“They are throwing that all away and saying, `We are quite relaxed about 30 deaths and 680 injuries and $230m’.

No, Prof. Sellman, National are saying “We suspect there is a great deal of bullshit in your figures”. I have to agree with them.

Estimates of the reduction in harm achieved by lowering the legal Blood Alcohol Concentration (BAC) from 0.08 to 0.05 are usually derived from studies like the ones in the WHO graph:

Assessing the relative risk of an accident will give you a rough idea of how many fewer accidents will occur. And from that you can work out lives saved. Possibly. This work has mostly been done using simulators in very controlled circumstances. The nice smooth looking curve is not so much a measure of the real-world risk, but a measure of the decreased speed of reaction and decision-making. It is therefore unsurprising that this produces such a neat graph – after all, we know that alcohol depresses reaction times in proportion to the BAC. It does not tell us whether accidents and fatalities would be reduced so attaching crash figures to this information is merely an exercise in math rather than a real-world scenario.

Zador’s well-known study (Zador PL, Krawchuk SA, Voas RB.  Alcohol-Related Relative Risk of Driver Fatalities and Driver Involvement in Fatal Crashes in Relation to Driver Age and Gender: An Update Using 1996 Data. J Stud Alcohol2000;61:387-95.) provides us with some actual crash data from the US databases. Zador showed that people with a BAC between 0.02 and 0.049 had a 2.5 times higher likelihood of a fatal crash and those with a BAC of 0.05 to 0.079 had a 6 times higher likelihood of a fatal crash. Unfortunately, as I have pointed out before, these are very wide bands, making it seriously difficult to determine the best place to set a maximum BAC. It is highly likely that the arbitrary nature of the bands has predetermined the arbitrary nature of a 0.05% limit. Again, it does not really address the issue of a safe BAC, but at least it indicates that more alcohol produces more fatal crashes.

A recent meta-analysis has suggested that no BAC may be considered “safe” for a complex activity such as driving. Having read the paper, I have no problem with this conclusion at all. The upshot is that, despite the emotive language and the dubious figures cited in the media, the debate around a reduced BAC limit is entirely missing the point. The question should be whether we should people to drink any alcohol and then drive.

This question is not as simple as it seems. Danyl at the Dim-post baldly puts it thus:

The problem is that the 30 to 60 people that will die during the two year research period don’t know who they are so they don’t know that their freedom has been compromised, while the many thousands of people who like to have a few drinks and then drive home do know they’ll be trivially inconvenienced by a reduction in the drink-drive limits.

Sarcasm aside, this argument overlooks the fact that we already allow dangerous people on our roads. The elderly and the young both have high accident rates even when sober. A teenager with a BAC of 0.5 has an increased risk of a fatal crash up to 17 times the rate of a sober driver. An adult with a BAC of 0.8% is not statistically more dangerous than a perfectly sober 17-year-old. Should we deny the young and the old the ability to drive themselves?

There are people who routinely speed and people who routinely tail-gate. There are those who have sleeping problems and drive tired and those who drive under the influence of pain killers and cough medicines. There are those who drive while adjusting their radios and those drive with children in the car. Some drive cars that are falling apart and some drive left-hand drive imports. For one or two of these drivers we have laws that may cause one to be fined, but the vast majority of these motorists drive with impunity, despite being far more dangerous than the average driver.

We choose to allow these people on the road because we strike a balance between increasing our danger and a person’s freedom to drive. Sometimes the risk is too great (people with no license, the recidivist drunk, the drunken youth) but usually we accept an increased risk of around 2-3 times greater than normal (most of the people mentioned above). The question therefore remains as to exactly what reduction in risk we will be achieving by lowering the BAC level to 0.05%. The data is not yet conclusive. Most countries who have lowered their BAC from 0.08 to 0.05 have experienced about a 8-12% improvement in accident statistics. As the lowering of the limit has invariably been accompanied with a raft of other measures and a police blitz on alcohol, it is hard to be sure exactly what this means. Joyce is right to want to gather better data so that we know whether such a reduction is actually worthwhile.

The decision is not as trivial as Danyl makes out. A BAC of 0.05% may put a large number of responsible citizens afoul of the law and achieve little or nothing in terms of road safety.

Related posts:

1. Pushing the Limit
2. Drinking to the Limit
3. Booze Scoop

Hi Jim,
I remember reading a while ago that you thought a medical ratings website might be a good idea. Well found this on trademe forum the other day, looks like its going to be a reality?
http://www.medrate.co.nz

Thanks
Steve

Sadly for Steve, I am generally not that much in favour of medical rating sites. In November 2008 I was mildly supportive of such a site. However, seeing how they have panned out overseas, I am now firmly of the opinion that they do not serve the purpose for which they were intended; namely, giving the public sufficient information to determine a suitable doctor to visit. I can think of four distinct reasons why these sites fail in this endeavor.

