This, from Austin Frakt over at the Incidental Economist, is a terrifying chart. It shows potential years of life lost to different diseases, from circulatory issues to congenital defects, in the United States compared with other OECD countries.

The bubbles with numbers greater than one mean the United States is losing more life to a particular condition than the average member country in the Organization for Economic Cooperation and Development. A bubble with a number less than one means Americans are losing fewer years of life, although you don't see many of those, because, in every category measured in 2008, the United States did worse than than average.

Americans lose three times as many years of life to infectious diseases as the average OECD country and loses twice as many years to metabolic diseases. There are some categories in which America used to lose fewer years of life than other countries back a few decades ago. But, ever since the 1980s, that hasn't happened.

How did we end up here? Here's the JAMA authors' attempt at an explanation, via Carroll, which lays blame at the very fragmented structure of the American health-care system:

Possible causes of this departure from international norms were highlighted in a 2013 Institute of Medicine report and have been ascribed to many factors, only some of which are attributed to medical care financing or delivery. These include differences in cultural norms that affect healthy behaviors (gun ownership, unprotected sex, drug use, seat belts), obesity, and risk of trauma. Others are directly or indirectly attributable to differences in care, such as delays in treatment due to lack of insurance and fragmentation of care between different physicians and hospitals. Some have also suggested that unfavorable US performance is explained by higher risk of iatrogenic disease, drug toxicity, hospital-acquired infection, and a cultural preference to "do more," with a bias toward new technology, for which risks are understated and benefits are unknown. However, the breadth and consistency of the US underperformance across disease categories suggests that the United States pays a penalty for its extreme fragmentation, financial incentives that favor procedures over comprehensive longitudinal care, and absence of organizational strategy at the individual system level.

source:  www.washingtonpost.com

The World Health Organization is considering cutting the amount of sugar it recommends in your daily diet to half the current limit.

Experts are proposing cutting the recommended level that people should consume from no more than 10 percent of their calories from sugar to no more than five percent, based on fears of heart disease, obesity, and tooth decay, The Sunday Times in the UK reports. The new requirements equate to about five teaspoons of sugar a day - about the same as in a Mar bars or in half a can of a soda.

"It is political dynamite," said Philip James, president of the WHO-affiliated International Association for the Study of Obesity, in the report. "The food industry will do everything in their power to undermine this."

"I would agree with the recommendation to reduce it to five percent," added Shrinath Reddy, a cardiologist and a member of the WHO panel of experts. "There is overwhelming evidence coming out about sugar-sweetened beverages and other sugar consumption [being linked] to obesity, diabetes and even cardiovascular disease."

According to recent data from the Centers for Disease Control and Prevention's National Center for Health Statistics, most U.S. adults get a whopping 13 percent of their total calories from added sugars alone. Not only does that add a lot of extra calories which contribute to making us fat, sugary items often displace healthier items, such as fruits, vegetables, and foods packed with nutrients.

source: www.nydailynews.com

A new report by UK think tank Overseas Development Institute says the number of people who are overweight or obese rose 23 percent from 1980-2008. But the overweight population in developing countries has surpassed developed countries.

About 1.46 billion people, or one-third of the world's population, is obese or overweight. But 904 million who are overweight are in developing countries compared with 557 million in developed countries. Obesity is a worrying trend in healthcare as it increases the risk of developing chronic conditions such as diabetes and cardiovascular disease. Many countries in the developing world are facing a two-pronged problem of hunger and obesity.Geographically, the most dramatic increase in overweight people has been Southeast Asia, where numbers rose from 7 percent to 22 percent, according to a BBC analysis.

Some of the biggest drivers behind the weight gain is the fact that with rising incomes people have more choice of what they want to eat. That has led to a shift from eating cereals and grains to greater consumption of fats, sugar and oils. An increase in city dwellers can mean less opportunity for exercise.

One of the conclusions of the report is that governments need to take a less timid approach to diets similar to the way they have addressed smoking.

When taking action to limit smoking, governments have often led the way, driven by the strong evidence from medical studies showing the harm caused by cigarettes. Although diet is a more diverse and complex issue than smoking, there may be scope for government to take more incremental measures, perhaps using measures in combination, to pave the way for public acceptance that something needs to be done if future health costs are to be contained.

A 2013 World Health Organization report offered a dramatic illustration of the spread of obesity. It pointed out that its spread to almost every region of the world meant that the years of life lost from obesity outnumber those lost by hunger.

source: medcitynews.com

Tripling cigarette taxes would prevent tens of millions of smoking-related deaths worldwide over the next few decades, and about 200 million premature deaths over the remainder of the century as a whole, a Canadian-led review concludes.

