Effect Measure

Some angry thoughts about the pandemic

WHO today declared we an influenza pandemic is underway (aka, phase 6), which is not news to anyone. This beast has been barreling long for at least 3 or 4 weeks and the reluctance to call it what it was was related to resistance from some of WHO’s member states (the UK, China and Japan have been often fingered as the chief culprits). The apparent lack of cases in Europe didn’t fool most experts. The EU was using a testing protocol designed to minimize the case count. It was refreshing not to have the US party to these kinds of shenanigans, but of course we had no opportunity: it started here in North America. Still, US health authorities have so far acquitted themselves fairly well. We are all in uncharted territory, and communicating risk when you don’t know the size or nature of the risk, is, well, risky. CDC continues to gather information and advise federal agencies, especially regarding general recommendations and vaccine issues. All pretty useful, but as we move into the heart of this pandemic, it will become of increasingly marginal value. The brunt of the pandemic will have to be managed locally. And there were are in big trouble.

Since the Reagan era we have been systematically disinvesting in the public sector and particularly in public health and the social safety nets that catch the weak and sick as they fall. It’s a Republican idea but too many cowardly and weak Democrats threw their lot in with these enemies of public health. Clinton did little to reverse it and in some ways accelerated it. The coup de grace, of course, was reserved for George W. Bush and the Republican congress post 1994, who pulled the trigger with satisfaction and enjoyment. Now we will all suffer the predictable consequences.

While flu is unpredictable, the consequences of destroying the public health infrastructure are not. The flu virus doesn’t know which of its victims voted to cut taxes and which didn’t, but it owes a special debt of gratitude to the former, even as it goes on to infect everyone.

The fact that WHO waited until the pandemic was well underway may have helped some individuals and governments to get used to the idea it wasn’t the end of the world. Yet we don’t know where it is going. We put up our first post almost the day the first novel virus diagnosis was made (April 22). That was when two cases of infection with a novel swine origin influenza virus were accidentally discovered in San Diego. It is now less than two months later. The virus has spread to 74 countries with almost 30,000 confirmed cases and maybe ten or twenty times that number not counted. It’s gone from the northern hemisphere, where it continues to circulate outside of normal flu season and continues to infect the young, to the southern hemisphere which is just entering its normal season for influenza. No one knows what it will do there, nor are we sure what it will do up here in the north. At one point it seemed like it might just peter out. Forget that. Then it was characterized as a “mild” flu (if there is such a thing). Now WHO is calling it of moderate severity. As I type this, it seems to be striking an awful lot of people around me.

Am I afraid? No. But I am more than a little angry that shortsighted and ideologically motivated policies pursued by shortsighted and selfish people have left my community less prepared to face this than we should be.

Live and learn. At least some of us will. Live, that is.

Comments

  1. #1 GeorgeT
    June 11, 2009

    Well, what I was afraid of is true. The swine flu is totally out of the public’s radar. I was in a store yesterday and one teen joked “I’ve got the swine flu”. Then response from another teen was “Isn’t that over?” A third one said “Yeah”. At the same time, I said “No” but they weren’t paying me any attention.

  2. #2 John Carter
    June 11, 2009

    To bring it back onto the Radar of my cow-orkers I have been putting up simple models that indicate it is likely to be the leading cause of preventable death in NZ this year.

    However my estimates of the case fatality rate and infection rates are from fairly early data.

    Does anybody have some better estimates yet? Surely they must be out there somewhen!?

  3. #3 Maryn McKenna
    June 11, 2009

    A paper fast-published today in Nature (which I’ve written about at CIDRAP tonight, not posted yet) makes the excellent point that we could have been looking much earlier, and maybe could have found this:

    “…all three pandemics of the twentieth century seem to have been generated by a series of multiple reassortment events in swine or humans, and to have emerged over a period of years before pandemic recognition. Our results show that the genesis of the S-OIV epidemic followed a similar evolutionary pathway: H1N1 viruses with human pandemic
    potential had been identified, transmission from swine to humans was known and the disease had been made notifiable. Yet despite widespread influenza surveillance in humans, the lack of systematic swine surveillance allowed for the undetected persistence and evolution of this potentially pandemic strain for many years.”