Firstly , they tend to become forums for the disaffected only. People with an axe to grind are far more likely to write on such sites than people who get good service. It is therefore uncommon for such sites to provide any worthwhile data, simply because most doctors have irritated at least SOME patients. As I pointed out in my 2008 post on this subject, most people gravitate towards the negative opinions, immediately colouring their view of the doctor. Imagine choosing a doctor despite a single negative horror story about a missed breast tumour (all the other reviews are good). After a year or so of excellent service from this doctor, you suddenly discover a breast lump. Do you suddenly start to distrust your doctor’s judgement. What is the consequence to the doctor-patient relationship of your sudden lack of trust? Can this doctor continue being your GP?

The second problem is that, while some people appear to have a genuine medical grievance, the vast majority of dissatisfied patients are unhappy because of personality clashes with the doctor or disagreements with the doctor that have nothing to do with clinical problems (like being made to wait, being charged “too much”, not being given certain drugs etc.). People are genuinely ill-equipped to judge medical expertise. A doctor may be a better clinician and say “no” to your script for antibiotics for your viral infection. You then go to another who gives you the script, inappropriately. Yet your report on the site may be that the first doctor is bad and the second good. This is not to say that people do not recognise clinical expertise, but that that assessment of expertise may be coloured by the patient’s often unrealistic expectations.

Thirdly, medicine is not an absolute science. It not only requires a degree of skill but also, to a certain extent, a degree of luck. Nobody wants to hear about the “but for the grace of God there go I” moments, but every doctor has a story of a patient that was treated completely by the book and still developed rare and terrible complications. In fact, my experience is that it is often patients for whom you go the extra mile, who do the worst. It would seem manifestly unfair to blacken a doctor’s name when the complication was both unforeseeable and unpreventable by NORMAL medical management (I stress “normal” because often some whizz-bang doctor with 20/20 hindsight will attempt to tell a patient that this could all have been prevented by this <insert non-standard, esoteric and expensive test here>).

Lastly, there is always the ugly possibility that some person may wage war against a doctor’s reputation, not for any of the reasons above, but purely for personal reasons. I have heard of an ex-wife assuming multiple internet identities and blacklisting her ex-husband into oblivion.

There are, of course ways that these problems could be addressed – including allowing a separate professionally-assessed database and logging MAC addresses to ensure no-one can duplicate entries. But, in reality, there is no particular need for such a site in New Zealand. We are a small country with a small community of doctors. If you really want to know who is a good doctor in your area you just ask around. Ask the local hospital nurses. Ask the local physio. Ask your neighbours. Chances are the nurses and physio will tell you the best clinicians and the neighbours will tell you who is the nicest. Pick one who is in both groups and you will probably be happy.

Related posts:

1. The Shame Game
2. Medical Ratings
3. Bullying Doctors

I have blogged on a number of occasions that the reason why people are so enthusiastic about eusthanasia is because of the woefully inadequate state of palliative care in New Zealand. Dr Pollock attempts to turn this argument on its head by saying:

Yes, most pain can be relieved to a large extent but at the cost of symptoms such as constipation, nausea and drowsiness, which may be partially controlled by other drugs with their side-effects.

Breakthrough pain is common and its prevention requires constant medical attention which is not often available. We are not good with neuropathic pain. Other symptoms are poorly controlled – in particular that horrible, hopeless, helpless state of feeling so weak and ill you can enjoy nothing – not food, not conversation, not reading, not telly, not even the touch of loved ones.

Actually we have the medical technology and know-how to alleviate most of these symptoms but very few people with the skills to provide this sort of care. Even neuropathic pain, notoriously hard to treat as it is, can be ameliorated to a large extent by selective dorsal root lysis of nerves and similar techniques. The point is that quality of life for dying patients is entirely dependent on the amount of skill and effort put into their medical and psychological management.

Dr Pollock correctly points out that, if we had a pet in the same situation, we would usually turn to euthanasia immediately. There are two reasons for this. Firstly, while we care for our pets a great deal, they are, after all, merely animals. It is not possible to get them to understand concepts such as quality of life or purpose and meaning. Secondly, we kill our animals for a much more mundane reason – it is cheap.

Maintaining adequate pain relief and caring for derangements of normal functionality is a very expensive process. Coupled with the fact we would never be able to make our pets understand what we are doing, it simply is not worth the effort and expense to maintain their lives.

This brings me to the central problem I have with human euthanasia.

