Guest columnist--Love the cheeks. Are you storing peanuts for the rest of the flight?

By Spyros Andreopoulos

A mumps outbreak of more than 1,000 cases in Iowa and six neighboring midwestern states, and their possible link to two infected airline passengers, exemplifies the ever-present threat of contagious diseases and raises new concerns about recycled cabin air as a source of spreading disease during flights.

Past reported outbreaks aboard commercial aircraft have included Severe Acute Respiratory Syndrome (SARS), tuberculosis, measles, influenza and smallpox. SARS aboard Air China Flight 112 in 2003 showed that we still have much to learn about how viruses are transmitted in airline cabins because the disease was spread to as many as 25 passengers. During the SARS epidemic, in which some 8,000 people in more than two dozen countries got sick and 812 died, the United States reported 192 suspected SARS cases among internationalair travelers, according to the World Health Organization. Eight cases showed positive laboratory evidence of infection, and there were five deaths. Canada reported 251 probable cases, and 38 deaths.

Despite evidence that proper ventilation within confined spaces is
critical in reducing the spread of contagious diseases, there has been little study of medical issues related to behavior of micro-organisms in cabin environments. As air travel increases and the population ages, the number of medical events aboard commercial aircraft will get worse. Computer models indicate that doubling the ventilation rate can cut the risk of infections in half.

There was a time when airline passengers breathed fresh air that
circulated through the cabin every three minutes. In the mid-’80s the airlines, in an attempt to boost fuel economy, redesigned the ventilation systems for planes so that instead of 100 percent fresh air they use 50 percent fresh air and 50 percent recirculated air. Critics claimed that recycled air made people uncomfortable and often very sick. Congress has debated the issue with no resolution because of doubts that fresh air in an airline cabin would have any effect. Conventional wisdom is that any risk of contracting a viral infection is related to the proximity of the infected source, which might be little comfort if you are seated next to someone with a hacking cough or explosive sneeze. At least in this regard, airplanes are not much different from other forms of mass transit. But in an airplane, passengers don’t have the option of leaving the flight in midair.

Some airlines have moved on their own to improve cabin air-quality standards, including installation of high-efficiency particulate filters (HEPA). Filtering of cabin air to reduce exposure of infectious particles is established in the scientific literature and supported by the medical community. But carriers are not required to use HEPA filters, and there are serious gaps, thus many air passengers are breathing unfiltered air. A 2005 U.S. General Accounting Office survey of major U.S. air carriers found that 15 percent of large commercial aircraft that recirculate cabin
air and carry more than 100 passengers did not use HEPA filters. The number in smaller regional commercial fleets approached 50 percent. At congressional hearings a year ago, witnesses testified that regulations requiring HEPA filters for all aircraft that utilize recirculated air should be considered.

The Flight Attendants Association, representing 40,000 members, and
otherorganizations has asked Congress to require the Federal Aeronautics
Administration (FAA) to set a high standard for in-flight air quality. Germs are not the only concern of flight attendants. Studies have reported instances of increased carbon-monoxide levels in aircraft cabins causing headaches and even brief loss of consciousness in passengers during long flights.But with airlines facing severe economic pressures, these issues do not seem to be a high priority on FAA’s agenda , as the necessary study has dragged on for years.

Advice on what travelers can do to protect themselves from infection
during flights remains good personal hygiene. Dr. Lucy Tompkins, professor and chief of infectious diseases and geographic medicine at the Stanford University School of Medicine, for example, advises passengers to wash their hands frequently, particularly before eating, to cover their nose and mouth when sneezing or coughing, and to wash their hands afterward to protect others.

Colds (rhinoviruses) are usually transmitted from droplets spread via sneezing or picked up from contaminated surfaces, such as an armrest or a washroom basin.

Short of wearing a mask on the plane, Tompkins says, hand hygiene is the only avenue for a passenger to protect against infections that can be transmitted from surface contamination. She recommends the use of alcohol gels for hand hygiene.

Air travel is allowing diseases that once took years to spread from
continent to continent to move as quickly as a transatlantic flight.
Solutions will depend on renewed commitment to research that brings
together talents from aircraft engineering, computer science, mathematics, epidemiology, infectious diseases, immunology, ventilation technology and other fields. They require international collaboration in surveillance of emerging infectious diseases, which currently is discouraged by fears of bioterrorism and government policies that restrict involvement of foreign citizens and communication of scientific information. They require educating the public on the importance of immunization, good hygiene and
even cough etiquette.

