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23 Jun

Posted at 18:39h in Aaron Carroll MD

 

(Reprinted from The Incidental Economist)

Sometimes I write pieces and can’t place them. I usually save them for later. In this case, I feel strongly enough about it that I’m posting it here. It won’t get the eyeballs it might at a major media site, but it’s more important to me that I publish it now.

Public health has a messaging problem. It’s made the management of COVID hard in the past, and it’s potentially damaging our ability to manage future issues. Some are arguing that declaring the protests more important than infection is damaging the credibility of experts to recommend actions related to preventing outbreaks.

Both the issues being protested and the pandemic are crises. But comparing them, or weighing their relative worth, is a mistake. Black Americans are at real risk from state violence and structural racism. They are risking their lives if they don’t protest, and they’re risking them if they do. Many of us cannot understand the risk calculus, and we likely shouldn’t try. Instead, we should focus our messages consistently on improving health, admitting what we don’t know as well as what we do.

This isn’t the first time we’ve failed to be transparent and clear.

When the pandemic initially reached our shores, we told people that masks were not necessary, because – at that time – most people were wearing masks to protect themselves from infection. Now, however, the prevailing wisdom is that masks might prevent people from infecting others. There’s some evidence for this, although we wish there was more. Given that many more are infected in the United States now, encouraging the wearing of masks seems like a low-cost, potentially beneficial thing to do to protect others.

We have failed to explain these nuances well.

When the pandemic first raged, we did not know how many people were infected, where they were, or how catastrophic this might be. In addition, we feared that many were spreading the disease without knowing they were sick. Studies showed that people without symptoms were infecting others, and because of this, we needed to separate everyone, even when it meant economic or personal sacrifice.

Recently, though, the WHO muddied the issue by first appearing to assert, and then walking back, the claim that asymptomatic transmission is ‘very rare’. Communication could clearly be better.

When I saw protests by people demanding the country open, I noted a lack of masking and social distancing. I was concerned.

When I see protests by people demanding an end to structural racism, my concern remains. I support the call for social justice and radical reform, and I support recommendations that reduce the risk of infection.

That message has been articulated differently by many in public health. Some have taken to making judgments about the value of protest activities, and whether they are, therefore, “worth” the risk. Such judgments from public health experts may make infection control efforts more difficult because others will deem different activities “worth” risk themselves.

More consistent messaging would be desirable.

Public health might be better served continuing to push for the things that will make everyone safest in the coming months and years. These include both the need to eliminate structural racism and the need for better infection control.

As we move into the next phases of this pandemic, we must shift from extreme social distancing to risk minimization. I discussed this weeks ago when focusing on camp. We can do the same with protests.

While outside activities are less likely to lead to an outbreak, the potential still exists. The time and intensity of exposure also matters, and as we seek to minimize risk, we should try and limit both as much as possible. Therefore, we should, as much as we can, limit discretionary activities that take place with other people. When such activities occur, we should make them as safe as possible.

Protests are almost all outside, which is a good thing. In an ideal world, protestors will also respect social distancing and stay physically apart from each other, as they are able. They should wear masks if they’re shouting/chanting/singing. They should wash their hands, or at least carry hand sanitizer.

If they’re sick, protestors should absolutely stay home.

If they are worried about having been exposed, or have any reason to think they might be infected, they should get tested. They should self-isolate while awaiting results. They should be concerned about infecting others, and make every effort to keep their fellow protestors safe.

Police and public officials have other things to consider. They can avoid crowding people. They can avoid using tear gas and other agents that might increase transmission. They can avoid physical contact and wear masks themselves.

Most importantly, they can avoid arrests.

A recent study published in Health Affairs looked at the relationship between jailing practices and the pandemic in Illinois. They found that “jail cycling” is significantly related to COVID-19 infection. In fact, it accounted for 55% of the variance in case rates in Chicago and 37% in all of Illinois.

Jail cycling was more of a predictor of variance than race, poverty, public transportation, and population density. Unbelievably, cycling through Cook County Jail alone was associated with 15.7% of all documented COVID-19 cases in Illinois and 15.9% in Chicago as of mid-April.

Locking protestors up will increase infections.

Infection control efforts might be better served focusing on these facts and continuing to argue for the things that will make everyone safest from COVID transmission in the coming months and years. That includes continuing to call for much better and more ubiquitous testing so that we can really understand who can participate in riskier activities and when. That also includes the elimination of disparities in every aspect of society, including both the health care and criminal justice system.

