In from the cold
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1688 (Published 25 March 2010) Cite this as: BMJ 2010;340:c1688
All rapid responses
Amongst the cases flushed out following the introduction of the NHS
were giant inguinal hernias, fungating breast and oropharyngeal cancers,
rheumatic and congenital heart disease and chronic renal and liver
diseases. I would be most surprised if this were to occur in the US
following the passage of this bill for people are so much more aware of
their own health and in the many years I was in practice in the US I never
saw a partient in need refused treatment because of inadequate funding.
The social services were always able to work something out and, if they
were unable to cover all the costs the difference was met by the
institution concerned. I anticipate that much of the new funding of
healthcare generated by this bill will be spent on making up for the lost
revenues and managing an increased load of chronic medical diseases with
pharmaceuticals, an increasingly suspect practice when viewed it in terms
of all cause mortality and disability-adjusted life-years. Witness the
NEJM paper on tighter blood pressure and lipid control in type 2 diabetes
reviewed in the BMJ short cuts this week. No one BP, lipid or glycaemic
target fits all, concluded the accompanying editorial. That is an
unrestricted licence to print money for internists and pharmaceutical
companies if ever I saw one unless there is a fundanmental change in the
way patients are treated.
In short I see the passage of this bill adding fuel to a raging fire
partly if not wholly caused by system failures as Ivo P Janecka, MD, MBA,
PhD, implied in his rapid response.
Competing interests:
None declared
Competing interests: No competing interests
Dear Fiona Godlee,
Very good comments on Obama’s efforts to give the American
people a good disease care cover, but America badly needs
health care cover (change of mode of living and tranquility
of mind) more than disease care that they are going to get
in the new bill! It is the medical scare system that has got
America the last but one place in the fourteen country study
of health status recently. American medical care is not the
best as of now. (1) The study showed that America suffers
from a surfeit of doctors per capita as also too much
specialisation and sub-specialisation leading to over
intervention and over investigation resulting in higher
morbidity and mortality. In addition, the disease mongering
efforts are at their best in that country, thanks to the
pharmaceutical lobby.
I must point out a few variations in your historical
explanations. History is what the historian writes. Edward
Jenner deserves credit for many things but not for smallpox
eradication as his original idea used cow pox virus which is
not genetically the same as small pox virus. As such cow pox
vaccination can not give protection against small pox. The
truth is that small pox vaccination originated from India
and Dr. T. Z. Holwell, MD, FRCP, FRS, studied the system
prospectively for two decades in India and then wrote a
detailed paper presenting his findings to the Royal College
in 1767 which was the basis of the small pox vaccination
which we claim did eradicate the scourge. The “Brahmin”
priests from the five great universities in India of those
days were practising vaccination systematically for “times
out of mind“ in India which Holwell studied and brought to
England in the eighteenth century. Graphic descriptions are
available in the Royal College archives as also on the web
now. (2)
The true picture of Jenner’s efforts is found in the book
Jenner and Vaccination, by Dr. Charles Creighton, (p. 44), a
noted Scottish physician. One sentence there is worthy of
mention here: “The only correlation between smallpox and
cowpox is that both names ended in POX. Heaven and Hell both
start with the same letter H but they are vastly different
places.” (3)
Yours ever,
bmhegde
References:
1) Starfield B. Is US medicine the best in the world?
JAMA 2000; 248: 483-485.
2) Hegde BM. Vaccination in India. Jr. Associ. Physi.
India 1998; 46: 472-473.
3) Holwell, J. Z., M.D., An Account of the Manner of
Inoculating for the Smallpox in the East Indies, London,
1767.
Competing interests:
None declared
Competing interests: No competing interests
If this health reform is the civil rights act of the 21st century,
maybe President Obama should be offered the Nobel Prize for Peace.
Oh, but he's got that already.
So maybe the one for Medicine, or the Noble Prize for the noble
profession.
VSR
Competing interests:
None declared
Competing interests: No competing interests
The Editor, Fiona Godlee, perceptively differentiates US medicine
from US health care: The first one being first class, the second one not
even competing for the silver when measured on the world scale. Unequal
access, very high cost, motley outcomes are some of the grossly visible,
and hard to understand, dysfunctions illustrated by the Editor. The
questions: Is it really a true “system?” Are there ways to judge it as
such? Where should we look for solutions?
Systems science offers fundamental principles applicable to any
biologic/societal system. It emphasizes all-inclusiveness of numerous and
variable components engaged in reciprocal bidirectional and value-based
relationships among others. It is engaged in self-organization and
functional coherence assisted through vertical/governing hierarchy. A
failing system expresses not organized but disorganized complexity and the
entire complex adaptive system is failing; it escaped from its “health
territory” of optimal function/adaptation, and entered the zone of chaos.
It is in this zone that sudden, unexpected “black swans” occur and
randomness prevails; the capacity of such a system to adapt has been
exhausted hence the risk stemming from partial fixes.
Three paths are plausible from such a state: One- an exponential
“malignant/undifferentiated” growth (analogous to cancer or financial
meltdown); Two- entropy where non-functionality begins to predominate and
the system is nearing a standstill; Three- a rescue path of reestablishing
organized complexity and differentiation (see
http://seekingalpha.com/user/139406/instablog for graphics). A system
succeeds or fails as a system; no societal strata are immune.
For applicability of systems science to the current health care
debate or cancer control, see the following references:
Janecka IP: Is the U.S. Health Care an Appropriate System? A
strategic perspective from systems science. Health Research Policy and
Systems 2009, 7:1 (Highly Accessed) http://www.health-policy-
systems.com/content/7/1/1
Janecka IP: Cancer control through principles of systems science,
complexity, and chaos theory: A model. Int J Med Sci 2007; 4:164-173.
http://www.medsci.org/v04p0164.htm
Competing interests:
None declared
Competing interests: No competing interests
Re: Noble prize for Obama
Mr. Obama has proven himself to be a deserving recipient of Nobel
prize and secured his rightful place in history books .
But let's wait and see how the vested interest[Republicans, Insurers
and the big pharma] succed in diluting,if not scuppering his
unprecedented achievement.
As ever, the devil has to reside in detailed implementation of his
Bill. Watch this space.
Competing interests:
None declared
Competing interests: No competing interests