roe/caviar, asparagus, cauliflower, mushrooms, peas, beans and lentils; plus there is the traditional culprit alcohol.

So if you know someone with gout, don’t make fun of them, as gout is definitely NOT a fun thing! Be sympathetic when they have an attack and either help them out with rest and ice packs or leave them alone for a day or two to get over it. By all means encourage people to seek expert care, as there is a lot more treatment available these days than when those old men cut the toes out of their shoes!

Where can I claim my reward?

2010-02-06T15:35:00.001+10:30

As a sufferer from depression and pretty much unemployed for 2.5 years, I have been feeling a terrible lack of opportunity to be rewarded- either with money or something else I favour. People tell me (and I have started telling myself) not to WANT things. I really do have what I NEED for basic sustenance- sufficient food, a roof over my head, clothing, warmth, a partner, sex, 3 cats and friends. But despite telling myself to concentrate on how lucky I am (ie. think Haitian kids, one of whom I sponsor through World Vision), I have this terribly human trait of WANTING stuff/experiences/different stuff. Well now the people in the labs, those white-coated loonies of popular folklore, have discovered that our brains need enough of a particular substance to actually FEEL rewarded by anything. Not surprisingly, this substance is serotonin, the stuff that your neurons like to bathe in regularly, so you don't feel depressed. These guys (along with a host of others) found that serotonin was the vital part of the brain's REWARD system.

Now, how can we get more rewards? Do things and eat foods that increase the free-floating serotonin levels in the brain. There is a lot of bullshit, "natural", nutrition and New Age claptrap around, but the truth seems to be that foods containing plenty of tryptophan (trip-to-fane) are the go. These are mostly tasty proteiny things like, lean red meat, turkey, chicken, nuts, cheese, beans and pulses (eg. lentils, chick peas). As part of a normal diet, we need to consume these with a little carbohydrate (which is hard to avoid, given the composition of most food)- the more complex ans slower to burn in our systems, the better. So- no added sugar, but good complex carbohydrates such as in vegetables, grainy breads and some fruits. Traditionally they say chocolate and bananas increase serotonin, but they're better with some protein as part of a meal, not an EXTRA snack on the side! Appropriate fats are good too- mono-unsaturated oils like olive oil, omega 3 and 6 oils like fish oil/some nut oils, and recently some authorities have recommended pure cold-pressed coconut oil (which I find good). There seems to be little about dietary coconut oil, except as an antioxidant- by which the scientists mean that the components of coconut oil roam around our blood stream "scavenging" those things called "free radicals" which seem to age us and may play a role in the beginning of cancer. So even if the virgin coconut oil is not yet proven to help with depression and reward experiences, the mere thought that it's doing you good may help anyway!

Now, I'm no medical authority, so don't call me to account for this one, but there were recent reports that a pediatrician (children's doctor) in the USA was treating her prematurely dementing husband with coconut oil and getting promising results. There is nothing in the conventional medical literature as yet, but I'm waiting with interest.

However, leaders in the field of cognition in ageing caution that there is no clear or longterm proof of the worthwhile use of various oils and other substances in slowing brain decline.

Light REALLY DOES make migraines worse

2010-01-12T18:47:00.000+10:30

As an ex-migraine sufferer I was interested to see this article in the latest Nature magazine which demonstrated that light definitely makes migraine headaches worse. I always felt that it did and would always try to stay away from bright light when I had a migraine, but some people thought it was just a function of screwing up my eyes in the light making my head muscles tense up more. Plenty of migraine sufferers out there can now declare they're not as neurotic as their friends think!

The researchers in the Nature article compared blind people with migraines with normal-sighted people also suffering regular migraines, who had been matched on age, age of onset (most started around age 17 to 18, give or take several years), occurrence of an aura and other medical factors. They found that only the blind people with an intact optic nerve had their migraine exacerbated by light, along with the seeing people. The blind people whose optic nerves were still Okay (ie. they could transmit information to the brain about light vs. dark, but not about lines, shapes and colours) had their migraines made worse whereas the blind people without optic nerves and/or no eyeballs did not.

The authors give really detailed information for the knowledgeable about the nerve pathways involved, but I won't go into any of that. I think the fact that the study appeared in such a prestigious scientific publication is good evidence that the research is quite sound and migraineurs can be assured they're not crying wolf!

Doing Health Policy in Australia

2010-01-10T20:51:00.000+10:30

Doing Health Policy in Australia
This sounds good- I wonder if I can get hold of a copy?

Christmas public health hazards

2009-12-15T10:07:00.000+10:30

As I haven't composed a useful post recently, here's a link to a great public health post from a more conscientious soul- you'll like it!:

http://scienceblogs.com/effectmeasure/2009/12/a_christmas_public_health_haza.php

It's about stuff like this:

When 6 weeks worth of identical, low toxicity tablets are individually encased in tight-fitting shrink packaging! Crazy waste of resources and impossible for most people to open easily (or without giving themselves at least another stomach ulcer!)
Let's try to make sure Christmas is injury-free!

