Assignment 4: U.S. Health Care

1. Briefly describe the Dartmouth Atlas Project. What did they find?

The Dartmouth Atlas Project was a national study to assess the health care system in relation to the cost of care across the United States. The study found that some areas were able to provide great quality of care and much lower costs than similar health care programs that cost more but provided the same quality of care. It showed that more spending does not automatically mean higher quality of care.

2. Do you think that access to health care is a right or a privilege? Explain.

I believe in a country as rich as America, health care is now a right. If this were a third world country that was unable to afford basic health care, the lack of an equal system for all would not be as unsettling. However, we are the richest country in the world and could provide health care of great quality to everyone regardless of income. Health care is not a luxury that would be "nice to have". Without proper and affordable health care, people can suffer serious illnesses that can easily be prevented. The right to health care is similar to the right to education and sanitation. It is a right because it affects people's well-being. To take it away as a right and label it a privilege would be to institutionally enforce the inequality established by income.

3. Describe and discuss at least one innovation from each of the medical systems visited on the program that you find important/ interesting.

The first medical system visited was the one in Grand Junction, Colorado. I found it rather self-less and interesting that so many doctors agreed to pool the fees for all procedures, coming up with set fees for each procedure for all payers, regardless of insurance. This truly allowed healthcare for everyone as even the doctor in charge of the program states that a person with only Medicare qualifies for the same procedures as he does. The pooling of resources could be railed against by conservatives as "socialist" health care, but in reality, it is the only way to truly support the less fortunate. The program in Grand Junction is a prime example of the equal access that could happen across America. The program's commitment to all pregnant women regardless of insurance is also admirable and shows how this generous model is truly economical by the thousands of dollars saved from fewer premature babies.

The second system was that of GroupHealth which had the concept of a "patient-centered medical home", an innovative idea that allowed doctors longer and more personal time with patients. I found the use of technology in this system very interesting because it seems like the model that we will see first in the future. Though I question whether a doctor would be able to properly give advice solely over email or phone, I do think that emailing and calling can be valuable additions to normal visits. It helps doctors build relationships with their patients and work with them to improve their health in a personal way. This is important because it will encourage patients to follow their doctors' advice more and therefore cut costs on future illnesses.

The third system was in Everett, Washington where doctors and insurance companies shared data to lower costs on medication. This is important because the cost of medication is a huge part of the total cost of care. If costs can be lowered in any way, they should.

The fourth system was that of the Dartmouth-Hitchcock Medical Center where doctors gave their patients a true say in their treatment instead of the traditional model of expecting the patient to blindly follow. I hadn't thought about the personal aspect of health care before, except in religious contexts where a patient could refuse life-saving surgery due to religious objections. But giving patients a say in their treatment is very important to their satisfaction with the health care system. The system's goal is to increase and maintain the well-being of the patient, mentally and physically. If a patient prefers not to get rid of his or her pain for personal reasons, the health care system should accomodate that because to do otherwise would affect the patient's mental well-being unnecessarily. This prospective emphasizes that health care is not only about keeping everyone's body healthy but that there are many mental and social factors to consider.

4. Do you think the way medical care is delivered in the places visited in the program can be duplicated in the area you are from ? Why do you think it hasn't occurred already?

I'm from Fullerton in the suburbs of Southern California and I think it's certainly possible to duplicate the health care systems visited in the program there. The video lists and focuses on three changes that need to happen: doctors and insurance companies need to work together to lower costs, they must be willing to adapt new technology so doctors can spend more time with patients, and doctors must be willing to give their patients a real voice in their treatment. Though some doctors and insurance may be willing to lower costs out of self-less concern for their communities, others may not. Lowering costs may make the cost of care cheaper, but doctors may loose money and therefore may not be willing to do so. Regarding new technology, many hospitals and clinics have changed to electronic records but some, for selfish reasons, may try to take on more patients instead of using the extra time to focus on the patients they already have. The third change is trickier to implement. Even if the doctor is willing to be selfless, he or she may not want to leave medical decisions like whether or not to have surgery up to the patient, out of concern that he or she does not have the medical understanding to make a right decision. So really, for many of the changes needed for health care to be improved like the systems featured in the program, doctors and other figures of the medical field need to set aside their selfishness out of concern for their communities. Whether these medical leaders in Fullerton will choose to act, truly depends on their sense of duty to their communities. I think these changes will be easier to implement in smaller towns like Grand Junction, Colorado and my hometown of Fullerton, California, where the doctors in the town probably all know each other and have a greater sense of community. I don't think it hasn't occurred already in my hometown because the median income is rather high and most people can afford the current system of health care, so there has been no rally for change. In areas different from Fullerton, where there is an immediate need for change, they may not have occurred because doctors are not willing to give up some of their pay for the community.

