Just a reminder of how an epidemic scales. Slow and easy at the start. Then the Tipping Point. Then a massive non linear acceleration.
Here is another view of how this works. Key nodes create centres that are linked. Remind you of anything? Of course the web which is built on the same model. The key is to cut the links or to prevent them from being made. Timing is everything. You have to get control before the Tipping Point. If you don't no one or nothing will stop it.
So finger crossed for us all.
Bit of a mystery as to why such a high death rate in Mexico - about 7% but so mild here so far.
The Spanish Flu was about 2.5%. Seasonal Flu about .01%. If the Mexican ratio stands this would change our world if it got a grip.
I think that the authorities are being smart to get ready. I was very impressed by New York's response today. They are ready.
No prizes for negligence. If we are safe this time, no prizes for thinking that we are OK. With 7 billion people, a highly connected world and an intensive food system, it is only a matter of when not if.
I am going to lay in about a month's worth of food - rice pasta etc. Part of coping is to stay away from people until it passes. Cut the links.
A factor behind the spread of the Spanish flu was the policy of concentration. Getting all the infected to travel across town to a central hospital. Mayor Bloomberg told people to stay at home.
The Mexican Flu - like the Spanish Flu seems to kill the young and the fit. The reason is that a particular type of flu sets of a massive overreaction of our immune system. We in effect kill ourselves. The young and the fit have the strongest immune systems - hence the risk with this type. This is called a Cytokyne Storm
Stats Canada have announced that 4.1 million Canadians do not have a family doctor.
Almost one-quarter of rural residents reported going to an emergency room, compared to eight per cent of urban residents.
The president of the College of Family Physicians of Canada says
walk-in clinics, emergency departments and other alternatives are a
good safety valve in the system for those unable to access medical care
any other way.
But Dr. Ruth Wilson says they are not the best choice for patients
who need long-term management of chronic diseases like diabetes and
high blood pressure.
About 25% of rural Canadians - code for Islanders - don't have a doctor. Chronic diseases such as diabetes are endemic here.
On P.E.I., 10 per cent couldn't find a doctor, the highest
percentage of any province.
Is it possible for PEI to attract and keep more doctors here? I don't think that this is realistic. Fewer choose family medicine. All have huuuuuge costs involved in their very long training. Let's face it folks - they are not coming.
So what to do?
Let's consider a phone triage interface staffed by nurses and some doctors. You are now only a phone call away fro having an experienced person help you though what is going on. It can be staffed centrally and even of Island. Islanders can know that they will get help in a few minutes.
If it is serious - then you go into the hospital. With your file!
Plus such a system can then connect you to social help. Much of the treatment and many of the issues for people extend beyond diagnosis and treatment plan. How do you give a 2 year old an injection? How can you lose 40 pounds. How do you cope with a colostomy? See what I mean? It is other people like you that can help you live with the disease not the medical profession.
Now we start to get at the core of the other related problem. Cost.
What really happens now is that you have your 3 minutes with the doc who prescribes a drug. She has no time to hear you nor to help you make the changes that will really make you well. So drugs and even surgery are the substitute. I go to see the knee man this Friday. I do have a problem but if I lost 30 pounds, I would be better! My doctor can't help me with the weight loss but you might!
So today we have the most expensive process possible. You have to leave work, home, your kids and drove to the doctor/hospital. There you meet the most expensive person in the system - the Doctor/Gatekeeper. Who substitutes time with you by giving you a drug or a procedure.
As the times get tougher - surely we have to start thinking about healthcare in a new way?
Once upon a time there was a shipwreck and 3 sailors made it to the shore of a desert Island.
As they crawled up the beach they were met by a band of natives. The natives seemed friendly but firm as they were taken back to the village.
There was a huge feast that was shared with the sailors - things looked good. But when the meal was over, they were brought before the chief who of course spoke English.
"You have a choice" he said to the first sailor - "Death or Chi Chi"
"Chi Chi" said the first sailor - He was tied to a stake and slowly skinned alive dying hours later in agony.
"You have a choice" the chief said to the second sailor - "Death or Chi Chi"
The second sailor was a shrewd man. This was obviously a trick question. He answered "Chi Chi"
He too was tied to the stake, skinned alive slowly and died hours later in agony.
The last sailor was horrified and knew that there was no trick. So when he was asked what he would choose shouted out "Death!"
"Good choice" said the chief. "But first Chi Chi."
Remind you of how things work in the medical world?
