Archives for posts with tag: WHO

[This is G. Sallust, and today I’m doing a [hopefully] short post on health care, a subject that’s bedeviled our politics for years. More specifically, we’ll talk about the Patient Protection and Affordable Care Act[1], popularly known as Obamacare, passed in 2010. As you may know, we did a lengthy blog a while back detailing how that was done, and the rather clownish debate that accompanied the complex parliamentary procedures employed by both sides.[2]  As I recollect, the Republicans took the position that anyone who supported the bill probably was a Marxist, while the Democrats said that basically the Republicans just wanted to kill the poor. The “debate” was not a consensus-building exercise.]

As we all know Obamacare finally did pass, and thereafter Republicans in the Congress voted repeatedly to abolish it. None of these efforts got by President Obama because a President has the power to veto legislation, and it’s very hard for Congress to overcome one of those even when Conservatives wish it so. [3]  My take on President Trump is that he is more moderate on Obamacare than the far right wing of his party really likes. He’s willing to “repeal and replace” the program, not just do away with it. We’ll find out what that means when the Republican House and Senate produce legislation that they both agree to. If he signs it, that act will define his Administration’s policy.

Best Care in the World?

Back in 2009, 2010 one of the arguments against Obamacare was that we already had the best medical care in the world, so why tamper with it by regulating service and letting more people in? That would have been a good argument if it were true, but it wasn’t. In 2000 WHO [the World Health Organization] published a report that studied and ranked health system performance around the world.[4]   France was ranked # 1 in “Overall Health System Performance”; Germany, # 25; and the U.S., # 37.[5]

When WHO issued its 2010 report, in time for the great debate on healthcare here in the U.S., it had even more embarrassing facts for people who thought we were the greatest. [6] Just looking at the same 3 countries, France, Germany and us, it’s obvious that the people there live measurably longer than we do here. Our life spans are OK, I guess, but definitely we’re not # 1, ever. Take a look at these statistics from 2000 and 2008:

Life Expectancy at Birth in 2000, 2008, for France, Germany and the United States

France

  • CY 2000: men 75 years; women 83 years; average 79 years;
  • CY 2008: men 78 years; women, 85 years; average 81 years;

Germany

  • CY 2000: men 75 years; women 81 years; average 78 years;
  • CY 2008: men 77 years; women 83 years; average 80 years.

United States   

  • CY 2000: men 74 years; women 80 years; average 77 years;
  • CY 2008: men 76 years; women 81 years; average 78 years[7]

So did things get better in 2015? They did so marginally; but we were still last of the 3, and again men were dying sooner than women:

Life Expectancy at Birth in 2015 for France, Germany and the U.S.

France

  • CY 2015: men, 79.4 years; women, 85.4 years; average 82.4 years;

Germany

  • CY 2015: men, 78.7 years; women, 83.4 years; average 81.0 years;

United States

  • CY 2015: men, 76.9 years; women, 81.6 years; average 79.3 years. [8]

U.S. Spending

But in spite of our poor performance compared to France and Germany, we do lead everyone in one important area. We spend more on healthcare than anybody else in the world.  And how do I know that? Well, the CIA keeps track of that kind of thing. According to the CIA World Factbook[9],

  • The U.S. spent 17.1 % of its GDP on healthcare as of 2014
  • France spent 11.5 % of its GDP on healthcare as of 2014
  • Germany spent 11.3% of its GDP on healthcare as of 2014

So we lead the pack overall in spending, if not in results. After all, the spending numbers are expressed as a percentage of Gross Domestic Product; our GDP is the largest in the world, at least for now; and we spend the highest percentage of GDP on healthcare, so we are, by definition, the big spenders of the planet. We just don’t get as much for our money as others, like the French seem to do. And costs here are going up. If you don’t believe that, take a look at your medical insurance premiums, deductibles and co-payments. Word is, they’ll rise again, unless the insurance companies drop their medical coverage altogether, or the Government steps in with a subsidy. Is this a great country, or what?

And by the way, current news is that the new president of France, Emmanuel Macron, is looking for ways to improve French health care.[10] He seems to think that the French system is a bit too expensive. Hopefully he won’t ask us for advice, or if he does so to be diplomatic, he won’t take it. Why would he want to ruin the better [and less expensive] French system by adopting our mistakes? It would be like sending American wine to France and expecting people there to like it.

