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Speaker: The system's pretty good, the expectations are crazy

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  • Russell Brown,

    Now can we stop with the PC manning of hysterical barricades for political reasons and talk about reality, please?

    Actually Peter, perhaps you could be less of a jerk about it. It should be possible to discuss public health without being rude and didactic.

    Auckland • Since Nov 2006 • 22749 posts Report Reply

  • steven crawford,

    My friend in Christchurch, one a biggest looser commutation

    *Competition, not commutation, that was a spelling error.

    And I see I used the word one, instead of won. Early days, as they say.

    Atlantis • Since Nov 2006 • 4310 posts Report Reply

  • Craig Ranapia,

    What you describe is all part and parcel of Type 2 diabetes, and you are right having Polynesian ancestry makes you highly prone to developing it. When exposed to a modern western diet. The two are inextricably linked.

    Um, yes... but I also have a couple of high risk factors for heart disease -- I'm male, Maori, have a sedentary job, and have a family history of heart conditions on both sides. (My Dad was also a Type 2 diabetic, a condition which killed my paternal grandmother.) But I gave up smoking -- and am in the process of reforming the diet and exercising more -- for a reason.

    To get back on topic, I don't know how anyone can argue with the truth of the old proverb that an ounce of prevention is worth a pound of cure; but that doesn't mean a thing if the prevention isn't reality-based. I don't believe for a moment that I'm doomed to be a Diabetic alikie who is fated to die of a heart attack. But QFT that making a lasting lifestyle change isn't as easy as flipping a switch.

    That is all.

    North Shore, Auckland • Since Nov 2006 • 12370 posts Report Reply

  • giovanni tiso,

    But QFT that making a lasting lifestyle change isn't as easy as flipping a switch.

    I presume you meant "is" there? Then again, I'm reading Psychocybernetics, a self-help book written in 1960 by a plastic sourgeon who had discovered Weiner* and according to him it's exactly as easy as flipping a switch.


    * Norbert, the scientist - oh, grow up!

    Wellington • Since Jun 2007 • 7473 posts Report Reply

  • Craig Ranapia,

    I presume you meant "is" there?

    You presume wrong -- because there's still patches where I'm tempted to drown my troubles in a G&T or twenty with a couple of ciggies to take the edge off. :)

    North Shore, Auckland • Since Nov 2006 • 12370 posts Report Reply

  • andin,

    Oh Well, no one thought my channelling of Jon Stewart was clever or even funny. Woe is me.

    All right, health it's a serious business,( I can do serious) it needs deep thought and its a mine field.
    Our genetic make ups are vastly different, evolution has served us up a quandary of monumental monetary considerations.
    Where should the money go, who is best qualified to decide this distribution.
    Where can we get the most bang for our buck.
    Well Gareth points in a few directions, but the solutions need to be fleshed out.

    There's considerable and mounting evidence, for example, that early childhood experiences (such as developing a loving bond with a mother) can have a positive impact on a lifetime's worth of health outcomes,

    Yeah good, so mum stays at home and looks after baby. So does that mean she dont need to return to the work force after 3 months is it? I'm not sure if this is a solution rather than raising a whole load of other questions and "topics for further discussion".

    This kind of preventive medicine shades into the realm of social care. Health and well-being has been shown to be correlated with indicators from many other areas of life, especially education, housing and employment

    So what, we shouldnt live in overcrowded people unfriendly environments like cities? But up here Mr Greene said this about healthcare facilties:

    We also continue to throw money at remote, inefficient provincial hospitals. These are expensive to run, provide minimal services and because few doctors want to work there they end up relying on expensive locums.

    So people will fare better in less intensive industrial places, but there wont be any doctors or hospitals, cause it's expensive and anyway doctors don't like living away from cafes? Yes It's a problem I know.
    New Zealand's chance to become a pastoral egalitarian paradise was lost in the mid seventies.
    http://en.wikipedia.org/wiki/Ohu
    Big Norm, where are you.

    raglan • Since Mar 2007 • 1881 posts Report Reply

  • Bart Janssen,

    So people will fare better in less intensive industrial places, but there wont be any doctors or hospitals, cause it's expensive and anyway doctors don't like living away from cafes?