Unless we develop a shared culture of awareness and responsibility about what needs to be done, and Congress adopts unambiguous policies to help the public-health professionals who are trying to minimize this threat, we will be facing continuing problems with each developing crisis.


Spyros Andreopoulos is a science writer and director emeritus of the
Office of Communication and Public Affairs at the Stanford University
School of Medicine. The article represents his opinion alone.
———————————————————————————————————

Copyright 2006 SF Chronicle

Bloviation: Passengers Will Please Refrain from Passing Water While The Plane is at the Terminal

We’ll begin boarding with our first class passengers, members of the Frequent Migratory Ducks Club and standing room passengers--I remember when flying was a special experience. Many people got dressed for the flight; stewardesses (that’s what they were called) were all lovely young women with actual smiles; the food came in plates with silverware and despite comedian jokes was actually edible, and the seats were comfortable with plenty of leg room. Fares were reasonable and controlled. I remember one flight going to college on a DC-7 (yes, I’m that old), with a gin and tonic in hand, watching the sun set on the cloud tops thinking this was a terrific way to travel. You don’t need me to tell you those days are long gone. Now an article in the New York Times points out that--and this is going to be hard to believe--things are about to get worse. [Click headline or here]

With the exception of the CD industry, no industry in America does more to piss off the very customers it needs most than the airlines. They are now getting paid back for the abuses they piled on their best customers before 9/11. And they have learned nothing. Nothing! It’s getting worse. Northwest now charges extra for an aisle seat.

Now comes news that having crammed as many humans into their flying tubes as they could, they now have found ways of jamming in even more. Are you ready for standing room? Airbus is thinking about a section on the new planes where you would stand, strapped to a back board in the rear of the plane. It does not necessarily violate safety rules and would only be used for short flights, say island hopping in Japan. So far, Japanese airlines are cool to the idea. I should hope so.

Currently, the pitch--the space between the front of one seat and the back of another--commonly is 31 inches, which means, if you have long legs, crossing them is out of the question. Some rows on some airlines are even down to 30, and American Airlines, which once advertised more legroom in its coach sections, has piled them back in. Newer, thinner seats which could be used to increase leg room are being used instead to steal another inch from each passenger.

New planes aren’t going to be the answer. Boeing’s upcoming 787, was designed for eight rows across two aisles. At least half the airlines ordering the plane have asked for nine across. The giant Airbus 380 (500-passengers, double-decked), has generated stories that it would have bars, beauty parlors and shopping malls on board. Nonsense. The airlines will fill every square inch with seats.

We can go into the economics of airlines some other time. The fact is, you and I are partially responsible for this. We will fly with whoever has the lowest fares, even if those fares lose money for the airlines, drive their planes to turning them into sardine cans with wings, and accept terrible service. I stopped flying the worst abusers (Northwest and Delta). You can’t have rock bottom fares and good service. It doesn’t work that way. What’s the difference between flying from New York to Chicago and taking a Greyhound? The Greyhound is more comfortable. It just takes longer

And someday we’ll discuss deregulation, malicious mischief disguised as public service. And of course, really fat passengers in coach. Bring back the CAB!

Decline of Western Civilization—Part V I--Everybody knows there's no sanity clause

Look, we sat in the back room smoking a joint and this is the best we could come up with--The Federal Food and Drug Administration (FDA) announced yesterday there was “no sound scientific studies” to support the use of marijuana for medical purposes. The announcement, of course, directly contradicts a study by the Institute of Medicine of the National Academy of Science which says exactly the opposite. Strike another blow for the Bush administration’s war against science. It also is another in a long situations in which the states have assumed leadership in American society because Washington is a lost cause. Think Massachusetts and health care. Eleven states have legalized medicinal use of marijuana and have repeatedly told the federal government to shove its objections. The Supreme Court ruled that the feds can arrest anyone using marijuana even if they are complying with state law, but that decision is unlikely to last very long. The Supremes are getting older and you know, some get sick and... A spokesman for the Institute of Medicine said the FDA statement was wrong--which it is.