Or perhaps he might decide to adopt the good parts of our system and forget the rest. If he does that, and can identify them for us, then perhaps we should take his advice, rather than vice-versa.  But actually I don’t think our economists, or politicians, would ever accept ideas from a foreigner that contradicted their own. We are the greatest, right?

 

 

[1] The official citation is Pub. Law 111–148, Patient Protection and Affordable Care Act, 124 Stat. 119 – 1025 (March 23, 2010).

[2] See the blog of 09/19/2013, Health Care Again and Again, available at https://opsrus.wordpress.com/2013/09/19/health-care-again-and-again/

[3] See U.S. Constitution, Article 1, §7. For an interesting article on the veto, see Cameron, The Presidential Veto, available at https://www.princeton.edu/~ccameron/The%20Presidential%20Veto%20v3.pdf

[4] See WHO, The World Health Report 2000, available at http://www.who.int/whr/2000/en/.

[5] Id. at p. 153 – 155.

[6] See WHO, World Health Statistics 2010, available at http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf?ua=1

[7] Id. at Mortality and Burden of Disease, p. 50 – 54.

[8]  By the way, for future reference you can download the most recent data from the WHO Global Observatory, at http://www.who.int/gho/publications/world_health_statistics/en/ These numbers are taken from Annex B, Part I of the 2015 data.

[9] This is another Government document that’s not a secret, but this time it’s intentional. You can  find it at  https://www.cia.gov/library/publications/the-world-factbook/fields/2225.html#fr

[10] See The Lancet, Casassus, Macron’s vision for the French health system (13 May 2017), available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31268-0/fulltext?elsca1=etoc

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Viral haemorrhagic fever is a general term for a severe illness, sometimes associated with bleeding, that may be caused by a number of viruses. The term is usually applied to disease caused by Arenaviridae (Lassa fever, Junin and Machupo); Bunyaviridae (Crimean-Congo haemorrhagic fever, Rift Valley Fever, [and] Hantaan haemorrhagic fever); Filoviridae (Ebola and Marburg); and Flaviviridae (yellow fever, dengue, Omsk haemorrhagic fever, [and] Kyasanur forest disease).

World Health Organization[1]

The Good Samaritan gave Money to the Host where he had lodg’d his Patient, and said, TAKE CARE OF HIM, and what thou spendest more, I will repay thee.

Benjamin Franklin[2]

[If you’ve read this blog for very long, you know we paid a lot of attention to the Ebola outbreak of 2014 – 2015. Ebola – the version that broke out in 2014 – was and is an ugly customer, but actually it’s only one of a family of medical horrors. WHO[3] names them at the beginning of this piece, and there’s none I want in my home town [or yours, either]. Ebola’s relatives are worse even than the heroin epidemic that’s sweeping our benighted land. A user gets involved with heroin and its friends by an act of will; he [or she] takes a first dose and gets addicted. Hemorrhagic fevers [note the American spelling] jump out at us from friends and family, etc., and may infect even those who run away.

Of course we’ve made a lot of progress treating Ebola, or at least the version that scared us in 2014. In spite of early missteps, that epidemic is over, at least for now. As one commentator put it: “A stuttering, uncoordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands, was followed by one of the most successful global partnerships between foreign and local governments and multinational aid [organizations] to stem an international health crisis.”[4]  Also, as we noted last time, there’s at least one vaccine in our future. Too bad we can’t fix the heroin problem the same way.

But this blog is about Ebola, and what remains to be done. Why dwell on that? Well, because Ebola may evolve and return; and its ugly relatives are still out there. Is it possible our recent success also set a pattern for defeating them the next time they appear? If so, are we learning from our success, or simply ignoring the hemorrhagic fevers on the theory that we’ll deal with them later?]

Dangers of Ebola

Let’s talk for a bit about how dangerous Ebola was in 2014. It was very bad for humans. WHO described it as “highly infectious, rapidly fatal, with a high mortality rate ….” It “spread through direct contact with body fluids (blood, stool, vomit, saliva, urine, sperm, etc.) of an infected person,” or by contact with surfaces or equipment, including linens, contaminated by body fluids from someone who was infected.[5] WHO also said that health workers were “between 21 and 32 times more likely to be infected with Ebola than people in the general adult population.”[6] Nurses and nurses’ aides were particularly vulnerable.

A lot of people died from Ebola, but even the lucky survivors may have problems today. These include mental health issues for “survivors and other family and community members,” and, possibly related, an “increasing recognition that Ebola virus may persist in selected body compartments of survivors.” If the virus persists can a survivor reintroduce it to an area “where transmission [was] previously … eliminated?”[7] Is it any wonder that the neighbors might worry?