If current smoking trends hold, tobacco will kill about one billion people this century, Prabhat Jha, director of the Centre for Global Health Research at Toronto's St. Michael's Hospital and the University of Toronto writes in this week's edition of the New England Journal of Medicine.

In Canada, smoking remains the leading cause of preventable deaths. More than 40,000 Canadians die each year from lung cancer and other smoking-related diseases, according to the Public Health Agency of Canada.

Many are killed in middle age: Studies in the U.K. the U.S., Japan and India show that smokers are two to three times more likely to die between the ages of 30 and 69 than non-smokers, according to Jha and his co-author, Sir Richard Peto of the University of Oxford.

"Some of those killed in middle age might have died soon anyway, but others might have lived on for decades," they write.

On average, smoking costs people a full decade of life, Jha said.

But his own research published this past year shows that smokers who quit before age 40 avoid 90 per cent of that excess risk, "meaning you get back nine of the 10 years you would have lost if you had continued to smoke."

Even those who quit at age 50 gain back six years of life expectancy.

"The risks are big, and the benefits of quitting are huge," Jha said.

"This prompted us to ask, what would it take to really knock down consumption?"

Doubling the inflation-adjusted price of cigarettes should cut consumption by about a third worldwide, Jha and Peto conclude.

In low- and middle-income countries, that would mean tripling inflation-adjusted specific excise taxes on tobacco — tax hikes that would double the street price of cigarettes in many countries, and more than double prices for cheaper brands.

In Canada, the federal excise tax on a carton of cigarettes is $17, according to background material released with the study.

Federal and provincial sales taxes bring the total cost of a carton to between $46 and $87.

But Jha said there hasn't been a significant increase in the federal tobacco tax since then Finance Minister Paul Martin raised taxes in the early 2000s.

France and South Africa halved consumption in less than 15 years by tripling cigarette prices.

In Canada, smoking rates have flatlined after years of steady decline.

Statistics show that five million Canadians were smokers in 2011, as many as there were in 2008.

"Our evidence suggests that, even in Canada, a big increase in the federal excise tax could get about one million smokers to quit and save about 5,000 lives a year," Jha said.

The biggest barrier is tobacco's "enormous profitability," he said. Worldwide profits for the tobacco industry reached $50 billion U.S. in 2012, or about $10,000 for every smoking-related death, Jha said.

But he and his co-author argue that the extra revenue per pack would offset the effect of tax increases on consumption, and that raising excise taxes to double prices "would raise about another $100 billion (in U.S. dollars) per year in tobacco revenues, in addition to the approximately $300 billion that the WHO (World Health Organization) estimates governments already collect on tobacco."

But the biggest argument is the "hundreds of millions of tobacco-related deaths if current smoking patterns persist."

source: www.montrealgazette.com

After an almost 10-year delay, the law on the national social security system will be implemented on Jan. 1. This Law No. 40/2004 is equivalent to the Old Age, Survivor, Disability and Health Insurance Act or the Social Security Law of the US. Both laws were enacted after severe financial crises that alerted the countries to the crucial need for a social security system to overcome financial catastrophes.

While the US law covers four programs, Indonesia's national social security covers five programs, namely health insurance, occupational injuries, provident funds, pension and death benefits.

There are some differences between the laws of the two countries. The US Social Security Law, without health insurance, was passed just three years after the 1932 Great Depression.

Indonesia's law was enacted six years after the 1998 financial crisis and two years after the amendment of the 1945 Constitution. Further, the health insurance part of the US law was added later in 1965, creating its Medicare program.

But Indonesia's health insurance covers only the elderly using a pay-as-you-go funding mechanism. In Indonesia on Jan. 1, the health insurance part will for the first time cover Indonesian citizens and foreigners residing in Indonesia for more than six months. Another difference is that the entire US social security system is administered under a single agency, the Social Security Administration under the federal government.

Meanwhile, the administration of our social security is under two different quasi government agencies under Social Security Providers (BPJS), one catering to health coverage and the other in charge of the other four programs. The Indonesian model follows the similar separation of short-term and long-term programs of social security in Taiwan, the Philippines and South Korea.

Another unique feature of the Indonesian system is that since the beginning, in 2004, the Cabinet of President Susilo Bambang Yudhoyono seemed reluctant to pass the Social Security Law. The government, however, bowed to pressure following a lawsuit and widespread demonstrations mobilized by the Action Committee for Social Security (KAJS), which comprised 66 labor unions, student associations and NGOs.

