Begin Rant: Hung is good, m’kay?

•August 28, 2013 • Leave a Comment

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

Thinky: On the Ethics of a “Nanny State”

•June 24, 2013 • 6 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.

How likely is the NSA PRISM program to catch a terrorist?

•June 8, 2013 • Leave a Comment

bayesianbiologist

Recent revelations about PRISM, the NSA’s massive program of surveillance of civilian communications have caused quite a stir. And rightfully so, as it appears that the agency has been granted warrantless direct access to just about any form of digital communication engaged in by American citizens, and that their access to such data has been growing significantly over the past few years.

Some may argue that there is a necessary trade-off between civil liberties and public safety, and that others should just quit their whining. Lets take a look at this proposition (not the whining part). Specifically, let’s ask: how much benefit, in terms of thwarted would-be attacks, does this level of surveillance confer?

Lets start by recognizing that terrorism is extremely rare. So the probability that an individual under surveillance (and now everyone is under surveillance) is also a terrorist is also extremely low. Lets also assume…

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The digital future of infectious disease maps

•June 3, 2013 • Leave a Comment

Wellcome Trust Blog

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You are stuck in bed with a snotty nose and flu. You grab your smart phone and use 140 characters to declare to your Twitter followers: “Feel awful. Fever burning up my bed #sickday”. Unbeknownst to you, your tweet could be part of a global effort to map infectious diseases.

Tweets have been shown to be extremely useful in predicting outbreaks of disease. In the US, studies have found that analysing trends on Twitter could indicate an outbreak of flu two or three weeks before the Centres for Disease Control and Prediction announce a problem. It does, however, come with a note of caution and a warning about common sense. In one study they found a massive spike monitoring the symptom word “fever”. Closer inspection revealed the tweets were a meme about pop star Justin Bieber (“Bieber Fever”).

Tweets are among the innovative information-gathering methods David Pigott and a…

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Do Science: A back of the envelope about Claire’s killer cough

•June 2, 2013 • Leave a Comment

I’m a big fan of reason.

That’s why I don’t have a lot of time for the anti-vaxxers and the wind farm opponents etc.  It’s not always the anti-science crowd who make foolish statements though.  See my discussion on the “40% of backpain to be cured with antibiotics” and “don’t shave before a flood or you’ll die” idiocy previously.

There’s obviously been a lot of discussion about the NSW “No Jab, No Play” legislation and the advocacy journalism of the Daily Telegraph.  So this article came through my twitter feed this morning.

Selfish anti-vaccination conspiracy theorists putting Australia at risk

Even if you didn’t read the rest of it, you may have seen the leader: “My body’s a deadly weapon. So is yours.”

Later in the article is this gem:

"If I'd walked in to visit Dad with a simple case of influenza, 
let alone a more serious communicable disease, 
I could have killed the entire ward in one cough"

Ok folks…

Yes, I have this on a T-shirt

image from xkcd.com

Assumptions:

  • I’m going to ignore the fact that patients in wards are usually in rooms and that only the patients in Claire’s Dad’s room would be at significant risk
  • I’m going to ignore the staff (who are probably at slightly higher risk than the patients).
  • We will assume that Claire passing through the ward counts all the patients on that ward as a “close contact”, whereas walking past a single cough would be associated with a much lower level of risk.

Background:

  • Influenza is typically thought to be droplet spread, although there is some evidence to support aerosol transmission. Droplet is generally considered to only be transmissible at short range; via directly being coughed on, or by the droplets settling on your hands when you cough and then being contact transmitted to someone else. (That’s why you should cough into your elbow not your hands).
  • The attack rate of an infection is the proportion of persons exposed to that condition that become infected.
  • I haven’t used my reference manager (Mendeley, by the way) or sourced any data except from things freely available from a Google search.

