By Dianna Douglas

The Affordable Care Act is nearly one and a half years old, but the complexity of its reforms and their gradual roll-out have made it difficult to grade. Different disciplines are still parsing the legislation, attempting to figure out how it will change the future of their field. Experts in the field of Family Planning and Contraceptive Research has been puzzling over an enormous and perhaps unanswerable question: How will health care reform affect the reproductive lives of women and girls?

That was the primary question at the section’s spring conference, “Reproductive Justice and Health Care Reform: the Impact of Reform on the Reproductive Health of Underserved Women and Youth.” The phrase “reproductive justice” connotes the activism to give women and girls of all races and incomes the access to the same choices and education for controlling their reproduction. Panelists argued that some aspects of the bill, particularly the expansion of insurance coverage, would benefit this cause. But there were also warnings about the political resistance, exemplified by Representative John Boehner’s statement that he doesn’t think reproductive health care services are the business of the federal government: “How can you spend hundreds of millions of dollars on contraceptives? How does that stimulate the economy?” he asked in 2009.

Speakers at the conference, which was co-sponsored by UChicago’s Center for the Study of Race, Politics and Culture, posed many unanswered questions about how the Affordable Care Act will affect women and girls in America. Some expressed hope that it could close the gap between black and white and rich and poor in all areas of maternal health, unintended pregnancy, intimate partner violence, and infant mortality.

But Harold Pollack, PhD, professor at the School of Social Service Administration, gave both sides of the story. He argued that the Affordable Care Act is not only health care policy, but it is the defining document of America’s public policy on reproductive health care.

“Near-universal health insurance coverage will reduce disparities in health,” Pollack said. One of the goals of the Affordable Care Act, passed by Congress and enacted by President Obama in 2010, was to stop people from skimping on health care when they couldn’t afford it. If enacted properly, the health care plan would extend reproductive health care to millions of women.

Under the law, Pollack said, insurers can no longer require a referral to see an obstetrician or gynecologist, and must offer women direct access to these specialists. They are required to pay for some preventative services, like screenings for breast and cervical cancers and sexually transmitted infections. Insurers are required to pay for certain vaccines for women. They have to pay for preventive care for children and adolescents, including screenings for pregnancy. And, insurers may be required to pay for contraception and other family planning services.

All of these requirements were designed to improve women’s health across income levels, but basic access to physicians is the key. “When you visit a doctor because your knee hurts, the truth is that she probably won’t do very much for your knee. But you’ll get your blood pressure taken. She’ll ask you about your diet. And she’ll recommend you for other screenings and lifestyle adjustments,” he said. Oregon recently found that poor people with health insurance were healthier than poor people without it.

Pollack’s keynote address was not uniformly cheerful, however. “The bill is vulnerable, and reform is a risk,” he said. The politics around health care reform have become poisonous, he said, and some of the best public policies in the bill are the most under attack.

Pollack lamented that the great benefits of health care reform won’t be enacted for a few years, during which time public opinion on health care reform could sour more dramatically. “Backloading was the sin of this bill,” Pollack said. It takes time for reforms to embed in society, he said and the legal challenges to the bill may stop the process before it can begin.

To keep the Affordable Care Act on track and make the reforms sustainable, Pollack suggested that the people who support the bill should put a human face on it. “Americans are deeply ambivalent about sexuality and reproductive health,” he said. “But even people who disagree with abortion are uncomfortable with making a poor woman carry a baby to term after a rape or if the pregnancy will seriously damage her health.”  The more human and less theoretical the reforms can become, the more likely they are to survive the next few years of budget cutting.

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In the recent kerfuffle over the national debt, one of the rhetorical flashpoints was the $800 billion “stimulus package” pushed by the Obama administration in 2009 to fight the economic slowdown. Though the benefits of the American Recovery and Reinvestment Act on unemployment and the economy are fiercely debated, the impact upon the scientific world is just beginning to be felt. Roughly $5 billion of the stimulus money went to the National Institutes of Health for funding biomedical research - and $42 million of that sub-total came to projects involving University of Chicago researchers. Two years later, the fruits of that investment are beginning to ripen, as stimulus-funded projects reach the point of publishing results.

The largest piece of the stimulus pie awarded to UChicago researchers was the $5.6 million designated to form the EVE consortium, an unprecedented national effort to search for the genetic and environmental causes of asthma. Over 34 million Americans are diagnosed with asthma during their lifetime, and the rates are increasing every year. But the origins of this respiratory disease are still mysterious, with the relative contributions of genetics and environmental factors such as air quality and smoking still being unraveled.

One recent tool in decoding the causes of asthma has been genome-wide association studies, or GWAS, where genetic information from a large pool of patients with the disease are compared to a control pool of asthma-free people. But to find a gene or gene variant associated with a complex disease like asthma, a huge number of subjects are needed for statistical reasons. The expenses of successfully recruiting, diagnosing, and genotyping the thousands of people needed to create a sufficiently powerful GWAS were beyond the means of any one research group, frustrating the search for asthma-related genes.

“It has become clear to geneticists studying nearly every common disease that GWAS are often under-powered,” said Carole Ober, Blum-Riese Professor of Human Genetics and obstetrics/gynecology at the University of Chicago. “Unless you pull together many people doing the same thing you’re just not going to have the power to find genes.”

In the world of asthma genetics, nine groups of investigators were encouraged by the National Heart, Blood, and Lung Institute to pool their respective GWAS results to create a shared pool of data large enough to sniff out genes associated with the disease. But that collaboration was easier said than done - until the $5.6 million ARRA grant enabled the hiring of personnel to make the EVE consortium a reality.

“It would never have been possible without the grant, this was a huge amount of work,” said Dan Nicolae, PhD, associate professor of medicine, statistics, and human genetics at University of Chicago, and co-chair of the consortium with Ober. “The key was the ARRA funding that allowed us to move it faster.”

Now, just short of two years since the grants were announced, the EVE consortium has announced their initial results in the journal Nature Genetics. With a new larger data set of over 5,000 asthma cases, the group was able to pinpoint with high accuracy five genetic regions associated with asthma, including one with a very selective profile. Unlike a similar consortium formed in Europe (called GABRIEL), the EVE dataset reflected the ethnic diversity of the American melting pot with subjects of European origin, African origin, and Hispanics. That diversity proved useful, as the EVE data revealed an asthma-associated variant in a gene called PYHIN1 that only appeared in African-Americans and African-Caribbeans - ethnic groups not present in the GABRIEL sample published last year.

“Asthma rates have been on the rise in recent years, with the greatest rise among African Americans,” said Susan B. Shurin, acting director of the National Heart, Lung, and Blood Institute, which co-funded the study. “Understanding these genetic links is an important first step towards our goal of relieving the increased burden of asthma in this population.”

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One of the sectors closely monitoring the debt debate in Washington is the medical world, where hospitals, physicians, and patients anxiously await the final agreement on cuts to Medicare and Medicaid. Of particular concern to academic medical centers [pdf] are proposed cuts to graduate medical education, funding used to pay the salary of residents and fellows who are both training as physicians and specialists and working on the front lines of patient care. In a time when a patient’s wait time to see a specialist grows longer and longer, squeezing the bottleneck of physicians-in-training even tighter could have long-term consequences.

This week, the Medical Center’s executive vice president for medical affairs and dean Kenneth Polonsky took to the newspapers to argue against these damaging cuts. In an op-ed letter published by the Chicago Tribune, he expressed concern that the proposed cuts would “would reduce access to doctors, multiply waiting times and do lasting harm to patients in Illinois and nationwide.”

No one questions the need to rein in spending on health care or the obligation of hospitals to do their part. But we need to maintain a high level of patient care, and to make certain that our country has enough physicians in the future. Policymakers in Washington must maintain their support for graduate medical education and find more equitable ways to distribute the budget-cut burden.

Elsewhere…

Speaking of Washington and health care policy, without the Patient Protection and Affordable Care Act, 63-year-old Glenn Bovard of Valparaiso would not have been able to receive life-saving gift this past Father’s Day: a new heart. The Post-Tribune profiled Bovard’s story and surgery, performed by the Medical Center’s Valluvan Jeevanadam and Jai Raman. “The surgery was a cakewalk compared to the heart attack,” Bovard told the paper.

As many as one-third of patients with epilepsy cannot control their seizures with medication. Local newsmagazine Chicago Tonight profiles efforts by Wim van Drongelen, technical and research director of our pediatric epilepsy center, to develop new ways of helping these patients by modeling how seizures begin and spread in the human brain.

At the end of a long, difficult week, many people like to unwind on a Friday evening with a drink? But does alcohol relieve stress, or prolong it? A new study by Emma Childs of the University of Chicago Behavioral Pharmacology Laboratory and written up by the Gannett News Service suggests a double-edged sword - stress reduces the positive effects of alcohol, while a drink may extend the tense feelings produced by a stressful event.

A cautionary tale about when newspapers twist the words of scientists for sensationalist ends - did paleozoologist Darren Naish really say that the Loch Ness Monster was “more fact than fiction?”

Evolution isn’t only a process that happened in the distant past. Carl Zimmer’s wonderful cover story in the Science Times this week follows New York evolutionary biologists as they hunt for signs of urban evolution in progress for mice, fish, ants, and other city-dwelling critters.

In Akira Kurosawa’s 1950 film Rashomon, the story of a crime is told three times from the perspective of three different witnesses/participants. Due to the biases of each storyteller, the details of the three accounts fail to align, ultimately leaving the film’s narrator - and the viewer - unsure about what truly happened in the central incident. Historians have their own version of the Rashomon effect, filtering past events and organizing historical narratives according to their own beliefs, whether the influence is subtle or overt.

In an attempt to offset any such potential bias in his Regis J. Fallon Lecture at the University of Chicago, health law expert Timothy Jost of Washington and Lee University School of Law chose to present three parallel narratives in his discussion of the history and future of American health insurance. Despite a relatively brief run as a major player in our country’s health care system (”there are many people alive today in Chicago who were born before modern health insurance arrived,” Jost said), health insurance has quickly risen to a place of great importance, as demonstrated by the industry’s role in last year’s passing of the Affordable Care Act. The goal of that legislation to make sure that all American citizens have health coverage will likely be a key turning point in the story of American health insurance. But to understand which direction health insurance will travel after the ACA is fully implemented, you need to understand how it got there in the first place, for which Jost offered three tales.

