Tag Archives: Health Care

Experience, Health, Money

Global Health: Availability of Appropriate and Affordable Medicines

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This week’s course focused on Access to Medicines. The presenter was lawyer Rachel Kiddell-Monroe. (Her complete presentation is available here.)

Yale and HIV Drugs

In 2001, Doctors without Borders (or Médecins sans Frontiéres, MSF) approached the pharmaceutical company Bristol-Myers Squibb (BMS) to ask for a cheaper generic version of their HIV drug, d4T. The drug was available in developed nations for $1,600 per year per patient. However, MSF was trying to work in South Africa, and needed the drug to be affordable to make a real impact. BMS refused the request, saying that they required the money to support research and development of new HIV drugs.

So MSF went to the source. A professor at Yale University, William Prusoff, was the discoverer of the d4T treatment. As is common practice, the university had sold the d4T licence to BMS, allowing them to distribute the product as they wished. It is for this reason that Yale, too, decided it could do nothing for MSF. Its hands were tied.

Enter students. Groups of students at Yale University organized in protest. After all, their tuition money was the reason that Prusoff was able to discover d4T in the first place. Professor Prusoff was also upset and wrote an editorial in the New York Times stating his position that, “d4T should be either cheap or free in sub-Saharan Africa.”

At this point, BMS was aware of the negative publicity over the subject and changed their decision. Within a year the cost of d4T for South Africa was reduced by 96%.

The drug d4T is no longer the preferred treatment for HIV in developed nations. However, in developing nations it is still part of the typical cocktail of drugs – thanks in part to its affordability.

Access to Medicines

It is estimated that 2 billion people in the world lack access to life-saving drugs – that is one third of the world’s current population. In sub-saharan African, about half of the population lacks access.

But lack of access to medicines is caused by many factors. As we see above, a major factor is Affordability, but of equal importance are Availability and Appropriateness. Let us look at each of these separately.

Affordability

In 1995 an international agreement was made, called TRIPS, that required the honouring of international patents (some countries, e.g. Brazil, did not allow patenting of pharmaceuticals). The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) “establishes minimum levels of protection that each government has to give to the intellectual property of fellow WTO members.”

In one fell swoop, the agreement (as of 2005) ended any manufacturing of generic drugs for cheap, local distribution, and increased the profits of patent-holding pharmaceutical companies.

There have been cases where governments cannot afford to provide medicines for the needy in their country. These countries knowingly broke the TRIPS agreement to provide adequate medicines for their citizens. Some in return, as is the case with Thailand, were penalized via trade barriers with the United States. The Abbott drug company even withdrew its pharmaceuticals from the country.

Availability

The medicine needs of the developing nations differ from those of the developed nations. For example, malaria barely affects the developed nations, whereas a malaria medicine is greatly needed in some developing nations. This is true for many other diseases, dubbed Neglected Diseases.

But drug companies refuse to create new and/or improve old drugs for these diseases. The financial incentive is not there. What results is the use of old medicines with terrible side effects or even attempts to use animal formulas. Failing even these last-ditch efforts, the only course is simply NOT treating patients.

Appropriateness

Rachel Kiddell-Monroe was working with MSF in Rwanda. She was touring a local hospital when she was brought to a barred-off wing. Her inquisition into what was behind the barricade gave her this answer: people waiting to die. The patients behind the barricade were mostly HIV patients (without a proper diagnosis). She was struck by the knowledge that if these people were in one of the developed nations they would not be dying. Instead they would have access to the medicine they needed and would probably be leading normal lives. But all Rachel could do, along with the help of her crew, was sit with these people, holding their hands, so they could die with dignity.

The issue in this case was a lack of appropriateness of the HIV drugs that had been created. Even if they could have been afforded, they would not fit the needs of the population. Most times the drugs make some requirement, e.g. that you take them with meals, three times a day. If you have no access to three meals of food, or even necessary drinking water then the drug may not work or even show adverse effects.

Drugs, like so many other things, needs to be created with a context in mind.

Hopeful Future

In 1999 Médecins Sans Frontiéres won the Nobel Peach Prize. With the money from the prize the organization started the initiative Access to Medicines. That initiative lead to the availability of the d4T drug mentioned previously, and continues to be a major player in providing medicines to those who need them.

Universities have also continued to play a leading role in universal access to medicines. The group Universities Allied for Essential Medicines (UAEM) aims to:

  • promote access to medicines for people in developing countries by changing norms and practices around university patenting and licencing
  • ensure that university medical research meets the needs of the majority of the world’s population; and
  • empower students to respond to the access and innovation crisis.

