Friday, April 30, 2010

Taxing Cigarettes Is Reasonable - Be Honest About It Though

The Australian government has increased the tax on tobacco and announced changes to labeling laws, which will mean that from 2012 cigarettes will need to be sold in plain packets without colors or brand logos

Cigarette smoking is, after obesity, the second largest cause of preventable disease and premature death in Australia. Until fairly recently, it held the number one spot, and in many countries still does. The tax increase will add $2.16 to a pack of 30 or about 7c a cigarette. This is not a huge amount but may well encourage some to stop burning their money.

However, the government does not expect huge reductions in consumption as it is counting on an extra AUD $5 billion in revenue over the next four years. A statement said it expected consumption to drop 6% and that 2 or 3% of smokers would quit based on the price hike. The revenue raised will be used to fund hospitals and $27.8 million will be spent on anti smoking programs. The move has, of course been welcomed by the public health brigade on the basis that it will save lives. No doubt they are already devising ways to use the extra “funding” that is so beloved of those in public health.

The issue of packaging is interesting. Youth workers are not convinced that teenagers will be put off experimenting with smoking if it is in plain wrap. Equally It is unlikely manufacturers would invest so much in branding if it makes no difference. However how are we to explain teenagers using marihuana or other illicit drugs, which do not come in, branded packages? The tobacco industry will get little sympathy. However that does not mean that the move will have much effect or has much basis other than allowing the government to “look to be doing something”.

I have no issue with an increased tax on cigarettes. As I have written previously smoking is a choice people make and they can choose to stop if it gets too expensive. Governments see smokers as a soft target and a group who wont get much sympathy. It can be argued that by putting the tax money raised into hospitals it is a form of “user pays” albeit a clumsy one.

I have an issue with dishonesty. This move has nothing to do with health. It is a revenue move. This is patently obvious in that the projections are for a significant increase in revenue. If there were a serious drop off in smoking revenue would be static or decline. Governments can be expected to dress up any tax hike (justified or not) and use spin. But what excuse do the public health people have?

The public health crew does not want to bite the hand that feeds them so they peddle the government line that these moves are about health whereas in fact they are not. They also tend to see being “anti” the tobacco industry as somehow an achievement of itself. Nothing like having an enemy to make yourself look like a hero.

The bottom line is that some people may, of their own volition, choose to stop smoking as a result of the tax increase. The increase is a reasonable revenue move by a government searching for dollars to fund its promises.

Can we just be honest about it, please?

Sunday, April 25, 2010

Swine Flu- One Year On And Still A Storm In A Teacup

It is just on one year since the world first heard of swine flu. It is still extraordinary that a mild flu like illness has led to such a completely over the top behavior from “health officials”.

The program to vaccinate children aged between six months and four years has been “temporarily suspended” by the state of Western Australia. This was after at least 60 cases of adverse reactions including fever, vomiting and febrile convulsions. A number of children had to be admitted to hospital. One child remains in a critical condition. The number of reported cases is likely the tip of the iceberg and there may be hundreds if not thousands of children who have had milder reactions that are not reported.

An urgent meeting of the Therapeutic Goods Administration (TGA) has been called to investigate the matter. The Australian Chief Health officer who two weeks ago sent a letter to doctors urging them to vaccinate, today said doctors should stop vaccinating children under five immediately. This response has been swift and is to be commended. There have been suggestions that these reactions have been known about for two weeks and it has been “kept quiet”. Hopefully this is not the case.

The recommendation is that everyone else can continue to be vaccinated. The reactions have been to the “seasonal” flu vaccine, which as usual has three strains. This year one of the three is H1N1 or swine flu. The chief health officer has said that it remains safe for children to have the swine flu vaccine by itself.


Here are some facts. The vaccine is tested on a small group of people and an even smaller group of children. If there is a one in 5000 reaction this may not show up in a trial of 200 but there will be 20 cases by the time 100,000 doses have been given. In 1976 a mass vaccination campaign resulted in more deaths from complications of the vaccine than of the virus. This was with a strain similar to H1N1. Clearly it is this component which is the problem.

