Monday, March 19, 2012

From your Kiwi Correspondent Part III

Imagine that you’ve driven your car off the road and into a Eucalyptus tree and busted up your ankle. During the subsequent ambulance ride, what thoughts might pop into your head?

“Thank goodness no one else was hurt.”
What in the heck were those possums doing?”
“I’ve never liked Eucalyptus trees.”
“How in the world am I going to pay my medical bill?”

A Marin County resident could conceivably have some, or all, of these thoughts. But here in New Zealand, at least one of these notions would be quite unusual. And no, it’s not the one about possums – they are as plentiful as sheep around these parts. Rather, it is the bit about medical costs. You see in New Zealand, accident and injury-related medical care is fully compensated – regardless of insurance or fault. More about that soon, but first, for those who may have missed my last column, a quick catch-up…I’m in the midst of a six-month stay in Auckland, grappling with how Kiwi perceptions of health and wellness differ from American ones. Now, I recognize (disclaimer alert!) that perceptions of health are diverse and that this endeavor hazards broad generalizations. Perhaps my query is as unanswerable as the age-old “nature versus nurture debate.” Nonetheless, there are identifiable differences in geography, culture and statute that would seem to shape how health is perceived in these two countries.

Let’s return to the example of medical care for the wounded. We all know that some injured patients in the U.S. just cannot pay for healthcare, but that eventually (probably in an ER) they are likely to receive treatment anyway.  Everyone else picks up the tab for this through higher insurance premiums and other cost shifting. Of course, in some cases, it’s not that simple. For example, some uninsured patients might be able to pay their medical bills, but risk bankruptcy in the process.

Injuries are handled quite differently in New Zealand under a system called the Accident Compensation Corporation (ACC). First enacted in 1974 and revised many times since then, the ACC hinges on a crucial trade off – free medical care for injuries (regardless of fault) for all citizens and non-citizens alike in return for higher taxes and, importantly, forfeiture of the right to sue for damages.

Here’s how it works… let’s say an American tourist tries Zorbing – a “sport” in which you are rolled down a hill inside a large plastic sphere that looks like an overfed yoga ball. This American then suffers an unscheduled tumble into the path of a campervan. When he is taken to the Accident and Emergency (aka, the ER), the physician will complete an ACC form, verifying that he has sustained a valid injury and that his medical care will be paid for by the ACC. In return, said American cannot sue the Zorbing company, the driver of the campervan, the physician who treats him, or anyone else. He can, however, take solace in the fact that if any of these parties has acted negligently, they may be criminally prosecuted (as opposed to sued).

This system, it seems to me, helps mitigate fear. I’ve noticed this on many levels but it’s most pronounced with the children. There is a tool bench at my son’s preschool and it’s equipped with actual carpenter-worthy hammers, screwdrivers, nails, and Philips heads for actual building projects (take that Bob the Builder!) The kids go shoeless much of the day – they take their kicks off when they arrive at school and  (maybe) put them back on when they leave (of course the lack of poisonous snakes or spiders helps make this a safer proposition than it might be elsewhere). Trampolines and “bouncing pillows” are common, as are the injuries they cause. Kids play rugby, without helmets, which does not seem like a good idea to me. For young adults, the fearlessness manifests in adventure sports such as white water river sledging (river rafting on a boogie board). But it’s in professional life where diminished fear may make the most substantive difference. Kiwis I’ve spoken to are amazed at the thought of staying in a bum job just because it offers good health coverage. An American physician who spent a decade in New Zealand put it this way, “we [Americans] have to buy protection against the health care system that could make us poor. They have freedom from that fear.” Of course, these are perceptions, not hard facts, and fear (especially the type that softly itches at you each day) is a hard thing to measure objectively.

There are certainly downsides to the ACC scheme – a 2% earner’s levy (income tax) which caps at approximately $2000/year/person as well as the potential for both fraud and reckless behavior. As to the latter, Kiwis are certainly adventurous, but not particularly reckless. The roads are safe and well-policed and fatal motor vehicle accidents rare (396 in all of 2008) and less frequent (per vehicle) than in the U.S.  And, while I see far more unhelmeted cyclists here than at home, I also note far fewer folks texting while behind the wheel. Any freedom that an individual might feel to act carelessly seems to be more than counterbalanced by a public health incentive (financial and otherwise) to prevent severe injuries. The only truly reckless activity I’ve heard about is as a coed rugby squad called the Nude Blacks (if that isn’t explanation enough, there are YouTube videos.)