    I don't think that was the suggestion. The idea is that you have lots of medical centres, some with quite a lot of gear in them, in the rural areas. Their job is to provide primary health care and also to stabalise patients for transfer to the cities where the big hospitals are located.

    Any time you need full hospital facilities it is more effective to move the patient to the city. It is probably even more effective to park a patient in a nice hotel for a couple of months before and after an operation than to have a rural hospital.

    The scary part is that if you do that there will, with absolute certainty, be people who die who would have survived if we had a rural hospital. And sadly the media will run the story on the front page proclaiming it as a failure of the health system and some politician will make a "stand" all the while forgetting that by not having the rural hospital there was enough money to save the lives of 10, 20 or 100 other people - sigh.

    Auckland • Since Nov 2006 • 4451 posts Report Reply

  • Danielle,

    There's considerable and mounting evidence, for example, that early childhood experiences (such as developing a loving bond with a mother) can have a positive impact on a lifetime's worth of health outcomes,

    Yeah good, so mum stays at home and looks after baby. So does that mean she dont need to return to the work force after 3 months is it?

    Yeah, I was going to say something about this. According to this argument, would it actually be cheaper for the health system, long term, to extend paid maternity leave? And really, what does 'loving bond' even mean, in this instance? You can have a loving bond on the DPB, but if you're living below the poverty line it probably wouldn't make a blind bit of difference, surely? (Also, what about loving bonds with fathers? Do they help? Or is this just back to guilt-tripping mothers for Not Doing It Right, again?)

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • Kyle Matthews,

    I do not deny any of what you say. I am only pointing out that some people have managed to lose significant amounts AND keep it off. I make no claims for this for universality, as I make clear. Neither do I say it makes it easy, which I also make clear.

    Peter, I think that given that the discussion is about suggested changes to NZ's public health system, a bit of universality is what we need. A system, or systems, which do work across the population.

    Since Nov 2006 • 6243 posts Report Reply

  • andin,

    I don't think that was the suggestion.

    I was exaggerating for effect...sorry.
    But yes It is a problem and one that I don't think is considered carefully enough.
    It's great if this book is a starting point for a deep conversation within our society for the future of healthcare.
    However it seems to me there are many such conversations, about many of the institutions that surround us, that need to be started.
    I sometimes feel they wont.

    Danielle I hope women will take this up I dont think I am in any way able to contribute on the subject in any detail or depth.
    So over to youse.

    raglan • Since Mar 2007 • 1881 posts Report Reply

  • Danielle,

    Aw! I don't want just women to talk about this! That's how we all ended up in this mess in the first place. :)

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • Bart Janssen,

    However it seems to me there are many such conversations, about many of the institutions that surround us, that need to be started.

    Yup. And if I were to generalise I'd say that in most cases the problems occur when you start paying managers more than people who actually know what they are doing. We have a culture that says wearing a suit and going to meetings is more important (and deserves more pay) than actually doing the productive job with skill. As a result there is a point in all the "institutions" where really talented people who actually do the job of the institute have no incentive to progress because all the jobs with power (and reward) are held by suit wearing MBAs.

    The health system is simply one (very important) example.

    If we had a culture that said "yes we need managers (with MBAs) but we aren't going to pay them more than the engineer who designs the bridge" we might have more productivity.

    Auckland • Since Nov 2006 • 4451 posts Report Reply

  • steven crawford,

    Aw! I don't want just women to talk about this!

    Now you've set up an ear worm, thats going to be hard to shake out.

    Oh, I think the Rolling Stones did it.

    Atlantis • Since Nov 2006 • 4310 posts Report Reply

  • BenWilson,

    Looks like I was wrong and their is will-to-fat-fight after all. I'm going to try to threadjack it away a little, using the fat-fight as a convenient lead.

