H1N1 vaccination part 2

This is written in response to the previous question (Nov 18) raised, as well as to provide a brief update on the H1N1 vaccine.

"What do you feel is the most prudent/cost-effective way of spending $6 million of taxpayer's money (with regards to low H1N1 fatality and 200,000 vaccine doses set aside for essential government personnel)?"

I have been reluctant to respond, because it is clear that the answer will vary depending on one's perspective and priorities, and the circumstances at that point in time. There are many interest groups in health that will appreciate a $6 million injection - research (even though the funding has already been exceptionally generous, especially to a few focus groups), cancer care, elderly, mental health, dialysis, safety initiatives, community coverage, etc. Try to cater to all, and even $6 million starts to look rather miserly. Disburse the money to a few, and the others will inevitably wonder about priorities/favoritism.

MOH has chosen to spend this money on H1N1 vaccine doses for essential government personnel, all of whom no doubt can afford the vaccine on their own (but probably only about half who would otherwise have spontaneously gone to get themselves vaccinated). That is its prerogative, and the decision is not as bad as it has been made to look.

Now, about the inactivated H1N1 vaccine (or the various types of inactivated vaccine - they are more or less similar):

1. Its efficacy in published studies is anywhere between 61% to 92%. Obviously less effective if one is older, or one's immune system is less robust. On average, the vaccine will probably not trigger off a protective response in 1 of 4 persons. These figures are similar to the usual seasonal influenza vaccines. Of course, if you have already had H1N1, there is no need to get vaccinated.
2. The side effect profile is the same as seasonal influenza vaccines as well. Most people with adverse events have fever, while a rare few will have a more serious adverse event. Anywhere between 0.8 to 6 persons out of every 1,000 vaccinated will develop an adverse event. In short, the vaccine is far safer than getting H1N1.

Many doctors I know have not received the H1N1 vaccination - even though it is free for healthcare staff in the local public hospitals. There are a plethora of reasons (including convenience and work schedule issues), but the gist of it essentially boils down to this: the fear of getting a rare but serious side-effect outweighs the (higher) risk of getting a largely benign illness that one is familiar and experienced with. It is a known psychological issue, and it is not because the doctor has somehow obtained secret/unreleased knowledge about H1N1 vaccine risks.

Subsidized healthcare

I am one of those who read Dr Lee Wei Ling's (i.e. the MM's daughter and NNI director) articles in the Straits Times regularly. Although her writing is sometimes somewhat divorced from the reality on the ground, her pieces are often thought-provoking and she is one of those with the capability of pointing out unpleasant truths in our system.

Yesterday's piece was no exception. In just a few short lines, she has laid bare some of the issues of subsidized patients in our public hospitals. If you are not a full-paying patient, you cannot choose your doctors - that is well understood. What is less well understood is that sometimes, the doctors may not choose you. Usually there is a senior doctor on call each day for each specialty who will review all comers for that day. But the subsidized patient may be operated on by a junior doctor (for a surgical case) if the condition is not sufficiently complex, or be followed up as outpatient by a junior doctor. If you are better connected (i.e. if you are related to the powers that be or if you know Prof Lee), the rules may be bent. Sometimes to a degree that is quite disturbing (a bouquet of flowers!), if you read her article.

Access to services can be a bit slower as well for the subsidized inpatient. We are not talking about the former notorious NHS-style speeds, but that CT or procedure may just be a day or two slower than for a full-paying inpatient. Part of the medical officer or intern's job scope (and this is not spelt out in medical school) is to improve the efficacy of service delivery by trying to get that procedure or scan done faster. Sometimes, these junior doctors lie outrageously or pull strings, but hey - whatever gets the job done.

Does this difference in treatment between subsidized and private patients in public hospitals matter? MOH has always been careful to suggest that it doesn't. But you cannot find many published studies that have examined this issue with any amount of rigour. You might want to ask why not - after all, it is a very relevant area of study with regards to health policy locally.

The more myopic question is - why won't some (I have to reiterate that it is "some" and not "all) senior doctors see subsidized patients more regularly? I am sure this is not a problem at NNI, where the director would come down like "a tonne of bricks" on errant doctors. The answer has probably to do with incentives and how senior-grade doctors are remunerated in the public hospitals. Ultimately, they just get paid more for seeing - or performing procedures on - private patients. Or better yet - foreign private patients that fuel our medical tourism industry (where a surcharge above even the private rate can potentially be levied).

Interesting Article About The ER

Forwarded by someone who reads my personal blog. Thank you. :)

Something to remember with the holiday season coming. This piece may come from the U.S., but we face the same situations here.


Choice quotes:

"We have people who've called an ambulance for earwax impaction or prescription refills."

"Even if it happens to be less busy on a night or weekend, the staffing is lower. There may only be five people ahead of you, but it will take a while to get seen."

"People will come in and say 'I'm on five different drugs,' but that isn't as helpful as knowing the actual names."

"He recommends keeping the names of your medications on a card in your wallet. Or throw your medications into a bag and take them to the hospital to show the staff."

"Try to be understanding: The reality of the ER is that unless you're dying, you're going to be treated after someone who is in much worse shape. "Going up to the nursing station and yelling and raising your voice about a relatively minor complaint is often counterproductive." "