“Normal fear protects us; abnormal fear paralyses us,” so wrote Marin Luther King Jr. True enough, but what is “normal,” and how much is it defined by the social contract of the society in which we live?

It would seem that American society creates certain “abnormal” fears that may not exist in New Zealand. And this might help explain differences between the two peoples in regard to how they view their health. It does not, however, explain what the heck those possums were doing in the the road.

From your Kiwi Correspondent Part II

Soon after arriving in Auckland for a six-month sojourn, I picked up the local paper (The New Zealand Herald) and was surprised to read this from columnist Paul Holmes…  

“Now, my health. It seems to have been a matter of speculation since last Sunday and I don't want you to think I'm on my last legs, so here's what happened…It was all to do with damage done by radiotherapy during the first days of the prostate cancer treatment a decade ago…
In mid January, my bladder shut down. That is to say, its ability to drain itself was blocked by an enlarged prostate strangling the urethra. So I could not pee. Meantime the bladder continued to swell and believe me, this must be one of the most painful conditions in the world. The immediate solution is to insert a catheter to drain the bladder, a moment of immense relief. And you walk round with the bag attached to your leg until they can do what I call a re-bore.
Sounds weird and unpleasant I know, but it's happened to me now a few times over the years and you kind of get used to it.
But it's what can happen after prostate cancer. Like any cancer, it is a nasty, unpredictable thing, and its effects can hang round for years and change your life forever.”

I read this, and then re-read it to be sure. Did a prominent newspaperman just describe a personal and painful medical condition in a public and matter of fact manner? Why, yes, he had. And it occurred to me that one would be hard pressed to read such an account in the mainstream American media. This in turn had me asking, are we Americans a bit squeamish about our health? You certainly don’t see much about bladder blockage on the opinion page of the New York Times, but it’s not just that. Rightly or wrongly, many Americans would prefer to keep matters of reproductive and mental health (among others) in a black box. For instance, I would wager that there are precious few (if any) U.S. neighborhoods that feature billboards urging men to…“Give it a shot, there’s a 1,000,001 reasons to be a donor.” Sperm donor, that is. Such billboards are abundant here in Auckland. You also are unlikely to find your local paper running a feature on male cosmetic surgery, entitled “Beauty and the bloke.”

What you will find in the U.S. is a large number of people addicted to prescription narcotics. But while the U.S. is facing an unprecedented epidemic of prescription drug mis-use and abuse (prescription narcotic-related deaths numbered 14,800 in year 2008), what there is of Kiwi statistics on the topic suggests it is nary a problem here. The most recent published report I could find documents 92 prescription drug abuse deaths in the whole of New Zealand for the entire 2001-2002 time period. Why the difference? From my observations so far, and from what people tell me, it seems that Kiwis with chronic pain are better able to manage their pain with a regiment of Tylenol and the occasional happy hour. Or it could have something to do with the fact that hydrocodone is not available here in New Zealand. When I asked a Kiwi physician about this drug, she replied “No, haven’t heard of it. Related to morphine is it?”
But, there could be more to it. Limited investigation, some of it quite dated, suggests that there are cultural differences between Americans and Kiwis when it comes to pain perception and disability. A comparison study (Carron et al, 1984) of one hundred some chronic low back pain in each country indicated that “despite nearly similar between-country reports of pain frequency and intensity, the U.S. patients, both at pre- and post-testing, reported greater emotional and behavioral disruption as a correlate of their pain.” A more recent qualitative study (Dean et al, 2011) of rural Kiwi workers with low back pain observed a return-to-work ethic in spite of pain driven by a “‘can do’ attitude to work, managing [low back pain] within the context of having job control and flexible work practices.”

Am I saying that Americans are prudes and wimps when it comes to health? No, I have no such authority and we Americans would have no such monopoly. Besides, who’s to say that health squeamishness is a detrimental trait? I’m just pondering why there appears to be a health-minded difference between New Zealanders and Americans?

