Sin taxes and the cost of health

Over the last few days, there were several FULL PAGE advertisements by the tobacco association and distillery companies in the Philippines. As all obvious vested interests go their way, these companies have the money (and temerity) to splurge on full page ads in order to block the passage of additional sin taxes for vice.

Glaringly different is the stand of some government officials (whose brains I don't know where manufactured from) regarding the cost of medicines in the Philippines.

Let's put the facts in order.

The World Health Organization's most recent report on Global Health Risks puts into perspective the reality of health problems in high-, middle-, and low-income countries. The full 70 pages report published in 2009 should serve as an eye-opener and reference material not only to the public, but to every government official who still is confused at what kind of Philippine laws to roll out (if only to grand stand for the upcoming election).

Based on the WHO regional classification, the Philippines falls under the Western Pacific Region and NOT Southeast Asian Region. Countries are grouped by WHO region and income per capita. WHO member states are categorized as low and middle income (LMIC) if their 2004 gross national income per capita is less than USD$10,066.00 and as high income (HIC) if it was greater than this amount based on estimates provided by the World Bank.

In the Western Pacific Region, those considered HIC are: Australia, Brunei, Japan, South Korea, New Zealand and Singapore. Considered LMIC are: Cambodia, China, Cook Islands, Fiji, Kiribati, Lao People's Democratic Republic, Malaysia, Marshall Islands, Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, Vietnam.

For the record - NONE of the countries in Southeast Asia region are high income countries.

The technical report's summary is concise and direct to the point in just the first paragraph of the SUMMARY section:


"The leading global risks for mortality in the world are high blood pressure (responsible for 13% of deaths globally), tobacco use (9%), high blood glu- cose (6%), physical inactivity (6%), and overweight and obesity (5%). These risks are responsible for raising the risk of chronic diseases such as heart disease, diabetes and cancers. They affect countries across all income groups: high, middle and low."

To explain in layman's language, let me define two terms:
1. DALY (disability-adjusted life years)
and
2. Health risk


DALYs measure the burden of disease and quantifies the gap between a population's health and an ideal situation wherein one lives to old age in full health. Ergo, 1 DALY is equivalent to one (1) lost year of "healthy" life.
Health risk is defined as a "factor that raises the probability of adverse health outcomes."

It is in this context that we need to understand and balance the musings and lopsided advertising b*llshit that tobacco and distillery companies pointed out.

Based on the data provided by the WHO technical report, of 19 health risk factors, 15 of them are life style risk factors (regardless of income in the country). Rounding up the top 8 risk factors are: hypertension, tobacco use, high blood sugar, physical inactivity, obesity and overweight, high cholesterol, unsafe sex, and alcohol use.

If you considered the DALY of the 19 health risk factors, based on country income level, the devil in tobacco and alcohol usage would still rank in the top 8. Obesity, high colesterol and inactivity would follow suit.

The technical report summarizes these findings as follows:

"Five leading risk factors identified in this report (childhood underweight, unsafe sex, alcohol use, unsafe water and sanitation, and high blood pressure) are responsible for one quarter of all deaths in the world, and one fifth of all DALYs. Reducing exposure to these risk factors would increase global life expectancy by nearly 5 years."

"Eight risk factors (alcohol use, tobacco use, high blood pressure, high body mass index, high cholesterol, high blood glucose, low fruit and vegetable intake, and physical inactivity) account for 61% of cardiovascular deaths. Combined, these same risk factors account for over three quarters of ischaemic heart disease: the leading cause of death worldwide. Although these major risk factors are usually associated with high-income countries, over 84% of the total global burden of disease they cause occurs in low- and middle-income countries. Reducing expo- sure to these eight risk factors would increase global life expectancy by almost 5 years."

"Nine environmental and behavioural risks, together with seven infectious causes, are responsible for 45% of cancer deaths worldwide. For specific cancers, the proportion is higher: for example, tobacco smoking alone causes 71% of lung cancer deaths worldwide. Tobacco accounted for 18% of deaths in high-income countries."

For those that are ignorant of how heart disease and these other risk factors play a role in health risk, the causal chain below illustrates the pathway on how there is interaction in increasing the risk. (You can read the full report in the link if you're interested in understanding this further)

"Health risks are in transition: populations are aging owing to successes against infectious diseases; at the same time, patterns of physical activity and food, alcohol and tobacco consumption are changing. Low- and middle-income countries now face a double burden of increasing chronic, noncommunicable conditions, as well as the communicable diseases that traditionally affect the poor. Understanding the role of these risk factors is important for developing clear and effective strategies for improving global health."