We should also publicly recognize that sacrifices matter, financial and personal; it is difficult to make them. COVID-19 is deadly. Economic ruin is horrific. Missing out on important life events is soul-crushing.

Structural racism is all of these things.

Aaron E. Carroll, MD, MS  a healthcare speaker, professor of pediatrics at Indiana University School of Medicine who speaks/blogs on topics such as COVID-19, health research and policy at The Incidental Economist and speaks LIVE on Healthcare Triage. 

08 Apr

Posted at 17:05h in Uncategorized

Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.

The better question is: “How will we know when to reopen the country?”

Any date that is currently being thrown around is just a guess. It’s pulled out of the air.

To this point, Americans have been reacting, often too late, and rarely with data. Most of us are engaging in social distancing because leaders have seen what’s happening in Europe or in New York; they want to avoid getting there; and we don’t have the testing available to know where coronavirus hot spots really are.

Since the virus appears to be everywhere, we have to shut everything down. That’s unlikely to be the way we’ll exit, though.

Some cities or states will recover sooner than others. It’s helpful to have criteria by which cities or states could determine they’re ready. A recent report by Scott Gottlieb, Caitlin Rivers, Mark B. McClellan, Lauren Silvis and Crystal Watson staked out some goal posts.

  • Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care.

Other cities and states fear that they will approach New York City’s state of crisis. They’re trying to increase the number of available beds and ventilators — as well as doctors, nurses and other health care providers — to make sure they aren’t overwhelmed in their capacity to provide care to all those who need it.

This is the most immediate bar, and the focus of most public health officials’ attention. At the moment, there’s no reason to believe any area is over a surge of cases, and analysts’ models predict many places won’t peak for weeks to come.

  • A state needs to be able to test at least everyone who has symptoms.

Dr. Gottlieb and colleagues estimate that the nation would need to have the capacity to run 750,000 tests a week — this is after things have calmed down greatly. There are times we might need even more.

“The 750,000 number should be viewed as a reasonable expectation for when we haven’t been having any major pockets or regional outbreaks to manage,” said Mark McClellan, an author of the report and a professor of business, medicine and policy at Duke. “If more testing to help contain outbreaks and potential outbreaks is needed, which seems very plausible, especially early on, the number would need to be significantly larger. We’ll also have to do some surveillance of people without symptoms, especially in higher-risk settings.”

A national estimate means less in deciding whether a state can reopen than its local capabilities. A state would need to be sure it could test every single person who might be infected, and have the results in a timely manner. That would be the only way to achieve the next requirement.

  • The state is able to conduct monitoring of confirmed cases and contacts.

A robust system of contact tracing and isolation is the only thing that can prevent an outbreak and a resulting lockdown from recurring. Every time an individual tests positive, the public health infrastructure needs to be able to determine whom that person has been in close contact with, find those people, and have them go into isolation or quarantine until it’s established they aren’t infected, too.

This will be a big challenge for most areas. Other countries have relied on cellphone tracking technology to determine whom people have been near. We don’t have anything like that ready, nor is it even clear we’d allow it. The United States also doesn’t have enough people working in public health in many areas to carry out this task.

Building that capacity will take significant time and money, and the country hasn’t even started.

  • There must be a sustained reduction in cases for at least 14 days.

Because it can take up to two weeks for symptoms to emerge, any infections that have already happened can take that long to appear. If the number of cases in an area is dropping steadily for that much time, however, public health officials can be reasonably comfortable that suppression has been achieved, defined by every infected person infecting fewer than one other.

In suppression, cases will dwindle at an exponential fashion, just as they rose. It’s not possible to set a benchmark number for every state because the number of infections that will be manageable in any area depends on the local population and the public health system’s ability to handle sporadic cases.

“We wanted to suggest criteria that would allow locations to safely and thoughtfully begin to reopen, but what that looks like exactly will vary from state to state,” said Caitlin Rivers, another author of the report and an epidemiologist at the Johns Hopkins Center for Health Security. “We therefore included some flexibility for jurisdictions to tailor these criteria to their local context.”

These four criteria are a baseline. Other experts think we will need to add serological testing, which is different from the viral detection going on now. This type of testing looks for antibodies in the blood that our bodies created to fight the infection, not the infection itself. These tests can be much cheaper and faster than the ones we’re currently using to detect the virus in sick people.

Testing for antibodies will tell us how many people in a community have already been infected, as opposed to currently infected, and may also provide information about future immunity.