Go To Jail. Go Directly to Jail. Yahoo! Sent you--Yahoo!, the ubiquitous Internet company has now helped the Chinese government send a third pro-democracy Internet writer to jail. Reporters Without Borders has obtained a copy of a verdict in the case of Jiang Lijun, who was sentenced to four years in prison for exercising free speech. Yahoo! helped the police finger him. According to the rights organization, Yahoo! is responsible for squealing on most of the people the group is defending. Yahoo! and Google, which has also sold its soul, claim they have no choice if they want to do business in China. Yes they have. They can move their servers out of the country. Or not do business there. They really do have choices. We all do.

Look, skepticism is a psychiatric disorder and we just happen to have a little pink pill--A study at Tufts University found that 56% of the 170 experts who put together the Diagnostic and Statistical Manual (DSM), the bible of psychiatry, had a monetary relationship with a drug company. I know. I know. You find that hard to believe. Do keep in mind we’re talking about an industry that comes up with a drug first and then finds a disease for it. According to the Tufts researchers, 95 of the experts who worked on 1994 edition of DSM had at least one monetary relationship between the years 1989 and 2004. Usually, it meant research funding. Lisa Cosgrove, the lead author, said that doesn’t mean there was influence but it does mean the manual doesn’t have a disclosure policy. People using the book need to know this. One defender, Michael First of Columbia, said the drug companies had absolutely zero influence on the contents. This is the book that lists dozens of normal human attributes as diseases for which--wait for it--there just happens to be a drug. Uh huh.

The President's Song

"The President's Song"
Parody by Phil Alexander
(Based on "The Major-General's Song" from Gilbert and Sullivan's Pirates of Penzance )


PRESIDENT:
I am the very model of a bible-bound creationist.
A blinkered, blind and narrow-minded dumb-ass revelationist.
I find it hard distinguishing religious from political,
And so I make decisions that are highly hypocritical

I try and change the law to save the life of someone comatose,
While ordering a war and killing anyone who comes too close.
The latest body count was twenty-thousand-plus civilians,
But I've got policies that could cause carnage by the millions

ALL:
But he's got policies that could cause carnage by the millions,
But he'sgot policies that could cause carnage by the millions,
But he's got policies that could cause carnage by the millions

PRESIDENT:
I know the world was made for us, and has been since it first begun.
It says so there in Genesis, and God knows I'm a Christ-ee-yun.
In short, in matters biblical, a congregagginationist.
I am the very model of a bible-bound creationist

ALL:
In short, in matters biblical, a congregagginationist. He is the very
model of a bible-bound creationist

PRESIDENT:
My country's use of gasoline is profligate and decadent.
It's harming our economy and the whole world's environment.
Global warming morons warn of crises so hysteric and
It makes me thank the Lord that I was born to be American

Like anyone in power who wants to show their adherence.
I pick and choose the bits I use from both Old and New Testaments.
The Satanic secular types show how much they fear me.
When I announce that evolution's no more than a theory

ALL:
When he announces evolution's no more than a theory.
When he announces evolution's no more than a theory.
When he announces evolution's no more than a theory

PRESIDENT:
Then I can draft a scary bill that's more than taking liberties.
But arguing impugns your patriotic sensitivities.
In short, in matters patriotic, criminal or terrorist,
I am the very model of a bible-bound creationist

ALL:
In short, in matters patriotic, criminal or terrorist.
I am the very model of a bible-bound creationist

PRESIDENT:
In fact, when I know what is meant by true religious parity,
When I don't think the West is under threat from secularity.
When my lack of brain-power's not undermined by literacy,
And when my foreign policy's less gunboat, more diplomacy

When I have learnt the difference 'tween sandwiches and sand wedges
When I can use with confidence the whole damn English lang-u-wedge.
In short, when I can state a statement oh, so very statedly,
You'll say no president's ever misunderestimatedly

ALL:
You'll say no president's ever misunderestimatedly.
You'll say no president's ever misunderestimatedly.
You'll say no president's ever misunderestimatedly

PRESIDENT:
I know there ain't much knowledge that's contained within my cranium ,
I went to see the Wizard, but he can't give me a brainium.
But still, in things political or educa-ca-cationist,
I am the very model of a bible-bound creationist

ALL:
But still, in things political or educa-ca-cationist .
He is the very model of a bible-bound creationist

[Thank you, Carol]

Is that a cell phone in your pocket or are you throbbing to see me?