    Smith GJD, Vijaykrishna D, Bahl J et al. Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A epidemic. Nature advance online publication 11 June 2009

  4. #4 M. Randolph Kruger
    June 11, 2009

    Revere-What you are saying is tantamount to blaming the ills of the world on Republicans. That just isnt so.

    In fact it was a very prominent Democrat Governor from Colorado when questioned about UHC and the lack of care for the elderly when it came to the hip replacements, the eye surgeries, the heart valve replacements that will never get done under UHC, he just said that the older people will just have to get out of the way for the younger ones. Why? Because under UHC and Obamanation you dont count once you clear 60. Now can fight over shortsightedness.

    The big question is whether H1N1 is going to bankrupt BC/BS’s of the US or will we do UHC and watch the government become bankrupt instead. Take your pick, a country or a company. Poetic in the latter for you I am sure. But,UHC Australia is already on the ropes by 8 BILLION USD and thats in the minutes from their legislative branch. This is putting people into the hospital for weeks even though its not killing them mostly (yet).

    So we can argue the ablutions of UHC right up until the time it starts to bankrupt Oz. Then as they said last week at their MOH, “Decisions will have to be made.” That was in DIRECT reference as to who was going to get care. Hey, old guys… You paid taxes longer than anyone out there and footed the bill completely and now you get screwed by the government and….maybe Barack “Universal Hussein Care” Obama.

    For the record they have pulled out their pandemic flu plan and it says those below 50, kids with no underlying illnesses will get zip for care and vaccines. Those that will get vaxxed will be politicians, police, fire, military and responders first.

    Seems to me that the equal protection clause under the Constitution of the US will prevent any of that happening. One lawsuit unless martial law is declared and that puts that on hold. State of emergency wont do it.

    One death, and then one provision of the Constitution goes into effect. Wrongful death… How much is Ms. R. or yourself worth in a wrongful death suit? He I like you guy but this isnt going to work.

    Remember costs to be paid for by the taxpayers. But, alas the fatalities likely will be the young, so in a generation there will be a total lack of taxpayers to pay for any UHC. The poor? They are going to be 1918’d and damned fast. Why do you think the goddamn military is so integral to the friggin’ NPFP? Its also the reason Revere that I tossed in a long time ago and agreed to work. If I can do anything to prevent this BS from going into effect and to keep Barack Obama or any president from becoming dictator, I would and will do it.

    Angry thoughts? Oh vey! They havent even begun to start yet. Better than that, the lawyers are going to be licking their chops to get their hands on this mess. Sooner or later order will and would return. There will be some schmuck out there saying that he was the sole voice of reason but went unheeded (mostly because the indictments will be rolling by then) and then you find out that the NPFP wasnt followed to the “T” and then those lawsuits roll out too.

    Disease is inevitable but many like you Revere think its a right… Its not. Its a privilege and if this turns high path then thats going to become immediately apparent to everyone. If the threads start to pull then its all over with until it reaches a state of equilibrium.

    There is a lot that you say is right but the difference is that there will be poor always and always someone that will say its OUR responsibility to take care of them. The last society that said that? Rome. The last society to be taken over by socialists was Germany and they too were fascinated by a great orator that said one thing and did the unspeakable doing another.

    Wait and see. I would rather that Obama complete his economic plans before taking on yet another problem. If we get 1/2 of the population sick or dying all of his programs are dead on arrival anyway because we will be back on the gold standard instantly. Economic collapse if that happens.

    Take care of yourself Revere and the family. I know everyone is down and feeling raunchy.

  5. #5 revere
    June 11, 2009

    Randy: I blamed one kind of evil on Republicans in this post and also took cowardly Dems to task (read it again). As for Dick Lamm, he was a nut case. I’m not very happy with a lot of things Obama is doing, either, although everything is relative. Compared to what we’ve been through with Congress 1994 -2006 and GWB he looks good. But Why compare to something so dismal? Why can’t he be just good, period?

  6. #6 revere
    June 11, 2009

    Maryn: Thanks for the heads up. I’ll go over to Nature and take a look (I get the print copy, but it’s always a week later than the web so I don’t see stuff like this right away). Sounds like they are saying 1918 was swine origin, too? Runs counter to Taubergerger and company. Will be interesting to see what they say.

