Category Archives: Medical Issues & Health

Public health vs Private freedom

Peter Singer, Project Syndicate

PRINCETON – In contrasting decisions last month, a United States Court of Appeals struck down a US Food and Drug Administration requirement that cigarettes be sold in packs with graphic health warnings, while Australia’s highest court upheld a lawthat goes much further. The Australian law requires not only health warnings and images of the physical damage that smoking causes, but also that the packs themselves be plain, with brand names in small generic type, no logos, and no color other than a drab olive-brown.

The US decision was based on America’s constitutional protection of free speech. The court accepted that the government may require factually accurate health warnings, but the majority, in a split decision, said that it could not go as far as requiring images. In Australia, the issue was whether the law implied uncompensated expropriation – in this case, of the tobacco companies’ intellectual property in their brands. The High Court ruled that it did not.

Underlying these differences, however, is the larger issue: who decides the proper balance between public health and freedom of expression? In the US, courts make that decision, essentially by interpreting a 225-year-old text, and if that deprives the government of some techniques that might reduce the death toll from cigarettes – currently estimated at 443,000 Americans every year – so be it. In Australia, where freedom of expression is not given explicit constitutional protection, courts are much more likely to respect the right of democratically elected governments to strike the proper balance.

There is widespread agreement that governments ought to prohibit the sale of at least some dangerous products. Countless food additives are either banned or permitted only in limited quantities, as are children’s toys painted with substances that could be harmful if ingested. New York City has banned trans fats from restaurants and is now limiting the permitted serving size of sugary drinks. Many countries prohibit the sale of unsafe tools, such as power saws without safety guards.

Although there are arguments for prohibiting a variety of different dangerous products, cigarettes are unique, because no other product, legal or illegal, comes close to killing the same number of people – more than traffic accidents, malaria, and AIDS combined. Cigarettes are also highly addictive. Moreover, wherever health-care costs are paid by everyone – including the US, with its public health-care programs for the poor and the elderly – everyone pays the cost of efforts to treat the diseases caused by cigarettes.

Whether to prohibit cigarettes altogether is another question, because doing so would no doubt create a new revenue source for organized crime. It seems odd, however, to hold that the state may, in principle, prohibit the sale of a product, but may not permit it to be sold only in packs that carry graphic images of the damage it causes to human health.

The tobacco industry will now take its battle against Australia’s legislation to the World Trade Organization. The industry fears that the law could be copied in much larger markets, like India and China. That is, after all, where such legislation is most needed.

Indeed, only about 15% of Australians and 20% of Americans smoke, but in 14 low and middle-income countries covered in a survey recently published in The Lancet,an average of 41% of men smoked, with an increasing number of young women taking up the habit. The World Health Organization estimates that about 100 million peopledied from smoking in the twentieth century, but smoking will kill up to one billion people in the twenty-first century.

Discussions of how far the state may go in promoting the health of its population often start with John Stuart Mill’s principle of limiting the state’s coercive power to acts that prevent harm to others. Mill could have accepted requirements for health warnings on cigarette packs, and even graphic photos of diseased lungs if that helps people to understand the choice that they are making; but he would have rejected a ban.

Mill’s defense of individual liberty, however, assumes that individuals are the best judges and guardians of their own interests – an idea that today verges on naiveté. The development of modern advertising techniques marks an important difference between Mill’s era and ours. Corporations have learned how to sell us unhealthy products by appealing to our unconscious desires for status, attractiveness, and social acceptance. As a result, we find ourselves drawn to a product without quite knowing why. And cigarette makers have learned how to manipulate the properties of their product to make it maximally addictive.

Graphic images of the damage that smoking causes can counter-balance the power of these appeals to the unconscious, thereby facilitating more deliberative decision-making and making it easier for people to stick to a resolution to quit smoking. Instead of rejecting such laws as restricting freedom, therefore, we should defend them as ways to level the playing field between individuals and giant corporations that make no pretense of appealing to our capacities for reasoning and reflection. Requiring that cigarettes be sold in plain packs with health warnings and graphic images is equal-opportunity legislation for the rational beings inside us.

