On Impossibility:

•March 8, 2014 • 2 Comments

An Open Letter – from the anonymous SMO to the Premier  of Queensland and the Minister for Health

These words are not mine – but the opinions in them are common to many of us.

[9-Mar 1700: One clinical example edited at request of the unknown SMO and a couple of rogue apostrophes removed]

 

Date: 7 March 2014 10:48:17 PM AEST
Subject: Nothing here is impossible Mr Springborg

Dear Minister Springborg and Premier Newman,

We have been told that your legislative changes are irreversible, and the train carrying these individual contracts has already pulled out of the station,
and cannot be stopped.

We sincerely hope that your talks with the SMO representatives around the concerning issues in the contracts result in a successful outcome for all.

If SMOs are not convinced that our ability to continue to practice public health medicine with safety is secured, then the state will be in grave danger of losing its’ brightest and best.

Please listen:    We say to you that nothing in your legislation, and the individual contracts, is irreversible. This train wreck can most certainly be stopped.

You are dealing with a group of people who understand what is truly irreversible and impossible, as they have stood in the face of death and tried to stare death down,
bargained against time with their knowledge, skills, equipment and courage, and sometimes failed, and often times not.

When you have to tell parents that their child has autism and intellectual impairment and that their lives will forever be filled with difficulty and challenge, and watch their grief unfold – that is irreversible.

When you watch a child bleed to death before your eyes as you pump blood in their arm only to see it pour out of the gaping hole in their skull, where it has been sheared off from a motor vehicle accident -
that is irreversible.

When you tell parents that their baby has cerebral palsy and will never walk or talk, or even eat independently, because their brain is malformed or damaged beyond repair   –  that is irreversible.

Nothing here with your individual contract legislation is impossible to change – we’ll tell you what is impossible.

When parents beg you to save a child’s life after a second failed bone marrow transplant for leukaemia, as you’re watching them die from an infection they have no white blood cells left to fight  -  that is impossible.

When you’re trying to bring back a heart beat in a child who has been pulled from the bottom of a pool, an hour after its heart beat stopped  -  that is impossible.

Don’t you dare sit there and tell us that this legislation is irreversible and that stopping this contract roll out is impossible.
Because we know that all it takes is a show of hands in a parliamentary room, and the swipe of a pen across a piece of paper.

No fancy machines, no million dollar drugs, no transplanted tissues, no 12 hour operations, and no miracles of fate.

Just understanding and good will from your colleagues and yourselves. And if you’re up all night to achieve that, then welcome to our lives.

We have each others’ backs, us medicos  -  we always have and always will.

Because we have all stood there with the sick and the dying, and we know how lonely that journey is without colleagues at our shoulders, and support and resources at our backs.

So we will stand together, even if we have to walk away, together  - until you listen, and pull on the brakes, and stop this train wreck from playing out to its end.

Please enter the discussions with good will, and open minds and hearts, and leave your egos on the coat rack outside.

The health of the state is in your hands – please don’t throw it away.

Sincerely,
Senior Medical Officers of Queensland Health.

PS To all of our colleagues – please don’t walk away or sign just yet – stand at our shoulders because we’ve got your backs.

PPS Please someone send this to every QLD SMO.

Dear Chemo

•December 1, 2013 • Leave a Comment

Originally posted on drkategranger:

Dear Chemo,

I thought I’d commit some of my thoughts about you to paper. I’ll warn you that this may make for uncomfortable reading at times and I may seem a little harsh.

There is no doubt that just under two years ago when we first encountered each other you managed to save my life. I completely get that and am deeply grateful to the doctors and nurses who helped to prescribe you and infuse you into my damaged body that was teetering on the edge of remaining alive. I had always been a little stand offish about entering into a relationship with you though. I had seen what you could do to my own patients back when I toyed with the idea of becoming a Haematologist.

The first time we came together I will never forget the nausea and vomiting you caused. It was horrendous. I didn’t eat for…

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HIV, Stigma and teh Jernlisms (again)

•November 27, 2013 • 2 Comments

This Sunday is World AIDS Day.  The theme for our local campaign is “Zero”.

Zero new infections. Zero AIDS-related deaths. Zero discrimination.

The Queensland Government HIV strategy aligns nicely with these messages. The four priority areas are:

  1. Implement a comprehensive prevention campaign.
  2. Promote increased uptake of testing.
  3. Ensure 90% of positive patients are on treatment
  4. Increase community awareness and reduce stigma and discrimination

It’s point 4 that I’m going to talk about today.