The Access to Medicines debate isn’t just a hope for headache-remedying Tylenol, it is an issue of life and death. And life that is not just the avoidance of death but the opportunity for a truly meaningful existence.

Joseph before and after treatment for TB and HIV

Health, Money

An Introduction to the Canada Health Act

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In 1984 Canada and the provinces agreed to five principles as part of the Health Act. Originally it was agreed that the budget would be split 50 – 50 (federal funds – provincial funds), but this has since changed with more money being provided by the provincial governments.

These five principles, as you will see, are open to interpretation – and actually opened to formal discussion as of December 14th, 2010.

Health Act Principles (1984)

  1. Public Administration
    The government will control the operation of the health care system on a not-for-profit basis.
  2. Comprehensiveness
    This depends on the province. For example, in some places physiotherapy is covered. Provinces can also have different criteria for allowing patients into nursing homes.
    Truly comprehensive services across the country include the following, however criteria leading to these services may differ:

    • Physician Visits,
    • Hospital Stays; and
    • Hospital Dental Services.
  3. Universality
    All Canadians have access to health care – 100%.
  4. Portability
    Canadians can move around and still get health care, even out of country. However, if payment is required then the province will adequately reimburse the resident/patient at the rate of the home province, NOT the rate where health care was received.
  5. Accessibility
    There should be no barriers to health care.

The two principles that are most often multi-interpreted are Comprehensiveness and Accessibility. It is imperative that we take a closer look at these.

Comprehensiveness

As stated above, the truly comprehensive services that are available for every Canadian citizen are Physician Visits, Hospital Stays and Hospital Dental Services. Let us look at each of these in a little more detail.

Physician Visits

Physicians are paid on a fee-for-service basis (i.e. they get paid per medical act). These fees are negotiated between the government and the medical association (the act is called Physician Remuneration…and yes, there is a lot of paperwork). For a visit to the General Practitioner (GP) that occurs in his/her office (i.e. the patient is an ‘outpatient’), the fee is $37.00. For a visit that occurs in a hospital (i.e. the patient is an ‘inpatient’), the fee is $17.00. This difference exists to help physicians cover the overhead costs of running an office. Keep in mind that being ‘seen’ by a doctor could involve a five minute conversation or a simple sweep of your chart and vitals.

Hospital Stays

Hospitals are expensive. They involve the costs of personnel, pharmaceuticals, food, building expenses, etc. It is averaged that a single day at the hospital costs $1000.00. This is why hospitals are constantly trying to reduce the length of hospital stay required before and after procedures. For example, new mothers without complications are sometimes out the next day.

Hospital Dental Services

Dentistry in general does not fall under health care (although if we consider cost-effectiveness it really ought to). However, dental services can be part of emergency procedures at which point they would be covered through the Canada Health Act.

Accessibility

Oh, this is so complicated. Here, you take a look:

12.1.a. In order to satisfy the criterion respecting accessibility, the health care insurance plan of a province must provide for insured health services on uniform terms and conditions and a basis that does not impede or preclude, either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons.

Or, insured persons (i.e. tax payers) should not have barriers to health care. One barrier is finances, therefore patients should not be met with user fees or administration fees (direct charges) in order to access health care.

I know you’re wondering why some services (e.g. Québec walk-in clinics) are allowed to charge money. The answer is simple, you don’t NEED to go to that clinic. There exists a clinic that will not charge you fees (even if it IS the emergency room where you will wait 6 hours to be seen, where your condition will potentially worsen, and which will decrease your economic productivity – sigh). In Québec clinics charge $95.00 a visit. Compare that to the $37.00 physician remuneration I mention above. That is a ‘user fee’ or ‘facility fee’ or ‘service fee’ of $58.00.

So, if you have money you can visit a faster user-fee-charging clinic and get back to making money. If not, then either you live with being ill or cram into a free clinic with other sick people and wait – one of the reasons that socio-economic status is an excellent indicator of health. These two speeds, called a two-tiered system, are just the beginning of provincial rule bending in regards to the Canada Health Act.

Personal Note:

I would like to propose that finances are NOT the only issue of accessibility. Consider rural areas. Where I come from the closest ‘hospital’ is over 30 minutes away – and that is only if it is open. If a physician is not available I may need to continue ANOTHER 30 minutes (that’s a hour if you’re adding) to reach the next hospital. The act of getting to a doctor suddenly becomes difficult, so there are three choices:

  1. Call an ambulance
    The ambulance (expensive) must travel the same 30 minutes to get to you (20 minutes if they are heavy-footed) and then turn around and go back. Remember that irreparable brain damage occurs after four minutes.
  2. Travel
    Elderly, handicapped or poor patients would see travel as a infringement to the accessibility of their health care. Without a car, gas, a licence and the physical ability, these distances cannot be traversed (especially since there is no local transportation in this area).
  3. Avoid
    Ignoring a small health concern will likely lead to it escalating (see option #1).

