Value of Empathy
In the first  piece, Dr. Pauline Chen discusses an academic article that explored the way physicians communicate empathy to their patients who have serious and life threatening illnesses.  The conclusion of the research, (which looked at the experience of people who had lung cancer), was that physicians miss 90% of the opportunities to connect empathetically with their patients.

The researchers speculated that physicians don’t engage patients empathetically because they are concerned that this would take too much time. However, according to Dr. Chen, the researchers found that “empathy, expressed throughout the patient-doctor encounter, may actually help alleviate problems with time.”  This occured because when empathy was not acknowledged at the beginning of the visit, patients would to try to elicit that type of support from the physician, which could actually extend the time of the visit.

Patients Make a List
The second article was from Jane Brody – a wonderfully gifted health writer – who wrote about ways patients can improve their communications and interactions with clinicians.  Her list had two parts: 6 things to keep written down and bring to your doctor appointments, and 4 tips on how to interact with clinicians.  Her list of 6 things you should keep written down is a good one, and in essence [with my annotations] it is:

1. Questions for the doctor
2. Diary of symptoms
3. List of medicines, supplements and vitamins you take - with name, dosage and how frequently you take them. [Also, please tell your doctor if you are not taking the medicines as instructed for any reason, including if you are having a problem affording any of them.]
4. Your understanding of how you are supposed to be treating your medical problems [Doctors may think that because they told you something at your last visit that you both understood what they said and are following their guidance.]
5. Medical history for yourself and your immediate family
6. Your use of alcohol, tobacco and any drugs not included in #3

The other 4 items on Jane Brody’s list are also valuable:

1. “Be willing to see a physician’s assistant or nurse practitioner for routine care.”  [They will likely be able to spend more time with you on preventive and wellness care issues.]
2. Ask if the doctor uses email for non-urgent issues and questions.   [Some physicians do and some don’t – possibly because they don’t get reimbursed for communicating with patients via email or over the phone.]
3. If the doctor tells you to go to the Emergency Room because of your symptoms, don’t wait.  [Go right away.  Don’t wait for your TV show to be over, for the laundry to finish, or to put on makeup or shave.]
4. If you are told you have a life threatening condition or you need surgery, get a second opinion.

Physicians Use Lists Too
Lists are clearly good things to use so that important things are not forgotten.  People involved with critical, safety-conscious activities like flying airplanes have used lists to make sure that everything is set before takeoff and landing.  After what has probably been too long, such lists are making their way into modern medicine in a more standardized way.

Last December, Atul Gawande wrote in The New Yorker about how such lists are being used to improve the quality of care and save live (and money) in Intensive Care Units.  The first standardized and studied checklist was for putting in a central intravenous line.  The results were remarkable – lowering infection rates in lines that had been in patients for 10 day from 11% to essentially zero.  Peter Pronovost and his collaborators have since developed many other such checklists, (or protocols as they may sometimes be called), and their use has expanded to many, but still probably not most hospitals.

While these lists are clearly beneficial and valuable, like many medical advances, they are first developed and used for the most critically ill patients in hospitals.  This makes sense, because for hospitalized patients a mistake - or action not taken - can mean the difference between life and death.  And hospitals are also places where systematic changes can be implemented and the results measured.

More Use of List by Physicians
Physicians treating patients outside of hospitals often have lists too, but they are often incomplete and are certainly not standardized.  For example, the charts for most patients have problem lists, which list the individual’s medical problems.  However, it is up to the physicians to refer to them, otherwise, the only problem that may be addressed by the clinician will be the one that brought the patient to the office that day – so any needed preventive or wellness care (like an annual eye exam for someone with diabetes) might be overlooked. This is one reason why the list recommended by Jane Brody is so important.

So while physicians may have their own lists, and they know the reason why each patient has come to see them that day, they might be better served by making a list for each patient’s visit so they can make sure to cover all the things that are needed for that individual patient – and of course, that list should also include a reminder to connect empathetically to the patient.  (This is the same concept as having an agenda before any business meeting that not only lists the topics to be covered, but also states an overall objective and concludes with a wrap-up of actions to be taken – a practice I try to follow and force others to do when I’m invited to a meeting.)