    It seems to me that one of the causes of modern obesity is very similar in many ways to the causes of any number of other ailments, many of them quite expensive. Basically, advancing improvements in every aspect of technology, social organization, science, understanding of human psychology, basically "progress" of every kind, leads to an increasing and paradoxical handing over to the 'group' of decisions that would formerly only be made at an individual level. There are advantages and disadvantages to this. Or maybe just side-effects, and points of view on those.

    Jacking away from obesity to my own chronic ailment, eczema, we find that here is another illness enjoying an inexplicable rise in modern times, despite the fact that we know more about eczema than we ever have before, and are constantly inventing new treatments. Here we have something that it is much harder to invent evolutionary reasons for the rise of. It's a bit harder to say "well, we used to have it less because we chased animals around by necessity". But naturally there are still a plethora of offered explanations. Many blame modern foods, and the additives etc in those. Bottle feeding is one I often hear. Others blame pollution. Other explanations I've heard are that eczema can be treated with UV, so perhaps our past of being outside more contributed to less of it. Then there's the idea that we are more stressed now, that stress is linked in with the ailment. Some think it comes from overmedication. Others think it's from underexposure to natural irritants, so that we haven't developed tolerance. Yet more think that it's an evolutionary thing, that in the past extreme skin conditions would have more likely led to death, or a failure to procreate on account of disfiguration.

    There's also combination viewpoints, which is pretty much what the doctors who treat me seem to take. In absence of a 'cure' for me, all bets are off, and anything is possible. Naturally they won't put their name to most of them, keeping their prescriptions to drugs and other hospital treatments that they can monitor. Certainly any link to foods has never received the slightest positive from any specialist I've ever seen, although they've never said that it's not that. But that's moving into dietary control, a minefield for doctors.

    Being the only person who can actually observe what I do all the time, I've got my own take on a major source of my problem. Scratching. Scratching makes it worse. Almost 100% of the time. This is for lots of reasons, no real need to go into them - it's pretty obvious that systematically tearing layers of skin off around an afflicted patch of skin will damage it, and probably spread it. Which makes it a much bigger problem, requires more medication to clear it up, which develops a stronger resistance to the medication, and in the case of steroids, weakens the skin too, making it more prone.

    Of course the doctors know this, and a huge prong of the treatment centers on ways to stop scratching. So there's antihistamines, moisturizers etc, which are mainly aimed at reducing the urge to itch, or removing some of the dryness that leads to itchiness, etc.

    But this defers the problem. It puts it on the doctors to find a way to stop me doing something. The other obvious option for me is "stop scratching". And at some level it really is as simple as that. When the choice to scratch is presented to me consciously, there is some sense in which I can simply stop. I'm doing it right now, in fact. Well, ok, just a little eye rub, lightly, with a finger tip (and so it starts). People often ask my why I don't just stop scratching. The answer is always "because it's itching". Of course I can stop, but the scratch does have a pleasant effect, if temporary. It removes the itch, for a short time. In fact, the harder you scratch, the more it removes it, which is how I end up scratching to bleeding point, and often beyond.

    I can say that it's unconscious, that it's impossible to control. It does seem that way sometimes. But at other times, it just seems like bloody mindedness - itching is so incredibly distracting and annoying that scratching a little seems like the lesser of evils. And yet, there are plenty of times when I don't scratch. In company, it's usually at a minimum.

    Is anyone seeing the parallel to eating in all of this?

    Basically, what I'm saying here is that the mental side of this affliction is huge. There is no other gatekeeper to my fingernails than myself. And yet, clearly that gatekeeper is insufficient (so far). So medical science (and quack science) have a vast array of alternatives, most of them leading, in some way, indirectly and yet inevitably to the final result - I stop scratching. Which is the only real cure. It could have been the starting point. Why isn't it? What has really changed in the modern world on this score?