1. A Failure of Socialized Medicine

In this tale, the public’s push for universal government health care was repeatedly rebuffed by special interests and conservative politicians throughout the 20th century. Though incremental victories were achieved, from the push by labor unions for employer-provided health benefits to the passage of Medicare and Medicaid during the Johnson Administration, the century ended with a whimper for socialized medicine advocates thanks to the doomed health care reform of the Clintons. Opposition from organized medicine, small-government Republicans, and an increasingly powerful private insurance industry thwarted the push to join other developed countries who had switched over to government-run health care after World War II - “for two decades, we saw no progress,” Jost said.

2. A Failure of Market-Driven Medicine

But according to the second narrative, this lack of progress was good news. From this perspective, Americans are “overinsured…because of misguided government policies that have encouraged private insurance for routine as well as catastrophic medical costs,” Jost said. By placing the cost burden on employers and government programs, the American health insurance system has severed consumers from the true price of their own health care - the main culprit, many economists believe, for the exponential rise in medical spending over the last century. Under this narrative, the steering wheel of health care should be handed back to the market with a strategy of tax credits, vouchers, and the roll-back of Medicare - key components of the current Republican budget plan.

3. A Messy Compromise That Kind of Works

Mixing the two narratives together creates a third storyline, one that Jost seemed to prefer despite describing it as “muddling through to moderate success.” In this history of health insurance, the industry grew haphazardly over the 20th century, incorporating elements of both government- and market-driven approaches according to the fickle political winds of different eras. From the birth of modern health insurance as “health services plans” (guaranteeing coverage of hospital costs) in Dallas in 1929, through the expansion of coverage to all types of care including routine visits, pharmaceuticals, and even dental, the unlikely bedfellows of consumer demand and labor union pressure combined to nurture the explosive growth of the industry. And for a while, this worked, Jost said - 82.4 percent of the population held private heath insurance in 1980, the peak of such coverage.

“The United States seemed to have solved, through private initiative supplemented by public programs…the problem of health security that other nations had addressed through social insurance or public provision,” Jost said.

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More Honors for Shubin

In 1863, in the midst of the Civil War, Abraham Lincoln signed an order creating the National Academy of Sciences, an organization bringing together the country’s most esteemed scientists to “investigate, examine, experiment, and report upon any subject of science or art.” From the original 50 members, the group has blossomed to 2,100 today, with roughly 200 of those Nobel Laureates. Any club with a 10 percent Nobel ratio is pretty exclusive, so being elected to the Academy’s lifetime membership is a thrilling honor for a scientist.

This week, evolutionary biologist Neil Shubin was the latest UChicago scientist given the honor of NAS membership, part of this year’s class of 72 new members and 18 “foreign associates.” Shubin becomes the 40th current member of the NAS located at the University of Chicago, and joins Medical Center faculty such as Janet Rowley, Martin Weigert, Donald Steiner, Bernard Roizman, Robert Haselkorn, and David Jablonski, who was elected last year (Fermilab director and professor of physics Pier Oddone was also elected in this year’s class). Election is no simple matter - each new member must pass a 10-step process [pdf] and be voted in to the academy by their potential peers.

Shubin is most famous for the discovery of the pivotal fossil named Tiktaalik roseae, a transitional species between ancient fish and the first limbed creatures to walk the land. But Shubin’s research is more than just fossil-hunting, as he studies the genetic programs that control development of limbs in the embryos of species such as sharks and salamanders. On the blog, we recently featured a paper by Shubin and former graduate student Andrew Gillis, where the embryos of strange creatures called holocephalons revealed some of the earliest steps in limb evolution.

In all likelihood, Shubin’s election was helped by his scientific communication skills as well. From his book about the discovery of Tiktaalik and the story of human evolution, Your Inner Fish: A Journey Through the 3.5-Billion-Year History of the Human Body, to his appearances as a correspondent on WTTW, to his anatomy teaching duties at Pritzker Medical School, Shubin has proven himself eager to educate the public at large about science. Appropriately enough, a second honor announced for Shubin this week was the Distinguished Service Award for Enhancing Education through Biological Research from the National Association of Biology Teachers. Once again, he finds himself in good company, as previous recipients include James Watson, Stephen Jay Gould, and Richard Dawkins.

“I am deeply honored to receive the NABT Distinguished Service Award. In an age where the ideas and tools of biology are increasingly playing a role in our lives, it is a deep honor to be recognized by those who are at the front lines of educating the next generation,” Shubin said.

The Science of Killing Bin Laden

A news story as big as the killing of Osama Bin Laden spares no beats, and there were plenty of science stories written this week in the aftermath of Sunday night’s surprise news. The most direct scientific angle was in the identification of the terrorist leader’s body, a step U.S. officials wanted to prove beyond a doubt before going public with the news. Like many of the events surrounding the raid, many of the details remain classified. But that hasn’t stopped science writers from writing explainers on how biometrics and DNA matching likely would have been used to make sure the Navy SEALS really had killed Bin Laden. President Obama himself confirmed that DNA testing was used to confirm they had the right body, but one fascinating mystery is where the DNA used to make the comparison was gathered. Nature blog The Great Beyond describes the candidates - from Bin Laden’s half-brothers and half-sister to one of his purported 26 children - and talks a bit about the recent history of using DNA identification techniques in criminal matters, including one crook busted by DNA he left on a slice of pizza.

