The evil you cannot see

Published in Australian Medicine 11 December 2017 http://bit.ly/2BhCKYQ

THE DOUBLE-ENDED SPOON AND HOW TO MEET OUR HEALTH NEEDS

The Productivity Commission has recognised how joined up care for people with serious and complex illnesses can enhance their quality of life. Opportunities to prevent these problems abound and the time for action is now.

Two observations made by David Morley (1923-2009), an eminent English paediatrician who worked in a mission hospital in Nigeria and later in the UK, deserve consideration as we face the health challenges of the next decade in Australia.

Morley’s first observation was of a strong connection between effective health care and prevention.  The second was that resources work to best effect when distributed according to the needs of the patient, not the provider.

First treat, then prevent

Morley invented cheap technologies for treating sick children, such as a double-ended plastic spoon for mothers to measure out the correct amounts of salt and sugar to make oral rehydration fluid for their children dehydrated with gastro.

There’s an analogy here: Morley observed that preventive messages (boil the water) for avoiding gastro in village children needed to be underpinned by effective treatment (I can save your child): if you can’t show that you can treat the child with the problem there is no reason to believe your preventive message. The two ends of the spoon stand for treatment and prevention.

Our challenge is not gastro but chronic disease.  But we are doing well with treating serious and continuing illnesses whether of the heart, lungs, joints and muscles, (to a lesser extent) mental illness and cancer.  Often we can cure and our credibility for treatment is high.

In developing effective therapies we have come to know much more about how to prevent these conditions.  Yet these insights have not appeared in the print read by the community, at least not to the extent that they warrant. 

Health literacy is low and while great progress has been made with tobacco, alcohol, excessive processed food and lack of exercise have not yielded much territory.  An imbalance between knowledge and action has led to shocking rates of obesity.  We all have a Morley spoon in the cutlery drawer and know what it is for but we have been reluctant to use it.

Put the patient at the centre when allocating resources

The second of Morley’s observations – the one about resources for health care in Nigeria – is eerily relevant to us. He wrote, as noted in Wikipedia that "three-quarters of our population are rural, yet three-quarters of our medical resources are spent in the towns where three-quarters of our doctors live; three-quarters of the people die from diseases which could be prevented at low cost, and yet three-quarters of medical budgets are spent on curative services.” 

The recent report of the Productivity Commission drew attention to the gains if money and effort for health were invested in care that links together all the services that patients with serious and continuing and complex problems require.  The gain in productivity, as shown in trials of ‘integrated’ care, is expressed in the improved quality of life of those receiving such care.  We have found this in our evaluation of three such programs in western Sydney. 

One sticking point:  integrated care programs require 24/7 coverage in the community, with continuity, once provided by regular general practitioners.  This has changed, probably irreversibly.  What is put in its place is not clear and thought and effort must be applied here to avoid hospital emergency departments continuing as the default option. 

When the financing of integrated care comes from one source instead of several (state and federal, public and private as it does in Australia), then economies follow and efficiency improves, and money may be saved.  But that is not the primary objective.

Taking prevention to heart

Related to the endorsement of trials of integrated care the Productivity Commission favours a serious approach to prevention.  Our knowledge base is strongly built:  what is needed now is action. 

Advocacy must be applied in the political domain because less health-sustaining urban development is more profitable and planners close their eyes to what is needed to build a health-promoting environment instead.   The political power of the industries that sustain our current food consumption patterns is immense.  This advocacy can be picked up by all informed health professionals. 

The changing health of our communities is there for all to see.  We can see what is happening as we all fatten up and exercise less – more bit and less fit. But no longer do we not know what to do about these new problems – both through integrated care and prevention.  Money and well-trained health workforce must be relocated into these two arenas.

Commentators including Fairfax economics journalist Ross Gittins have noted the new emphasis in the recent Productivity Commission report on human flourishing as the ultimate object of our economic activities.  The time is now – in terms of need and opportunity – for action.

So take the Morley spoon out of the drawer and start using it – both ends.

Stephen Leeder directs the research and education network in Western Sydney Local Health District

Physician - care for thine own health

Published in Australian Medicine 21 Nov 17 http://bit.ly/2hXLZCj

Health care homes won't solve chronic disease

The establishment of medical homes based on voluntary general practice registration has begun formally, and quietly.  

At the start of this month, the first 22 Health Care Homes pilot sites began registering their patients with chronic illness, with another 180 due to go live in two months’ time.

The Federal Government has agreed to pay practices lump sums of $591 a year for patients with mainly self-managed illness, $1267 for those with moderate illness and $1795 for patients with chronic and complex needs, including palliative care.  In return, these homes will provide continuing primary care for these patients — delivered by a team of health care professionals. 

The Health Care Homes reform will finally test the effectiveness of the medical homes model that has been lauded for many years as key to improving the care of those with chronic and complex problems.

We must be clear from the start that Health Care Homes is not going to be the only solution to chronic disease care — but it could be one of the solutions. 

Over the next five years, if medical homes become part of the Australian healthcare system, it will be important not to overload them with too many expectations.

Instead, we’ll need to assess what they do — and don’t — do well.

The reality is that although serious and continuing illness take up to one-third of GPs’ time and fill the majority of hospital beds, we have been slow to adapt our way of managing them.

These illnesses are usually defined in the life of the patient by intermittent acute episodes. It is these events that can and should be better managed in their early stages, by community-based practitioners who know the patient and can determine what is best — rather than an ambulance automatically being called.

Yet, the infrastructure — practice management, staff and support — to effectively provide this kind of care is expensive. Whether the proposed Health Care Homes fee structure will be adequate remains to be seen. 

From experience, however, I can say that such trials often fail to demonstrate the effectiveness of major changes in care delivery. 

Over the past few years, I have been involved in three experimental programs in western Sydney designed to better integrate care between hospital and general practice for patients with chronic illness.  

The first two are now complete, revealing there is serious unmet healthcare need in the community, and that the pursuit of integrated care as a way to reduce costs, at least in the Australian setting, may be in vain.

Such trials may make for greater practitioner and patient satisfaction, but we found no measurable decrease in hospital admissions.

What we did find was a need for increased investment in supportive community-based services.

Part of the explanation for this is that our understanding of the life of a patient with serious and complex illness is often incomplete.

Another study we undertook used in-depth patient interviews to determine their perceptions of what they needed.3 I learned two powerful lessons.

First, I came to realise how dependent such patients are on family and friends. Only a tiny proportion of their care — let’s say 10% — came through the healthcare system.  

We need to be careful not to kid ourselves that rearranging what we doctors do will make a huge difference to them.

Second, serious and continuing complex illness is a slippery slope to poverty. Carers, not just patients, quit work. Travel is time-consuming and expensive, and many ancillary aids are not covered by the PBS or other government funds.  

I am not saying for a moment that the medical home model is a flawed idea that should not be tried. It should be.

But in our approach, we should keep in mind that patients with chronic diseases are often in deep and complex trouble. Their needs are multiple and extend from money to loneliness.

And, while our healthcare system is generous by world standards, it cannot alone meet more than a fraction of their needs.  

Anyone expecting Health Care Homes to reduce the cost of healthcare is looking in the wrong place. Providing high-quality integrated care (including the many social needs of these patients) is going to cost money, and lots of it.  

However, if we consider the care of these people to be part of the mission of medicine, then we need to press on and advocate for adequate resources to do the job well.

This article first appeared on the Medical Observer website. http://bit.ly/2y3unzC

Brenda Fitzgerald: Trump’s public health chief wants to partner with industry

BMJ 2017;358:j4233 doi: 10.1136/bmj.j4233 (Published 2017 September 13)                                                                              Page 1 of 2

FEATURE

Brenda Fitzgerald: Trump’s public health chief wants to partner with industry

The new head of the US Centers for Disease Control and Prevention has received praise for obstetrics campaigns, writes Jeanne Lenzer, but criticism for supporting quackery and using Coca-Cola’s money to fund anti-obesity programmes

Jeanne Lenzer associate editor, The BMJ, USA

When President Donald Trump named Brenda Fitzgerald as the new director of the US Centers for Disease Control and Prevention in June, several public health officials praised his choice to lead the seminal public health institute.

Georges Benjamin, executive director of the American Public Health Association, commended Fitzgerald, saying she is a “strong choice” to lead the apex public health agency. His statement read, “From her work as a practising

obstetrician-gynecologist to her recent service as the commissioner of the Georgia Department of Public Health, Dr Fitzgerald is more than prepared to face the health challenges of our time.”

scientific rigour and ensuring institutional independence from industry—Fitzgerald may not be such a surprising choice.

Bad science

Fitzgerald is a fellow of the American Academy of Anti-Aging Medicine (A4M), an organisation that promotes homeopathy, unproved stem cell therapies, plastic surgery, “bio-identical” hormones, and testing saliva and blood to “individualize” therapy with supplements and hormones to stave off ageing.

On her professional website, Fitzgerald informed patients that she had special training in the use of “bio-identical” hormones and supplements to treat problems such as osteoporosis, “middle

3 4

Others praised her position on abortion because she has said that the choice should be between a woman and her doctor—although she also has favoured restrictions on government payments for abortions.

As health commissioner of Georgia from 2011 to 2017,

age spread,” sex hormone problems, and general ageing.

Steven Goldstein, a professor of obstetrics and gynaecology at the New York University School of Medicine, told Forbes’s reporter Rita Rubin that he was “shocked” by Fitzgerald’s affiliation with the A4M, calling anti-ageing treatments “snake

5

Fitzgerald helped to reduce the high proportion of elective deliveries that took place before 39 weeks’ gestation in the state. She launched a campaign to inform healthcare providers that early elective deliveries led to “an increase in neonatal intensive care admissions, increased antibiotic use, and increased respirator use.” Her campaign led to a drop in early deliveries from 65% of elective deliveries to just 3%, and after a new Medicaid exclusion to pay for early deliveries, the rate fell further to 1%.1

Fitzgerald says that she practises what she preaches, “I typically hit the ground running by 6 am. I start with 30 minutes on the treadmill or around my neighborhood. A little sun salutation yoga and then I’m ready for breakfast—and I love breakfast. A pot of green tea and scrambled eggs with salsa and a slice of avocado are among my favorites.”2

She might seem to be an unlikely pick for Trump, who relishes fast food; has said that women who have abortions should face punishment; and whose budget plan includes a 17% cut in funding for the CDC.

