HFA Inhaler: No CFCs here

     How far are we willing to go in the name of leading eco-friendly lives? Growing environmental pressures have forced us to evaluate our daily effect on the environment and make significant changes in our handling of carbon emissions, garbage management, recycling, use of non-biodegradable materials, deforestation, etc. However, the recent sprint towards a green utopia should not conflict with the resulting effects on health care accessibility.

     An article published on the University of Michigan Health System website reports on a letter written by Dr. Harvey L. Leo on this year’s shift from chlorofluorocarbon (CFC) albuterol metered dose inhalers to hydroflouroalkane (HFA) inhalers, which presents a catch-22 for asthmatics and society alike. On the one hand, these new inhalers offer a greener approach to asthmatic medication, thus decreasing the environmental footprint per 6.5 million asthmatics in the US. Specifically, the transition from CFC to HFA comes as a direct result of the negative effects of CFC on our ozone layer. Unlike most other aerosols inhalers continue to utilize CFCs, which are known to cause depletion of the Earth’s ozone layer. However, this transition will cost families 200-300 percent more out of pocket and our struggling health care system 2 to 3 fold more than the CFC inhalers. The specific price difference between CFCs and HFAs based inhalers stands at $5-$25 vs. $30-$60 respectively.     

And for the 6.5 million American children with asthma, newly mandated environmentally friendly inhalers will come at a greater cost to low- and middle-income families most will see a significant increase in their prescription co-payments or out-of-pocket costs, especially since a generic version of the medication will not be available. [Source] 

     The price difference between the inhalers does not result particularly from manufacturing cost, but rather from a patent. The process necessary to make the HFA inhalers is patented, which eliminates the possibility of generic inhalers and drives up cost. Though the patent expires in 2010, it seems a bit ludicrous that asthmatics must pay significantly higher prices for their essential treatments, just because of a monopoly on the production of these inhalers. Consequently, with nearly 650.000 US asthmatic children uninsured, Dr. Leo suggests that many will resort to halting use of the inhalers or cutting back, thus providing ineffective treatment for their asthma.

     As not only a lifelong asthmatic, but also one from a low-income background, I can attest to the life-saving relief provided by those little canisters. In times when inhalers were unavailable, home remedies only provided minimal relief. Had my asthma been worse and the accessibility of inhalers less, my fight with asthma would have certainly been more lopsided. However, thanks to the low cost of CFC inhalers my asthma was kept under control. Though I certainly support efforts to make medicine more eco-friendly, it should not be at the cost of the health of others.

     Ultimately, in response to observations such as those of Dr. Leo, it is necessary to question whether going green, in this case, is truly more important than the health of future generations. The green revolution will certainly fail if we triumph in preserving our planet, but fail at conserving the future generations that are supposed to enjoy it.

Sources

- Revolution Health
- Lungusa.org

     In a recent conversation with a dedicated health care worker, the groundbreaking book Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care drove our discussion to ask two questions: “who?” and “why?”. Though these are seemingly natural questions to ask about anything, really, in this case they exposed several interesting ideas. The answer to the first question seemed obvious, we looked for the authors and editors of the book and came across: the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care (Author), Brian D. Smedley (Editor), Adrienne Y. Stith (Editor), Alan R. Nelson (Editor). However, as  we dove a bit deeper and ran down the list of committee members, we found several with racial and ethnic backgrounds in communities that would be considered underserved. This in turn provided us our first clue as to why such a study might have been proposed in the first place. Furthermore, to gain a full view of our topic, we included the historical environment of this study. With airs of the election of Barack Obama as the first African American president to the United States, we discovered that in September 1993 then President Bill Clinton selected Joycelyn Elders to position of Surgeon General, making her the second woman chosen for this position, but more importantly the first African American to hold the position. Subsequently, two more African Americans held the position until February 2002, all under former President Clinton. In comparison to the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care , established in 1999 and the book in question published in 2002, we arrived at the true answer to our second question of “why?”.The creation of the committee and publishing of the Unequal treatment had not been by pure chance or federal self-reflection, but, in fact, a direct result of the active participation of individuals from underserved communities in the government. 

