Process reflection 3

What interests me most throughout the course is how actors such as big pharma, insurance companies, medical providers, policy makers and consumer groups influence the medical landscapes today on a macro level. Unlike most of the premed students in the classroom who resonate with the medical professionals more often, as a business major student I think more about the regulatory environment and sustainable growth for the companies (outside the limitation that defining ourselves by our majors, I surely learned a lot from my classmates and adjusted my opinions along the course). Not surprisingly, the mainstream sentiment in the teaching materials is the anger towards almost all the for-profit entities. But since further commercialization is inevitable in our social development, we need to shift from being angry to collaborating with the businesses with new corporate social responsibilities to create a better healthcare system. Furthermore, policymakers have huge power to allocate the interests among different groups thus shifting the whole landscape. For example, the coverage change in Medicare can transform the model of nursing homes, create a new industry such as Hospice, or significantly impact the life of certain population such as people diagnosed with cancer. Those topics are probably outside the scope of this course, but they could be very good extensions and leave questions for further research. Besides, I have only been in this country for about four months, so all the assumed knowledge towards US healthcare system is very new to me! Therefore, this course has been very eye-opening and rewarding.

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How does a Hispanic CAM share a dance with the medical dominance

According to a recent NewYorkTimes article Wary of Mainstream Medicine, Immigrants Seek Remedies From Home, the popularity of herbal therapies is increasing in the Latino and Carribean community. Researchers such as an “ethnobotanist”, local Botanica, and Hispanic consumers are actively exploiting the treasure of traditional herbal remedies. Not only does this type of alternative therapy widely preferred among the Hispanic population, mainstream science is also put more efforts in exploring the mechanisms behind it.

The so-called “alternative therapies” (Complimentary and Alternative Medicine, “CAM”) are neither taught in medical schools nor widely used by doctors even if they sometimes are covered by health insurance. For example, there are herbal remedies, acupuncture, meditation, faith healing, sex therapy, etc.

The clientele e pool mostly consists of Latino and Caribbean immigrants. Instead of abandoning traditional herbs after moving to urban areas, in New York’s immigrant communities, the latest wave of people from Mexico and Central America and Dominicans, Puerto Ricans and Jamaicans have been comparing notes on using herbs and foods as medicines. This subculture is not only popular but also solid. The Hispanic community has a strong belief in the efficacy of herbal remedies. Dr. Vandebroek said, “many Dominicans believed that drugs merely hid the pain of disease but did not cure it. Herbs were thought to expel the root causes of illness.”

Why does Hispanic community prefer herbs? There are a number of reasons. Although the constrained choice theory was originally proposed to explain women’s disadvantage in receiving healthcare, The Hispanic community is facing the similar situations here.

Their preferences on traditional herbal remedies could be attributed to several factors. First of all, it could derive from their difficulty in affording mainstream medical treatment and successfully engaging in the physician-patient interaction due to the language barrier. The situations where minority patients are underserved are not uncommon. According to the author of the article, 43 percent of Hispanics in the United States do not have a primary personal care physician or health provider. More than one-third lack health insurance, nearly double the rate for blacks and triple that for white Americans. Known as the Hispanic paradox, the better health condition of the Hispanic immigrants in the US is not completely cracked yet. Now the herbal therapies, as well as the spiritual healing and community care, offer another hypothesis.

 

However, apart from the gradual recognition of the (modern) scientific mechanism of alternative therapies, postmodernism itself is the driving force for this popularity. This Botanica provides more than just herbal pills. According to the former patient, treatments from this Latino herb shop include “cleansing the spirit of negative aura”. Patients are looking for holistic, spiritual treatment, as well as affectionate care and unhurried service. In this case, the legitimacy of natural science itself is questioned. Its limitations are being sought and magnified. Additionally, consumers nowadays are seeking products that are whole and natural. The authentic image of the alternative therapies fits this imagery. Therefore, this trend could be the results of a new tide of marketing schemes.

