Great articles : future

Two news articles caught my attention today that described breakthroughs that will have big effects on our lives in the not so distant future.
The first is an article that describes the ability of Biomedical engineers to run a computer simulation of a cell metabolism. This is a big step in making biology a more concrete science and similar technologies will likely come to dominate pharmaceutical and physiology research in a few years.

The second article describes robotic garages that are being built in NYC. This is likely the future of parking in cities. It is safer, better for the environment, and takes up much less space then regular facilities. I predict that in 10 yrs, we will be wondering what we did before.

Opinion : More on Healthcare reform

Notes to 2008 presidential candidates: How to achieve universal healthcare.

No one is more for universal healthcare than I am, but we need to provide it in a way that makes economic sense. Laying off 1000's of American workers for the benefits of cost cutting does not make economic sense. There are many ideas out there that can save money, but throwing them all on at once will cause a disaster. Healthcare reform needs to be a gradual process that helps everyone and also contains costs. Here is my plan (most of which I stole from Ed Rendell's advisors)

Immediately:

The key here is to save just the amount of money that it will cost to cover the people who don't currently have insurance. First determine exactly how many people are under or uninsured, and how much it will cost to provide them with the minimum acceptable level of coverage. Then determine how much we are currently spending on care minus charity care and services to the uninsured. Take the cost to provide expanded coverage as a percent of total current costs and this is the amount that we will need to cut/find/raise in taxes.

The cuts at this point should be able to come with simple efficiency improvements to the system. This can include: going to centralized electronic records, requiring generic drug use, mandated error control and reporting procedures, outlawing competitive advertising, and limiting the amount of profit that private insurance companies can make based on payouts.

It is also important to establish long term health trends at this point that will stabilize costs. This can include smoking and trans fat bans (or any other public health measures), starting exercise programs, and beginning to negotiate pharmaceutical drug prices. If extra financing will be necessary (Pennsylvania claims it will, Massachusetts says it won't, who knows) then now is the time to pass the necessary measures, such as lotteries, sin taxes (alcohol, firearms, pollution, casinos and tobacco) or private insurance taxes.

In the near future:

The key in future years, once everyone is covered, will be to contain costs, improve quality, and expand services. The ideal cost increase per year should be roughly the rate of inflation (about 3%) plus the rate of population growth (around 1% depending on immigration laws). measures should be phased in slowly to decrease system wide costs each year. These include: geographic redistribution of resources, training more general practitioners, opening more nursing and urgent care clinics, implementing chronic disease management plans, expanding hospice, malpractice reform, negotiating cheaper drug and equipment prices, etc.

There should also be an effort to improve quality and access, mainly by education and out reach and by cracking down on under-performing operations.


In the long term

We need to move towards a more unified and non-profit, centrally planned health care system. As laws are passed and reforms are implemented, Growth and profit should be reduced industry wide and private companies will have motive to sell out. Eventually the goal should be to consolidate systems into non-profit or government run, vertically integrated units. The eventual goal should be Community based pricing by a single payer or a few non-profit payers, in a system organized and overseen by individuals who do not stand to profit from it. This will ensure that care delivery is fair and patient centered. I hope that this is not only a dream.

Opinion : The Discovery Channel

They seem to make this network over every now and then, along with its sister networks: TLC and Discovery Health. (I rarely get the science channel so I cant comment on that one) As a loyal fan, I have a few observations, starting with the positive ones:

During the day, I have recently noticed that the Discovery channel is repeatingly airing a show called How its Made. This is a show that shows random things being manufactured with a little dry commentary and some strange repetitive background music. Apparently this show was made by some Canadian public broadcast station or something. It is oddly surreal and beats any other Day time television that is on, although I will admit that I am a little embarrassed when my roommates catch me watching it...It may be the dorkiest show on television.

Something that really sucks is that the TLC network seems to have been given over to chick programming all the time. I have nothing against having a network for that crap (alright, maybe I do) but I really liked what used to be on The Learning Channel. There is no learning involved in gay men making over houses.