But a closer look at Fitzgerald suggests that when it comes to two of the most important tasks of the agency—ensuring

oil” that “plays on people’s worst fears about their mortality.”

In response to a query from The BMJ about scientific rigour at the CDC, Fitzgerald said, “As director of CDC, I am committed to both science based decisions and [as] a former health commissioner, I also understand the importance of supporting states and clinicians, who are on the frontlines protecting the health of communities and treating patients, and making sure they have the state-of-the-art health information they need.”

But, Vikas Saini, president of the Lown Institute in Brookline, Massachusetts, told The BMJ that Fitzgerald’s embrace of unproved remedies “raises the risk that one of the world’s leading public health institutions may embrace the growing trend to permit anecdotes and observational data into regulatory decisions, instead of being a steadfast champion of rigorous science.”

Under the influence

The CDC has been under fire for accepting industry funding, including from Coca-Cola.6 7 (The agency began “winding down” its ties to Coca-Cola around 2013.) As health commissioner of Georgia, Fitzgerald was criticised after she accepted $1m (£760

jlenzer@bmj.com

BMJ 2017;358:j4233 doi: 10.1136/bmj.j4233 (Published 2017 September 13)                                                                              Page 2 of 2

000; €840 000) from Coca-Cola to fund a programme to reduce childhood obesity that focused on exercise to control weight gain without mentioning the role of fizzy drinks in the child obesity epidemic. Despite earlier criticism, Fitzgerald has declined to say whether she will reject future funding from the drinks giant, telling the New York Times that she would consider any proposals through the agency’s standard review process.7

Besides Coca-Cola, the CDC is funded by several drug and device manufacturers,8 a practice Fitzgerald defended in her statement to The BMJ, saying, “Public-private partnerships can be powerful tools that help extend government’s ability to save lives, solve problems, and speed innovation.”

Saini says that Fitzgerald’s work on reducing elective induction of labour is “important and laudable,” but he is worried that her willingness to partner the CDC with industry comprises a clear conflict of private interests with the public interest. This, he says “will continue to reduce trust in our institutions at a time when we need it more than ever.”

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; not externally peer reviewed..

1     Fitzgerald B. Improving care for women and infants in Georgia. Georgia Fiscal Management Conference 2014. http://georgiafmc.org/annual%20conference/2014/2014Presentations/ DPHImprovingCare.pdf.

2     Member Spotlight. Brenda Fitzgerald. 2017. http://www.astho.org/StatePublicHealth/ Member-Spotlight-Brenda-Fitzgerald/2-23-17/.

3     Dr Brenda Fitzgerald FAQs. Internet archive. 2010. https://web.archive.org/web/ 20100823214125/http://www.drbfitz.com:80/index.php?pid=23

4     Levitz E. Trump’s CDC pick peddled ‘anti-aging’ medicine to her gynecologic patients.

New York Magazine 2017 Jul. http://nymag.com/daily/intelligencer/2017/07/trumps-cdc- pick-peddled-anti-aging-medicine-to-patients.html

5     Rubin R. New CDC head Fitzgerald peddled controversial “anti-aging medicine” before

leaving private practice. 2017. https://www.forbes.com/sites/ritarubin/2017/07/09/new- cdc-head-fitzgerald-peddled-controversial-anti-aging-medicine-before-leaving-private- practice/.https://www.forbes.com/sites/ritarubin/2017/07/09/new-cdc-head-fitzgerald- peddled-controversial-anti-aging-medicine-before-leaving-private-practice/

6     Waters R. Trump's pick to head CDC partnered with Coke, boosting agency's longstanding ties to soda giant. Forbes 2017 Jul 10. https://www.forbes.com/sites/robwaters/2017/07/ 10/trumps-pick-to-head-cdc-partnered-with-coke-boosting-agencys-longstanding-ties-to- soda-giant/.https://www.forbes.com/sites/robwaters/2017/07/10/trumps-pick-to-head-cdc- partnered-with-coke-boosting-agencys-longstanding-ties-to-soda-giant/.

7     Kaplan S. New CDC chief saw Coca-Cola as ally in obesity fight. New York Times 2017 Jul  22.  https://www.nytimes.com/2017/07/22/health/brenda-fitzgerald-cdc-coke.html.

8     Lenzer J. Centers for Disease Control and Prevention: protecting the private good?BMJ 2015;358:h2362. doi:10.1136/bmj.h2362 pmid:25979454.

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