Worldwide, there are more deaths due to being overweight or obese than being underweight. Diet-related risk factors and physical inactivity in LMIC is similar to being burdened with HIV/AIDs and TB. The 6 risk factors in this category include: high blood pressure, high cholesterol, high blood glucose, overweight and obesity, low fruit and vegetable intake, and physical inactivity.


http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf


The bottom line for this technical report is revealing. It shows us that in order to address health care, we need to address the root cause of the disease. We cannot be a culture where we discover a pill for every ill, when there are non-pharmacologic (no need to use drugs) treatment plans.

Making tobacco and alcohol inaccessible to those who consume it more (the poor consume this more than those who have money and ironically, spend more for vices than for putting the right food on the table); putting into perspective a healthier life style by shunning fast food chains (read - McDonalds, Mang Inasal, Red Ribbon, Jollibee, KFC, etc) and encouraging our children and people to eat healthier meals (feeding is a habit that is learned); engage in sports activities and move around (instead of simply sitting down with an iPad or texting in wild abandon)...these are the simplest solutions to the increasing chronic problems that plague our people.

We cannot allow a culture where people simply learn to mortify their bodies by taking a "pill for every ill". It does disservice to the public if the government does not have the "balls" to reign in the vices that use "economic displacement" of a country as the prime mover and shaker for something that is altogether wrong. If the line of reasoning of the tobacco and distillery industry is that "putting additional taxes on tobacco and liquor will make this less accessible to the buying public and will displace hundreds of thousands of workers" and hence the law on additional sin taxes should be blocked, then it is a stupid line of reasoning provided only by those with selfish interests to stay in the Forbes list of billionaires. I would go to the extent of arguing with them that if this were the case, then let's let all the shabu and marijuana producers and dealers and sellers be made legal because they only push drugs as a source of livelihood.

Finally, I'd like to take a jab on how pathetic some law makers are on making the cost of drugs a major issue. For the record, we have one of the most number of generically equivalent drugs in the world. How we have over 50 brands of each drug is a puzzle even to me. With so many of them in the market, I even doubt the quality assurance of many of them. Making them dirt cheap is not the solution at curbing the problem of inaccessibility of every Juan to medicines. No matter how cheap you sold the drug, as long as each Juan does not change his outlook on lifestyle diseases, the idea of decreasing health risk through a more cost-effective government program is not achievable. Cheaper medicines is NOT the solution to accessing health care.

Health care requires politicians to think out of the box.

There's a saying that if you give a man fish, you feed him for the day. Teach him how to fish, and you feed him for a lifetime.

It is time we teach every Juan to fish for his life.

The prelude

It's been a few weeks since I've been doing a bit of pencil pushing and sitting down with all concerned parties regarding a project that would entail the use of digital technology in improving the delivery of health care services between the patient, the pharmaceutical industry, the healthcare business, and the health care providers. Because all these segments are linearly related and cross paths at different angles, it makes sense in providing a business solution at addressing the gaps encountered in the efficient delivery of better, optimum and quality health service and information to all the parties at stake. After all, the healthcare industry, while complex in nature, is the most vital of all services we all seek. There is a price we need to pay for staying healthy, and a greater price we pay for being sick.

For one, it is time that we professionalize the process and services of patients whom we provide health service to on a pay-for-fee basis. We can improve the relationship between the health care provider and the patient by making patients more accessible to doctors to address their needs - from having to queue at the clinic, to responding to requests for information even when we are out of the office. I am sure my friends will agree with me that most of us are selective to whom we give out our mobile numbers to. While we are justified at keeping our private lives less accessible to patients, the latter may have serious concerns that will require our attention after they have consulted us in our clinics. Unfortunately, if there is no regulation at the text messages sent to the doctor, this problem escalates to being simply ABUSED ending in a scenario where patients text messages anywhere from inquiring if you're still in your clinic to asking for a diagnosis or a prescription based on an MMS photo sent as a diagnostic challenge to the physician.

On the other hand, as physicians, we need to provide patients with efficiency in the delivery of our services to them as well. When we say our clinic begins at 9AM, we must at most times, start on time. Unfortunately, many of us would make patients queue till forever because we don't want to wait for them or we would prefer that they're all there already when we start our clinics - which is unfair for the patient who also has other things to attend to or whose time is equally important to them as it is to us.

The age of digital technology has changed the landscape of creating a more productive relationship between patients, the pharmaceutical industry, the healthcare industry and the healthcare provider.

From Apps designed to providing electronic medical records to designing programs where patients can access their health records and linking to pharmacies where they can easily pick up their prescriptions paperless, to having their labs available real time - there are countless ways at improving the interlocking grid of the healthcare industry.

Two decades ago, Pocketbell or the paging system became the defining line as a business solution to providing more efficient service through prompt communication to all. In less than a decade, the advent of mobile phones replaced the paging system. Today, digital technology has literally changed the way we live - from eating to breathing, from fine dining to shopping, from selling to promoting - we have become entrenched in the power of the internet. It has served as the portal for many successes and solutions to improving every imaginable service.