From the outset everything to do with swine flu has been rushed and corners have been cut, based on the fear of this virus. The estimates of swine flu have been wrong from day one. The 2009 southern winter and 2010 northern winter have been the mildest, in terms of flu, for many years. Predictions of millions of deaths were ridiculously wrong and deaths were less than usual. Every year some people die in relation to flu. Most of these have other illnesses and there are a small number where there is overwhelming infection.

The USA, UK and many European countries slashed their orders for vaccines and still had many doses to spare. The Australian government is sitting on a huge stockpile of vaccines. The notion that the only way to protect yourself from flu is to be vaccinated continues to be promoted with no regard given to the fact that a competent immune system is your best protection from flu or any virus. I am yet to see any advice from health authorities on ways to strengthen your immune system.

I am not into conspiracy theories so do not see swine flu as a government plot in collaboration with the vaccine manufacturers. It is my opinion that conspiracy is not the correct interpretation of events when incompetence or stupidity would be an equally valid explanation.

This is also not a debate about vaccination per se. In the same way that if a drug is withdrawn from the market, it is about that drug, not drugs as such.

Swine flu has been a textbook health scare. The threat was way over stated and the reaction was way out of proportion to the threat. Now we have the situation where those who got it wrong are too attached to their position to admit error. The continuing push to vaccinate on the basis of fear is wrong. If even one child dies or sufferers serious harm based on a program that was not needed, then this is not acceptable.

The issue is not about the rights or wrongs of vaccination in general. It is about whipping up fear and telling people that only a vaccine can protect them from a mild illness.

The authorities got it wrong. It is time for them to fess up. Ongoing attempts to reassure the public about the safety of a vaccine, which is unnecessary, will only serve to further undermine confidence in vaccination and in health advice.

Tuesday, April 20, 2010

No,Prime Minister,People Need Sleep To Function Effectively

It is fair to say that many government decisions are not particularly good. There may be an obvious reason for this emerging. Australian Prime Minister Kevin Rudd is “unapologetic” about his staff working long hours and there being a high turnover rate of staff.

Apparently staff can start at 4.30 am and still be on the go at 10pm.Seven day weeks are not unusual. Mr Rudd claimed a year in politics is like a dog year, seven years crammed into one. He claimed that people expected their government and politicians to work hard.

It seems the PM is unable to differentiate between quality and quantity when it comes to work. Furthermore he also seems to be unaware of the health effects of long hours and its impact on decision-making and the impact of high turnover.

Any human resources manager will tell you that staff turnover places a huge burden on business. There is loss of corporate knowledge, and the time taken to get a new staff member up to speed can be some months. All the while productivity suffers. This is quite aside the monetary costs of paying people out and the costs of recruitment. In business these costs affect profit whereas in government it is just borne by the taxpayer.

It gets worse. Sleep deprivation affects both health and productivity. NASA studies have shown that after 20 hours continually awake your brain is affected the same as with a blood alcohol reading of 0.05%. This is the cut off level governments set in most countries for drink driving. At this level you are not fit to drive. So how can you run the country?

In addition to this lack of sleep contributes to an increased rate of high blood pressure and heart disease. People who do not get enough sleep are more likely to be obese. When they do finally drive home, obviously there is a greater chance of a road collision and injury to them or someone else. Lack of sleep contributes to stress and in turn this can increase the likelihood of getting cancer five fold over a ten-year period.

For governments who claim to be concerned about health and wanting the population to be healthier this is a strange way to act. However even if we totally ignore this (and one wonders what the Health Minister would say if a public company forced employees to work these hours) there is another aspect.

Experiments have also been done on productivity and sleep. Sleep deprived people are less likely to work co operatively with others, are more irrational and more prone to emotional outbursts. Has anyone ever seen the behaviour of a tired child? Well it is the same in adults.

