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    Sunday, July 07, 2002

    Reader Thoughts on Smallpox Vaccine: A reader emailed these thoughts on the government's smallpox vaccine strategy:

    From a purely military perspective the best approach is somewhere on the spectrum between mass pre-emptive vaccination and mass reactive vaccination. The details of vaccination risks and attack scenarios determine what you select. I suspect that once there is an assured supply of vaccine available, the present "500,000 medical staff pre-emptively vaccinated and mass reactive vaccination" will be modified. Given the high adverse reaction rate for smallpox vaccinations, my strategic choice would be:

    - Pre-emptive vaccination for military staff and hospital medical staff
    -Suggested pre-emptive vaccination for all other medical, police,fire, with warnings
    -Available pre-emptive vaccination for the general public, but with very strong advisories about the potential adverse reactions.
    -Pre-positioned vaccines for massive immediate reactive vaccination in the event of attack.

    This balances the negatives of pre-emptive vaccination -- casualties,hysteria, backlash over casualties -- against the negatives of reactive vaccination -- much higher casualties in the event of attack, hysteria, backlash over lack of vaccination. Making pre-emptive vaccination available with warnings reduces the hysteria and backlash level for the reactive choice because those most concerned can get vaccinated. There is a much higher tolerance for personally chosen risks, so the adverse reactions will not induce much backlash.

    From a military perspective it preserves the war making ability and the ability to provide the reactive vaccination. This discourages the potential attacker because they know that they will not inflict heavy casualties and they will face an enraged enemy military force. It also minimizes the self inflicted casualties.

    I suspect that this sort of thing is exactly what the government is considering, and it is a vast improvement over the older CDC recommendations.

    And on the Malpractice Insurance Crisis: The same reader had these thoughts on malpractice insurance premiums:

    Just to be complete, the problem is more than just the legal claims.There are signficant costs from routine insurer mismanagement. (They manage their companies just as incompetently as they manage your paperwork.) There are huge secular costs from secular mismanagement. (They lost a bundle on really stupid price wars, really stupid underwriting, and really stupid investments.) There are also significant costs due to medical incompetence. There is evidence that appropriate use of specialization and certification has huge impact on outcomes. (The outcomes difference between high volume specialized centers and local treatment can be dramatic.) But there has been only glacial progress at revising treatment approaches to reflect this and other introspective analyses of medical treatment.

    There are completely unrealistic attitudes by patients both in terms of accepting their own responsibilities and having realistic outcomes expectations. Some of this is understandable (if wrong). I've read the warnings on clinical trials (6 pages of "this probably won't work. this might kill you. Here are all the horrible things that can happen.") and then listened to people who signed the agreement and still think that this will cure them.

    And there are the legal leeches who take advantage of all this.

    I agree that some, but not all, of the dramatic rise in malpractice premiums is from insurance company mismanagement and bad investments. However, a lot of it is due to rising awards. Malpractice rates are highest in states that do not cap the monetary awards. This isn't because those states have more badly managed malpractice insurance companies, or more incompetent doctors. It's because the insurance companies have to pay higher damages on average in those states. I am a strong believer in the justice of our legal system. I would much rather an angry patient hire a lawyer than a gun to address any percieved harm. I also recognize, and feel strongly, that is my responsiblity to acknowledge and take responsibility for any mistake I might make. But, the damages that are awarded for pain and suffering can be outlandish. The current legislation for tort reform before Congress addresses this issue:

    In April, a bipartisan coalition of representatives introduced a tort reform bill that includes everything from capping noneconomic damages at $250,000 to allowing future economic damages to be paid over time. And patients -- except when the injured party is a child younger than 6 -- would have three years to file a lawsuit. That statute of limitations is shorter than what exists in most states now.

    No one is denied their day in court. No one is denied compensation for medical bills. The only thing they and their lawyers are denied is the chance to hit the big jackpot in jury prizes.

    posted by Sydney on 7/07/2002 11:48:00 AM 0 comments


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