Recent Trends

I don’t know about you, but in 2014 I saw the world intervene massively in West Africa to treat Ebola patients and contain an epidemic. It turned out that extraordinary measures weren’t needed because the more traditional methods of treating and isolating the disease broke the epidemic first. Fair enough, I thought; but at least the facilities we built and the people we trained will improve medical care in the area. But apparently that wasn’t the case. Why? Some of the projects were completed on time, but most weren’t completed at all, in large part because they were no longer needed to fight Ebola. The disease was already in retreat. [8]

So our extraordinary efforts didn’t strengthen the medical infrastructure of the infected areas? Apparently that’s the case. A recent study in Guinea,[9] for example, shows that today mothers and children have less access to health care than they had prior to the Ebola crisis. The situation has deteriorated, not improved, at least with respect to them.

  • Child births in hospitals and subsequent visits increased markedly prior to the Ebola outbreak; then reversed during the epidemic; then reversed again when the epidemic was over, but ultimately the trends stagnated;
  • The same happened with childhood vaccinations. They trended upward prior to the epidemic, then reversed during the epidemic[10] and, in some cases, continued to decrease in the post-epidemic period[11];
  • “Most maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions.”[12]

So why did this happen?  Is it because the women and children of Guinea are afraid of or simply don’t trust their health care providers?  Or have the providers died or left the area because of Ebola virus disease? Or is the local health infrastructure too damaged by the epidemic to function properly? Or are more than one of these factors in play?[13]

Whatever the answer, the experts seem to agree that a lot of work needs to be done to improve health services in West Africa.  “Targeting the root causes, preventing future epidemics, and improving access to health services for the millions affected by weak public health infrastructure will require the international health community … to show unwavering commitment to the long, slow, collaborative work required for meaningful capacity building.”[14] And why should the “international community” be concerned about health and epidemics in remote places? Well, because these days epidemics are tourists; they may start in one place, but like humans they can travel just about anywhere.

Conclusion

So I think old Ben Franklin had it right. The developed world, like the Good Samaritan, should work to strengthen the health infrastructure in places like West Africa. Otherwise epidemics may pop up where folks are most unprepared to fight them, and we’ll all lose valuable time and possibly lives as a result. Help the people there now and most likely we’ll help ourselves later

At least that’s what I think. And who am I? Why Phil, the blog philosopher.

[1] The quote is from the World Health Organization [WHO]. See World Health Organization, Health Topics, Haemorrhagic Fevers, Viral, at http://www.who.int/topics/haemorrhagic_fevers_viral/en/ We’ve added some semicolons, hopefully for clarity, but have not changed the spelling of “haemorrhagic.” In the U.S., of course, we would drop the “a,” to spell it “hemorrhagic.”

[2] See Franklin, Silence Dogood, the Busy Body, and Early Writings (LOA, 1987, 2002) at p. 170, Compassion and Regard for the Sick (March 25, 1731)

[3] WHO’s official web site has lots of information on diseases worldwide. It doesn’t focus, only on Ebola. See World Health Organization, at  http://www.who.int/en/

[4] See The Lancet, Comment, Siedner & Kraemer, The end of the Ebola virus disease epidemic: has the work just begun? (February 22, 2017 (online)), available at http://thelancet.com/journals/langlo/article/PIIS2214-109X(17)30079-7/fulltext?elsca1=etoc

[5] See World Health Organization, Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola (December 2015), at p. 6, available at: http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1&ua=1

[6] See World Health Organization, Preliminary Report, Health Worker Ebola infections  in Guinea, Liberia and Sierra Leone (21 May 2015), available at http://apps.who.int/iris/bitstream/10665/171823/1/WHO_EVD_SDS_REPORT_2015.1_eng.pdf?ua=1

[7] See World Health Organization, Interim Guidance, Clinical care for survivors of Ebola virus disease  (April 2016 ), at p. 5, available at http://apps.who.int/iris/bitstream/10665/204235/1/WHO_EVD_OHE_PED_16.1_eng.pdf

[8] See, e.g., The Washington Post, Sieff, U.S.-built Ebola treatment centers in Liberia are nearly empty as outbreak fades (January 18, 2015), available at https://www.washingtonpost.com/world/africa/us-built-ebola-treatment-centers-in-liberia-are-nearly-empty-as-disease-fades/2015/01/18/9acc3e2c-9b52-11e4-86a3-1b56f64925f6_story.html

[9] See The Lancet, Article, Delamou et al., Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study (April 2017), available at http://thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30079-7.pdf

[10] Id. “Similarly, the increasing trend in child vaccination completion during the pre-epidemic period was followed by significant immediate and trend reductions across most vaccine types”

[11] Id.  Especially vaccinations for polio, measles and yellow fever.