Optimism for the Future
In the future, more diagnostic and treatment protocols and guidelines will be developed and configured into standardized checklists to be used in the outpatient setting.  Integrating these into electronic medical records (EMRs) – which include prioritized problem lists with links to recommended preventative exams and monitoring tests – will certainly help improve the quality of care and control the growth in costs.  Of course, this is predicated upon the development of EMRs that can provide such information in ways that are easily used by physicians and their associates.  (This too might be an area where the medical IT industry can learn from those designing airplane information systems.)

While physicians have railed in the past about guidelines and protocols forcing them to practice cookbook medicine, I hope that in the coming years they will welcome them as a way to standardize and simplify their practices so that they can actually work to individualize care for every patient, and connect empathically with them as individuals.  In decades past, that was one of the primary functions of the local doctor, and perhaps if that function again rises in prominence, the interpersonal rewards of practicing primary care medicine will help it grow in popularity with graduating medical students and residents.

This is interesting since Pfizer has (and had) a large number of products in heart disease, including Lipitor, and pharmaceutical companies have typically continued to do research in areas where they have had products because they have established sales people who are knowledgeable about the disease area and have relationships with clinicians in those areas.  The countervailing force is that many effective medicines to treat heart conditions (like high blood pressure and high cholesterol) are available in generic forms and thus the value bar (benefit/cost ratio) that new medicines must reach to be competitive is much higher than when they competing against other non-generic medicines.

However, one common and very expensive heart condition where better medical treatments are needed is heart failure - often called congestive heart failure (CHF).  According the the National Heart Lung and Blood Institute, 5 million Americans have heart failure, and 300,000 die from it each year.  The costs for these patients are very significant: Total costs for treating heart failure in the US are estimated to be $34.8 billion in 2008, and Medicare spent $4.7 billion for hospitalizations related to CHF in 2006.

The chart below from the Centers for Disease Control and Prevention shows the rate of hospitalization (per 1000 people) for heart failure in the US by age group over the years 1979-2004 - clearly a growing problem.

 Hospitalization Rate (per 1000 people) by Age Group for Heart Failure
1979-2004

So what does this mean for better treatments for CHF? According to the pharmaceutical industry’s web site database, there are currently 35 therapies in clinical trials for heart failure or congestive heart failure - including 3 based upon stem cell therapies, 1 based upon cell transplantation, and 1 using gene therapy.  (This compares to the 105 therapies in development for cancer, and 81 for pain.)  So I guess there will continue to be new treatments developed for heart failure, just probably not by Pfizer.  But, recognizing that there are lots of medical problems and limited resources need to be prioritized, will this be OK for current and future patients with heart failure?

Companies allocate and prioritize research and development resources according to three fundamental factors:

1. Unmet Medical Need
2. Scientific Opportunities and Discoveries
3. Market Potential

It is this last one that apparently Pfizer has decided has decreased, so they will be putting their resources into other areas where the combination of all three factors looks more appealing.  As long as all the research-based biopharma companies don’t make those decisions in the same direction (i.e. into and out of the same diseases), then research resources will likely be allocated in a reasonable way to meet societal needs. In that way the needs of people with heart failure will be balanced against those with cancer, chronic pain, diabetes, neurological diseases and immune dysfunctions - which is what society and patients really should want, since people often have multiple diseases or medical problems, so they should want new and better treatments for all of them.

Addendum: The memo from Pfizer’s R&D leadership about their strategic realignment has been posted by Forbes - click here.

