Letters to the Editor, submitted to The New York Times, January 19, 2010
My exposure to European universal health care systems began in 1971 when I became Director of Research and Development, in the UK, for an American pharmaceutical company. In that position I had frequent contact with European physicians associated with teaching hospitals. Also, as an American resident in the UK for many years, I always received prompt, modern care from the UK National Health Service. Excellent as I think that organization is, its performance isn’t directly relevant to the current US health care reform debate because no such truly “socialized” single payer system is being considered for this country.
However, I believe that the insurance-based universal health care systems operating in western continental European countries, do provide us with highly relevant models from which we cdan benefit. Hoping to be able to contribute constructively to the ongoing debate, I undertook several months ago to learn more about the systems in Germany, The Netherlands, Switzerland and France. I have come away with the following conclusions.
- Any initially-created US system will inevitably be changed over time. Based upon the European history of continuing refinement, amendment and occasional drastic overhaul, it would be a mistake to make the controversial “Public Option”), an “all or nothing” issue now. The essential goal should be to establish a workable and affordable system which embodies the principle of universal coverage. Once this is in place, any serious shortcomings in the initially created system will become evident and subject to correction.
- Most of those now opposing establishment of a universal health care system will become its supporters because once it is in operation it will gain overwhelming public support. This has repeatedly happened in Europe and it happened after the establishment of Medicare. .
- The “Public Option” need not be an insurance company run by government bureaucrats. The French government-created “Assurance Maladie” is divided into five autonomous, but regulated, insurance funds. Their supervisory boards are made up of representatives of health care providers, labor unions, employers and private insurance companies.
- Contrary to the assertions of zealous advocates of the Public Option, non-profit insurance companies can provide effective premium-cost competition for for-profit insurers. Also, premium costs can be controlled by regulation.
- A risk equalization mechanism is a crucial component of the Dutch and Swiss systems. In the Netherlands all insurers who have provided participants with the government-mandated basic health insurance package receive payments from a special government-supervised fund. The amounts of these payments are determined by an analysis of the demographics of the policy-holding populations served by each insurer. The more high-risk policy holders a company has insured, the higher the risk-equalization payments it receives. These payments have overcome the traditional aversion of insurers to covering high risk individuals.
- Administrative costs can be minimized by mandating a basic health insurance coverage that is identical for everyone and under which the same approved reimbursement amounts apply to all patients and providers.
- In these European countries, for- profit insurance companies compete vigorously in the selling of popular supplementary “top up” policies. Having this opportunity, they accept strict regulation of the costs of the mandated basic health insurance policies.
- Improvement in the availability and effectiveness of preventive care and primary diagnosis and treatment have been basic thrusts of the European systems. In France a network of thousands of neighborhood clinics has been created. Primarily in poor areas, these provide pre- and post partum examinations and care for mothers and regular exams and needed care for infants and children. The care provided by these clinics may well be a primary reason that infant mortality in France is 11th best in the world while that in the US is 33d. In The Netherlands, neighborhood clinics actively help people adopt healthy, disease- preventing lifestyles (e.g. to stop smoking). They provide convenient access to the services of a GP, treat minor illnesses and accidents and are open evenings. Their services reduce the need for more expensive E.R.and specialist visits, and hospitalizations.
- The U.N.’s 2006 “league table” of life expectancies at birth for years 2005-2010 says to me that the lifetime health care provided the populations of the four European countries is superior to that now provided in the USA. The figures are: Switzerland 81.7 years, 4th in world; France 80.7, 10th; Netherlands 79.8, 17th; Germany 79.4, 23d; USA 78.2, 38th. (Japan ranks 1st in the world with 82.6 years life expectancy at birth)..
- Costs for a medical education are generally government-paid in the four European countries; doctors in these countries do not start their careers heavily in debt. We need to subsidize the cost of medical school for students who commit to go into primary care practice.
- Costs of malpractice insurance and lawsuits are not serious issues in these countries. We need tort reform.
– Lloyd H. Conover, Ph.D. St. Petersburg, FL
Thanks to all my friends and colleagues who responded to my email asking for online science content. The list we generated covers a wide range of topics from Epidemiology, Environmental Chemistry, Public Health, Statistics, Microbiology and Open Science. The formats vary widely: email alters, websites, rss feeds, expert blogs, discussion boards, list serves, and linked news sites. One things is clear, that if you want to access science online there are many formats available– and just find the format that works for you.
NEWS / FEEDS
> Infectious Disease Resarch and Policy – http://www.cidrap.umn.edu/
> CDC selected topics – http://www.cdc.gov/emailupdates/index.html
> CDC selected news items – http://www.cidrap.umn.edu/services/email
> Community of Science (CoS e-alerts) – http://www.cos.com/login/join.shtml
> EnvironmentalHealthNews – http://www.environmentalhealthnews.org/subscribe.html
> Science Commons (open access news) – http://sciencecommons.org/feed/
> MicrobeWold News (microbiology current events) – http://feeds.feedburner.com/microbe-news
> 60 sec science blog by Scientific American (broad topics, current events) – http://rss.sciam.com/60-second-science-blog
> MIT Technology Review – http://feeds.technologyreview.com/technology_review_top_stories
> Science Planet Blog – http://blogs.america.gov/science
> Andrew Gelman, social science stats- http://www.stat.columbia.edu/~gelman/blog/
> ScienceBlogs – http://scienceblogs.com/channel/rss.php
> Effect Measure (A progressive public health science blog) http://scienceblogs.com/effectmeasure/
> everyONE (PLoS ONE community blog)- http://everyone.plos.org/feed/
> Open Access News – http://feeds.feedburner.com/blogger/wPhg
DISCUSSION / LISTS SERVES
> Recreational water quality list serve (not just for the great lakes) – http://www.great-lakes.net/glba/beachnet.html
> DIYBio (google group on homemade biology experiments) – email@example.com
> Applied Env. Microbiol. – http://aem.asm.org/papbyrecent.dtl
> PNAS – http://www.pnas.org/rss/
> BMC bioinformatics papers – http://www.biomedcentral.com/bmcbioinformatics/
> Env. Science & Technol – http://pubs.acs.org/journal/esthag
> Lancet Infectious Diseases – http://www.thelancet.com/rss
> Lancet – http://www.thelancet.com/rss
> Am. J. Epidemiology – http://aje.oxfordjournals.org/rss
> Int. J. Epidemiology – http://ije.oxfordjournals.org/rss
> Nature (short abstracts from journal) – http://www.nature.com/nature/current_issue/rss
I’ve been trying out a several formats and hit a few dead ends. I find email alerts annoying and delete them almost reflexively. I bookmark sites on http://delicious.com/DaveLove but rarely visit them. I even tried using delicious to keep a community lit review, but others didn’t use it. The one method that does work for me is using rss feeds, because they can pile up unwatched and scanned in bulk quickly. I drop rss feeds into Thunderbird (on my computer) and in parallel on Google Reader (for use on other computers). I’m curious what others do?
“In a study that looked at the happiness of nearly 5000 individuals over a period of twenty years, researchers found that when an individual becomes happy, the network effect can be measured up to three degrees. One person’s happiness triggers a chain reaction that benefits not only their friends, but their friends’ friends, and their friends’ friends’ friends. The effect lasts for up to one year.”
“The graph shows the largest component of friends, spouses and siblings in 2000. Circles are females, squares are males and the lines between them indicate relationships (black for siblings, red for friends and spouses). Colors show the average happiness of a person and all of his or her social relations, with blue for sad, yellow for happy and shades of green for in-between. (Credit: JamesFowler, UC San Diego)”
quoted from ScienceDaily
James H Fowler, Nicholas A Christakis. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. British Medical Journal, December 4, 2008
Friday night I was puking my guts out. I narrowed the list down to either something I ate, or spending the last 2 days knee deep in Monterey’s wastewater treatment plant (WWTP; secondary effluent). The wastewater is an easy horse to bet on, until you hear about the food. For lunch on Thursday I ate 3 tacos azados at a taco truck (affectionately called a roach coach by Gordor) parked outside the Monterey, CA municipal landfill. After that meal I had a slight stomach ache but nothing worse than you would expect from greasy meat and chiles. On Friday I ate lunch from leftovers that that sat out overnight, namely tomato soup with rice made Thursday evening and still on the stove. My guesses are either a virus or bacteria acquired 24-48 hrs previously at the “roach coach” or a toxin/ chemical in the lunch of leftover. The symptoms were vomiting about 5 hrs after eating lunch and lasting for about 8 hrs. Because Gordor didn’t get sick from the tacos I thought the leftovers were the culprit.
After a quick Wikipedia search for “rice disease” I found that most likely what I had eaten was the toxin produced by Bacillus cereus. I vaguely remember my mom telling me not to eat leftover rice, and certainly not rice that has been cooked and left in a warm environment… but when you are hungry you make excuses. My excuse was that by reheating the rice I would kill the bacteria… only to my dismay I learned that B. cereus’s toxin is heat stable!
