Saturday, January 25, 2020

The Novel Coronavirus - should you worry?

The sky is falling, the sky is falling! We are all going to die of coronavirus! Or are we?

(Note that I will periodically update this post though the original posting date of 1/25 will not change. Last update 2/24.)

In December 2019, there was an outbreak of pneumonia in Wuhan, a city of 11 million people in central China. All the patients with pneumonia were linked to a seafood wholesale market in Wuhan. A previously unknown coronavirus was discovered in samples from the patients and named 2019-nCoV (now officially named SARS-CoV-2). Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. While most coronaviruses found in humans are associated with the common cold, the MERS and SARS variety were the cause of severe disease in humans, and both were transmitted from animals (camels and swine respectively) to humans and then human-to-human. The illness caused by this virus is now officially called COVID-19.

The major concern is the history of MERS and SARS. The Middle East Respiratory Syndrome resulted in 2500 cases, of which 34% died. The Severe Acute Respiratory Syndrome which broke out in China in 2002-3 led to some 8000 cases, of which 10% died. Could this new virus behave similarly? As of February 18, there have been some 72,500 confirmed cases in China, and 1870 (2.5%) have died. The facts of modern travel have resulted in spread outside Wuhan. Small numbers of cases have been reported from Thailand, Japan, Hong Kong, South Korea, France, Australia, Canada and the U.S, where 35 cases have been found as of Feb 24, all in returning travelers from Wuhan or their spouses or passengers evacuated from the Diamond Princess cruise ship. As of February 24, the large majority of cases have been in China, most of those in Hubei province around Wuhan. There have been over 1000 cases world-wide outside of China, with South Korea reporting a sharp upsurge from 30 last week to 602, linked to a packed church service and few deaths outside China have been reported. Another hot spot is Japan, and Italy is also reporting an upsurge from 3 to 219 this week. While you will see headlines proclaiming that the death toll exceeds that from SARS, note that from the beginning, the death rate from this virus has stayed at 2-2.5%. It should also be noted that the number of new cases in China appears to be falling. Reported cases took an apparent upward spike mid-February when Chinese doctors adopted a new definition of the disease but are now falling.

The Chinese authorities have responded vigorously. After an unfortunate period in which they tried to keep the outbreak a secret, they have been open about the situation, which is very helpful to public health personnel in other countries. They have implemented a virtual quarantine of the entire city, to the consternation of its people, but which should help contain the epidemic. Chinese scientists were on the scene early, identified the virus DNA and shared this with the global scientific community, which has proven very helpful in understanding the epidemic. Unlike it's response during the SARS epidemic, China will finally allow WHO experts to evaluate and offer advice, Returning travelers from central China are being identified at airports and checked for fever. Flights to and from China have been curtailed or stopped completely.

Given the relatively low fatality rate, and the relatively low person-to-person spread (estimates are that every person infected could infect between 1.5 and 2.5 others), it does not appear there is a need to panic. The World Health Organization initially decided against declaring this a public health emergency, but did do so on January 30. An obvious concern is the belief that spread can occur before someone has symptoms.

What does this mean to you? First, I would call off that trip to Wuhan specifically and China in general (if you could even find a flight!). Second, if any of your friends or colleagues have recently returned from central China, be extra careful to avoid them if they are at all ill. Masks? Don't bother; they may do more harm (by frequent touching) than good. Wash your hands regularly with soap and water. Don't worry about packages - the virus will not survive over the trip from China. Recent arrivals from China, who may arrive via third countries, should self-quarantine for 14 days or be required to do so if they do not do so voluntarily. The incubation period is between 5 and 14 days, so anyone who is not ill after two weeks is very unlikely to carry the virus. If you are the sick one, cover your mouth and nose when you cough or sneeze - but NOT with your hand - use your elbow or a tissue that you then toss.

Most important, while the 2019 Novel Coronavirus has so far killed over 1000 people, there is a much worse virus circulating that has already killed some 14,000 Americans this season, and is estimated to kill 35,000 each year. That virus is the influenza virus. So, if you have not already done so, get your flu shot!

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, January 18, 2020

Waste not, want not

The October 7, 2019, New York Times headlined “The Huge Waste in the U.S. Health System,” referencing a study published in JAMA, the Journal of the American Medical Association. The article went on to say that the estimated waste is at least $760 billion per year. “That’s comparable to government spending on Medicare and exceeds national military spending, as well as total primary and secondary education spending.” None of this should have come as a surprise to readers of my book Prescription for Bankruptcy, nor was it really “news.” Back in 2012, both another paper in JAMA and a report from the National Research Council estimated waste in the system at 30-35% of total spending.

