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Disability is a full time job

19 Oct

For persons enduring a severe disability, daily life is a full time job.
Two bloggers share courageously with us their daily struggles to show the amount of supplementary efforts they have to produce just to save an appearance of fluidity (not to say normality).
One blogger compares disability with an iceberg whose greater part is not visible:
An other blogger compares disability with an handful of a limited number of spoons. All seems normal to the surrounding peoples who examine her life as long as she has a sufficient number of spoons left in her hand. But each daily life efforts along the day takes one spoon away from her and when there is only one left in her hand she must stop for the rest of the day and all the activities she has still to do must wait for the next day:

The body of work that economists have done on the field of relationship between happiness and disability shows that not only the disabled persons themselves are less happy but also are their spouses, although this must be tempered by the numerous adaptive strategies that the couple puts in place.
A resume of the scientific literature here:

Journal of Public Economics
June 2008, Vol.92(5):1061–1077, doi:10.1016/j.jpubeco.2008.01.002
Does happiness adapt? A longitudinal study of disability with implications for economists and judges
Andrew J. OswaldNattavudh Powdthavee

Social Science & Medicine
December 2009, Vol.69(12):1834–1844, doi:10.1016/j.socscimed.2009.09.023
Part Special Issue: New approaches to researching patient safety
What happens to people before and after disability? Focusing effects, lead effects, and adaptation in different areas of life
Nattavudh Powdthavee

Social Science & Medicine
April 2014, Vol.107:68–77, doi:10.1016/j.socscimed.2014.02.009
Is shared misery double misery?
Merehau Cindy MervinPaul Frijters

We find that the events befalling a partner on average have an effect about 15% as large as the effect of own events.

Quoted from :

Journal of Economic Psychology
August 2009, Vol.30(4):675–689, doi:10.1016/j.joep.2009.06.005
I can’t smile without you: Spousal correlation in life satisfaction
Nattavudh Powdthavee

Geography is destiny in medicine

6 Apr

Heraclitus of Ephesus (Ἡράκλειτος, Herakleitos; c. 535 BC – 475 BC), a Greek philosopher, is known for having said: character is destiny (otherwise said A man’s character is his fate.)
The two main reasons why the derived adage “geography is destiny” applies to medicine are first that exposure to diseases risk factors varies from one region to another in a same country with the same health services and health insurance coverage :

and second that the pattern of care chosen by practitioners to treat the population for a given condition also greatly varies depending of the place of abode (still at a same health services and health insurance coverage level):

“A study of the geographic distribution in elementary school children discloses no correlation between Tonsillectomy and any other factor, such as overcrowding, poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications for operation.”

Quoted from:

Click to access goodman.pdf

There is tremendous unexplained variation in rates of surgical procedures from hospital catchment area to hospital catchment area, and region to region that cannot be explained by epidemiologic factors. For example, colleagues and I discovered in 1992 (see Spine, 1992) that the 15 fold difference in surgical procedures on the spine in Washington State was inexplicable by almost all population and diagnostic factors.

Quoted from:

From the citations quoted above we could even go further in completing the adage by saying: in medicine geography is not only destiny it is also the caregiver.

The Decrease of life expectancy.

18 Mar

For the first time in history life expectancy decreases in a industrialized country as shown in the study below:

The New York time reported one of the key result of the study in a article entitled “Life Spans Shrink for Least-Educated Whites in the U.S.”here:

These data must be integrated to the social policies that are based on the assumption that the upcoming generations will live longer.

Paul Krugman, the Nobel prize of economy, explains this reversing trend by the increase of income inequalities at a macroeconomic level here:’s-greatest-public-health-champion/

How we pay our Doctors

2 Mar

Before the health insurances era Doctors were often payed in nature with eggs, chicken or other farm products. Needless to say that they were often poorly paid, furthermore people called them so lately that the care was unable to keep them alive and the doctors lost their patients in the same time. Once the Doctors and the people they cared got the health insurances to be created Doctors received currencies for their services and could see more than once their patients. The issue of payment was transferred to the insurer. In the beginning insurers reimbursed with a fee for service model like the patients did previously. But the increasing amount of money needed made them think of an alternative payment model. And here came the Pay for Performance model.