You may have seen me retweet a couple of links yesterday on HIV in Greece.  I’ve included the photos below in case they get eaten by the internet.

ImageTweet posted by timmyconspiracy

There was also a screenshot of the primary report that this was based on – from WHO’s Review of Social Determinants of Health in the European Region. The relevant section is page 112 of the PDF at the other end of that link, which I’ve reproduced below (also from timmyconspiracy).

Image

Surely if the WHO put it in one of their technical reports, it must be the real deal, hey?  It was certainly taken as authoritative by several sources in the media.

The trouble is, it’s just not true. (Official WHO erratum here: thanks, Paul Davis for pointing out I forgot to link this)

You’ll notice the statistic about HIV infections in the WHO report isn’t specifically referenced.  Reading around this, it is variably attributed to a statement by the Greek Health Minister (can’t find any primary evidence of this) or based on an article (actually a letter) in The Lancet.  This letter says specifically:

“A significant increase in HIV infections occurred in late 2010…with half of the currently observed increases attributable to infections among IV drug users.

“An authority report described accounts of deliberate self-infection by a few individuals to obtain access to benefits of €700 per month and faster admission onto drug substitution programmes.”

That second sentence was referenced to the Report of the ad-hoc Expert Group of the Greek Focal Point on the Outbreak of HIV/AIDS in 2011. Its points were:

  • The increase in cases occurred without any change in harm reduction interventions
  • Increased law-enforcement crackdown on IVDUs resulted in less access of drug use support workers to the users
  • Increased needle-sharing and unsafe sexual practices
  • An important factor in these risk behaviours are the economic crisis

and finally:

“An additional factor the committee believed worth considering is the well founded suspicion[my emphasis] that some problem users are intentionally infected with HIV because of the benefit they are entitled to…and also because they are granted “exceptional admission” to the substitution programme.”

Further background is in the EMCDDA report on HIV/AIDS among IDUs in Greece:

I won’t block quote big sections of the report, but abstracting it for you, the issues identified were very similar

  • Most of the increase in cases were centered on Athens
  • Increase in prostitution by users unable to fund their habit in other ways due to the economic crisis
  • Opioid substitution clinics in Athens have a long waiting list so less IVDUs in Athens are on a program
  • Very limited coverage of needle/syringe programs in Greece compared to other countries in Europe.

So let’s be very clear on this.  Some Athenian drug dependency doctors put in a report they had a “well founded suspicion that some problem users” were self-infecting in 2011 and this managed to make its way into a WHO report as saying that “half of new infections in 2013″ were self-infected.

Obviously WHO dropped the ball with this one.  An authoritative scientific report on social determinants to make an outrageous claim without reference is really just not good enough.  But where was the critical journalism of this report?  The UKs Daily Mail managed to quote the original report with the suspicion quote, but still said “research said around half of new cases could be self-inflicted”.  Based on what?

My thoughts

Why is any of this important in Australia?  Adding the stigma of people deliberately infecting themselves onto the already significant challenges experienced by people who are down-and-out and turning to drugs and prostitution is hardly going to contribute to either better health outcomes or better community acceptance the people or their disease.

Secondly, there is the clear evidence that a policing and enforcement policy on IV drug use not only does not work, but also results in worse health outcomes. I have signed the Vienna Declaration – and I encourage all of you who believed in evidence-based policy to sign it as well.

This year’s Kirby Report found that 2% of newly diagnosed HIV infections were associated with IVDU. This figure is similar to previous years, and is only a small fraction of the figure for some overseas countries – up to 40% according to the most recent UNAIDS report. Maintaining tough on drugs does not work, and any cuts to NSPs or other (evidence-based) harm minimisation programs could potentially open the door to a more generalised HIV epidemic than we currently have.

And none of this helps people who are living with HIV get on with their life, free of discrimination.

My Week on RealScientists

•November 25, 2013 • Leave a Comment

ICYMI, I was tweeting for RealScientists last week.

Welcome blog post is here: http://realscientists.wordpress.com/2013/11/17/superbugs-stewardship-and-sci-fi-welcome-dr-trent-yarwood-to-realscientists/

Farewell post is here: http://realscientists.wordpress.com/2013/11/24/mutate-or-die-farewell-and-thanks-dr-trent-yarwood/

And the storified tweets of the week are here (part 1) and here (part 2).