On the left is Dr Mireille Lecours - the nearest to a saint that we have on PEI - she attended both my in laws in their last year and was Robin's GP during her Cancer treatment.
How we are born and how we die is surely a marker of who were are as a culture. We have made both birth and death a mechanical process where all the control has been given up to the profession of medicine. There are cracks in this regime with births and now we are seeing the same cracks appearing for death - at least on PEI.
There has been a change this week in policy that I think will make a huge difference in reclaiming being human on PEI. The government will now pay for palliative care drugs at home.
For my American readers in Canada the government will pay for your drugs only if you are in a hospital. This means that most people who are terminally ill or just dying of old age, end up being aggressively treated in hospital. For that is what they do in hospital, they try and make you better. Hospitals do not do palliative care, they do treatment. There is a world of difference between the two.
The result is that we spend more than the entire prior lifetime spend on the last year of life - effectively doubling the cost of healthcare - and we make dying a mechanical and inhuman matter. I will never forget two nurses arguing over a bit of gear in front of a family member in her last hours. It was as if she was not there or was a lump of meat.
The truth is that for many of us who will be terminally ill or who are simply dying of "old age" there is no cure. What there is, is the opportunity to die with our dignity. To be without pain. To be with our loved ones in a human setting. The best place of course is to be at home.
Until now this was not possible. Until this week, drugs would only be paid for on PEI if you were in hospital.
I think that this is a historic and welcome step - well done all who have ben involved!
Now we have our own scare and 5,700 images are in question and nearly 5,000 people are involved.
Point #1 - Volume - But as I heard the story last night, I got to wondering - there are 47,000 households on PEI.
10% of Islanders are involved? Doesn't this sound odd to you too? What is going on that so many of us "need" imaging?
Point #2 - Volume - A huge challenge for all rural societies is to have skilled technicians locate in the hinterland. Realistically will PEI ever get a lot of technical talent here? When I say technical talent I mean the ability to interpret complex situations such as interpret pictures and to do complicated but routine operations such as knees. To be any good you have to have talent and you have to have lots of volume.
Why not have a strategy to define a sector of treatment that has to be done in a large centre and send the images there and send the patient there if necessary?
It will never happen that a place like PEI can have a critcal mass of such talent here.
Like many governments, the new PEI government now have access to the books and they are likely appalled at the trends behind the healthcare costs. These costs are growing exponentially and will in a few years, drain resources from all other sectors.
That is why they have hired a consultant to look for ways to save money. But I fear that at best, the will find peanuts.
The real issue is to ask the real question. The real question is this: What are the assumptions and hence drivers for the costs? Who are the groups that drive the costs? What are the results on the health of Islanders by what we do?
Here are some quick answers that in themselves offers a direction for policies that may have a chance of reducing the burden.
There are three groups of people that drive most of the costs and of course they are related.
About 30% of Islanders drive more than 60% of the costs. They drive costs all their lives and as they get older they drive even more
As we get to 65 our use of the system explodes
Finally the costs balloon for most Islanders in the last 2 years of life - often exceeding the entire prior lifetime cost per person
What is going on and what can we do about this?
The 30% - This is a modest estimate - are that group of people who also enter school at grade 1 unable to cope, behave and read. They have been wired for helplessness. The critical problem for them that causes a lifetime of health problems is their immune system. If you grow up believing that you have no control in your life, your flight or fight stress process works all the time flooding your body with cortisol. It is this that weakens and finally compromises your immune system.
This is true in all primates.
All of these people are likely to have heart heart disease, diabetes. They will tend to have addictions.
Lowered immunity and inflammatory responses in the body, slowed wound healing, and other health consequences
Increased abdominal fat, which is associated with a greater amount
of health problems than fat deposited in other areas of the body. Some
of the health problems associated with increased stomach fat are heart attacks, strokes, the development of ,
higher levels of “bad” cholesterol (LDL) and lower levels of “good”
cholesterol (HDL), which can lead to other health problems!
As this group get older, more and more breakdowns occur and the more ill they become. Their illnesses are chronic and drive huge amounts of healthcare costs.
These people cannot be "cured". The cannot be cured because the cause of their illness is not curable by a pill or by medical treatment. It is driven by their mindset and that is driven by their perceived place in the world. That was largely set in the first 3 years of life.
Everything we do today is "downstream" from the real causes of the problem. To have a chance at helping and also reducing our costs, we have to work in a new way. We have to make the early years a larger focus and we have to look at what does work to help people deal with the underlying cause of their problems.