    The quote “Without us there would be no questions” becomes even more pertinent in this context, revealing the importance of diversity. Yes, diversity the often over-used and, even sometimes irritating term that dominates much of the lexicon now a days. Nevertheless, the need for a variety of opinions and experiences in order to develop new questions grants a new strength to the word. The achievements of the aforementioned surgeon generals extend beyond their own personal gains and changed the way we view health care in this country. With their experiences, they brought new questions that others could never have posited. With these new questions, came the urgency to address health disparities and the discovery of novel answers to these novel questions.

    This idea extends beyond health care and finds direct application in education, namely higher education. As one of the first in my family to delve into higher education, I have been privy to: on the on one hand the lack of minorities, for lack of a better word, at well respected institutions of higher education, but more importantly the lack of minorities striving towards attending these institutions. Take for example my sister and her classmates, all  one time students a well-respected parochial school, yet upon commencing the college application process, they all chose not to apply to the institutions in question, but rather state and community colleges. This observation is made, not to down play the importance of attending college in general, but instead to bring light to a important question. Why are these students not applying to these well-respect institutions of higher education and secondly, how can we can expect these institution to adjust their recruitment methods, if their student population does not bring these questions to the forefront. Much like the investigation of health care disparity required the presence of minorities in positions of power, the needed wave of change in the interaction between well-respect institutions and students of color requires the presence of these same student of color in the institutions population. 

    Though the issue of a required presence to discover new questions establishes a sort of paradox, it is necessary that we all become involved in the various social obstacles we face. It is the existence of an “us” that allows us to create and ask questions, uncover answers and progress, because without us there would be no questions.

     In the vast world of possible careers, the pursuit of medicine is often considered aiming high, or going for the gold, if you will. Socially, doctors are viewed with high prestige and importance. They are those who exemplify true selflessness, putting the lives of others before themselves and their families. They are those who endure years of schooling, pressure and competition for the mere opportunity to step in when the rest of the world needs them most. Yes, these are doctors: selfless, shameless and honorable modern-day superheroes masked by their mighty white coats. Right? Not exactly.

     The description provided above certainly deserves ridicule, as it paints an absurdly ideal and picturesque view of doctors. However, it approximates the view of doctors held by many in our society. It is this view that propagates the constant battles between physicians and the legal obstacles in our health care system that aims to protect the patient. In addition, it is this view that conflicts with the role of clinical diagnosis emphasized in current medical school curricula. Ultimately, the overestimated power and capacity of doctors contributes to an already severe confrontation between patients, doctors and the legal system.

     In reality, doctors are actually more like Clark Kent than Superman, on the Clark Kent to Superman scale. Doctors are in fact human. Shocking, I know. They are individuals who much like everyone else chose a career that requires X years of training and a certain passion for Y subject matter. It is in the variables, X and Y, that we uncover the elevation of this career to unrealistic proportions. X, in this case, equals the seemingly endless years of studying, processing and application of a large amount of information. The incidence of burnout and suicide in medical students is well documented, as in Dr. Pauline Chen’s NYT article and in an article published in the Annals of Internal Medicine. This not only speaks to the emotional effects of a career in medicine, but it should also bolster the necessity to adjust our view of physicians to a more reasonable one. As we continue our algebraic adventure, Y, representative of subject matter, really comes down to people. Doctors are passionate about the human in the context of health and biology. Medical education strives to give students an intimate understanding of how the body works. Furthermore, physicians are privy to our most intimate processes and workings in the physical sense. As we continue to analyze the knowledge that they, doctors, hold, it becomes only logical that we should hold doctors to such high standards. Most of us, take care to allow only those who we highly respect and value to learn and handle our intimacies.