 

Researchers such as Dr. Vandebroek who received modern higher education from universities are now trying to include herbal remedies in the mainstream medicine. First of all, they may use the methodology and methods from modern science to explain the biochemical mechanisms of herbal medications. Secondly, they emphasize that alternative therapies and mainstream treatment share traits and origins. For example, they claim that until the 19th century, physicians were generally botanists as well. We can found out that the anti-mainstream feature of CAM is greatly downplayed. The ideal future should be that the two systems work in parallel, a.k.a., “hand in hand”. The power of consumers is prevalent in deciding the survival of certain CAM.

One benefit of “inclusion policy” is the safer practice of CAM. Similar to any other unregulated activities, the safety of herbal remedies are little scrutinized and monitored. The lack of dosage guidelines and scientific evidence of their efficacy are prominent. Worse still, the possible adverse interactions with pharmaceutical drugs will still exist if these remedies keep living in the shadow.

 

 

 

Process reflection 2

In October, we moved to the broader discussion of medicine and public health. The discussions on the intersection of gender, SES, race and health conditions are very similar to those I experienced in introductory sociology courses. That is to say, they seem to be the “typical” issues explored. The major difference is the health contexts. But the relationship between medicalization and social control is very interesting to me. Especially, the topic on the shifting engines of medicalization touched various underlying social forces. In the past, medical doctors are the major players of medicalization. They have the power to define and categorize new diseases and provide treatments. They were also portrayed as the dominant roles over patients and other subordinate medical practitioners. While during the recent stage of medicalization, biotechnology, consumer and managed care ascend to become the major forces. Doctors evolved to become the gatekeepers and spokespeople for pharmaceutical companies. This is also related to commercialization and consumerism in healthcare.

But I also suspected the limitations of our study. First of all, sometimes we focus too much on the sociological side of the issues while neglecting the biological or practical reality. As I pointed out in my previous posts, sometimes the teaching materials seem biased and jump to conclusions too soon, e.g. the correlation between stress level and SES and the real reasons behind claimed gender inequality in drug tests. I understand that one main message behind medicalization is that some interest groups use medicalization as a tool to cover bigger social issues and shift the problems to the individuals’ health. However, I don’t think we should assume this “viciousness” without an examination of a specific problem. The second limitation is related on the first one, but with a focus on the structure and format of the course. Certainly there are a lot of issues to be discussed in this course and our discussion time is always too short for that. But I am not very sure that a very light touch on each question and then moving to another one is the best approach. Also, I really hope we have more conflicting voices in lectures and in discussion sessions. I wish to see more about how the pharmas/doctors/policy makers defend themselves against everything of which we accused them.

Lastly, this is a great course and I really enjoy the process. Although I proposed a few possible limitations, I have to say that this is a very informative course and that Professor Guseva and Rebecca are truly helpful.

This WHO report might shift the definition of herpes

According to WHO’s first global estimates of herpes infection, more than 3.7 billion people under the age of 50 – or 67% of the population – are infected with herpes simplex virus type 1 (HSV-1). The “herpes” we know as an STD is genital herpes caused by HSV-2. WHO’s latest journal article highlights that HSV-1 is also an important cause of genital herpes.

HSV-1 causes lesions on the lips or around the mouth commonly referred to as cold sores or fever blisters. It’s primarily transmitted by oral-to-oral contact. Both oral and genital herpes viruses can sometimes be spread, even when you do not have mouth sores or blisters.

This report should raise concerns on the unequal distribution of healthcare and necessary infrastructure resources. Based on WHO’s data, we can found that the rate of infection is significantly higher in regions such as Africa and South-East Asia than regions such as the US. Fewer people in high-income countries are becoming infected with HSV-1 as children, likely due to better hygiene and living condition. One implication of policy making is to provide more access to hygienic water as well as other resources to underdeveloped regions. At the same time, public education is also important because most people get infected as children. For example, some parents chew food for their children and pass the virus to them.

