Category Archives: Medicine

One in sixteen

This, in the BMJ was a shocker. One in sixteen women in Africa die from complications of pregnancy and childbirth. Compared to one in 4 600 in the United Kingdom (which still puts it above a whole bunch of other causes of death that are talked about more). Which means that, taking the UN projection of 819 million for 2000 (which I gather is now considered high, because of AIDS), assuming about half of them are women, still works out to 25 million women by my reckoning. 25 million women.

This, from The Lancet only evoked a sigh of requited pessimism. The Bush administration’s anti-abortion policies may well result in strings being attached to AIDS prevention funding in developing countries that may decrease its accessibility by the very people who need it most. As Marge Piercy puts in in her poem on the Iraq situation “we dote on embryos … but people, who needs them?” It’s not her best poem, too declarative, but contains one striking internal rhyme. I am rereading a fourth or fifth hand (found in a charity store for 50c) copy of her novel Vida, a portrait of an American radical activist after years living underground, wanted for bombings and acts of sabotage against institutions and corporations, a frank and sympathetic portrait of her life, politics, relationships and times; I wonder if it would be published today? For a country that takes freedom speech as a near-religious tenet, America seems oddly unable to find undamaging forms of settling its internal strife. Freedom of speech seems to be freedom to be abusive. Never more evident in the arguments over Iraq.

Stigma and denial

I’ve been tidying up my thinking somewhat since I wrote “From my dead hand”, getting straight (I hope) that there seemed to be a distinction between mental illness and the broader category of mental disorder, and discovering just how controversial the whole issue was.
A recent BMJ editorial and its responses give the flavour of the debate. The editorial writers favoured the narrow distinction, and argued in support of well-known research that mental illness (psychosis) is not associated with violence; while a forensic psychiatrist took issue with so narrow a definition, because it excludes the wider category of mental disorder (substance abuse and personality disorders) that do seem to be overrepresented among criminal offenders. The on-line responses to the editorial range from considered, poignant, to ideological. Unfortunately, we seem to have a choice between stigma and denial: stigma for mentally ill people (or anyone who fits the profile) who then endure societal and judicial discrimination, and denial of the increased risk associated with certain disorders, which in turn results in people not being able to recognize true danger signals.

The Hitchhiker's Guide to Galactic Medicine

You didn’t know that the first edition of The Hitchhiker’s Guide to the Galaxy had an terribly useful appendix entitled "A compendium of astro-travel medicine", did you? Its highlights, and its sad fate are detailed in the Christmas issue of the Canadian Medical Journal.

And it had me laughing until I wheezed in an empty office at 8 pm, 3 hours into overtime on zany deadlines with the computer system playing up. It is therapeutically funny.

Other peoples' opinings

Further opinings

Where do I myself stand?

  • I support universal access to therapies of demonstrated benefit. It’s difficult to tease apart the inequities of access to healthcare from other social inequities, so it’s difficult to know for sure whether unequal access to healthcare alone is bad for the population overall, but the World Health Organization’s (and others’) statistics suggest that in countries where there is wide socioeconomic disparity, everyone’s health suffers, rich and poor.
  • Cost to the user is a barrier to access. It is not the only barrier, and it is not necessarily the determining barrier, but it is the barrier that receives most attention. I think there should be some cost to the user, so that they value health care as they value their CDs, costume jewellery and concert tickets – which can cost the same as a prescription and are paid for without complaint. There is a strong element of take for granted for a free system. That said, there will be people who must have the cost covered, and the process of getting the cost covered should not in itself be a barrier. Chronic ill-health is impoverishing, and, conversely, poverty is bad for your health. And the cost must be capped. Need for health care is not shared equally, and a minority of people will be very needy for most of their lives, most of us will be very needy for small parts of our lives, and another minority will die suddenly and – from the point of view of the health care system at least – cheaply.
  • I said proven interventions, and I am of the opinion that a universal access health care system cannot afford to pay for what has not been shown to work. Which is a statement laden with traps for the pronouncer, because our knowledge of what works changes weekly: witness the recent flip-flops over recommendations about hormone replacement therapy and mammography, and does anyone know whether I’m supposed to be eating cholesterol or not this week? The present “gold standard” for evidence, this decade at least, is the double-blind randomized controlled trial, but there are immense challenges in running such trials well, so as to get good answers on meaningful questions, and they answer the questions for people-in-aggregate rather than individuals. With emerging information from the human genome project and molecular pathology it’s becoming apparent that people respond differently to treatment, and diseases that we thought were uniform entities actually have very different subclasses. Then there is the question of how to feed evolving scientific knowledge into a beaurocracy, so that not only do you have to keep track of what works this week, but what is paid for this week … um.