So, to the science (although it’s actually really maths)

  • Influenza attack rate: 2.4%  (reference: here via here)
  • Likely vaccination rate of hospital patients: 75% (figure for Adults >65, a reasonable surrogate, from here)
  • Vaccine efficacy: 60% (lowish average estimate, from here )
    • these last two stats mean the percentage of people with effective immunity is 60% x 75%  = 45%
  • Influenza case-fatality rate: 1% (approx rate for >65 year olds to be consistent with the vaccination rate; whole population rate is much less – of the order 0f 0.1%; data here )

So, the probability of a ward full of  “close contacts” vaccinated at current rates resulting in a death is:

Risk of exposure (strike rate) x Risk of no immunity (= 1- effective vaccine rate) x risk of death

= 0.024 x 0.55 x 0.01

= 0.0132% , or 1/7500 give or take a bit. (open disclosure: that’s a bit higher than I thought it would be when I started this)

Although, remember that I have over-estimated very significantly the risks of transmission based on a hospital ward environment, and taken low-end estimates of vaccine efficacy and a very pessimistic mortality rate.

(In case you think I’m arguing against vaccination generally, I’ll leave it as a thought experiment for you to imagine what would happen with measles, which is aerosol transmitted, and can infect people in a room 20min after a measles carrier leaves, with an attack rate of 70% ish).

The chance of lethally infecting two patients on the same ward is around one seventh that of winning first division lotto and the risks decay exponentially (note that means actually exponentially, not “really fast” as the term is commonly abused).

Why is this important and not just science pedantry?

First, because one of the reasons people want to do away with AVN is because of their long-standing practice of misquoting science to their own ends.  There are lots of people with crackpot beliefs about lots of things.  Aggressive secularists would include religion in this group. But having those beliefs is not a reason to ban organisations. Even their adherents promoting them isn’t really even good enough. It is because they are promoting them in a misleading way that AVN is in the sights (as well as their rather shoddy financial affairs and others).

If it is wrong to say “MMR causes autism” (it doesn’t), then it is equally not ok to say that a cough could kill thirty (it couldn’t). To suggest that one is bad and the other is good because of their position relative to our own biases or current public health policy is censorship, not science.

The second reason is that a standard tool of the vaccine objectors is to cry conspiracy theory.  Big Pharma, health professions and the media are in some Illuminati-backed global plot to falsely scaremonger about the risks of what *really* are benign diseases, sell vaccines and inject the public with poison.  Of course, you can never disprove this wingnuttery to a believer – because you’re part of it, man!  What I can show you is a pretty decent example of an article in the mainstream media that is falsely scaremongering about the risk of influenza (hint: I’ve hidden a link to it somewhere in this article) to people in hospitals.  Don’t feed the trolls.

Close to my own heart is the primal terror that infectious disease seems to engender in the public – from subtle influence like the difficulty I have trying to buy hand-soap that isn’t antibacterial to the very overt – all the medical students due to come to our team shortly after swine flu broke in 2009 pulled out, citing concerns over personal safety.  People think that my job poses some great risk of personal illness – in fact I’m probably at lower occupational risk than pretty much every other specialty (I don’t do procedures on people – and I know when and how to wear personal protective equipment!).

 

The piece in question was an opinion piece and I’m sure the feeling in question was a genuine one. But publishing nonsense in the name of science is bad for everyone, regardless of the issue or your opinions on it.  A good friend of mine is quite a fan of pointing out how poorly scientists communicate the implications of their research to the public.  But it’s really important to remember that there are two parts to “science journalism”.  Science without journalism may not get through to the public but journalism without science can misinform, mislead and create panic.

By all means, stay away from visiting at hospitals if you’re unwell.  Cough into your elbow and wash your hands.  But if you start sneezing on your way back to the car park, don’t flagellate yourself for being a “deadly weapon” – because it’s just bullshit.

 

Whither the progressive voter?

•May 20, 2013 • Leave a Comment

This is a great summary of the election issues facing the “progressive” voter this year.

The Opposition #NDIS no show. A rant from the heart by @R_Chirgwin

•May 18, 2013 • Leave a Comment

The epic rant of Richard Chirgwin should be preserved, especially as the media seem to have let this one go through to the keeper.

Australians For Honest Politics

Wed, May 16 2013
People’s obligation in the first instance is to be in this Parliament.  — Warren Entsch:
  1. The LNP’s absence in Parliament in the chamber for the NDIS legislation … atrocious. Nutlessness as a service.
  2. So, Abbott tells the whip “nobody attend”. Whip tells nutless sheep “nobody attend”. What a grovelling bunch of coprophages they are.
  3. A minimal gesture of respect to the disabled would have put at least Abbott in the chamber for the NDIS first reading. (Yes I’m ranting)
  4. (Mute me if you like…

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