HSV-1 infected disease is also a good example for illnesses affected by social factors. According to WHO, though the virus is highly infectious and incurable, symptoms such as blisters only occur when the patients’ immune system is under stress. Some people, if they get a lot of sun exposure, they’ll get an outbreak, or women during pregnancy or when they have their menstrual periods.

The high estimated proportion of the herpes infection has significant effects. Even in the region that has the lowest rate (Americas: 178 million women (49%), 142 million men (39%)), nearly half of people under 50 are infected. This undermines what we define as an illness. There have been such comments from the public as: “It is not herpes; it is cold sores” or “Everyone is infected”. These comments surely exaggerate the facts. However, it reflects how the big number can reduce people’s definition of a certain illness. If over 99% of the adults are infected with HSV-1 worldwide, would it still be recognized as an illness or simply an accepted impairment in our immune system.

We need to acknowledge that, people who are infected with herpes, even the HSV-1, are stigmatized in most societies. Will the new WHO findings promote the de-stigmatization of the diseases? Due to the high infection rate? WHO has stated that “People with orolabial herpes symptoms may face social stigma, and can experience psychological distress as a result.” On the other hand, this finding may evoke panics among the public and accentuate the stigmatization on sexual activity as general. For example, on the website of Centers for Disease Control and Prevention, several suggestions were given. “The only way to avoid STDs is to not have vaginal, anal, or oral sex.” “If you are sexually active, you can do the following things to lower your chances of getting herpes: Being in a long-term mutually monogamous relationship with a partner who has been tested and has negative STD test results.” Not only do those suggestions emphasize the isolation of infected population but also propose a preferred way of conducting sex. This a good example how the disease and they way people perceive it can shape the public’s view on sex and certain sexual conduct such as multiple partners.

Dig in the “gender inequality” in medical research concerning experiment animals

Both in lecture and discussion group, we talked about the preference on choosing male experiment animals over female ones in drug tests. We were surprised that not until 4 months ago that female labradors were introduced in cardiovascular medicine research as experiment objects. I suppose, first of all, science is perceived as relatively objective and fair (though the male dominance of researchers exists in many fields). Such sex preference seems so “outdated”. Second of all, we suspect and actually assume that only using the male objects will lead to disadvantages for female patients. We suspected that because the drugs produced will apply to male bodies more efficiently than female. But I think this conclusion seems too arbitrary.

First of all, the preference on experiment animals of a certain sex is determined by the contents of the experiment. Most of time, for the convenience of conducting the experiment. Sometimes scientists prefer male animals because pregnancy will make the experiment more difficult. For another, female animals are more easily influenced by hormonal levels, which disrupts the experiment results.  There are tons of examples where female animals are preferred or only used or where equal quantities of male and female objects are required. For instance, in an experiment on the treatment for osteoporosis, there two common methods of causing osteoporosis artificially. The medicine injection method is very difficult and expensive while the other is the removal of ovaries, which is much easier. As a result, only female rats were used in this medical research project. 

Some people can argue that we should not sacrifice equality for the sake of convenience. Well, it is not the case. Here scientists are trying their best to control the variables so they can test the elements they focus on, especially during the early stage of research and development. It seems very outdated and naive to me that insisting on absolute “gender equality” on every stage of the experiment. I support the equal treatments on men and women during the stage of clinical trials as it is important to ensure gender equality for the patients. All in all, the judgment on “gender inequality” in medical research depends on the details of the experiments. We should not jump to the conclusions too quickly. I am very sorry that I didn’t find the original articles about the no use of female labradors until 4 months ago. All complement and comments are welcomed.