Elsewhere…

The creation of new drugs, and the death of old drugs - Medical Center researchers commented on both sides of the pharmaceutical life cycle in newspaper stories this week. In the New York Times blog Fixes, reporter David Bornstein looks at the “valley of death” in developing new drugs for less-than-common diseases, and focused on the Myelin Repair Foundation and researchers such as Brian Popko (who we have featured twice). Then yesterday, the Chicago Tribune’s Bruce Japsen wrote about the upcoming patent expirations on the popular drugs Plavix, Lipitor, and Actos, and talks to our Caleb Alexander about the implications for health care.

How do you make a new species in the lab? It’s easier if you find a lizard species that is entirely female and can reproduce by cloning. Ed Yong at Not Exactly Rocket Science describes genome mash-ups, asexual reproduction, and the trickiness of species-naming in this great post.

A retired nurse and research coordinator at the Medical Center talks with Dawn Turner Trice about her experiences working with a small rural clinic in Ghana.

The fickle attention of political pundits has shifted of late from health care reform to budget cuts and labor union protests. But as the Patient Protection Affordable Care Act (known as “Puh-Paca” or the ACA in medical circles) nears its first birthday, much of the real drama is just beginning. Because its changes were designed to roll out slowly over 4 years, many people have not yet directly felt the effects of the ACA in their lives. But the primary players in American health care, including insurance companies, hospitals, and doctors, have been scrambling to guess where they will find their footing in the new medical landscape. That isn’t easy,  Jeff Goldsmith warned in his MacLean Center for Medical Ethics seminar, as the future landscape remains in unpredictable flux.

In the late 70’s and early 80’s, Goldsmith worked at the Medical Center as Director of Planning and Government Affairs and Special Assistant to the Dean of the Pritzker School of Medicine. Now he runs Health Futures, a health care consulting firm, and frequently writes and speaks on the changing world of health care. As you might expect, Goldsmith is pretty well-versed in the gritty details of the ACA, having read the entire 2900 pages of the legislation twice, he said.

“The depths of my masochism now stands revealed to you all here in public,” Goldsmith joked. “I’ve become a Talmudic scholar of this legislation.”

Now that he is well informed about the content of the act, Goldsmith’s critical assessment was a pretty firm thumb’s down - not as a partisan, but as a policy analyst. Goldsmith criticized the delayed activation of many of the act’s effects, arguing that spacing them out over two election cycles made it vulnerable to repeal if power shifted in Washington (as it started to in 2010). Though reducing medical costs was touted as a priority of the bill, the legislation does “nothing meaningful” along those lines, he said. And by expanding Medicaid and placing additional financial burden upon already struggling state budgets, the reforms may threaten the bottom line of hospitals who depend upon government reimbursement for treating patients on public insurance.

“We’ve taken an enormous fiscal risk, and it could turn out great, or it could turn out terrible,” Goldsmith said.

But many of these worst case scenarios are dependent upon how the legislation is implemented and whether new models of care and payment can be designed - quickly. The act gives the Centers for Medicare and Medicaid Services $1 billion a year (up from $30 million a year) to evaluate new ideas for delivering health care more efficiently and at lower cost. That’s one area where academic medical centers have the power to step up and steer the future of health care through programs like Healthcare Innovation Zones, Goldsmith said. The emphasis on cutting-edge research and the integration of clinics and hospitals at academic centers should also be an asset as the healthcare rules begin to shift.

“I think academic institutions have numerous strengths that give you a capability to respond that doesn’t exist in non-academic places,” Goldsmith said. “I think both the meritocracy and the reverence for science that pervades these places are a plus in environments where you have to begin making choices about what care people receive.”

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When health disparities in urban populations are discussed at the University of Chicago Medical Center, it’s not an abstract, far-away concept. Only a few blocks west and south of the hospital campus are some of the poorest neighborhoods in Chicago, where nearly every health statistic one finds is shocking. Pick any measure - diabetes, heart disease, obesity, infant mortality, or violence - and the numbers in some South Side neighborhoods are closer to those found in developing countries than they are to more affluent North Side neighborhoods mere miles away. The problem is exacerbated by a decline in health services on the South Side of Chicago, from losing more than 2,000 hospital beds in the last decade to a sparse density of grocery stores and exercise facilities.

In response to this health crisis, the Medical Center launched the Urban Health Initiative to execute a multi-faceted campaign of patient care, education, and research. But an important first step in fixing the health disparities on the South Side of Chicago is measurement, obtaining updated and accurate statistics on the healthcare needs of the region and cataloging the resources already available. At the MacLean Center for Clinical Medical Ethics seminar series earlier last week, associate professor of obstetrics/gynecology and medicine Stacy Lindau updated the progress of the UHI’s measurement arm, the South Side Health and Vitality Studies.

The first aim of the SSHVS is to build a map - not of transportation routes, but of neighborhood assets. Recently, organizations such as the World Health Organization and the Robert Wood Johnson Foundation have started to define an area’s health system as “intersectoral,” stretching beyond direct medical care to other aspects of the community that impact the population’s health. For the last two years, the Community Asset Mapping project of the SSHVS has sent out college and high school volunteers to measure assets such as grocery stores, gyms, daycare centers, government services, churches, and more on the South Side of Chicago. The fruits of those efforts are twofold: both a resource for the community and a baseline for UHI research on improving the broader infrastructure of the region, Lindau said.