    I think all of the suggestions above to this are plausible. I've had extensive (and expensive) testing to isolate the variables, all of them unsuccessful. I did not respond to UV. Allergy testing picked up nothing. I've tried cutting out some foods (there's not enough time in my life to be systematic about all of them). I've tried self-hypnosis, I've tried antihistamines, I've tried *everything*. So I get to the point where I'm at a loss - the cause is probably something I'm stuck with, and the cure is an act of volition, that magic quantity that may or may not be real or possible on a sustained basis. A constant undending act of volition, since I'm always itching somewhere.

    I'm deeply resistant to the idea of psychoanalysis for it. Deeply deeply. You get that way when you've been raised by a psychologist, particularly one from the behaviourist school (at least it's the only school he ever claimed). Maybe that's my problem. I don't know. But who else can ever know? The problem is heavily subjective. And the drugs do work. They're just degenerative and have huge potential side effects (cancer for instance).

    To throw that into some kind of perspective, my GP decided I was definitely in the 'too hard' basket and referred me to the hospital when he asked me why I didn't stop scratching, and my answer was "I do stop scratching. I'm stopping right now". He asked "how itchy do you feel, what is it like?". "Like I'm lying naked in a bed of gorse". He seemed startled, and looked at me very closely, I was sitting reasonably still, conducting a conversation with him. I was being honest, I was really that itchy that day, but I'm so used to it, that controlling that to some extent seems normal. It's the only option. To other people it might seem like I'm just weak when I finally give in to the one itch out of the 20 odd I'm feeling simultaneously, and decide to scratch it, just to give myself a moment to think.

    So I can fully understand why obese people feel judged when someone says 'just stop eating so much'. It's a very easy thing to say if the urge to eat in oneself is not particularly strong. If it causes physical pain and distraction then you might feel differently about how easy that is to get around.

    But on the other hand I can see that it is ultimately going to be the end result of any useful advice on obesity, or indeed any cure that doesn't come via advice, like stomach stapling or some kind of hunger suppressant medication. In controlling the urge to scratch, it does help for me to take responsibility for it, sometimes. In passing responsibility to medical science to cure my ailment, I may have missed the point entirely. I think this might be a modern trend, every bit as much as 'not running around after our food' or 'not getting out in the sun' or 'eating different stuff to what we used to'. Basically we're overthinking the problem, because we can, because we are encouraged to, because anything less might seem irrational.

    Auckland • Since Nov 2006 • 10633 posts Report Reply

  • Geoff Simmons,

    Thanks for all the responses, it is very heartening to see the conversation happening.

    The obesity and personal responsibility issues seem to have captured the collective imagination. There is much more in the book on obesity which I won't repeat here, but suffice to say that prevention is better than cure here too. Getting primary care to help people manage weight, diet and exercise issues better would be a good start, but as with smoking prevention means a lot more than health care changes. A huge shift will be needed in town planning, education, and ultimately food taxation and regulation to sort this out. Our health system is far more complex than we realise (as has been mentioned our relationships and family play a huge role) which makes change complex. But we could start by growing up and getting over the nanny state conversation.

    The other touch issue we need to get used to talking about is where to put our health dollar. The comments on "death squad" - this sort of scaremongering has handicapped US reform. Lets not go down that road here, unless we all want an unlimited health care budget. Life and death decisions happen all the time, the ideas in Health Cheque are about making these decisions a bit more transparent and evidence based. Rather than who shouts the loudest.

    Wellington • Since Dec 2009 • 4 posts Report Reply

  • andin,

    Aw! I don't want just women to talk about this!

    I wasn't excluding any others of the male sex from joining in, just me.