Another gripe is that the health channel seems to be going the same way. More and more the only programming on there is women talking about being pregnant. The still occasionally do the "real-life" versions of ER and forensic detectives, but they stopped showing my favorite thing: late night surgery. They used to show random taped surgery at night on that channel, and I was a big fan. Now they seem to show prime time re-runs. Its alright though, I recently discovered videos of surgical telecasts on Hahneman Hospital's website...

Great Article : Human modification

I would not modify my self, unless I could be sure there was no side effects (which is likely impossible) . I am not sure what I would do In the case of a Handicapped child, all I know is that the parents should have the option.

I honestly don't know what I would do with respect to most types of body modification, many of which are laid out in this great article.

Opinion : A new Iraq plan

To be honest, I haven't even researched Bush's new plan, but I am sure that it contains nothing new or exciting (yet somehow it is very controversial). Well with our leaders abstaining from any creative thinking on the subject, I have taken it upon my self to propose a solution. My solution should be quick, cheap, and effective and not cost any American lives.

Step 1: Build giant Mercenary army

This would actually be very simple. We take a few ships down to sub-Saharan Africa, where the avg person lives on $2 a day, and offer everyone $20 a day to join the new force. Most people in these regions are already accustomed to war and violence, and are likely skilled in firearm use and guerrilla tactics, so they will make perfect troops to fight Arab insurgents. As a side effect, the removal of aggressive young troops from Africa may help to quell the regional unrest there, and the infusion of American capital should help with the extreme poverty thing. About a million or so should do.

Step 2: Deploy Mercenary army

Once armed and trained (basically given guns and shown pictures of Iraqi people), Turn this new army loose in Baghdad. This should be accompanied to moving American troops to outlying areas, where their sudden surge in numbers will allow them to track down the foreign terrorists and more importantly, to secure the oil fields. While it is hoped that the Iraqi army could organize the mercenaries into a useful and efficient security force, this is neither probable nor necessary. More likely chaos will ensue (as it has for the last 3 years anyway) and the shear number of new foreign targets should reduce civilian casualties (or at least distract the UN and aid agencies from counting them). As an added bonus, the infectious disease burden unleashed by the Africans should wipe out most of the Arab population anyways, making any future missions much easier, and containing the local anti-American feelings that this plan will likely cause.


Step 3: Profit

This war has been expensive, and it is only fair that we recoup our investments. While the African mercenaries are taking care of Baghdad, Large numbers of newly freed up American troops should proceed to take control of Iraq's oil fields and infrastructure. Once secured, we should pump as much oil as we can and sell it directly to western companies (and China if we need to bribe them to go along with this) at fixed rates. This should generate lots of revenue for the government, lower gas prices, reward our allies and undercut OPEC. If any OPEC members don't appreciate this plan (Iran, Venezuela, etc), there are plenty more potential mercenaries where those came from...

Opinion : Pennsylvania health care reform

Rendell's new plan is a huge step in the right direction, but it does have a few problems that I can see.

1. It doesnt address the fact that Pennsylvania has the highest malpractice rates in the US. This does not help the cost of healthcare...

2. It doesn't make the new employer programs mandatory (see Massachusetts). Why pay "only $180" per employee when you can pay $0. I am confident the Eagles will win the superbowl before Walmart (or any retailer) decides to buy 2000 employees healthcare out of the goodness of its heart.

3. Most of these programs require a huge initial investment (e-records, error reporting, chronic care plans), especially if they plan on pushing cooperation with incentives. It is not clear how these will be financed in the near term.

This is an amazing plan however. The community pricing, statewide smoking ban, e-records, and chronic disease management are all innovative and necessary reforms.

Opinion : Assisted Reproductive Technology

Submitted for a grade as part of my medical ethics class:

The ethics surrounding assisted reproductive technology (ART) involve the basic issues of both human rights and scientific progress. The science continues to provide us with new techniques to help couples conceive or carry a child while societal attitudes about reproduction rights shift to reflect current ideas. While science is concerned with what we can do, the moral side of the debate asks if we "should" just because we "can". It is important to distinguish between these two sides, because it is important to let the science side advance the technology but allow the moral side to impose limits on the use of this technology. It is not that the right to scientific discovery is more important to the right to reproduce; it is simply a matter that developing the science will not hurt anyone or disrupt any families, where as the act of becoming a parent can have serious consequences.

