Measles, MMR and the Wrong Denominator

It is ten years since Andrew Wakefield had his now-discredited paper on the MMR jab, published in the Lancet. This paper sparked off a scare that the vaccine caused autism in children and many parents opted out of the jab, going for single vaccines instead, or not having their children vaccinated at all. The scare reached its peak in 2002 and it was two more years before it was thoroughly debunked by Brian Deer, a Sunday Times reporter. But the damage had been done and now unfortunate parents and their children are rediscovering that measles cause corneal scarring,deafness, croup and encephalitis(inflammation of the brain).It is one nasty disease and Andrew Wakefield bears a heavy responsibility for the new outbreaks of measles that have been recently reported.

However, there may be another element to this rise in measles, and that is the way in which data collection for communicable diseases changed in 2002. Before 2002, COVER statistics (Cover of Vaccination Evaluated Rapidly)were collected from computerised child health systems, which record what a child has been vaccinated against. These figures were then compared to the size of the health authority or trust population. This told the health authority how many children had been vaccinated, and vitally, how many had been missed or had gone unregistered. In 2002, when primary care trusts were introduced, the same method of collection was used, but the denominator changed from the size of the trust population, to the size of the population registered with a GP practice and residence for unregistered patients. This resulted in a near 100% vaccination record for measles and other diseases. However, when a researcher called Julia Granerod compared the vaccination statistics with population figures from the Office of National Statistics, she found that there was a discrepancy. She estimated that for 1998 - 2001, 10-20 000 children per annum had gone unregistered; in 2002, between 20 -40 000 children had gone unregistered and in 2003, the figures had dropped back to 2- 8000 children unregistered. This is vital information that is missing from the main statistics, and at a time when outbreaks of measles are happening, it is very worrying. Particularly worrying is the 2002 statistic. In the Granerod paper it was assumed that this blip was due to the re organisation of the trust areas, and a delay in registering people with the appropriate trust. But 2002 was the year that the MMR scare was at its height; it may be that these children were actually not vaccinated as opposed to being simply unregistered. These figures need analysed as a matter of urgency, and the Department of Health needs to re-consider how it is measuring vaccination uptake. Otherwise it could find itself in the middle of a major outbreak without the essential data to counter it.

Suffer Little Children

It has been a pretty grim week in the news as far as children are concerned. Firstly, the case of baby P is about as shocking as it gets, even for hard boiled reporters and social workers. The scenes in Parliament this afternoon at Question Time have been denounced as disrespectful to the dead child, but really the politicians could be forgiven for this; it was quite obvious that they, like us, are in shock.
The second case this week was that of Shannon Matthews, who was kidnapped, drugged and tethered to a roof beam, so that her mother could claim money from the Madeleine McCann fund to find her. She was kept at her uncle's house for three weeks,until the police tracked her down.
The third case this week,(please bear with me, because it will become clear why I'm including this), is the case of Hannah Jones who has refused heart transplant treatment, so that she can spend her remaining days at home. The local Primary Care Trust were going to raise a High Court action to force the operation, but they dropped it.

What has struck me about all these cases, is the immediate pinning of blame onto professionals and the reluctance of the media to consider the role of the parents in these cases.

In the case of baby P, the blame has been put squarely on social workers and doctors. Now, something has gone seriously wrong here and it needs to be sorted, but let's be clear about this; it was baby P's parents who killed her. No one else. We are having a discussion about the failings of the system; we are not discussing the fact that her parents killed her. Compare that with the Vicky Hamilton case, where Peter Tobin, who is a stranger, has had the blame of Vicky's murder laid squarely at his door (and rightly so.)

Next is the case of Shannon Matthews. When this case first occured and the police did what they always do; that is they checked family, relatives and friends for clues as to what had happened, they were denounced in the press for this. They were told that they should be looking further afield, that the case was not getting the publicity that the McCanns got and in some sections of the press, it was alleged that there was snobbery involved; because Shannon Matthews' parents were working class, they were not taking it so seriously. When Shannon Matthews was found, all the critisism disappeared like snow off a dyke.

The third case, which is different, is that of Hannah Jones. Now, I think the decision that this girl has taken is reasonable. The operation she would have had, would have perhaps prolonged her life, but that was the best outcome. There was a risk that the leukaemia that she had had, would come back, and she would have been on heavy medication to prevent transplant rejection. She also would have been in and out of hospital at a time when she wanted to be with family. But I do not agree with the pasting that the Trust has taken over this. This girl is twelve years old. She is very sick and looking after someone sick is very wearing. It is entirely possible, (although I don't think it has happened here) that her parents might have encouraged her in this decision, because they are worn out caring for her. It happens, as I said in this post. But the media have panned the trust for being 'interfering.' As if that isn't bad enough, some are using this as an argument for assisted suicide, whereas this is a very clear cut case of refusal of futile medical treatment.