Why are you standing there smiling and stroking your leg?--You are sitting at your desk, or at a movie or walking down the street and you feel it. Your cell phone, set on "vibrate," is beginning to throb. You pull it out, flip it open and--nothing. You have been the victim of phantom cell phone vibrations. Cell phone companies deny it can happen. A search of the scientific literature produces nothing, but we all know it happens. The only literature I've found on the subject is a piece done last year by Joe Orso, a student at the Columbia Graduate School of Journalism. Orso's problem is writing a story without experts. He was too far ahead of the field. He interviewed several people on theorizing the phantom phenomenon, and the lay explanations ran from psychosomatic (you are consciously or subconsciously expecting a call) to hallucinations (you are in love or something). The closest he gets to an expert is Christine Rosen, who has written on cell phones for New Atlantis. “Cell phone users talk about the reassurance of being constantly connected,” Rosen said. “It signals to everyone around you that you’re part of another community. So you’re not just a stranger in a public space, but you’re a person who’s in demand and who can demand the attention of someone else.”

He does have one psychology grad student to suggest that the vibes are similar to phantom call tones: if the ring is similar to a common pitch, you may hear it when it isn't there. Then there is the coed who honestly admitted she wants people to call her continually and when they don't, well, the phone throbs.

When we are done researching that, we can get to the other phone call vibration question: why does it feel good when it goes off in your pants pocket?

[By the way, do you know why they vibrate? The have little fly wheels with weights on the end and a phone call gets the fly wheel spinning.]

One thing you have to say about New Jersey: the ground doesn't move

Hey dude, that house is definitely worth a million-five, and I just adore the landfill it’s built on--I loved living in California but one of the reasons I moved had to do with a little adventure on Oct. 17, 1989. I was walking from the restroom down a corridor at my Stanford office when I heard the unmistakable sound of a train running under the building. I knew perfectly well what that meant: there is no train under my office. It was an earthquake. This one seemed dramatically larger than any I had been in before, so I assumed a fetal position on the floor while books, book cases and anything not tied down began to fly around the room. The whole thing lasted 15 seconds (trust me when I tell you it was the longest 15 seconds of my life) and when it was done I was pulling a pregnant co-worker out from under a desk covered by office debris. My son, then a Stanford student, spent the night in a tent until the engineers could determine if the dorm was safe, several old buildings on campus were totally trashed. It was the Loma Prieta Quake

My wife-to-be was on a bridge over a creek in the woods that comprises the UC Santa Cruz campus, also safe, but downtown Santa Cruz was a wreck and people died. If you were watching the Giants-As World Series on television, you saw what happened when a 7.1 quake strikes the Bay Area.

I bring this up because it is the anniversary today of the Big One, the 1906 earthquake and subsequent fire that destroyed San Francisco (the fire did more damage than the quake, by the way). Also, some scientists are releasing a computer model of what happens if that quake is repeated in the Bay Area. Kind of makes real estate prices look even crazier.

It could easily match Katrina. The study, reported at a meeting in San Francisco by structural engineer Charles Kircher of Mt. View, using 2,000 census tracts, predicted that as many as 3,400 people could die, 700,000 people would be homeless (when you are homeless from a million dollar cottage you are homeless indeed), the exteriors to 130,000 buildings would be wrecked and damages could be as much as $125 billion. That’s billion with a b. It is absolutely true that modern building codes in California work--think of what a 7.1 quake would do in Afghanistan--but there are still buildings grandfathered out of the code, and even the best code and construction can’t save everyone. The urban core of Oakland, Berkeley and San Francisco still have lots of those buildings and of course that’s where the poor live. You see the picture. The population also is 10 times what it was in 1906 and land values are out of sight. And the same people who handled the hurricane are still in charge. Need I say more?

Most of the people and most of the one-trillion dollars in property are within 25 miles of the San Andreas fault, the geological fault that ripped in '06.

Our dear friend lived in a beautiful house in the Santa Cruz mountains in 1989, one of the most beautiful houses I’ve ever seen. One minute she was indoors doing something and 15 seconds later she was outdooors. The house collapsed around her. It had not been attached properly to the foundation. It’s likely she’s not the only one that happened to.

The 1906 quake would have registered 7.9 if there was a Richter scale then (remember the scale is logarithmic so the difference between 7.1 and 7.9 is substantial) and it killed 3,000 people and destroyed San Francisco from the bay to Van Ness Street. The federal government got immediately involved and made the situation worse. Some things never change.

Meanwhile, I live in Maryland and now if it is sounds like a train is going under my house--well, it still isn't a train.