France has already put in place such a payment model here:

Click to access conv_med_annexes_110726.pdf

USA will implement this mode of payment in 2019 here:

Developing countries have already experienced these kind of payment here:

Click to access impact-of-pay-for-performance-on-utilization-of-health-services-and-quality-of-care-in-low-and-middle-income-countries.hccr.1000116.pdf

Below are other links related to the way Doctors will be payed in the future:

Breast cancer mortality and screening: results of a randomized trial approved by the School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada;

15 Feb

In 1980 the School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada approved a randomized controlled trial: 89 835 women, aged 40 to 59, were affected at random to either an annual mammogram during five years or an annual physical examination without any mammogram during the same period of time. Now 25 years after the results are publicly available here:

Click to access breastscreening.pdf

And they are astonishing, so astonishing that we feel compelled to quote them:

“Conclusion Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.”

Meaning: not only searchers did not find any evidence of difference in the instantaneous risk of death from breast cancer between the two groups (hazard ratio not significantly different from one) but moreover what they found was over-diagnosis of breast cancers (ie 106 more cancers in the mammogram group even 15 years after the screening that is even when all the cancers of the non screening group should have been detected due to their natural evolution).

Those chilling facts have to be discussed, that is the least that we should do in the health services community given the budget allocated to breast cancer screening by mammograms.

Perhaps the mammographies in the eighties were not as sophisticated as those which are offered now? And in the contrary physicians in the eighties were perhaps more efficient than the 21century doctors at the physical examination of the breast?

Thanks to the incidental economist who gave me the news:

Health care costs

28 Jan

Interesting thoughts of a retired Doctor:

Who is the caregiver?

26 Dec
English: Healthy Life Years and Life Expectanc...

English: Healthy Life Years and Life Expectancy with Disability in the 25 EU Member States, 2006, both sexes (Photo credit: Wikipedia)


The end of life is not the same for women and men. It is common to think that women are more healthy, live longer and thereof can support their partner. But in fact, at birth, the difference for one individual between his Life Expectancy (acronym LE) and his Healthy Adjusted Life Expectancy (acronym HALE) is larger in average for women than it is for Men. So there is some chances that the care giver could not be the one we thought of at the first sight.
The link below is the address for a very sensitive article posted by France Woolley.




Hospital Spending Intensity and Patient Outcomes

25 Dec
English: Data Source

English: Data Source (OECD Health Data 2009). Health care cost rise based on total expenditure on health as % of GDP. Countries are USA, Germany, Austria, Switzerland, United Kingdom and Canada. (Photo credit: Wikipedia)

An amazing study implemented by Canadian health services researchers and published in the Journal of American Medical Association, suggests that depending which side of the border between Canada and the USA you live on, the consumption of the same expensive acute health cares results in different outcomes in term of patient’s health and quality of care. In other words, it is not so a matter of “how much” but rather a matter of “how” when it comes to question the legitimacy of a nation’s health care expenditures. The authors schedule to extend the field of their study to European countries and also to the long-term cares of chronic conditions.

Changing Mindsets -Strategy on health Policy and Systems research

22 Dec

The report referenced below with its internet link reflects the strong incentives given by the WHO to enhance the articulation between research in health systems and research in health policy in one hand and the decision making at the political level in the other hand in the realm of health care and health coverage. Nine countries are studied, including China, Thailand and Nepal for the Asian part of the World.

Click to access alliancehpsr_changingmindsets_strategyhpsr.pdf

Social spending after the crisis

12 Dec
English: World GDP growth rate and GDP growth ...

English: World GDP growth rate and GDP growth rate of total OECD countries. Data source: World Bank Group and OECD. (Photo credit: Wikipedia)


Social spending after the crisis

This report by the Organization for Economic Cooperation and Development (OECD) ranks the countries with regard to their net social expenditure in proportion of their Gross Domestic Product. When taking into account the taxes applied to social benefits and the social expenditures borne by the private sector, France and the USA rank in the first places (30 % of their GDP) while Korea and Mexico are the two countries that spend the less in social expenditure be it in cash or in kind (around 10 % of their GDP). Overall the average is 20 to 25 % of the GDP. The social expenditures includes cash benefits like pensions or unemployment benefits (12.6% of GDP in average) as well as the financing of social and health services (9.0% of GDP in average).

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