No one can stop an idea whose time has come.

At the end of the day, by putting order in this chaotic complex healthcare system, it becomes the avenue for efficiency so that we can all lead more productive, healthier lives.

Virtually at our finger tips - we can make the healthcare industry work to the advantage of all stakeholders.

My Virtual Health Care Solutions...it's about time.

The fury of HIV infection - is the Philippines ready?

The National Epidemiology Center released the September 2010 data for newly diagnosed HIV cases in the Philippines.

Last month alone, there were 153 new HIV Antibody seropositive individuals confirmed and reported to the HIV and AIDS registry in the Philippines. A 173% increase (53 cases in 2009) for the same period last year. Most (95%) of them were males and the median age was 28 years (range: 18-58 years). The largest age group affected was 20-29 years (54%). Half (~50%) of of the cases were from the National Capital Region (NCR).

Of the 153 new cases last month, reported mode of transmission was sexual contact in in 98% (150 cases) with only 3 cases reported from re-use of needles among injecting drug users. Males having sex with males (homosexual or bisexual) was the predominant type of sexual transmission (83%). Most (9%) were asymptomatic at the time of reporting.



Three (3) of the cases in September 2010 were documented AIDS (acquired immune deficiency syndrome). The median age of the AIDS cases is 25 years. All three cases were males having sex with males.

Based on demography, 14% (N=21) of the reported cases last September were OFWs. Most (91%) were males with a median age of 32 years. All cases acquired the infection through sexual contact - 75% males having sex with males.

The total number of reported cases from January - September 2010 alone was 1,201 or an average of about 4 cases per day. In September alone, the number had the highest jump to 5 cases a day being reported positive for HIV infection.

From 1984-2010, we have reported 5625 cases of HIV infection alone, with 85% of those infected being asymptomatic. Males (77%) outnumber females (23%) in total number affected based on sex. Almost 20% of those afflicted with HIV infection belong to the age group 15-24 years old. At least 6% have reportedly died due to AIDS since 1984.


I share the update with my blog readers so that they are informed on the situation of HIV infection and AIDS in the Philippines.

What do the data show?

1. That there are more new cases reported daily. These new reported cases are voluntary. And therefore the statistics are an underestimation of the true situation of HIV infection in the country. It is surmised that it probably is only the tip of the iceberg. Which means that most probably we are looking at about 10-25% of the actual cases of HIV in the country. Extrapolating that to the real scenario would mean that there are about 5 new cases a day.

2. The practice of safe sex is mandatory in the current post-HIV scenario. Of course, I am in no position to demand monogamy, but if it cannot be avoided, I advise people to please try to contain the consequences of unsafe sex among themselves. While I see all the billboards splash the walls with the NO SMOKING ads and the NO SECOND HAND SMOKING advertisements, HIV is very much like this as well. Confine the infection to yourselves. If you cannot abstain from having sex, do not get others infected at the very least.

3. No one dies of AIDS. In a country like the Philippines where infectious diseases is the leading cause of morbidity and mortality, an era where you have both HIV infection and say, tuberculosis, is devastating. You will not need contraceptive methods to decrease the total number of Filipinos multiplying in the country. HIV infection is a debilitating illness that not only drains the family emotionally but the government financially as well. If we have an outbreak of HIV infection, that will put the country three steps back in any of its program to move forward.

4. As you will notice, the bulk of the age group affected are young. Very young. I can only surmise that these are those who probably engage in unprotected sex and promiscuous behavior. As evident in the data, the bulk are males and the bulk are those that engage in male to male sex (whether homosexual or bisexual in nature). While the data for the mother to child transmission rate is very low, this is good data. If a program is in place early, it can focus on target individuals especially the teenagers who have very minimal information on sex education because the church and government officials are struggling to find a middle ground on when and whether it is time to provide sex education to our students.




5. There is a need to educate the OFWs as well on the growing problem of HIV infection. While it is true that loneliness finds its way to seep into the loins of those separated from their loved ones, it is sick to cavort elsewhere and bring the infection home to scatter the seeds of wrath with your beloved.

The data is alarming and should be a wake-up call and an awareness especially among the youth and those that practice unsafe sex. There is no excuse for ignorance. Technology today has changed the pace of the world by providing access to valuable information for everyone. We can use technology to our advantage by disseminating this information.

But there will be those that will choose to ignore this. And use the internet for desires of the flesh - a source for meeting up scrupulous people for copulation and lust. A recent study showed that the youth are most vulnerable to the latter. Raging hormones in this age group is no reason for acting careless and stupid.

What goes around, comes around. The fury of HIV infection has not yet reeled its ugly head, but the 5 NEW cases a day from last month's data should serve as an early warning that this storm is not far behind.