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Banning the sweet tooth- an EVOLUTIONARY need?

Daniel Lieberman, New York Times, June 21 2012

OF all the indignant responses to Mayor Michael R. Bloomberg’s plan to ban the sale of giant servings of soft drinks in New York City, libertarian objections seem the most worthy of serious attention. People have certain rights, this argument goes, including the right to drink lots of soda, to eat junk food, to gain weight and to avoid exercise. If Mr. Bloomberg can ban the sale of sugar-laden soda of more than 16 ounces, will he next ban triple scoops of ice cream and large portions of French fries and limit sales of Big Macs to one per order? Why not ban obesity itself?

The obesity epidemic has many dimensions, but at heart it’s a biological problem. An evolutionary perspective helps explain why two-thirds of American adults are overweight or obese, and what to do about it. Lessons from evolutionary biology support the mayor’s plan: when it comes to limiting sugar in our food, some kinds of coercive action are not only necessary but also consistent with how we used to live.

Obesity’s fundamental cause is long-term energy imbalance — ingesting more calories than you spend over weeks, months and years. Of the many contributors to energy imbalance today, plentiful sugar may be the worst. Continue reading

‘The global food system is causing a public health disaster’

By , The Guardian,9 March 2012

The UN rapporteur on the right to food says governments in rich and poor countries must bring in tough measures to combat the unhealthy products being marketed.

More than 1.3 billion people around the world are overweight or obese

More than 1.3 billion people around the world are overweight or obese. Photograph: Finbarr O’Reilly/Reuters

The global food system is making people sick in both rich and poor countries, the UN expert on food warned on Tuesday, as he called for a range of dramatic measures to overhaul it and tackle what he described as an international “public health disaster”.

The UN special rapporteur on the right to food, Olivier De Schutter, presenting his latest report to the UN Human Rights Council in Geneva, called for governments to bring in tough measures. He wants to see taxes on unhealthy products, including fizzy drinks; much stricter regulation of junk processed foods that are high in saturated fats, salt and sugar; a global crackdown on advertising and marketing of junk foods; an overhaul of the subsidy regimes in the EU and US that make the commodity crops that form the basis of junk food diets cheap while leaving healthier foods such as fruit and vegetables expensive; and a redirecting of support to local food production that allows farmers around the world to earn a decent living and consumers to afford nutritious food.

The report marks a significant increase in pressure on agribusiness. As rapporteur on the right to food, De Schutter has previously highlighted the way the system of global food trade – dominated by a small number of transnational traders, manufacturers and retailers – marginalises farmers in developing countries and threatens food security. But it is the first time he has produced a full report on the burden of disease the system also inflicts on western consumers.

His analysis echoes that made by NGOs and campaigners in recent years, from Professor Tim Lang in Food Wars to Raj Patel in Stuffed and Starved, and my own books Not on the Label, and Eat Your Heart Out. The policy pursued postwar, and in particular since the 1970s Soviet grain crisis, of going for maximum production of cheap calories over quality of diet has served neither affluent countries nor developing ones. One in seven people remain undernourished today, with many more suffering from serious micronutrient deficiencies, while at the same time more than 1.3 billion people around the world are overweight or obese.

The solutions offered by agribusiness of more hi-tech or fortified foods cannot solve the problems, which are systemic, according to De Schutter.

But since this view is in effect an attack on the major economic interests of the west, the question is how the rapporteur thinks change can be brought about. For De Schutter, the UN agencies that have influence over policy in the area of food and health are where they were with tobacco in the 1980s. At the UN high-level summit on non-communicable disease in New York last September, the US blocked tougher wording on goals to combat the epidemics of obesity, diabetes and heart disease in order to protect their agrifood companies.