Assignment 3: Vaccine Wars

Summary: The video discussed the controversy surrounding vaccinations, particularly the MMR vaccination. There are pockets of anti-vaccination areas where many parents are choosing not to vaccinate their children out of fear of vaccine-related mental disabilities or allergies and because many feel that they are unnecessary. In particular, the debate really began with claims of parents that the MMR vaccine which is federally required was causing children to develop autism. Critics claimed that the mercury preservative caused the intestines to secrete harmful bacteria that in turn caused autism. They claim that vaccines definitely carry a significant risk of mental disorders and should not be required or even recommended until they are made safe. Scientific research has shown these claims to be false in regards to the MMR causing autism but are unsure whether there is truly a link or not. The ethics of non-vaccination is between vaccination for the greater good (herd immunity) or vaccination as a strictly personal choice.

1. Did the video influence the way you think about vaccinations? Why?

The video made me more of an advocate for vaccines because it explained the public health position of vaccinations as the parent's social duty for the society as a whole instead of vaccinations as a strictly personal choice. I consider vaccinations as both duty to securing the safety of my child but also the safety of the children in my community now. However, I am more aware of the possible risks after seeing the large number of parents who claim that their child's mental disorder was caused by vaccines. I don't think researchers have yet disproved that and thus the risk of a vaccinated child developing mental disorders, despite how miniscule it is, should still be taken into account.

2. What is herd immunity? Define the term and explain how it relates to the public health importance of vaccinations.

Herd immunity is the protection a child in a community of vaccinated people receives from diseases not from direct immunization but from everyone else being immunized already. Herd immunities underlines how vaccinations carry a different set of bioethics. Vaccinations cannot be personal decisions because those personal decisions effect everyone in the community. They therefore need to be treated with more importance and sense of obligation than other personal medical decisions.

3. In what ways is vaccination different from other types of personal health decisions? Who should be involved in deciding whether children receive a specific vaccine?

As said in the previous question, vaccinations are different because the personal decision of choosing to vaccinate or not vaccinate does not just affect one's child but instead the child and other people in the community. Ideally in an ethical world, the community that is affected, which would include the parent, would be involved in deciding whether children are immunized. But that is not a practical policy. Practically speaking, I think it's quite appropriate for the government to require parents to make the choice to vaccinate their children because it isn't fair to others to be exposed to diseases because of the choice of one person.

4. Describe several reasons why children might not receive the recommended immunizations. Consider reasons that originate from the patient/parent, the physician, and the healthcare system.

One reason would be the parents refuse because they decide that the risk of their child becoming autistic is not worth protecting them from diseases that they likely will not contract. The patient may have illnesses that prevent them from being able to receive the vaccination. The parents may not be financially able to pay for vaccinations. The parents may have religious or other moral reasons for refusing to vaccinate.

5. What should be the public health response to increase vaccination rates? That is, as a public health policymaker, how would you attempt to increase vaccination rates?

As stated in the video, it is rather difficult to dispel harmful and ungrounded ideas that spread from the Internet and by word-of-mouth, especially when people are more willing to believe what they heard from their neighbor than from an established medical institution. I think public health policies should emphasize more of the social duty aspect of vaccinations. For example, they should hold up the baby who contracted whooping cough, Vanessa, as a real and completely plausible consequence of not immunizing one's child. Research journals and other evidence/ experiment based papers should be summarized and easily accessible with visible links to the original papers for parents who want to see proof that there has been no link established with vaccinations and autism.

Assignment 2: Second-hand Smoking and Lung Cancer: Cause and Effect

1. Briefly summarize the study design and results.

The study followed 91,540 married non-smoking women above the age of 40 for 14 years from 1966-79 in various districts of Japan. It tried to assess how their husbands' smoking habits affected their risk of getting lung cancer. The smoking habits of the studied husbands ranged from non-smoking to more than 20 cigarettes per day. The study considered possible confounding variables such as rural/urban homes, lifestyle habits, and individual health risks. The results for risk ratio was found to be the following: non-smoking household (1.00), ex-smoker household (1.43), and chain smokers (1.90). The study concluded that the number of smokers' wives who had a higher risk of lung cancer than the wives of non-smokers was statistically significant indicating a high correlation. The husband's smoking habits did not affect the risk of the wife developing other types of cancers but did effect her chances of getting emphysema and asthma.