  7. #7 MoM
    June 11, 2009

    In today’s media briefing, Dr. Frieden repeatedly made a couple of points (as did Anne Schuchat). That influenza is notoriously unpredictable, that the move to phase 6 was a measure not of the seriousness of the disease, but of the spread, and that although it has been compared to seasonal flu, seasonal flu is not a benign illness, and this one isn’t either.

    I hadn’t heard him speak since becoming “the boss”. All-in-all, not a bad performance.

  8. #8 BostonERDoc
    June 11, 2009

    Now is not the time to be pointing fingers or assigning blame. We have a major league problem brewing and there is no public health infrastructure, hospital capacity or ER surge capability. What we need to be doing –and I see no one doing so in Gov’t or public health–is setting up degradation of care triggers and protocols (when can I stop offering dialysis or intubation, when do I just offer morphine without getting the pants sued off me?), figure out how to synchronize what little public health and hospital resources we have(has never been done in US health care history) and establish laws that limit liability to physicians who volunteer to help in in a health crisis. I practice medicine in MA and I am ashamed of the lack of leadership in public health in both the state and federal levels on this. The MA health dept stopped accepting flu swabs only 3 days into the outbreak–they don’t even have the capacity to track the outbreak how in the hell are they going to figure out mitigation strategies when they cant even do the most fundamental part of outbreak control? I am sure this is the same for most states. My ER has no surge capacity–I already see 30-50% of my patient encounters in the hallway and I know of no hospital that can accommodate more than 10 surge patients at any given time. The White House did a telephone survey in March 2008 and called 32 trauma centers throughout the US at the same time (Monday afternoon). They simulated a terrorist bombing scenario similar to the Madrid train bombings in which 200 victims needed medical attention. Not 1 of the trauma centers could accommodate any appreciable surge patients and most were already at 100% capacity. This table top exercise reflected a “big bang” event and hospitals couldn’t even accommodate a one time patient surge. The pandemic could bring a “slow simmering” of surge and you already know what is going to happen. And don’t forget we could aso have a double whammy with both pandemic influenza getting the young and seasonal influenza taking out the grannies and pappas in the Fall—time to get the cabin in the White mountains ready.

  9. #9 Kathryn
    June 11, 2009

    Could we improve our surge capacity at emergency departments by reducing the number of people using them for non-emergency care? Maybe if people started worrying about catching swine flu at the ER they’d be less likely to come in for things that could wait to see a doctor in the morning or on Monday. (Yes, I know there’s a big mess with uninsured patients who go to the ER because they can’t be turned away there for lack of funds. I doubt that side of it can be fixed fast enough to make a difference.)

    Perhaps we could free up some hospital beds if we encourage some patients with elective surgeries to postpone their procedures until after the pandemic is over. I don’t know what percentage of patients in hospitals are there for procedures that could be safely delayed a few months, and I should probably try to look that up somewhere.

  10. #10 revere
    June 11, 2009

    BostonERdoc: Now is the time to make the diagnosis of what is wrong so we can make the investments to fix it, some of which you set out. Public health has the word “public” in it. It is inherently political and now is the time to put pressure on politicians and policy makers to make the hard choices (which are political choices) and to call it like it is. The same people who got us into this fix are still there (sound familiar?) and it is time to call them out. We still hear the same windy rhetoric and I’m sick of it. You’ll never get what you need until you make them provide it and making nice to these bastards is not the way to do it. You can kiss their ass if you want to, but I’m not going to. If you live in MA, maybe you were one who didn’t want to pay more taxes (just asking)? Because plenty of people in your state were, land I blame them for this. If I am not mistaken, the state public health association fought it (and I think that may also be true of the medical society), so you can’t blame that leadership. It is the political leadership, which is barely better now under Dems than it was under the criminally dreadful Republicans.

  11. #11 Phila
    June 11, 2009

    there will be poor always and always someone that will say its OUR responsibility to take care of them. The last society that said that? Rome.

    I thought Jesus said that, actually.

    But regardless, Rome wasn’t the last society that said it.

    The last society to be taken over by socialists was Germany and they too were fascinated by a great orator that said one thing and did the unspeakable doing another.

    Hitler was not a socialist, and Nazi Germany was not a socialist state. Its workers did not own the means of production, it outlawed trade unions, it viewed inequality as the natural result of competition, and rejected egalitarianism as dysgenic and contrary to the laws of nature. These really aren’t difficult distinctions to grasp.