Gregg Gonsalves, a professor of epidemiology and law at Yale, said: “I’d feel better if we had serological testing, and could preferentially allow those who are antibody positive and no longer infectious to return to work first. The point is, though, that we are nowhere even near accomplishing any of these criteria. Opening up before then will be met with a resurgence of the virus.”

He added, “That’s the thing that keeps me up every night.”

Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.

It would also prevent us from offering false hope about when America can start reopening. Instead of guesses, people could have clear answers about when they might be able to go back to a closer-to-normal way of life.

 

Aaron Carroll, MD, MS is a professor, speaker and author who keynotes events on the future of healthcare.  Invite him to your next meeting.

Originally appeared on The Upshot (copyright 2020, The New York Times Company)

08 Jul

Posted at 23:43h in Uncategorized

By Aaron Carroll, MD

“Americans argue over insurance while Singaporeans keep perfecting the delivery of care.” says Dr. Aaron Carroll.

The following originally appeared on TheUpshot (copyright 2019, The New York Times Company).

Singapore’s health care system is sometimes held up as an example of excellence, and as a possible model for what could come next in the United States.

When we published the results of an Upshot tournament on which country had the world’s best health system, Singapore was eliminated in the first round, largely because most of the experts had a hard time believing much of what the nation seems to achieve.

It does achieve a lot. Americans have spent the last decade arguing loudly about whether and how to provide insurance to a relatively small percentage of people who don’t have it. Singapore is way past that. It’s perfecting how to deliver care to people, focusing on quality, efficiency and cost.

Americans may be able to learn a thing or two from Singaporeans, as I discovered in a recent visit to study the health system, although there are also reasons that comparisons between the nations aren’t apt.

Singapore is an island city-state of around 5.8 million. At 279 square miles, it’s smaller than Indianapolis, the city where I live, and is without rural or remote areas. Everyone lives close to doctors and hospitals.

Another big difference between Singapore and the United States lies in social determinants of health. Citizens there have much less poverty than one might see in other developed countries.

The tax system is progressive. The bottom 20 percent of Singaporeans in income pay less than 10 percent of all taxes and receive more than a quarter of all benefits. The richest 20 percent pay more than half of all taxes and receive only 12 percent of the benefits.

Everyone lives in comparable school systems, and the government heavily subsidizes housing. Rates of smoking, alcoholism and drug abuse are relatively low. So are rates of obesity.

All of this predisposes the country to better health and accompanying lower health spending. Achieving comparable goals in the United States would probably require large investments in social programs, and there doesn’t appear to be much of an appetite for that.

There’s also a big caveat to Singapore’s success. It has a significant and officially recognized guest worker program of noncitizens. About 1.4 million foreigners work in Singapore, most in low-skilled, low-paying jobs. Such jobs come with some protections, and are often better than what might be available in workers’ home countries, but these workers are also vulnerable to abuse.

Guest workers are not eligible for the same benefits (including access to the public health system beyond emergency services) that citizens or permanent residents are, and they aren’t counted in any metrics of success or health. Clearly this saves money and also clouds the ability to use data to evaluate outcomes.

The government’s health care philosophy is laid out clearly in five objectives.

In the United States, conservatives may be pleased that one objective stresses personal responsibility and cautions against reliance on either welfare or medical insurance. Another notes the importance of the private market and competition to improve services and increase efficiency.

Liberal-leaning Americans might be impressed that one objective is universal basic care and that another goal is cost containment by the government, especially when the market fails to keep costs low enough.

Singapore appreciates the relative strengths and limits of the public and private sectors in health. Often in the United States, we think that one or the other can do it all. That’s not necessarily the case.

Dr. Jeremy Lim, a partner in Oliver Wyman’s Asia health care consulting practice based in Singapore and the author of one of the seminal books on its health care system, said, “Singaporeans recognize that resources are finite and that not every medicine or device can be funded out of the public purse.”

He added that a high trust in the government “enables acceptance that the government has worked the sums and determined that some medicines and devices are not cost-effective and hence not available to citizens at subsidized prices.”

In the end, the government holds the cards. It decides where and when the private sector can operate. In the United States, the opposite often seems true. The private sector is the default system, and the public sector comes into play only when the private sector doesn’t want to.

In Singapore, the government strictly regulates what technology is available in the country and where. It makes decisions as to what drugs and devices are covered in public facilities. It sets the prices and determines what subsidies are available.

