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A $1 Pill That Could Save Thousands Of Lives: Research Suggests Cheap Way To Avoid U.N.-Caused Cholera

(United Nations Photo/Flickr)

(United Nations Photo/Flickr)

By Richard Knox

Here’s a way to get a big bang for a buck:

If a few hundred United Nations peacekeeping troops had taken a $1 antibiotic pill five years ago before they were deployed to Haiti, it may well have prevented a cholera outbreak that has so far sickened 753,000 Haitians and killed more than 9,000.

That’s the takeaway of a new study by Yale University researchers in the journal PLoS.

The authors believe their evidence should prompt the U.N. to adopt a simple and incredibly cost-effective strategy: Make sure all the 150,000 peacekeepers it sends out into the world each year from cholera-afflicted countries get preventive doses of antibiotics before deployment.

It’s not the first time the U.N. has gotten that advice. It was first suggested by a panel of outside experts the agency appointed back in 2011 to investigate the Haitian epidemic. But so far the U.N. has rejected the panel’s recommendation on preventive antibiotics.

It’s not clear whether that will change. The U.N.’s chief medical officer, Dr. Jillian Farmer, said in an interview Friday that she welcomes the new study. But she noted it does not address “the biggest barrier to implementing the antibiotic recommendation” — a concern that what she calls “mass administration” of antibiotics would give rise to antibiotic-resistant strains of cholera.

“It may be we will be able to do this [administer pre-deployment antibiotics to U.N. peacekeepers],” Farmer said. “I don’t have a closed mind.”

The Yale researchers and others argue that the concern about generating resistant cholera strains is overblown because the antibiotics would be targeted — not administered massively. They further argue that the U.N. should sponsor research to answer that question, given the urgency of the question.

“When we have a case as extreme as Haiti showing the status quo doesn’t work, we should be working to build evidence for a solution that does, not using a lack of proven solutions as an excuse not to act,” said Adam Houston, who works with the Boston-based Institute for Justice and Democracy in Haiti.

The new study is the latest chapter in a tragic story that’s been unfolding since mid-October of 2010, when, researchers say, a single U.N. peacekeeper from Nepal most likely introduced cholera to Haiti, touching off the most explosive cholera epidemic in modern times. Before the outbreak. Haiti had been cholera-free for at least a century; thus, its citizens had no immunity to the disease.

“Based on DNA evidence, this outbreak was probably started by one or very few infected, asymptomatic individuals — I would guess one,” said Daniele Lantagne, a Tufts University environmental engineer who was one of four independent experts appointed by the U.N. in 2011 to investigate the outbreak.

Since none of the 454 Nepalese peacekeeping troops deployed to Haiti in late 2010 showed any symptoms of cholera, all of them would have had to take a prophylactic dose of antibiotic to prevent any one of them from starting the outbreak. That would have cost around $500 — a tiny price to pay to avoid a devastating epidemic that — absent the investment of billions of dollars in clean water and sanitation — will continue into Haiti’s indefinite future.

The new analysis finds that prophylactic antibiotics would have reduced the chances of the Haitian epidemic by 91 percent. When antibiotics are combined with cholera vaccination, the risk of an outbreak goes down by 98 percent.

The U.N. began requiring cholera vaccination of all its field personnel late last year. But the new study says vaccination by itself isn’t very effective; it reduces the risk of an outbreak by only 60 percent at best.

That’s because vaccination can prevent someone from falling ill from cholera, but it doesn’t prevent infection — so a vaccinated person can still carry the cholera bacterium and pass it on to others.

“Vaccination alone is not enough,” said Virginia Pitzer, who led the Yale research team. “Vaccination plus antibiotic prophylaxis would be best.”

“Antibiotics are far and away the most effective and the least expensive,” added epidemiologist Joseph Lewnard, the study’s first author. “It hits the problem from two angles. It not only prevents those exposed to cholera from experiencing an infection, but if they do get infected it shortens the duration of shedding the bacteria. So once they arrive [at their deployment destination] they would no longer have bacteria in their stools.” Continue reading

U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

The extent of the government's role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17 in Charleston, S.C. (Mic Smith/AP)

The extent of the government’s role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17. (Mic Smith/AP)

By Richard Knox

Readers, a pop quiz:

The proportion of U.S. health care paid by tax funds is (a) less than 30 percent, (b) about half or (c) more than 60 percent.

