Friday, June 24, 2011

The somewhat arbitrary condemnation of profit-seeking in healthcare

This morning's California Report covered the illegal exportation of marijuana from CA to other states. I really recommend listening to the story linked above. California is the largest medical marijuana industry in the country, after Prop 215 made medical marijuana legal fifteen years ago. What I found most fascinating was the condemnation of "unscrupulous" physicians who were "misusing" their access and prescribing power of medical marijuana to improperly profit from the bounty of California pot. Multiple commentators in the news piece maligned these doctors for their activities. One physician emphasized that doctors should only prescribe marijuana for the "right reasons," and that doctors need to "police" themselves. One commentator notes that "somebody got rich" from the ability to sell the marijuana at about $3000-$4000/lb.

The story prompted me to think about the health insurance industry, which is explicitly designed to maximize profits. Or the pharmaceutical industry, which also turns sometimes naturally-occurring compounds into profitable pills. These legal practices that seek out profit do not receive the same vilification from mainstream media. I realize that the physicians' participation in the export of the marijuana is illegal, but this is one of those moments in which the illegality seems completely arbitrary. This also reflects a by-product of the medical marijuana movement, that in order to garner support and emphasize the innocuousness of using marijuana medicinally, it also needs to be portrayed as an organic, non-capitalistic product. At some point, when/if marijuana is legalized, it will surely be converted into all sorts of packaged and processed products. THC, one of the main compounds in marijuana that helps stimulate appetite, is already purchasable (and reimbursable by health insurance) under the name Marinol. Reading the National Institute of Health's recommendations on the use and dosage of Marinol is unsettling and a great example of the transformation of health and wellness into a highly medicalized practice.
"Dronabinol comes as a capsule to take by mouth. When dronabinol is used to treat nausea and vomiting caused by chemotherapy, it is usually taken 1 to 3 hours before chemotherapy and then every 2 to 4 hours after chemotherapy, for a total of 4 to 6 doses a day. When dronabinol is used to increase appetite, it is usually taken 2 times a day, before lunch and supper, or once a day in the evening or at bedtime. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take dronabinol exactly as directed."
The transformation from a self-medicating product that the marijuana dispensaries allow to an FDA-regulated and medically managed pill is transparent in the package instructions that the NIH has put on its website.

Not once in the story, which links the physicians to underground drug gangs, is there an exploration of the consequence of making the plant illegal. While they discuss the value of a statewide registry to help crack down on moving marijuana into illegal markets, they fail to really consider the challenges of making health part of the capitalist system. I'm not interested in ranting on and on about capitalism, but I do think we need to inject more of the economics of health into the discussions of issues like this one. The story emphasizes how people take advantage of the medical marijuana system, yet not once is there a consideration of how pharma and health insurance companies are also taking advantage of a very badly structured "system." The medical marijuana conundrum is about more than legal and illegal use of a plant, but rather reflects the slipperiness between medicine and profit.

Tuesday, June 21, 2011

Excess of care and the ongoing need for improvements in women's health

One of my main critiques of the HPV vaccine has been that the new technology may pre-empt efforts to improve existing practices. Women's healthcare remains full of unnecessary interventions, insufficient information, and an over-emphasis on reproductive health rather than holistic health. In the case of the HPV vaccine, I have argued that gynecological care remains static and frozen (in some respects) with the availability of new method for preventing HPV, rather than critically refining the way we do things now. And the way we do things now could use some refinements.

Almost two years ago, the guidelines for mammograms, the screening of women's breasts for potential tumors, were changed from recommending screening at age 40 to starting screening at 50. Part of the change was due to concerns of unnecessary tests that may produce false positives. The cost and the stress of the ambiguous results did not seem worthwhile. Further, the earlier testing failed to demonstrate a "significant" reduction of mortality due to breast cancer.

A lot of women were publicly outraged. They felt their health was being sacrificed for solely cost-saving reasons. My favorite post was George Lakoff's, a philosopher who teaches at Berkeley, who claimed that there would be thousands of women's lives affected by the changes. His argument was highly suspect, as he uses arithmetic to argue that nearly 42,000 women would die due to the new regulations. This is a far too simplistic argument for understanding health risks. Further, I expected more from a philosopher; his statement that women would die due to the regulations is completely fallacious. Not every woman with breast cancer dies. The reaction across the States to the change in regulations is a common one when it comes to shifts in existing medical interventions. None of us wants to be the one "sacrificed" for population-level purported benefits. And yet, this sense of entitlement is so very American and so very much part of why we have one of the most bloated and expensive healthcare systems in the world.

In a related article, shortly after the 2009 changes in mammogram recommendations, Barbara Ehrenreich wrote very convincingly about how the breast cancer advocacy industry has, in some ways, co-opted the feminist movement. The pink ribbon consumerism is the new rallying cry for women, rather than more substantive women's health concerns. Women's outrage about the mammogram guidelines' shift lacked a real understanding of the reasoning for the shifts. She also takes Lakoff to task for overly individualizing the experience of breast cancer (by a man, whose wife received a false positive, no less, though she does not make this point). And this undermines women's movements and the quest for improvements in women's healthcare, for which Ehrenreich calls.

