Should Marijuana Be Legal?

California's Proposition 19, on the ballot for the November 2 election, proposes legalizing and taxing marijuana state-wide. The law would treat marijuana use like alcohol use. For example, it would be illegal to give marijuana to anyone under age 21, and it would be illegal smoke marijuana while driving a car.

It has been legal to use and sell marijuana in California for medical purposes since 1996. To purchase and use medical marijuana to treat or mitigate a serious illness such as chronic pain or cancer, you need a Medical Marijuana Identification Card, obtained by getting a recommendation from your health care provider. Although the Medical Board of California sets standards for health care providers to control which patients get these identification cards, the cards are notoriously easy to obtain.

Proposition 19 takes the medical marijuana law (Proposition 215) one step further, making recreational marijuana use, possession, and cultivation legal for all adults. With or without legislation, the lines between medical and recreational marijuana use are already hopelessly blurred here.

New Scientist's Jim Giles wrote an excellent overview of the issues around Proposition 19 ("All eyes on California for marijuana ballot"). He points out another wrinkle in the debate: the legalization issue ultimately comes down to money. "California's tax authorities estimate that a levy of around $2 per gram would bring in $1.4 billion per year," Giles wrote. "Hundreds of millions of dollars would also be saved in policing costs."

Of course, California's current and proposed laws around marijuana use are in direct opposition to federal marijuana laws. Over the past few years, federal agents have occasionally raided "Cannabis Clubs" that distribute medical marijuana in California and elsewhere. But federal agents have bigger problems to tackle than medical marijuana. In 2009, Attorney General Eric Holder promised to stop raiding medical marijuana sites.

In San Francisco, recreational marijuana use is clearly not prosecuted often. I sometimes come across someone (usually a young adult) smoking marijuana in public, which I don't like, especially if I have my children with me. An NBC reporter from Dallas found a few people smoking it the other day while he was covering the World Series. At least the reporter laughed off the incident, which I think is the best approach. Sometimes you have to pick your battles.

Besides, alcohol consumption, which is far more socially acceptable than marijuana use, is equally unhealthy - just look at information on fetal alcohol syndrome or alcohol-related traffic fatalities. It's a bit hypocritical to make recreational alcohol consumption legal for adults and recreational marijuana consumption illegal for adults. Legalizing marijuana would make it easier to regulate, at least, and still (ideally) keep it out of the hands of minors.

Don't Get Sick if You're Middle Class

The American middle class, created in large part by the G.I. bill after World War II, is suffering especially acutely in the current economy. A study in the journal Family Relations, for example, found that middle class shoppers are increasingly going to thrift shops and yard sales to buy basics they need such as clothes and small appliances.

Freecycle, an organization through which people give away or request household items, is growing in popularity; online coupon sites are everywhere. The only group that seems to have plenty of disposable income in this economy are childless young women.

But where can middle class families find the bargains in health care? The Census Bureau recently released a study that found that the number of people without health insurance rose from 46.3 million in 2008 to 50.7 million in 2009. Half of this increase is among people with incomes over $50,000 per year, who have limited access to government help with health care costs, as a Commonwealth Fund study pointed out recently.

Here in California, where unemployment tops 12%, health care is excruciatingly expensive. This is especially true in the San Francisco Bay Area, as Andrew Van Dam pointed out in a recent Covering Health blog post. For patients without access to government assistance, hospitals in some parts of the Bay Area bill about $35,000 per inpatient (versus about $19,000 per inpatient in Los Angeles County). Here's a Kaiser Health News map that lays out the statistics.

Health care reform helps, but the insurance exchanges that should provide affordable insurance options to those without good coverage aren't legislated until 2014 (although California is trying to fast-track that process in the state). Meanwhile, people who are uninsured or under insured are left to consult Dr. Google if they get sick. At least the doctor is affordable and always in, if not always right.

More Fees, Less Health

With open enrollment coming up, Kaiser Health News' Michelle Andrews wrote an interesting article about how health insurance costs may increase for consumers with the new health care reforms in place. The potential costs, which will especially impact people with family coverage, include:

• Higher premiums and deductibles. Employers and insurers are passing on greater amounts of the cost of health insurance to their employees. "In the past five years, employees' premium contributions have grown 47 percent, while overall premiums increased 27 percent," wrote Andrews. Furthermore, over 25% of employees pay $1,000 or more in an annual deductible that must be paid before the insurer picks up any costs.
• Both co-pays and co-insurance. In addition to small, flat rate co-pays to visit doctors, some health insurance plans will also require people to pay a percentage of the total bill (co-insurance) for hospital stays, ER visits, and/or prescription drugs. Co-insurance is usually about 10% to 30% of the bill, according to a New York Times article on insurance changes.
• Surcharges for dependents. Some insurers will charge extra for each dependent on a plan. Other insurers might charge a surcharge for employed spouses who have access to other insurance through their employers, hoping to drive them off the family plan.

These extra fees seem especially painful in light of a recent Commonwealth Fund study that found that Americans are faring worse in health outcomes than their counterparts in other countries. The 30-year study looked at health care costs and 15-year survival rates for 45-year-old men and women and for 65-year-old men and women, in the United States and in twelve other wealthy nations.

"The United States now spends well over twice the median expenditure of industrialized nations on health care, and far more than any other country as a percentage of its gross domestic product (GDP)," wrote the study's authors, Peter A. Muennig and Sherry A. Glied, in the journal Health Affairs. Although U.S. survival rates have improved during the study time (1975 to 2005), the improvements were greater in the other countries in the study.