If you picked “more than 60 percent,” you’re right — but you’re also pretty unusual.

“Many perceive that the U.S. health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France or the United Kingdom,” David Himmelstein and Steffie Woolhandler write in a new analysis of U.S. health spending in the American Journal of Public Health.

They find that 64.3 percent of U.S. health expenditures are government-financed. And they project the tax-supported proportion will rise to 67.1 percent over the coming decade as the baby boom generation ages and retires — nearly as high as Canada’s 70 percent.

“We are actually paying for a national health program, we’re just not getting it,” Woolhandler says.

tax dollars for U.S. health spending

Now, Himmelstein and Woolhandler have an agenda. For decades, they’ve been perhaps the leading researchers promoting the kind of single-payer health system that Socialist and Democratic presidential candidate Bernie Sanders has put on the debate agenda. One recent poll suggests more than half of Americans (and 30 percent of Republicans) support the idea.

But even if you disagree with the Himmelstein-Woolhandler ideology, their research is generally regarded as sound, and their method is straightforward.

They added up what federal and state governments spend on health through Medicare, Medicaid, the Veterans Health Administration, government employees’ health care premiums, tax subsidies and other programs. They argue that accounting by government agencies (the Center for Medicare and Medicaid) undercounts the real tax burden because it leaves out major pieces of the pie — such as government employees’ care ($156 billion a year) and tax subsidies for private, employer-sponsored coverage (nearly $300 billion).

And whatever you think about Medicare-for-all, it’s a good idea to see the present U.S. health care system for what it is — an increasingly government-funded financing scheme. Continue reading

Options Weighed To Address State’s Health Care Price Variations

Updated 6:50 p.m.

BOSTON — Variations in prices for the same service at different hospitals in Massachusetts do not reflect different qualities of care and have not evened out over time, according to a Health Policy Commission report released Wednesday.

The report found that higher prices “are not generally associated” with better care, and that prices vary across the different types of hospitals — academic medical centers, teaching hospitals, community hospitals — as well as within each individual group.

To highlight the difference in costs just at community hospitals during a Wednesday meeting, Health Policy Commission executive director David Seltz pointed to levels of spending on maternity care. Spending for a low-risk pregnancy ranged from $16,000 at North Shore Medical Center to $9,000 at Heywood Hospital.

“While some variation in prices is warranted to support activities, unwarranted variation in prices — combined with a large share of volume at those higher-priced institutions — leads to higher spending overall and inequities in our distribution of resources,” Seltz said.

Continue reading

More Evidence That Growing Up Poor May Alter Key Brain Structures

Allan Ajifo/flickr

(Allan Ajifo/Flickr)

Poverty is bad for your brain.

That’s the basic takeaway from an emerging body of research suggesting that the distress associated with growing up poor can negatively influence brain development in many ways, and in certain cases might also lead to emotional and mental health problems, like depression.

The latest study, led by researchers at Washington University School of Medicine in St. Louis, found that poverty in early childhood may influence the development of important connections between parts of the brain that are critical for effective regulation of emotions.

The study, published in the Journal of American Psychiatry, adds “to the growing awareness of the immense public health crisis represented by the huge number of children growing up in poverty and the likely long-lasting impact this experience has on brain development and on negative mood and depression,” researchers report.

Continue reading

When It Comes To Happiness, Time Trumps Money, Study Suggests

(Amanda/Flickr)

(Amanda/Flickr)

By Joshua Eibelman
CommonHealth Intern

What do you value more: your money or your time?

A new study by researchers at the University of British Columbia suggests that those who place a greater value on their time, rather than their money, are happier.

Among the study’s 4,600 participants, there was an almost even split between those who prefer money and those who put a higher value on their time.