People want government to be effective. This is measured by outcome not hours spent. Indeed what we are seeing is that the modus operandi of government leads to poorer results by making its employees less healthy and getting them to work when their brains are far past their best for the day.

I would not want to be operated on by a surgeon with a blood alcohol level of 0.05% or equivalent in sleep deprivation. I do not want decisions made about the governing of the country by people with a blood alcohol of 0.05% or the equivalent in sleep deprivation.

The final irony is that the hard work keeping everyone up was on … health reform.

Friday, April 16, 2010

Parks Are For Exercising Even If It Wears Down The Grass

It is always amazing how little things can make a big difference. You would think that with all the talk about problems with obesity and people being too sedentary that all levels of government would be taking steps to encourage people to exercise. At very least you would not expect them to put up barriers.

Sadly you would be wrong. The City Of Stirling (in West Australia) wants to charge personal trainers up to $50 an hour to use parks and reserves. Two bizarre excuses were offered. One was that the council must charge trainers because of the wear and tear on parks. The other was that parks are not provided for businesses to get a “commercial gain”.

What a load of rubbish!

Parks are actually designed to be used. They are not ornamental. The whole purpose of having public parks is so that people can use them. Large grassed areas are ideal for running, throwing a ball or doing all forms of healthy outdoor activity. The “wear and tear” line reminds me of the lady in a Fawlty Towers episode who had difficulty hearing but when asked about her hearing aid said she did not use it because it ran the batteries down.

We have parks but we do not use them because it wears the grass down! Even if there is some truth to this, all levels of government are encouraging people to be more active and public parks are provided for…public use. Every year we pay rates to councils and basically all they do is collect the rubbish once a week and water the parks. If maintaining public parks in the face of public usage is too hard for the poor dears then they need a reality check.

The second excuse is completely self-serving. Most trainers are small business people. Most do not charge huge amounts of money. It is also a fact that the presence of a trainer will encourage people to exercise and push themselves a little bit. Exercising in a group is popular as it provides a social benefit as well as the fitness side. The fact that the trainer provides a service to those people exercising does not mean they are getting a “commercial gain” from the park, they are earning a living by providing a service to people who live in the area and pay rates to the council to maintain a park for public use.

One trainer, is not wearing down the grass, it is the collective use of all the people exercising. Presumably this council hopes that its charge will discourage trainers. In turn that means it hopes ratepayers will not exercise in the park and not wear down the grass. One can assume it hopes they will stay inside watching TV instead.

Rather than discourage trainers, if governments were serious about health they would subsidize trainers at every park so that more people would do regular exercise. Some of this money could be diverted from funding of elite athletes. Some could come from the health budget.

With a healthier population, there might be just enough savings from the health (disease) budget to pay for grounds maintenance.

Tuesday, April 13, 2010

Pharmaceutical Influence Is Changing Shape

The links between doctors and the pharmaceutical industry are coming more and more under the spotlight. To be upfront, I have over the years been given various pens, coffee mugs, and have been to sponsored dinners. Over the past few years I have deliberately stopped going to these and have not regularly seen reps since 2005.

It always struck me that these promotions were advertising and that it was up to me to decide whether the claims were valid in much the same way, as I would assess claims made about products advertised on TV. The media has tended to focus on these gifts as the main game.

What has become clear is that pens, mugs and dinners are not the main game. The big issue is payments to doctors as consultants and speakers. Pfizer has reported that in the last half of 2009 it paid $US20 million to doctors and medical professionals for consulting and speaking. A further $US15.3 million was paid to academic medical centres and research groups for clinical trials. Other companies are also disclosing payments.

Some states in the USA now have laws covering gifts given to doctors from pharmaceutical companies. Various universities and medical schools have implemented disclosure policies. Harvard Partners Healthcare put a cap on how much doctors can be paid to sit on boards.