    (Also, the Democratic People’s Republic of Korea is neither democratic nor a republic. Honest!)

    Obama is not Hitler anymore than Bush was. Some people would argue that it trivializes Hitler’s crimes to imply otherwise. I’ll settle for calling it inaccurate, though.

    Minor points, I know. But still worth mentioning.

  12. #12 BostonERDoc
    June 11, 2009

    Revere, everything you said and double. Kathryn most of the US population will need a frontal lobotomy before we see more appropriate use of the ER. The uninsured are only a small percentage of the problem–it is the entitled mentality of us Americans–we don’t want to wait to see a primary care doctor and most don’t have the capacity to see you without an already scheduled appointment made months prior, we want our health care now and rationing only pertains to the other guy not me. Most hospitals are not public and survive day to day financially by doing procedures. The Operating room and Cardiac cath labs are the money makers for the financial success and health of a hospital. You cancel elective surgeries without some form of compensation to hospitals and the hospital quickly goes bankrupt. So we are going to have to keep the ORs buzzing even during a pandemic otherwise there wont be any hospitals period.

  13. #13 Phila
    June 11, 2009

    Now is not the time to be pointing fingers or assigning blame.

    I’ve never understood how we’re supposed to address political problems without understanding their causes. And I’ve never understood how we’re supposed to understand their causes without assigning blame. A lot of people seem to think that holding elected officials and their appointees accountable is a luxury we can’t afford. The opposite is true, if anything.

  14. #14 Grace RN
    June 11, 2009

    I could listen to BostonERDoc all day.

    I work in a large university-based hospital in Phila and he/she hit the nail on the head-what surge management? I see ‘entitled’ people all day long, the very poor, the well-off-they’re all the same and there is no pleasing them.

    Getting people discharged from the hospital is a nightmare-if they have Medicare they get a written notice of their appeals process at discharge-that’s right, they have the right to appeal their doc’s decision to be discharged and sit in the hospital waiting out the appeals process while the ER stacks up like an airport in the fog.

    What will happen when everyone at home is ill with the flu? Will they take home a recently hospitalized family member? When the nursing homes AKA ‘rehabs’ are closed because of the flu and the families can’t/won’t care for an elder, and homecare agencies face their own staffing crises-how will we get patients discharged?

    Thinking about how to tell families they can’t get a venilator for a family member because: A.there are no more, B.their family member doesn’t meet the triage criteria C.whatever? Try closing the ER’s-the result will make the LA riots look tame.

    Hospitals better hire machine gun-toting burly security guards and issue Kevlar jackets to all staff because people will go nuts. Nurses were kidnapped in 1918 pandemic-is this society more civilized-I think not.

    Go see/call your family doctor? Pipe dream now. My husband was discharged from the hospital after major surgery and was told by his pulmonologist to be seen in the office in 7-10 days? Nice try-no appointments available for weeks, even tho’ they know he was in the hospital. Gets to be seen in six weeks!

    In a pandemic will more office slots suddenly open up? Nope. Doctors get sick too.

    No one seems to be addressing any of this-in fact, in NJ, the plan is to use nursing homes as off site care facilties for flu patients! Are TPTB out of their freaking minds?

    There is no health infrastructure in America. This could grind what little is left into sub-atomic particles-what a good time to sweep it out the door and start all over.

  15. #15 hidy
    June 11, 2009

    I just think it is rediculous while many major American cities are spreading the flu around the world, while the news about the flu in the national news network is way off the front page. I get my news about flu from the newspaper of my home country in Asia. How come?

  16. #16 Ian Musgrave
    June 12, 2009

    M. Randolf Kruger wrote:

    But,UHC [universal health care] Australia is already on the ropes by 8 BILLION USD and thats in the minutes from their legislative branch.

    Well, that’s new to us Australians. We spend around 9% of our GDP on health care, for better results than the US, which spends 15% of it’s GDP on health care. Sure, we could do better. But we already do better than the US and spend less doing so. We aren’t going to be bankrupted by Medicare.