“Has anyone ever described anywhere all the components of an intersectoral health system and how they’re working together? Has it ever been empirically evaluated or studied? The answer is no,” Lindau said. “But where are we starting to this? Here on the South Side of Chicago, where we’re mapping every single built asset in the primary service area of the University of Chicago…and trying to understand: if everybody’s in the health system, then what’s everybody’s role?”

So far, 11 of the 34 community areas that make up Chicago’s South Side have been mapped, and the information is already proving its value as the “highest-quality asset list for this region,” Lindau said. Compared to the most recent commercially-available resource guide, the mapping project found 4o percent more assets…and found that 30 percent of the resources listed in the commercial guide were no longer in existence. Unlike that flawed information, the mapping project’s data is available for free through a customizable map program on southsidehealth.org (one of many website domains the program has wisely snapped up for community outreach purposes) that allows visitors to search by asset-type and location for 16 different categories. Lindau also hopes to someday incorporate the information into electronic medical records, so that patients can take home a printout of their nearby health resources after a doctor’s appointment.

“You can’t do this on Yelp or Google,” Lindau said. “You can’t map places by disease or by need. I think we have something really special here.”

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The bacteria that started it all.

When scientist/entrepreneur J. Craig Venter announced that his company had created “synthetic life” in March, a predictable tsunami of media hype followed. Though the discovery was more accurately an important step in synthetic biology, rather than the creation of life from scratch in a laboratory, the story provoked rampant speculation about what this new field might be capable of. Interest in the promise and dangers of synthetic biology went up to the very top - the White House, where President Obama ordered his Presidential Commission for the Study of Bioethical Issues to look at this new science as their first item of business.

Today, seven months later, the commission’s report [pdf] is being released, with recommendations on what the federal government should do - and not do - about the growing field of synthetic biology. Our own Daniel Sulmasy, professor of medicine and ethics at the University of Chicago Medical Center and the Divinity School, is one of 13 members of the commission, and was kind enough to walk ScienceLife through the highlights of the report. The over-arching theme is one of “prudent vigilance,” Sulmasy said.

“We rejected the position that progress is so good, let’s just forget about any kind of regulation,” Sulmasy said. “But we also rejected the very cautious ‘precautionary principle,’ that says until something is proven safe we shouldn’t do it. I think that would cripple scientists and the potential of progress here that may be of significant benefit.”

Someday, synthetic organisms may provide renewable fuel sources, efficient vaccines, new ways of fighting pollution, and improved agriculture. While those applications are a long way off, Sulmasy said now was the right time for the commission to start a conversation about the ethics of such scientific breakthroughs, even if it is decades before they come to fruition. There’s a danger in being too early, he said: ethicists discussed the possibility of cloning organisms as early as the 1970’s, yet those discussions were largely unacknowledged, leaving policymakers unprepared for the ramifications of Dolly the Sheep in 1997. But open the ethical conversation too late, and it’s “like trying to put the cat back in the bag,” Sulmasy said.

“I hope that we can take a look early enough that we can have the ethical debate before the science is being done in widespread fashion and it’s impossible to regulate,” Sulmasy said.

Still, not knowing where synthetic biology may lead left the commission in a tough spot. Of the 18 recommendations listed in their report, the majority suggest using public funding organizations such as the National Institutes of Health, the Department of Energy, and NASA to share lifeguard duties over the field, without proscribing any specific restrictions. The agencies should fund promising research projects in synthetic biology, the report says, and make sure that adequate testing is done before the products of thatresearch are released beyond the laboratory.

Keeping scientists at academic institutions and private research companies in line should be possible under this structure, but the report identifies a newer, less predictable group of experimenters: DIY scientists. Shrinking costs of genome sequencing and scientific tools have led to a community of hobbyists doing synthetic biology research at home, Sulmasy said.

“There already is a lot of regulation and oversight on the academic and industrial side, so we didn’t think there was a need to create an independent commission or mechanism for assuring the safety of this work there,” Sulmasy said. “Where we did discover a gap is in a small number of people who are doing this kind of work at home and are very intrigued by it. For those who fall outside of the usual communities, we want to bring them into the fold without causing resistance.”

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Tuesday’s midterm election results appeared to deliver a strong message of discontent to the young Obama administration. With Republicans gaining control of the House of Representatives and closing the gap in the Senate, many analysts saw the election as a rebuke of the Democratic agenda of the last two years. Perhaps the highest-profile of those policies was the Patient Protection and Affordable Care Act, the product of the epic legislative battle over health care reform. Though many of the PPACA changes have yet to be activated, its opposition has loudly and repeatedly warned that the reforms will bring rationing of health care for the American public.

That’s a false bogeyman because rationing is already here, according to a commentary by the University of Chicago’s David Meltzer in last week’s Journal of the American Medical Association. Though the word “rationing” brings to mind making do with scarce resources during wartime, the term applies to any time a good or service is divorced from the economic forces of supply and demand. With the influence of government subsidies, private insurance companies, and managed care, the American health care system has long been subject to rationing.

