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    Tuesday, April 25, 2006

    Big Brother is Watching: Elizabeth Whelan on New York City's newest public health initiative - tracking and nagging diabetics:

    Some are resigned to this new regulation, arguing that if government is assigned the role of paying for health care, it is entitled to intervene to reduce the risks of disease and thus reduce the costs. But as we set forth into this brave new world of public health, some facts cannot be ignored:

    The implicit assumption behind these monitoring and follow-up programs is that government can be as successful in reducing chronic disease through legislation as it was in wiping out many infectious diseases through classic public-health measures like vaccination and chlorination of water. However, there is no evidence that these new government efforts will pay off in terms of better health.

    Matters of patient confidentiality and personal responsibility have been totally overlooked. It is safe to say that most Americans do not want their medical profiles to be a matter of public record. And they do not want clerks from the local health department calling them and telling them how to live their lives. Since so many of the risk factors for chronic disease involve lifestyle factors — overeating, lack of exercise, smoking, and more — the emerging health policies are blurring the distinction between public health and personal health, the former lending itself to community-wide mandates, the latter more appropriately the sphere of individual action and commitment.

    In contacting diabetes patients to urge them to follow various protocols to preserve their health, the city is not only shattering the confidentiality of the physician-patient relationship but assuming that personal physicians are incapable of performing this role.

    When the government's phone calls and letters nagging people to eat better, quit smoking, and be more physically active don't work, the next phase of the war on chronic disease may be a harshly punitive one, with fines and other restrictions on those who fail to heed the health warnings. The message will be: Live a healthy life or the government will punish you.

    New York City's law mandating the reporting of diabetic blood tests is a harbinger of more intrusive legislation to come — all in the name of public health. It is high time we reflect upon the difference between public and private health, critically evaluate what role the government should play in the prevention of chronic disease, and carefully assess what cost we might pay in privacy and individual freedoms as the government performs "interventions" to protect us from ourselves.


    This is a disturbingly popular trend in the public health community - to assume that government can regulate every aspect of health. At its core, it ignores the most fundamental cornerstone of Western philosophy - the free will of men.
     

    posted by Sydney on 4/25/2006 01:17:00 PM 7 comments

    7 Comments:

    It has become boilerplate in many medical journal articles to begin with a pronouncement that disease X is an important public health problem.I think the authors usually mean that it is an important and fairly common disease or condition not that the public health department need to "solve" the problem.Of course,the NY health dept. cannot fix the diabetes "epidemic"and they will trample on indivdual rights in the process.

    By Blogger james gaulte, at 2:04 PM  

    "arguing that if government is assigned the role of paying for health care, it is entitled to intervene to reduce the risks of disease and thus reduce the costs."

    It's my understanding that the doctrine known as "qui tam" - used by whistleblowers - may well be used by an individual in, say, a governmental health program. The theory is that an individual or individuals could file a qui tam suit against other participants for damages that the other participant(s) caused. For example, imagine non-smokers suing smokers, alleging that smoking increased their taxes used to fund the national health plan. The possiblities are endless and dismaying.

    I suspect the legal thinking is way ahead of the public on this one and all that is needed is that there be a governmental system, to create the conditions in which qui tam cases health care cases would begin.

    John Fembup

    By Anonymous Anonymous, at 2:09 PM  

    If they are really serious about this, they will eliminate the greatest causes of accidental injury also. Outlaw: skateboards, bicycles, horses, basketball games, etc.

    By Anonymous Anonymous, at 1:38 PM  

    But, but, but... Surely we diabetics are a threat to the community! I mean, we take dangerous psycho-active drugs, and... We don't? Well then, our need for wheelchairs indicates we should not be... We don't? Well surely, we should not be breathing on others and spreading... We don't? WEll, a large percentage of us are obese, and since that causes 430,000 deaths a year... What do you mean, 22,000?

    Yeah, a goodly percentage of deaths and other probems. Bring back the Black Death, typhoid, cholera (or Ghenghis Khan, for that matter) and watch that percentage plummet.

    By Blogger John A, at 9:23 PM  

    This issue is stereotypical of the left-right debate. It can be boiled down to these two choices:

    1. I want to be left alone with my health. If I am too poor to pay for my amputation when my diabetic vasculopathy goes bad, I accept the prospect of being left to die of gangrene.

    or

    2. I paid my taxes all my life and, therefore, deserve government help when I get sick. Since all insurances need to minimize their risk, I accept to comply with preventative measures to insure the survival of my health plan.

    What is unfortunate here is that these New Yorkers do not seem to have this choice.

    By Anonymous EM, at 12:40 PM  

    If they are really serious about this, they will eliminate the greatest causes of accidental injury also. Outlaw: skateboards, bicycles, horses, basketball games, etc.
    Also elite-level sports. Lots of injuries in gymnastics and figure skating. Also, don't forget cars. Imagine how much fewer injuries there'll be if we all go back to horse carriages.

    2. I paid my taxes all my life and, therefore, deserve government help when I get sick. Since all insurances need to minimize their risk, I accept to comply with preventative measures to insure the survival of my health plan.

    Em, just how much money is going to be saved by this program? Is it more than will be wasted on burearacy? I doubt it, but if you believe that this and other preventive measures are cost-effective, I'd love to see your math. If somebody dies sooner, would this person waste public money or save it? We will all die at the end, so you will not save on end-of-life care. You may save on some treatment like amputation, but you'll spend somewhere else - like on lifetime medication.

    Still, unlike some other preventive measures, I imagine diabetes control is cost-effective, but is it sufficiently cost-effective to cover the cost of this program? Also, if we follow your choice 2 to its conclusion, then anybody who has health insurance or gets medicare has no right to refuse any kind of treatment. Do you really want to go there?

    Also, do you know that some preventive measures are not even remotely cost-effective - one of the popular recommended screening test would've never been paid by insurance unless government forced it. Because the cost of screening+cost of false positives + cost of treatment of overdiagnosed cases is several time greater than the savings on maybe less treatment for very few.

    So following your logic, anybody who chooses 2. shouldn't have any screening test that isn't cost effective even if it is recommended and has a very small probability of saving his/her life.

    By Anonymous diora, at 1:18 PM  

    This is so typical of what many of us in NY refer to as the nanny state mentality.

    Personally, I still think individual responsbility should count for something. However, I don't have a problem with economic sanctions on irresponsible behavior like high taxes on cigarettes and alcohol as well as higher health insurance premiums for smokers and those who are significantly overweight.

    With respect to management of any chronic disease, I'm not sure that perfect compliance with respect to medication, diet and exercise, which might maximize longevity. will necessarily result in lower lifetime healthcare costs vs someone who is non-compliant and dies sooner.

    By Blogger BC, at 5:05 AM  

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