Saturday, December 24, 2005

Using public health policy to raise revenues

The City of Cagayan de Oro practices the principle of transparency in governance in the name of public interest. One way is to televise the City Council session proceedings held each Monday afternoon. Sly winks of some wits infer that the exposure also benefits the actors in the drama, but I have no objection to the expense (of some of my tax money) as I learn how laws are made despite the caveat that it is unwise to know how sausages and laws are made.
Watching one such session, several months after the current city administration took office, the new city health officer proposed a novel health measure to protect community health. The proposal required all workers in the city, not just commercial sex workers and GROs (euphemism for prostitutes) and those employed in food establishments, to undergo a pre-employment physical examination and obtain the requisite health certificate. The physical exam entails the conventional routines of stethoscope listening to breathing, heartbeats, and other sounds, knee tap jerks, eye-ear-nose (perhaps genitalia) scrutiny, and a chest x-ray allegedly as an anti-TB measure. The last item seemed to me unjustified.
Despite my self imposed equanimity to avoid excitement and stress, I decided to appeal to the conscience of the august body and wrote a letter to a levelheaded member:

Letter to a City Councilor

I write to express my concurrence with your stance on the proposed ordinance requiring TB X-ray tests for workers in private firms. You may find the data I offer here of some value in the next reading.
The X-ray machine is a diagnostic tool for detecting internal images in a body, usually to confirm a doctor’s diagnosis of an ailment. But as you pointed out, the x-rays emitted by the device which has great penetrating power, overexposure could cause harm: sterility, skin disorders, cancer and radiation sickness. X-rays, cosmic and gamma rays are known as ionizing radiation and have sufficient energy to damage living tissue by smashing into its atomic structure and ionizing it by dislodging electrons.
The electromagnetic spectrum of radiated energy waves starts with low-frequency audible sound waves, above which are (in order of increasing frequency) radio and TV wave bands, the microwave band (ovens and telecom), infra-red radiation, visible light, and finally “ionizing radiation”: ultra-violet radiation, x-rays and gamma rays. Only the last three are known to cause biological damage, although concern over the biological effects of microwaves and high voltage power lines are under serious study.
(Writer’s comment: this portion enclosed in asterisks was deleted from the actual letter)*** Exposure to ionizing radiation is expressed in rads and rems, and small doses in thousandths or millirads and millirems. Rad stands for “radiation absorbed dose” and is a measure of energy per gram of body tissue. Rem is the measure of the relative mutagenic potential, or, in other words, the ability to do biological harm to the genes. For example, each of us receives on the average about 84 millirems of background radiation from natural sources each year. A nonfluoroscopic chest x-ray by comparison delivers 20 to 60 millirems. A single dose of 600 rems or more produces acute radiation sickness, like that which killed thousands of Japanese in the two weeks following the bombings of Hiroshima and Nagasaki
It is known that the effects of ionizing radiation are cumulative. The first x-ray that you ever received is still with you today, and its effect is compounded by each subsequent dose. That’s why established standards are stated in terms of allowable levels over a given period of time. The maximum exposure level for nuclear workers, for instance, is currently 5 rems (5,000 millirems) per year. Some experts say that there may be no safe level of exposure.
Shoe store fluoroscopes existed in the U.S. in the 40’s, as a sales gimmick. When studies found that cases of radiation-induced leukemia tend to peak 7-15 years after exposure., shoe store fluoroscopes were outlawed in most states in the late 50s (Adage: Good judgment comes from experience and much of that comes from bad judgment). The U.S. Public Health Service said the average device emitted between 7 and 14 roentgens per dose, but one study found that some machines emitted as much as 116 roentgens. (For comparison, a person standing within 1500 meters of ground zero at Hiroshima got hit with more than 300 roentgens. To think that X rays were once used to treat benign enlargements of the thymus, tonsils and adenoids, for instance, triggering many cases of thyroid cancer. Pregnant mothers and babies were routinely fluoroscoped by pediatricians, causing leukemia.
High frequency radiation has the ability to displace electrons from molecules in the body, thereby creating ionized molecules that undergo chemical changes. If these transformations take place in the chromosomes, the result may be cancer, while if they occur in the germ cells (which produce ova and sperm) the result may be sterility or birth defects. Experts say that if you’re planning a pregnancy, get a physical examination first so that any necessary x-rays can be taken prior to conception. Or, if you know or suspect that you’re pregnant, avoid all x-ray examinations of the back or lower abdomen unless there is a strong indication of a serious condition.
A pamphlet prepared by the U.S. Food and Drug Administration in cooperation the American College of Radiology suggest that while X-rays are often needed to establish an accurate diagnosis, there are conditions in which they are not medically necessary. The pamphlet provides tips for consumers on how to help their doctors and dentists use x-rays appropriately. It also includes a record card that enables the patient to keep track of the x-rays he has, the doctor who orders them, the purpose of each examination, its date and where the films are kept. ***
Decades ago, the American College of Radiology, which represents 13,500 board-certified x-ray specialists, joined several professional groups in urging restricted use of routine chest x-rays for job applicants, admission to hospitals, tuberculosis-screening programs and other purposes. The basis of their position was a study of U.S. FDA’s Bureau of Radiological Health which estimated that about a third of the X-rays performed in the U.S. are unjustified, costly and were not needed, since there was little likelihood that they would detect a disease, or change its treatment or outcome if they did.
The rhetoric of the City Health staff is plain hype and thus unconvincing. The data offered, about 1500-1800 TB patients treated yearly (but not increasing), is inconsistent with their claim that TB contagion has a geometric progression rate (one person infects 200 others). The spread of the disease, if any, cannot be considered sufficiently alarming to justify the proposition to invoke “police power” of the state, and therefore is highly inappropriate and objectionable.
Inordinate reliance on X-rays for TB prevention is not rational ─ it poses undue exposure to radiation risks to otherwise healthy taxpayers, as well as being an onerous imposition on them. Since TB bacilli are airborne in transmission, wouldn’t a no-spitting campaign be a more effective and lower-cost preventive? (Certainly, not a no-spitting ordinance, as it would go the way of the no-urination drive)
Sincerity in public health policy can be cheaply effected, as one doctor admitted, by good nutrition. Simple nutritious food builds a strong immune system, and, if augmented with good sanitation and personal hygiene, would protect public health from TB and other pathogens.
I do hope you would persevere in your role as City Council conscience.

The all-embracing ordinance proposal finally subsided into Ordinance 8847-2003 requiring each worker employed in licensed City establishments to pay an annual fee of P150 assessed by their employer for city coffers, in effect mutating from a public health measure into a revenue generating imposition. Status quo for the prostitutes.

No comments: