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MONTERREY, MEXICO – If parents here are late getting their child inoculated, a public-health nurse will come to their home, pull down the youngster's pants and give the vaccination right there in the living room. If the parents are away at work, the nurse does not wait for them to come home and give permission. Shots are given anyway, and the paperwork is left with the baby sitter. It is a paternalistic approach almost impossible to imagine in the United States - where privacy rights and other freedoms are highly valued and immunizations are increasingly feared - but it has proved remarkably effective: Mexico has a 96 percent vaccination rate for children ages 1 to 4, compared with an immunization rate of 79 percent for 2-year-olds in the United States.
Regrettably, the cost of insurance comes up frequently in my practice by necessity. Not just with figuring out which medicines an insurance company will reimburse for (down to needing to figure out if they prefer I prescribe capsules vs tablets of the sane medicine) but which procedures are reimbursable, which specialists they can see, how they get psychotherapy, if they can afford a followup visit with me, how their colonoscopy might get billed, or if their finances will be nuked to high heaven if they end up in the emergency department of hospital.
14 years ago in residency I did a rotation in Ireland and was amazed how much different practice was there (at least in rural County Clare) than what I'm used to in the US. Our copay here cost the same as the cost of their entire visit. The state paid for hospitalizations for everyone. Dr Gerry ran his entire practice on a 500 Euro piece of software with one nice lady in the front office and he got paid about the same as his US peers. He also had a nurse who handled much of the lady business. 16 year old girls were counseled on not imbibing more than two (imperial) pints a night.
Here, we need about 5 support people per primary physician to handle all the rules, paperwork, insurance reimbursement, claims and billing; and our computer system costs something on the order for $30,000 per doc per year all told. The Irish marveled at tales of how nuts our system is. Canadians (politely) make fun of it when we're at the same conferences. Seriously, WTF?
Some of our previously insured patients seemed miffed because, just like before, medical care is expensive and the system is complicated. Some of them who used to blame the insurance companies now blame Obamacare.
My sincere apologies if you think I don't care about this question; it's one of several I care about very much and have great difficulty reconciling. The hospital chaplains' best explanations have amounted to, "Jesus said 'Suffer little children, and forbid them not, to come unto me., for such is the kingdom of heaven." Realizing that KJV usage has a different connotation for suffering, there's still a lot of suffering. I've never thought to say to one of these parents that this must be the result of sin. If you have a better explanation I could use to comfort the afflicted - afflicted, in this view, somehow by original sin which seems awfully distant - I'd love to hear it.
The deal is if you are (say) an Rh positive fetus in an Rh negative mom who was previously exposed to another fetus's D antigens (and D is often the culprit) you can get your blood cells nailed by mom's previously-formed anti-D antibodies. You get anemia, jaundice as well, and the potential various bad side effects therefrom (heart damage, brain damage, swelling all over[may not be safe for work]). Similar havoc ensues with anti-K. Preventive therapy with RhoGAM is available to prevent anti-D disease; it's a soup of anti-D antibodies that scavenge any fetal Rh-D positive blood cells that happen to find their way into mom's circulation. It's produced from pooled human blood plasma, though even most Jehovah's Witnesses (since a 1974 church opinion) and Jews (because there's an escape hatch in kashrut for saving human life) find it acceptable for treatment in order to prevent this fairly terrifying surprise G-d had in store for a few unlucky babies.
Government-supported access to contraception is likely highly cost effective - it makes not just intuitive sense, but studies seem to bear this out. Without all the bother of just letting teen moms and their homeless kids, you know, die in the streets and spread measles all around.
Tuberculosis tends to spread in crowded conditions and where treatment is not readily available - but treatment is different than vaccination. Mexico does routinely vaccinate against TB (with BCG vaccine, which sorta works); the US doesn't. Latent tuberculosis, for what it's worth, is about equally prevalent in migrant populations from Eastern Europe in my part of the world (Pacific Northwest United States), who tend to be legal immigrants. See http://ethnomed.org/clinical/t... for pretty graphs.
So, I wouldn't look so strongly at Mexico, as I would at San Diego, which is the backyard of Dr Bob Sears and his Vaccine Book. He promulgates a non-evidence-based Alternative Schedule that more or less gives privileged white parents permission to be suspicious of the pro-science crowd. (See http://pediatrics.aappublicati... for cogent commentary on the same.)
With a panel of about 2000 patients, I've got more or less 0 vaccine refusers among my Mexican and Central American population, which correlates well with the Unicef data cited above.
Cherry JD. Measles virus. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, et al (Eds), Saunders, Philadelphia 2009. p.2427.
Bernstein DI, Schiff GM. Measles. In: Infectious Diseases, Gorbach SL, Bartlett JG, Blacklow NR (Eds), WB Saunders, Philadelphia 1998. p.1296.
In some sense, increasing cancer mortality likely results from people in industrialized nations being killed less often by other stuff (cars, emphysema, smallpox, contaminated water). And walking 10 km (on a regular basis) probably has significantly decreased cancer mortality, probably by changes in hormone balance and metabolism. Cancer research may not always be flashy, but they do seem to dig up useful stuff over time.