2009-11-30T20:34:00.000+10:30

Go small and save the world- and yourself!!

2009-10-16T09:05:00.001+10:30

Blog Action Day 09!
I've been thinking about preventing cardiovascular disease and associated problems like diabetes (which follows obesity) and kidney failure (which follows diabetes)...etc. SO much of the medical and scientific literature is about what they conveniently term "secondary and tertiary prevention"- but that is all AFTER THE FACT! The community seems to be abysmally slack in stopping it all from starting in the first place- even with adults who are already headed down the heart disease track we say "It's your individual responsibility to exercise and eat properly" as though that absolves everyone from worrying about it any more. I've come to the conclusion that we have to stop all this Anglo-Saxon protestant crap about responsibility- TELLING us what we SHOULD DO...and BELIEVE humans are basically neglectful sods far more interested in "The Moment" and start SHOWING US WHAT TO DO!
Give us a bl**dy DEMONSTRATION every day and keep showing us. Encourage us to join in ALL THE TIME, come walking and playing in the park with us and tell us we're doing OK. Where are the personal trainers for every neighbourhood? PLEASE MR RUDD! Why don't we do it first in Australia and show the rest of the world we will not fall into the Western black hole of fat and sloth!
It frankly gives me the creeps when people my own age are having stents in their coronary arteries, being investigated for mini-strokes and have been put on drastic hospital-directed diets and prescriptive exercise programs they find deadly boring!
I know that lots of so-called "cost effectiveness" studies have shown that many heart disease and obesity prevention programs are not "worth it"- but I think they've left something vital out of their equations. What about all the wasted resources teenagers and adults have put into getting fat and clagging up their arteries?? Can't we count that as a potential saving for the future? As a small person, (though no longer sylph-like! LOL), I have always been pissed off with the wear and tear caused by larger people- not only do you consume more than your fair share of the planet's food, you also wear out the environment faster- paths, roads, lawns, carpets, furniture, cars- everything- you great galumphing sods!! Your clothes are bigger- taking more earthly resources (cotton and linen) and more petroleum (synthetic fibres), there are kilometres more sewing in your seams, tonnes more rubber in your shoes, less space and more load in your fridges! An article in the New York Times seems to agree with me a lot!
GET SMALLER AND PREVENT CLIMATE CHANGE!!!!!
Here's someone else who seems to have cottoned on as well!

Catching fat habits- currently popular press

2009-10-06T16:50:00.000+10:30

There have been a number of comments and critiques on some research coming out of the classic Framingham Heart Study on the phenomenon of "the obesity epidemic". It is certainly within the realm of social psychology that you can acquire the habits of friends by using them as your role models. The New York Times article on the topic is here: http://www.nytimes.com/2009/09/13/magazine/13contagion-t.html?pagewanted=1&_r=1&em
The original article is here in full: http://content.nejm.org/cgi/content/full/357/4/370The spread of obesity in a large social network over 32 years.by Christakis NA, and Fowler JH. In the New England Journal of Medicine.

I'm particularly interested to read: Is obesity contagious? Social networks vs. environmental factors in the obesity epidemic. by Cohen-Cole E, and Fletcher JM. from the Journal of Health Economics as it will be good for my major essay!
I must try to find some of the diagrams I saw which illustrated how the obesity clusters related to each other, linking groups of obese individuals and showing isolated slimmer ones. Grr- can't find it in my Favourites Folder now.
Try the video:

Quick bit on obesity prevention

2009-10-02T21:52:00.000+09:30

Today was a bit deadly to blog about, but anyhow... I did get a fair bit done on my health economics assignment. I was exploring materials on the estimated costs of prevention campaigns against obesity and cardiovascular disease. Most of the studies done are of older people who already attend their GP with a risk factor or early disease- they already have high blood pressure, obesity, high bad cholesterol levels or diabetes 2- or a combination of these. The researchers just look at the costs of giving them various drugs and using verbal information to encourage them to eat more wisely and lose weight. I'm much more interested in the primary end of prevention, where young children and their families are encouraged to eat wisely from the beginning and to make exercise a natural and enjoyable part of their lives, so that it doesn't seem like a chore later in life.
There are lots of recommendations and suggestions from the World Health Organisation (WHO) and FAO on primary prevention, but I haven't heard of any great implementation efforts in Australia. I just came across a Collaborating Centre for Obesity Prevention at Deakin Uni, but I'd never heard of it before- which is a bit odd since I'm studying public health in Australia already.
This piece actually got transported over from my personal blog.
My overall view is that our national governments need to incorporate healthy exercise into the national healthcare programs, putting as much emphasis on getting people to participate from early childhood as they do on other things. How would we feel if exercise was given as much funding as GP visits, hospital admissions, drugs and pathology tests!? It seems a bit odd at first encounter, but to me its a logical transition- let's see someone taking some steps in this direction.