This personal note is corroborated by the Canadian government’s September 2006 Report “How Healthy are Rural Canadians?”:

The reality of living in rural and remote areas is that there are fewer health care services. Geographic isolation and problems with access to and shortage of providers and services are multidimensional problems. For instance, poor road quality combined with greater periods spent on the road not only contribute directly to higher incidence of injury, but also compromise access to health services. Moreover, difficult economic circumstances, travelling time to the city and the lack of car ownership can affect access to and demand for health services.

Health, Studying

Global Health, Well-Being, and Conflict

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According to the WHO (World Health Organization), “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”.

In Global Health terms, health has a lot to do with conflict. Today, 90% of deaths in wars are civilians. Conflict used to be confined to inter-state wars (consider the world wars), but increasingly regular are intra-state conflicts (feuds within political boundaries).

The United Nations (UN) has always had the mandate to take care of Refugees (those who leave their country’s borders). However, just recently has the UN finally been mandated to take care of Internally Displaced peoples (those who don’t leave their country’s borders). This means that the numbers have increase substantially, considering that Refugees number somewhere around 9 million, while Internally Displaced peoples amount to over 22 million.

Also important to consider are the causes of conflicts. Sources of conflict include race, religion and natural disasters. Consider these images of Lake Chad which indicate the physical source of strife that has escalated to the Darfur conflict.

The shrinking of Lake Chad

(Image found at A Town Square)

The impact that a source (such as drought) can have is a direct result of susceptibility. Impact includes things like:

  1. Increase in morbidity and mortality
  2. Forced migration
  3. Disease
  4. Increasing competition for resources

Number Four is best exemplified by this image:

Haiti - Dominican Republic Border

(Image found at Wiley GeoDiscoveries)

This is the border between Haiti and the Dominican Republic – the raging deforestation in Haiti is extremely evident.

The first section was presented by Dr. Kirsten Johnson, MPH.

_________________________________________________________

Dr. Tarek Razek (rightmost white man)

(Image from Outpost)

Dr. Tarek Razek is a medical doctor as well as the Director of the McGill Trauma Program. In his spare time, Dr. Razek is a trauma physician with the International Committee of the Red Cross (ICRC) and educator with the Canadian Network for International Surgery (CNIS).

Dr. Razek notes that Canada is odd. That we really are rare in terms of our consideration of multiculturalism as normal. This facet of our society leads to Canadians being excellent members of Emergency Response Units (ERUs). This was imperative in the past when Canadians were deployed as part of ERUs of other countries. Just recently Canada has acquired its own Emergency Response Unit (including kits, pharmaceuticals, tents, teams, etc.) which has just been sent to Haiti to help fight an outbreak of cholera.

Safety is a continued issue for Dr. Razek, who has a family. The threat of death, injury and kidnapping is real. The position of trauma surgeon in a conflict area is not entered lightly. But Dr. Razek acknowledges that his work is necessary and rewarding.

Dr. Razek tells the story of his experience doing surgeries 10 hours a day for 7 days a week. Each of his surgeries required the permission of the patient (or guardian). As such, there needed to be translators present. Because the Red Cross camp was located in an area that was surrounded by multiple tribes it seemed like it would be a challenge to decipher which translator was needed. However, tribal customs differed in an interesting way in that area, so translators were able to lift the shirts of the patients and use the tribal markings on their chests to determine the correct dialect.

Trauma is an unrecognized epidemic. It is the leading cause of death, and in 2020 will become the number one cause of years of life loss. Dr. Razek has many stories and pictures to share detailing bullet wounds, bullet wounds, bullet wounds, and landmine injuries.

He shares this story. In some areas where landmines are prevalent, parents make the youngest child walk in front of the family. If that child is too light to set off the landmines then the child will be weighted down. Dr. Razek goes on to explain that the father and the mother are necessary entities in the family, without which the family would cease to operate. The older children are also necessary members because their labour abilities help bring in revenue for the entire family. The youngest child is dispensable – not yet offering tangible benefits to the family unit except for through its dispensability.

Dr. Razek’s presentation was one that offered insight into global emergency care. And more importantly he offered palpable stories and feelings to a room full of medical personnel who are also interested in working in a global context.