Indonesia's national health insurance (JKN) program is administered separately by BPJS Kesehatan, previously PT Askes Indonesia, in a program similar to that in the US, Canada, Taiwan and Australia. It represents a single payer health care to meet basic healthcare needs, meaning all medically necessary treatment, of the entire Indonesian population.

The JKN covers comprehensive benefits, from influenza to expensive medical intervention such as open-heart surgery, dialysis and cancer therapies.

The program covers medical necessities and hotel-type services. JKN funding comes from mandatory contributions from all workers and a government subsidy for the poor and near poor. Hotel-type services are limited to a first- or second-class room and board for those who pay 4.5 to 5 percent of their monthly wages. The poor and the near poor needing hospitalization, covered by the government subsidy, are entitled to a third-class room and board.

The BPJS Law No. 24/ 2011 prescribes that on Jan. 1, the JKN will start by integrating the administrations of four current public health insurance plans. To undertake the JKN, the world's largest national health insurance plan, PT Askes (currently a parastatal company) has been transformed into a public, non-government entity named BPJS. While PT Askes was tasked to make money or profit from the sick for the government, the BPJS must ensure that every contributor gets necessary medical care. From the New Year, public health insurance will first cover about 120 million people.

An additional 10 million to 20 million people may enroll during 2014, most likely those suffering from chronic diseases or catastrophic diseases such as renal failure and cancer.

Many have criticized the fact that the scheme is not supported by adequate number of healthcare providers. However, the current utilization of healthcare providers shows that, for example, the average bed occupancy rate of all hospitals has been only about 60 percent. Similarly, many offices or clinics are under-utilized.

Meanwhile, our healthcare system is suffering from a shortage of specialists and low-quality care resulting from severe underfunding. In the last 40 years, Indonesia spent only about 3 percent of its gross domestic product (GDP), much below other large countries such as China and India that spend more than 5 percent of their GDP on health.

Despite all the preparations by the government and the BPJS, there are still potential problems — mainly low contribution resulting from unfair intervention by some employers and employee associations.

Some employers' association representatives lobbied the government to set a low-ceiling for wages and thus low health security coverage contributions; while employees, citing their low wages, refused any cuts for social security.

Similarly in 2014, the government is only willing to contribute Rp 19,225 (US$1.57) per person per month for the poor. Although the amount is much higher than the 2013 allocation, the figure will not meet average market costs to provide good care by the private sector.

The government's contribution was being criticized as discriminatory; as the President also issued a decree on financing supplemental health insurance for high-ranking officials at Rp 1.6 million per person per month, about 80 times more than the government contribution for the poor. Following such criticism the President revoked the regulation on Monday.

Fearing insolvency caused by current contribution levels, the Health Ministry set low reimbursement levels. Although private healthcare providers are not mandated to contract with the JKN, the low reimbursements will create low interest among private providers, leading to overcrowded clinics and beds at state providers. Currently, state hospitals nationwide supply about 50 percent of beds.

Further, the fact that the BPJS will issue BPJS membership cards will create a perception of non-inclusiveness by healthcare providers. The BPJS should issue a JKN card, as commonly practiced around the world.

The low payments to healthcare providers and the exclusivity of the BPJS will discourage quality medical services. The JKN needs quick monitoring and rapid fixing to ensure sustainability. So, let's fasten our seat belts to anticipate some turbulence in the first stages of Indonesia's universal health coverage.

The writer is chair of the Center for Health Economics and Policy Studies, University of Indonesia, and was a former member of the Presidential Task Force for the National Social Security System.

source: www.thejakartapost.com

As head of the Centers for Disease Control and Prevention, Thomas Frieden oversees an agency with the sprawling mission of reining in diseases in the United States and across the globe. From fighting food-borne illness outbreaks and influenza epidemics to educating people about the risks of obesity and smoking, the CDC's work touches every corner of public health.

Given that broad range of responsibilities, we asked Frieden about what he considers the top public health priorities for 2014. Below are five areas he said deserve special attention, and why each is important. His comments have been edited for length:

1. Increasing human papilloma virus (HPV) vaccinations.

The bottom line here — this is an anti-cancer vaccine. Usually, when we introduce a new vaccine, we expect the uptake will be gradual and will increase by about 10 percent per year. HPV has stalled. We're at 30 percent, and it didn't increase at all last year. The country of Rwanda is at 85 percent. If we were at 85 percent, then 4,400 girls alive today would not get cervical cancer in their lifetimes. But because we're not, they will.

