Category Archives: Culture

Give Boomer Esiason a break on birth comments

Retired football star and current radio host Boomer Esiason has opened the floodgates of righteous indignation by suggesting that the Mets second baseman should have encouraged his wife to have a scheduled C-section before opening day. That would have prevented him from missing the first two games of the season when he flew home to be with her.

Esiason got the blowback that he should have expected, and made a lengthy apology for his comments today.

I’m happy though, that this mis-step has turned into an opportunity to educate people about the dangers of early elective delivery. There’s actually been a major, successful effort underway to reduce the use of early elective deliveries. Such deliveries –either induced or scheduled C-sections before 39 weeks– represented 17 percent of births in 2010 (as high as 25 percent in some states). As of 2013 the rate has fallen dramatically, to less than five percent according to the New York Times.

It turns out babies born at 37 or 38 weeks have a lot more health problems then those born at 39 or 40  weeks, even though it doesn’t seem that such a short time difference should be so important. So I hope the reaction to Esiason helps to get this message across.

Esiason is getting the word out. Here’s what he said:

I’m very grateful to my many friends over at the March of Dimes who graciously reached out and re-educated me that if a pregnancy is healthy, it is medically beneficial to let the labor begin on its own rather than to schedule a C-section for convenience. In fact, babies born just a few weeks early have double the risk of death compared to babies born after 39 full weeks of pregnancy. As their promotional campaign says, ‘Healthy babies are worth the wait.’ And as a proud father, I couldn’t agree more.

I find it quite interesting how societal expectations about fatherhood have changed in the recent past. A generation ago, the notion of a father being in the delivery room was unheard of. Fifteen years ago I had a job interview with a large financial services company. The hiring manager (in his early 30s at the time) told me the job required an all out commitment, and that while he hoped to be present at the birth of his child, that wasn’t really the way things were prioritized there. I didn’t agree with that sentiment then, but it was the norm in many places.

So it’s interesting to me that Esiason took it for granted that the player would be present for the birth –he didn’t seem to question whether work should come first.

Esiason said the wrong thing, but I think we should cut him some slack. First of all, being a football quarterback is different from being a baseball second baseman. Baseball teams play 162 games per season, NFL teams only 16. A star quarterback plays every game, whereas even star baseball players get a day off from time to time. So maybe we can accuse Esiason of lack of empathy for thinking about how he would have behaved, not what a baseball player would do. But I understand his point about not wanting to miss a game.

Esiason is 52 and times have changed. He gets part of the new way of thinking –dad should be there for the birth. But he screwed up by suggesting unnecessary surgery. And while I don’t fault him for not knowing that earlier births aren’t good for babies, at least it gives people a chance to bring it up and make it known to a wider audience of would-be fathers who might otherwise not be paying attention.

By healthcare consultant David E. Williams of the Health Business Group


CVS and cigarettes: Asking the wrong follow-up question

After CVS, what's next for smoking?

After CVS, what’s next for smoking?

CVS’s decision to stop selling cigarettes is a smart one. Cigarette sales are incompatible with the company’s positioning as a health care provider. With the reduction of smoking rates, growing restrictions on where people can smoke, and increasing numbers of localities banning cigarette sales in drug stores it will probably make business sense over time as well.

I’ve been surprised that so much of the commentary on CVS’s decision has focused on what else the company should stop selling. Candy, gum and soda are bad for you, too, so maybe CVS should stop selling that. And the list goes on from there –maybe some of their toys are dangerous, for example.

Asking what else CVS should stop selling is asking the wrong question. Cigarettes cause an order of magnitude more harm than those other categories and are more addictive. That’s a good reason  to stop selling smokes without having to stop selling other things that aren’t 100 percent healthy.

I’d like to see a bigger emphasis on reducing the availability of cigarettes more broadly and making them more expensive.

Cigarette taxes vary wildly by state. Missouri is the lowest at $0.17 per pack and New York is the highest at $4.35. (New York City tacks on an additional $1.50.) The federal tax is $1.01 and some places add other taxes including state and local sales tax. The average retail price for cigarettes is about $6, so tax represents a big part of the price.

These big differences provide a major incentive for smuggling. Although no one knows exactly what percentage of cigarettes are smuggled, it’s a lot.