It is a cheap cop-out.

Least I be called insensitive in the face of Dr Pollock’s eloquent and  emotional letter, let me say that I say this entirely in the context of medical practice. I do not consider Dr. Pollock’s desire to die rather than suffer a “cop-out”, I consider the legalisation of euthanasia to be a cheap (and nasty) alternative to adequate palliative care. And therein lies the chief dilemma.

Governments being what they are, as soon as euthanasia is legalised, there will immediately be a subtle drive to euthanase dying people. It will not escape bureaucratic attention that  having granny die a few months earlier will save the government health budget millions a year. Recall that the bulk of expenditure in healthcare is spent on the last year of life. The vast majority of these people are clearly terminal in the last three to six months of this period. Imagine the cost-savings of involuntary euthanasia.

While I am fairly certain involuntary euthanasia will never become a healthcare cost-cutting tool, there is no doubt in my mind that pressure will be subtly placed on the terminally ill to “end it all”. It will be put as an “escape from suffering” or “to spare the family” or “to not be a nuisance/burden”. But it will still be coercion no matter how it is dressed.

Is this really how we want our society to be? Driving the elderly and infirm to a premature death in the name of convenience? Are we really so unable to train our physicians in the proper care of the terminally ill? Or is the word compassion only reserved for those who would kill rather than care?

Related posts:

1. Euthanasia (Part 1)
2. Care For The Dying
3. Euthanasia (Part 3)

Applying that research to today is therefore extremely dubious.

The script fee is essentially the pharmacist’s profit for dispensing funded medicines on behalf of the government. Most of it is now paid for directly by the taxpayer. There is no particularly good economic reason for retaining the $3.00 surcharge. The amount generated is relatively trivial and mostly swallowed by increased processing costs. In addition, it does not prevent overuse of medicines as a true part-charge may. All funded items must be prescribed by a doctor. I can tell you for certain that no doctor considers the script charge when prescribing drugs. The primary reasons why you would want to keep the number of script items down is that:

1. People are less likely to take their medicine if there are a large number of items (two or three seems about the limit).
2. The chances of an unexpected interaction between medicines increases rapidly with each additional script item.

A $3.00 script fee is not even a distant third.

This means that the script fee could be easily removed with no sudden blow-out of Pharmac’s precious budget. Unfortunately, this will almost certainly make only a small difference in the number of scripts that are not collected. Almost every large town and city has pharmacies that waive the $3.00 script fee. Whatever the percentage of patients in 2010 who claim that they can’t afford the script charge, that percentage is largely a proxy for lack of transport (if they had access to transport, they could get their scripts for free). While there are many reasons why people do not collect their medication, the predominant one has always been lack of transport. The other major reason is pride. WINZ is more than happy to provide temporary funds for medication. People simply do not want to ask.

A small percentage of people may not fill their script because they feel the doctor has not explained what their medicines are for. MacDoctor’s advice for these people is: find another doctor.

Occasionally, certain people are interested only in the sick note provided – never wanting treatment for their cold/flu/back pain/nausea etc.

Removing the script fee may assist some people whose GPs are within walking distance of a pharmacy that currently does not waive fees. These numbers are not large but, as the cost of removing this fee is likely to be marginal (when processing costs are taken into count), it is probably a worthwhile thing to do.

Extra bonus point for Mr. Ryall. Labour would hate it.

Additional:

I see David Farrar has also blogged on this.

So 94% do manage to pay the $3 charge. To me that suggests that rather than scrap the fee for everyone, you look at targeting assistance to those on the lowest incomes or greatest health needs.

Been there, done that. Some will still slip through the cracks, just as they do for the CSC. The fee is already pretty much worthless. May as well scrap it entirely.

And, as usual, DPF’s comment trolls suggest that, if people can afford smokes and alcohol, they can afford a script fee. May I remind them that the vast majority of medical transactions are unplanned. People spend their money on smokes THEN get sick and need medication. And planning ahead is what these people do worst – that is usually why they are poor…

Related posts:

1. Pain Killer?
2. Money for Nothing
3. No Relief

All this uncertainty make one thing completely certain. No government in the world is going to make any inroads on tackling the problem, regardless of how much of our money they want to throw at it. Politicians are a simple breed and need a simple target and plan. Unfortunately, the temptation to give politicians a simplistic answer is simply too great for some weight zealots.

Doctors in the UK are demanding action from their government. It seems as though they have settled on the enemy – junk food – and the method – tax. It also seems that their agenda involves the eventual banning of junk food (despite prohibition being a consistent failure). Sadly, I can predict that there will be little agreement amongst them as to what constitutes junk food. Remember, doctors are the people who told you that eggs (probably the most nutritious cheap food on the planet) were an evil collection of cholesterol that would kill you faster than Jack the Ripper. Expect only confusion and knee-jerk politics from this lobby-group.