Why is waste so prevalent? There are many sources. The biggest one, and the one that should most concern patients, is “low value care:” care that offers little or no benefit or even harm but which costs patients and their insurers money. This ranges from antibiotics for viral illness that will not improve the infection but may cause side-effects to back surgery for non-specific low back pain that may leave patients worse.

Using branded medicine when generics are available is obvious waste. There is enormous waste in testing and medical services. Not only are U.S. prices for most services dramatically higher than those in other countries, but prices for the same service vary widely within the U.S. If the same imaging study can cost $1200 in one location and $4000 in another in the same geographic area, is not the $2800 pure waste?

Studies at major medical centers have shown that a very large percentage of the tests ordered are clearly unnecessary: tests repeated for no reason or tests done so soon after another that they are unlikely to be different. A study of eye surgery showed that huge volumes of medications were discarded because they came in amounts much greater than normally used. Surgical “kits” used by different surgeons for the same operation can vary 4-fold in cost with no obvious difference in performance. Patients having cataract surgery are routinely required to have “pre-op clearance” with a physical exam and ECG even though the national organization of ophthalmologists has said this is not needed.

Tests that were not needed in the first place often show some minor abnormality, which leads to a “cascade” of further tests and rarely benefit the patient subjected to this testing.

Probably the largest source of waste is the huge administrative overhead embedded in the U.S. healthcare system. Fully 25% of “healthcare” spending goes to the direct cost of private health insurers and to the cost to physicians and hospitals of billing and meeting various “mandates” that the insurers place on them. An argument for a single payer system is that it could cut payments to physicians by 10% and at the same time cut their costs by at least that amount by reducing the administrative burden, leaving them financially whole.

With a system that is so expensive, why has there not been some movement to cut waste? A large factor is the lack of interest by those who would have to move the needle. Why should a hospital cut the cost of their surgical kits when they can simply pass the cost on to the insurers?

Another, and perhaps the major factor, is that one person’s wasteful spending is another person’s income. Only under huge pressure from the public and the government are we going to see change. I am not holding my breath.

Prescription for Bankruptcy. Buy the book on Amazon

Tuesday, January 7, 2020

Dying to be beautiful

Personal care products (nail polish, polish removal, hair products, skin creams, etc.) are found in every American home, and most are perfectly safe if used as intended. There are, however, situations in which these can be dangerous and even deadly.

The most obvious concern is accidental use by small children. An article published on-line in Clinical Pediatrics estimated that between 2002 and 2016, almost 65,000 children under 5 were treated in US emergency departments for poisoning by cosmetics. Toddlers are naturally curious, and as soon as they begin to walk begin to investigate their world, often by putting what they find in their mouths. Products that are perfectly safe when applied to the hair or nails may be dangerous when swallowed. By far the most common cosmetic-associated injuries were poisonings, and this was particularly common in children under 2. About 20% were burns or other contact injuries, and often involved the eyes. It does not help that many of these products are brightly colored and attractively packaged. What entices adults to pick them out on crowded shelves also attracts the attention of exploring toddlers.

Another issue is endocrine-disrupting chemicals, particularly parabens and phthalates that are commonly used as preservatives in cosmetics (and other household products). Researchers found that when women used these extensively during pregnancy, their daughters had significantly earlier onset of puberty. This can be psychologically difficult for the girls and has also be linked to higher risk of breast cancer.

Least common but truly deadly is the finding that many skin-lightening creams bought from other countries or over the Internet are contaminated by mercury. Inorganic mercury IS effective at lightening skin and a widely used contaminant. A California woman was recently hospitalized with severe neurologic damage that was found to be due to mercury poisoning. A cream she bought from friends was imported from Mexico and found to contain high levels of organic mercury, even more dangerous than the inorganic kind.

My take-homes?
1. If you have toddlers or small children at home, treat cosmetics the way you should treat medicines: keep them out of sight and out of reach, preferably in locked cabinets.
2. If you are pregnant, try to avoid skin products containing parabens or phthalates; these should be easily identified by reading the label.
3. Do not use any skin-lightening product from any but a reputable local store. Clearly do not use any imported products, and I would not use any bought over the Internet based on recent revelations about how poorly Amazon vets some of its third-party sellers.

Prescription for Bankruptcy. Buy the book on Amazon