  17. #17 Pork Flu
    June 12, 2009

    According to the Influenza A(H1N1) – update 47 on WHO’s website, the USA has 0 new infections since the “Newly confirmed since the last reporting period”.

    http://www.who.int/csr/don/2009_06_11/en/index.html

  18. #18 Hidy
    June 12, 2009

    If there is no cases in the US, why so many infected people in Asia are those who took flights from major cities in the US?

  19. #19 raven
    June 12, 2009

    We’ve been through this twice before in some people’s lifetimes, the Hong Kong and Asian flu pandemics. Unfortunately, I was too young to remember what happened.

    According to local sources on the West coast, the flu cases are winding down here. As to how they know this, they don’t go into details. So far this is looking like a herald wave and the big event will be next winter in the Northern hemisphere.

    The swine flu is now in the Southern hemisphere and they are starting their winter. We should get a good idea of what to expect from what happens in Australia, New Zealand, South American and so on.

    I understand the problems with surge capacity and so on, but if and when a major flu pandemic hits, we will have to deal with it one way or the other. A vaccine might make a huge difference and I know they are going ahead now. Just hope it isn’t Tamiflu or Relenza resistant when it returns.

  20. #20 raven
    June 12, 2009

    Ed Yong on the scienceblog notrocketscience has an excellent overview of the new swine flu evolution findings. The researchers used sequence data from 800 flu isolates to untangle the evolutionary history of the new strain. A huge amount of data.

    They make the point that occurred to me. Since flu is an RNA segmented virus that reassorts readily, one has to trace the evolutionary history of each segment of the 8 to get any sort of fine detail.

    One interesting point. The new H1N1 seems to be still evolving, adapting from pigs to its new human host. If the swine flu returns in the fall from the Southern hemisphere, it is likely to be subtly different and more adapted to the largest mass of large animals on the planet, H. sapiens.

  21. #21 Phila
    June 12, 2009

    But we already do better than the US and spend less doing so.

    You and the rest of the civilized world….

  22. #22 K
    June 12, 2009

    Health infrastructure is not the only infrastructure that is in trouble. Part it is lack of investment in people to man and repair the infrastructure. But hey this means more money for whoever runs things. However when large numbers of people are out of work due to the flu that will mean there are not trained backups to run things. The infrastructure that worries me the most is the electric grid. The grid takes constant monitoring to keep functioning and electricity is the lifeblood of our civilization. As we know from a few years back a small event can bring down a large section of the grid. Things connect in ways we don’t think about. The deadliness of this pandemic may not be so much from the virus as from a society that thought it more important for already rich capitalists to squeeze out every dime rather than to provide redundancy in essential workforce.

  23. #23 Mathematician
    June 12, 2009

    Amusing to see Americans taking for granted that they can’t get in to see their family doctor without waiting weeks – here in the land of the NHS, GP appointments within 48 hours, or same day if urgent, are now the norm (both in theory and IME in practice).

  24. #24 Last Hussar
    June 12, 2009

    Backing up what Mathematician said. That 6 week wait would be the sort of thing that gets right-winger wound up about the NHS- oh, look it is their preferred system!

    Earlier this year we had a small kitchen fire. The Fire Brigade called a paramedic, who tested my O2 levels, then took me to hospital. Following a blood test I was place on pure oxgen for an hour, then given another test, before being discharged. Any one know how much that would have cost me in the US? Also whats a normal ER wait for life threating stuff (eg suspected broken bone etc)

    It is interesting to note that the US Government alone already spends more per capita than the entire per capita spend of the UK, including private and so called ‘Third Way’.

  25. #25 Julie Stahlhut
    June 12, 2009

    Mathematician — Usually, we (in the U.S.) can get in to see our family physicians, or at least someone in the same practice, within a day or two when we need immediate care, but lining up a first appointment to get oriented to a family physician can take weeks to months. So, people who have just moved to a new area, or who are living on their own for the first time, often still have to rely on ERs or ambulatory care centers for some time even if they have insurance.

    It can also take months to get a routine first-time appointment with, for example, a gynecologist. (If your physician refers you to one because you’re having problems, it’s more likely to take only a week or two.)

    So — we’re definitely used to waiting for non-urgent care. BTW, I’ve always been fortunate enough to have health insurance, and I’ve still routinely experienced these waits.

  26. #26 Tom DVM
    June 12, 2009

    WHERE’S THE PANIC?