“Attempts to resist change using the specter of rationing are not reasonable because rationing already exists and is inevitable,” Meltzer, an associate professor of medicine and economics, writes with Allan Detsky of the University of Toronto.

Because each individual’s personal demand for health care is unpredictable - a person could go the next year without needing to see a doctor, or get in a serious car accident tomorrow - insurance companies (and government programs such as Medicaid and Medicare) play the role of mediators, evening out the cost and lowering the risk. But that role gives insurers the power to make decisions about what care is appropriate and necessary, which may include the ability to ration health care through denial of coverage. Because a patient can pay for the procedure themselves, it’s not quite the same as the wartime rationing of goods, but when an unapproved procedure can run hundreds of thousands of dollars, the result may be no different.

The real debate then is over who should be making decisions about health care rationing: profit-driven private insurers, or politically-prone government officials, the authors write.

“I think it’s silly to talk about rationing without more subtlety,” Meltzer told ScienceLife in a separate interview. “We should absolutely have a debate about rationing, but it’s not a debate about whether, it’s a debate about how.”

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Many people take pride in never missing a day of work, and fighting through what they perceive as a minor illness to put in a full shift at the office. But what if your office is a hospital ward? Doctors who show up for work sick run the risk of spreading their illness to patients, further complicating their health issues. But with the tight schedules and long hours of the hospital, there’s even more pressure to get out of bed and fight through your sniffles (or worse).

Medical residents, physicians in their first few years out of medical school, have the tightest schedules and longest hours of all, and a study by University of Chicago and Massachusetts General Hospital researchers found that population to be especially guilty of “presenteeism.” In the wake of last year’s H1N1 flu epidemic, concerns about this bad habit have grown, and Vineet Arora, Anupam Jena and colleagues surveyed residents from 12 medical centers. In a study published in the Journal of the American Medical Association, they found that 60 percent of residents surveyed showed up to work sick at least once in the academic year 2008-09.

“Hospitals need to build systems and create a workplace culture that enables all caregivers, not just residents, to feel comfortable calling in sick,” Arora said of the results. “Their colleagues and their patients will thank them.”

See coverage at CNN, Scientific American, and AP.

Elsewhere…

How many species bear your name? If your name is Robert F. Inger, the answer is more than 50, ranging from Calamalaria ingeri to Ingerna charlesdarwini. That’s the kind of list you rack up when you’ve spent seven decades studying amphibians and reptiles in Borneo, Thailand, Malaysia, India, and China. Last week, Inger - a graduate of the University of Chicago and curator emeritus at the Field Museum in Chicago - celebrated his 90th birthday, and his colleagues put together a website to celebrate the occasion.

The official opening of the University of Chicago Center in Beijing was celebrated this week, a space designed to foster collaboration between our faculty and Chinese researchers and experts. As this feature describes, many such partnerships are already underway, including the AIDS education efforts of professor of medicine Renslow Sherer and fossil-hunting projects by paleontologist Paul Sereno. By a stroke of luck, ScienceLife will write about another Sino-UofC research collaboration next week - stay tuned!

Our contribution to President Obama’s Commission for the Study of Bioethical Issues, physician/bioethicist/friar Daniel Sulmasy, was profiled in the Chicago Tribune.

Another genetic sequencing race, this time between…Mars and Hershey’s? The Snickers maker struck the first blow with Wednesday’s online public domain publication of the Cacao Genome Database, while a group funded by Hershey’s hopes to publish their sequence in a journal soon. The competition is both delicious and beneficial, experts said, and may someday yield more efficient cocoa famring as well as chocolate that is both healthier and better-tasting. Yes, please.

General internal medicine might seem like an awfully vague term. But assuming the health care reform bill signed by President Obama in March will be fully implemented, the general internists will finally have their day. Many of the bill’s provisions are focused on a reshuffling of the American medical landscape, which is currently dominated by sub-specialists focused on one organ system. In recent years, fewer medical students have chosen to pursue lower-paid and less glamorous careers in internal medicine, leaving a worrisome shortage in primary care doctors and hospitalists just as 32 million uninsured Americans are about to go on the books. The spotlight is about to focus on internal medicine.

“About time,” would probably be the response from most of the doctors assembled in Minneapolis last week for the 2010 Society for General Internal Medicine national meeting. Over three days, thousands of internists met in discussion groups and research panels to chart the course for a new age of American medicine. Though some fears were expressed about how an already overwhelmed system would be able to deal with the new influx of patients, the conference was more focused on seizing the opportunity to rehabilitate U.S. primary care and bring medical services to those who are traditionally underserved. The urgency of the moment was expressed right in the caps-lock and exclamation point of the meeting’s theme: “Value(s)-based generalism: THE TIME IS NOW!”

Of course, many of these efforts to expand the net of primary care didn’t start when Obama used 22 pens to sign the health care bill on March 23rd. Many of the presentations by University of Chicago faculty at the conference discussed pilot programs already being tested to improve the care of those who have traditionally fallen through the health care cracks, efforts to reduce disparity that may be instructive as the reform measures fall into place.