Next Week: Access to Essential Medicines

Exercise, Food, Health, Money, Studying, Teaching, Technology

Learning about Health Care

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Dear whoever is interested,

I am currently enrolled in Health Care Management, a Master’s course taught at McGill University. Some of you have shown an interest in the subject as well as voiced very interesting and provocative questions and ideas.

In response to that interest, and to aid in my own learning, I am going to make weekly(ish) posts with summaries of what was discussed in the class the previous week.
If you are at all interested in reading or commenting please do so. Discussions are where learning really happens, and where ideas are formed. It will also give us the opportunity to share some field-specific data and perhaps formulate changes that could help improve the system for all of us.

Thank you for your interest. I hope to chat with you soon.

-Jacenta

Health Care Management
Summary – Week 1
January 5th, 2011

In health care management there are five key economic principles that come into play:

  1. Costs
    There is no limit to how much money we can throw at health care. Increases in health care spending could continue until immortality is achieved for every citizen.
  2. Outcomes
    There need to be results (presumably benefits) of the health care system.
  3. Effectiveness
    The relationship between Costs and Outcomes is of the utmost importance. Only when a treatment/idea proves adequately effective should it be funded through health care. Take, for example, the cancer drug Avastin. Canada may refuse to offer this (extremely expensive) drug to cancer patients because it seems that in the end it only lengthens lives by two weeks. (Note: This is an average. For some, it may be longer. If there was a clear determining factor for its success it could be used more discerningly, thus increasing its effectiveness.)
  4. Trade Offs
    With a fixed budget, health care is a constant juggling act. When we give more money to pharmaceuticals we must take money from somewhere else. On an even grander scale, if we want more money for health care do we take it from education? transportation? security? Or just increase taxes?
  5. Structure
    Health care can also be manipulated through its structure. Using non-monetary incentives and organization techniques the system may be altered and potentially improved.

______________________________________

Now let’s talk about Health: What makes a healthy society?

An initial reaction is often to say Access to Health Care. Interestingly, this only accounts for 25% of health. Biology accounts for another 15% (including things like gender and genetics). And Physical Environment covers 10% (including clean air and water, food and shelter).

The most influential determinant of health at a whopping 50% is Social and Economic Environment. Topping this list is socio-economic status (i.e. how much money you make), but also important are your social support netoworks (e.g. do your friends keep you physically active? do they smoke or drink? do they engage your mind?).

Clearly these categories are not mutually exclusive. For example, your socio-economic status will often dictate what physical environment you live in and therefore the quality of your air, food, water and shelter.

Also note that this is only one of the percentage-per-category correlations. Other researchers present the data differently. For example, a chart produced by the Georgia Health Policy Centre uses data from the McGinnis and Foege publication “Actual Causes of Death in the United States” (Journal of the American Medical Association, 1993). This chart rates the determinants of health as:

51% – Lifestyle (smoking, obesity, stress, nutrition, blood pressure, alcohol, drug use)

20% – Human Biology

19% – Environment

10% – Health Care

Note: The research article used to support the above percentages only provides data for the Lifestyle section (~50%). It is unclear how they calculated the other sections. Also note that the original article states that Sexual Choices are a high ranking Lifestyle factor.

To hammer home the idea of social factors playing such a crucial role in health, take a look at this video: Judy Heyman Public Health (highly recommended).

______________________________________

To Truly have Health Care in Canada, we need Canadians to care about health.

Let’s start with food.

(Image from Greek Reporter)

In 2008 the British Medical Journal published a meta-analysis of the Mediterranean Diet. The Mediterranean Diet which focuses on whole grains and fresh fruit and vegetables has an astonishing impact on longevity and health. In fact, adherence to the Mediterranean Diet has “been found to be associated with a reduction of overall mortality and mortality from cardiovascular diseases and cancer” (2008, pg. 1).

To completely convince you, take a look at these (from the 2008 article):

Figure 1:

Risk of all cause mortality associated with two point increase in adherence score for Mediterranean diet. Squares represent effect size; extended lines show 95% confidence intervals; diamond represents total effect size.

Figure 2:

Risk of Parkinson’s disease and Alzheimer’s disease associated with two point increase in adherence score for Mediterranean diet. Squares represent effect size; extended lines show 95% confidence intervals; diamond represents total effect size.

A Health Care System alone does not ensure health. As we see in the numbers, without the other systems we support as a society (such as nutrition and lifestyle as part of our education system) we would have decreased health. Clearly a trade off from the education sector to the health sector would be detrimental  – just like reducing the number of preventative general practitioners (GPs) in order to increase emergency room use, which we would never do…errr…more about this next week.