RS is a great idea – if you’re a scientist (or clinician) I think it’s worth a turn around. Tweet the admins or email them here

.

Law of Unintended Consequences

•October 28, 2013 • Leave a Comment

You’ve probably all heard of the Law of Unintended Consequences.  It even has a page on Wikipedia. In short, it says that things that you do may have results that you did not intend.  Of course these can be unexpected windfalls as well as other, more unfortunate side-effects.  There is also limited benefit to saying “think about the consequences of your actions” because obviously – 1) people don’t and 2) there may well always be unforeseeable unintended consequences.

But there are a couple of pretty straight-forward examples where a very limited amount of thought would prevent quite a significant knock-on effect.  Of course, this knock-on may well create work for someone else, so you probably don’t care all that much.

Imagine you are a doctor.  (Some of you may have to work harder than others).

Imagine a parent brings a child to you with spots.

You’ve never seen a case of measles – because it’s almost been eradicated from Australia.  I’ve only seen one actual case, and I’m an infection specialist (although I’m in my 30s – older GPs have probably seen a bit).

Measles cases in Australia

Measles cases in Australia

Here you have a couple of choices.

1) You could explain that you’ve never seen a case of measles, so you’re not sure if is or not.  You could do some tests and send them home, letting the mum know you’ll tell her when the test results come through.

2) You could call someone who might have more experience to ask for advice.

3) You could confidently declare that it’s measles and tell the child’s parent to keep them home from school so they don’t cause any secondary cases – after all, that’s what it says to do in the Time Out guidelines.

Option 3 happens surprisingly often.

So let’s look at some of the unintended consequences.

  • The mum goes home and wikis Measles – and becomes rather anxious that the article says it used to have a 30% mortality.  She also clicks on Subacute Sclerosing Panencephalitis – and gets a bit worried that her child has an illness that can cause a progressive incurable brain disease
  • The mum helpfully rings the school principle who then anxiously calls the public health unit wanting to know why they weren’t notified directly and should they notify parents and OH MY GOD THE ANXIETY!
  • The mum also tells her friend who tells their friends who tells someone else who works for the local rag which precipitates an email like this:

“Hi, I’m a journalist from the Local Rag and we have reason to believe there are cases of Measles at Local School.  Can you please provide information on this as we intend to run the story on tomorrow’s front page. Our deadline is 4pm”

  • One of mum’s other friends is a conscientious objector to vaccinations and then either presents to the local hospital or rings the public health unit requesting prophylactic immunoglobulin because her child (Storm or Phoenix) isn’t vaccinated and urgently needs less effective and more risky post-exposure treatment because they aren’t immunised.

The mum rings the public health unit to try and address all her questions about the diagnosis of measles.  The public health staff start asking the mum a few questions and explain to her that:

  • There isn’t actually any definite evidence that the case is measles because no testing was done.
  • Some directed questioning reveals that the child almost certainly doesn’t have measles because
    • The child has had two doses of MMR and is almost certain to be immune to measles
    • There have been no cases of measles in the local area in the past few weeks
    • The child and its family have not traveled outside the area and have had no contact at all with anyone who was sick
    • The illness doesn’t actually meet the case definition for measles which is quite specific – rash, fever present at the time the rash comes on and one of (cough, runny nose, conjunctivitis or Koplik spots).
  • This precipitates a round of “but my doctor said…” in which public health staff have to politely and subtly point out that the doctor probably got it wrong while being mindful that they haven’t actually seen the patient and also of professional courtesy

The rest of the day is spent in arranging appropriate testing, reassuring the school principle, drafting a media release explaining that there isn’t measles anywhere and filling in a mountain of paperwork.

Contrast this with:   Admitting you don’t know what it is, looking up the guidelines and doing some appropriate tests, calling public health and letting them sort it out tomorrow.

Let’s be clear:

  • Measles is a rare disease in Australia (although sadly not so rare as it used to be)
  • You probably haven’t actually seen an actual case unless you’ve been in clinical practice for many years
  • There are many causes of morbiliform rashes – and the pre-test probability of it being anything other than measles is quite high.
  • If the child is fully vaccinated, measles is quite unlikely (but not impossible)
  • If the child has been given antibiotics in the past week, consider that it might be a drug eruption.

I hear you saying “that’s all specific public health / infectious diseases knowledge, surely it’s not my job to know that”.  This is quite true, it isn’t really.