Indian reservations are another source of low-tax cigarettes. High tax states like New York have seen considerable friction as non-Indians have sought out on-reservation stores for bargain prices.

The effects can be insidious. A friend told me recently about a public housing project in his area where a man goes door to door selling cigarettes he obtains cheaply on a nearby reservation. If the price were higher the rate of smoking in this price sensitive population would be likely to decline.

I’m not proposing a specific mechanism to address these challenges, but I would like to see the low tax states raise their tax rates,  more enforcement effort devoted to stopping interstate smuggling, and more aggressive action to reduce the availability of reservation cigarettes. Although this will never happen, one approach could be fore the federal government to charge a tax of $6 minus whatever the states charge. That would provide an incentive for every state to raise the tax to a uniform, high amount.

photo credit: The Guncle via photopin cc

By David E. Williams of the Health Business Group.

Legacy videos by the terminally ill: What does the future hold?

What's over the horizon?

What’s over the horizon?

It’s been common practice for decades –and probably longer– for terminally ill parents to write letters to their children. The idea is for parents to be able to communicate to their offspring as the kids get older and are able to handle more mature messages. Some parents leave letters to be opened at specific times, like a 16th birthday, college graduation or wedding. Not surprisingly these letters are being supplemented and superseded by legacy videos, according to a recent Wall Street Journal article (A Mother’s Last Gift to Her Children May Be a Legacy Video).

Multiple organizations –including Just So You Know and Thru My Eyes have been set up to enable patients to make these videos for free. I think it’s a great idea. I would record such a video myself in the same situation. Many surviving children and other family members find the videos to be a source of comfort, and the ill patient often finds the process therapeutic.

There are some challenges, though. As the article says,

“Legacy videos also can sometimes contain painful messages, overbearing advice or wishes that the children don’t feel they can carry out.”

That got me thinking about how the evolution of technology will inevitably take us beyond the legacy video. In the not-too-distant future technologies including virtual reality, artificial intelligence, and natural language processing may enable legacy projects that are a lot more powerful, with the potential to be more comforting and meaningful but also more invasive and even spooky. And going even further, what happens when someone’s entire brain can be downloaded and ported to a new medium?

Not to be too futuristic, but it’s reasonable to expect that these videos will evolve into something a lot more lifelike and interactive within a few years. The potential for good is real, but we’ll have to navigate through some sensitive issues to make sure that’s the case.

What do you think? Would you record a legacy video? Have you received one? Would you want to be the producer or recipient of something more interactive? Let me know in the comments section or @HealthBizBlog

photo credit: Pilottage via photopin cc

By David E. Williams of the Health Business Group.

Marijuana is not gay marriage


It’s tempting to draw parallels between the legalization of gay marriage and legalization of marijuana. A pollster is quoted in today’s Boston Globe (Marijuana advocates lay groundwork for legalization in Mass.) doing just that:

“Opinion is changing very quickly on marijuana,” said Steve Koczela, the president of the nonpartisan MassINC Polling Group. He said a number of 2013 national polls found, for the first time, that a majority of Americans favor legalization of the drug. The rapid change, he said, “mirrors, in some ways, the same-sex marriage shift that’s taken place over the last few years.”

And the parallels go beyond that. Decriminalization of marijuana as Massachusetts has done is akin to allowing civil unions. The next step: full legalization, is viewed as a natural evolution of tolerance.

But there are serious differences. Civil unions lead to gay marriage because the rest of the population has a chance to discover for themselves that gay couples are no threat to heterosexual families. Contrary to some irrational fears, children are not “recruited” into homosexuality just because acceptance of gays goes up and is enshrined in the law. Once gay  couples are accepted and not feared, it becomes an equal rights issue –civil unions confer only partial rights and there’s no rationale to withhold full rights.

Time will tell, but I expect that experience with marijuana legalization will be different. Marijuana use is a health threat. Legalization does make underage use more acceptable, increasing harm. It becomes harder for parents to keep their kids from using pot.

It’s not inevitable that marijuana laws will become more and more lax. Cigarette smoking is becoming increasingly restricted and less culturally acceptable. The latest frontier is over smoking in public parks. Trans fats are being legislated out of use. New York City’s drive to limit soft drink sizes is not as crazy nor unpopular as it sounds. And beverages that mix alcohol and caffeine have been pushed from the market.

