Thursday, December 02, 2004
Rationing Influenza VaccineThe second article is a Sounding Board piece, The Fragility of the U.S. Vaccine Supply. It is written in an apolitical style, which is characteristic for medical journals. The authors are to be commended for their restraint.
Thomas H. Lee, M.D.
Volume 351:2365-2366 December 2, 2004 Number 23
[...] With the flu-shot crisis, everyone — including the patients — knows that the shortage is not artificial. The problem is not some company's unwillingness to pay for care or society's reluctance to suffer a tax increase. Patients are not questioning physicians' financial motives. And most patients say they want their flu shots to be saved for patients who are sicker than they are.
The flu-shot shortage may never be repeated, and we may never again be as successful in persuading doctors and patients that the rationing of care is appropriate. After all, the American Way is for each person to try to get everything that might be beneficial. However, this season's experience suggests that, if the need is genuine and clearly understood, physicians and patients can deal with limited resources and unlimited demand with grace and dignity. [...]
When I read it, I felt inspired to use it as source material to criticize the Bush Administration. After all, there was evidence that we had advance notice of the possibility of a vaccine crisis, yet nothing had been done. It is true that this did not turn out to be a big issue in the election, but only because nobody understands what the term "national security means," and what the priorities should be.
<rant-tangent>The fact is, the flu season this year will kill more Americans that any terrorist attack ever has. And over time, influenza probably will kill more Americans that terrorists ever will. Unless, I suppose, terrorists use influenza as a biological weapon, and deploy it successfully. That, of course, would be incredibly stupid: whatever group would use it, it would kill more of them than it would of us.
Background on Influenza"National security," as defined by the Bush administration, means protecting national pride; it has nothing to do with protecting actual people. The bogus war on terror in Iraq probably will kill more Americans than it will save, but for some people, at least their pride will be intact.
Epidemics of influenza typically occur during the winter months and have been responsible for an average of approximately 36,000 deaths/year in the United States during 1990–1999. Influenza viruses also can cause pandemics, during which rates of illness and death from influenza-related complications can increase dramatically worldwide. Influenza viruses cause disease among all age groups. Rates of infection are highest among children, but rates of serious illness and death are highest among persons aged > 65 years and persons of any age who have medical conditions that place them at increased risk for complications from influenza.
Now we know why pride is one of the "deadly sins." </rant-tangent>
Anyway, back to the point. I wanted to use the second NEJM article to criticize the Bush administration. It turns out, though, that the facts do not support such as criticism. At least not the facts that I could find in a couple of evenings.
The main point of the second NEJM article is that the Institute of Medicine (IOM) released a report in 2003 (Financing Vaccines in the 21st Century: Assuring Access and Availability. summary, full report) that addressed the problem of the potential for vaccine shortages. It was published on August 4, 2003, probably too late for there to have been any hope of forestalling the current crisis. The NEJM article goes on to discuss the recommendations in the IOM report, and to point out the political problems inherent in any attempt to implement the recommendations. The main problem is that it is going to cost a lot of money to ensure an adequate vaccine supply, and of course nobody in Washington wants to spend the money.
But wait. That IOM report was a follow-up to a previous IOM report (Calling the Shots) first published in 2000; coincidentally, starting in the year 2000, there was a series of shortages of various vaccines:
The pneumococcal conjugate vaccine, introduced in 2000, had a considerably higher price than previous vaccines and local, state, and federal governments had difficulties identifying funds to purchase the vaccine. In addition, temporary shortages of several vaccines occurred beginning in late 2000. Consequently, in 2002, the National Immunization Program of the Centers for Disease Control and Prevention (CDC/NIP) asked the Institute of Medicine (IOM) to carry out a study [...]The division of The Dept. of Health and Human Services that is responsible for vaccines is the National Vaccine Program Office. They were aware of the 2000 IOM report, and the 2002 vaccine shortages, as is evident from a glance at their web site. That might mean that the government had plenty of lead time, yet failed to act.
Well, no, the facts do not bear that out. The NVPO had several conferences about the problem, asked the IOM to come up with concrete proposals, and that led to the 2003 report, Financing Vaccines. So they were doing something. The only way to turn this into a criticism, then, would be to demonstrate that, although the Administration was doing something, they were doing it with inexcusable slowness. Recall, though, that the second NEJM article pointed out the problems that face any administration that tries to address the potential for vaccine shortages. I did not quote the details. Interested persons can follow the link and read it for themselves. Basically, it would be a particularly gruesome form of legislative sausage making. It would necessitate hundreds of millions of dollars in government funding, all for something that is not a particularly hot political issue. And there would be no definite payoff. The only benefit that would accrue would be that something really big would not happen. There's no glory in that.
In fact, there are substantial risks. Those of you old enough to recall the 1976 epidemic-that-wasn't know that Gerald Ford took a lot of political heat for his decision to mobilize a large-scale vaccination effort against swine flu. He lost to Jimmy Carter later that year. It will be a long time before the Republican Party forgets about that.
In conclusion, I must say that I could not find a way to turn this into a criticism of the current Administration. I still think they're pretty inept, but not because of their handling of our Nation's vaccine situation. If there is blame to be assigned, we have to look at the failure of leadership (among myriad other factors) that has led us to value our individual pride over our collective health.