[12] Id.

[13] See The Lancet, Comment, Siedner & Kraemer, The end of the Ebola virus disease epidemic: has the work just begun? (February 22, 2017 (online)), available at http://thelancet.com/journals/langlo/article/PIIS2214-109X(17)30079-7/fulltext?elsca1=etoc

[14] Id.

The vaccine, called rVSV-ZEBOV, was studied in a trial involving 11 841 people in Guinea during 2015. Among the 5837 people who received the vaccine, no Ebola cases were recorded 10 days or more after vaccination. In comparison, there were 23 cases 10 days or more after vaccination among those who did not receive the vaccine.

WHO[1]

[As the man says, recently there’s been good news and bad news about Ebola. You remember Ebola, don’t you? That’s the version of hemorrhagic fever that exploded in West Africa two years ago, and for a time pretty much terrorized the continent and, ultimately, much of the world. Ebola breaks out periodically, and we don’t seem to know where it hides between rampages. The most recent outbreak also was by far the largest; and survival rates vary widely, ranging from a low of just 10%, to a high – in the most recent outbreak – in the neighborhood of 50%. The “advantage” of a high death rate, if you want to call it an advantage, is that there are fewer survivors to care for, and less people who might carry residual amounts of the virus. More survivors may equal more potential medical problems down the road.

Sorry to be so callous, but there’s something about Ebola that makes me cold. It’s a truly a horrific disease, and two years ago we didn’t have much available in the way of medical care, other than to relieve symptoms and hope for the best. Nevertheless, last time the overall survival rate was close to 50 percent. “Sierra Leone’s survival rate is currently about 65 percent. Guinea’s hovers around 50 percent, and Liberia’s is around 40 percent[,]”according to one contemporary source.[2] Why the improvement over, say, 10 percent? Well, the thought is that the palliative care doctors could provide allowed many patients to survive long enough for their own immune systems to take over and repel the disease. Anyway, that’s what people today think might be the case.

With these survivors, of course, came a sheaf of new questions, the big one being: “Is he [or she] infectious, after recovery, and if so for how long? We didn’t really focus on this when we last discussed Ebola, mostly because we didn’t know much about survivors. Of course even then doctors thought survivors might be a problem; it was estimated, for example, that the virus could hide in a man’s seminal fluid for weeks after he recovered from Ebola.[3] Now the list of areas where the virus can hide is expanding. These include the eye, cerebrospinal fluid, the female breast, the urinary tract[4] and, most recently, the lower respiratory system.[5] That is, Ebola can hide in areas of the human lung.

That’s interesting because, as far as I know, the official US government position is that Ebola can’t be transmitted through the air.[6] However, once Ebola strikes, it can take up long-term residence in the human lungs? Without being detected, until now? So my question is, what happens if a person infected in the lungs coughs, spits, kisses another, or even breathes in a closed space? Are others in danger? Is it time to go back to the laboratory, perhaps, to look again at transmission?

OK, let’s move on to the better good news. Of course, it was good news that more people survived the last Ebola outbreak than is customary, but that good news also had negative consequences. The survivors need to be continuously monitored – in some cases, for an unknown period – to determine if they become infectious again. That’s bad news.

The better good news is that we – i.e., the world – seem to be making progress in developing an Ebola vaccine. That’s the point of the quote that introduces this piece. I first saw this good news in an article from the Ghana News Agency.[7] It said the vaccine, rVSV-ZEBOV, was studied by WHO [and others] in Ghana during 2015. A total of 11, 841 people were involved; of these, 5837 were vaccinated; and of that group, none of them were recorded as having Ebola “10 days or more” after vaccination. Of the group not vaccinated, “there were 23 cases [recorded] 10 days or more after [the] vaccination [date].”

The research team also found that, when people in a group were vaccinated, those around them tended to benefit also from so-called “herd immunity.” As people in a group are immunized to a disease, the remaining individuals also are less likely to catch it because, guess why? The potential sources of infection have been reduced.