Large Companies (>199 employees) Offering Health Benefits:
Eligibility, Take-Up and Coverage Rates

The Kaiser Family Foundation’s Report also included an interesting table that provides some insight into what I wrote earlier this week about the differences in employer health benefits between high and low turn-over industries.  The relevant information from  the Kaiser report’s Exhibit 2.3 is below:

Percentage of Firms Offering Health Benefits by Industry in 2008
Agriculture/Mining/Construction                                                67%
Manufacturing                                                                           73%
Transportation/Communications/Utilities                                    89%*
Wholesale                                                                                74%
Retail                                                                                        40%*
Finance                                                                                    81%*
Service                                                                                     58%
State/Local Government                                                           97%*
Health Care                                                                              71%
ALL FIRMS                                                                          63%

[* Estimate is statistically different (p<.05) from all other firms not in the industry category.]

Given the findings of the research discussed in my other post, these industry differences shouldn’t be surprising.  However, I do wonder if after this week the Finance Industry will still be on the high end of providing health benefits.  Of course, it also raises the question of whether financial firms that survive through a federal “bailout” or “takeover” (whatever the end result is) will offer health benefits 97% of the time like state and local governments?  If so, then the number of employees that have access to health benefits may increase - although I also suspect that the number of employees in that industry may decline overall, and possibly add to the number of people without health insurance.

In any case, I’m confident that the issue of employees’ health benefits will not be a significant concern for those trying to work out stabilizing solutions for the upheaval in the financial industry.  This would be consistent with the priorities that led to the famous statement about the 1992 Presidential campaign, “It’s the economy stupid.”  Or was it, “It’s the stupid economy”?

Professor Fiona Scott Morton noted that the value employers get from providing health benefits depends upon their industry - specifically whether the company retains employees or has a high turn-over rate.  This makes sense, since it would take time for employers to have a positive return on investing in employees’ health.  Professor Scott Morton also pointed me to a very interesting research article by professors at Duke and NYU that looked at this issue by analyzing data bases that included individuals occupations.*  By comparing workers in high and low turn-over industries they found several interesting things, including:

• Employers in low turn-over industries provide better health benefits
• Employees in low turn-over industries use more health care services while working
• Employees in high turn-over industries use more health care services when retired

This paper had many other interesting conclusions, and I’ll confess to not being able to fully assess all its conclusions because of some of the mathematical modeling used and the manner in which they presented their quantitative findings.  However, from what they said, I do wonder if much of the effect they observed could be due to higher wages in the lower turn-over industries.  This makes simple economic sense to me, because the researchers used average vocational preparation for the employees in the industry as a proxy for turnover (see footnote), and companies that depend on higher skilled workers would likely pay them more - which would also lead these companies to retaining their employees.   In addition, companies with lower skilled workers might also be less likely to provide paid sick leave as an additional form of compensation - which could account for the lower rate of doctor visits and preventive care the researchers found for the employees in the high turn-over industries.

What this means for health reform - and the future of employer-based insurance in the US - is that for some employers and employees the current situation works well, and seems to benefit society overall since retirees from higher skilled/low-turnover companies are less of a financial burden on Medicare.  However, for employees and employers in industries with high turn-over rates, the  employer-based insurance situation in its current form may not be working so well - although I’m still concerned about how much of the researchers conclusions are related to income -  either directly or as a proxy for less generous health benefits.  In any case, the findings from their paper point out some of the areas where our health system is working and others where it needs some fixing.  Hopefully reform initiatives in the coming months and years will address those realities.

* The researchers used the average Specific Vocational Preparation (SVP) - a Department of Labor categorization system used in the databases -  for each industry as a proxy for employee turn-over since other researchers have found an inverse relationship between average SVP and employee turn-over.

Because they have a workforce that is divided between their offices and customers facilities, Pitney Bowes has been able to conduct a natural experiment and see how providing access to different health and wellness services can effect their employees and the company’s costs.  What they found was that providing a good quality health benefits package in conjunction with healthy food and exercise options, etc., has reduced health care costs for their employees that work in their own offices compared to employees who work off-site.

I haven’t been able to connect with Mr. Critelli to get more data, but he did state that the saving have been around $2.3:1.  Pitney Bowes careers web-site states, “We recognize that our people are key to our success. Simply speaking, our business growth depends on the talent of our people.”  This sounds like the rhetoric that many companies use, but apparently at some level they actually put their money behind this statement.