But just yesterday, you thought that your knowledge was sufficient to diagnose a rare disease that you’d never seen without any tests, recommend a management plan based on these feelings (which was actually wrong, by the way) and failed to notify your suspicions in accordance with the public health act.  You can’t have it both ways.

The man who admits his ignorance shows it once. The man who conceals it shows it many times

–Proverb

Don’t be such a fucking muppet.

Begin Rant: Hung is good, m’kay?

•August 28, 2013 • Leave a Comment

Trent:

I agree with this so much I’m just going to reblog it.

Originally posted on Begin Rant::

Less than two weeks to go in election 2013 and I’m going to do it. I am hereby declaring my prediction of another hung parliament.

By that I mean I’d really like another hung parliament, and I’m just as capable of interpreting almost every poll being within the margin of error of a dead heat (or in the case of Essential an actual dead heat) as being predictive of another hung parliament result as others are interpreting it as a Liberal landslide.

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Thinky: On the Ethics of a “Nanny State”

•June 24, 2013 • 2 Comments

It’s fair to say that my politics are not those of The IPA, but I do quite enjoy reading Chris Berg – he’s rather amusing on twitter and he’s written some cracking articles on videogame violence, the expansion of national security because terrrorism and internet censorship. As you might expect from a left-of-centre geek, I get my news from ABC Online and Crikey – I used to live in Brisbane and since nobody actually thinks the Courier-Mail is a real newspaper, I tried to read the Australian – although I gave up in disgust at their partisanship when they launched their pogrom on the Greens.  I generally find the political analysis of Bernard Keane (twitter) to be on the money.  If you’re interested in Internet freedom, I strongly suggest grabbing a copy of his book War on the Internet. Apart from internet censorship, one thing Chris Berg and Bernard Keane agree on is their deep disdain (to put it mildly) for the public health “nanny state”.  See articles by Chris here, here, here and here and by Bernard here, here and here. See here for a wrap-up of rebuttals to Bernard’s posts (the articles from Richard Di Natale and Simon Chapman are particularly worth a read.

I’d encourage you to read the articles I’ve just linked to;  I’m going to try and pose the case for the other side.  I don’t expect to move the positions of Berg or Keane, but it’s more for the people who read their articles and say “yes, that makes sense” – I’ve had some discussion on Twitter with some people from the Pirate Party which – although it doesn’t have a preventive health policy is generally libertarian in its ideals.

Medical Ethics 101

Doctor-friends and medical readers can skip to the next subheading, unless you enjoyed ethics at med school or need some revision.

There are four main ethical principles that guide our interactions with patients. Here’s another link if you want some more.  I won’t labour the point, but briefly:

Beneficence:  The things we do for patients should serve the best interests of patients.  This is pretty straight forward.

Non-maleficence:  This is the principle of “primum, non nocere” – first, no harm.  This is a little bit more nuanced than just not doing things that cause harm to patients.  The implication is that it may be better to do nothing than to do something that poses a risk of net harm to a patient.  It involves considering the risk/benefit of medical interventions and the less obvious side-effects of our medical interventions.

Autonomy:   In the past, medicine operated in a more paternalistic manner – “doctor knows best”.  Medical advice was given by the doctors to the patient, with an expectation it be followed.  Modern healthcare stresses the “therapeutic partnership” much more – where doctors and patients work together to achieve good outcomes for the patient.  I’ll come back to this shortly.

Distributive Justice:  Isn’t very well covered in the Wikipedia article, but it relates to ensuring needs-based access to health care.  This too, is much more complex than just having a public health system as I’ll discuss further below.

Applied Ethics in the Real World

You can find your own definition of ethics, but I like the one that involves it being the study of the interaction between the rights of the individual and the rights of society.  In medical ethics, there is going to be a necessary compromise between some of the principles.  An easy example is informed consent for an elective surgical procedure in the public healthcare system.  The procedure is recommended by the doctor because he thinks the procedure is indicated (beneficence) and that the benefits outweigh the risks (non-maleficence).  The patient is given an informed discussion on the risks of the procedure, and allowed to decide whether they want to go ahead or not, and what the alternatives would be (autonomy).  The patient goes ahead and is placed on a waiting list (justice) such that more urgent cases, or those which have been waiting longer are done first.

It’s worth considering that you can’t give absolute priority to one principle over another.  If you literally interpreted “no harm” you’d never perform any surgery or prescribe any medication because they all have risks of side-effects attached.  Complete patient autonomy would create a situation where patients’ wishes about their management would override the doctor’s assessment (it’s worth noting that a patient can’t force a doctor to provide a treatment they feel is inappropriate or unethical; but the doctor provide a referral to someone else for a second opinion).