A workshop moderated by Marshall Chin, professor of medicine, presented four examples of programs funded by Finding Answers, Chin’s Robert Wood Johnson Foundation-supported group for studying racial and ethnic health disparities. Chin said the mission was to “evaluate interventions that reduce racial and ethnic disparities,” and the short presentations showed the breadth of that mission. Projects using cultural awareness training, electronic medical record software, and pay-for-performance programs were all discussed as potential solutions, with researchers from Harvard, Brigham and Women’s Hospital and Baylor outlining projects currently underway. One fascinating approach, described by Barbara Turner from Penn, employed African-American patients who had successfully controlled their high blood pressure as “peer coaches” to help fellow patients struggling to adhere to treatment - an elegant way of using community bonds to spread healthy messages.

Another successful example of community health intervention was presented in tandem by Deborah Burnet, section chief of internal medicine at the Medical Center, and Lorri McClinton-Powell, a teacher from Woodlawn Elementary School on the southeast side of Chicago. Last year, Burnet and colleagues conducted a pilot study of the POWER-UP program, an anti-obesity effort based around after-school activities for children and parents, with 40 children and their parents at Woodlawn. Fourteen weekly sessions - focused on themes such as “Muscle Mania” and “Stop & Shop” - taught the children about healthy eating, exercise, and behavior at restaurants and grocery stores. Though small, the study’s results held promise, with declines in overall body mass index among all but the heaviest kids at baseline. The group is currently working with Chicago Public Schools on the possibility of expanding the program for a larger study, Burnet said.

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Eric Goren and Eric Whitaker at Bloomberg Health & America Briefing (photo by John Zich)

If there’s anything clear about health care reform, it’s that it’s unclear. Over the last 15 months, what has mostly been heard has been the two loudest sides, as political supporters and enemies of the health care policy changes under debate in Washington state their views frequently, at maximum volume. But the landmark reform legislation signed by President Obama in late March is expected to cause ripples in many worlds, both in the health care industry and beyond. The rules for doctors, patients, hospitals and medical schools will certainly change, but so too will the effects be felt in the financial sector, the 2010 elections and the technology industry. As such, the health care reform bill is kind of an amorphous entity, one that takes on totally different shapes depending on one’s professional perspective, political beliefs, and educational background.

Getting a read on all the ramifications of reform is an ambitious project, and the Health & America Briefing, organized by the Bloomberg news organization and the University of Chicago Medical Center on Tuesday, was suitably epic in its scope. Drawing upon dozens of experts from all corners of the country and all sectors of the economy, the event at the downtown Gleacher Center employed interviews and panel discussions to try to circumscribe the enormous changes the health care reforms are expected to cause. Some voiced optimism, some voiced concern, and the entire chorus only agreed on one thing: no one can predict the ultimate impact of what some called the most significant legislation of the last 50 years.

The most optimistic view was presented, logically, by one of the health care reform bill’s lead architects. Ezekiel Emanuel, special advisor on health policy in the Obama administration, led off the conference in a one-on-one chat with Bloomberg News’ Washington editor, Al Hunt, and called the bill “the most complex piece of social legislation America has ever tried.” Emanuel, while slightly less strident than his younger brother, White House Chief of Staff Rahm Emanuel, was still demonstrative in his defense of the bill, which he said would still cause sweeping improvements despite the necessary compromises it required to pass through a divided Congress.

Reaching beyond the insurance extensions that have gotten most of the ink, Emanuel pointed to several measures he thinks will dramatically restructure American medicine: an independent federal cost-control commission, improvements in health care technology, and added incentives for doctors to practice primary care. The hope, Emanuel said, is that the health care system can learn from small successes in improving care and bring those lessons to a wider population.

“You see pockets almost everywhere in the country with fantastic practices, and the issue…is scaling them,” Emanuel said. “I think that over the next five years may be our biggest project, is can we scale the good things that the health care system does: the efficient things, the high quality things.”

One place where Emanuel allowed a modicum of defeat was in the arena of end-of-life care: the massive expenditures accrued by medical interventions in terminal patients. While more than a quarter of Medicare dollars (and 10 percent of health care costs overall) are spent on end-of-life care, “no one is satisfied by it,” Emanuel said. Efforts to change how that process is handled by doctors and patients were demonized during the legislative debate as “death panels.”

“We have to do better,” Emanuel lamented. “It was a sad loss for the entire country.”

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Daniel Sulmasy is used to wearing many different figurative outfits, from the white coat he wears as a physician at the University of Chicago Medical Center to the brown robe he dons after work as a Franciscan friar. Now, Sulmasy will have another important role in his wardrobe as a member of President Obama’s Commission for the Study of Bioethical Issues. The 12-member committee was formed by Obama last fall to replace the Bush Administration’s Presidential Council on Bioethics, and will advise the president on forthcoming issues in science and medicine.

“This is quite an honor and a pleasant surprise,” Sulmasy said of the appointment. “I testified in 2006 to a previous presidential ethics council, but I never expected to become a member of such a group.”

Sulmasy, the associate director of the McLean Center for Clinical Medical Ethics, becomes the latest University faculty member to moonlight as ethical advisor to a president. The Medical Center’s Leon Kass and Janet Rowley both played prominent roles on the panel assembled by President George W. Bush, that most famously informed his decision to limit federal funding on stem cell research. On Obama’s panel, announced today, Sulmasy’s unique background as doctor and friar stands out among a panel made up of scientists, doctors, lawyers, and Muhammad Ali’s wife (an advocate for Parkinson’s disease). With experience in both religious and medical spheres, and an accomplished ethics background, Sulmasy should be a valuable voice for a panel that will have to wrestle with the difficult questions orbiting scientific advances in genomics, biotechnology, stem cell research and health care in the coming years.