[Top photo, city hall, photo by Jack London (yes, that Jack London) courtesy California Parks, middle, dead horses San Francisco 1906 via USGS. Bottom photo Pacific Ave., Santa Cruz 1989 via Santa Cruz Redevelopment Authority].

I’ll take the Hopkins lipstick, the Stanford rouge and oh yes, a six-pack of M.I.T. Beer--2nd DAY LEDE

So I'm walking down the street and I see a sign advertising Johns Hopkins skin cream, and I'm thinking, hmmm. I need to get me some--Johns Hopkins Medicine said yesterday it was backing out of a deal it made with a cosmetics firm that touted its product as having been developed in consultation with the prestigious medical school. The announcement came after waves of derision and really bad publicity suggesting some smearing of ethical lines.

The Wall Street Journal reported [subscription required] that Johns Hopkins Medicine was allowing a cosmetics firm to use its name on the label. The medical school and hospital were not endorsing the beauty care products, only affirming that the testing was done in consultation with Hopkins. You have to read the small print. The cosmetics company, Klinger Advanced Aesthetics has the Hopkins brand on a new premium-priced skin-care line sold by Sephora, a unit of LVMH Moët Hennessy Louis Vuitton. Payment for use of the name would go to research. All hell has predictably broken loose, with newspapers having no trouble finding ethicists who are appropriately appalled.

According to the Baltimore Sun, this is what happened: The president of the university, Dr. William Brody, was walking down Fifth Avenue in New York [I'm not making this up!] and saw a poster for a new line of expensive cosmetics trumpeting the name Johns Hopkins Medicine in big letters. "Gee, I didn't think that's where we were going to go with this." I was going to ask for a show of hands of anyone who believes that, but decided against it. I believe it.

The arrangement was unique. No other research university has ever come up with a commercial arrangement quite like this, and a number of ethicists thought Hopkins had crossed the line. Many in the faculty were unhappy, and one wonders what other donors might have felt about the deal. Hopkins was to get money, equity and a place on the company's board. It now has announced it was giving up the equity and the chair and that the company can't use the Hopkins name. To go any further would probably mean a law suit. Hopkins said it acted only as a consultant, and wasn't endorsing anything except the testing procedure.

Blame the urge to get research funded with the federal government pulling back. According to Frederick Brancati, professor of medicine and epidemiology, who, helped get Hopkns into this mess, “We have to be inventive and creative.” The use of the Hopkins name is not an endorsement of the product, he said. According to ethicist Art Caplan at the University of Pennsylvania, “Unless you have acute vision and a lot of time to read [the small print], this is going to look like a product endorsement.”

Indeed, if Klinger was sure people would read the fine print they wouldn’t be paying Hopkins. If Hopkins had agreed to monitor the tests without giving permission for Klinger to use its name, Klinger wouldn’t have bothered.

“Hopkins says they are not endorsing the product, but they are,” said Mildred Cho, associate director of the Stanford Center for Biomedical Ethics, quoted in the Baltimore Sun. “What is the consumer supposed to take away from the fact that Hopkins’ name is attached to this product?”

Sephora’s website advertised Cosmedicine ™ “the first skincare line tested in consultation with Johns Hopkins Medicine.” Further clicking got you to a long, convoluted statement from Hopkins explaining the relationship, coming under the heading of protesting too much. If it takes you that long to explain what you have done, you probably shouldn’t have done it. The site is being changed.

In a great line, one former NIH researcher, quoted in the Sun, called the deal a ‘weapon of mass promotion... I don’t believe this is the function of a university.”

No it isn’t.

[Note to faithful readers: the owner of this here blog worked for Hopkins Medicine and was laid off two-and-a-half years ago on a financial restructuring. He is not amused. A family member still works there. He wishes them all well.]

Oh God, now they have a choice--UPDATED STILL YET AGAIN

If you were waiting for the other shoe to drop it's time to wash your socks--Apple just did what many of us suspected it would do: it has produced software that will allow Macs to run Windows. The stock, already astronomical [I resisted buying it at $15 before the split because I was told by experts never to buy stock on emotion], jumped seven points. And well it should.

Apple has released a beta of Boot Camp, software that will permit Windows XP to run on Intel-based Macs, the newest machines they sell. By year's end, all new Macs will have Intel dual processors. The moment they made the Intel announcement, people were wondering if that meant they could run Windows, which was designed for Intel microprocessors. Several hacks accomplished the deed. Apple first said it wouldn't support such a thing--go do it if you want to but leave us out of it. They apparently didn't mean a word of it or changed their minds. The new Mac operating system due later this year, Leopard, will include a final copy of Boot Camp and while Microsoft will have to support it, Apple won't mind.