According to WHO’s Assistant Director for Health Systems and Innovation, the study’s lead author, “[w]hile these compelling results come too late for those who lost their lives during West Africa’s Ebola epidemic, they show that when the next Ebola outbreak hits, we will not be defenceless.”[8]

This news definitely is good, but there’s still plenty of work to be done. For example, WHO is not really sure how the vaccine works. “It was not possible,” WHO says, “to collect biological samples from people who received the vaccine in order to analyse[9] their immune response. Other studies are looking at the immune response to the vaccine including one conducted in parallel to the ring trial among frontline Ebola workers in Guinea.”[10]

Fine, you might say, but answer one final question. What in the world is a “ring trial?” Well, that’s relatively simple. When an Ebola case presented itself, the researchers immediately tried to identify all people who had contact with the victim in the previous three weeks. These were a part of the victim’s “ring,” or cluster and were included in the study. WHO says that, all in all, “a total of 117 clusters … were identified, each made up of an average of 80 people.”[11]

Anyway, there’s a long road to follow before this vaccine, apparently the most promising of the current lot, is fully approved for use. Technically it’s not licensed, and normally this can take a long time. However the U.S. FDA and the European Medicines Agency have agreed to follow expedited procedures in this case.[12] Also the developer of the vaccine, Merck, has agreed to manufacture some 300,000 doses for emergency use, and to submit it for “licensure” by the end of 2017.[13] We’ll see how that works out.

All in all, we are much better off than we were back in 2015. Of course, there’s more than one type of Ebola, and a vaccine that works on one may not work as well on the others. Nevertheless, call me an optimist. The next time there’s an Ebola outbreak, most likely we won’t be defenseless. If that’s not good enough for you, support more research!

 


 

[1] See World Health Organization,  News Release (December 26, 2016), available at http://www.who.int/mediacentre/factsheets/fs103/en/

[2] See International Business Times, Ross, Ebola Survival Rates: Why Patients’ Outcomes Vary (10/21/14 ), available at http://www.ibtimes.com/ebola-survival-rates-why-patients-outcomes-vary-1708555

[3] See CDC, MMWR, Possible Sexual Transmission of Ebola Virus — Liberia, 2015 (May 08, 2015), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a6.htm?s_cid=mm6417a6_w  “If male survivors have sex (oral, vaginal, or anal), a condom should be used correctly and consistently every time until further information is known. Used condoms should be handled and disposed of safely to avoid contact with semen. After handling of condoms, or following any physical contact with semen, skin should be washed thoroughly with soap and water.” See also New England Journal of Medicine, Mate et al., Molecular Evidence of Sexual Transmission of Ebola Virus (December 17, 2015 ), available at http://www.nejm.org/doi/full/10.1056/NEJMoa1509773?query=featured_ebola&#t=articleTop

[4] See CDC, Interim Guidance for Management of Survivors of Ebola Virus Disease in U.S. Healthcare Settings, available at https://www.cdc.gov/vhf/ebola/healthcare-us/evaluating-patients/guidance-for-management-of-survivors-ebola.html

[5] See FoxNews.com, Ebola can hide out and multiply in the lungs (January 6, 2017), available at http://www.foxnews.com/health/2017/01/06/ebola-can-hide-out-and-multiply-in-lungs.html “Ebola has been found lingering in patients’ semen and breast milk several days after conventional tests can detect it in blood. But now, scientists have confirmed another likely haven for the virus, which ravaged West Africa and killed more than 10,000 people during the 2013-2016 outbreaks: the lungs.” See also WebMD, Dotinga, Ebola Can Linger in Lungs, Study Finds (Jan. 5, 2017), available at http://www.webmd.com/news/20170105/ebola-can-linger-in-lungs-study-finds

[6] See CDC, Ebola, Transmission, available at https://www.cdc.gov/vhf/ebola/transmission/

[7] See Ghana News Agency, Awumah, Experimental Ebola vaccine trial shows positive prospects (Jan. 6, 2017)     available at http://www.ghananewsagency.org/print/112001

[8] A note to Microsoft: “defenceless” is not a misprint; it’s the British spelling. Over here we would say, “defenseless.”

[9] Another British spelling.

[10] See World Health Organization,  News Release (December 26, 2016), available at http://www.who.int/mediacentre/factsheets/fs103/en/

[11] Id.

[12] Id. “The vaccine’s manufacturer, Merck, Sharpe & Dohme, this year received Breakthrough Therapy Designation from the United States Food and Drug Administration and PRIME status from the European Medicines Agency, enabling faster regulatory review of the vaccine once it is submitted.”

[13] Id.