Nuts and Death

According to the latest diet_vs_death research, nuts are good. On the heels of the PREDIMED strudy (AKA Mediterranean diet study) that showed reduced mortality in subject who would tank themselves up with olive oil and had increased nut intake (30 g a day) comes another nutty study (1). This study looked at nut consumption of about 118,000 people over 30 years (by analyzing results from Nurses' Health Study [76,000 women] the Health Professionals Follow-up Study [42,000 men] cohorts). There was significant reduction in mortality associated with nut consumption. Those who ate nuts 7 and more times per week had 20% less rate of death compared to nut abstainers.

What about the weight gain? Does not appear to be associated with nut consumption. Actually, several studies referenced in the NEJM paper showed reduced waist circumference.

So... go nuts.

Perceptions of Medicare

An interesting report published in NEJM revealed several public misconceptions regarding Medicare:

• more than 60% of respondents think that Medicare spending is rising faster in the last 5 years. In reality, it slowed.
• Only 53% of Americans correctly believed that Medicare is a one of the largest spending items of the federal budget. Only about 30% see Medicare as a major cause contributing to the federal deficit, and almost 25% think this is not a cause at all.
• Majority of public believes that Medicare recipients get benefits worth about the same (27%) or less than (41%) what they have paid in payroll taxes. In reality, on average Medicare beneficiaries paid $1 for every $3 they receive.
• despite the perception that Medicare spending is accelerating, the majority (except those in 18-29 yr group) oppose reductions in future spending on Medicare, and the older people get the more they oppose.
• Poor management by the government, fraud and abuse in health industry, and excessive charges by hospitals were identified as reasons most important why Medicare costs are rising. The cost of new drugs, tests, and treatments was the lowest ranking reason with only 6% identifying it as a cause responsible for Medicare spending.

The following finds are also instructive:

• The overwhelming majority (74%) recognizes Medicare as a federal government program.
• A similar proportion of public (72%) have very or somewhat favorable opinion of Medicare. Among those older than 65 yr, favorability is 88%.
• 
  
• Only 50% are aware that doctors are paid less by Medicare than by private insurers.
• Two-thirds were supportive of fee-for-service payments rather than a capitated model.
• And almost 60% won't vote for a candidate supporting major cuts to Medicare to reduce federal budget deficit.

There are rather large gaps between perceptions and facts.

32

Virtually all conversations about health care with my friends leaning Republican break down along the issue of personal vs social responsibility for an individual maintenance of health. In my opinion, while each of us should strive to to make smart and healthy choices for ourselves individually, we also make choices as a society that improve us as individuals. For example, we as a society decided to subject our children to vaccinations. Our Constitution does not mention vaccinations. And yet everyone can get them. With exception of some fringe individuals and groups, majority seems to agree that there is indisputable evidence that vaccines save lives. While it is an individual responsibility of parents to physically bring a child for shots (although house calls certainly work just as well), it was us as a whole society that made that choice to invest in vaccination programs, manufacturing, distribution, and education. If there were early doubters of this social responsibility, and I am sure there were those who screamed socialism and usurpation of individual rights, vaccines worked and saved lots of lives, not to mention money. And now Republican children also get vaccinated. For free and not feeling as if they are giving up their individual rights. To receive a vaccination became both a social and personal responsibility.

Perhaps even better an example is our commitment to education. As a society we decided to provide K12 education for free. We could have left it fully in the realm of personal responsibility of well-heeled parents. But no, we decided that education, even though not a Constitution-charted right is a right nonetheless for everyone. Who can argue that by doing so our society became prosperous, with obvious benefits to ourselves, our economy, our lives. We, as a society made a choice to invest in firefighters rather than leaving firefighting an individual responsibility. We probably saved lots of lives and money this way. Did anybody question this idea by arguing that have one's property saved by firefighters is not outlined in Bill of Rights?

All these choices are examples of social insurance that effectively spread risks among all of us. Those who refuse vaccines also get a benefit from herd immunity, a phenomenon that describes protection from disease by virtue of lack of disease due to many vaccinated individual around the one who is not. Those who are vaccinated do not carry pathogens and therefore cannot transmit them to anybody including those who are not vaccinated. A risk of not being educated was spread through the entire population. We decided that education is worth it.

So why is health care so different? Take for example a recent ban on soda in New York City by the mayor Michael Bloomberg (which has been just struck down.) He argued, and not without good evidence, that consuming supersized amounts of sugary beverages cannot be good for one's health. And there seem to be an agreement on this even among advocates of individual rights. Of course, this is because metabolism has no regard for one's position on individual rights. It's all about calories in and calories out, and obesity affects Democrats and Republicans soda-gulpers equally badly. The divide is clearly along the individual freedom to enjoy all 32 ounces of it without a bureaucrat saying that you cannot have it.