Take it from me– it isn’t worth a day of vomiting– throw away leftover rice and save yourself the trouble.
Here is what the New Zealand Food Safety Authority says about B. cereus and rice:
There is no way of telling that cooked rice is contaminated. Cooked rice that contains toxin produced by B. cereus will not look, taste or smell off or any different to normal rice. To ensure that cooked rice is safe for eating, a number of steps can be taken to reduce the risk of illness.
• If rice is to be cooked in advance, do not cook too much at one time as large amounts take too long to cool.
• Either, keep cooked rice hot (>60ºC) or cool rice as quickly as possible. Rice will cool more quickly if removed from hot container and divided in clean shallow containers (<10cm deep). Alternatively, cool in a colander under cold running water.
• Cover cooked rice and store in a refrigerator (<4ºC)
A Reuters article passed on the recent news that L.A. planning committee approved a ban on new fast food restaurants in a 32-sq-mi area in L.A. This ban lasts 1-yr and can be extended if it works.
“If passed, it would affect about half a million Angelenos living in an area that supporters say already has about 400 fast-food eateries and few grocery stores.
The proposed moratorium follows a report last year which found that [about] 30 percent of children living in the South Los Angeles, West Adams, Baldwin Hills and Leimert Park areas are obese compared to about 21 percent in the rest of the city.”
BBC world news announced that “73% of South Los Angeles restaurants were fast food, compared with 42% in affluent West Los Angeles.” Although I support the ban and the political leap that the city will take… it seems to me that this planned ban is too late! The fast food restaurants are already there. In addition to alienating fast food stores in public, they should also try for back-room deals to include fast food restaurants in writing new menus and subsidizing public school P.E. classes or other types of health education.
I was curious if bike helmets protect bicycle riders from injuries to the head, and the answer in the epidemiology literature is “yes.” If that is all you are interested in, then read no further. Jk. Actually the topic is quite nuanced and has a lot of different interest groups besides just cyclists- groups like helmet companies, government, and public health researchers and clinicians.
One thing I found is that more studies on bike injuries are needed. It appears that the critical question of helmet vs. no helmet has been answered, but big gaps in research still remain about the safety of specific helmet designs (shape, fitted vs. ill fitted, specific materials and failure rates), differences in driver behavior towards helmet wearers, the psychology of wearing a helmet, and policy decisions about legislated vs. non-legesated helmet use. Even simple surveys of helmet use are lacking. Many times helmet data is not collected after traffic accidents- such as NYC with “only 1/3 of 1037 serious injury crashes from 2001-2003 was helmet use recorded” (pdf).
Do helmets work?
It is known with some confidence that helmet use greatly reduces the risk of bicycle-related head injuries
What is the risk of injury?
One study estimated that children <17 iu urban areas have serious bike related accidents at a rate of 37.4 in 100,000 (article). I could not find a rate for adults or all riders.
What are risk factors for bicycle injuries (article):
- Cyclist is male.
- Cyclist is nine to 14 years of age.
- Cycling in the summer.
- Cycling in late afternoon or early evening.
- Cyclist does not wear helmet.
- Motor vehicle involved.
- Unsafe riding environment.
- Cyclist is from an unstable family environment.
- Cyclist has preexisting psychiatric condition.
- Cyclist is intoxicated.
- Cyclist is involved in competitive mountain-bike racing.
I have a few risks to add myself:
- talking on a cellphone (driver or biker)
- near an intersection
- deaths by collision with a large vehicle
- helmet type/shape (data not collected on round vs. aerodynamic helmets, but there is research that shows that aero helmets cause more neck strain in sideways/rolling falls)
- helmet fit (article)
- defective or not maintained parts. I see people all the time with dangerously bad breaks and handlebars. Either by ignorance or laziness these problems persist. One way to tell is somebody’s bike is not in good shape is to look for little things that are not dangerous problems, like unraveling handlebar tape, but could indicate general neglect.
- on an arterial street or highway
Are you still not convinced?
Bicycle helmet companies and bike activists won’t say this, but if you absolutely don’t want to wear a helmet there are other ways to reduce your risk of major injuries while riding. These involve reducing other risks associated with injuries, such as from the list above. Best best are to ride on secondary roads with slow traffic, good lighting, few intersections, and wide lanes. Ride with a friend to be more visible and better at clogging up the right lane. Another speculative idea is to bike with a mild wobble to cause cars to give a wide berth.