The study looked at the impact of population diversity, smoking, obesity, traffic fatalities, and homicides on the health of Americans, but found that these factors did not contribute significantly to the health differences between the U.S. and other countries. Instead, the authors concluded that the high cost of health care might be making the U.S. fall behind the other countries. For example:

• High health care costs have made insurance unaffordable for many Americans. The number of uninsured Americans rose during the study period, and going without health insurance affects both short-term and long-term health.
• High health care costs might divert money from important public health campaigns. "At current spending levels, investments in public health, education, public safety, safety-net, and community development programs may be more efficient at increasing survival than further investments in medical care," the authors wrote.
• Expensive fee-for-service care and the rise of specialized care might lead to unnecessary procedures and poor communication between a patient's different health care providers. Complications from unnecessary procedures and medical errors from poor communication might contribute to Americans' poor health outcomes.

Ideally, health reform will ensure that more Americans have health insurance, create incentives to support public health programs, and reward the medical community for focusing on cost-effective, coordinated preventative care. If consumers become healthier because of these initiatives, insurers will save money on treatment costs. But since we're not there yet, insurers still view Americans as unhealthy and costly, and will continue to charge them heftily for that.    

Stopping Childhood Obesity

At the recent American Academy of Pediatrics' conference this past weekend, childhood obesity was a recurring theme. Obesity is primarily influenced by environment, something that parents have a fair amount of control over. What you feed your child, how active they are, whether you restrict screen time or not, and how much sleep they get all affect your child's weight. With one in three U.S. children now overweight or obese, though, clearly something has broken down.

In his session "Identifying and Treating Obesity Related Comorbidities," William J. Cochran, MD cited these jarring facts:

• Forty percent of children ages one to five years old have a television in their bedrooms, contributing to sendentary screen time
• About 20% of overweight and obese children get too many calories from sugary drinks such as soda
• Most parents and their children don't understand how big a portion of food is, making it hard for them to gauge their food intake
• If a child's parents are obese, that child has a 60% chance of becoming obese. If a child's parents are normal weight, that child has a 9% chance of becoming obese

The CDC states that our society is also "obesogenic," rife with unhealthy food choices and sedentary lifestyles. A family's lack of knowledge or tools to stop obesity just adds to the problem.

The question is what to do about obesity. Policy changes and initatives can help, such as Michelle Obama's "Let's Move" campaign to reinforce healthy behaviors in kids. There have been more extreme measures to stop obesity as well. Because obesity and its unhealthy extreme, morbid obesity, can cause a host of other health problems, such as Type II diabetes, sleep apnea, high blood pressure, and heart disease, on rare occasions parents of morbidly obese children or teens are charged with child neglect or abuse, as a single mother was in 2009 when her 14-year old son weighed 555 pounds. Most pediatricians are understandably reluctant to go down this path, since it would be best if the family could makes changes to help the child control or lose weight.

At the AAP conference, the Nestle Nutrition Institute and the AAP announced a new campaign to stop childhood obesity before it starts, by trying to instill good eating habits in children ages 0 to age 4. Their Healthy Living for Active Families (HALF) Project plans to distribute materials about healthy eating, serving sizes, and physical activity in pediatricians' offices, workplaces, and child care facilities.

Admittedly, Nestle is an odd partner, with its well-known candy brands and scandals over formula marketing in developing countries. Hopefully the AAP's voice will dominate the discussion, and get parents to take the threat of obesity seriously.

Stories Sell Science

In an article in New Scientist this week, epidemiologist Ian Roberts explains how published case reports of miraculous recoveries contributed to the increased off-label use of a blood-clotting drug to stop traumatic bleeding. Based on these case reports, the drug became adopted internationally in civilian trauma rooms and was used to treat battlefield injuries.

"A compelling medical story can burn itself onto a doctor's memory," wrote Roberts. "Stories weave a simple yarn of causation between events, imposing order and banishing uncertainty."

But when Novo Nordisk analyzed this off-label use of its hemophilia drug NovoSeven in a now-halted clinical trial, they found that the use of the drug did not affect the survival rate of the patients who received it. The drug's use might contribute to future life-threatening blood clotting problems in the patients as well, Roberts wrote. 

"The moral of this particular medical story is clear," wrote Roberts. "In the absence of evidence from randomised controlled trials we should remain sceptical about drug efficacy. Medical stories may be compelling, but they do not always give us the full picture."

Stories sell, though, and it's human nature to absorb information more easily through dramatic stories than through, say, an enormous Excel spreadsheet or a jargon-laden medical study.

International aid organizations have known this for quite a while. In their donor literature, instead of just listing depressing statistics about the effects of a famine, natural disaster, or civil war, for example, aid groups such as Mercy Corps also tell the stories of a few people who were affected by the event. They have found that they can get more donations by focusing on a few compelling stories of how they helped stricken individuals. Organization such as Berkeley's Center for Digital Storytelling are also being used to inform people about larger social problems through individual stories of people affected by these problems.

Health care providers (and their patients) are clearly swayed by the power of storytelling as well, as the Roberts article makes clear. But maybe it's time to turn this model around and use stories to promote good science. Scientists, steeped in the details of their research, are often accused of not explaining their ideas in a clear and compelling way. Then they wonder why the public doesn't "get" science, or underfunds scientific research.

Data can be compelling, fascinating, and instructive, but people listen to - and remember - stories. Scientists, and those who work with them to promote their work, need to think about and talk to people who might benefit from the work they do. These personal stories can help explain science to the public, and motivate scientists in their own research as well.