Knowing the Pinoys, they will never be ready for this, unless we change our paradigm today.

[Data from the National Epidemiology Center, Philippine HIV and AIDS registry, Department of Health, Philippines. Click on the illustrations/graphs/tables to see a larger image of the data]

The health of our nation

Last Saturday, Dr. Emmanuel Johann Obana, was interviewed in the Mindanao Agenda.

The latter is an investigative TV program of GMA network in Davao City. Dr. Obana is one of a handful of idealistic doctors in the Philippine government's "Doctors to the Barrio" program.

In the interview, Reporter John Paul Saniel showed how Doc Eman tried to divide a bottle of paracetamol among several kids or how he used one overly used thermometer for practically all patients, or how difficult it was in grabbing a banca (water boat) to see patients that were difficult to reach.

It was in Doc Eman that I flashbacks on my days as training officer for pediatrics of a government hospital (Ospital ng Maynila) and a private hospital (UST Hospital).

My years in training the residents in pediatrics was blood, sweat and tears. It was not the measly pay that the local government provided (P2,400/month and you were required 8 visits a months), or the fact that you had to wait 3 months to get paid (or 6 months on some occasions), or being castigated by some hot shot councilor because the patient's parents were complaining about why we were asking them to buy medicines (answer - because the hospital does not carry it stupid!)...

Yup. Those were the years when I shared my teaching skills with my residents and took the time, patience and sighhhh....even money. But it was hard for some government big time assholes to see the light at the end of the tunnel. To them, even the plight of health care in the Philippines was (and should I say - IS) just a show. The media frenzy is the their big turn on. These shit heads have crap on their shoulders. I hated them - not for their guts, but for their brainless behavior.

I once interviewed a prospective candidate applying for residency in pediatrics. I asked her why she wanted to pursue pediatric training, considering that she is a city health officer (in one of the big cities in Metro Manila) already. She said that the Lina Law on the devolution of the local government had made her mayor lose significant IQ points. In short, he turned from dumb to dumbest overnight. (He's a public official - it was a curse he was to inherit.) He told the local health officials that their pay would be scaled down because NO ONE can get a pay more than his pay! Sounds logical right? Wrong! It's stupid.

We are not mayors. We are doctors.

We cure people and we work more hours toiling to see patients get better.

In our professional practice, we do not steal.

I was appointed to head the pharmacy of the government hospital. On my first day on the job, I was told that there was going to be good news. I am being given P3M to purchase drugs for the 400 bed capacity hospital.

Then the bad news. I will need to spend that money for the purchase of drugs for the whole fiscal year. Watdfuk!?!?!

I did my math. It meant P250,000 in medicines per month. Assuming that there will only be 400 patients for the whole month, (which is the thinking of Councilor Stupid), this would mean P625.00 for medicines for each patient. Presuming that he will be admitted for the whole month, that would mean medicines worth P20.83 per day. Sanamagan!?!?!?! Only in the Philippines!!!

That same year, they repainted the whole hospital, changed the glass panes of the windows (which were still quite new), bought new air conditioners for some offices, painted lines in the parking slots, upgraded the medical directors office - all to the tune of P50M.

The following year, I resigned from my position in the Pharmacy and as residency training officer and as consultant in pediatrics. I needed to keep my sanity and did not want to die an angry man early in life because some asshole politician forgot to clean his sh*t! And I'm not going to clean it for him.

In the report of poor flung to the barrios doctor in Caraga, the reporter noted that Caraga Mayor Alice Mori had several stacks of government-issued medicine supplies in her possession. And nope, it was not located in the health center nor the municipalities. It was in her house. When interviewed, Mayor Mori claimed that the medicines in her house will be used for medical missions. (The election is near and it is time to hoard for political campaigns?) The mayor refused the reporter's request for video footage on the drugs because she said that it might be used as propaganda by the political opposition (well, I guess this is the opposition's opportunity to bash the mayor).

As reported by Carlos Isagani T. Zarate in the Daily Inquirer, "before the TV program on the interview of Doc Eman was over, the good doctor had already said a mouthful that not only described his frustrations but even aptly indicted the skewed priorities of the government's health program. Doc Eman is one of only two 'doctors to the barrios' assigned in far-flung areas of Southern Mindanao..." Doc Eman hails from a poor family in Cavite.

It's people like him that actually go back to basic grass roots of trying to pass goodness forward.

"Unfortunately, last Wednesday - before Mindanao Agenda was shown on local TV - Doc Eman was pulled out by the Department of Health from Caraga, Davao Oriental. He received death threats via text messages on his mobile phone two days after Saniel did an interview on him and Mayor Mori."

In a country so much in dire need not only of spiritual healing, even those who tend to the living bodies are not spared by the politics of desperation and greed. There is no remedy to this. Even in death...