Implications for Health Reform
At a time when some are proposing to shift the tax incentives for the purchase of health insurance from the employer to the employee - which would dramatically reduce the percentage of health insurance provided by employers - the experiences of companies like Pitney Bowes should be very informative.  Having grown up in the Insurance Capital of the World, I saw how companies that understand the value of employees health and satisfaction make extensive efforts to promote both.  Only time will tell what direction health reform will take in the US, and whether immediate cost reduction or longer-term health and productivity of the workforce will be the higher priority.

Part of our discussion was how the selection of Sarah Palin as John McCain’s Vice Presidential nominee will effect the Republican ticket’s position on stem cell research.

Doing a quick search on the internet, it appears that John McCain is refining in his position to support research on adult stem cells, while maintaining a foundation that doesn’t alienate the conservative base of his party.  Specifically, the only reference to stem cell research that I could find on the campaign’s web-site is:

Addressing the Moral Concerns of Advanced Technology

Stem cell research offers tremendous hope for those suffering from a variety of deadly diseases - hope for both cures and life-extending treatments. However, the compassion to relieve suffering and to cure deadly disease cannot erode moral and ethical principles.

For this reason, John McCain opposes the intentional creation of human embryos for research purposes. To that end, Senator McCain voted to ban the practice of “fetal farming,” making it a federal crime for researchers to use cells or fetal tissue from an embryo created for research purposes. Furthermore, he voted to ban attempts to use or obtain human cells gestated in animals. Finally, John McCain strongly opposes human cloning and voted to ban the practice, and any related experimentation, under federal law.

As president, John McCain will strongly support funding for promising research programs, including amniotic fluid and adult stem cell research and other types of scientific study that do not involve the use of human embryos.

Where federal funds are used for stem cell research, Senator McCain believes clear lines should be drawn that reflect a refusal to sacrifice moral values and ethical principles for the sake of scientific progress, and that any such research should be subject to strict federal guidelines.

I also found other articles and analyses concerning his earlier positions on stem cell research which seem less equivocal than his current campaign position.

Q: Would you expand federal funding of embryonic stem cell research?

A: I believe that we need to fund this. This is a tough issue for those of us in the pro-life community. I would remind you that these stem cells are either going to be discarded or perpetually frozen. We need to do what we can to relieve human suffering. It’s a tough issue. I support federal funding.

Retrieved from http://www.ontheissues.org/Social/John_McCain_Abortion.htm

Source: 2007 GOP primary debate, at Reagan library, hosted by MSNBC May 3, 2007

New Ad
Our weekend discussion also turned out to be a bit prescient, since my internet search turned up information about a new radio ad the McCain-Palin campaign is running that touts all the benefits of stem cell research without making any qualifications about what types of research would be allowed, or any of the moral issues raised on his campaign’s web-site.

Stem Cells Probably Not a Defining Campaign Issue
While stem cell research is certainly a sub-issue of the abortion/choice debate, and would not likely be a deciding factor for many voters, it is an issue of particular interest for biomedical researchers and some patient groups concerned with the development of better treatments and cures for cancers, (as discussed in the Economist), and degenerative diseases like Parkinson’s and Alzheimer’s.  It will be interesting to see how this issue plays out in the next few weeks and if it is raised during any of the debates…. Stay tuned.

Incentives to Become a Specialist
The first article in my inbox was a Washington Post story stating that only 2% of graduating medical students were contemplating going into primary care.  However, what the JAMA study actually found is that 2% of those entering Internal Medicine residency programs were planning on going into primary care. The Wall Street Journal correctly noted that the study also found that 12% of students are planning on going into pediatrics, and 5% into family medicine.  However, that means that 8% of physicians in training who will be treating adults in the future are planning on being primary care clinicians…. And even if some of those specialists go into research or other non-clinical careers, the percentage of primary care clinicians for adults will likely not be more that 10%

The reason why so many graduating medical students were planning on becoming specialist was clearly stated in the opening sentence of the Wall Street Journal article: “Yes, higher pay is prompting many U.S. med students to choose lucrative specialties over primary care….”