    For the last five years, the World Health Organization and it’s subordinates, sovereign regulatory agencies and Governemts have been fighting the battle of ‘Phantom Panic’.

    So you predicted panic and that was why you couldn’t act. So where’s the panic…I don’t see any!

    The fact of the matter is that panic is a human emotion that is as much and maybe more helpful then it is deleterious.

    In my opinion, we were never fighting panic, we were fighting apathy…and the greatest contributor to the apathy was the actions of the World Health Organization.

    The end result…we have a serious pandemic on our hands with possible 1918 potential…and nobody cares.

    Excellent Work!!!

  27. #27 Stu
    June 12, 2009

    The Fire Brigade called a paramedic, who tested my O2 levels, then took me to hospital. Following a blood test I was place on pure oxgen for an hour, then given another test, before being discharged. Any one know how much that would have cost me in the US?

    Well, with insurance it wouldn’t be bad at all — my HMO would charge me $50 for that. Without insurance, the ambulance ride alone could cost you $3,000-5,000.

    Also whats a normal ER wait for life threating stuff (eg suspected broken bone etc)

    A suspected broken bone is life-threatening?

    Anyway, depends on day and time of day. A suspected broken bone could take 1-3 hours of waiting.

  28. #28 maryinhawaii
    June 12, 2009

    Boston ER doc. Excellent points, all of them. I want to comment on this one “What we need to be doing –and I see no one doing so in Gov’t or public health–is setting up degradation of care triggers and protocols (when can I stop offering dialysis or intubation, when do I just offer morphine without getting the pants sued off me?)”

    First, I think there needs to be triage at the door: No ER care for minor illnesses. Trained RN’s take temperatures, check wounds, hand out pamphlets which advise how to treat and send people on their way if they are not serious/life threatening.

    Second: No one gets to sue an ER or its personnel. It’s the first thing you sign in order to get seen.

    Finally, and this is the one that’s going to make me very unpopular…I think we as a society have to be willing to let people die when it is their time. We have hospitals and ERs and long term care facilities filled with people who are being kept alive by extraordinary measures in order to ‘comfort” the family who can’t bear to let them go. If there is no chance, if prolonging life is ultimately cruel to the patient, they should be given the morphine or whatever palliative measures make their end more comfortable, and be done with it. Save the intensive care for those who can be saved.

  29. #29 Chirp
    June 12, 2009

    Don’t forget to throw poor risk communications into the cauldron. Today’s Philadelphia Daily News (Grace RN, take note) has an article – “Parents fearing swine flu keep kids out of school” – which has the following quotes from the school district spokesman and the Health Commissioner:

    * Philadelphia School District spokesman Fernando Gallard: “Parents are really concerned. They have not been reassured enough that this is another seasonal flu.”

    * [Quoting Health Commissioner Donald F. Schwarz] The issue is not the severity of the illness but that it is easily spread, especially among young people, he said. [Sounds like a good reason to keep kids home. -Chirp]

    * “If we try to isolate this virus by closing schools, we will not succeed,” said [Health Commissioner] Schwarz. “It’s circulating [in the community at large – groceries, buses, libraries] …” [True school closures won’t stop the spread. But it’s one significant, controllable way to *slow down the spread* – a KEY goal in mitigation (which a Health Commissioner KNOWS). -Chirp]

    * [Apparently an indirect quote from Health Commissioner Schwarz] Closing [schools] would result in a loss of instructional time, an end to meals provided through school programs, and the potential health risk of having unsupervised children out of school. [Of course, all of these are previously-anticipated ramifications which the city or school district should have addressed in their pandemic plan(s). -Chirp]

    The school district and Health Commissioner are providing what I consider misleading information and/or demonstrating a lack of pandemic preparation by the city and school district.

    My background is in communications … and such misleading statements just drive me NUTS! I posted a couple of comments at the newspaper site. But fighting such misinformation is an uphill battle.

    Chirp

  30. #30 GeorgeT
    June 12, 2009

    I’ve always been able to get into the doctor timely. And now with urgent care facilities all over the place (which are often cheaper than the doctor’s office), it’s really not hard.

  31. #31 rayj
    June 12, 2009

    http://www.theaustralian.news.com.au/story/0,,25628852-2702,00.html?from=public_rss

    Worth reading!