2. Fighting the growing problem of antibiotic resistance, which kills an estimated 23,000 Americans each year.

We talk about the antibiotic era and the pre-antibiotic era. But if we're not careful, we're soon going to be in a post-antibiotic era. There are now organisms out there that are resistant, potentially, to all the drugs that we have. And they're spreading. We need to scale up the work that we're doing at CDC to support doctors and hospitals to have more rational and more effective strategies for treating patients, so that we can treat infections that could be fatal but don't waste the antibiotics that we need to preserve for ourselves, our kids and grandkids.

There's a series of things we have to do. One is, we have to track things better so we know what's happening when, where and why. The second is to do a better job of responding when there are outbreaks. So, if we have a cluster of cases, we swoop in with the state, with the hospital, with the local in coordination and stop it. The third is to prevent it better, so we figure out how it's spreading and prevent that in the future.

3. Reducing deaths attributable to prescription painkiller abuse and overdose.

This has been one of the very few things in health that has gotten substantially worse over the past decade. There's no reason it has to. This is a problem that is, to a very great extent, caused by the health-care system. I believe we can do a great deal to reverse this problem through public health action and coordination with law enforcement. There's really good, bipartisan agreement on what needs to happen. But we need to make it happen. We need to support states, support localities and reduce the risks to people by improving the management of people with chronic pain.

We want to make sure people with pain get effective treatment, but we know that all too often, the path of least resistance for a physician may be to prescribe long-acting opiates. But the risk-

benefit ratio of those opiates isn't adequately recognized. There are a lot of risks and pretty uncertain benefits. Someone who's got cancer and is likely not to survive the cancer — we want to absolutely make sure they get every bit of palliation they need. But that's very different from someone who's got back pain and comes in and asks for a prescription and may end up addicted for life.

4. Ending polio once and for all.

Polio eradication is something that CDC has been working on since 1988. We're closer than we've ever been, but that last mile is always the hardest.

Fundamentally, it's about Nigeria and Pakistan. In both countries, you have insecurity and violence. In Pakistan, you have assassination of health workers who are protecting children from paralysis. It's almost inconceivable. In Nigeria, you have some violence in some areas; that was the big setback last year. But you also have a health system that doesn't always reach where it's most needed.

When we began this [effort] in 1988, there were about 1,000 kids per day who were paralyzed by polio. Last year, there were just a couple hundred. So we've made a lot of progress. But until we get over the finish line, every kid everywhere in the world is at risk, because polio anywhere is a risk everywhere.

5. Defending against health threats that originate elsewhere in the world.

We are all connected by the air we breathe, by the water we drink, by the food we eat. What we're seeing is that it's part of our self-interest to ensure that countries all over the world are better able to find, stop and prevent health risks. It will help them be safer, more productive, more stable. And it will help us protect Americans from threats that could end up making us sick or killing us.

Ten years ago, after the SARS epidemic, the Chinese government began working with the CDC and said, "We want to create something like a CDC for China." And they did. When it came to the flu, we helped them learn how to grow the flu virus in the lab, how to do tracking to see where flu is spreading. We helped them to become a World Health Organization collaborating center for influenza. We helped them learn how to sequence the entire genome of the flu virus.

Because of that, when the H7N9 [virus] hit, they found out about it promptly, they rapidly responded and they informed the world openly about it. In fact, they posted on the Internet the genome of the H7N9 within hours of identifying it. That allowed us to make a diagnostic test so we could find out if people have flu, and to begin making a vaccine.

This is a long-winded way of saying that it was a harvest of 10 years of collaboration with the Chinese, that they were able to find this faster, stop it faster and share information faster. We need to do that with many countries and many diseases, all over the world, or we won't be safe.

source: www.washingtonpost.com

Health authorities in China are investigating one of the nation's biggest vaccine makers after eight infants died in the past two months following injections that were meant to immunize them against hepatitis B.

The government said this week that it had suspended the use of millions of doses of a hepatitis B vaccine produced by the manufacturer, Shenzhen Kangtai Biological Products. Government inspectors have been sent to examine the company's facilities.

Six of the deaths have been linked to vaccines produced by Shenzhen Kangtai; the two other infant deaths occurred recently after the use of a hepatitis B vaccine produced by another drug maker, Beijing Tiantan Biological Products. The government did not say whether any action had been taken against Beijing Tiantan or its vaccines. Investigators have not determined the cause of the deaths or linked them directly to the injections, but the cases come at a time of growing public concern in China about food and drug safety problems.

In recent years, China has been troubled by a series of scandals, including tainted rice and milk and the mysterious appearance of thousands of dead pigs floating in the Huangpu River in Shanghai. China has vowed repeatedly to crack down on food and drug safety violations and has moved to strengthen the powers of health officials.