Institutions, which employ doctors, are able to put conditions on employment. Doctors in private practice are of course not bound by such conditions. Consequently there is a trend to get local doctors to give talks. The payments for this can be lucrative with reports of payments of tens of thousands of dollars.

None of this is “wrong” as such. Speakers are paid in all forms of industry. Companies are free to promote their wares and pay people to endorse them. Many sports people earn more from endorsements than they do from their chosen sport. So is it a surprise that some doctors can earn more from “endorsements” than their practice?

The short answer is no. However there is one key difference. When you see and add with a celebrity you know they have been paid to advertise the product. When doctors talk about drugs it is presented as clinical information. It is known that pharmaceutical companies seek out “opinion leaders” in medicine so that their names can be quoted to other doctors. “Specialists”, who, rightly or wrongly, are deemed to know more about particular areas of medicine, can influence primary care physicians.

I do not believe any doctor will say things at a talk, which they do not believe. The point is that they are selected because of their views. A doctor advocating lifestyle treatments rather than drugs probably will not be invited to speak. It is more about what is not said. A talk on diabetes sponsored by a drug company will of course focus on drug treatment rather than diet and exercise.

Bottom line is that millions of dollars would not be spent if there were not some return to the company. This matters because the costs of drugs are generally borne by governments and insurers rather than the individual. Hence unnecessary use costs everyone.

As the rope tightens around this method of promoting pharmaceuticals another subtler one is opening up. This is payment by pharmaceutical companies to patient support groups. In some instances pharmaceutical grants have been used to set up patient groups. Australian figures show several pharmaceutical companies donated over $1 million to assorted health groups including the Heart Foundation. The Australian Lung Foundation was set up by a grant from a company that makes a quit smoking drug. Guess who may have funded the establishment of Impotence Australia.

Once again none of this is “wrong” or illegal. However might your view of a news story quoting a health group be affected if you knew who had funded them? As with the doctors it is not about paying people to say things they do not agree with. It is about finding people who agree with you and then having them promote your line “independently”. Similar to celebrity endorsement, this is patient endorsement.

Many patient support groups have a “saintly” air about them and claim that they are all about advocating for the people who have a particular disease. Fair enough. It also means they can have an interest in “disease mongering” and encouraging people to see traits or minor symptoms as part of some disease or syndrome. This builds the number of people they “represent”.

This leads to the medicalizing of life. In turn there is increasingly a drug to treat this medicalized life. These drugs are sold for a profit by the same pharmaceutical industry, which supports these groups in spreading the word.

If we take three steps back, it may become apparent that there is something not quite right with this picture.

Friday, April 9, 2010

Being Human Is Not A Disease

Humanity has a breadth and depth to it. We are not all the same. It is interesting then how some differences are accepted and others are not. It is particularly interesting how some differences are increasingly been made into diseases. The medicalization of human behavior is a real trend. If a human trait can be reclassified as a disease, then suddenly there is the potential to “treat it”, especially with a pharmaceutical agent.

Let us look at a ridiculous example. Height can vary considerably. Whilst there are genetic causes at the extremes of the height range, the vast majority of people are either to the taller or shorter end of the spectrum. It is not considered a disease to be five feet high even though this is at one edge of the range.

So why is it then that with behaviors we are increasingly regarding those towards one edge of the spectrum as having a disease? ADHD is a classic example of where particular traits have been reclassified as a disease and the people, mainly children, involved have been put on drugs. Attention spans like everything else vary, but this is not to say those at one end of the scale have a disease, particularly when these children usually have other talents which the school system may not recognize or reward. Even allowing for the fact that some children may have difficulty with sitting still, that does not make it a disease.

Shyness is another human trait. Some of us are more outgoing than others. In the 1990’s this was reclassified as Social Affective Disorder and people were treated with antidepressants. This has fortunately gone out of vogue. If shyness is a problem to people then there are ways of dealing with it; it does not make it a disease.