2. What do you find interesting/important about this study?

This study seeks to prove the link between second-hand smoke and lung cancer, an important health hazard. If causation is proved, it changes public policy regarding smokers and also how people view smoke. Ever since studies such as this one have indicated that second-hand smoke raise the risk of lung cancer for non-smokers, many states and countries have made it illegal to smoke in public places. This study is therefore important because it decreases many people's chances of getting lung cancer. From a sociological standpoint, I find the social change caused by this study rather interesting. People now view smokers as not only harming themselves, but as harming those around them, whether it's the general public or the smoker's immediate family and they often are shunned or scolded for their bad habit.

3. What is the advantage of using this type of study design here?

The large number of subjects observed and their varying lifestyles allowed for an accurate measurement of the effects of various confounding variables like rural or urban location, drinking habits, etc. It also allowed for researchers to observe a range of non-smoking, formerly-smoking, and currently smoking husbands as well as the range for smoking from 1-20 cigarettes per day. Possible subjective bias from one spouse to the other was also eliminated by interviewing the couple separately. By having a long term study, researchers were also able to have a more accurate statistical analysis.

3. You read in Schneider (Chapter 6) about proving cause and effect. Discuss why or why not you feel the results of this study support second-hand smoke as a cause of lung cancer.

Though I believe there is definitely a cause and effect relationship between second-hand smoke and lung cancer, I do not believe that this study proves it. Though a strong correlation between second-hand smoke and lung cancer was made, correlation does not necessarily mean causation. For example, it is possible that perhaps breathing in the smoke is not what increases chances of lung cancer, it might be the lingering smell of smoke in the house or on the spouses' clothes that does damage to the lungs. The study also sought from the beginning to prove that second-hand smoke caused lung cancer. It is possible that the statistics of the study were unintentionally skewed in order to support this theory.

Assignment 1: MMWR Binge Drinking Among Women and High School Girls

1. Briefly summarize the article (what are the main findings, where did the data come from).

The article studied binge drinking among women and high school girls. The data for women came from the Behavioral Risk Factor Surveillance System (BRFSS), a randomized telephone survey that assesses various health risk behaviors in U.S. adults aged 18 or older.  The data for high school girls came from the Youth Risk Behavior Surveillance System (YRBSS) which essentially was the same study for a younger age group. The study had several useful results. There was a strong correlation between the level of binge drinking in women and high school girls. Women and high school girls who abused alcohol frequently usually also binge drank frequently. Those who binge drank tended to do so frequently and in high amounts.

2. Explain why you think this is an important public health issue.

As a college student female, the problem of binge drinking is one that affects me directly. Though I feel that Hopkins has done a good job of informing students of the dangers of binge drinking and focusing on the issue, many of my friends who attend universities that do not. The general consensus among my friends from universities has been that they focus more on the dangers of any alcohol abuse, without the specific focus on binge drinking. Though I am not suggesting that universities condone alcohol abuse, I think it's smart of a college campus to recognize that it does happen and to focus on preventing binge drinking specifically. Though I can see where some people would see this as a university condoning drinking, just not binge drinking, practically speaking, such an emphasis would probably do more to reduce the negative effects of alcohol abuse than campaigns focusing on drinking in general because students would actually pay attention to it.

3. Are you surprised by the results? Notice that the data source is a survey, might there be some issues with the accuracy of self-report data on alcohol consumption?

I was surprised by the figures showing that women and girls who drink regularly usually also binge drink. I would hope that campaigns focusing on binge drinking would reduce this correlation so that women and girls, especially those in college, who do drink do not also binge drink. I do think that there are some issues with the accuracy of the self-report nature of the survey and that unfortunately, the figures are probably lower than the actual numbers. However, I also think the survey, which I assume was either anonymous or assured participants of privacy, was close to the real figures.

4. How would you try to reduce the prevalence of binge drinking in college or high school age women?

As mentioned in the article, I think the most effective type of campaign against binge drinking would involve the use of figures and statistical evidence demonstrating the high likelihood of suffering the negative consequences of binge drinking.