But now his report is presented, governments will have to come clean on their individual positions. As with tobacco, it will be a long haul – but the scale and cost of diet-related disease will also concentrate governments’ minds. In Mexico, for example, 70% of the adult population is overweight or obese and the average adult requires medical treatment for 18 years for related diseases such as diabetes. China too has reached a tipping point, where 10% of the population is overweight or obese, matching for the first time of numbers of its citizens who are undernourished.

Key to changing the food system is addressing the excessive concentrations of power in the chain. Another report (pdf) from the Centre for Economic Policy Research highlights how cartels in global agrifood have contributed to food price spikes in recent years that have threatened the food security of millions around the world. The report, Trade, Competition and the Pricing of Commodities, records 36 international cartels involving food that distorted prices in the 2000s.

The unethical side of science: Syphilis “Laboratory” in Guatemala

We studied this in last year’s Science package – here is a hard look at the legacy left behind by the deliberate infection of Guatemalans with Syphilis in the bid to study the disease.

“Obama may have apologised last year for the 1940s US medical experiments that intentionally infected Guatemalans with syphilis, but as this startling report shows, its legacy continues to destroy lives.

Soldiers, prostitutes, the mentally ill and even orphaned children; no one was safe from the American government’s decision to deliberately infect them with syphilis. The costs are still being felt today in Guatemala as the infected and their descendants, who have inherited the disease, all bear the painful scars of those experiments. Dr Cutler moved his base when he was banned from practising in the States, after watching the effects of syphilis on African-American men who had no idea they were infected. Treating the disease “would interfere with the study”, Cutler said. All are victims of a “serious crime” says the lawyer pressing a lawsuit against the US government on behalf of the Guatemalans. Obama’s apology for this atrocity is a start but it isn’t enough to mend the ruined lives of the surviving human guinea pigs.” 

The High Cost of Health Care

The New York Times, November 25, 2007

The relentless, decades-long rise in the cost of health care has left many Americans struggling to pay their medical bills. Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare.

Health care costs are far higher in the United States than in any other advanced nation, whether measured in total dollars spent, as a percentage of the economy, or on a per capita basis. And health costs here have been rising significantly faster than the overall economy or personal incomes for more than 40 years, a trend that cannot continue forever.

It is the worst long-term fiscal crisis facing the nation, and it demands a solution, but finding one will not be easy or palatable.

Continue reading

How Technology Can Help Fight Our Most Expensive Health Care Burden

By , The Huffington Post, 4/2/11

Our lives have transformed so dramatically when it comes to utilizing technology to communicate. We have our hand-held devices, our iPads and tablets as well as our Facebook pages. But, what is most exciting is that we are finally seeing the wireless generation being applied to help advance the care of chronic diseases and conditions.

For example, diabetes places a huge burden and tax on people’s health, quality of life and on our economy. In fact, the statistics are daunting; there are 25 million people in the United States currently suffering from diabetes. The American Diabetes Association has calculated that the disease’s total annual cost to society to be around $218 billion. This translates into approximately $9,000 per diabetic per year. It’s a staggering number for such a terrible and debilitating disease — the full societal, emotional, and health care costs of which we will never fully appreciate.

Diabetes still has a long way to go here in the U.S. However; there are ways to manage the disease. Health care providers and medical companies are quickly learning how to leverage emerging communication and electronic technologies to make diabetes management more efficient, reducing hospitalizations and ultimately decreasing the cost of the disease to individuals and on society.

What’s more, the health care market is seeing a large influx of companies who are putting technology to use in a growing field of healthcare communications and health-record management; at a basic level, this means using technology to manage health records and share information with a patient’s physician or other approved health care providers and caregivers — including family members.

But, for treating diabetes patients in particular, the use of technology has been slow. This is quite ironic since the ever-changing condition of diabetes, by its very nature, could benefit from up-to-the minute capabilities that technology brings. Why? I have wondered this myself and I believe the answer lies in the age old tradition of sticking with the status quo. Diabetes care was slow to change. It seemed to work — for the pharmaceutical companies — and the patients weren’t demanding new and more efficient ways to treat the disease.