Incentives to Become a Researcher
The second piece in my inbox was a notice from the NIH about their loan repayment programs for recent doctoral program graduates.  When I worked at the NIH in the early 1990s I helped start a loan repayment program for researchers working on AIDS related research.  At that time there was tremendous need for more people to focus on HIV and AIDS research, and that loan repayment program was restricted to NIH-based employees.  What struck me about the NIH’s notice was how much their loan repayment programs have grown: They now fund 1,600 researchers each year with a budget of $70 million.  While many of the individuals benefiting from these programs are not physicians, they do include pharmacists, psychologists and dentists.

Conclusions and Thoughts About Overall Priorities
What I found interesting – and somewhat concerning – is that if increasing the number of primary care physicians is a high priority, and Medicare is being advised to take steps increase financial incentives for primary care, (something I’ve written about previously), then why have the NIH’s loan repayment programs expanded to draw more clinicians into research?  Certainly research is a worthy endeavor and a great career, but the current structure of the programs given our national priorities, the expansion of NIH’s funding (which helps support researchers salaries), and the growth in the private biomedical research industry, all together beg the question about how these loan repayment programs fit into our overall national strategy and NIH’s funding priorities?

I’m sure that some people will criticize me for questioning these NIH programs, but I look forward to hearing their perspectives – both on the loan repayment programs and how incentives for primary care should be increased.

I’m also concerned about the JAMA study’s findings because they point out that changing financial incentives for primary care may not happen soon enough - and clearly today’s students haven’t gotten any messages that these incentives will likely change in the future.  However, they may be getting their information from their teachers - who likely directly and indirectly relate the financial and life-style attributes of primary care versus specialty careers.  While Medicare and other payers cannot make promises about how their reimbursements will be structured years or decades from now, perhaps there needs to be more educational efforts directed at medical students and residents about what the future financial incentives for physicians may look like.

Clearly there is much work to be done in this area to ensure a greater supply of primary care clinicians and to drive research efforts forward with appropriate priorities.

The contentious issue in Massachusetts is a proposal to require employers to both pay at least 33% of full time employees’ health insurance premiums and ensure that at least 25% of their employees are covered by their health plan. (The current requirement is that they do one or the other.) So why should this difference be the basis for a law suit?  Actually, there isn’t really any legal difference.  In either case, an employer that provides health benefits to their employees by self-insuring, (rather than directly buying coverage from a health insurance company), could sue based upon the Federal ERISA law that regulates employee benefits.

The real difference between the proposal and the current law is political and philosophical rather than legal – employers are willing to live with the current either/or requirement, but don’t want to be pushed down a slippery slope where the coverage requirements and/or the small penalty of $295/employee for failing to meet the requirements are increased.  And their legal backup is ERISA.

So What is ERISA?  (Without going into too much detail.)
ERISA stands for the Employment Retirement Income Security Act of 1974, and it is a Federal law that governs how companies provide benefits to their employees.  The law is overseen by the Department of Labor, and was originally designed to ensure that pension benefits were properly managed and funded.  However, it also encompasses health benefits – but only for companies that provide the benefits themselves by self-insuring rather than purchasing health insurance for their employees from insurance companies.  The result is that ERISA mostly applies to larger companies which typically self-insure for several reasons:

• They don’t have to comply with state health insurance mandates – which is one reason why large companies can reduce their health benefit costs by self-insuring
• Since many large companies have employees in more than one state, by self-insuring, they can operate a single health benefits plan – under what is called an ERISA exemption – rather offer different health insurance options in each state based upon the states’ insurance laws
• By accepting the financial risk of self-insuring, they can also receive any financial rewards from controlling health care spending.  This also gives them incentives to keep their employees healthy as well as productive

ERISA is a Linchpin for Federal or State Health Reform
ERISA is a crucial part of health reform that is not very well appreciated and generally not discussed outside of very wonkish circles – which is probably why the Boston Globe article doesn’t even mention it.