Over the next half dozen or so columns, I will explore various angles and nuances of this question – incorporating stories and observations from New Zealand and relating them, when applicable, back to the U.S. system. In the process, I hope not to, as a Kiwi might say, “Make you a whole lot of knackered,” which translates loosely to “bore you to sleep.”

To start this endeavor off, we must address size and population density. New Zealand is a country roughly half the size California with only 4.5 million people. By way of comparison, the San Francisco Bay Area registers just about this many all by itself.

As Don, a rather sharp-tongued tour guide told us… “Four-point-five million, that is not so many that you couldn’t fit them all in your backyard and still have room for a game of golf.” To put this in perspective, topics make it into The New Zealand Herald that would surely be drowned out by other news in the U.S. For instance, it’s front section news that a woman “abducted” a newborn baby from its mother – after asking and receiving permission to take the baby for a stroll. Articles also appear regularly about hospital food and clothing. The sticky stripe socks are, by the way, considered a smashing success! 

New Zealand, however, does have a high profile epidemic in progress. A nationwide surge of late night chip (French fry) cooking–induced house fires (1,005 of them in 2008-2009) prompted the Kiwis to launch a public service campaign called “Don’t drink and fry.” If you have a moment, pull up the TV ads on YouTube, they are richly entertaining. Somewhat remarkably, this campaign seems to have contributed to a nearly 40% decrease in frying fires in 2009-2010.

So size matters – both in the nature of what’s news and what demands public health attention. But, there is more to this topic of comparative squeamishness than that. Next time, I will explore the role of fear – in particular the fear of losing health coverage or not having it all – and how this impacts a culture’s approach to health and wellness. 

From your Kiwi Correspondent Part I

“Hello there, this is your captain speaking. Today, we’re going to skip the details about your personal flotation device… if you find yourself needing that, well, talk about one in a bazillion…And I know that you know how to click together a bloody seatbelt. Our seatbelts work like every other one you’ve ever used, and if you can’t figure it out, well, perhaps you shouldn’t be out in public in an unsupervised fashion. So instead, why don’t you pay attention to some health tips that might actually be useful.”
Don’t you wish airline pilots would give it to you straight like that? I sure do. 

Recently, I took a twelve-hour flight from Los Angeles to Auckland, New Zealand and, as it turns out, twelve hours is a long time to spend on a plane. Especially if you’re seated next to a hulking rugby player whose taut triceps nudge you into an awkward diagonal position. The good news is that this (seemingly interminable) discomfort gave me plenty of time to consider what is really worrisome about an extended plane flight. And you know what, the location of the personal flotation device is not high on the list. In fact, the Transportation Safety Board of Canada, among others, has concluded that even in the rare circumstance that such a device be required, it is highly unlikely that it will be used unless the passenger is actually wearing it beforehand. And since I’m not interested in advice (such as wearing a life vest for the duration of an overseas flight) that makes flying even more uncomfortable, we shall focus on more tangible threats. 

1       Deep Vein Thrombosis (DVT): “Stretch your bloody legs.”

We all know that DVT is a common and potentially deadly condition and that prolonged immobility is a major risk factor. But how common is the airline DVT, dubbed by some as “Economy Class Syndrome”? We don’t know for certain, but some estimates are staggering. In 2001, The Lancet (Scurr et al) published an analysis estimating that one million cases of DVT related to air travel occur in the U.S. each year and that 100,000 of these result in death. A more recent review article by Gavish and Brenner put the risk on long-haul flights (6 ½ hours or longer) at 3-12%. This is a pretty stunning incidence – equaling approximately one DVT per one to four rows of economy seats in a Boeing 777. The American College of Chest Physicians (ACCP), on the other hand, have – in both their 2008 and 2012 guidelines – estimated a lower incidence, calling the risk “mild.” It’s thought that the risk of DVT is due not only to in-flight immobility but also the relative hypoxia in the cabin. As with all DVTs, risk factors include age over 40 years, female gender, pregnancy, oral contraceptive use, lower limb varicose veins, obesity, and genetic thrombophilia. The ACCP has recently added sitting in window seats to this list (Grade 2C evidence) while also observing that “Economy Class Syndrome” may be a misnomer – those in first class have the same DVT risk as those in the back of the plane. Notably, even the absence of risk factors does not put you in the clear. A Norwegian study (The Lancet, 2000) observed a substantial hour-by-hour increase in blood clotting factors (2-8 fold) occurred in all twenty healthy subjects studied in a simulated (hypobaric) environment.