And this is a juncture where my understanding of my Republican friends' positions tapers off. They argue that personal responsibility should kick in right before one gulps all 32 ounces of sugary fluid and the society should not intervene. The premise my Republican friends base their argument is two-fold. They argue that these 32 ounces can only hurt the person who gulped them, and as long as that person is aware of consequences (which is of course a gulper's responsibility to find them out), gulp away. The second common problem cited with such "broccoli laws" is their boundaries: people in power could start banning everything they perceive harmful,  and this is a shortcut to a totalitarian state. 

It is easy to see how someone gulping 32 ounces of soda raises health care costs for all of us, in some part because all we, and insurance companies, know the consequences. And insurance companies are in the business of risk assessment, and the one who drinks lot of soda has a higher risk for diseases associated with indiscriminate diets. Insurance companies of course can jack this indiscriminate dieter's insurance premium. But the most important problem is that this gulper's health costs will most certainly be higher over his life time than if he was not such an indiscriminate dieter. And since the goal of insurance is to spread risks over large number of people, the cost translates to all of us. So as a society, wouldn't it be smart to lower our costs by making it a little harder to be an indiscriminate dieter? How much harder? Just get two 16-ounce gulps instead of one 32-ounce drink. We have sacrificed more important civil liberties than this one without much peep.

Our own third-world country

I have recently had a discussion with a friend of mine regarding international rotations during post-graduate medical training (A.K.A. residencies.) A great many programs exist that send residents all other the world on month to two-month long rotations when residents engage in local health care and do lots of teaching and learning. In some cases, these rotations are based in fairly advanced large hospitals, and in others, not so much. My friend had recently returned from such a rotation, during which she had an opportunity to practice in a hospital and teach local medical residents, and extensively travel the country. Not unexpectedly, such rotations could be a lot fun, and have large appeal for global health-inclined crowd.

During the last year of med school I wanted to go on such an international rotation. My partner was at that time working for Partners in Health, which is an organization delivering sustainable international health care for the poor in a dozen of countries. When she heard me talking about setting up an international rotation, she suggested that I would do a rotation in the US but at a place that closely approximates a third-world country, an Indian reservation. That was a great idea, and I spent a month at Gallup Indian Health Hospital working in general medicine and infectious disease clinics, and doing home visits on the Rez.

I wrote a little bit about health care and economic disparities on the Navajo reservation before. And to make it stick, here are a few telling numbers:

• Total population of Navajo Nation: 250,000
• Unemployment rate: 44%
• Families living in poverty: 30.5%
• Homes without complete plumbing facilities: 78.6%
• People living with diabetes: 55,000

Per Capita Personal Health Care Expenditures Comparison (Jan 2012):

• Indian Health Service expenditure on user population: $2741
• Total U.S. population expenditure: $7239

While a lot can be  (and will be) said on the sad state of health affairs on Indian reservations, it is only a part of a bigger picture. In my view the largest problem is essentially lack of sustainable economy on the Rez. With unemployment up to 50%, forty percent of incomes is less than $10K, 82% of incomes are below $50K. Only 11% of those living on the reservation travel less than 20 miles to a grocery store. A lot of money is spent in "border towns," which are not on the reservation. In 2011 Navajo Nation lost more than $200M in sales taxes in purchases in border towns. In comparison, total gross revenue projection for Navajo Nation in 2013 is $247M.

There simply no sustainable jobs because there is no economy as we know it. A brisk search for Navajo businesses returned a smack of links and a website of the Navajo Nation's division of economic development, which really looks paltry on data and initiatives. Similarly, a website of Navajo Nation's Department of Agriculture is a throwback to HTML1 era, which on the face of it has not been updated since September 2010 (but does have information on Department of Agriculture Fourth Annual Conference in 2013 if you look for it).

These are all very broad strokes, and I am sure all devils are in the details, as in any bureaucracy. All sort of politics are in play, not insignificantly between the Navajo Nation and the federal government over resources and land, and I don't pretend to know a first thing about. But what I saw on the reservation gives me a lot of hope.

What I saw one day traveling through a region with a small river was a lot of cultivatable land, lots of crops and greenhouses full of greenery. I saw lot of action in the fields. And this made me think then and now -- there is absolutely no excuse, political or otherwise, to prevent people of the Navajo Nation from making their own land fertile and prosperous. These are hardworking and proud people with fantastic work ethics.

And this is where I stumble, and don't really know what to do about it. One country that comes to mind is Israel. Essentially a desert country, Israel became an oasis, both agricultural and technological. I don't know the numbers, but I dare to guess that the US government invested heavily in Israel economy and infrastructure. Can we do the same here and get rid of a third-world country conditions here at home?