In the vaccine cases, the government is focusing on the role of Shenzhen Kangtai, a privately run drug maker formed in 1992 with government support and the cooperation of the American pharmaceutical company Merck.

Merck helped the company build its drug-manufacturing facility in the city of Shenzhen in the 1990s, and it gave the company the biological technology to produce a hepatitis B vaccine royalty free as part of an unusual joint venture aimed at improving health standards in China. At the time, up to two million Chinese children were being infected annually with hepatitis B.

Since then, China has made great strides in early vaccinations under a national program subsidized by the government. And Shenzhen Kangtai has become the country's biggest producer of hepatitis B vaccines, with a 60 percent market share, according to China's state-run news media. The company has also announced plans to build a $140 million research and development and drug manufacturing center in Shenzhen.

A representative for Shenzhen Kangtai could not be reached Wednesday, although the company denied last week that its vaccines were at fault in the recent infant deaths.

Although the authorities have banned the use of Shenzhen Kangtai's hepatitis B vaccines at medical facilities, health experts say there are enough vaccines produced by five other Chinese drug makers to meet the demands of the national immunization program. In China, most hepatitis B vaccines are provided free to newborns.

Hepatitis B, which attacks the liver and can lead to death, is the most virulent form of hepatitis, according to the World Health Organization. Chronic forms of hepatitis affect about 500 million people a year worldwide.

source: www.nytimes.com

Jakarta's progressive healthcare program — then known as JPK Gakin — has been officially named since 2011 as a pilot project for nationwide universal health care, which the central government must implement beginning in January.

The program later rebranded and expanded under the Jakarta Health Card (KJS), becoming the centerpiece program for Jakarta Governor Joko "Jokowi" Widodo when he took office in 2012. The former mayor of Surakarta launched the program within a month of moving into his new office in Jakarta.

KJS instantly became the envy of people in other towns and cities who wondered why they could not have the same benefits. Surveys show that Jokowi is the most popular candidate for the 2014 presidential elections, even though it remains uncertain whether he will run or be nominated.

Like Obama, Jokowi's political fortunes hinge on the rise or fall of his healthcare program.

If the KJS fails — and there are many who want to see it fail — it could stymie Jokowi's presidential ambitions. But success might mean Jokowi will cross Monas Park from the governor's office to the Presidential Palace next October.

"Jokowi-care" faces major problems that need addressing, especially when the program is introduced at the national level. There are questions about the availability of resources (doctors and hospital wards), funding and its sustainability, and about the overall efficiency and effectiveness of government health care.

Some of these problems have already emerged.

In March, 16 private hospitals threatened to leave the KJS, citing unfair soaring costs.

They backed off after Jokowi agreed to reimbursement rates for hospitals under the KJS.

The program's effectiveness depends on the collaboration between the government, state-owned health insurance company PT Askes and hospitals, according to Hasbullah Thabrany, a public health expert at the University of Indonesia (UI).

"The problem is there is still little trust between these three," he says.

While welcoming the move to standardize hospital rates under the Indonesia Case Base Groups (INA-CBGs), he questions why the government must further allow some hospitals to charge vastly different rates.

"When you buy a cup of coffee, why would you want to pay so much more for the same cup? Hospitals essentially provide the same treatment, so why should we allow some to charge more?" he asked.

The KJS uses the INA-CBGs to set reimbursement rates from the Jakarta government.

INA-CBGs is an online software system that calculates claims for 14,500 ailments and 7,500 procedures, and includes doctor's fees, facilities, medicine and third-class rooms.

The rates were set through negotiations led by the Health Ministry, hospitals and doctors. The INA-CBGs differentiates the rates for 12 different reference hospitals, allowing up-market facilities to file higher claims.

Officials at Askes believe that the national healthcare system will follow the KJS mechanism, including requirements for local health community center referrals.

Askes will deploy staff at hospitals and train hospital workers to administer the program, says Irfan Humaedi, Askes chief public relations officer.

Taufiqqurahman, a member of the Jakarta Legislative Council and a vocal critic of KJS, has toned down his opposition to "Jokowi-care."

"I am not opposed to the program, I actually support it," says the politician from the Democratic Party.

"But I had problem when Jakarta enlisted the services of PT Askes, because it makes the program prone to graft," he says. "Health care should be provided by the government, not by private companies."

Still, Taufiqurrahman did not miss Jokowi's penchant for populism, such as when the governor visited neighborhoods and personally handed over health cards at the start of the program.

"Jokowi is politicizing this healthcare issue to boost his own image," Taufiqurrahman says. "He should be working to improve the number of doctors and hospital workers, improve their salaries. He should not be out there giving out cards."

source: www.thejakartapost.com