Presumably this excitement from the UK has sparked a reciprocal shrill cry from anti-obesity groups in this country. Evidently there are a number of “experts” (in what?) who believe that the government is not doing enough.

Amazing. It seems that my weight problem is all Tony Ryall’s fault. And I thought it was something to do with the fact that pizza and beer is my favorite meal and that I get as much exercise as an arthritic sloth…

A health committee inquiry into obesity and type-2 diabetes in 2007 said the obesity epidemic threatened to overwhelm the health system without a concerted government-led response.

Recommendations included restrictions on advertising, improving health promotion and changing food labelling.

The National Government has ruled out a tax on fatty foods, or regulating food advertising.

So, if I understand the above correctly, changing food labeling and taxing fatty foods will make me thinner? Suddenly it is all clear to me now. My obesity has been caused by bad food labeling, not by “death by chocolate” desserts! With another government pamphlet in my hands, I could lose 10 kilos overnight! As long as I never see another KFC advert, I will morph into a svelte waif and live forever!

There has got to be a Tui advert in there somewhere.

Absurdly, all of these things have been tried by other governments, without a lot of success. There is absolutely zero evidence that any of them will work, with the exception of a tax on food. The problem here will be to decide which food to tax. Will you tax KFC (fried chicken) but not Nandos (grilled chicken)? Is the fat in a bag of potato chips any worse than the sugar in tomato sauce? Which is the worst part of my staple diet, pizza or beer?  Are you going to tax things made with butter but not things made with olive oil?

How will you handle the deleterious effect of such a tax on the poor? Obesity is especially prevalent in poorer households for multiple reasons, not the least being that more expensive, healthier food tend to be markedly less satisfying. Poorer families fill up on bread and fatty cuts of meat. A tax on these staples will see such families simply eat less of these – not more of expensive, healthier foods – often to the detriment of their overall nutrition. Attempting to mitigate this through subsidies will, of course, be entirely self-defeating, unless those subsidies are directed at the healthier foods. Unfortunately, this is a recipe for complex, ineffective government intervention (politicians like simple, remember) and unintended, but entirely predictable, consequences.

The central problem behind this conundrum of obesity is that neither fat nor carbohydrates are by any means bad for you. It is overconsumption of fat and carbohydrates that make you fat, not the food itself. As this is an entirely volitional problem, it is not something that a government can solve, even if it wanted to. Only a society as a whole, mainly by peer pressure, makes a difference to a person’s free choice.

While the banning of advertising, control of  labeling and restriction of use have all had some part to play in the reduction of smoking, none of this would have been achieved without a real change in the attitude of the general public towards smoking. However, there is no way that we can produce the same sort of result for obesity. While a smoker can quickly put his cigarettes aside and become “normal” again, there is no way an obese person can temporarily dump 20 kg of fat. We simply cannot produce the level of disapproval required to make inroads on obesity without cruelly discriminatory behaviour. This is clearly not an acceptable proposition.

This is one area that any government would be well advised to step away from. This kind of intrusive social engineering is not well tolerated in New Zealand society. I suspect Tony Ryall understands this. Which is why a Fat Tax is a non-starter.

Besides, the so-called obesity epidemic is not an epidemic at all. Estimates of the cost of obesity to the health system almost entirely fail to account for the fact that the vast majority of obese people have mild to moderate obesity, which has minimal health consequences. It is only when you start to carry more than 50% above your expected weight that you develop serious health consequences. There is not really a lot of evidence that an extra 10 – 15 Kg makes a whole heap of medical difference, particularly if you otherwise exercise and eat well. Thus statements like this…

Experts believed obesity was the biggest health problem facing the nation, with a cost to the health system estimated at $500 million a year.

…are wildly exaggerated for effect. It should be obvious to the “expert” quoted above that accidents are the biggest health problem facing the nation – after all ACC spends three billion a year on them. And it is highly unlikely that obesity alone accounts for $500 million in expenditure. This is almost certainly a composite figure that includes estimated contributions of obesity to heart disease and diabetes. The problem here being we have no idea how many people classified as obese are sufficiently overweight to increase their chances of heart disease and diabetes, so this figure is little more than a guess.

Of course, this wouldn’t be the first time a government has found a non-functional solution to a dubious problem that is constructed almost entirely of conjecture and guesswork, wouldn’t it?

Related posts:

1. Food Fascists
2. But Would You Eat It?
3. Heavy Fuel