    Bart. That seems like a topical issue. I don't know the pay structures within the health system.

    raglan • Since Mar 2007 • 1881 posts Report Reply

  • Danielle,

    Ben, I... don't even know what to say. We're not overthinking the problem. The point is that, in apparently willing collusion with the diet industry and the peddlers of high-fructose corn syrup, we have been *underthinking* the problem for decades and our dumb-as-hell approach *isn't working* for most people affected. (Despite your assertion that the obese have passed the issue on to doctors, 'personal responsibility' is the most popular idea in the dieting world, you know. It's like a Randian wonderland in Weight Watchers. Hardly any of the millions of western people currently on calorie-restrictive diets would thank me for telling them their diet is unlikely to succeed longterm.)

    The comments on "death squad" - this sort of scaremongering has handicapped US reform. Lets not go down that road here,

    I was kidding. I do that.

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • dyan campbell,

    we know more about eczema than we ever have before, and are constantly inventing new treatments. Here we have something that it is much harder to invent evolutionary reasons for the rise of.

    Eczema sounds terrible, it sounds like a thousand mosquito bites. There has been some encouraging work at Otago - it's not quite as simple as "just eat some yoghurt" but have a look at this study - there is no overwhelming success, but there it is still promising, but I understand they are using probiotics before the digestive and immune systems are fully developed. It might be worth emailing the researchers for a word of advice anyway - they are based in Otago (see paper).

    Probiotics to treat eczma - Otago study

    I have a friend in Canada who had eczema as a child (severe) and swears it was cured by eating 8 - 12 fresh walnuts every single day. It turns out he may be right, and as walnuts are pretty nice anyway it might be worth a try. It took a good 6 months to take full effect, but he has been eczema free for years.

    Walnuts - Nutritional Benefits

    Islander, this may be useful for you:

    Osteoarthritis

    This website may be useful in general for anyone. Fabulous recipes.

    Healthiest Foods in the World

    auckland • Since Dec 2006 • 595 posts Report Reply

  • giovanni tiso,

    Basically, what I'm saying here is that the mental side of this affliction is huge. There is no other gatekeeper to my fingernails than myself.

    It reminds me of Nanni Moretti's excellent Dear Diary, the doctors episode, where he suffers from dermatitis, and they tell him it's all in his head and it's all up to him. "And I just know that if it's all up to me," he says "I'm done for."

    (It turns out it wasn't dermatitis, it was cancer. True story.)

    Wellington • Since Jun 2007 • 7473 posts Report Reply

  • Hilary Stace,

    I'm so pleased we are back to eczema again. Ben, I'm a recent fan of cetomacrogol (a cooling lotion) which you can buy cheaply from any chemist in big pots. Unfortunately, you can't put it in your eyes. That itching can feel like gorse pushing out of your eyesockets.

    Wgtn • Since Jun 2008 • 3196 posts Report Reply

  • BenWilson,

    Danielle, I've been more careful not to take a stance this time. I just raise 'overthinking', in a very long winded way, as a possibility - of course it was already raised, and it's not a new idea.

    I don't think it's something that even can be resolved, one way or the other. It seems to me like a resolution that might work for some people, a self-selecting hypothesis. If you were reading me as intended, you saw that it hasn't worked for me, wrt eczema. The urge to scratch wins most days. But I know people for whom it has worked, they just used discipline. Whether this was easier for them because they just weren't as itchy is impossible to know.

    In terms of prevention for eczema, it's fairly easy for me to see that it's possible. Both of my kids have it, which was always highly likely, and I've managed it much better than it sounds like it was managed for me when I was small. On the elder child, we haven't had to use steroids for over a year. But I can't really be sure if it's just that neither child is as chronic as I am, and time will tell if it comes back. We have much better information than we used to about some possible links from childhood feeding habits to adult eczema.

    Certainly my GP is much happier to give me drugs to manage it than he is for most of the parents he deals with - they will usually just slap the steroids on until the problem goes away, which is not actually the best thing to do. At least it's not the only thing you should do.

    Auckland • Since Nov 2006 • 10633 posts Report Reply

  • BenWilson,

    Hilary, cetomacrogol is good stuff. Used it for years. Now I use even greasier stickier stuff. It does help.