Similarly, cervical cancer screening guidelines have also changed in the recent past. Instead of annual screenings with a pap smear (the scraping of cervical cells to identify abnormalities in the cervix), women over 30, who have normal results with a combined HPV test (a DNA-based test that can determine whether a woman has the higher-risk type of HPV that can lead to cervical cancer or the lower-risk type that does not lead to cervical cancer) and pap smear can then shift to the every three years' pap smear. Similarly, younger women should receive the pap every two years. (I should add that the guidelines are very convoluted and full of logic twists and turns that it's no wonder no one knows what is considered "appropriate" anymore.)

There's a recent government study that shows that MDs are actually over-testing women using both the pap smear and the HPV test. The issue of over-testing is similar to the reasons that the mammogram guidelines shifted. Or rather, similar, but also different. Young women are likely to have HPV if they're sexually active. But they're also likely to clear the infection on their own. If all women who are identified as having HPV receive the progressively more invasive interventions due to their positive HPV results, many women will be over-treated than necessary. And here, even more so, I think, than with mammograms, over-treatment is about more than just the economic burden. The biopsies and colposcopies that make up cervical cancer prevention are incredibly traumatic as is the even more invasive technique of loop electrosurgical excision procedure (LEEP).

Both the skepticism about mammograms and excessive gynecological interventions support my argument that we're not actually thinking very carefully about medical technologies. Another recent article on the excessive use of mammograms proposes that mammograms may not be the real reason for the decline in mortality due to breast cancer. The emphasis has been on more is more!! Let's do more! But this thinking obscures the existing problems with well-tread practices, and it fails to improve practices that might require tweaking without full-on replacement of new methods that have their own limitations.

Friday, June 10, 2011

The over-hype of technology

During my recent stint working in health technology, I've been reminded of what I already knew. The romanticization of technology as a salve and solve-all is highly flawed. In the tech world, there's a tendency to frame technology as synonymous with new and innovative. This framing overwrites the fact that technologies are all around us, some have aged out, such as the printing press, or the early 2000s' cell phone, but they remain technologies. They are all tools that have evolved. Technology is not just something that is intrinsically novel -- to use that definition risks naturalizing all the tools around us. Theoreticians of science and technology studies (STS) have broken apart these assumptions endlessly, but I think it's a concept that still requires closer reflection in the public sphere.

In STS, the concept of the black box was one way to represent the pre-eminence of technological practices, discussed by Fujimura, Latour, Woolgar, Wynne, etc. (I ought to do this concept a little more justice, but will perhaps later). It considers the way that all the processes and practices that are necessary to produce some technological object (or event) get obscured. Digging into how things come to be and the actors involved in the production of these things can reveal fascinating details. The design/psychology world considered these ideas, most notably in Donald Norman's book The Design of Everyday Things, by reminding his readers that human error with tools does not stem (usually) from the user's stupidity or incompetence. Instead, he argues, one should question the logic behind an object's design.

All this brings me to think about how there's a mutation of black boxing in the technology world. Innovation is always seen as more essential than actually refining the object. New, new, new must mean better, right? Further, I think the prioritization of digital as the meaning of technology today overly segregates how people actually behave and engage with objects.* It almost seems as though there's an expectation that all things will be distilled into a data representation and that material objects are no longer really technology.

Perhaps I'm a bit biased after working in a world where there seems to be a lot of pressure and anxiety to transform existing practices into "new and improved" digital versions. But I think this is a huge problem in the health technology world. It's far too easy to forget that all sorts of medical practices remain technologies (even if they become outmoded/less efficient than newer practices). Such segregation is extremely naïve and misses opportunities to improve existing technologies by preserving the things that work while enhancing the things that don't always work so well.

* Having spent an entire month dealing with the Bay Area transit system's "upgrade" to an electronic transit card, I have a lot of opinions about enhancing an existing system into a completely dysfunctional mess. I will refrain from a rant, but suffice it to say, it will remain my epitome of ill-conceived digital upgrades.

Friday, June 3, 2011

Oncology care and end of life choices

Since I first started working in the pharmaceutical industry, a year ago, I have been conflicted about the cost and limited increase in lifespan that oncology drugs offer to metastatic patients. This statement risks putting a value on people's lives and makes judgments about what is meaningful to any one individual, but the high cost of oncology treatments and the often short increase in survival rates perturb me.

Last year, Atul Gawande wrote in the New Yorker about the value of hospice for dying patients, both for the patient and for the family who has to watch a loved one die. The article suggested that in lieu of the very expensive and highly toxic treatments, choosing palliative care might be a more graceful way to confront the end of life. I reference this article a lot in various conversations because it affected me deeply. It made me cry.

Now, in the context of debates about Medicare cuts, there is a post in The New York Times about the high cost of oncology treatments at the end of life and their often limited ability to significantly extend life. As the columnist, Mahar, notes at the very end of her opinion piece, research suggests that people who die in hospice care often live longer than those who remain in the hospital. While shorter survival for those in hospitals could very well be due to the higher rate of secondary (or tertiary) infections, there could also be a real benefit to dying in a less sterile environment, surrounded by people who are important to you, rather than a roster of medical professionals.

This is not a simple anti-pharma screed, but rather an attempt to think more seriously about what it means to die, what it means to be caught in the pharmaceutical complex, when under duress and facing limited options, and a challenge to where our priorities really lie when we talk about improving cancer treatment options.

In other news, I just stumbled across the fascinating and seemingly awesome Breast Cancer Action group. They have a campaign, Think Before You Pink, that criticizes the pinkification of breast cancer, turning "support" into a questionable consumerist practice often supporting companies who use chemicals known to be carcinogenic. This merits its own post, but I recommend learning more about them and supporting their work.