At the State level – as in Massachusetts – ERISA theoretically precludes state governments from placing requirements on self-insured company’s health benefits programs.  However, ERISA does regulate how the benefits are provided, has requirements about providing information to employees about their benefits – aspects that are consistent with the law’s original focus on pension benefits – and has four coverage mandates:

• Non-discrimination against pregnancy as a medical condition
• Hospital length of stays for women following delivery: 48-hours or 96-hours following a Cesarean
• Parity between mental health and other benefits
• Reconstruction following mastectomy

ERISA has also been changed to require that companies continue to offer health coverage for a limited amount of time to employees after they leave the company (COBRA in 1986), and to limit or ban the exclusion of pre-existing conditions or other factors that might predict their need for future health care needs (HIPAA in 1997).

ERISA coverage requirements has rarely been modified because of the lack of any clear consensus for what changes should be made, and the concern that adding coverage mandates to ERISA would increase costs without expanding the number of people with insurance or improving quality. In essence ERISA is a major obstacle for health reform because it regulates one of the largest and most stable parts of the employer-based health insurance system. For example, the Kaiser Family Foundation’s annual survey of employers has shown that 98-99% of companies with more than 200 employees have offered health insurance to their employees every year since 1999.  Similarly, the percentages of employees who are eligible and who chose insurance coverage have remained relatively stable from 1999-2007:

Large Companies (>199 employees) Offering Health Benefits:
Eligibility, Take-Up and Coverage Rates

[It should also be recognized that health insurance costs are a significant factor for large companies to outsource jobs to small companies or independent contractors here in the US, or to send those jobs overseas to companies that have cheaper labor costs.]

The ERISA Chasm
ERISA is a huge uncrossed chasm for health reform because virtually any state law that places requirements on the health benefits provided by self-insured companies could be subject to a Federal lawsuit.  And at the Federal level – as noted above – nobody has come to a consensus as to what should be done, except for some chipping at the edges with worthwhile requirements.  In addition, the Committees with jurisdiction for ERISA generally have not made ERISA health benefit issues a high priority: In the Senate, jurisdiction for ERISA is shared between the Finance and the Health, Education, Labor and Pension Committees.  Each of these committees has significant other responsibilities, including Medicare, Medicaid, biomedical research and the FDA.  And in the House of Representatives, the Education and Labor in the House of Representatives has jurisdiction for ERISA, which is really their only health related area of authority.

ERISA’s Implications for Obama and McCain Health Reform Proposals
The importance of ERISA and its Federal oversight over all self-insured employer provided health benefits raises the question of how the plans of Senators Obama and McCain would be effected by ERISA?

Senator Obama’s plans clearly call for more Federal regulation of health insurance which could significantly change how health benefits are provided to employers.  This avenue for  creating a more stable system for health insurance/benefits changes would have to involve ERISA. However, his proposals explicitly state that individuals could keep the coverage they now have – which would likely mean limited changes to ERISA, and those changes might not raise too many objections from the large business community.

Senator McCain’s plans are based upon shifting the purchase of health benefits from the company to the employee by moving the tax deductibility from the company to the individual.  (It appears that there would also be a dollar limit on this deduction, and in essence also shifting from the general current situation of health benefits being a “defined benefit” to being a “defined contribution” – something that happened with many pension plans in the last ten years as a means for companies to control or limit their future financial liabilities.)  If a McCain plan required everyone buy their own insurance from insurance companies, then changes to ERISA wouldn’t be required, but it might lead to much more state legislative and regulatory action as millions more people become subject to state laws for both insurance company marketing and plan design.  In addition, one selling point used for McCain’s campaign positions, is that it would enable employees to take their health insurance with them as they went from job to job.  For that to be true across state lines, then tremendous changes to ERISA would be necessary – and probably much more than under the proposals that might come from an Obama Administration.