In a similar way the concept of depression has been expanded to include everyone who feels down. If it is not a disease to feel happy after winning the lottery, then it is not a disease to feel down, for example, after a death of a loved one or relationship breakdown. Whilst some people do have genuine depression, many others now come under this banner for basically having human emotions, which are reclassified as a disease.

We saw in the 1980s the reclassification of menopause, which is a normal part of life, as a disease. Many women were placed unnecessarily on hormone treatment, which was found to cause more harm than good. Some of the issues surrounding clinical trials, which supported hormone treatment, are still being investigated.

Some men at times have difficulty getting an erection. This is not new and is not a disease but was reclassified as one and named erectile dysfunction. Sure if taking a tablet helps you and you want to take one, then do so, but do not call it a disease. The latest attempts will be to make premature ejaculation and jet lag into diseases. Neither is. The first can be distressing and can be dealt with. The second is the obvious result of our ability to move time zones more quickly than our body can cope with. Calling sex addiction a disease is just making excuses for people who choose not to control their behavior.

The bottom line in all this is that a drug looking for a disease always accompanies the reclassification of a human trait, emotion or tendency. If people want to use pharmaceutical or even illicit drugs because it makes them feel a certain way, or allows them to do something they might not otherwise do (remember the songs written in the 1960’s under the influence of substances) then the rights or wrongs of this can be debated.

However let us not use the label of disease to justify our actions and certainly let us not reclassify normal parts of life as a disease especially if the main reason is to boost the sales of pills.

Tuesday, April 6, 2010

Prostate Testing Is Not Black And White

Prostate testing remains controversial. In one camp we have those who are pushing for more testing so that more cancers can be detected. This group feels that prostate cancer is under diagnosed and under treated. In the opposing camp are those who feel prostate testing is not helpful as a screening (as against a diagnostic) test and feel that too many men have unnecessary biopsies and surgery with all the associated risks and possible complications. Interestingly, in this latter group is the inventor of the test.

Whilst stories of men who had their life “saved” by having a PSA test make the headlines, stories of men who have incontinence and impotence after unnecessary surgery do not.

What is the average man to make of this? The issues are not straightforward.

The PSA test measures a protein in the blood, which comes from the prostate gland. Like with all tests there is a statistically defined normal range and this increases with age. There is also a sub set of “free” PSA versus PSA bound to another protein.

In an ideal world a raised PSA would diagnose prostate cancer. It does not. The level can be raised for a number of other reasons including benign enlargement, infection and can be raised by some over the counter medications. The PSA can also be normal even if cancer is present. In medical terms this test is classed as having a high” false” positive and negative rate.

It gets more complicated. There are two types of prostate cancer. One form which is fatal and the other is not. In simplest terms it has been regarded that all men will eventually get cancer cells in the prostate if they live long enough. They will die with not of the cancer. Hence the finding of prostate cancer in someone of 70 is regarded as less serious than in someone of 55. Age whilst a guide, is again not an absolute determinant of the form of cancer. The PSA does not give us any clue either.

The final complication is that in many instances we do not know if treatment makes a difference. In other words in many cases we do not know if a man who has undergone surgery and radiation and lives would have lived just as long without treatment.

There are conflicting trial results too. An Australian study claims that Australian men are under diagnosed and under treated. This is based on the fact that 60% of biopsies were positive for cancer compared to 30% in the USA. It also found that when radical prostatectomy was performed that on 5% had “insignificant “ cancer compared to 25% in the USA. This could also be interpreted, as showing that there is better case selection for surgery in Australia.

Once again it would be simple if the finding of cancer and treatment meant a better and longer life. A large American trial over ten years showed PSA screening did not reduce death rates in men over 55. A European study showed a small decrease in death rates. For every 48 operations there was an increased survival of one. This means 47 men had surgery, which can cause incontinence and impotence for no net gain.