But, now we are finally on our way to technological applications being used across the board in caring and monitoring diabetics. In fact, just in the past few years, there finally has been marvelous progress in diabetes care. This isn’t just with insulin pumps and home blood glucose monitoring systems. The technologies available now and those at the cusp of development are really encouraging and exciting.

For example, there are new computer programs that support the analysis of home blood glucose data. Insulin pens are finally the norm and diabetes sufferers are using not just more convenient and expedient methods of insulin administration – they are now using more accurate methods because of technologies that provide improved measurement and monitoring. The idea of subcutaneous glucose sensors were a dream only a decade ago and now they’re an everyday part of diabetes care.

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International Cooperation is Key to Reversing the Global Obesity Epidemic

By , The Huffington Post, 10/25/11

Since 1980, the prevalence of overweight and obesity has more than doubled worldwide. The statistics are staggering: in 2008, 1.5 billion adults were overweight and nearly 1 in 10 were obese. The health consequences are enormous — obesity is a leading cause of global mortality. More than 2.8 million adults die each year as a result of being overweight or obese. In all, 44 percent of the world’s diabetes burden, 23 percent of the death and disability from cardiovascular disease and between 7 and 41 percent of certain cancers are attributable to overweight and obesity. As a result, 65 percent of the world’s population lives in a country where overweight and obesity kill more people than hunger and under-nutrition. [1] Although once considered conditions of affluence, overweight and obesity are now on the rise in low- and middle-income countries. As a result, these nations are now facing the double burden of infectious and chronic diseases.

In 2010, according to the World Health Organization (WHO), of the world’s 43 million overweight children, almost 35 million live in developing countries, compared to 8 million in developed countries. [2] This is particularly alarming, given that childhood obesity is associated with a host of health consequences, including Type II diabetes, respiratory conditions such as asthma, hypertension and mental health concerns. In addition, obese and overweight children face an elevated risk for premature death and disability when they reach adulthood. Even in countries with relatively low adult obesity rates, childhood obesity is rising dramatically. For example, Italy, where 42.9 percent of the adult population is overweight (among the thinnest adults in the industrialized world), 35.9 percent of children ages 8-9, are overweight — among the highest rates in the world based on available data (see Boxes 1 and 2). [3]

What is causing this alarming surge in global obesity? Worldwide, there has been a decline in physical activity due to more sedentary jobs and modes of transportation. Moreover, the intake of energy-dense foods high in fat, salt and sugar, and low in nutrients has accelerated rapidly with increased global trade and development. These societal changes in diet and physical activity are in turn exacerbated by agricultural trade policies, food marketing and a lack of urban planning and transportation that foster healthy lifestyles.

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Will a fat tax make Denmark healthier?

Posted by , The Washington Post , 10/04/2011

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(Larry Kobelka for The Washington Post) Over the weekend, Denmark became the first country to tax saturated fats.

The tax — 16 Danish kroner per kilogram of saturated fat in a food – works out to about $6.27 per pound of saturated fat. It hits all foods with a saturated fat content above 2.3 percent. Danesreportedly began hoarding butter and other fatty products before the new regulation kicked in.

Denmark’s tax is the first of its kind in other ways. “This is a major development for two reasons: It’s an entire country, and they’ve taken on a particular part of the food supply,” says Kelly Brownell, director of Yale’s Rudd Center on Food Policy, who is widely credited with introducing the idea of a soda tax in the 1990s.

The Danish government implemented the tax because it wanted Danes, who lag behind European life expectancy numbers, to get healthier. Will they? The research on “fat taxes” is sparse, but there’s good reason to be skeptical about the potential public health gains.