Current ART methods that are widely available are fertility drugs, surrogate motherhood, and IVF. These methods are commercially successful and have helped many couples have a child. These methods have shown to be safe and effective so there is no real scientific reason contraindicating these procedures. The more controversial ART methods include uterine transplants and cloning procedures. Currently these procedures are likely to have complications for the mother and child respectively, and therefore more animal testing and early stage clinical trials are necessary (see article summary). The main objections to ART in general mainly comes from the moral argument that human beings should not mess with nature. This argument is misguided at scientists, however, as there is nothing inherently wrong with the technology itself. This is the same as the idea that there is nothing wrong with manufacturing a gun, it is using the gun to commit a crime that is the problem. It is the people using the ART for their own ends who deserve the moral scrutiny, and should be subject to guidelines and rules.

Before guidelines can be made however, the ethical issues about the right to procreate must be addressed. Current laws in the US protect the right of a mother to terminate a pregnancy, yet they do not extend an explicit right to begin a pregnancy. This is a major oversight, as the ability to start life is just as important (more so existentially) as the ability to end it. The mother (hopefully with paternal consent) has control over the life of any potential child. This raises the question of whether that control should have limits, and whose interests those limits should be based on.

It is a great regret of many that there is no way to limit reproduction of fertile couples based on their qualifications to be parents. This lack of limits has caused many children to be brought without consent into lives of poverty, abuse, and neglect. It is perhaps stemming from society's inability to prevent this injustice many members seek to limit the parental rights of those who need to rely on ART to conceive. The reliance on ART and subsequent limits leaves infertile couples vulnerable to judgments of others and holds them to a higher standard than other would be parents. "Higher standards" is a bad argument against limits however, because any number of bad parents is no excuse to allow other bad parents to have a child. Any abuse or neglect that can be prevented against a child is worth stopping. Furthermore, parents are subject to scrutiny if they go for the standard alternative to ART: adoption.

When couples choose to use ART, they are making a conscious decision based on their own needs and interests. Unfortunately, people's interests are often selfish and decisions based on love are frequently irrational. This is why society should set limits on ART technology. The technology itself is not wrong, but the humans who use it sometimes are.

Opinion : Barry Bonds

I have said before that I am not entirely against baseball players using performance enhancing drugs (they have to live with the risks, the game is evolving, etc) but one egregious case is really bothering me. That would be the case of Barry Bonds. First of all, Bonds was a superstar with out the drugs (NL MVP, several 40-40 seasons), and his muscle growth around age 40 leaves little doubt that he is guilty. The problem I have though is that he is also a criminal, and he is escaping the consequences of his actions.

Lets put it this way: What would happen to me if I smuggled illegal drugs into this country and then used them in a scheme to make millions of dollars for my employer who would then kick that money back to me. And what if upon the allegations of this activity, I went on a spree of obstruction that included bribing my best friend to silence them (and other witness tampering), lying under oath to the US congress, perjuring myself in front of a federal grand jury, and violating gag orders placed on the investigation. I would probably be in prison for the rest of my life, and therefore Barry Bonds should be too. Bonds has continued to act as if rules do not apply to him, and it is time to teach him that they do.

I would have no problem with Bonds or his records if he just admitted what he did, took his punishment for lying, and moved on. Yet he continues to flaunt authorities, tarnish baseball, and make drug use look good to younger players. I hope he goes to prison for a long time.

On a side note, McGwire doesn't really deserve to make the hall of fame. This is because he was a fat, one-dimensional player who never hit well for average and couldn't field. Neither was he a leader on the field and he rarely lead his team to many victories. A one year freak show does not qualify someone for Cooperstown.