    Auckland • Since Nov 2006 • 10633 posts Report Reply

  • Peter Ashby,

    As Ben Wilson says from the icy centre of his control (I shudder at the thought of walking a mile in your shoes) volition is all very well, but. WRT diet and thank you Ben for making me think of it, what is available for us to eat when we can't resist eating makes a big difference. You can engineer a situation, we have done it, where there are no bad options available. No easy ones anyway. There are no bags of chips on our house, few chocolate biscuits (and I can't eat them, gluten), no white bread and my wife gives me the chocolate to squirrel away so she has to ask, but lots of fresh fruit and veg and low GI crackers. Want to chomp something? peel a carrot.

    We eat a takeaway once in a blue moon and the high fat content means my wife will suffer if we do. So we choose not to. And I find I don't miss it. A treat is a proper home made rice pudding. I make my own gluten free muesli and it is absolutely delicious. I've cracked delicious, low GI gluten free bread and I can cook a low salt, low fat, utterly delicious lasagne for my wife (lots and lots of herbs and quark for the cheese sauce).

    So we have both lost weight and kept it off and we consider we eat well. My wife does not exercise either. The problem is it is not cheap to eat this way and you do have to cook, and bake and I have a large herb garden that is well used (keeps down the cost of fresh herbs). And you do have to turn a blind eye to many of the special offers in the supermarket. We also interrogate labels minutely (no trans fats).

    We are also fortunate in having strong scientific backgrounds to understand all this and be able to remember it without carrying crib sheets around. It is not easy. Which is the point, why is it not easy? This is what we need to solve, why eating badly is so cheap and easy. Until we solve that one people will continue to find the wrong options too easily to hand when that moment of weakness arrives.

    @Ben
    I have done an exclusion diet (down to pork, pears and rice, then add things back). It doesn't take much time, its just deathly boring to eat and cheating invalidates the whole thing. At the start of mine I would have put money on dairy so I was surprised when gluten was fingered, then confirmed. If your trigger is dietary it does sound like it must be a pretty universal element, like gluten. It is the only way to find out.

    If it turns out to be gluten I have a pile of good, tested recipes I can fling your way.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Matthew Reid,

    @Giovanni yesterday

    i've got nothing against people who live longer because of their healthier choices, all power to them, but during those extra 20-30 years of life they are going to be riddled with expensive ailments, regardless of how much they've looked after themselves at 44

    When looking at the impact of longer life expectancy there are three scenarios: expansion of morbidity, compression of morbidity and dynamic equilibrium.

    You seem to be in favour of the 'expansion of morbidity' model in which an increasing percentage of life-expectancy will be affected by ill-health. This model assumes that longer lives for those with chronic diseases will result from advances in medical care, but the longer survival will be with more years of ill-health.

    An alternative is the 'compression of morbidity' model. This model has people survivng longer, but with more healthy lives, and a shorter period of ill-health before death. This relies on the postponement of ill-health being greater than the increase in life expectancy and therefore that the period of morbidity would be compressed between the later onset of ill-health and the end of life.

    The 'dynamic equilibrium' model sits between the other two. It assumes that even if the number of years lived with ill-health increase, the number lived with severe ill-health will decrease.

    NZ research, although five years old, suggests the dynamic equilibrium model may be operating here, while other research points toward compression. Treasury says it's complex but 'in the future, the incidence of disability will decline as the population ages, meaning that people will be living longer and healthier lives'.

    South Africa • Since Nov 2006 • 80 posts Report Reply

  • andin,

    Getting primary care to help people manage weight, diet and exercise issues better would be a good start, but as with smoking prevention means a lot more than health care changes.

    So does that mean identifying problem people early? How?
    Tho' that does kind of suggest something you don't seem to like.

    But we could start by growing up and getting over the nanny state conversation

    Or am I reading it wrong?

    raglan • Since Mar 2007 • 1881 posts Report Reply

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