One thing we do know about food taxes is that they have to be really high to change behavior. Brownell and Tom Frieden, now director of the Centers for Disease Control and Prevention, wrote in a 2009 New England Journal of Medicine article that the 5 percent taxes on unhealthy foods that states tend to pass just don’t cut it. Brownell’s research has found it takes a 1-cent-per-ounce tax to change behavior; anything lower, will do great at bringing in revenue but likely won’t lower soda consumption.

In reducing fat consumption, the bar may prove to be even higher: While soda isn’t generally thought of as a meal, solid foods are a different ballgame, what people eat when they sit down to dinner or lunch. And what little research we have on fat taxes bears this out. A 2007 study form the Forum for Health Economics and Policy modeled the impact of a 10 percent fat tax on dairy products and found unimpressive results.

“Such a tax results in less than a 1 percent reduction in average fat consumption,” the authors found. “To have a substantial effect, the tax rate would have to be quite high. For example, a 50 percent tax only lowers fat intake by 3 percent.”

Moreover, the authors worried that a fat tax would be quite regressive, hitting lower-income families much harder than higher earners. “The welfare loss to a family earning $20,000 is nearly double that of a family earning $100,000,” they found.

Since the Danish tax covers foods with higher fat content at a greater rate, its impact could be all over the board. It may reduce the consumption of really high-fat foods, but not those with a fat content. Denmark’s Confederation of Industries calculated that the tax adds 12 cents to a bag of chips, 39 cents to a small package of butter and 40 cents to the price of a hamburger.

Denmark’s tax is, in Brownell’s view, an important “bellwether:” He believes it will test both whether the policy works, as well as the political appetite for such levying such fines.

“If foods with saturated fats now cost more, you don’t know what people will eat in their place. The hope is they’ll eat healthier things.”

As we watch the effect of Denmark’s new tax, we’re about to find out

Whatever happened to the AIDS vaccine?

By Mitchell Warren, Huffington Post, 29 Sept 2011

Recent news about HIV/AIDS has focused on the good — promising trial results that prove the antiretroviral (ARV) drugs used to treat HIV can also prevent HIV infections — and the bad — retreats in donor commitment that imperil the substantial gains that have been made in treating global AIDS, at the precise moment that treatment has been recognized as a powerful prevention strategy. In discussions about whether AIDS treatment can be used to end the AIDS epidemic, scant attention is paid to the search for an AIDS vaccine.

When AIDS vaccines do get mentioned, it is often in the context of questions about whether a vaccine is still needed, or whether the search for an AIDS vaccine is affordable in today’s economic climate.

Researchers and advocates who gathered Sept. 12-15 in Bangkok, Thailand, for the AIDS Vaccine 2011 conference have clear answers: Yes, we still need a vaccine, and yes, we need to continue to invest in AIDS vaccine research.

Thailand was home to the world’s largest AIDS vaccine trial, which two years ago provided proof that an AIDS vaccine is possible. The positive results of the RV144 Thai AIDS vaccine trial were not enough to move to license and produce a vaccine, but the trial did prove that it is possible to prevent infection with a vaccine strategy. In the months that followed, the AIDS vaccine field crossed national and institutional borders to execute a comprehensive search for clues about how the vaccine provided this protection. Working with incredibly limited material — a mere three millileters of blood per vaccine trial participant — the international team was able to draw intriguing conclusions about how the vaccine might have worked.

We don’t yet have a blueprint for an effective vaccine to roll-out. But, as presented this week in Bangkok, the complex success of the RV144 analysis, combined with a flurry of advances in understanding the development of broadly-neutralizing antibodies against HIV, show that the science of an AIDS vaccine is vibrant and vital.

Now is exactly the time to maintain commitment. Now is exactly the time to hold a steady course in funding for basic science, clinical trials and product development. It’s good business sense: Our investments are paying off — and the dividend, in the form of an effective vaccine, would have value beyond our wildest dreams.

But a vaccine alone is not the answer. The best scenario for ending the AIDS epidemic is combination prevention — scaling up proven interventions now, including new options, such as pre-exposure prophylaxis (PrEP)treatment as prevention and male circumcision, while continuing investment to develop and deliver microbicides andvaccines as well.