(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
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Sunday, November 28, 2004
Those who do not read and understand history are doomed to repeat it.Ownership Society: noun,(nr-shp s-s-t) 1. A society in which, if you do not own anything, you are not a part of the society; 2. A form of social organization patterned after the popular board game, Monopoly ®, as promoted by members of the faith-based community. See also: the rich get richer and the poor get poorer.
-- Harry Truman
I have read history, and I understand it, but I seem to be doomed anyway.
Aristotle got off to a good start; he was the first empiricist. A number of wars and other unfortunate events could have been prevented, if only his ideas had flourished. Unfortunately, the Roman Empire fell, the Dark Ages ensued, and Theocracy became ascendant throughout Europe. I don't mean to be Eurocentric, exclusively, but as most of the good weapons were in Europe, that is where the power was: the power that exerted the greatest influence on the form of the modern geopolitical leviathan.
Then we had the Renaissance. This brought Copernicus, Galileo, and Francis Bacon. Like a dicotyledonous seed, the influences of logic and observation began to sprout. In the Enlightenment, that seed was empowered, as sunlight empowers the photosynthetic apparatus. The empiricists of the Enlightenment gave rise to John Locke's notion of "government with the consent of the governed." This, in fact, was the foundation of the American political system. At about the same time that Locke was dreaming up the ideas that would form the foundation for the Constitution of the United States of America, Christiaan Huygens invented the pendulum clock, based upon Galileo's ideas. The ability to measure time, with both accuracy and precision, was a prerequisite for the Industrial Revolution.
It was fortunate that the idea of government with the consent of the governed came about prior to the Industrial Revolution. Industry allows great power to be concentrated int he hands of a few persons, to an extent greater than had been imagined previously. Without some kind of control, via democracy, that power could be very bad. It is only because of the great thinkers of the Enlightenment, that the Industrial Revolution has not yet destroyed the planet.
The key to averting this destruction is to keep power decentralized. Any form of government that has too much power, is dangerous. That seems pretty obvious. What may be less obvious is the fact that this depends upon a resolute separation between church and state. It also depends upon a system for the distribution of wealth.
From time to time, the leaders of the United States of America seem to forget the principles of its foundation. Allowing Religion to govern politics carries with it a grave danger. Note that I make a distinction here between Religion, on the one hand, and religious principles, on the other. There is nothing wrong with borrowing religious principles to enrich one's political views. But to allow organized Religion to influence politics is to promote too great of a concentration of power. The same idea applies to economics. Having a strong middle class, an accountable upper class, and an upwardly-mobile lower class is necessary for the prevention of an unfettered concentration of power.
Now, we have an Administration that embraces the influence of Religion, effectively escape accountability, and seeks to widen further the gap between rich and poor. They also carry a suitcase with a big red button inside. Underneath the button is this label:
One means of increasing the wealth gap, and thus increasing the concentration of power, is to have what some have called the Ownership Society (O.S.S).
"Another priority for a new term is to build an ownership society, because ownership brings security and dignity and independence."Yes, ownership can bring those benefits, but is the Ownership Society the way to do it, and does it do it without unacceptable risks? I've stated before that politicians should not be allowed to make claims that they cannot prove. This is a good example. The Ownership Society is an idea whose time has come -- and gone, back in the sixteenth century.
--George W. Bush, November 3, 2004
I'm not going to detail all the problems with the O.S.S.; see James Surowiecki's bit in the New Yorker, or, for a less diplomatically worded piece, see Jeffrey Feldman's work on Daily Kos. A choice excerpt:
The phrase "Ownership Society" is an umbrella phrase, the big picture concept behind all social program reforms to be proposed by the Bush administration. The basic premise of an ownership society is that individuals--not "big government"--are responsible for themselves. According to this flawed conservative vision, if the country dismantles all social programs and "returns" both tax money and social responsibility to individuals, the net result will be an general increase in "liberty" and a brighter future for all.The arguments that favor an O.S.S. are great, except for one thing. They ignore reality. An empiricist would ask for evidence. Although economics is a difficult science, and trying to create a mathematical model for the economy of the planet is a prodigious task, we all have some experience with a simpler model: Monopoly ®.
This logic is flawed.
President Bush and the Conservative movement do not want to increase liberty and create a brighter future for all. The goal of the Bush administration is to dismantle the social welfare state because they believe that social programs unfairly burden the wealthy and privilege the poor (viewed as weak by the conservative movement). The real motivation behind the push for an "ownership society" is to eliminate all barriers to unregulated free markets, allowing unlimited concentration of wealth, and the emergence of an American aristocratic permanent ruling class.
The phrase "Ownership Society" is a very powerful metaphor, because it invokes a noble vision of an America where everyone owns their own home. When we imagine ourselves as home owners, we imagine ourselves happy, warm and secure.
The "Ownership Society" concept is a broad strategic initiative designed to convince Americans that government programs to help the poor, the indigent, and the disadvantaged are the real problems preventing them from realize the dream of home ownership and a secure future. [...]
Remember this guy? He's the guy who promotes a completely free market. Anyone who's played the game knows how it goes. Whoever is lucky enough to get a small advantage, early on, is able to use that advantage to get a bigger advantage. The disparity in wealth grows until there is one winner and everyone else is a looser. Experience shows that this result is inevitable. An empiricist would favor that over any other kind of argument.
As a game, Monopoly is great. As a political system, it is a grand deception. It throws out the great advances of political thought, and returns us to what is essentially a feudal system. Everyone is on their own, unless they can curry favor with those in power.
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