Conclusions
Sorry about the very long post, but as the title states, ERISA is truly an unbridged chasm.  Many health reform proposals have raced up to its brink only to suddenly stop short at the edge of the ERISA cliff – sort of like the comedy Westerns of the 1950s where the rider gets pitched over the head of the horse into the canyon.  In this analogy, perhaps the public and the politician are the horse, (I’ll let you decide which half is which), and the proposal is the rider – which gets lost in the depths of the canyon because the horse can’t find a way across.

For significant health reform to be achieved, all constituencies and stakeholder groups need to reach some consensus to build a bridge across the ERISA chasm.  Otherwise, no action will likely continue to be everyone’s second and fall-back option.

A microcosm of such progress was described in a recent article in The Economist.  This article describes advances in our understanding of stomach ailments – one of my favorite areas of biomedical progress because in the last several decades dramatic changes have occurred in our basic knowledge about this area, and so many people can relate to stomach problems.

The most significant change occurred in 1982 when two Australian scientists disproved the dogma that because of its very acidic pH the stomach was sterile.  They showed that the H. pylori bacteria could live in the stomach and cause the stomach inflammation associated with an upset stomach.  Subsequent research showed that H. pylori could be the cause of ulcers and stomach cancer. Following those discoveries, medicines were developed to change the pH of the stomach to treat the stomach inflammation and eliminate the H. pylori.

While lowering the acidity of the stomach with medicines would often improve symptoms, it also raised the question about what bacteria might be able to live in the stomach under less acidic conditions?  This question is more intriguing because it has been observed that when people taking medicines to lower their stomach’s acidity stopped taking these medicines, they have a resurgence in their symptoms.  This could be because their stomach had become accustomed to the less acidic conditions and then reacts to the renewed acidity; Or it could be because the bacteria that were living in the less acidic stomach are not happy with the greater acidity; Or perhaps the H. pylori that had been struggling in the less acidic stomach multiply very happily with the return of the acidic conditions.

H. pylori – Obesity and Asthma
The Economist article discusses some even more interesting ideas about the role of H. pylori in the stomach.  For example, they cite researchers who speculate that the elimination of H. pylori from the stomach may be linked to rising rates of obesity and cancer in the esophagus. These researchers at NYU School of Medicine also found that children who had not been infected with H. pylori were more likely to have asthma.  The article summarizes these observations with the speculation from NYU’s Dr. Blaser that perhaps H. pylori should be viewed not as a pathogen, but rather as a symbiotic organism “that is sometimes helpful and sometimes harmful.”

One of Dr. Blaser’s key observation is that H. pylori appears to not just be a passive resident of the stomach, but may actually regulate the stomach’s acid levels to keep the stomach’s pH in a range the bacteria prefer.  However, the substance that H. pylori secretes to get the stomach to produce less acid may be toxic to the stomach and result in ulcers and local cancers.  Thus, while eliminating the H. pylori would eliminate the toxic source of ulcers and cancers, it can also allow the stomach to produce too much acid – which can lead to cancer of the esophagus, as well as “acid reflux disease,” a.k.a. “heartburn.”

The H. pylori-obesity link is based upon the possibility that the bacteria modify the secretion of certain hormones effecting how people feel hungry, and the H. pylori-asthma link is based upon the effects the bacteria may have on children’s developing immune system.  (See The Economist article for more information about these areas.)

Conclusions
These findings lead to the conclusions that perhaps treating stomach ailments and preparing peoples’ stomachs for healthy lives should be based upon their genetic makeup, and seeding children with strains of H. pylori that don’t produce the toxins that can lead to ulcers and stomach cancer, could benefit them without doing harm in the long run.

Overall, this is a great example of how once more knowledge is obtained about a disease and the relevant human physiology, scalpel-like treatment and prevention strategies can be developed and implemented.  Of course, educating clinicians, patients, payers and others about these advancements – and why they are important – are also important challenges, because improving health care treatments and our healthcare system involves not just determining what should be done, but also how to actually accomplish those things.