The abuse of prescription drugs is finally starting to get the notice it deserves. Parents are waking up to the fact that their kids –and if not them, their kids’ friends– are awfully interested in what’s in the drug cabinet, especially if that includes painkillers like Vicodin or Oxycodone. Something similar will happen with marijuana: barriers to its use will fall when the stigma of buying it from a dealer is removed and when its purity and freshness can be guaranteed by the retailer. I don’t want to see that happen in Massachusetts or elsewhere.

Having said that I do support decriminalization so people’s lives aren’t ruined by a marijuana possession conviction and so law enforcement loses the incentive to pursue property seizures.

photo credit: Eric Constantineau – via photopin cc

By David E. Williams of the Health Business Group.

Sleep: The new health craze?

The last few decades have seen various wellness fads and health scares. Some topics that come to mind are sodium, cholesterol, saturated fats, trans fats, carbs, acai berry, bran, oats, whole grains, organic, jogging, yoga and yogurt.

Maybe it’s time we focus on sleep as the key to health. After all we are a sleep deprived nation, with 50-70 million US adults having trouble sleeping. Two news articles today make me think it might be time for sleep to gain its due:

Regular bedtimes help kids’ behavior reports on a study of 10,000 seven year old kids. Those who went to bed at a regular time had significantly fewer behavior problems than those who didn’t have a regular bedtime. The effects were reversible, too: kids who started going to bed at a regular time started acting better, and those who reverted to more variable timing got worse.

Kids are one thing –and adults may not give that much attention to those little brats anyway– but when studies start linking sleep patterns with neurological decline, then people will take notice. Sleep takes out brain’s trash; buildup of refuse makes you sleepy offers a theory for why we sleep. According to a new study, all systems in the body build up waste products that need to be disposed of, but the brain is a bit different in how it deals with it.

“The lymph system collects metabolites from tissues throughout the body and dumps them into the bloodstream, where they’re carried to the liver for breakdown and removal. The brain’s metabolic waste concentrates in interstitial fluid present in all corners of the brain. A second slurry — cerebrospinal fluid — circulates throughout the brain, and where the two fluids flow together, the metabolic byproducts are carried away by the cerebrospinal fluid…

Scientists… found that the brains of mice — whether they are sleeping or anesthetized — showed more activity and volume at the “transfer stations,” where interstitial and cerebrospinal fluid meet, than did mice who were awake and active. The result was that by the end of a sleep period — around early evening — mouse brains had their lowest concentration of neural refuse of the day. By the time they were ready to sleep again, those concentrations had reached their peak.”

The researchers highlight the link between lack of sleep and neurodegenerative disease, and hint that not getting a good night’s sleep may lead to dementia, since the “trash” doesn’t have the chance to be taken out.

So my prediction: the next health craze may be sleep.

By David E. Williams of the Health Business Group.


Why are ObamaCare opponents so vehement?

A non-health wonk relative emailed me recently:

“Can you tell me in very brief terms, why the far right is so much against the Affordable Care Act?  To me, it makes good long-term economic sense, is immensely beneficial for the health and welfare of those currently without insurance, and puts us in sync with other advanced societies.  I just don’t get the opposition.”

For mainstream folks who aren’t health wonks or political junkies, it can be perplexing to try to understand why House Republicans are so eager to fight the Affordable Care Act that they are willing to shut down the government, possibly cause the government to default on its debts and steer us into a Constitutional crisis.

There are a variety of explanations. Among the more charitable readings:

  1. They feel the legislation was rammed down their throats and they were disenfranchised
  2. They honestly feel ObamaCare will be the ruination of the world’s greatest health care system
  3. They believe ObamaCare will bankrupt the country
  4. The bill is too complicated
  5. They want to appeal ObamaCare and replace it with something better

But none of those explanations hold water:

  1. The law is a moderate one and full of Republican ideas –like the individual mandate and marketplaces –that were included in the bill partly to try to bring moderate Republicans on board. The public option is out, there’s no single payer, and the use of comparative effectiveness research is neutured. And the notion of disenfranchisement rings hollow when we consider how President Bush acted like he had a mandate even though he lost the popular vote. Obama was re-elected and although the House stayed in GOP hands it’s only due to gerrymandering. The average voter voted for ObamaCare
  2. People who believe ObamaCare will ruing a great system don’t understand the US health care system and how broken it is. Those who actually work in it know it’s full of problems, is more costly than elsewhere in the world, and has less to show for the extra spending in terms of outcomes –never mind equity
  3. The GOP are the ones that wasted the Clinton surpluses and passed the Medicare Part D drug benefit without worrying about how to pay for it. ObamaCare was scored by the CBO as deficit-positive. Even if that doesn’t turn out to be the case it’s going to be cheaper than Part D
  4. ObamaCare is complex because it’s moderate. Single payer would be a lot simpler and shorter
  5. There’s very little substance to the so-called “replace” ideas, which anyway took two years to appear

A more objective read is that some opponents have whipped themselves into a lather over their revulsion to all things Obama and are living in an echo chamber where these views seem rational. It would be better for everyone if they went back to the Birther madness.

Patients should not be responsible for telling doctors to wash their hands

Hospitals struggle to get doctors and nurses to wash their hands. That’s a serious problem, since hand washing is one of the keys to reducing healthcare acquired infections that afflict more than a million patients a year and kill over 100,000. And it’s one of the reasons you should try your best to stay out of the hospital.

For the past few years I’ve heard suggestions that patients should take a more active role, and in fact have the responsibility to speak up. Today’s Wall Street Journal (Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’covers the topic again, with a pretty strong message that patients need to take charge.

I strongly disagree.

Here’s one excerpt from the article:

The CDC has provided 16,000 copies of a video, titled “Hand Hygiene Saves Lives,” to be shown to patients at admission. In one scenario, a doctor comes into a room and the patient’s wife says, “Doctor, I’m embarrassed to even ask you this, but would you mind cleansing your hands before you begin?” The doctor replies, “Oh, I washed them right before I came in the room.” The wife says, “If you wouldn’t mind, I’d like you to do it again, in front of me.”

And here’s another:

“We’ve been focusing on intensive interventions to improve hand hygiene among health-care workers for decades, yet we’ve really shown very little progress,” says Carol McLay, a Lexington, Ky., infection prevention consultant and chair of the committee that designed the campaign [to get patients to speak up]. “We are trying to empower patients and families to speak up and understand their role.”

Am I the only one that thinks the situations described above are absurd?

Here’s how I see it:

  • If infection control specialists have been failing to make progress with health care workers for decades then they need to figure out what’s wrong and fix it, not throw the problem onto patients. Here are some ideas: education to get more buy-in from clinicians on the idea of frequent hand washing, technology to track whether hand washing is occurring, harsh penalties for lack of compliance –like closing down a hospital floor, or firing or suspending staff, or making lack of hand washing subject to malpractice claims. If you believe the conventional wisdom (which I don’t –but that’s another story) then physicians will be so focused on avoiding lawsuits through defensive medicine that they’ll instantly get to 100% compliance on hand washing
  • The scenario in the video of first asking a doc if he washed his hands –and then not accepting his answer that he just did it but instead wanting to see him “cleanse” his hands again– is ridiculous. That’s not my vision of patient engagement
  • Lack of hand washing is reasonably visible to the patient, but what about all the other things that occur? Is it practical to verify that my doctor performed all the correct diagnostic tests, interpreted the results correctly, made the right differential diagnosis, prescribed the most appropriate antibiotic and dosing level,  that the hospital stored the medications properly and disinfected their equipment, that the nurses didn’t fake their credentials and that their immunizations are up to date, that I was referred to the right specialists, etc.? All of these things –and many, many others– are important, but I count on the hospital to deal with it and the regulators to oversee that it’s done. I want quality ratings that take into account these issues and I don’t mind payment incentives that reward certain behaviors and penalize others

Don’t get me wrong. I hate the idea of doctors and nurses not washing their hands. If I’m in the hospital and I see something I’m unsure of I do speak up. I bring an advocate when I’m a patient and act as one for others. I would even bring up hand washing in certain circumstances.

But I really resent the idea that I’m supposed to be the handwashing police. Hire someone else to do the job.