     Though convenient and to some extent understandable, the heroic view of doctors may actually be negatively affecting the financial stability of our health care system and the treatment we receive as patients. In a few articles on Emergency Physicians Monthly(EPmonthly) and at KevinMD.com , both physicians discuss the resulting “Defensive Medicine.” Defensive medicine, KevinMD describes, “is the deviation from sound medical practice to avoid the threat of malpractice litigation.” The belief that doctors should provide care without error combined with the ever-present threat of malpractice lawsuits drive physicians to second guess their assessments and rely on potentially unnecessary tests in order to cover all their bases. Consequently driving up the cost of care per patient and draining the system unnecessarily of funding that would be have been better allocated.

     Moreover, the practice of defensive medicine contradicts the training provided by the medical schools. In my current application to medical school, I have become intimately familiar with an array of varying school curricula. Consistent throughout most has been the use of Problem based learning (PBL). This system of learning relies of the idea of using student’s curiosity and the discovery of solid evidence to arrive at well thought out diagnoses. The students develop the confidence to make proper medical decisions based on their assessment of each patient. However, PBL is not directly applicable in a system that drives a physician to undermine this confidence for fear of being sued.

    In my exploration of the current view of the physician, I can’t help but recall the questions presented by the graphic novel and upcoming motion picture, Watchmen, “Who Watches the Watchmen?” (Quis custodiet ipsos custodes?) This graphic novel takes on the potential interactions of modern society with the rise of normal individuals as masked heroes. Though initially welcomed and praised, the heroes are ultimately pushed the edges of society and ultimately into retirement. The view of the role of the physician draws parallels with the basis of this story. Once praised for their efforts to preserve life, doctors are now continually under attack for attempting to help to the best of their abilities. Though the question “Who Watches the Watchmen?” is certainly important in terms of regulating good medical practice, it need not border on fostering an environment of distrust between patients and their doctors.
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A new take on inhalers has completely flipped my asthmatic world! Tired of those boring and common L shaped or circular inhalers. Well, leave that fatigue aside and meet Joe Dougherty’s concept combination asthma-peak flow inhaler. This is genius! Makes me wonder, why aren’t other medicine more kid friendly or even people friendly? No one likes taking medicine so why not add a little color or a little style to medicinal tools, such as inhalers. Personalizing my inhaler would be awesome! No longer will it be viewed as a standard piece of “nerdware” in the negative sense, but rather a chic accessory.

If we imagine the potential situation on the other side, we might find true medical malpractice that has caused harm to a patient. Nevertheless, it is also just as likely that we find a more complex situation that goes beyond the control of the doctor. In this case, not only has the patient been harmed, but so has the doctor. Beyond the financial repercussions, malpractice suits have long lasting personal effects on medical professionals. The stress that accompanies such an accusation can severely affect the overall emotional stability of the doctor as a person. As noted at KevidMD’s blog and the AAFP, doctor’s have reported contemplating suicide as a result of malpractice suits.  The AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis notes, “Malpractice is a profound experience…It changes how physicians look at themselves and how they practice.” Though the advertisement does not provide us the specifics of each case, the fact that the law firm uses its malpractice victories as positive marketing drives at the major flaws in the way we hold medical professionals liable for their potential errors. I understand the importance of maintaining high standard for medical professionals, but we must not forget that  they are also human and that there are certain variables that out their control.

As I look forward to a career as doctor, the thought of malpractice suits definitely sours the feeling. However, I hope that within the next 5-7 years great strides can be made to adjust this system, so that not only are patients protected, but so are medical professionals.

- JARB

JARB

I promised more science, didn’t I…

JARB

• Switched over to wordpress as you can see
• Changed the title and header
• Along with this change, comes a bit of a change of focus. I still be geeking it up as per usual, but sometimes in a different way. In other words, I hope to include a bit more science and medicine into the mix as they are passions of mine.

I’m excited to keep on blogging and keep on chugging (like a little engine of sorts). 

What do you out in the internets think?

JARB