Clearly, even if Economy Class Syndrome is a misnomer and some incidence estimates overblown, it seems that DVT prevention advice would be a useful aspect of an in-flight safety program (more helpful, perhaps, than a reminder to stow your tray table in an upright position.)

The trick to prevention, as we all know, is to keep those bloody legs moving! Any combination of the following will help: 1) graduated compression stockings for high risk patients at 15-30 mg of Hg, 2) calf and ankle exercises such as pumping up and down on the balls of the feet for 2-3 minutes every half hour, and 3) frequent walks up and down the aisles. Some evidence suggests that patients in high-risk demographics may benefit from a prophylactic anti-thrombotic – with low-weight molecular heparin (LMWH) likely being the best (but not so convenient) choice. A comparative study by Cesarone et al. published in Angiology, found that LMWH (given two to four hours pre-flight) was statistically superior (no DVTs in 82 subjects) to control (4/82) and aspirin alone (3/84). The current ACCP guidelines, however, do not recommend routine anti-thrombotic therapy, even for high-risk patients. Thus, it’s not likely that we will soon see “Leg Care Clinics” popping up in international terminals to offer a quick pre-flight shot of anti-DVT elixir. 

Dehydration: “Drink some blasted sports drink.”

It’s so easy to get dehydrated when traveling. There’s the dry air of a pressurized cabin, the mile-high altitude, and the stress and exertion of it all. With dehydration can come fatigue, grumpiness, a wicked headache, and (perhaps) an increased risk of DVT. So, what is the best way to stay hydrated? Common sense dictates that one avoids excessive alcohol and limit caffeinated beverages. But, what about drinking water? A 2002 JAMA study by Hamada et al. found that in-flight blood viscosity is better controlled with an electrolyte-enhanced beverage (110 mg of sodium and 30 mg of potassium per 8 oz) versus water alone. Perhaps your flight attendant should be serving Powerade rather than punchless coffee? Since that’s not likely to happen, bring packets of sports drink powder to mix with flight beverages.

The dry air of a plane can parch external body parts too – like the nose, eyes, and skin. A bloody nose or corneal abrasion at 30,000 feet is not going to help anyone sit back and enjoy the flight. So, for at-risk folks, Vaseline for the nostrils and liquid tears for the eyes are great ideas.  

Dry skin can be a real issue too – and believe it or not this has been documented in the literature. A French study of eight volunteer long-haul airline passengers observed that in-flight skin capacitance decreased rapidly on both the face and forearms – with the most pronounced changes on the cheeks where it decreased by up to 37%. So, how about some aloe vera to go with that moist towelette?

The good news about the arid airline air is that it helps keep infectious organisms at bay. Thus, I wouldn’t worry too much about the cabin air circulation, but would, of course, worry about a febrile-appearing lady with a productive cough sitting right next to me.  

      Physical abuse from your surroundings: “Avoid the pill-popping rugby player."
      I am well aware that carry-ons can tumble out of the overhead storage bins and that tall guys, like me, can bonk their heads, but accidental strangulation by a fellow passenger? That hadn’t occurred to me until several hours and two movies into our flight to Auckland. I sat crookedly next to my large and slumbering neighbor and resolved to fall asleep. Suddenly, though, a fire-siren-like scream rocketed through the cabin and a log-sized arm pinned my neck against the seat. Fortunately, the arm relaxed and I breathed again as my seatmate stood up, still screaming, and starting shaking the row in front of him. It all looked like an impromptu Maori war dance, the Haka. Luckily for me, and for the economy class as a whole, this hulking fella had some equally large friends with him – they jumped to his (and my) aide. Later, as they mercilessly ribbed him, I learned that he’d taken a double dose of Ambien, which had contributed to a very realistic nightmare. Why hadn’t my captain warned me about this. 

     Well, there you go, a brief guide to keeping the skies health friendly. Oh, and please do not forget, systematic reviews have established that “tampering with, disabling or destroying the lavatory smoke detectors is prohibited by law.”

      Kia Ora (Cheers) from New Zealand.