While the participants’ median age ranged from 20-45, older people tended to value time over money, possibly because over the years, their priorities shifted, and they feel greater satisfaction from quality time with friends and family, researchers found.

The study, published in the journal Social Psychological and Personality Science, looked at what kinds of trade-offs people were willing to make to achieve “happiness.” For instance, participants were asked whether they would prefer a higher paying job farther from home or a lower paying job closer to home.

College students surveyed at the University of British Columbia were asked various questions about what fields of study and jobs they’d choose and how they would prioritize time commitments versus potential salaries.

Participants were told that they’d been admitted to two graduate programs and had to decide between a higher starting salary with more more work hours, or a lower salary with fewer hours, the study said.

Those who are willing to make trade-offs in favor of time, the study found, tend to be happier. Interestingly, researchers report, “These findings could not be explained by materialism, material striving, current feelings of time or material affluence, or demographic characteristics such as income or marital status.”

Happiness was measured though a number of self-reporting tools and questions about the number of positive emotions people feel in a day, said lead researcher Ashley Whillans, a doctoral student in social psychology at the University of British Columbia.

Whillans likened preferences for either time or money as “personality characteristics.” Continue reading

Opinion: What A Cancer Cure ‘Moon Shot’ Might Look Like

During his final State of the Union address, President Obama announced a new national effort to cure cancer. He said Vice President Joe Biden, who lost his 46-year-old son to cancer last year, would lead the effort. (Evan Vucci/AP)

During his final State of the Union address, President Obama announced a new national effort to cure cancer. He said Vice President Joe Biden, who lost his 46-year-old son to cancer last year, would lead the initiative. (Evan Vucci/AP)

In his final State of the Union address Tuesday night, President Obama called for a historic new effort to find a cure for cancer, a “moon shot.”  

“For the loved ones we’ve all lost, for the family we can still save, let’s make America the country that cures cancer once and for all,” Obama said in naming Vice President Joe Biden to lead the effort. 

So what might such a massive endeavor look like? Here, Barrett Rollins, M.D., Ph.D., chief scientific officer at the Dana-Farber Cancer Institute, offers his vision:

President Obama’s call for a new national effort against cancer — a “moon shot” — comes at a most opportune time. Cancer research has advanced significantly and now genomic analysis of tumors can reveal the specific DNA changes that drive cancer growth.

Our patients at Dana-Farber/Brigham and Women’s Cancer Center and Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, through the Profile research project, are benefiting from this — using the powerful technique of next-generation sequencing, scanning more than 300 cancer-related genes in every patient’s tumor to look for abnormalities. In a growing number of cases, the DNA changes can be targeted by precision therapies such as designer drugs that block overactive growth pathways. Often it will take combinations of targeted drugs to halt cancer progression, and many studies of these combinations are underway.

At the same time, there’s enormous promise in the field of immunotherapy. We’ve learned how to boost the body’s natural defenses against cancer and how to remove the molecular “brakes” that cancer cells exploit to hide from immune soldier cells and hinder their attack on tumors. Drugs that help the immune system fight cancer are coming quickly to the market, and there is promising research on related strategies such as cancer vaccines and genetic manipulation of immune cells to recognize cancer cells in the body. Continue reading

Analysis: Controversy Over CDC’s Proposed Opioid Prescribing Guidelines

OxyContin pills are arranged at a pharmacy in Montpelier, Vt. in this 2013 file photo. Opioid drugs include OxyContin. (Toby Talbot/AP)

OxyContin pills are arranged at a pharmacy in Montpelier, Vt. in this 2013 file photo. Opioid drugs include OxyContin. (Toby Talbot/AP)

Updated at 3 p.m.

By Judy Foreman

The U.S. Centers for Disease Control and Prevention recently came out with controversial proposed guidelines for opioid prescribing through a process that critics say may harm pain patients and is based on relatively low-grade evidence.

One of those critics is Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, a patient advocacy group which receives funding from opioid manufacturers. Steinberg said in an interview and in emails that she’s worried the guidelines may negatively impact patients suffering with severe pain. “I am concerned that if these guidelines go forward as they are now written, they will lead to further restrictions on access to opioids for people with unremitting pain who truly need them and take them responsibly,” she said.