Opinion : Prescription Drug Reform

The Congress is debating, and is close to passing, a Medicare-prescription drug reform bill. Part 1 of this bill requires the government to negotiate with the drug companies to lower the price of drugs to seniors. This is a very important and much needed law that is a good idea. Unfortunately for seniors, however, this law has a second clause. Another part of the bill would make it illegal for the government to use formularies in Medicare plans. The problem is that formularies are by far the most important tool the government has in pharmaceutical negotiations.

Think how the negotiations would unfold: The Government and the Pharm. reps are sitting at a table deciding drug prices. If say 4 companies make a certain class of drug (assuming similar efficacy profiles) then the government could pit them against each other by saying that only the cheapest will be included in the formulary. This would likely reduce the price to nearly cost, as drugs in competitive classes would be forced to compete. The problem with the current plan however, is that the government will not be able to limit any of the competitors. This will greatly reduce the incentive to compete amongst companies. Even if one company bids a lower price, how will the government make people use that drug? Remember that the government is now paying the bill no matter which drug people choose, so there is little economic incentive to take the cheaper option.

To make matters worse, this will also provide more incentive to Pharmaceutical marketing, as the race will be on to push consumers away from the newly low-price drugs and to make them request the higher price version. If market share is increased successfully (and recent history suggests it will) then the companies will now have even more power in those required negotiations. This just shows me further proof that the pharmaceutical companies are not simply bribing "ahem…lobbying " the republicans….they are bribing everyone.

And by the way, short of a single payer system, the best solution would have to allow both formularies and consumer choice…oh wait, that’s exactly what Medicare D is now…

Disclosure: I own stock in pharmaceutical companies and am currently helping one of them run a clinical trial.

Great article : Cloned foods

Great Article. I could not have said this better my self. Cloning is the future of food and the science is clear. Scientists rarely have to call the Democrats closed-minded, anti-progress, fear mongering, moralists, but if the shoe fits...

Opinion : Emergency CPR

Submitted as part of my medical ethics class:

Many people would agree that there are many cases of waste in the American healthcare system that could be reduced if physicians would back down from using aggressive treatments. Often these treatments are costly and have low probability of success, wasting both staff and financial resources. A good example of this is the emergency cardiopulmonary resuscitations (E-CPR) outlined in this week's article. I believe that these are a waste of resources and should not be performed until further technology is developed that significantly improves outcomes.

Many physicians consider death as a failure and do anything to prevent it. Unfortunately, in cardiac resuscitations, they are rarely successful. According to this study, only about 10% of patients successfully have their heart restarted, less than 1% ever regains consciousness, and no one in this study survived to be discharged. (1) The co-morbidities and causes of the arrest ranged from nothing, to Cancer to CAD, and only congestive heart failure showed any survival improvement, and even then lee than half the patients survived. No one with stroke or hypertension was successfully resuscitated. (1) With present techniques and technology, E-CPR is simply ineffective as a medical treatment.

If E-CPR were cheap and easy, or we had unlimited resources, then we might argue that it can't do any harm, so why not give it a try on everyone, even if it rarely helps. Unfortunately, these ideal conditions do not exist, and resources that are used on ineffective treatments are resources that are wasted. In this case, it is estimated that taking care of those who were successfully resuscitated averaged over $5000 (removing an outlier who cost over $95k) (1). The hospital also spent almost $150,000 just to get to those few successful cases (1). That is a steep bill for treatment that did not actually save any lives. It is not clear whether that accounts for staff costs, but it clearly does not take into account the other hospital resources that were used, including ER beds and equipment. The end result of providing E-CPR to all these patients was likely to cause longer ER wait times for the other (presumably surviving) patients and ultimately raise insurance premiums. This clearly does not benefit the community, although this would be more difficult to determine if even one life had been saved.

This study indicates that E-CPR is an ineffective and wasteful treatment. Its use should be restricted immediately and further research should be performed to determine ways to improve cardiac arrest outcomes.

1. Gray, WA. Capone, RJ. Most, AS. Unsuccessful Emergency Medical Resuscitations: Are continued efforts in the ED justified?. NEJM. 1991. pp1393-1398