The common thread running through all of this, is our reluctance to accept a very grim fact of life; parents hurt their children. We have not learned to accept and deal with this as a society, and so whenever a case of child abuse comes up, it's always someone else who is responsible. So we profoundly resent 'interfering' when the health care trust goes through all the proper checks as to the actual wishes of the child and her set up at home, but we bay for blood and sackings when a case of child abuse is missed as in the case of baby P. We are perfectly comfortable with a stranger like Peter Tobin being caught and convicted; we accuse the police of harassment, when they go through the proper procedure of search for someone like Shannon Matthews. We are reverting to the primal instinct of blaming the stranger.

Parents hurting their children is the ultimate nightmare. Who do you trust, if you cannot trust your parents? But we cannot turn away from it. We can't pretend that it doesn't exist. And it is not right that professionals doing their job, should become a media punchbag because we are unable to face this very ugly reality.Let us be grateful instead that they deal with child abuse day in, day out, so that we don't have to.

Your Good Health- Obama's Proposals for the American Health Service

Adulation today, a nightmare of an inbox tomorrow. Barack Obama doesn't have his troubles to seek, what with a global financial crisis and Iraq and Afghanistan to deal with. Yet there is one issue that may prove to be an even bigger challenge than these; and that is his proposals for American health care.

American health care, quite frankly, is a disgrace. America has the biggest GDP in the world, yet it is 41st in life expectancy, behind nearly all its Western European neighbours (Portugal is 42nd). Americans spend 15% of their GDP on healthcare and yet there are 67 million Americans uninsured. Drugs are prohibitively expensive, as I commented on in this post. Although there is a loose federal structure to healthcare in America, and Medicaid,(the state medical system)caters for the poorest, standards and access vary wildly.

Well, it won't be for much longer, if Obama gets his way. Here are his main proposals;

1.) Mandatory health insurance for children.
2.) Mandatory health insurance to be offered by employers to their workers. Small businesses will be exempt.
3. A set of national standards for medical insurance companies. At the moment, states have minimum requirements, but this varies a lot.
4.)Insurance companies will not be allowed to turn away people who are sick or old.
5.) The set up of a National Insurance Exchange, which will allow people on low incomes or who work for a small business, to purchase an individual plan, complete with tax credits to help them purchase the plan.

Now this looks like la-la land at first glance, doesn't it? Especially when the federal cost of this has been estimated at $1300 billion over the next ten years. But let's look at it another way.

America's GDP is $12,417 billion. 15% of that goes on health, which is $1,861 billion. But only half of that money is paid out by the government; the other half is what individual Americans pay. So the Treasury are in fact paying out $921 billion, or 7.5% of GDP, equivalent to the lowest percentage contributions in Europe. Barack Obama's plan is estimated to cost an extra $1300 billion over ten years, or $130 billion per year. So add that on and that takes you to $1061 billion per annum or just over 9% of the GDP. For that investment, the government will be able to add an extra 34 million Americans to the insurance books.

Next question; how are the insurance companies going to take all this? I think in the present climate, that they will actually take it quite well. Standardisation of rules will not go down well; neither will the insistance that they have to take on the old and chronically ill, thus increasing the risk. But in return, what they are going to get is far more customers and a captive market, at a time when many Americans will be opting out of medical insurance. The risk pool will be spread by the use of a National Exchange, which means that they can take on less profitable customers without too much loss.

How will Americans take it? In the land of the free market, spongeing off the state is seen as un-American. But the folk who would normally take this attitude, are struggling themselves just now, and will fall into the category of lower income earners who are eligible for tax credits. The ideal of pooling resources in a difficult time to create a public health service, will seem very attractive just now.

One group who will really like standardisation, will be public health officials. Standardisation at central government level will mean health data collection at central level. At present, this doesn't happen in America; there is no overall governmental body responsible for data collection and it makes it very difficult to plan for disease management. Do you remember how Annabel Goldie kept asking the government to establish a national methadone register? This was so that it was known how many people were on methadone, how many people had a drug problem, and therefore how important it was to set up drug rehab centres, instead of handing out methadone like sweeties. That is how important data collection is.

There are two groups that will not like these plans; employers and pharmaceutical companies. Many big employers do contribute to health plans for their employees at present, but Obama is planning to classify the employers' contributions as taxable income. This is a flaw in his plan, and it will arouse resentment. I think he should leave the contributions tax free, and take a lesson from what happened to pension plans in Britain when Gordon Brown decided to tax them at source and on maturity.

Pharmaceutical companies are really, really, really going to hate these proposals. Standardisation of insurance companies and the cost of premiums means more government involvement. More government involvement means more accountability for prices charged. More accountability for prices charged, means lower prices for drugs, and no more carte blanche. They are the group most likely to try and put a spoke in the wheel of these proposals; when Hilary Clinton tried to introduce health care reforms in 1993, they fiercely opposed her and succeeded in sinking them.

These reforms are a gamble. They are audacious, to coin Obama's phrase. But I think that if the insurance companies and pharmaceutical companies end up in opposing corners, instead of banding together, then he could get it through. And if he does, he could do more to combat inequality in America than all the civil rights movements before him. I wish him the best of luck and the American people the very best of health.