Social class and stress level

In the first documentary shown in class, one prominent cause proposed for class-related health issues is stress. I have doubt about the suggested correlation between the socioeconomic status and stress level. In the university hospital, from the top the CEO to the bottom the floor cleaner, all employees are facing a high level of stress. The director justifies his conclusion by explaining that CEOs like Jim have better access to leisure, vacation, exercises, healthy diet, etc. Moreover, the director claimed that the high-income earners have less sense of insecurity.

I acknowledge all the resources that wealth can create for health. However, I found it really hard to assign a stress level to people based on their social class or develop a general pattern. For example, in Deresiewicz’s book Excellent Sheep, students in prestigious schools are suffering greater anxiety than their counterparts studying in other schools. The majority of them are from elite or upper-middle class. Besides, there are people who rely on the low-income welfare subsidiary and refuse to find a job. The life quality is less desirable for sure, but it is arbitrary to assume that this population have more stress than some high-income population. Among those most stressful occupations, many of them are the high salary jobs.

When it comes to an end — Health care for the dying

By Zeya Qiu (Denis)

One The Economist article in September One door closes, another opens (Sep 19, 2015; Vol. 416, accessible on BU library page) touched the heated topic on physician-assisted suicide legislation.  Recently, “by narrow margins, California’s state assembly and senate passed the bill on legalising such procedure. It will soon be legal if the governor, Jerry Brown, does not veto the bill within 30 days.” The article also made a contrast between the voting results of similar bills in California and in the UK and called for the same protection of patients’ liberty.

What potential impacts could this legislation have on the health care system? Short answer is that this could help reduce the huge amount of costs in some way.

Costs and coverage are the two main concerns in health care system. When talking about the high medical costs in the United States, the first things some people would complain about are the unnecessary tests, over-prescription and overuse of expensive drugs, and over-treatment in the hospital. It is not rational to blame this problem on the profit-seeking of the medical providers. Patients mentality also plays an important role in shaping this medical landscape. Patients as consumers, lacking the expertise on medical science, generally believe that more treatments equal better treatments.

Our focus here is how patient mentality shapes another scenario of over-utilisation, a less mentioned one. The costs of care for patients in the hospital near the end of their life usually soar in very short period. According to the documentary Money & Medicine, sometimes the patient and/or family would ask for highly risky and expensive surgery to give a relatively short time for the patients. Or they may require expensive medical care to sustain the extremely low-quality life of the dying person. The medical bills from this kind of care are usually unbearable for a non-wealthy family, even if they have health insurance.

What I found interesting is people’s attitude towards health care in this special time, or also related, towards death. For example, what is a good “last days’ health care”? What is a good death?

Patients themselves have diverse opinions on the demarcation of a “good death”. Or maybe, death is never good. Some would love to stay in this world as long as possible, despite the pain, suffering and possible financial distresses. Some would prefer to “let nature takes its course”. Some would ask for a death with dignity. We should understand that all these dying wishes derive from human nature and all of them should be respected. Many of the overwhelmed families would love to sustain their loved ones’ life or to fulfil their wishes at any cost. As a result, there come piles and piles of medical bills.

Cultural factors could also influence the family’s decisions. For example, in traditional Chinese culture, “filial piety (孝道 xiao dao)” is very important. The care for a dying family member is one good presentation of this moral. Nevertheless, sometimes in very extreme cases, some people ritually put more energy and money towards the “last days’ care” than in the daily care before their family member gets into severe medical situations. This phenomenon surely attracts moral criticisms. By providing premium or even excessive health care for the dying person, those families who are still alive feel better about them and their guiltiness is partly relieved because they have given a good death to him/her.

Although we mainly discuss the issues concerning financial costs here, a legislation like this apparently involves more dimensions such as bioethics and religion. In places where doctor-assisted dying is abandoned, many patients are not surviving with dignity because the pain and sufferings they have exceeded all the emotions of death, which is the main drive for the legalisation process.

This legislation might not only relieve the families who are currently bearing the financial burdens from last days’ care, but also gradually change people’s perception towards death and care for the dying by offering an alternative.