  32. #32 BostonERDoc
    June 12, 2009

    EMS systems in the US now charge when you call 911. The typical bill ranges from $600 if you only need a stretcher and the fire fighters to transport you to the hospital (BLS or basic life support). If you have a trigger complaint like chest pain or difficulty breathing or I think I am having a stoke then the bill starts esclating due to the need for paramedics (ALS or advanced life support). In the Boston, MA region ALS service will cost you about $1,200. This will get billed to your insurance or the gov’t but it is not an automatic that they will pick up the tab. A broken bone will fetch me a $250 USD fee and the hospital will bill a $800 USD facility charge and the orthopedic surgeon if needed will fetch about $300-500 if no surgery needed. ER wait times vary depending upon the region in the US but typically a 6 hour wait is fantastic in the Boston region. I also shake my head when I pick up a chart at 4 am in the morning and see someone that came in at 7 pm for nasal congestion that only started earlier that day. They sit out in the waiting room staying up all night for me to tell them that their mother was right–take plenty of fluids, eat chicken noodle soup and get plenty of sleep. This is pretty much what 90 % of those who contract novel H1N1 infection as I am sure Revere and his family only required. In the US we have stopped teaching common sense and health so many people lack the capacity to evaluate when they need to see a doctor and when they are experiencing a life event such as a shooting zing down the leg that lasts 3 seconds then goes away or a stuffy nose that stated 3 hours ago. I strongly agree with Mary in Hawaii. Most americans are not exposed to death–typically only seeing it once or twice before they are middle aged and as a consequence our society is scared shitless about it. 150 years ago death was no big deal–you typically had a couple kids die before they were 5 and would go through 2-5 husbands or wives because the grim reaper came a calling. Heck I think Paul Revere went through a couple of wives himself and had 13 kids.

  33. #33 K
    June 13, 2009

    My husband is on medicare and I don’t have insurance and am not old enough for medicare. We can see virtually any Dr we want, and I can choose any treatment I feel is best for me as long as I can pay for it. When I was on insurance I could not choose any Dr. I wanted and not all treatments were covered. Medicare has covered my husband well and is much easier to deal with than filing insurance claims through insurance companies. I vote for just extending Medicare to all Americans. IT WORKS WELL.

  34. #34 M. Randolph Kruger
    June 13, 2009

    Well prologue is about to hit the US just as soon as it cools down. It is completely runaway in the UHC of Australia. It would be runaway in the US if it was September and BC/BS had cases. This is starting to wade in on the Australians and New Zealanders. God help them if it turns highly pathogenic as I am seeing the fabric of society start to unweave here.

    They might get off lucky with just a government change there. The GPs are taking it in the shorts from the people. Look here:

    http://www.news.com.au/story/0,27574,25629354-421,00.html

    I am concerned though by the comments that follow that story. These people sound pretty frosted about the whole thing and this IS UHC and not a slam. Its a statement of fact. The same is starting in Ireland and Scotland from what I am reading each day. All I can say is that this is bird flu light. The assertion that jumping into UHC and solve all of the healthcare problems in the US isnt panning out. Sounds to me like a complete muck down there. Like our health officials they are doing the two step.

    Not reassuring. K-Here is something for you to consider. California on about the 15th of next month due to budget shortalls may have to END WELFARE. Simply cant pay for it. Part of that is the California contribution to Medicare. What do we do if that happens in even 20 states for bird/swine flu or other reasons? Cant print any more money.. Just makes what you have more worthless.

    Its a thought that should hang with all of us.

  35. #35 Earl Mardle
    June 15, 2009

    I’m a Kiwi and not about to get into a pissing match over UHC and whether it works or not.

    The reality is that NZ, Aus and Western Europe all have varying grades of UHC, the US has the most radical form of private health care on the planet.

    It is now too late to change models or strategies or education models, anything substantive about public health planning, the lot.

    This pandemic is a test. It is a test of education and systems and we will all fail to some degree or another. And when it is over, the survivors will have had a real-world demonstration of the efficacy of whatever system used to be in place.

    The results will be cold comfort to anyone, but they will be valid. No amount of polemic at this stage about whether one is superior to another will make an iota of difference.

    Lets focus, people, on what we can do.

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