Dr. Jane Ballantyne, president of the non-profit Physicians for Responsible Opioid Prescribing (PROP), which is part of a larger group involved in the guidelines process, said in a telephone interview that the worry about limited access to opioids for chronic pain patients is a “very legitimate fear.” But, she added: “We don’t want to reduce access for people already dependent on opioids. The guidelines are designed to not have so many people dependent on opioids in the future…”

Ballantyne said that the new guidelines are similar to previous guidelines with two key exceptions: lower dose limitations and the recommendation that, for acute pain not related to major surgery or trauma, opioids should be prescribed for only three days.

The month-long period for public comment on the proposed guidelines will be over Jan. 13.

A major concern of some critics is the lack of solid evidence backing up the guidelines, which give recommendations on prescribing practices; they include when to start opioids, how to establish treatment goals, how to discuss risks and benefits, recommended limitations on drug doses, duration of treatment and other issues. Continue reading

Mass. Wants To Be Home To Nation’s Leading Cluster Of Digital Health Companies

Massachusetts government leaders and the state’s health care and technology sectors have announced a new partnership. The goal is to make the Bay State home to the nation’s leading cluster of digital health companies. WBUR’s Curt Nickisch reports the announcement shows political and industry will, but little money, at least not yet.

More Coverage:

Mass. Launches Partnership Aimed At Boosting Digital Health Sector

Gov. Charlie Baker speaks at a press conference at Boston Children's Hospital Thursday announcing a new public-private partnership to boost the state's digital health care sector. (Greta Jochem for WBUR)

Gov. Charlie Baker speaks at a press conference at Boston Children’s Hospital Thursday announcing a new public-private partnership to boost the state’s digital health care sector. (Greta Jochem for WBUR)

Updated 5:40 p.m.

BOSTON — If you own a smartphone and use it to track your steps, count calories, check your blood pressure or monitor your health savings account, you’re helping to build the digital health sector. A recent Goldman Sachs report says the sector will grow to $32 billion within a decade.

A new public-private partnership announced Thursday aims to make sure much of that growth is in the Bay State, where leaders argue the elements are already in place.

“Massachusetts has a wealth of capabilities,” Boston Children’s Hospital CEO Sandy Fenwick said at a press conference Thursday announcing the new digital health initiative — a wealth of knowledge and talent, Fenwick added, in biotech, pharma and technology.

Fenwick has been part of a two-year working group, formed by the Massachusetts Competitive Partnership (MAPC), that included the leaders of area companies, hospitals and universities. MAPC reached out to Gov. Charlie Baker, members of his cabinet, Boston Mayor Marty Walsh and House Speaker Robert DeLeo to form the public side of this joint venture after deciding that digital health offered the best potential for job growth in the tech sector.

On the private side, MAPC has a four-part plan.

1. Financing: Startups in Massachusetts routinely complain they can’t find financing, and the numbers show they’re right.

(Source: MAPC)

(Source: MAPC)

No firm dollar amount has been pledged yet. Vertex CEO Jeff Leiden, who led the working group for MAPC, says there will be an announcement about several innovative strategies and an investment commitment within the next six months.

2. Standard Agreements: All the software and tech licensing agreements as well as sponsored research agreements used in the state’s digital health initiative will use standard language. MAPC says MIT, Harvard, Northeastern, UMass and Partners HealthCare have agreed to use the agreements, which may be a first for academic institutions in the U.S.

3. Mentoring: There are lots of stories about young entrepreneurs getting advice from CEOs in Silicon Valley while standing in line at the coffee shop. Massachusetts may not get quite that loose, but MAPC is planning a speakers series that would give startups access to CEOs for support and guidance.

4. Space: MAPC will work with the state and MassChallenge, a nonprofit that runs a competition and programs for startups, to create a digital health innovation accelerator. Mayor Walsh says the city is working to help the project find space.

The Right Mix Of People

Startups will have the opportunity to test ideas in hospitals and other health care settings around the state, something Jacqueline Thong, who launched Klio Health here, which helps those with chronic conditions track symptoms and treatments, says will be invaluable.