As AA have shown, and as we are learning with PTSD in the military, the problem is spiritual and can only be remediated by peers acting in groups to provide the support that is required. The actual medication should only be a small part of this process. What works the best is when people are connected to others like them in a safe environment, where they are not judged and where they can help each other.
So what then about the inevitability about as we age, we use more healthcare resources?
Many seniors seem to be walking pharmacies. Are they ill and do all these pills work? What is going on?
First of all, a lot of the pill rolling is new and has been growing exponentially in the last decade. It is rooted in the system that we have. A doctor can only offer less that 10 minutes of her time to a patient. What many of the older patients need is attention. So to make them feel heard, they are given a prescription.
It will be vital to look at the reality of a doctor's world and the incentives that are part of it if we are to make a difference and to give the doctor a life too. They have had to disconnect from their patient and rely on the drug companies. Their costs are so high that they have no alternative.
If I was the Minister I would be making an analysis of the doctor's drivers a critical part of the work.
Secondly, the drug companies have made their fortune in lifestyle drugs. Most of this is based on a bogus idea that you ca cure high blood pressure, high levels of cholesterol etc that are all factors that increase the risk of us dying.
We all know that high levels of cholesterol are bad for us don't we? We in truth there is no correlation between these levels and death. You don't believe me - your doctor doesn't believe me.
This chart is unambiguous. It shows the relative rates of death in the UK civil service for Coronary Heart Disease. On the left are the most senior people - on the right the least. See that there is a gradient. If you are a deputy minister, you will live much longer.
Look at the right hand column. You will see that there are levels of cholesterol, blood pressure, smoking etc but that the largest factor in "unexplained".
We it is unexplained no longer. Sir Michael Marmot's research is now well known in public health circles - but maybe not on PEI!
Here is Sir Michael in a 58 minute interview making all of this more clear than I ever could.
26.55 is where Marmot goes into detail of the Whitehall study - the most important experiment in health ever undertaken.
Again, it is a gradient of social hierarchy that drives health outcomes. The more control you have, the longer you will live. The traditional health markers are merely guides to the upstream issue of the immune system and how this is affected by the stress of having low control.
All the risk factors that the drug companies offer us solutions for are merely indicators of a deeper problem - lack of connection and meaning in our lives. These medications merely costs a lot.
The great malaise of getting older is the risk of losing our identity and meaning. This is especially true for men who have made their work their life.
As in the early years, the real "Cure" is re-connection with others and to being able to make a difference.
Finally we come to the hardest part of all. End of life.
What ever we spend in our lifetime, whether we have been a heavy or a light user of the system, we spend it twice in the last 2 years of life. This is where most of the cost of the system is to be found.
So if we are serious about reducing the trajectory of health costs - we have to look here as the population ages.
Why do we spend all this money in this fruitless exercise of trying to cure death itself?
I think it is because we have indeed made death an "illness" that we should be able to cure.
Again we have separated the spiritual from the physical as we have with all modern medicine. We deny our aging and we deny our death. Families with a dying parent often pretend that their dad will get better and so never talk about the things that they really need to. Their father, afraid and isolated because no one will be straight plays along and hangs on.
So the family and the doctors do anything and everything to keep dad alive a for a few more months. I recall sitting by the bed of an aunt. She was in a coma, two nurses were arguing about how best to attach yet more equipment to her. Her daughter had been creating scenes with the staff telling them that they had not done enough. So her mum died not being held by her daughter telling her how much she loved her but isolated in ICU connected not to the people she loved but to machines. The voices she heard were angry ones of strangers.
This kind of death happens all the time. We are too afraid to accept death - we have made death a failure when it is the inevitable. We have made it into a machine event, when it is surely the most spiritual event of our lives - it is when our lives should have the most meaning.
This is where Hospice enters the picture. Hospice is about dying well. Dying well for all involved. It is on the fringes of the system now but I think needs to be placed in the centre.
There is going to be a revolution in healthcare similar to the one that took place 140 years ago when we learned about germs.
We are learning that the key to most illness is not the disease itself but the immune system. A healthy immune system can fight off most things. A compromised immune system actually makes us ill.
The key to a healthy immune system is to live in a healthy environment. This means less one that is clean etc. Less that we eat the right things and take exercise.
This is a healthy environment. It is where the young are loved up and cared for by a trusting group. It is where the mothers are loved up and cared for a by a trusting group. It is where the adults care for each other.
We are primates. Our immune system is driven by our social environment.