It's so danged complicated!

2009-08-28T17:48:00.000+09:30

My Health Economics lectures are still pretty interesting, although my friend, Polly, is not exactly enthralled. What I've noticed is how terribly complicated the picture is becoming surrounding the allocation of resources fairly within the health system!
We've been looking at how Australian public hospitals "never say NO" to performing surgical procedures or somehow treating a person's problem regardless of age or disability. I already figured there must be a bit of "NO" going on, or the hospitals would be bulging with 95 year-olds having heart transplants! Yes indeed, there are some "NO"s emerging, much to the disgust of several students in the class. For instance- an Intensive Care Unit that does not admit anyone aged 90 plus. I had been mildly surprised when my friend E told me her 92 year old MIL was in a high-dependency ward but not ICU after she had a stroke which made her quite delusional and unable to talk coherently- obviously her age was excluding her from the top treatment category. I had already been privy to the fact that certain physicians at unnamed hospitals "pull the plug" on young male accident victims whose brain injuries appear irremediable after some days in ICU, but hadn't heard about anything else. The over-90 rule seems perfectly sensible to me, given the expense of ICU, the pressure on the beds from younger people with more prospect of recovery and the average lifespan being 79 (men) and 80 (women) in Australia. In my world-view, the 92 year old has indeed had a "fair innings" as the noted health economist, Alan Williams, might have said.
However, the question facing everyone in the health care profession (and facing us as students during a tutorial!) is: How mindful of public dollars should the bedside doctor or nurse really be?
Obviously there are views ranging from "Of course they should be- who pays them anyway!?" to "It is not ethical for doctors to consider costs when saving lives".
I am inclined to think that having regard for the probability of a good outcome given the investment of public dollars should be a routine consideration- something "trained for" in a medical education, not something that comes as a big surprise when doctors are questioned later about particular decisions. It would be good to see that consideration of the general cost to society built into the contracts or agreements that medical personnel work with. Just because lives are involved doesn't mean people should abandon the principle of general utility- as a public servant I couldn't order an antique oak desk for my office even if I was allergic to the laminate in the generally supplied ones!
Now the outlook has shifted along to the issue of how we rate someone's prospects of a good life following a medical treatment, vs. how much it is going to cost the public purse, and ultimately, the taxpayer. For this some fancy measurements have been invented such as the Quality Adjusted Life Year or QALY. Be ready for a rollercoaster ride when I get stuck into this little monster!

Germs- eerrgghh!!

2009-08-22T17:33:00.000+09:30

I was inspired by Mike Mad Biologist (http://is.gd/2tdfe), to have a (-nother) rant about spreading germs.

I truly hate it when people:

a) sneeze, cough, spit or snort without attempting to cover it up or face away from others. If only the training most of us receive in childhood about these courtesies would stick!
and/or:

b) laugh at me when I ask them to keep their germs to themselves.

I'm quite phobic (in a mild sort of way) about catching seasonal viruses and things as I'm an asthmatic. My body is notorious for catching a virus, going all breathless on me and making fertile ground for a friendly bacteria to jump on board and lay me low for days or weeks. I've improved with age and learning to look after myself, but I still get horribly wheezy when I get a cold or whatever. I absolutely HATE IT! It feels like I am sidelined from real life for a while and I just have to sit here and take it, while life goes on as usual for everyone else. I don't seem to be able to carry on as usual like most people- I need rest, I can't breathe well enough to hold a decent conversation and I'm useless going out for a meal. The housework piles up, the cats get hungry, we run out of clean clothes and I scowl at the sheets that need changing while I'm stuck in bed gasping and snorting.

What's more, every time I get something serious, I'm reminded that both my grandfathers died in the 1918 Spanish flu epidemic- neither one having left their home towns for the First World War. Sure, one of them probably suffered from asthma as well and worked in a hospital; but the other grandfather was a pretty healthy bloke until then. They both left large families to be brought up by their wives and the eldest kids, which must have been a struggle in those days. Luckily both grandmas had small businesses, which is pretty unusual- one had a sandwich shop in Elizabeth St in Sydney and the other was a well qualified Tailor (-ess) in Wellington, New Zealand. It's not like many younger people die from colds or flu these days- it's mainly older people and those with pre-existing conditions (like asthma, which killed my education tutor at uni when she was only 29). However, so many days of work and useful life are lost from seasonal viruses that I think it's worth defending yourself and others the best way you can.
First line prevention is just what Mike the Biologist says: Wash your hands! and Cover those sneezes!

I'd certainly wear a mask if the flu really took hold- I think the Japanese are quite good with this measure, even though we have been laughing at them on their highspeed trains with their face masks all these years.

Let's get with it- protect ourselves and our mates and cost the country a lot less!

PS. I've been intrigued for some time with the notion that some schizophrenia might be precipitated by prenatal effects of viruses such as the flu or common cold on the developing brain. This article is a broad account of such ideas.

Fighting for health dollars!

2009-08-09T20:30:00.000+09:30

I was having some ideas while listening to the first two lectures in Health Economics. I guess what I think now will change over the course, so I should write down what I believe at different stages. At the moment I think the whole government health budget should be divided in a different way (of course, they couldn't SUDDENLY change the proportions of various segments, but could work towards it, in my ideal universe!).

Firstly I think we should look at the people in the population and see how many are in various age segments, and what these segments will average out being over the next 5 to ten years.

Then we should look at what services were used by the age groups, divided initially into medical/pharmaceutical vs. surgical vs community health and public health/health promotion. Obviously we'd find that not many dollars are spent in community, public health or health promotion. There seem to be stacks of dollars spent on pharmaceuticals and I noticed that dental costs take 6.6% of the nation's health $$- strange since we don't tend to think of our mouths as using a lot of our general health resources or time.
Dept of Foreign Affairs and Trade describes the health system for lay persons and outsiders: http://www.dfat.gov.au/facts/healthcare.pdf

How they work out costings at the moment: http://is.gd/2tfPT
And here is the expenditure in public and private sectors:
http://is.gd/2tfTR

I don't like DRGs (Diagnostic Related Groups) as they stand- although I may not understand them fully and therefore agree with them more than I think! However, I think that looking at the most prevalent illnesses for each age group and looking at the medical vs. surgical dollars spent on various procedures, rather than all admission costs, might result in a better idea of how to allocate funds in the future.
As well, I think that costs should be normalised/standardised for each age group and for the procedures and treatment packages most used so we can easily compare subgroups on a proportional rather than absolute cost basis.

Perhaps we look at the 50- 65 year old age group and find that there are a lot of cardiac-related surgical procedures and cardiac-related medications and GP consultations. We should look at what could possibly be "saved" by doing alternative things with the dollars at earlier ages and at how we might gradually reallocate the surgical dollars to prevention dollars. eg. we might see a lot of coronary artery bypass grafts (CABGs) and note that these cost a lot, whereas doing one or two stents on a younger person might achieve the same ends and give a longer average life after the procedure.
Giving a potential 25 years extra life to someone with a procedure at age 55 should be better than giving an extra 15 years at age 60 and each procedure and hospital stay ought to be cheaper on average, plus people are happier and have better mental health, saving some mental health dollars as well!

Therefore we need to use the Burden of Disease Statistics, look at getting the average number of years of life gained from various procedures/medical treatments, projecting the likely number of cases for the forward budget period and applying normed corrections for the proportions of the health budget to go to various health problem clusters. I noted that musculo-skeletal and respiratory diseases are priorities for the near future and that reducing cardiac disease and spending is also a continuing priority. There also looks to be a need to prevent acceleration in the obesity rate in order to avoid flow on costs to diabetes incidence/prevalence, cardiac disease strokes and falls. The community doesn't seem to have got the message about weight gain, especially in children and there don't seem to be huge innovative programs being introduced to remedy the situation- so this needs a lot of factoring in.

Anyway- rave rave. I'm just jotting here- will get down to specifics later.

Decisions decisions...

2009-07-11T19:35:00.000+09:30

Who decides what proportion of a country's GDP should be spent on health and how much on all the other stuff? How do they decide? Who wins? How? What do they decide should get health dollars? How do they work that out from all the competing claims? Since, in Australia, Public Health has only received 1.8% of the health budget in the past, how can we change this? These are some of the things I have been wondering about as a student of Public Health, a few weeks before I begin a semester in Health Economics (or Health Resource Allocation, as the department can't seem to decide what it wants to name the course!).
I have been triggered to start this blog by a session at the Adelaide 2009 Festival of Ideas, titled "Who cares? The limits of health."
My first note from the session was appreciation for the information provided by Professor Fran Baum on her work with the WHO on the Social Determinants of Health. She seems committed to the ideal of "Health for All" within each country environment according to their needs and available resources. And I wholeheartedly agree, even though many people think this view is rather "pie in the sky"- I think if there isn't an ideal to aim for, why start?
Here's a link to a big blog about the http://www.politicsdaily.com/2009/07/29/health-care-rationing-and-my-81-year-old-dad (health care of someone's 91-year-old dad) these are the issues most families must deal with. The medical profession then has to collaborate in decision making about these individuals, keeping quotas, budget constraints and the health of others in mind.