In the non-medical sphere, there is also a balance between ethical principles;  we accept some limits on our autonomy (laws) in exchange for living in a safe(r) society.

The Berg / Keane argument is that individual autonomy should not be infringed by public health programs seeking to improve the health of the population at large, along with a good dose of downplaying the health benefits of public health.

Tim Wilson from the IPA writes “Nanny state advocates argue the job of government is to coddle us from the world’s evils, avoid risk and use taxes, laws and regulations to either steer or direct our behaviour.”  Obviously there is some rhetorical flourish in there – or at least I certainly hope there is.

As Richard di Natale points out, our work plan in public health meetings don’t generally proceed along the lines of “how can we infringe on people’s liberty today”, rather along the lines of “what can we do to improve health” – a novel concept, to be sure.

Looking at Public Health Ethics Another Way

1. Public Health as Beneficence

This is hopefully pretty obvious.  Stopping people from getting sick in the first place is a good thing to do – in the ethical sense, as it reduces disease and human suffering. If you haven’t already read it, see the final paragraph of Simon Chapman’s rebuttal to Bernard Keane.   It also makes financial sense – healthy people don’t cost the health system money. (Although obviously you can debate the cost-effectiveness of public health campaigns – see here for a list)

2. Public Health doesn’t actually care about how much you <risk>

Clinical medicine is focused on the care of the individual patient. It’s often said that the unit of care of paediatrics (and palliative care) is the patient and their family.   But public health is focused on the health of the population.

As an individual, you make up part of the bell curve.  Your position on the bell curve isn’t particularly important to public health authorities, but what does matter is reducing the area under the curve.  This can be done by “shifting the curve to the left” (see here for an example (the graph) and a discussion of the principle).  If everyone drinks a bit less, then the “extreme drinkers” will be less numerous and/or drink a bit less and therefore alcohol-related harm will be reduced.

3. Public Health as pro-autonomy

The principle of autonomy relies on people making an informed decision about what to do.  This is the argument for (for example) calorie displays on fast-food menus and traffic-light labeling of foods.  There is compelling evidence that people with poor health literacy have worse health outcomes.  Public health education campaigns – and indeed the whole discipline of health promotion – aim to allow people to make better informed decisions about what they do.  Nobody can really complain if people make an autonomous informed decision to do something, a decision without all the available information cannot truly be said to be autonomous.

4. Public Health as Distributive Justice

There’s a couple of aspects to this, so I’ll tackle them one at a time.

a) “Regressive Taxation”

People from lower socioeconomic backgrounds have worse health literacy and also higher rates of use of tobacco and alcohol and lower rates of exercise.  Tax-based disincentives (like cigarette excise and alcohol taxes) target people of lower incomes more than they do people of higher incomes, as the taxes make up a greater proportion of their disposable incomes.

Stop and think about that for a second – people with higher rates of <x> and worse health outcomes associated with <x> (and everything else) are disproportionately targeted by measures which aim to reduce <x>.  Also, for some values of <x> (cigarette smoking; the recent “alcopops tax” not so much) we know that these measures are effective.

The flip-side of that is if you are well-off (and therefore more likely to have good health literacy), the tax will be a smaller proportion of your disposable income and less likely to influence your behaviour.

b) Health Access

In Australia, we have a public healthcare system.  Of course, there is also a private system, but the realities of how this works is that people with acute care needs will go to the public system and some of them will then be decanted off to the private system, which generally deals with less urgent or elective cases.

Health is a major government expenditure and continues to grow.  Public health services are a finite pie, not a magic pudding.  If you want to make an informed decision to drink yourself until you look like this or this and your liver looks like this then you will be spending tax dollars on yourself that might otherwise be directed elsewhere (take your pick of other patients or lower taxes, depending on your politics).

Conclusions

I could go on at greater length, but it’s taken me a month to get this far (new baby).  The short version of the message is that those of us that work in public health aren’t stopping you from having fun.  We’re about improving health, not infringing liberty.  My argument is very much that rather than primarily an issue of autonomy, public health is an issue of justice.

Finally, since ethics has a large chunk of relativism, when the liberty brigade tell you that the public health industry are anti-autonomy wowsers, maybe take a second to consider the fact that I think they’re a bunch of selfish, heartless individualists.  Understanding is a three-edged sword, after all.

 
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