Continue reading

Lost In Translation: How Foreign-Speaking Patients Suffer Without Medical Interpreters

Hospitals take different approaches to support people with low English-speaking ability. In this 2004 photo, medical interpreter Carmen Diaz interprets for Spanish-speaking patient at Temple University Hospital in Philadelphia. (Bradley C. Bower/AP)

Hospitals take different approaches to support people with low English-speaking ability. In this 2004 photo, medical interpreter Carmen Diaz interprets for Spanish-speaking patient at Temple University Hospital in Philadelphia. (Bradley C. Bower/AP)

By Dr. David Scales

When I met Mr. Y., he was sitting up in bed, sweating and breathing quickly. An elderly, Russian-speaking man, he was admitted to the cardiology ward at a large hospital where I was working. His blood pressure was dangerously high and he struggled to breathe. His fear was instantly apparent in his wide blue eyes. Panting, he told us that he had liver pain, pointing to just below the ribs on his right side.

It’s unusual for patients to complain about liver pain. In broken English, Mr. Y. explained that it began after starting new blood pressure medications a few months ago. But his chest X-ray told a different story. His lungs were drowning in fluid — the likely reason why he was so out of breath — and that couldn’t have been caused by the medications he was so worried about. Having already perused his laboratory results, his condition seemed like a straightforward case of heart failure, but I quickly realized admitting Mr. Y. would be linguistically and culturally complex.

I needed to understand what made him so short of breath, and why he thought his medications caused the problem. But no in-person interpreter was available for another hour and a half. The telephone interpreting service at this hospital was designed to be accessible — the interpreter can be paged from any hospital telephone and should call back. Yet, no one had called back after my two attempts. I imagined they were busy interpreting for other patients. In the meantime, Mr. Y. continued to pant and sweat, leaning forward in bed to help his breathing.

Reluctantly, I asked his adult daughter if she would interpret for me. She agreed, but was clearly reticent; her hesitance and discomfort apparent as she stumbled over questions about her father’s recent urinary and bowel habits. While I speak no Russian, I became suspicious of misunderstandings when she interpreted my question about previous “heart failure” as “infarkt,” which sounds like a medical term for a heart attack.

“Family members may struggle to interpret accurately when family or cultural expectations are upset by medically routine, but personally embarrassing questions.”

I know of studies showing patients suffer when clinicians do not use interpreters or use untrained, informal interpreters like family members. I learned this during medical interpreter training and in my own experience volunteering as an Arabic interpreter with Iraqi refugees in New Haven and Syrian refugees in Jordan. As was the case with Mr. Y.’s daughter, family members may struggle to interpret accurately when family or cultural expectations are upset by medically routine, but personally embarrassing questions.

As a trained interpreter myself, it is painful and frustrating when good interpreter services are not available. But it isn’t just a dearth of interpreters — it’s also a lack of time that presents challenges to providing good care to non-English speakers. If I had a leisurely day I could have waited or returned, but on an adrenaline-fueled day on call, waiting for the interpreter was not possible. I had to balance my limited time with Mr. Y. against preparing for the three other patients I expected to be admitted at any minute. Worried this would be my only chance to hear his story, I put my interpreter training aside.

Long waits for in-person interpreters, an unreliable telephone interpreting system and the pressure of three other sick patients waiting to be admitted put both my resident and me in the uncomfortable position of just “getting by.” I had enough information to treat his illness but not enough time to understand how he connected his liver pain to his new medications.

Interpreters are easier to obtain with better technology. One analysis points out that physicians tend not to use interpreters much in the system I was using. It’s where the patient speaks to the interpreter over the phone then passes the phone to the physician for interpretation. Advancements in technology to two handsets and videophones now bring the telephone interpreter into the room with my patients and me. Some studies show these technological improvements have increased the use of interpreters by physicians. In one small study, placing a dual-handset phone at every patient’s bedside led to a fourfold increase in the use of telephone interpreter services without a decline in demand for in-person services. Continue reading