You'll need to partition your hard drive, but with a Mac that's easy. Exchanging files may be a problem.

Why would you want to do such a thing? The current Mac system, Tiger, is already several generations ahead of Windows. But many people have software, usually corporate and proprietary, that only runs on Windows. Then there are all those games that run only on Windows. [Did you know there's not a single baseball emulation game for the Mac?] Now they can use Mac' OS X for everything else and still be able to run that stuff. Apple will sell a hell of a lot of computers to people who really want Macs and had been prevented by their IT people (scoundrels all) from using them. And Microsoft's new Windows won't be out until sometime next year--if they ever get their act in order. Computer geeks who've seen it, say the new Windows Vista still doesn't match Tiger, the current Mac OS, and by the time Vista is out, us Mac folks will be on to Leopard--with Boot Camp included.

[UPDATE: It should come as no surprise to anyone that industry observers are now reporting that Microsoft will delay Vista yet again, at least another three months, putting it back to about a year from now. Apple's Leopard should be making its appearance this fall. As one analyst put it, Microsoft is never on time.]


Several writers have suggested the next step, for which I approve heartily: make it possible for people now using Wintel computers (your Dell, your HP) to boot Mac OS. Then, instead of buying an expensive computer to run inferior software, you would be able to buy an inexpensive computer and run superior software. For a good explanation, go to Slate here. You miss the aesthetics of Mac hardware, but for some people that doesn't matter, particularly if you can save $500.

John Markoff's fine piece is here. The Windows-oriented PC World actually installed Boot Camp in a 20-inch iMac and was dazzled.

And remember, never buy stock on emotion. Sell Dell.

Have some Madeira, my dear, the benefits are abundantly clear. Or Not

I admired its nose, the vanilla nut foretaste with a little hint of cherries, cumin and high-density lipoproteins—Every couple of meals or so, I will open up a bottle of wine—Big House Red is the vin ordinaire on my table—for medicinal purposes, of course. It's good for my heart. [Sonograms of my heart taken only last week show a splendid organ, chipper and active]. Studies showing a relationship between moderate dinking and lower risk of heart disease are aplenty and get wonderful publicity—as well they should.

Now along comes a bunch of smart-asses at UCSF School of Nursing who claim all those studies are wrong because of flawed methodology. Geez! They think having a good aged red with your steak is not responsible for good health; it is a result of good health. The work goes back about 15 years to that of A.G. Shaper in London, who observed that many people who abstain from alcohol do so because they are getting old, are sick or use drugs affected by alcohol. These people then go get themselves counted in the studies on heart disease and lo, the number of people with heart disease who do not drink goes up. It biases the results. Not a lot of people took him seriously, mostly because we don't want to. I'll bet he kicks his dog too.

But the research at UCSF, published online at the journal Addiction Research and Theory, say we should pay attention. The researchers looked at 54 published articles on drinking and health and found that many of them included just those kinds of subjects, people who had just quit drinking for whatever reason, among those who abstained. Only seven discounted those subjects and all seven showed no benefit to the heart.

There is, however, biological evidence that light drinking has a beneficial effect, raising the level of high-density lipoproteins, the good cholesterol and I am content to leave it at that. I have a 15-year-old bottle of Ahlgren cabernet to be opened next year. It will do my heart good.

To hell with them.

Guest Columnist—I really don't want them to know about my hemorrhoids

By Spyros Andreopoulos

Despite a strong push by the Bush administration for the majority of Americans to have computerized medical records within 10 years, I am not sure I want the attending privacy risks.

I don't believe the hype dished out by our government that the odds of my survival after a heart attack would improve because the emergency-room computer would let the doctor connect to the Internet, type in a password, and within a few clicks, view my medical history and begin treatment. Those who write this fiction have never seen a real emergency room in operation.

I cannot deny the positive benefits for public health in having medical records computerized. They make it easier to track diseases and side-effects of prescribed medications. They can prevent redundant invasive procedures, X-rays, MRI and CT scans and blood tests. Universities, where most clinical trials of new drugs take place, have access to data for research. Billing is more efficient, and bad claims are caught more quickly. If an individual is insured or gets sick in another part of the country, that person's medical history is readily available to another doctor or hospital.
But I am wary at the thought of my medical history floating in cyberspace because we have no system to guarantee protection from hackers, insurers and drug-company marketeers.