What then could we do on PEI in practical terms to ensure that most Islanders had a healthy life and that this did not cost too much.
The first step for a province is to look not at individuals but to look at what affects populations. Policy can affect populations and groups. Therefore there is the potential of doing something if we take this view.
For the price of reading my blog - a lot less than $300,000 I will talk about this over the next few weeks.
But the one lesson for today - any savings you find by looking at how to make the current system more efficient are chicken shit and will do nothing to help us avoid the crisis that is coming.
When our son James was born nearly 30 years ago in England, we thought that circumcision would be a matter of routine. "Why don't you cut the whole thing off? " was one of the milder responses we got. Times had changed. We even went to a Jewish doctor and he sent us away with the advice that if there was not medical necessity, we should not have this done. Well there is more and more evidence that becoming a "Roundhead", as we called it at school when I was a boy (the other boys were of course Cavaliers) is not just a tribal relic but as Martha would say "A Good Thing". Here is the BBC today
Male circumcision could significantly reduce the burden of HIV in Africa, a study suggests.
It concluded that the operation could avert about six
million HIV infections and three million deaths in sub-Saharan Africa
over the next 20 years.
The findings build on research, published in 2005, that
suggested circumcision reduced HIV infection risk in heterosexual men
by about 60%.
The research is published in the journal PLoS Medicine.
An international team of researchers used data on HIV
infection rates and the prevalence of male circumcision across Africa
to predict the potential impact.
Using mathematical modelling, they looked at what would
happen if, over the next 10 years, all men in sub-Saharan Africa were
circumcised.
They calculated that within a decade some two million
new HIV infections and 300,000 deaths could be prevented. And in the
ten years after that, a further 3.7 million infections and 2.7 million
deaths could be avoided - with one in four of the deaths prevented
being in South Africa.
There is also a growing debate as to whether women's risks in getting cervical cancer are reduced if their partner is circumcised. It may be that fears of the small risk attendant on circumcising are overblown when compared to the overall health benefits.
So what to do? It is unlikely that asking an adult male to go through this, or even a small boy, will get a big take up. For any male other than an infant, who if my experience means anything, can't remember it happening, this is quite traumatic. Not the small incision that any anesthetic can mask, but the healing period afterwards. It is why St Paul insisted that converts to Christianity did not have to go through it to become Christians.
So what to do? If you are a concerned parent and have a baby boy, maybe you should consider it.
When I see all those ads for big Pharma telling me how much they care - I want to vomit.
Today there is an announcement that a drug that has been known about for many years called DCA, has signs of being a breakthrough. It is simple to take, in pill form, and shrinks many tumours without side effects.
BUT - because it cannot be patented, BIg Pharma won't touch it and do trials. OK, they are a business. BUT don't talk about how much you care then. Let's be straight - theyr care only about one thing - themselves.
What about an Open Source kind of approach to trials instead?
At the height of the middle ages the issue that really tipped the west into the Reformation was the sale of Indulgences. This was the process where the Church raised enormous sums of money by claiming that you did not have to live a good life to go to heaven and avoid hell - all you had to do was to buy a pass from the Pope.
We all can laugh at how silly people must have been to believe that how you lived your life could be canceled out by a piece of paper from the Pope. But are we not as silly?
Do we not as a matter of routine absolve ourselves from living a good life and instead take a pill from Big Pharma that has been dispensed by its sales force know colloquially as our Doctors?
Just as we are seeing signs that global warming is real, are we not seeing cracks in the unlimited confidence that we have placed in the idea that drugs are the way to health?
Who is to blame for all of this? Aren't we the user at the heart of the
matter. We have given up our responsibility to take charge of our
health and to challenge the system foir information. The Web gives us
the tools to do both.
Signs are emerging of "Trusted Spaces" where those with problems can share with others - support each other in making the life changes that they need to and also to follow the research more closely than the doctors. The Social Web will transform healthcare as it is all parts of life and will give back responsibility and control to us the patients.
In the follow on I have added some detail on 3 major situations where the system has been exposed.
Will obesity bankrupt the health system? This is what the BMA fear and I wonder what will be the result in Canada and on PEI (We are the nation's fattest).
Simply talking about this and hoping that individuals will take action is not working.- The follow on has more ideas about where to look for real answers
Time to look at the core reasons - our food industry, early eating habits at home that solidify into lifetime habits and at the few ways that we can turn the corner and lose weight permanently once we have gained it. I am at least 20 pounds overweight myself!
Recent Comments