The Australian study is being promoted by the Urological Society, which advocates PSA testing for all men over 40. It is worth remembering that their members earn a living from biopsies and surgery. This does not make their advice wrong but they have a vested interest. Other Australian groups recommend screening after 60 or no screening at all.

The tests inventor, Richard J Albin went public saying he never intended the test to be used as a screening tool and claims the original FDA approval was based on it detecting 3.8% of Prostate cancers. Whilst the case rate of Prostate cancer in the USA is 16% there is only a 3% death rate from it.

So to get back to our question of what are we to make of this? The simple answer is we do not know. Those who claim to have the answer need to be treated with great skepticism. Those who claim they are about “saving lives” need to be treated the same. Those who downplay the not insignificant costs in human terms of over treatment are not doing us any favors.

Ultimately the decision needs to come down to the individual based on his circumstances. Factors like family history and symptoms need to be considered. If a PSA is done and is raised it should certainly be repeated before further action is considered. Men need to be aware that it is not black and white; that a positive test may mean nothing and a negative test does not mean absolutely no cancer.

Whilst it would be nice to be able to offer a simple one size fits all advisory, I do not believe this is possible. Hence beware of those who do particularly if they stand to gain monetarily from it.

Saturday, April 3, 2010

Chocolate Is Actually Good For Your Health

Easter Sunday is the day when everyone can indulge his or her love of chocolate without feeling guilty-and rightly so. Chocolate is universal. It is said that nine out of ten people say they like chocolate and the tenth is lying.

So why is there guilt about chocolate, and do we need to feel guilty? Simple answer -NO Chocolate is not intrinsically bad for us. At levels of cocoa of 70% it is actually good for us. What applies to you will depend on how much you eat and the quality of the chocolate.

So lets look at the “health benefits” of chocolate. The good feeling you get is not imagined. Chocolate contains a phyto-nutrient, which is an endorphin. The “high” from eating chocolate can be similar to the high runners get. It comes from the endorphins (the bodies natural happy hormone). Chocolate is virtually an antidepressant. Is it any wonder people turn to chocolate when they feel down? A Swiss study showed that eating 40g a day of dark chocolate lowered stress hormones in the bloodstream making people more resilient to stress.

Research has looked at the health benefits of dark chocolate and the results are impressive. A Swedish study showed that after a heart attack, those who ate chocolate at least twice a week had a three fold increase in survival over an eight-year period. Meanwhile a Canadian study showed a decreased risk of stroke in those who ate chocolate once a week compared to those who do not.

The benefits come from the flavinoids in cocoa, which are a potent anti oxidant. These flavinoids have also been shown to protect our genes (DNA) from oxidative damage. This potentially makes chocolate an anti-aging compound.

Chocolate is viewed with suspicion because it tastes so good. As a “pleasure” it has been seen as sinful. There are also linkages between chocolate and that other great “sin” of humanity-sex. Hence, the association of guilt.

Dark chocolate has lots of minerals including potassium, zinc, copper, chromium and magnesium. Many women turn to chocolate if they have pre menstrual symptoms. This is related to low magnesium. Again the body knows what it needs.

Cocoa is rich in antioxidants (10g dark chocolate has the same amount as a cup of green tea). The glycaemic index (GI) of chocolate is 40. Polyphenols in cocoa can reduce LDL, which is the “ bad cholesterol. There are also good fats in chocolate.

Now this is all well and good, you may say, but you can get the most of the same minerals and antioxidants from other sources. This is where the extra dimension of chocolate comes in. Fun is one of the pillars of DIY Health. Apart from providing goodness for us, our food needs to give us joy. Chocolate scores ten out of ten on this one.

So as I said above, there is no need to feel guilty about eating chocolate on Easter or on any other day. This does not mean a bar a day and yes you can get all the above nutrients from other sources, perhaps without the same amount of enjoyment. The best is 70% cocoa and organic is great if you can get it.

As part of a balanced DIY health program chocolate hits the spot.

Happy Easter Enjoy!