I am also concerned because this new development is going ahead without adequate public participation. According to a 2006 survey by Health Industry Insights, a market-research firm, most respondents (70 percent) are unaware of the federal government's initiative to make electronic medical records available.

Another concern is cost. One estimate places it at $250 billion, to be offset by economic benefits of an estimated $700 billion that critics consider over-inflated. But these savings, spread over a decade, would go to the insurance industry, while the actual costs of implementing the system will accrue to doctors and hospitals. The new computerized system at Lucile Packard Children's Hospital in Palo Alto, for example, soon to go online, will cost $150 million.

The deployment of the new technology is also expected to create havoc among physicians with small practices who do not have the know-how, the management staff or capacity to re-engineer their practices according to the wishes of government bureaucrats in the same way as large group practices.

Experts doubt the government will succeed without committing tens of billions of dollars. There is no real sign the Bush administration will provide anything even remotely close to that sum. In Britain, the government's adoption of a similar goal is succeeding because it is driven by a single-payer system funded with an extra $10 billion in government contracts and enforced by mandated computerized standards applying to all hospitals and doctors. Approximately 95 percent of the doctors in the United Kingdom now use computers in their practice, as do most doctors in Sweden and European Union nations compared to a measly 20 percent in the United States.

There was a time when medical records were kept on paper in file cabinets of hospitals and doctors' offices. As electronic records gain ground, insurance companies and HMOs require detailed accounts of patient treatments and expenses to stem health costs. Previously, they asked only for basic information on diagnoses.

The chances for misuse are also greater. Employers could use the information to exclude applicants for employment due to medical history, and insurers to refuse insurance to those who are sick or have genetic predisposition to illness. The pharmaceutical industry is organizing conferences to explore how to "mine" information from electronic records for secondary purposes, including selling services and drugs to patients.

Let's not forget hackers and pranksters. Six years ago, a hacker downloaded thousands of confidential files from the University of Washington in Seattle containing patients' names, health conditions and Social Security numbers.

Polls suggest that 70 percent of Americans fear that there could be more sharing of patients' medical information without their knowledge; computerization could increase rather than decrease medical errors; some people would be reluctant to disclose information to doctors because of worries that it will go into their records, and existing federal protection rules will, in time, be relaxed in the name of efficiency.

Such fears are not without foundation. Last December's issue of Pediatrics reported, for example, that mortality rates for pediatric patients at Children's Hospital of Pittsburgh increased to 6.5 percent after the implementation of a computerized physician order-entry system, intended to prevent medication and patient management errors. While this finding does not mean causality and may have an explanation, it has stirred debate publicly and in cyberspace.

In the mid-1990s, Congress passed the Health Insurance Portability and Accountability Act (HIPPA) to protect patients from privacy violations. The regulations are full of loopholes and Congress may need to tighten the law's provisions. Under HIPPA, health-care providers have the right to process your insurance claims, discuss your case and send data about you to other specialists, respond to requests from public-health authorities, law-enforcement agencies, and your employer if you are injured at work, and send you fundraising materials. While these provisions may appear reasonable, HIPPA also allows health providers to share information with health-care business associates for the purpose of training their personnel. HIPPA gives patients the right to restrict uses of their medical information. Providers or health plans, however, are not obligated to agree to the restrictions if they state so in their privacy notices that patients sign when admitted for treatment. This is why patients must read the fine print carefully before signing.

Dr. David Brailer, appointed by President Bush to coordinate the move to electronic medical records, is a former software company CEO. In his public statements, he acknowledges the mind-boggling complexity of information systems, but with refinements and proper security systems, he believes electronic records can be made to work and be more secure than paper records.

If patient information moves successfully from paper to the computer, as its champions hope, the door to privacy abuses will swing wide open. One suggested solution is to give patients the right to work with the doctors to decide what is included in his or her record. A small step to be sure, but if the law and doctors were to give patients this amount of empowerment and autonomy, the doctor-patient relationship will have come a long way.

Spyros Andreopoulos is director emeritus of the Office of Communication and Public Affairs at Stanford University School of Medicine. Used with permission

And thank you, Spyros.

From: Technology and Privacy / Keeping snoops out of our health files