“There is careful scrutiny of the ‘latest and greatest’ technologies and a healthy skepticism of manufacturer claims,” Dr. Lim said. “It may be at the forefront of medical science in many areas, but the diffusion of the advancements to the entire population may take a while.”

Government control also applies to public health initiatives. Officials began to worry about diabetes, so they acted. School lunches have been improved. Regulations have been passed to make meals on government properties and at government events healthier.

In the United States, the American Academy of Pediatrics and the American Heart Association recently called on policymakers to impose taxes and advertising limits on the soda industry. But that’s merely guidance; there’s no power behind it.

In Singapore, campaigns have encouraged drinking water, and healthier food choice labels have been mandated. The country, with control over its food importation, even got beverage manufacturers to agree to reduce sugar content in drinks to a maximum of 12 percent by 2020.

Singapore gets a lot of attention because of the way it pays for its health care system. What’s less noticed is its delivery system.

Primary care, which is mostly at low cost, is provided mostly by the private sector. About 80 percent of Singaporeans get such care from about 1,700 general practitioners. The rest use a system of 18 polyclinics run by the government.

As care becomes more complicated — and therefore more expensive — more people turn to the polyclinics. About 45 percent of those who have chronic conditions use polyclinics, for example.

The polyclinics are a marvel of efficiency. They have been designed to process as many patients as quickly as possible. The government encourages citizens to use their online app to schedule appointments, see wait times and pay their bills.

Even so, a major complaint is the wait time. Doctors carry a heavy workload, seeing upward of 60 patients a day. There’s also a lack of continuity. Patients at polyclinics don’t get to choose their physicians. They see whoever is working that day.

Care is cheap, however. A visit for a citizen costs 8 Singapore dollars for the clinic fees, a little under $6 U.S. Seeing a private physician can cost three times as much (still cheap in American terms).

For hospitalizations, the public vs. private share is flipped. Only about 20 percent of people choose a private hospital for care. The other 80 percent choose to use public hospitals, which are — again — heavily subsidized. People can choose levels of service there (from A to C, as described in an earlier Upshot article), and most choose a “B” level.

About half of all care provided in private hospitals is to noncitizens of Singapore. Even for citizens who choose private hospitals, as care gets more expensive, they move to the public system when they can.

So Singapore isn’t really a more “private” system. It’s just privately funded. In effect, it’s the opposite of what we have in the United States. We have a largely publicly financed private delivery system. Singapore has a largely privately financed public delivery system.

There’s also more granular control of the delivery system. In 1997, there were about 60,000 ambulance calls, but about half of those were not for actual emergencies. What did Singapore do? It declared that while ambulance services for emergencies would remain free, those who called for nonemergencies would be charged the equivalent of $185.

Of course, this might cause the public to be afraid to call for real emergencies. But the policy was introduced with intensive public education and messaging. And Singaporeans have identifier numbers that are consistent across health centers and types of care.

“The electronic health records are all connected, and data are shared between them,” said Dr. Marcus Ong, the emergency medical services director. “When patients are attended to for an emergency, records can be quickly accessed, and many nonemergencies can be then cleared with accurate information.

“By 2010, there were more than 120,000 calls for emergency services, and very few were for nonemergencies.

Singapore made big early health leaps, relatively inexpensively, in infant mortality and increased life expectancy. It did so in part through “better vaccinations, better sanitation, good public schools, public campaigns against tobacco” and good prenatal care, said Dr. Wong Tien Hua, the immediate past president of the Singapore Medical Association.

But in recent years, as in the United States, costs have started to rise much more quickly with greater use of modern technological medicine. The population is also aging rapidly. It’s unlikely that the country’s spending on health care will approach that of the United States (18 percent of G.D.P.), but the days of spending significantly less than the global average of 10 percent are probably numbered.

Medical officials are also worried that the problems of the rest of the world are catching up to them. They’re worried that diabetes is on the rise. They’re worried that fee-for-service payments are unsustainable. They’re worried hospitals are learning how to game the system to make more money.

But they’re also aware of the possible endgame. One told me, “Nobody wants to go down the United States route.”

Perhaps most important, the health care system in Singapore seems more geared toward raising up all its citizens than on achieving excellence in a few high-profile areas.

Without major commitments to spending, we in the United States aren’t likely to see major changes to social determinants of health or housing. We also aren’t going to shrink the size of our system or get everyone to move to big cities.

It turns out that Singapore’s system really is quite remarkable. It also turns out that it’s most likely not reproducible. That may be our loss.

Aaron E. Carroll, MD, MS a healthcare speaker, professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. 

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