And while funding for additional research for AIDS vaccines and other new options should never come at the price of funding for treatment access, neither can we stop funding research to find new options. The solution to the global HIV epidemic is increasingly clear: Donors, including governments in both developing and developed nations, must invest in a comprehensive, strategic plan, including:

  • Near-term strategies, including treatment and care for all who need it and improved access to existing prevention options, like medical male circumcision, male and female condoms, clean needles and prevention of vertical transmission;
  • Mid-term strategies, including demonstration projects that will show us how best to implement PrEP and planning for the eventual licensure and roll-out of microbicides, pending the results of ongoing trials;
  • Long-term strategies, including basic research and clinical trials for AIDS vaccines and a renewed search for a cure.

There are many low points in the 30 years that we have been living with HIV, and far too few reasons to celebrate. But the last two years have given us many reasons to celebrate, as trial after trial has shown positive results that point us toward ending this epidemic. This run of good science and good luck began here in Thailand when the results of the RV144 vaccine trial were announced, and this week we’re seeing more evidence that will help make an AIDS vaccine a reality.

We still have a long way to go, but with the right resources, the right leadership and with support from communities and the participation of trial volunteers, we can have an AIDS vaccine in our lifetime. And we can end this epidemic.

So don’t ask whatever happened to the AIDS vaccine, ask what you can do to help make it a reality.

An AIDS vaccine is one important part of a strategy to end the AIDS epidemic. Read more about how we can end the epidemic and add your support at www.endtheepidemic.org.

A $1000 Genome


Animation of an MRI brain scan, starting at th...Image via Wikipedia

It’s been the catch-phrase of science geeks hoping to drive DNA sequencing to the next level: The $1,000 genome. There is a National Institutes of Health project to get us there, an X Prize to reward whoever gets there first, and a book (a great read) named after the idea. The $1,000 genome – it promises a day when we all carry around our genetic code on thumb drives and use it to decide what medicines to take, what to eat, and what diseases to watch out for.

Great buzzword, but it may never happen, especially not any time soon and especially not at a cost of $1,000. Research costs for sequencing a human genome may drop that low very soon, but that doesn’t include paying the doctors or the cost of information technology to process the data. Research genomes are not accurate enough for medical use. Getting better accuracy requires sequencing the DNA more times, which drives the cost back up. I’d think if we’re talking about actual medical use, $10,000 is a more accurate number. Certainly, it is not going to drop below the $2,000 level for a magnetic resonance imaging scan. And once the technology is in use, I think it is possible that the costs will go back up.

Even in consumer electronics, costs don’t always go to zero. Buying a decent computer (not the chintzy netbook I use for everything) costs as much now as it did ten years ago – the power behind the device you get has simply increased. But medicine is not like consumer electronics. That’s why we often pay astronomical prices for drugs that have real benefits –$93,000 per patient for Dendreon’s prostate cancer drug Provenge, or $200,000 per patient per year for one of Genzyme’s rare disease drugs. Sequencing isn’t going to mirror the drug business. It might be more like the PET scan and MRI business, with select hospitals buying huge, expensive machines. Or it might be that people don’t get their whole genomes scanned except when they have a hard to diagnose disease – patients with cancer might have a few hundred or a thousand of their tumor genes sequenced in order to pick the right drugs, for instance. All of this comes with the hurdles that neither doctors nor regulators really understand sequencing yet, and that’s bound to come with all sorts of hiccups. On the other hand, the first cases of using sequencing in medicine are arriving now.

That said, one of the arguments that this could be quite big is that you can get to pretty gigantic market sizes whether the cost comes down a lot or not. To quote Jay Flatley, chief executive of DNA sequencing leader Illumina: “If you look at the potential it verges on being insatiable through the next ten years,” says Flatley. “If you look at sequencing entire countries the potential volumes are really staggering, even at $1,000 a genome.