One issue that may immediately be put before the panel is Sulmasy’s area of expertise: end-of-life care. The decision-making process between terminally-ill patients and their doctors was distorted through the political funhouse mirror during the health care reform debate into the fictitious concept of “death panels,” but that polarized discussion only obscured a legitimately important medical topic. Many of Sulmasy’s over 140 published journal articles deal with this very topic, some studying how well patients are informed of their options when their prognosis is poor and some considering the ethical boundaries for doctors between withdrawing care for a dying patient and assisting that patient in ending their life.

Wrestling with such a difficult topic requires an ethicist’s strong stomach for navigating the uncomfortable - best characterized by the title of a 1998 Sulmasy paper: “Killing and allowing to die: another look.” Discussing how doctors can best help their patients exert control over their own death requires blunt language; in a 2001 position paper for the American College of Physicians, Sulmasy (with co-author Lois Snyder) wrote that “Our societal emphasis on ‘cure’ and the medical emphasis on intervention have sometimes been a the expense of end-of-life care.” With studies showing that the vast majority of a person’s health care expenditures are made in the last year of their life, these are decisions that stretch beyond medicine into financial, ethical and spiritual zones.

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Expanding the Human Family, One Cave at a Time

A couple weeks back on the blog, Callum Ross debunked a lemur-like creature, Darwinius masillae, purported by some to be a very distant human ancestor. If you were feeling sad about this contraction of the human family circle, you may have been cheered by news this week about the potential debut of a new, more human-like human ancestor. There is no fancy Latin name for this relative yet, because even the authors of the paper announcing its existence are unwilling to declare that an entirely new species has been found. But it’s enough to dream up some not entirely unscientific (and somewhat unsettling) daydreams of a time when what we know today as humans were not the only two-legged tool-using primates on the scene.

The uncertainty surrounding the finding published in Nature by Johannes Krause, Svante Paabo and colleagues is that the discovery was made with a little bit of paleontology and a lot of genetics. The human ancestors or cohabitants we’re more familiar with - like Neanderthals or Homo erectus - were discovered in skeleton form, the classical way scientists learn of extinct creatures. But Krause & company’s fossil findings are limited to a pinky bone discovered in a Siberian cave, dated to 40,000 years ago. Because you can’t tell much anatomically from a pinky bone, the researchers instead harvested DNA from the bone; specifically, mitochondrial DNA (mtDNA), a smaller stretch of genes inherited entirely from one’s mother. When compared to mtDNA from modern humans and Neanderthals, it was dramatically different from both species - roughly twice as different as the gap between humans and Neanderthals.

The authors (and most of the outside scientists I’ve come across online) reason that the most likely explanation for that difference is that the pinky belongs to a very old human-like species, one that may have branched off from modern humans 1 million years ago. There are other theories - Carl Zimmer proposes one alternate theory built on the rather salacious premise of interspecies lovin’ - but analysis from the nucleus DNA of the proposed new species is necessary to decide. In the meantime, it’s fascinating to think about a time when humans sort of like us had to compete with Neanderthals and whatever this new ancestor may have looked like for resources, much like different species of birds will fight over territory and food.

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Project Exploration's Junior Paleontologists in Hot Springs, South Dakota. (from PE blog)

Last year we covered both of Janet Rowley’s high-profile trips to Washington, DC to receive the Presidential Medal of Freedom and help that President expand federal funding for stem cell research. To start off 2010, we have another faculty member getting Obama honors, as famed fossil hunter Paul Sereno and Gabrielle Lyon’s Project Exploration receives one of 22 Presidential Awards for Excellence in Science Mentoring at the White House today. Sereno and Lyon started the group in 1999 as a way to expose city kids to real science, whether through a scientist visiting their class or an actual expedition to the fossil fields of South Dakota.

With scientific literacy at scary-low levels in the United States, such programs are essential for educating the next generation of potential scientists. As Lyon’s recent editorial for the Huffington Post argued, opportunities for kids to meet scientists and conduct real research are even more scarce in urban environments, particularly when tight budgets force public schools to cut back on materials for science classes and laboratories (those dissection frogs aren’t cheap). At the Tribune (where my final story was on Project Exploration receiving today’s award), I loved covering the annual Chicago Public Schools Science Fair, finding kids from all over the city who had a growing passion for science…some of whom already had pretty impressive projects! It’s great to see Project Exploration and programs like Science Chicago at the Museum of Science and Industry providing an outlet for these future researchers.

You can learn a lot more by cruising the excellent Project Exploration blog, where Lyon is updating live from the conference surrounding the award ceremony. One great program is Junior Paleontologists, which brought 14 Chicago Public Schools students to a fossil dig site in Hot Springs, South Dakota (so jealous). Or the Sisters4Science, where elementary school girls were visited by scientists from University of Chicago, UIC and the Willowbrook Wildlife Center to learn about urban wildife - in part by measuring live turtles. Or the Dinosaur Giants, where students train to be guides at the Field Museum, learning about science and then passing that knowledge on to other kids. Also: BoarCroc!

You can watch a live stream of the award ceremony at 12:30 central time here